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By contactus@rebyfootcare.com
June 07, 2015
Category: Uncategorized

  Excessive PRONATION can be a problem for children as well as adults.  Pronation is a triplane motion of the foot.  This means that when standing up, the foot normally goes through a motion described as pronation, and it occurs in all 3 body planes.  The arch typically lowers, the front part of the foot turns out a little, and the heel tends to evert (or turn so that it rolls out from under the ankle).  All of this is NORMAL - to a degree!  In order for the foot to adjust to uneven surfaces when it hits the ground, the foot is supposed to PRONATE, and then STOP PRONATING, and then SUPINATE - or start going the other way.  The arch should raise, the heel go back under the ankle, and the front of the foot rotate IN to make it a rigid lever to help push the body forward.  No one is 100% normal, but many people pronate or flatten out the foot TOO much when they stand, and this leads to what is often called a FLAT FOOT.   In adults, excessive pronation can lead to heel pain (plantar fasciitis), bunions, hammertoes, arch strain, and a whole host of other secondary problems.  

   There are many adults who pronate or flatten out their feet too much when they walk.  This starts in childhood.  Babies typically have a bulge of fat in the arch of the foot making all of them look like they have flat feet.  As they mature, this fat in the arch area should reduce, and the young child's foot  should take on the appearance of an adult foot, only smaller.  Some children have what looks like a very flat foot WEIGHTBEARING AND NON-WEIGHTBEARING.  This means the foot looks flat whether they are sitting or standing.  This is known as a RIGID FLATFOOT DEFORMITY.  Other children look normal when sitting, but when they stand, the arch lowers, their heels turn out from under the ankle, and they turn the front of the foot out.  This is known as a FLEXIBLE FLATFOOT DEFORMITY.  Not every child with flat feet (also known as pes valgus or pes planus) needs treatment.  The degree of the deformity is important, how the child walks, and whether or not there is any pain are imporatant considerations. 

   Custom orthotic devices are usually the first line of treatment for symptomatic and/or painful flat feet in kids.  Not all kids will say they hurt.  Some will not want to participate in sports, get tired easily, or seem to just be lazy.  If they relate LEG pain, especially cramping at night after they have had a busy day of activity, they may be suffering from this problem.  When in doubt, the best bet is to get it checked out.  A Podiatrist can evaluate the child's lower extremities ( feet, legs, knees, and hips) to see what may be abnormal.  If a hip, leg, or knee problem is found, referral to a Pediatric Orthopedist may be indicated.  If the problem is with the foot or ankle primarily, a custom foot orthotic may solve the problem.  The earlier this is instituted, the better.  If this does NOT resolve the problem - and I have seen cases where it completely eliminated the problem on ONE foot, but with deformity and/or pain remaining on the other foot - it may be necessary to consider surgery.  Unlike in adults, particularly in the FLEXIBLE FLATFOOT, soft tissue procedures may correct the deformity without resorting to osseous or bone procedures (often called osteotomies or arthrodesis - where bones are cut and repositioned or fusions of joints performed).  The use of implantable devices - once called a STA-PEG procedure, where a plastic plug or peg was placed in the foot to act as an "internal orthotic" - can be done successfully in many children, as long as significant arthritic changes have not occurred and the patient is young enough for the device to limit pronation successfully.    Secondary procedures, such as Achilles tendon lengthenings may also be needed, but the goal is to avoid surgery whenever possible.  In very young children, where there is an internal or external rotational problem in the lower limb, casting can also be instituted to attempt to turn the foot either OUT or IN, and there are also devices that can help with this, if used carefully and judiciously, in children that are not walking yet.  

   Excessive pronation or FLAT FEET can be considered borderline, mild, moderate, or severe.  It takes a skilled practitioner to determine the degree of the deformity, the necessity of treatment  and type of treatment that is necessary not only to resolve any presenting symptoms, but to reduce the likelihood of further problems as the child matures.  There are many adults with severe flat feet and secondary arthritic changes in the feet and ankles where the problem could have been prevented by recognizing and treating the problem when the patient was a child.  

 

Richard S. Eby, DPM

Eby FootCare and Laser Center

www.rebyfootcare.com

(423) 760-3115

   Foot surgery is often not considered to be MAJOR my many people.  Some of it, can actually be classified as MINOR surgery - especially that involving toenails, warts, cysts, and other surgeries involving a small incision or no incision at all.  There are foot surgeries done under LOCAL ANESTHESIA only, surgery done under GENERAL ANESTHESIA, and that which is classified as LOCAL with SEDATION.  While surgery under General Anesthesia is usually peformed in a hospital or surgery center, that done under LOCAL ANESTHESIA, whether done with or without sedation, can often be done in the DOCTOR'S OFFICE (if adequately equipped) OR in a hospital OR in a surgery center.  In many cases, the patient can choose one location over the other, but in far too many cases, the choice of the surgery is up to the surgeon, and the patient has little or no say in the matter.  

    Hospitals are typically the most EXPENSIVE option, and although most hospitals are well equipped to deal with potential complications or emergencies that may arise during the surgery, the most dangerous and immediate complications have to do with ANESTHESIA.  At one time, patients were admitted to the hospital the day before surgery, and then often spent one or more nights in the hospital after surgery.  All of that changed, starting back in the 1980's, when managed care became the buzzword, and the cost of being in a hospital, especially inpatient, became exorbitant.

   Surgery centers are usually less expensive than a hospital.  They still allow the patient to spend some extra time there postoperatively, especially if the patient takes some time to recover from the anesthesia.  Again, local anesthesia can, and often is used, for foot surgery.  Local anesthesia with IV or oral sedation can also be used.  In some cases, general anesthesia can also be used.  Surgery centers, however, are not the "bargain" that they appeared to be when they started springing up in the 1980's and 1990's.  The cost of the OR itself, the anesthesia, pathology lab to examine whatever specimen(s) is removed, the radiology (x-rays often done PRE- and POST-OP), along with ALL of the supplies used are itemized, just like in the hospital....and they must be paid either by YOU or YOUR INSURANCE COMPANY!   The surgeon's fees get paid to the surgeon whether in the office, hospital, or outpatient surgery center.  On top of all of that, MEDICAL DEVICE MANUFACTURERS sell most of their devices to the surgery center or hospital, and they pass the cost along to the patient!   Implants, which in foot surgery include such things as bone plates and screws, staples, pins, wires, etc. vary WIDELY in cost.  A k-wire can often be used to hold a toe in position when a hammertoe surgery is performed, but medical device manufacturers have come up with "new and improved devices" to hold the toe in position.  While some of these are nice devices, and they make the surgery more challenging and  interesting for the doctor, and have some benefit in healing - in certain cases, the cost can vary from $4 or $5 for a single K-wire to $1800 and sometimes $2000 or more for a really modern state-of-the-art device that can be a nightmare to remove if it ever becomes necessary to remove it.  So - add up the anesthesia fees, the radiology fees, the use of the OR (based on how long the surgery takes), the more expensive fixation devices used, along with additional lab fees, etc. - and that hammertoe surgery, for which the doctor may get a few hundred dollars, now becomes several thousand dollars!  "But my insurance will cover it" you say.   Maybe - maybe not.  Or maybe they will cover THIS surgery, but when it comes time to renew your health insurance, the premium is much higher each month, OR - they no longer cover "this type of surgery."

    I have seen patients have SOFT TISSUE SURGERY - repair of a tendon in one case - under LOCAL with SEDATION - where the total cost, including the surgery, anesthesia, supplies, labwork, etc. was nearly $30,000 !   And in this particular case, the patient had NO insurance.  If he had that same surgery done in the office - the "fees" would have been paid for - or "absorbed"  by the doctor.  That type of surgery would have been less than $1500, in fact, possibly less than $1000.  But instead - he is paying the surgery center every month until his bill is paid off.   Now.....what if he had health insurance?   First off all, he probably would have had a DEDUCTIBLE.  He may have had to pay $3000 or $5000 or more before his insurance would pay anything.... and then maybe he would have an 80/20 plan.  That means insurance would pay 80% After the deductible, and he would pay 20%.   So....let's just say he had a $2000 deductible - actually pretty good nowadays - and his insurance paid 80% of the APPROVED amount.  Well they probably would not approve $30,000.  Let's say they approved $20,000.  He would have paid $2000 deductible PLUS 20% of the remaining $18,000....so that is $3600. So when all is said and done, he would have STILL Paid $5600 for a tendon repair.  The insurance would have paid $14,400.  But if he went to a foot specialist with an OR in the office, he would have paid UNDER $1500.  Yes - the insurance would have paid $0.  I can tell you that my fee for that procedure, done in office would have been no more than $800.  Maybe less.   Even if he went to a doctor that charged a fee for the use of the in-office OR and anesthesia, MAYBE it would have been $1600 or $1700.  

    Sometimes "NEW and IMPROVED" is better.  Often times it is not.  If you are having foot surgery done - ask where the surgery will be done.  If done in the office, the doctor can give you a pretty good idea of the cost, and for how much you will be responsible.  He or she can't really do that if it is done in the hospital or surgery center.  Ask if it can be done in the office, and if so, can you be sedated at all or is it just local anesthesia.  If you are "pushed" into having the surgery at a certain surgery center, you may want to find out why?   Does the doctor have "ownership" in that surgery center?   If so, you can be sure the amount of money he or she will make off of doing the surgery will be far less than what the surgery center will make, but wait...that means the doctor will get some of that money also.  And there is nothing wrong with that.   It is perfectly legal, and he or she has a right to that money.  That doctor has invested in that surgery center and has a right to be compensated.  But, YOU,  as a patient just need to know.  You have a right to decide where your surgery is done.   You have a right to know how much you are going to be responsible for financially, because in this day and age insurance will only cover so much.  The days of "my insurance will pay it all" are over!

 

Richard S. Eby, DPM
Eby FootCare and Laser Center

7348 East Brainerd Road

Chattanooga, TN.  37421

(423)760-3115

www.rebyfootcare.com

    Heel pain, especially Plantar Fasciitis, is one of the most common problems seen in the foot and ankle specialist's practice.  This condition is very easy to treat, but often not very easy to cure.  There are many conservative treatment options for this condition, and as with many other foot and ankle problems, surgery is also an option.  Surgery for this condition, however, should always be the LAST option, and only considered when conservative measures have failed to give significant relief of pain.  Why do I say this?  First of all, there is no treatment for plantar fasciitis or pain on the bottom of the heel that is over 80 or 85% effective in curing this problem.  Surgery is only effective in about 70% of cases of plantar fasciitis.  Some studies report an even lower success rate in the 50 to 60% range.  There are SO many conservative treatment options, some of which we will explore below, that surgery should be the DOCTOR'S AND THE PATIENT'S LAST OPTION!  

    Conservative treatments for plantar fasciitis include the following:  exercises, steroid (cortisone) injections, NSAIDS (oral anti-inflammatory drugs), night splints, custom orthotic devices, over the counter supports and insoles, physical therapy, shockwave treatment, laser therapy, PRP (injections of platelet rich plasma), walking boots, stem cell injections, and there are surely others that I just can't think of right now.  Oh, but some of these are "unacceptable" to patients - or in some cases, the doctor - because (1) it takes too much time  (2) it alters the type of shoes worn ...and of course.....(3) it may not be covered under insurance,  So...in many cases, the patient, and sometimes the doctor, chooses SURGERY.  After all, you get it done in one visit and "it's (usually) covered under insurance."  But the downside with the surgery is a lot bigger than the downside with any of these conservative treatments.  With any of these treatments, there is always a chance it may not work.  With surgery, not only is there about a 30 to 40% chance it won't work...but also....you may get an infection, or a slow healing wound, or long term swelling,  you may get a flatter or more unstable foot, or  nerve injury/entrapment, or problems with the anesthetic (if you are given general anesthesia), or you may have a different problem or pain after the surgery that you did not have before the surgery.   One procedure, which was quite popular in the 1990's was the Endoscopic Plantar Fasciotomy.  A very small incision was made on each side of the heel, and a small scope was inserted in one side, cutting the ligament from the other side.  In some ways, it was a very effective procedure, in other ways it was risky.  I did the procedure in selected cases, and still do from time to time, but it is NOT without potential problems.  For a few years. this procedure was done so quickly by so many foot surgeons, where conservative treatment was not even tried, that it caused one very prominent Chicago foot and ankle surgeon to refer to it as "the rape of the plantar fascia."  

     Am I saying that surgery should NEVER be done for plantar fasciitis?  NO.  There are cases where it is necessary, especially if a person has had constant  severe heel pain for 9 to 12 months and has had multiple attempts at conservative treatment with little or no improvement.  My point is to be patient - don't consider surgery because one or two things that have been tried did not work - and most of all, don't let your insurance company decide how you are treated.  Be prepared that many of the most effective non-surgical treatments take time and are not covered under insurance.  Surgery should be the LAST resort for this problem. 

 

Richard S. Eby, DPM

7348 East Brainerd Road

Chattanooga, TN.  37421

www.rebyfootcare.com

423-760-3115

By contactus@rebyfootcare.com
May 17, 2015
Category: Nail Treatments
Tags: ingrown toenail  

     INGROWN TOENAILS are one of the most common afflictions of the human foot.  They can occur at any age (I've seen them in babies only a few months old and in people in their 90's), and can occur on any toe.  The big toe, also called the hallux or great toe in Podiatric jargon, is the most common place to get an ingrown toenail.  The problem can be a chronic problem, coming up over a long period of time, and sometimes kept "under control" by the person who suffers from these, or can be very acute and come on suddenly with redness, swelling, drainage, and progressive infection.  In some cases, the infection can even enter the bone (osteomyelitis).   Once you have this problem, what can be done about it? 

    In MILD or borderline cases, where there is no infection, wearing wider or open toe shoes may help, at least for awhile.  This will in no way "fix" the problem, but it may give some relief until something more definitive is done, and may prevent infection from starting.  Soaking the toe in epsom salt may also help when the toe starts looking red, and infection is a concern.    I can recall in one case, about 15 years ago, that I , myself, had a very "borderline" ingrown nail.  It rarely bothered me, and I never did anything about it other than avoid tight fitting shoes.  As long as I stuck  with wing-tips, good fitting loafers, or running shoes, I had NO problems.   THEN - I went on a cruise.  I felt underdressed on the previous couple of cruises I was on, so I decided to rent a tuxedo.  Of course, it came with shoes, and they looked so good, and after all I paid for them....so I HAD to wear them!   Big mistake!   First formal night, some mild discomfort, a little redness around the nail, and I just couldn't wait to get them off!   Then two casual nights, no problem with the loafers, well maybe a little tender, but not so bad.  Next time it was formal night, I was in agony. While the daily cruise planner said "guests are asked to remain in their formal attire thorughtout the evening" I disobeyed.   As soon as dinner was over, back to the cabin, and on went the loosest pair of shoes I had, which still hurt.  By the next day, the toe was fiery red, swollen, and a little drainage was present.  Thank God there were no more formal days!   Even on the semi-formal final night of the cruise, the wing tip shoes hurt very badly.  Out at sea - notmuch I could do.  As soon as I drove home form Fort Lauderdale where the cruise started and ended, I had the nail removed.  In this case a TOTAL TEMPORARY removal was in order.   IMMEDIATE relief ! 

    A total removal of the nail means the entire nail is removed.  A partial removal means just one, or in some cases, both sides or borders are removed.  A partial leaves most of the nail in place.  A partial can be permanent, meaning the root is removed or cauterized or can be just temporary, meaning the root or matrix is still in place and will grow back another nail (6-8 months is average, but can be quicker or longer depending on a number of things).  A total nail removal can also be temporary or permanent.  A total permanent removal means the entire root has been removed or "killed" and the nail will not grow back.  A total temporary removal means just the nail has been removed, and the entire nail will grow back.  

    When should a PARTIAL be done, and when should a TOTAL be done?   Part of it is personal preference on the part of the patient and the doctor doing the procedure, but in general my advice is as follows.  If only ONE side of the nail is ingrown/painful/infected, just remove one side.  This, in my opinion, looks the best and heals the fastest.  Even if it is a PARTIAL PERMANENT removal,  so little nail often has to be removed that it is often hard to tell anything has been done to the toe, once it is healed.  If the nail is very thick and/or incurvated (curved excessively so that it is not just a small part of the sides of the nail causing the problem), I feel it is better to do a TOTAL NAIL REMOVAL.  This can be temporary or permanent, depending on how long this problem has been present, the patient's circulation or bloodflow (or lack of it), the severity of the infection present, and how the patient feels about losing a toenail for good, as opposed to probably having it removed again in the future.  The real debate comes when the nail is normal in the center (not thckened or curved) and BOTH sides are ingrown.  In this case, there are good arguments for removing just the sides, and good reasons for removing the enitre nail.  It is really a judgment thing.  The doctor and patient need to talk, and a decision needs to be made what is in the best interest of the patient.  If the sides only are removed, especially if done permanently, the patient will still have part of the nail remaining.  Some patients, especially female patients, would rather have ANY nail than NO Nail.  The amount of nail however, may be only half of the normal nail, but could be up to 75%, depending on how much nail needs to be removed.  Also, removing BOTH borders of the nail at the same time, often loosens the nail.  This may not be a problem, but in young active patients, often getting their toes stepped on, or hitting them, they may lose the nail that is left.  Of course, this portion of nail WILL grow back, because the root or matrix is still present in the center.  Worse yet, I have known of a few cases where the nail was loose, was stepped on or hit several times, and did NOT come off, but started growing at an angle sideways, leading to a very abnormal and crooked toenail.  In most of these cases, the patient later elects to have the rest of the nail removed.  

    Ingrown toenails are one of the most common problems seen in the foot specialist's office, and usually the easiest to treat.  Permanent removal of the nail, when done correctly, can result in a 99%  cure rate, with no recurrence of nail.  It can result in a toe that feels, and often looks great.  It is one of the few procedures that can resolve a problem equally well whether it has been present 2 days or 20 years.

 

Richard S. Eby, DPM

EbyFootCare and Laser Center

7348 East Brainerd Road

Chattanooga, TN.  37421

www.rebyfootcare.com

(423) 760-3115

By contactus@rebyfootcare.com
April 26, 2015
Category: Routine Foot Care

     The term "Athlete's foot" is given to any type of fungal infection of the skin of the foot.  Tinea Pedis is actually the best term for this, and is the proper medical term for this condition.  It has also been called skin fungus and ringworm.   The term ringworm is a really bad term, because it implies there is a worm causing the condition.  Nothing could be more inaccurate.  Tinea or athlete's foot is an infection of the skin of the foot with a fungus or yeast, which is actually a plant.  This is much more similar to mold than it is to any type of animal.  It was called ringworm, because on flat surfaces - often not the foot, but the front of the leg, the abdominal area, or arms - it appears as a red ring with a clear area inside of it.  Someone thought it looks like a worm curled up in a ring, and hence the term ringworm was born!

    Tinea Pedis or Athlete's foot appears most often between the toes or on the bottom of the foot.  It can take more than one form, sometimes appearing as blsters - or vesicles - and other times as red, dry, and scaly skin. There is usually itching, sometimes very significant and persistent itching.  In a diabetic, however, or someone who may have neuropathy or impaired sensation, there may be NO itching.  In those cases, patients or other providers may simply pass this off as "dry skin."   Being able to tell the difference between fungus infections of the skin and dry skin is not always easy.  Similarly, many cases of Tinea are misidagnosed as eczema or other dermatitis conditions and vice versa.  It is not unusual for a patient to come into the office saying they have been on "every possible type of fungus medicine and none of them help!"  In a case like this, there are two possible reasons they may have not gotten better.  First, they may not have a fungus infection.  Contact dermatitis, many types of eczema, and psoriasis can often look just like athlete's foot,  In that case, there is NO antifungal medicine that will help!  Secondly, the patient may have used a very weak form of the antifungal or not used it often enough or long enough.  Even if it is a fungal infection, the condition will not improve if the medication is used for just a few days or only when the patient remembers to apply it.  Some people with fungal infections also become resistant to some of the over the counter antifungals, and these creams and ointments may no longer work.  In these cases, a SKIN BIOPSY is very important.  I talked about skin biopsy before, but briefly, for a skin condition such as Tinea or any dermatitis, a VERY small biopsy punch is needed.  Often less than one cc of local anesthesia, a 2mm biopsy punch, and a small dressing for a day with a bandaid for one or two more days is all that is needed.  The procedure can take five minutes or less, usually less than a minute once the spot is numb.  The information provided from that biopsy may be all that is needed to make the right choice on medication.  This can prevent time and money  being wasted on medications that will not work.  

    There are many topical medications, and there are a few oral medications that can be used successfully for fungal skin infections or Athlete's foot.   Clotrimazole and  Tolnaftate are two of the most common topical medications used.   Fluconazole and Terbenafine are oral medications that are often used for resistamt cases.   Soaks such as epsom salt can also help to dry and heal the blisters that occur, so that skin creams or ointments can be used to kill the fungal organisms.  If we are truly dealing with a fungus or yeast infection of the skin, it must be remembered that the condition will not improve until the fungus organisms die!  Unlike other skin conditions, where some improvement may occur in a day or two, several days may be needed to see any improvement and it may take weeks to get rid of the problem.  My personal feeling is that you never really "cure" the condition.  People who get these fungal infections have a predisposition to them.  In many cases, their feet may sweat excessively, or they take part in sports that increase their likelihood of coming into contact with the organisms in the locker room, showers, or poolside, and it is a matter of time before the problem comes back.  Shoe sprays, such as Clarus antifungal shoe spray and a very state of the art device called a "Steri-shoe" which uses Ultraviolet light to kill greater than 99% of fungal organisms AND bacteria in the shoes are very helpful in keeping this under control.  

   If you have any questions concerning this topic, please feel free to call our office or refer to our website.  

 

Dr. Richard S. Eby

(423)622-2663

www.rebyfootcare.com

 





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