As we prepare for National Diabetes Awareness Month in November, we may want to consider how we can ensure that every patient with diabetes receives optimal care for their lower extremities, which could improve productivity for patients and the organizations they work for, as well as decrease associated astronomical costs.

This is no easy task, as we have to look at this medical crisis from several angles:

• How can we collaborate with other medical providers to increase awareness of our valuable role and ensure that they include referrals to our offices as part of their treatment plans for their existing patient base?
• When we bring these patients into our offices, how can we improve their ability to be compliant, enabling us to provide effective treatments and support healthy lifestyles?
• Finally, how can we improve our "footprint" in the public's eye to increase awareness of the role we play as podiatrists and decrease the number of amputations that many of us must perform?
  

Here are six strategies the podiatric community should consider to address and improve the diabetes crisis that we are faced with:

1. Podiatrists should unite together as one voice and represent our local community in Pennsylvania, and participate in community outreach events that present a comprehensive message about managing diabetes, providing community-based education, raising awareness of diabetic foot care, the risk of diabetic foot complications, and the preventative podiatric treatments necessary. Our active presence and engagement will improve our position in public forums.

2. Strengthen the podiatric brand and its role in diabetes management on social media as an educational sounding board for followers to increase their awareness of the importance of podiatric care in diabetic patients. Social media is a resource that allows us to break boundaries and "speak" to our target demographic, share educational content, and highlight success stories, which may help increase awareness of podiatry.

With millions of people regularly accessing the internet to improve their medical knowledge, developing and sharing educational content on social media that resonates with individuals seeking or receiving treatment could be beneficial.

Furthermore, a series of social media posts developed throughout November for Diabetes Awareness Month, utilizing hashtags such as #NationalDiabetesMonth and #DiabetesSupport, may reach a wider audience.

3. Seek opportunities to reach other medical providers in a setting such as a clinical conference that may allow for time to devote to collaborating with different providers, such as vascular surgeons, endocrinologists, and dietitians. Increasing our presence in venues such as clinical conference settings will enhance our ability to develop relationships within the broader medical community and foster effective collaborations with key players in the diabetic medical community. This can lead to increased awareness of the importance of our role and direct referrals from these providers.

4. Share testimonials from patients to be impactful and relatable. As many of us work with diabetic patients and showcase their efforts to comply with treatment plans, we may want to consider asking for a release to be signed and for a patient to provide a testimonial that a diabetic patient may find relatable and learn from.

5. Creating and distributing marketing assets tailored to patients and the medical community would expand our reach and improve outcomes in both attracting and treating diabetic patients.

6. Implementing strategies to treat noncompliant patients to improve treatment outcomes can support both patients who want to do well and doctors who experience low job satisfaction and burnout when they are unable to engage patients in the manner in which they desire.

Noncompliance among patients with diabetes is associated with increased emergency room visits, frequent hospitalizations, and high treatment costs. The mortality rate among patients who do not adhere to their treatments is significantly higher than that of other patients. Reducing noncompliance can have a significant impact on the overall medical costs our country is experiencing.

Noncompliance is a complex issue and is usually not a deliberate refusal. Patients may have low health literacy, and they may not understand their diagnosis or the importance of follow-up care. Assessing patients' goals, capabilities, and barriers puts them at the center of the interaction about diabetes management.

Noncompliant patients may not fully understand their condition or the potential consequences of noncompliance. While the patient is responsible for the majority of diabetes care, doctors must recognize that they have little control over how patients manage their condition between office visits. It would benefit the doctor-patient relationship if time were taken to investigate the reasons for noncompliance.

Some of these common reasons include:

• Lack of understanding - Providing resources to enhance patient education through written materials (and making these materials available in Spanish and other languages) and using plain, concise language instead of medical jargon have been known to improve compliance.
• Unaffordability of medical treatment - The high cost of medication and medical supplies can prevent a patient from adhering to their treatment. Practices that offer a wide variety of medical supplies at lower costs compared to pharmacies and retail stores can be appreciated by patients who need to reduce their medical expenses, thereby decreasing noncompliance by providing solutions to financial barriers.
• Overall forgetfulness - Providing patients with weekly pill organizers can help simplify their complex medication regimens, improving their ability to stay organized and complete self-care tasks.
• Transportation concerns - Providing patients with information about local transportation services may help ensure they receive follow-up treatment.
  

Involving a patient in planning their treatment makes it more effective, as they are more likely to adhere to a plan they helped create. Collaborating with other podiatrists to learn what solutions have worked for them to improve noncompliance can also be helpful.

Podiatrists working collectively as one voice within our Pennsylvania Podiatry Medical Association position us as a powerful force. Leveraging our position in the medical community to be "present" is key. Together, we are a powerful collective force that can support one another, other medical professionals, and the patients we treat. Operating as one unit to fight the diabetes crisis is the only way we can reverse our current medical emergency.

Matthew Sowa, DPM, is a podiatrist practicing in Fleetwood, Pennsylvania. He serves on the PPMA Board of Directors.

Here are four patient behaviors that podiatrists need to be aware of, along with tips on how to overcome these challenges to achieve the goal of providing excellent care.

1.) Podiatrists will see patients who have anxiety.

2. ) Patients who present with an accompanying caregiver at their appointment

3.) Occasionally, a podiatrist may encounter a dishonest patient.

4. ) Most podiatrists have encountered non-compliant patients who seek advice but do not act upon it. 

Podiatrists may consider taking a moment to reflect on patients they have recently treated who may exhibit some of the behaviors we have addressed today. 

The following paragraphs will discuss the common pigmented lesions that can be seen in the lower extremity.

ACTINIC KERATOSIS

On exam, these present as reddish-brown macules or papules that are poorly circumscribed. They can be scaly and range from 2-5mm in diameter. They are considered pre-cancerous and can be considered an early form of squamous cell carcinoma.

Diagnosis: as with all lesions, if it is raised, perform a shave biopsy or 2-4mm punch for flat lesions.

In some cases, AK can sometimes resolve on their own only to return with sun exposure.⁵ In most cases however, the lesions are removed as a precaution. Some modalities for removal include cryosurgery, curettage and desiccation and laser surgery

Topical creams, gels and solutions are prescribed for use in patients with numerous or widespread actinic keratoses.

Approved medications

• 5-fluorouracil (Carac®,
• Efudex®,
• Fluoroplex®)
• Diclofenac (Solaraze®) and hyaluronic acid Imiquimod (Aldara®, Zyclara®)
• Tirbanibulin (Klisyri®)

BASAL CELL CARCINOMA

This is the most common form of skin cancer and accounts for more than .5 million cases diagnosed in the United States annually.  These can present as papules, plaques, nodules and pigmented lesions. These can also appear as a smooth papule with a central erosion or crust. BCC typically invades locally and rarely metastasizes.  Because they can growth in size, referral to dermatology is recommended for removal.

Some therapeutic interventions for more superficial basal cell carcinoma (BCC) include cryotherapy, topical chemotherapy, and photodynamic therapy.

More commonly, surgical intervention is utilized and this includes curettage, shave excision and standard excision. For larger and recurrent lesions, Mohs surgery will be employed.

SQUAMOUS CELL CARCINOMA

SCC typically arise from actinic keratosis as the result of exposure to UV radiation. Once actinic keratosis cells expand into the dermis they are then referred to as squamous cell carcinoma.

Squamous cell carcinoma most commonly appears as firm, smooth, or hyperkeratotic papule or plaque, often with central ulceration. Patients may describe a nonhealing lesion that bleeds with minimal trauma.

DIAGNOSIS

Shave biopsy if the lesion is raised, or 2-4mm punch if the lesion is flat

TREATMENT

Most SCC can be treated with curettage and electrodesiccation, cryotherapy, and excision. When recurrent, Mohs surgery is utilized.

Bowens disease (squamous carcinoma in situ) a more superficial version of SCC

Verrucous carcinoma is a more invasive, rare, variant of squamous cell carcinoma that commonly arises on the feet.  It is most common in the soles, but it can develop even on dorsal surface in areas of recurrent friction^. First-line treatment is complete surgical excision with wide margin; however, amputation may need to be performed due to local tissue destruction and late intervention.³

MALIGNANT MELANOMA

Melanoma accounts for only about 1% of skin cancers but causes a large majority of skin cancer deaths.⁴

The American Cancer Society’s estimates for melanoma in the United States for 2025 are:

• About 104,960 new melanomas will be diagnosed (about 60,550 in men and 44,410 in women).
• About 8,430 people are expected to die of melanoma (about 5,470 men and 2,960 women).⁴

Despite the statistics, melanoma is mostly curable if diagnosed and treated before reaching later stages. When diagnosing pigmented lesions, it is fundamental to be acquainted with “A,B,C,D” criteria for evaluation of pigmented lesions.

A (asymmetry)- lesions with irregular shapes and asymmetry are more unsettling. Whereas lesions that are round or oval are likely to be benign

B (border irregularity) irregularity to the border of the lesion is more concerning for malignancy while even and symmetrical borders tend to be benign

C (color) multiple shades of brown, black or blue black, red or white colorations are more troubling compared to less irregular pigmentation

D (diameter) Lesions greater than 6 mm warrant further evaluation, however earlier stages of melanoma may not precisely adhere to ABCD criteria.

Treatment

Surgical management is necessary and should likely be referred to a dermatologist.

Visual representations can be found by visiting The American Cancer Society.

Bibliography:

1. Gordon ML, Hecker MS. Care of the skin at midlife: Diagnosis of pigmented lesions. Geriatrics 1997; 52(Aug): 56-68

2. Jackson N, Allen T, Wagner R, Understanding Ultraviolet Radiation Dorsal Foot Injury at the Beach JAPMA Vol 109.No3. May/June 2019

3 D Nagarajan ¹, Malarvizhi Chandrasekhar ¹, Jim Jebakumar ¹, K Aravind Menon ^1,✉ Verrucous carcinoma of foot at an unusual site: Lessons to be learnt .Letter ,South Asian J Cancer

. 2017 Apr-Jun;6(2):63

4. Melanoma Skin Cancer | Understanding Melanoma. (n.d.). Www.cancer.org; American Cancer Society. https://www.cancer.org/cancer/types/melanoma-skin-cancer.html

5. Firnhaber J Diagnosis and Treatment of Basal Cell and Squamous Cell Carcinoma Am fam Physician. 2012;86(2):161-168

Todd Zeno, DPM is a podiatrist practicing in Hanover, Pennsylvania. He is a Past President of PPMA.

Remember to consider this differential diagnosis when performing the appropriate studies, which I will discuss below.

Raynauds is a condition caused by decreased blood flow to the tips of the toes and fingers. It could also reduce blood flow to our noses and ears. When Raynauds occurs on its own, this is known as primary.

When it happens with other medical conditions, such as autoimmune or connective tissue diseases, it is known as secondary. Some autoimmune and conductive tissue disorders include Lupus, Scleroderma, Crest Syndrome, Buerger disease, Sjogren syndrome, Rheumatoid Arthritis, Atherosclerosis, Thyroid, or Blood Disorders.

Patients usually complain that their feet feel very cold and tingly. They say they're getting discolored and turning white, blue, and red. Clinically, their skin feels cold, especially at the tips of their fingers or toes.
Often, doctors want to rule out peripheral vascular disease or acute arterial blockages, which can result in an arterial duplex.

A few other studies would help diagnose Raynaud's phenomenon. Common tests include a cold immersion/stimulation test and a cold pressor test:

• The cold immersion/stimulation study evaluates how well blood flows to the fingers and arteries. A small device measures the finger temperature. The fingers are then immersed in ice water for 20 seconds. The finger temperature is recorded every five minutes for 20 minutes until the study returns to normal. If it takes longer than 20 minutes for the temperature to return to normal after the ice water bath, it most likely means you have the Raynaud Phenomenon.

• The cold pressor test measures heart rate and blood pressure changes after immersing either hand or foot in ice water for one to three minutes. The cold stimulus activates sensory pathways that trigger a sympathetic response, which increases blood pressure. The test could also measure pain, thresholds, and tolerance.
  

Causes of Raynauds are usually triggered by prolonged exposure to cold temperatures. It could also be due to emotional stress.

Raynauds can be associated with autoimmune diseases like Lupus, Scleroderma, and Rheumatoid Arthritis.
If the patient's symptoms are severe or above the age of 35, doctors will want to rule out secondary Raynauds, which autoimmune or connective tissue disorders could cause.

Other tests to check for secondary Raynauds include nail fold capillaroscopy. The physician places oil at the base of a nail and examines it under a microscope. If abnormal arteries are present, it could indicate scleroderma or another connective tissue disease.

Blood tests also would be recommended to check for Lupus and Rheumatoid Arthritis; these labs would include an ANA, RA factor ESR, and CRP.

• Treatment includes keeping the fingers and toes warm, avoiding extreme cold temperatures, and wearing warm gloves and socks. 
• If patients will be out in extreme cold temperatures for a lengthy period, they could use hand and foot warmers. There are battery-operated or chemically operated hand and foot warmers. Exercise helps stimulate blood flow, which could be beneficial. If the patient is a smoker, it would help to talk to them about quitting smoking since nicotine is a vasoconstrictor. Avoiding or cutting down on caffeine and alcohol would also greatly benefit.
• It is rare, but complications could occur, which could lead to open sores on the toes and, left untreated, could lead to death of the tissue, which could lead to infection and Gangrene.

If the condition is related to secondary Raynaud's Phenomenon, I recommend discussing it with the patient's family physician or a vascular doctor. The patient may need to be prescribed medication to help dilate the blood vessels.

So, during these cold winter months, remember to put Raynauds in your differential diagnosis and work-up plan.

Jan Golden, DPM is a podiatrist practicing in The Northeastern part of PA in Moosic, Pennsylvania where she operates her own practice treating patients of the foot and ankle condition. Dr. Golden is Past President of PPMA.

There are times when patients may not always display a cheerful demeanor. A hostile and uncooperative patient can put a damper on your day and make it challenging to treat the next patient with the spirit they deserve.

In practicing podiatric care for 25 years, I have learned the importance of being positive and calm when listening to my patients and providing care.

Here are five tips to help podiatrists who are dealing with a difficult patient:

1. In treating patients who may not act their best, I have learned that just listening and letting them vent is the best way to abate their anger eventually. Not everything is about their care or your office; it can be just frustration with life or something at home. If it is about their care, they feel better getting their say, and then we work on coming up with solutions to their frustration and an apology from me for any office issue.
2. In dealing with them, it is essential to create boundaries to ensure that patients treat us respectfully and that nurses and medical assistants are treated well. As attracting and retaining employees continues to be challenging, employees who come to work in environments that are more stressful than they need to be are at risk for increased turnover. Having a policy and procedure for how staff can respond to these cases can better prepare them to ensure they are treated with dignity and can continue to come to work and engage positively with patients.
3. Understanding patients' moods may not have anything to do with you but more about them. Perhaps they are having a bad day. Learning not to take a poor attitude personally may not change the situation, but it may help change your perspective when patients come to the office in a less-than-ideal mood. I have no problem with a patient yelling at me, but I will not tolerate them treating the staff that way. I have learned to let their anger bounce off and not take home any patient issues. My staff knows that I have their back, and they can report any patient problems to me without engaging with the patient.
4. Validating the patient's feelings may be all they need to change the dynamics and continue with a positive appointment so the patient can receive care. I have found that just listening can often de-escalate most situations. For many older patients, their appointment may be their only outing for the day/week, and the only time they get to engage with other people.
5. Know your boundaries and establish a system for reacting to negative behaviors. Understand when it may be necessary to end an appointment and dismiss a patient. I feel that doctors need to take the reins and handle disruptive or angry patients, especially if we need to end the appointment or refer them somewhere else.
   

We all have bad days, and we do not have to allow others' bad days to impact our good days. Having a plan to react to less-than-ideal patients can establish boundaries and ensure that when a less-than-ideal circumstance occurs, a plan of action is there so that unnecessary stress does not happen. Your staff will also appreciate that you will stand up for them and they don't have to deal with unhappy patients on their own.

Dana Dober, DPM, is a podiatrist in Broomall, Pennsylvania, practicing at Podiatry Care Specialists. Dr. Dober serves on the board of directors of PPMA.

1. Blisters are among the most common foot problems experienced during outdoor activities such as hiking or running. They occur due to friction between the skin and footwear or between skin layers, leading to the formation of fluid-filled bubbles beneath the skin. Properly fitted shoes and moisture-wicking socks can help prevent blisters. These lesions should be regularly cleaned with soap and water or a topical antimicrobial agent. Individuals should avoid lancing these lesions and seek medical attention should the lesion appear blood- or pus-filled.
2. Athlete’s Foot: This fungal infection thrives in warm, moist environments like hiking boots or running shoes. Symptoms include itching, redness, and peeling skin. Keeping feet dry and clean and using over-the-counter antifungal treatments can help manage and prevent athlete’s foot.
3. Plantar Fasciitis: Plantar fasciitis, characterized by pain in the heel or arch of the foot, is common among active individuals who engage in high-impact activities. This condition results from inflammation of the plantar fascia, a band of tissue running along the bottom (plantar) aspect of the foot. Proper footwear with good arch support, non-steroidal anti-inflammatory drugs, and stretching exercises can alleviate symptoms. If symptoms persist with these modifications, one might benefit from seeking assistance from a podiatrist.
4. Fungal Nail Infections: Outdoor environments can expose feet to fungi that cause infections in toenails, leading to thickened, discolored, or crumbling nails. Keeping feet dry and clean and avoiding barefoot amputation in communal areas can reduce the risk of fungal nail infections.
5. Ingrown Toenails: This condition occurs when the edges of the toenail grow into the surrounding skin, causing pain, redness, swelling, and sometimes infection. Outdoor activities involving tight or improperly fitted shoes can exacerbate the problem. Correct nail trimming techniques and wearing well-fitting shoes are key preventive measures. If an individual notices drainage, pus, or severe toe swelling, they should seek assistance from their podiatrist.
6. Gout: Although not traditionally considered a pathology related to outdoor conditions, outdoor activities can trigger gout, which leads to dehydration and/or purine-rich diets. Gout is a form of arthritis characterized by sudden and severe pain, usually in the big toe. Staying hydrated and maintaining a balanced diet can help manage symptoms.

In conclusion, outdoor activities can present various foot-related challenges. Awareness and preventive measures, such as wearing appropriate footwear, maintaining foot hygiene, and staying hydrated, can mitigate these conditions and ensure a more enjoyable outdoor experience during the last warm months of the year.

References

https://www.footdoctorteaneck.com/blog/item/849-facts-about-foot-blisters.html

https://www.mayoclinic.org/diseases-conditions/gout/symptoms-causes/syc-20372897#:~:text=Gout%20is%20a%20common%20and%20complex%20form,in%20the%20middle%20of%20the%20night%20with

https://www.aad.org/public/everyday-care/injured-skin/burns/prevent-treat-blisters

https://www.hopkinsmedicine.org/health/conditions-and-diseases/plantar-fasciitis#:~:text=Plantar%20fasciitis%20is%20the%20inflammation,plantar%20fasciitis%20is%20heel%20pain.

https://orthoinfo.aaos.org/en/diseases--conditions/ingrown-toenail/

To provide some background knowledge, prescription opioids were the leading cause of drug overdose deaths from 2007-2013, which eventually progressed to heroin from 2014-2015. From 2016 to the present day, Fentanyl is the leading cause of drug overdose deaths [1]. Xylazine (primarily used as a horse anesthetic) is found to be a common adulterant in the fentanyl supply due to its low cost, availability, and effects. Philadelphia is believed to be the forefront location of the Xylazine drug supply crisis. According to a most recent study by the Philadelphia Department of Health, 90% of street opioid samples had Xylazine detected within the sample [3]. The patient population in Philadelphia commonly refers to Xylazine as “tranq.”

Xylazine is an alpha-2 adrenergic agonist that decreases sympathetic nervous system activity, thus leading to a sedative effect. It has a synergic with other drugs, such as Fentanyl or Heroin, and is theorized to extend the duration of the sedative effects [2,4]. In addition to the psychological impact of Xylazine, dermatologic manifestations leave patients with debilitating pain and sizeable soft tissue deficits. The exact mechanism by which Xylazine causes dermatologic manifestations is not proven. However, many hypotheses exist, and more specific investigation is needed. Xylazine is deemed cytotoxic, which can cause dermal necrosis. Xylazine has vasoconstrictive effects on peripheral vessels, ultimately leading to hypoxia and subsequent tissue damage/death. Fentanyl, being commonly adulterated by Xylazine, has a short-lived manifestation, thus requiring a shorter period between injections to maintain psychoactive effects and leading to a higher concentration of xylazine within the soft tissues. [4]

Xylazine wounds commonly manifest on the extensor surfaces of the lower extremity. The wounds start as blisters with intact skin that develop at or around the injection sites. The blisters often harden into dry eschar (the most identifiable feature) or can develop into ulcers, which can be extensive and lead to exposed tendons, muscles, and bones [5]. Based on the experience of the two authors, these wounds are very extensive in terms of depth and exposed structures; however, most often, the wounds are not infected. 

Caring for these wounds in the at-risk population provides an extremely difficult task. In the proper setting, local wound care will suffice for treatment. Dressings such as xeroform, collagenase, or hypochlorous acid wound solution have been used for local care [6]. Xeroform, followed by gauze, is often used for local care upon initial consultation. The ability to perform local wound care following hospital discharge proves difficult for this patient population, given unstable housing scenarios and limited access to adequate wound care supplies. Secondly, the patient’s ability to refrain from further injecting is often the most significant barrier. Relapse with opioid use disorder is not uncommon, thus starting the cycle over again. Another complicating factor is that drug treatment (detox) centers may reject patients who need medical management, such as local wound care, and skilled nursing facilities may reject patients with opioid use disorders [5]. 

Most of these patients at our institution are seen by the wound care service. Given the large volume of patients seen with this pathology daily, the surgical services (orthopedics, podiatry, general surgery) are only consulted when clinical evidence of infection is present, such as cellulitis, abscess, or radiographic evidence of infection. The Burn Surgery team is our institution's leading service in performing operative debridement. Initially, our tentative treatment plan is to perform a surgical debridement. Surgical debridement may be ill-advised, given the uncertainty of adherence to postoperative recommendations. Recent publications regarding managing these wounds suggest that debridement may also impair wound healing by exposing deeper underlying structures such as tendons and bones. Therefore, aggressive local wound care should be the initial mainstay treatment for this pathology.  Surgical debridement should ultimately be saved when the patients are active and stable in substance use treatment [4] unless operative debridement is needed for infection eradication.

In conclusion, with a large amount of street drugs containing Xylazine, there is a noted increased prevalence of extensive lower extremity wounds associated with injection drug use. Treating providers should resist the urge to perform debridement and continue with local wound care. Ultimately, surgical intervention is reserved for patients who have demonstrated continued ability to participate in substance use treatment and are most likely to follow up with postoperative care. When social circumstances are not optimal, local wound care is the treatment choice for xylazine wounds in the absence of infection. 

References

[1] Malayala SV, Papudesi BN, Bobb R, Wimbush A. Xylazine-Induced Skin Ulcers in a Person Who Injects Drugs in Philadelphia, Pennsylvania, USA. Cureus. 2022 Aug 19;14(8):e28160. doi: 10.7759/cureus.28160. PMID: 36148197; PMCID: PMC9482722.

[2] D'Orazio J, Nelson L, Perrone J, Wightman R, Haroz R. Xylazine Adulteration of the Heroin-Fentanyl Drug Supply: A Narrative Review. Ann Intern Med. 2023 Oct;176(10):1370-1376. doi: 10.7326/M23-2001. Epub 2023 Oct 10. PMID: 37812779.

[3] Philadelphia Department of Public Health Substance Use Prevention and Harm Reduction. Health Update: Xylazine (tranq) exposure among people who use substances in Philadelphia. 8 December 2022.

[4] Perrone J, Haroz R, D'Orazio J, Gianotti G, Love J, Salzman M, Lowenstein M, Thakrar A, Klipp S, Rae L, Reed MK, Sisco E, Wightman R, Nelson LS. National Institute on Drug Abuse Clinical Trials Network Meeting Report: Managing Patients Exposed to Xylazine-Adulterated Opioids in Emergency, Hospital and Addiction Care Settings. Ann Emerg Med. 2024 Mar 15: S0196-0644(24)00080-5. doi: 10.1016/j.annemergmed.2024.01.041. Epub ahead of print. PMID: 38493376.

[5] McFadden R, Wallace-Keeshen S, Petrillo Straub K, Hosey RA, Neuschatz R, McNulty K, Thakrar AP. Xylazine-associated Wounds: Clinical Experience from a Low-barrier Wound Care Clinic in Philadelphia. J Addict Med. 2024 Jan-Feb 01;18(1):9-12. doi: 10.1097/ADM.0000000000001245. Epub 2023 Nov 29. PMID: 38019592; PMCID: PMC10967264.

[6] Carroll JJ. Xylazine-Associated Wounds and Related Health Concerns Among People Who Use Drugs: Reports from Front-Line Health Workers in 7 US States. Subst Use Addctn J. 2024 Apr;45(2):222-231. doi: 10.1177/29767342231214472. Epub 2024 Jan 2. PMID: 38258791.

Wouldn't you rather spend time collecting sea shells than doctor's bills? No worries. There are ways to prevent these future foot predicaments so you can go back to your sun-kissed dreams and enjoy a liberated foot experience. LEARN MORE

Podiatric surgery is constantly evolving, and so are the methods and tools used by podiatric surgeons. Advancements aim to reduce surgical complications, post-operative pain, and recovery time, leading to better patient experiences. Innovative advancements in medical technology and surgical methodologies have ushered in improvements in patient results and abbreviated recovery periods.

There has been growing interest in minimally invasive surgery (MIS) to correct foot and ankle deformities. Although minimally invasive surgery for the foot and ankle has been around for many years, improvements in tools, implants, and surgical training have inspired the renewed popularity of these surgeries. A wide array of new shifters, guides, jigs, screws, and other devices have helped to improve foot and ankle MIS.  External jigs may aid in osteotomies and facilitate accurate placement of internal fixation.  Advancements in burr technology are another reason MIS of foot and ankle surgery has become more effective in recent years. Low-speed, high-torque burrs allow a surgeon to make an osteotomy without disrupting the soft tissue. Small incisions are cosmetically pleasing to the patient, avoid dissection and soft tissue stripping, which can result in postoperative swelling, and preserve blood flow to the surgical site, which allows for improved bone and tissue healing and faster recovery.  Another benefit from any MIS foot and ankle surgeries includes early weight bearing on the patient’s postoperative foot. There is a steep learning curve associated with foot and ankle MIS, and some factors may help to lower the learning curve.  These include attending saw bone and cadaver labs to practice techniques and spending time with well-versed MIS surgeons. To date, many MIS techniques have been developed to treat deformities such as hallux valgus, hammertoes, and bunionettes.  However, even more complex conditions such as Charcot are being addressed increasingly through a MIS approach. Percutaneous, minimally invasive techniques are being used to repair Achilles tendon ruptures. Historically, open techniques have been used to repair an Achilles tendon rupture, but they can be complicated by wound-healing issues and infection. This minimally invasive technique is ideal for middle-aged patients, where there may be a heightened concern for wound-healing issues.

Regenerative medicine, including platelet rich plasma (PRP), is becoming more commonly used in podiatry. Regenerative medicine therapies, sometimes called orthobiologics, use biologic tissues, such as blood or bone marrow, to improve symptoms of certain conditions and have the potential to enhance healing in musculoskeletal tissues. Platelets release growth factors play a critical role in tissue healing. PRP is produced by obtaining a small sample of a person’s own blood. The blood is centrifuged (spun down) to isolate and concentrate platelets that assist in natural tissue healing processes. PRP, which is depleted of red blood cells and granulocytes, including neutrophils, which are associated with inflammation, is then injected back into the site of the injury or surgical site. The injection contains proteins that can potentially decrease inflammation, reduce pain and improve tissue healing. PRP can be used to aid in healing tendon repairs, augment arthrodesis sites, and hydrate various bone grafts, such as demineralized cortical and cancellous grafts.

Autologous chondrocyte implantation is being used to repair full thickness cartilage defects of the ankle joint. Arthroscopic, single stage cartilage restoration is now available for foot and ankle surgeons. Autologous chondrocytes are harvested arthroscopically with a shaver and then mixed with PRP to make a cartilage-scaffold paste and an autologous fibrin glue to fix the chips in the cartilage defect. BioCartilage® extracellular matrix (ECM), from Arthrex, contains the ECM that is native to articular cartilage, including components such as type II collagen and additional cartilaginous growth factors. After processing, the dehydrated allograft cartilage has a particle size of 100 µm-300 µm. The small particle size improves its injectable nature after it is mixed with an autologous blood solution, allowing easier delivery to the defect site. PRP is productive when it comes together with cartilage. It has proliferative properties, can control inflammation at the joint repair site, and is pro coagulation which means less bleeding and quicker rehabilitation.

3D printing, also known as additive manufacturing, has revolutionized the treatment of challenging foot and ankle pathology. Treatment options for patients with large structural defects of the foot and ankle have typically included bulk allografts, autografts, and bone transport.  These options may be susceptible to donor site morbidity, nonunion, infection, and can require several surgeries to complete.  Bone allografts can also collapse over time.  Avascular necrosis of the talus is a disease process occurring when the blood supply to the talus is damaged either by trauma or systemic condition.  With advanced stages of AVN, removal of all avascular bone followed by arthrodesis was routinely the only surgical option.  Failed ankle arthroplasty is also difficult to manage.  If the native talar components erode and collapse, tibiotalocalcaneal arthrodesis and a bulk allograft can be performed, but the graft can collapse over time. A potential solution to improve management of large defects is the use of custom, 3-D printed porous titanium implants. 3-D printing technology has allowed for the development of custom metal implants that provide superior mechanical stability while also conforming to the patient’s anatomy.  Titanium alloy implants are designed with an interconnected porous architecture to encourage bony ingrowth. The implants can be made in a variety of sizes and footprints to reconstruct deformity and fractures across several anatomic indications. While 3D printing technology offers immense potential in orthopedics, there are several challenges. Cost-effectiveness and accessibility are key concerns, as implementing 3D printing infrastructure and materials can be expensive. Healthcare costs are a tremendous burden on hospitals and patients, and the use of expensive implants may be denied in favor of more traditional implants. Additionally, the long-term durability and biocompatibility of 3D printed materials need further investigation.

Numerous companies dedicated to foot and ankle surgery have emerged over the past several years.  The foot and ankle market are one of the fastest growing segments in the orthopedic industry. We are in the initial stages of harnessing the full therapeutic potential of biologics, and there are plenty of opportunities to advance the standard of care in foot and ankle surgery.  

Winter can be a rough time for all of us, especially our feet. There are many problems that are unique to winter time, ranging from the minor to severe and extreme.

Injuries are common
Sprains, Strains, Slips on the Ice, to Sporting Accidents. Many sports can be problematic due to the specific gear attributed to the activity. As you can imagine, a hockey skate supports the foot much differently than a ski boot or a snowboard boot. Custom-molded biomechanical foot orthoses designed to fit these types of gear can help tremendously to prevent many injuries.

One aspect that affects the athlete and non-athlete alike is the cold. Whether we are out playing or working in the snow, cold is the enemy of the foot. Those who are vascularly or neurologically compromised are particularly at risk—

• Frostbite will strike them sooner and often without warning.
• When out in the snow and cold for extended periods, it is essential to keep your feet both warm and dry. A good insulated boot that is waterproof is preferred. Materials such as Gortex, will keep the feet dry while allowing them to breathe. This prevents sweating that can lead to the feet becoming colder.
• Thinsulate is also an excellent insulator found in many boots, helping to keep them warm. You should look for high-gram content.
• In addition to boots, wearing thermal-insulated socks is highly recommended. Cotton socks, while good at wicking moisture from the skin, lose their thermal value when wet. Wool retains much of its insulating properties when wet, but has poor wicking ability. Combining the two can often be quite effective. Newer microfiber socks combine the best of both worlds, having multiple layers to do both jobs. They are widely available at sporting goods stores.

For those who don’t venture outdoors much in winter, you still could have your own unique problems. Many people ambulate in stocking feet around the house or in flimsy house slippers. While they may feel as comfortable as an old friend, they can lead to foot maladies in the long run. Walking in stocking feet or flimsy slippers can increase the risk of plantar fasciitis and other pressure and stress issues—

• With the humidity down and the furnace up, dry cracking skin becomes common, and is exacerbated by again ambulating without properly supported footgear. Heel fissures become more common, and in some cases lead to ulceration. For the diabetic and neuropathic this can become a crisis state. Daily moisturizing and foot inspection is crucial. Regular visits to the podiatrist can help keep these problems to a minimum.

BIO: Dr. Gronborg is a past president of the PPMA and currently acts as a consultant to the Executive Board. He is a physician with the Central PA Physicians Group with offices in Altoona, Bedford, Patton, and Roaring Spring, PA. The practice Website is www.centralpapg.com. He received his DPM from the Ohio College of Podiatric Medicine in 1989. He is a Diplomate of the American Board of Podiatric Surgery and a Fellow of the American College of Foot & Ankle Surgeons, as well as a Fellow of the American College of Certified Wound Specialists. He is a native of Erie, PA, and lives with his family in Bedford. Dr. Gronborg can be contacted at 814-201-2309.

By: Asher Cherian, DPM1 and Laura Sansosti, DPM, FACFAS2

1Resident, Temple University Hospital Podiatric Surgical Residency Program, Philadelphia, PA

2Clinical Assistant Professor, Temple University School of Podiatric Medicine, Philadelphia, PA

Pain control is an essential aspect of providing comprehensive care to our patients. There may be profound implications when inadequately managed, especially in the postoperative setting (1). In the background of an opioid epidemic, clinicians and healthcare providers should consider alternative methods to control acute and chronic pain. A multimodal approach to pain management is essential to reducing opioid requirements, minimizing adverse events from opioids, and hopefully increasing patient satisfaction. 

Local Anesthetics

Short-acting and long-acting local anesthetics can be used in a variety of clinical applications to provide non-opioid-based pain management. Local anesthetics have a unique benefit with overall low risk compared to oral medications. Local anesthetics can be administered via subcutaneous injection or topical application. Injectable local anesthetics are often administered during in-office procedures and pre-and post-operatively in the operating room to decrease postoperative pain and oral medication requirements. A significant amount of utility is provided by a local anesthetic infiltrated into an area of pain. It can provide adequate analgesia for several hours to days depending on the type and amount of local used. Depending on the clinical application, the determination to use a short-acting versus long-acting local anesthetic should be made. A diagnostic nerve block can also be a versatile tool for addressing painful symptoms for patients with idiopathic pain to a particular foot or ankle region. A literature review by Griffioen et al in 2018 found that regional blocks provided superior pain relief compared to opioids following a lower extremity fracture (2). There is also evidence within the orthopedic literature pertaining to total hip arthroplasty (THA) and total knee arthroplasty (TKA) that demonstrate the effectiveness and benefits of postoperative regional anesthesia. A study by Marques et al in 2014 showed that infiltration of local anesthetic following THA and TKA shortened hospital stays, reduced opioid consumption, led to earlier mobilization, and reduced vomiting (3). The study also concluded that receiving local anesthetic infiltration lowered pain scores at rest compared to controls after 24 and 48 hours (3). Postoperative local anesthetic blocks have provided significant postoperative analgesia after foot and ankle surgery (4). Patients who receive a popliteal fossa block have better pain scores, a more prolonged analgesic effect, and decreased opioid requirements in the immediate postoperative period (5). The popliteal fossa block was also found to have better pain scores and reduced opioid requirements than the ankle block (5). 

NSAIDs

NSAIDs work by inhibiting cyclo-oxygenase (COX), diminishing post-injury hyperalgesia. Mild to moderate pain can typically be treated with an oral NSAID or acetaminophen. Studies performed by Pogatzki-Zahn et al (2014) and Nonaka et al (2016) demonstrate NSAIDs to be more effective in postoperative pain control compared to acetaminophen (6,7). While these may not be benign medications in terms of potential renal and GI side effects and platelet inhibition, the use of selective COX-2 inhibitors decreases that risk. They also note that the harmful side effects of acetaminophen are often underestimated in terms of possible liver damage (6,7). Some may also argue that NSAIDs are detrimental to the early phases of bone healing. However, more long-term data is needed. A study by Cozowicz et al in 2018 found that COX-2 inhibitors and NSAIDs were associated with the strongest individual effect in opioid dose reduction. NSAIDs have also been shown to reduce opioid requirements following ankle fracture surgery (8). Effective pain control is critical during the first two days following ankle fracture surgery because patients, on average, consume the most opioids during this time. A study by McDonald et al in 2018 found that the addition of the NSAID Ketorolac significantly reduced postoperative pain while concurrently reducing opioid requirements (9). They also found that patients experienced less pain during postoperative days one to two, and the addition of Ketorolac maintained 

minor discomfort for up to four days post-operatively. The patients in their study found greater patient satisfaction with their pain management, less hypersensitivity, and fewer paresthesias when treated with a multimodal pain regimen, including NSAIDs (9). 

           With increasingly strict regulations on narcotic prescriptions and high addiction potential, the multimodal approach to postoperative pain control is critical. Each patient is a unique case and requires thought to their co-morbidities, planned procedure, and anticipated postoperative pain to determine the optimal regimen to control their symptoms. It is imperative to discuss expectations with your patient, especially regarding postoperative pain. Opioid contracts are increasingly utilized and serve as a good starting point for this discussion. For patients who have chronic pain, referral to pain management pre- or post-operatively can also be considered. By not solely utilizing opioid-based medications, we can reduce opioid dependency and provide better outcomes for our patients.

References:

1. Carr DB, Goudas LC. Acute pain. The Lancet. 1999; 353(9169): 2051–2058. 

2. Griffioen MA, O'Brien G. Analgesics administered for pain during hospitalization following lower extremity fracture: A review of the literature. Journal of Trauma Nursing. 2018; 25(6): 360–365. 

3. Marques EMR, Jones HE, Elvers KT, Pyke M, Blom AW, Beswick AD. Local anesthetic infiltration for perioperative pain control in total hip and knee replacement: Systematic review and Meta-analyses of short- and long-term effectiveness. BMC Musculoskeletal Disorders. 2014; 15(1). https://doi.org/10.1186/1471-2474-15-220.

4. Elliot R, Pearce CJ, Seifert C, Calder JD. A prospective, randomized trial is a continuous infusion versus single bolus popliteal block following major ankle and hindfoot surgery. Foot Ankle Int. 2010; 31(12):1043-1047. 

5. Schipper ON, Hunt KJ, Anderson RB, Davis WH, Jones CP, Cohen BE. Ankle block vs. single-shot Popliteal Fossa Block as primary anesthesia for forefoot operative procedures: Prospective, randomized comparison. Foot Ankle Int. 2017; 38(11): 1188–1191. 

6. Pogatzki-Zahn E, Chandrasena C, Schug SA. Nonopioid analgesics for postoperative pain management. Current Opinion in Anaesthesiology. 2014; 27(5): 513–519. 

7. Nonaka T, Hara M, Miyamoto C, Sugita M, Yamamoto T. Comparison of the analgesic effect of intravenous acetaminophen with Flurbiprofen Axetil on post-breast surgery pain: A randomized controlled trial. Journal of Anesthesia. 2016; 30(3): 405–409. 

8. Cozowicz C, Poeran J, Zubizarreta N, Liu J, Weinstein SM, Pichler L, Mazumdar M, Memtsoudis SG. Non-opioid analgesic modes of pain management are associated with reduced postoperative complications and resource utilization: A retrospective study of obstructive sleep apnea patients undergoing elective joint arthroplasty. British Journal of Anaesthesia. 2019; 122(1), 131–140. 

9. McDonald E, Daniel J, Nicholson K, Shakked R, Raikin S, Pedowitz D, Winters B. A prospective randomized study is evaluating the effect of perioperative NSAIDs on opioid consumption and pain management after ankle fracture surgery. Foot & Ankle Orthopaedics. 2018; 3(3). https://doi.org/10.1177/2473011418s00085. 

The etiology of anterior ankle impingement syndrome remains a debated topic within the literature as I will demonstrate here. However, when combining clinical evaluation and dedicated radiologic projections, a physicians’ ability to diagnose this troublesome pathology no longer becomes elusive. Numerous authors have reported excellent results in terms of patient satisfaction, functional scores, and improved ankle range of motion with arthroscopic debridement. Yet prognostic classification systems dedicated to size and location of osseous or soft-tissue lesion are still lacking within the literature. Nonetheless, complication rates following ankle arthroscopy for anterior ankle impingement are low, and these patients warrant surgical intervention when conservative measures fail.  
Ankle impingement syndrome is often seen in many different types of foot and ankle practices. It has been classically described as “athletes ankle” or “footballer’s ankle” due to its presentation in competitors participating in sports such as soccer, football, ballet, and running.1,2 Patients will typically present with chronic anteromedial or anterolateral ankle pain while running, kicking, or even climbing stairs. The origin of their discomfort can either be soft tissue and/or osseous in nature and warrants further investigation.  
Surgical treatment has advanced from open ankle arthrotomy to a more minimally invasive approach via ankle arthroscopy when appropriate.3,4 Whenever possible, the senior author (Michael Troiano DPM) takes advantage of advanced ankle arthroscopic techniques due to the wave of literature that supports this approach.  

EVALUATING ANKLE IMPINGEMENT SYNDROME 

Patient History 

• As with any ankle pathology, a thorough patient history and physical exam is important.
• Patients will often describe chronic anterior ankle pain and moderate swelling after activity.
• When performing a physical exam, physicians will often notice the ankle limited at the “end range” of active and passive dorsiflexion and internal and external rotation.
• It is especially important to evaluate for any signs of a talar dome lesion as these can potentially exacerbate the patients symptomology.
• Additionally, patients may report a remote history of an acute inversion ankle sprain or have signs of functional or structural instability.
• It has been reported in the literature that bony impingement is more commonly found over the anteromedial ankle while anterolateral impingement is often of soft-tissue origin.

Imaging

• Anterior boney ankle impingement can be evaluated with conventional lateral weight-bearing X-rays.
• You can further evaluate anteromedial osseous impingement with a special oblique view where the beam is aimed 45 deg craniocaudally with the leg externally rotated 30 deg
• The oblique anteromedial impingement view when combined with the standard lateral weight-bearing view has been noted to increase sensitivity in detecting osteophytes up to 85 percent noted on the tibia and 73 percent noted on the talus.
• Ultrasound is another imaging technique used for anterior ankle impingement and helps differentiate the disease process as osseous or soft tissue in origin.
• It has been reported in the literature that synovitic lesions larger than 10mm are associated with impingement symptoms.
• In my experience, CT scans help delineate osseous abnormalities. However, this is not my preferred cross-sectional imaging study in this subset of patients.
• Conventional MRI allows further evaluation of ankle ligaments, bone edema, tenosynovitis, joint effusion, thickened synovium, and concomitant chondral injury.
  
• Although MRI has been shown to have a sensitivity of 75–83 percent and specificity of 75–100 percent in detecting anterolateral impingement, a negative MRI does not exclude intra-articular pathology.

CAUSES OF ANKLE IMPINGEMENT SYNDROME 
Ankle impingement syndrome has multiple osseous and soft-tissue anatomic abnormalities that are thought to contribute to this pathology. Morris theorized that the cause of boney impingement was due to repetitive traction on the anterior joint capsule during an extreme plantar flexion force, leading to subsequent exostosis formation.  

Following further anatomic studies and arthroscopic evaluation, this hypothesis was deemed not plausible. Studies showed that when performing ankle arthroscopy on anterior boney impingement, the osteophytes were found within the confines of the anterior joint capsule and were not noted to be at the more proximal attachment of the joint capsule.

In approximately 2 percent of cases, acute ankle sprains have also been reported to lead to anterior ankle impingement.9 A supination type injury will occur to the anterior talofibular ligament (ATFL) with many of these patients initially dismissing this event as minor. In these patients, synovial tissue organizes into a meniscoid hyalinized mass leading to chronic inflammation and recurrent joint-line tenderness. Additionally, the thickened distal fascicle of the anterior inferior tibiofibular ligament (AITFL), often referred to as Bassett’s ligament, has been thought a cause of anterolateral soft-tissue impingement.

Other mechanical factors such as recurrent micro-trauma also play a role in anterior ankle impingement. It has been theorized that repetitive impaction injury to the anterior chondral margin of the tibiotalar joint leads to attempted repair with fibrosis. Eventually, fibrocartilage proliferation takes over resulting in the formation of osteophytes.

Anterior osteophytes have been proposed to limit the space available for the native anterior synovial fold and therefore exacerbate these entrapment symptoms. Histopathologic analysis procured following ankle arthroscopy has shown synovial tissue with chronic inflammation.  

TREATMENTS USED FOR ANKLE IMPINGEMENT SYNDROME 

Conservative

• Non-operative treatment of anterior osseous and/or soft-tissue impingement can be treated with rest, ankle bracing, shoe modification, orthotics, local steroid injections, and physical therapy to varying degrees of success.
• Non-operative management is always recommended as a first line treatment option for my patients.
• When patients continue to present with edema, limitation of motion, and joint-line tenderness, surgical intervention should be considered.

Surgical

• Surgical goals are to remove osteophytes and pathologic soft-tissue structures to restore anatomic motion of the tibiotalar joint.
• Surgical intervention has been proposed over the years by way of either an open ankle arthrotomy or more commonly by an ankle arthroscopic approach.
• The literature has shown that arthroscopic techniques have resulted in faster return to full activity compared to an open arthrotomy and is my preferred technique.
• The main classification system I have found useful is the Van Dijk classification based on appearance of osteophytes and joint space narrowing of the ankle evaluated with radiographs.
  
• Following arthroscopic bony spur removal, patient satisfaction was excellent or good in 77 percent of patients who initially had a lower grade osteoarthritic change of the tibiotalar joint.

MY PROCEDURE FOR TREATMENT 

1. In my practice, I generally approach these patients from an arthroscopic technique, using anteromedial and anterolateral portals with a 4.0 mm 300 scope.
2. I classically begin with a standard Ferkel 21-point diagnostic evaluation.
3. Following diagnostic evaluation, I introduce a 3.5mm oscillating shaver and debride the anterior joint capsule while simultaneously taking the tibiotalar joint through range of motion.
4. Although an electrothermal device has been described for soft-tissue debridement within the ankle joint, I do not generally use this technique.
5. Following my soft-tissue debridement, I evaluate any osseous spur formation on the tibia and talus and resect this with a burr or small osteotomy when appropriate.
6. Following standard portal closure, my patients are placed in a nonweight-bearing, short-leg posterior splint for two weeks.
7. After suture removal, patients will transition to a CAM walker boot for another two weeks.
8. At this point, physical therapy is initiated for range-of-motion exercises and edema reduction with a progressive increase of activity as tolerated.

Bibliography: 

1. Morris LH. Report of cases of athlete’s ankle. J Bone Joint Surg 1943;25:22.
2. McMurray TP. Footballer’s ankle. J Bone Joint Surg Br 1950;32:68–9.
3. Hensley JP, Saltrick K, Le T. Anterior ankle arthroplasty: a retrospective study. J
4. Ferkel RD, Scranton Jr PE. Arthroscopy of the ankle and foot. J Bone Joint Surg

5. Liu SH, Nuccion SL, Finerman G. Diagnosis of anterolateral ankle impingement. Comparison between magnetic resonance imaging and clinical examination. Am J Sports Med. 1997;25:389–93.
6. Maffulli N, Ferran NA. Management of acute and chronic ankle instability. J Am Acad Orthop Surg. 2008;16:608–15.
7. Van Dijk CN, Tol JL, Verheyen CCPM. A prospective study of prognostic factors concerning the outcome of arthroscopic surgery for anterior ankle impinge- ment. Am J Sports Med 1997;25:737–47.
8. Tol JL, Slim E, Van Soest AJ, Van Dijk CN. The relationship of the kicking action in soccer and anterior ankle impingement syndrome. A biomechanical analysis. Am J Sports Med 2002;30:45–50.
9. Ferkel RD, Karzel RP, Del Pizzo W, Friedman MJ, Fischer SP. Arthroscopic treatment of anterolateral impingement of the ankle. Am J Sports Med 1991; 19: 440–6
10. Bassett III FH, Gates III HS, Billys JB, et al. Talar impingement by the anteroinferior tibiofibular ligament. A cause of chronic pain in the ankle after inversion sprain. J Bone Joint Surg Am. 1990;72 (1):55–9.
11. Tol JL, van Dijk CN. Etiology of the anterior ankle impingement syndrome: a descriptive anatomical study. Foot Ankle Int. 2004;25(6):382–6.

DEFINING THE CORE  
There is a growing body of evidence to support the importance of core stability in the prevention, treatment, and rehabilitation of lower extremity injuries.  Active patients often tell me they either don’t do any core exercises or the only exercises they do are crunches. The core involves a whole lot more than what people picture as six-pack abs.  If you want a strong core, crunches should not be the only exercise.  Some argue you shouldn’t be doing them at all and should replace them with much more beneficial exercises.   

The core, defined as the lumbo-pelvic-hip complex, is the whole area between your diaphragm and your upper thighs. It involves the muscles of the abs such as the rectus abdominis, but also the sides (obliques and transverse abdominus); the back (rectus abdominis and multifidus); the pelvis (the gluteal muscles); and the hips (including the hip flexors, abductors, and adductors).  

To truly work the core, you need to put together a program of exercises that address all the major muscle groups.  Instead of doing 100 crunches, which are primarily working one muscle group, split it up and do 25 of each: planks, side planks, side lying leg raises, and bridges.   

Other beneficial targeted core exercises include:  Bird-Dog’s, Superman’s (trunk extensions), clamshells, and marches or leg extensions on a swiss ball.  Most of these exercises, if done properly with a stabilized lumbar spine position, can be much safer and more protective to the spine than simple crunches.   

There are a lot of complicated core exercises out there, remember to start with the basics, like a basic plank or a bridge to work multiple muscle groups so you are getting a lot more bang for your buck.   

WHY THE CORE IS IMPORTANT FOR LOWER EXTREMITY INJURIES 
Just like in the children’s song, all the bones in the body are connected.  Having a strong core (Hips/Abs/Back) is one important way to stabilize the entire limb to both prevent and treat injury.  In order to prevent “overuse” injuries, you have to evaluate the entire kinetic chain. In kinetic chain theory, motion or translation in any segment of the limb affects the entire limb.  It is important that we as podiatrists not just look at the pathomechanics from the bottom up, but also from the top down:   

• If there is excess tilt, rotation, or weakness at the level of the hip and pelvis then this can lead to uncontrolled joint displacements or unwanted accessory movements down the entire limb to the feet.
• Having weakness in the core not only can contribute to overuse injuries but can also increase your susceptibility to acute injuries such as sprains and strains.
• Picture this: if you are playing soccer and are cutting and changing direction, all your weight is on one leg. If your hips and glutes are weak and there is excess wobble at the hips, that motion is going to translate down to excess motion in your leg, which can lead to an increased risk of knee ligament injuries and ankle sprains.
• Research shows us that there is coupled motion between the core and the lower extremity muscles.  The muscles of the hip and pelvis have been shown to be activated before the initiation of lower extremity muscles can occur.  If muscles aren’t being activated properly and there is excess motion being passed down the limb, then the individual is more prone to knee, leg, ankle, and foot injuries.
  

One of the most common appreciable weaknesses I see in my practice, especially when evaluating novice and recreational runners/walkers, is gluteus medius or hip abductor weakness.  This can be seen on evaluation either with simply looking for the Trendelenburg sign; while observing increased hip displacement/wobble/dip during gait while viewing posteriorly; or with increased crossover with gait (foot crosses over the midline during strike).  This abnormal leg motion can lead to stress on the lateral leg muscles and structures such as the IT Band, leading to lateral knee pain; over activation of the peroneal tendons leading to tendonitis around the foot and ankle; and can contribute to many overuse and acute injuries of the lower extremity.   

DECREASE INJURY RISK BY UPDATING CORE EXCERCISES 
From a podiatrist’s standpoint, the best examples in the medical research for the importance of core stability with injuries are ankle sprains, chronic ankle instability, and medial tibial stress syndrome (more commonly referred to as shin splints).  In order to help decrease injury risk, core (and especially hip abduction) strengthening/stability exercises should be included in your weekly fitness routine.  Also, as practitioners, it is important to make sure that when our patients are doing physical therapy (either at home or with a therapist) that they are including core stability exercises as an important part of their rehabilitation both to treat their injury and to prevent reoccurrence.   

In conclusion, if you are not addressing it, or if you are only doing crunches, IT IS TIME TO UPDATE YOUR CORE PROGRAM!   

• Make sure your core exercises address the whole “lumbo-pelvic-hip” complex and not just the 6-Pack Abs.
• In order to help prevent lower extremity injuries and overuse conditions, you need to make sure your patients are addressing any core, and especially the hip, weakness.
• In patients who have sustained acute ankle sprains, make sure that core/hip exercises are included in their rehabilitation program.

In the world of sports medicine, core stability is becoming a very important factor for the overall health of the athlete as it is all about the kinetic chain. The importance of core stability is really just adding truth to the children’s song, “The foot bone’s connected to the leg bone, the leg bone’s connected to the thigh bone …” and so on! 

Polyneuropathy, peripheral arterial disease, structural foot deformities, repetitive micro-trauma, and elevated plantar pressure are all risk factors that contribute to the development of diabetic plantar ulcers.  

The gold standard for diabetic foot ulcer treatment includes debridement of non-viable tissue, management of infection, revascularization procedures if indicated, controlling blood sugar, proper nutrition, and offloading the ulcer. Adjunctive therapies have also been useful, such as hyperbaric oxygen therapy, advanced wound care products, and negative-pressure wound therapy.  

In this brief excerpt I’m going to focus on some of the different types of offloading options and devices— 

• Strict Non-Weightbearing. Crutches, walkers, and wheelchairs are devices to aid in non-weightbearing; however patients with weak upper body strength may have difficulty using them, and may lead to non-compliance.
• Foam/Felt Padding. An opening can be cut in the material that is slightly larger than the size of the wound and added either directly to the patient’s foot or into their shoe to offload the wound.
• L’Nard Splint/Offloading Boot. Used mostly while patients are lying in bed. Suspends the feet so there isn’t any pressure on the foot or toes.
• Reverse IPOS (half-shoe) Heel Relief Shoe. Aids in offloading plantar heel ulcers. The shoe is open in the back and angles at 10-degrees of plantarflexion.
• IPOS (half-shoe) and Orthowedge Forefoot Relief Shoes. Both keep pressure off the ball of the foot and have been very helpful in keeping pressure off the great toe. The IPOS, Orthowedge, and IPOS Heel Relief shoes can cause gait imbalance and instability.
• Charcot Restraint Orthotic Walker (CROW). A bi-valved AFO that uses a total- contact, custom-molded orthotic and a rocker-bottom sole. Used often during the 2nd and 3rd stages of Charcot arthropathy. They are effective but expensive to make. Non-compliance is high because patients can remove them.
• Prefabricated Walker. Similar to a CROW, but the sole of the prefab walker can be removed. This makes it easy to alleviate pressure at a specific spot, and at the same time inspect an ulcer. This is a removable device that leads to compliance issues as seen with the CROW.
• Ankle Foot Orthoses (AFO).  Custom-molded with thermoplastic material and a rigid ankle. Used mainly for a dropfoot, but has been useful in keeping pressure off the sole of the foot.
  
• Patella Tendon-Bearing Brace (PTB). Removable custom brace. Weight is transferred from the foot to the patella and positions the foot in a proper position for ambulation. Increases rotational control of lower extremity, which reduces pressure of the foot. Expensive and cumbersome.
• MABAL Shoe/Scotch Boot. Combination of fiberglass cast and a shoe. Allows for movement of the ankle and can be removed at bedtime.
• Total-Contact Casting (TCC). Remains the GOLD STANDARD offloading device for diabetic foot ulcers. Patient must have adequate blood supply in order to use a TCC. The cast must be changed weekly to monitor for other areas of irritation that can occur under the cast. Plaster of Paris can be used to make the TCC. There are also TCC kits that come with a walking boot and all of the materials needed to apply the TCC, which make a much easier application. Compliance is much better with a TCC than a CROW because it cannot be removed by the patient.

Remember that when treating diabetic foot ulceration, it should involve a multidisciplinary approach. A wound care team consisting of podiatrists, vascular surgeons, plastic surgeons, primary care physicians, endocrinologists, and nutritionists should all work together in the prevention and management of diabetic foot ulcers. 

A Bunion, medically known as hallux abducto valgus, is an orthopedic structural deformity that causes the bone behind the big toe to protrude. There are several causes for a Bunion deformity; the most common cause is over-pronation of the foot. The foot rolling inward weakens the ligaments and muscles causing the 1st metatarsal to shift, creating an over-growth bony deformity on the medial side of foot. Other factors that can lead to the formation of Bunions include trauma, having flat feet, wearing high heel shoes, as well as some hereditary factors. 

A Bunionette, or Tailor’s Bunion, is a smaller deformity on the outside of the foot associated with the little toe. It can be painful, similar to the Bunion deformity, especially if it rubs against the side of the shoe and limits range of motion at the joint site.   

Both deformities can begin with symptoms of redness, pain, swelling, and even blisters. If left untreated or not managed properly, these deformities can lead to: limited range of motion in the affected joint and arthritis; increased pain in the area; and skin breakdown leading to the need for wound care. 
Individuals with medical conditions such as diabetes and poor circulation can easily get bone infections from a Bunion or Bunionette, which would require long-term IV antibiotic treatment to heal the wound. If the bone becomes too infected, it could lead to gangrene and the possible need for an amputation.   
There are several conservative treatments and management options for a Bunion as well as a Bunionette: 

• These can range from ice and elevation of the affected area to a short course of anti-inflammatory medications to alleviate inflammation in joint.
• Also, various padding can be used around the area to help alleviate the irritation.
• Orthotics can also help limit the excessive pronation of the feet to aid in reducing and preventing the progression of a Bunion and Bunionette.
• Appropriate footwear, such wider-fitting shoes, can also relieve some of the pain caused by a Bunion deformity.

But when a Bunion or Bunionette does not respond to conservative treatment, your Podiatrist may recommend surgery to correct them. The surgery would remove the prominent, irritating bone deformity and correct any misalignment of the joint involved in order to restore proper toe function. 

Honestly, when I read any-thing about Vicks VapoRub (Proctor and Gamble) and onychomycosis, my “Myth-busters” mind gets activated. I can’t even count the times I have heard physicians and pa-tients extol the positives of this over-the-counter ointment. I understand the cost-benefit of using an easily attainable product, but I want evidence for or against it before recom-mending it.  

What are the components of Vicks VapoRub? Thymol, menthol, cam-phor, and oil of Eucalyptus seem to be broad-spectrum anti-infectives that have shown activity in vitro against Candida, Aspergillus, and some dermatophytes (1). That said, in a recent literature search for a chapter I am writing on the myths of onychomycosis, I came across several articles on the use of the mentholated ointment for toenails; one of which was a clinical trial.  
The first clinical trial completed using Vicks VapoRub on mycot-ic nails is a pilot study that was performed by a Family Medicine group (1). Eighteen subjects who had nail disease completed the 48-week study. There are some positive aspects of this study, but it did not follow all of the protocols that are normally done for topical antifun-gal studies. Unlike Phase 3 clinical trials for toenail onychomycosis, this study did not exclusively enroll patients who cultured dermato-phytes like T. rubrum or T. men-tagrophytes and did not limit the percent of affected nail to 50% or 60%. Instead, they allowed patients who cultured organisms like: “Fun-gal Elements”, Cryptococcus, Can-dida, Penicillium, and Fusarium and allowed up to 100% of the nail affected visually. Of the 18 patients, only nine subjects cultured either T. rubrum or T. mentagrophytes.  

Their results were the following: Five of the 18 (27.8%) had a my-cological and clinical cure, and 10 (55.6%) had “partial clearance”. But let’s dissect this further: if we were to look at the nine subjects who cultured the most common derma-tophytes causing onychomycosis, those who had T. rubrum fared the worst: Five had partial clearance (at times only a 10% change in the nail appearing clearer at week 48) and one had no change at all.  T. menta-grophytes infected toenails did the best with all three subjects going onto a complete cure, but a complete cure was not defined as 0% surface area affected—these patients still had 5% or more of the nail visually affected at 48 weeks. Of the other organisms involved, both subjects who had Candida parapsilosis went onto a complete cure, but Penicillium species and Candida albicans (one subject each) had no change. 

Ten of the 18 subjects had greater than 60% nail affected at the beginning of the study—with some having 89% or 100% affected nails. This is highly unusual for a toenail clinical trial, and certainly can be argued that a 48-week treatment period isn’t long enough to manage a totally dystrophic nail. Adding a modality such as nail debride-ment could be synergistic for a topical study that enrolls nails as involved as these.  

Did this study convince me to recommend Vicks Va-poRub to my toenail onychomycosis patients? No. While I think this study is a positive start in supporting or shattering the use of a mentholated ointment for mycotic nails, a study that controls percent nail in-volvement, nail thickness, nail debridement, organisms cultured, and product use (some patients used it daily; some only three to five times per week) while having a vehicle arm and a larger sample size, would be more convincing to me. Time will tell if this ointment truly can eradicate fungus, or by virtue of its ointment prop-erties, simply create a more hydrated nail unit that gives the appearance of a healthier nail.  

Reference:  
Derby R, Rohal P, Jackson C, et al. “Treatment of Onychomycosis using Mentholated Ointment,” J Am Board Fam Med 2011;24:69 –74.

Originally shared in the May/June 2021 PPMA Newsletter

Helping Runners Pick the Right Shoes Can Prevent Running Injuries

We all know these patients. We see these patients often. They are the ones who need pointed in the right direction as what to look for in a proper walking/running shoe, and subsequently help to avoid the running injuries we see regularly in our practices. Noting that most runners have a good feel for their shoe-gear. It’s the new runners/weekend warriors that tend to need to be pointed in the right direction. 

Spelling out the ‘anatomy of a shoe’ may be in order, something I find has helped my patients considerably. Especially when presented with these common run-ning injuries that sometimes manifest from shoe-gear—most commonly hammertoes, advanced metatarsalgia, ingrown toenails with or without subungual contusion, or subungual contusion alone. 

One common condition is “Runners Toe,” one where patients have sought repeated treatment. This problem presents with subungual contusions, which may lead to lysis of the nail-plate separating from the nail-bed. The source of the problem with this condi-tion may result from anterior shearing in the shoe. Thus not allowing the heel counter of the shoe to control the heel. This sometimes results from the lacing pattern of the running shoe. 

Going Back to Biomechanics Lab
It is typical for runners to increase their shoe size by approximately one-half their normal size. This takes into consideration the increase in swelling, which can occur with long-distance running. It also can compen-sate for the anterior displacement forces in the shoe; but what are we doing, as podiatrists, to prevent the foot from sliding anteriorly when running?

Being familiar with the anatomy of a shoe can make a difference with our patients. This goes back to our days in biomechanics lab in podiatry school when we reviewed the components of a shoe: the last, the shank, the medial posting, the shock absorption, and heel counter. 

1. The “last” refers to the template of the shoe, or the model for which the shoe is constructed. The last could be board (firm), slip (flexible), or strobel constructed. Strobel is most commonly found in running shoes. The shape of the last can be straight, curved, or semi-curved.

• Straight-lasted shoes are typically more supportive, and a curved last is less supportive.
• Most running shoes are a combination of moderate support with some flex to them and use a semi-curved last.

2. Overall, the shoe is divided into three parts: upper, outsole, and midsole. The upper, is the outside tip of the shoe and is stitched to the sole. The outsole is the bottom rubber, while the midsole is the insert between the two. This insert built into the shoe offers stability, along with the manufacturer’s insert.

• Stock midsole cushioning is typically made of EVA or a manufacturer’s proprietary foam.
• Midsole support often has a stabilizing bar extending from the medial arch to the medial heel. Different vendors have their own names for these, but they all aid in support, and tend to be more effective in controlling pronators. Additional medial posting may be found in rearfoot-motion-controlling shoes.

3. A shoe’s heel counter is considered the back of the shoe.

4. The shank is a rigid insert typically placed on/in the bottom outsole to create rigidity to the shoe’s midsole, and places more stress distally, allowing toe flexion to occur.

Together these things contribute to the overall fit and the amount of stability a particular shoe can provide. Most of the major brands all carry variations of these components, which may cause an underlying problem if the shoe doesn’t fit properly.

Evaluating a Patient’s Shoe-Gear 
I find it remedial to discuss/evaluate shoe-gear with patients. I evaluate the last, insole, and support, showing them the components of the shoes that may correlate and/or contribute to their pathology. We discuss biomechanics in layman’s terms.

Most often I find that patients wear shoes that are too small. Yet I have patients who present with symp-toms identical to those who wear their shoes too small, but the shoe size is correct. Examples would be—a subungual contusion or proximal nail-fold paronychia with a normal appearing nail. Here is what I do for these patients—

1. I evaluate the patient’s shoes by taking out the insoles and showing them the “wear pattern” of their toes. If these shoes are the appropriate size yet the
toe-pattern force acts as though the shoe is small, it means the toe-wear pattern is pushing up to the edge of the insole. 

2. From here, if the shoe is the appropriate size, we discuss a shoe-lacing technique to prevent the foot from sliding in the shoe. This obviously isn’t for those patients who necessitate velcro closures.

3. The technique is called the “heel lock” and is very simple. It is an effective way to lock the rearfoot into the heel counter, and is as follows so you can consider passing this along to your patients:

• This lacing pattern/technique creates an extra pulley-like tension at the proximal laces.
• This prevents the heel from sliding forward in the shoe.
• It is effective in controlling the heel in a proper-fitting shoe. 

It may seem like a formidable task to take more time with patients, but it has been in offering this basic education on a shoe’s anatomy that has greatly bene-fited my patients. Remembering also that some patients will always need velcro closures!   

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PHOTOS:

Figure 1: Heel-lock lacing creates a loop by utilizing the top two holes. One of the holes is usually offset a bit posteriorly.

Figure 2: Tighten laces as this creates the heel lock and aids in preventing anterior shearing forces

Figure 3: Use the loop as a "Lacing Eyelet."