A 62-year-old male presents with red, swollen, pruritic toes 2,3,4 on the left foot after hiking for an hour on snowy trails in 5-degree weather. He reports that his feet felt cold and numb after about thirty minutes of hiking in wool socks and non-insulated hiking boots that were a bit tight (due to thicker socks), but he continued the hike.  Upon returning home and removing the shoes, all digits were extremely cold when compared to other feet, red, purple, and white in appearance, and remained so for 1-2 hours. Treatment was a change of socks, loose-fitting shoes, and diclofenac 75mg p.o. BID.  Within an hour, there was significant pain, swelling of the toes, itching, and burning.  Gradual resolution of the discoloration was noted, but the pain and itching continued for 48 hours (and still does), as did some of the erythema to the digits.  No blistering or deep bruising was noted.

Pertinent medical history noted that he had neuroma excision 2^nd and 3^rd interspaces of the left (affected) foot many years before the incident.

Diagnosis: Pernio/chilblains due to prolonged cold exposure with Raynaud-like symptoms secondary to the disruption/removal of the plantar digital nerves post-neurectomy.

I am the patient in this case study. As I write this, my foot still hurts! 

I have treated many cold injuries over the past 30 years of practice, including my years treating patients in the cold weather in Pennsylvania and my time in which I was stationed abroad during my time in the U.S. Armed Forces.  I had seen frostbite in Alaska, trench foot in New Jersey, and pernio in Texas when the temperatures dropped, and the soldiers I cared for weren’t prepared for it.  I had a podiatrist who was stationed in Korea send me photos of a soldier's foot with red swollen toes, blotchy skin, and deep bruising on the distal aspects of several toes after being on guard duty in subzero temps.  It was not frostbite but pernio/chilblains; he had never seen this before and only vaguely remembered being taught about it in school. 

Every winter, icy ones like this year, many patients present with cold, discolored toes (and sometimes fingers) who have undiagnosed Raynauds Phenomenon. Less likely is Pernio/Chilblains and the aftereffects.  Recognition of these types of injuries/diseases is imperative, as is proper treatment and consultation with the appropriate medical specialty. Podiatrists must recognize these types of injuries and be prepared to treat them. DPMs may want to consider Googling this diagnosis and finding qualified content to familiarize themselves with symptoms, diagnosis, and effective treatments of conditions of the foot and ankle that mother nature has impacted during the cold winter months.  Investing a few minutes in enhancing your knowledge can only benefit you and your patients.

My feet are feeling better. I have decided to invest in more costly hiking boots that will be insulated, as well as better socks so that I can continue to enjoy being active in the outdoors during the cold winter months while reducing my risk of injection or injury.

Pete Smith, DPM, is a podiatrist practicing in Lancaster, Pennsylvania. Dr. Smith is a past president of the Pennsylvania Podiatric Medical Association and a board member of its educational component, The Goldfarb Foundation.

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.  

I mean that in the literal sense. One of the best forms of exercise is walking or hiking. Getting out there whether at the mall, many of which open early to accommodate seniors, around the neighborhood or out on the thousands of miles of trails here in Pennsylvania. There is something out there for everyone for all ages and all abilities. You just must take the first step!

Walking or hiking has been shown in study after study to

• Improve cardiovascular health
• Reduce stress
• Reduce blood pressure
• Brighten your mood
• Decrease depression and anxiety.
  

You can do it with family, friends or by yourself but just get out there and do it.

It is easy enough to just put on a pair of shoes and go out for a stroll but if you are going to walk or hike seriously then you need to get yourself in shape and ‘geared up’. The shoes you wear to walk around the block are certainly different than those used to hike the Appalachian Trail. The selection of walking/hiking shoes is enormous and often very personal, but it all comes down to what shoes fits you best and feels the best for the activity you are going to do. Walking around the block can be accomplished in most walking shoes or running shoes. Usually, a shoe that is a bit stiffer and more supportive. Many companies like New Balance, Reebok, Asics, Saucony and Brooks make excellent walking shoes. I recommend going to try these on at the end of the day when your feet are their longest, widest for the best fit. Try them on, do a few laps around the store, ask for help if you need it. Going to a local running shoe store is often a great place to start as they are usually very knowledgeable about shoe specifics and can match a shoe to your feet and needs.

Trail hiking and backpacking requires a different breed of shoe. These are usually much stiffer and supportive with a more aggressive sole for traction. Hiking in trail runners or a hiking shoe or boot can prevent many serious injuries. Trail runners are great shoes to hike in on those more rustic trails. Hiking shoes or boots offer maximum support and stability but are heavier to wear and ar great for backpacking or long treks. Picking out the right one for you is personal and you should try multiple different ones on to get the best fit. Places like REI offer an excellent variety and customer service.

Other considerations when starting out would be inserts and socks. There are hundreds of inserts and manufacturers out there and the same can be said for socks. Inserts need to be matched to the shoe they are being worn in. You need to take the inserts out of the box and put them in the shoes you will be wearing them in and walk around to make sure they feel good and fit right. Try multiple pair in different shoes. There will be a Goldilocks moment when everything feels just right! Your socks are important too. Most serious walkers/hikers wear lightweight or midweight wool or wool synthetic blend socks that give some cushioning. They will help reduce friction and prevent blisters.

Starting a walking program is all about that first step. Stretching before you start is a good idea as well as getting clearance from your doctor. Start by walking up and down or around the block as far as you feel comfortable doing. Start by going every other day and then gradually increase your distance over the course of weeks. Listen to your body, if it’s sore back off the mileage. Start on sidewalks rather than trails. When you feel confident move to a greater distance and faster pace. Know your limits, set goals, get out there and enjoy!

Dr. Pete Smith is an avid walker, hiker and backpacker.

Podiatrists see dermatologic symptoms and conditions every day in their practices.

In this article featured in Podiatry Today, the author outlines, in her experience, the top ten skin conditions of the lower extremity and shares insights on presentation, diagnosis and treatment aimed towards optimizing patient outcomes

Visit the Philadelphia Inquirer to view the story and quotes by our own, Dr. Laura Virtue-Delayo as reported by Sarah Gantz!

Incorporating foot care into your company wellness program helps your employees be safer, healthier, and happier.

Heading out on a hike or setting up camp for a few days is exciting. But, you never know what you might face in the wilderness.

PPMA's guide for foot and ankle first aid will help you be sure you're prepared for anything so you can enjoy every step of the way!

Learn how to care for and prevent:

• Blisters
• Cuts
• Bites
• Sprains
• and more!

Wherever you go, put your best foot forward by taking care of your feet throughout your journey. Get your foot care first aid guide:

DOWNLOAD THE FREE PDF GUIDE

Written by Sara Mateen, DPM and Jane Pontious, DPM, FACFAS

With the warmer weather approaching, our patients will be trading in their winter boots for summer sandals. Before we all can enjoy the sunshine, along with some return to normalcy, we should consider educating our patients on a few things for proper foot care. 

Summertime means lazy beach days or hanging poolside with a good book, but to prevent pedal issues, proper foot care is a must for the summer season. 

FOOT PROTECTION 

Barefoot
Green grass and cool creeks are inviting during the summer. This is why it is important to caution patients that walking barefoot outdoors can increase the risk of foot injury or infection such as viral warts, fungal infections, or aquatic-type infections. 

Sandals
Patients should avoid prolonged-wearing of flip-flops during warm summer days. The thong portion of the flip flop in between the hallux and second digit can create friction and subsequent blister formation, particularly with our high-risk diabetic patients. Help patients choose sandals that are comfortable and have the necessary arch support.

Closed-toed shoes
There are 250,000 sweat glands in each foot. Patients should also avoid wearing closed-toed shoes in the summer for prolonged periods where sweat build-up can occur. This creates a dark and moist environment, the perfect breeding environment for bacterial and fungal infections. Remind patients to take their shoes off periodically to dry them out and prevent these infections from occurring. If patients need to wear closed-toe shoes, recommend they wear synthetic or acrylic socks to decrease perspiration. These fibers allow for better moisture evaporation than socks made from cotton or wool. Also, shoes with mesh fabric can be beneficial for the aeration of their feet during hot and humid days. 

New shoes
Inform patients to check their old shoes and maybe splurge on buying a fresh and supportive pair. Old shoes can cause pressure areas and blister formation, especially in warmer weather, so out with the old and in with the new!

FOOT CARE

Self-pedicure
A new season means a new chance for self-care. Inform patients that performing a self-pedicure can help remove dry skin and promote self-relaxation. Nail polish should not be left on the toenails for too long as this can cause nail breakdown and discoloration. 

Exfoliate and moisturize
Another important factor to having healthy feet is exfoliation and moisturizing. With winter officially over and springtime transitioning into summer, many people have dry skin build-up from the cold weather. Properly exfoliating and moisturizing the feet with a pumice stone removes rough patches on the soles of the feet, especially the heels. Purchasing a foot scrub can leave feet healthy and glowing.

Reduce swelling
After a hot day, a patient’s feet may be swollen or sore. You can recommend cold water soaks to help with the swelling as well as elevation of the feet. Patients can put their feet in cool water for about 5-10 minutes and pat them dry with a towel. 

SUN PROTECTION

Sunscreen
One of the most important points to educate patients on this summer is the application of sunscreen to the feet. Patients will typically protect their face, arms, body, and legs, but tend to neglect their feet. To be the most effective, sunscreen should be reapplied often and especially after swimming. 

Self-inspection
Feet are just as exposed as the rest of the body in the summer and malignant melanoma can go unnoticed. Early detection is crucial. Patients are at greater risk for developing melanoma if they are fair-skin with blonde or red hair, have a history of sunburns and blistering before 18 years old, and those with a history of several moles at a young age. Remind your patients to use the ABCDEs of melanoma for self-inspection: asymmetric, border, color, diameter, and evolution. If our patients have any suspicious lesions, we need to recommend they visit their foot and ankle specialist right away. Educating patients on prevention by repeat-edly applying sunscreen to the feet (both the dorsal and plantar portions), as well as inspecting their feet daily, is key. 

SAFE TRAVELS

With so many fun summer activities to do, whether at home or on vacation, patients should be mindful of a few things for safe travel. 

Hydration and swelling
During those smoldering July and August days, remind your patients to drink lots of water. It is so important for them to stay hydrated for their overall health, but also to prevent lower extremity swelling caused by excessive heat. If patients are experiencing swelling, continue hydration and cold water soaks for 5-10 minutes to reduce the swell-ing when they get home from a long day. 

Travel footwear
When patients are traveling, they should consider having a pair of slippers or flip-flops for their hotel room to prevent any bacterial or fungal infection from the room. 

Recreational activities
Summer activities will vary whether patients are at the beach, lake, or river. Educate patients on proper shoe gear if they plan to do any specific activities that will require different grip strengths (such as rock climbing) or just simply lounging at the pool. 

Water gear
Adventure-seeking patients may want to consider packing protective water shoes for their vacations. Remind patients to dry out the shoes after wearing them to prevent a bacterial or fungal infection from water saturation. 

Injuries
Patients who get a foot or ankle injury should seek medical attention from a podiatric physician right away to prevent further injury or infection. This is especially important if it involves any skin abrasion, laceration, or even a simple ankle sprain. Suggest preparing a first aid kit with sterile bandages, lotion, sunscreen, aloe vera, blister pads, pumice stone, anti-bacterial cream, and any type of anti-inflammatory medication. An emergency kit can be extremely helpful during outdoor activities and hard to come by on an adventure, so it is important to prepare ahead of time. 

Written by Dr. David Quinlan DPM

Runners are finally getting back into their routines now that stay-at-home orders have lifted. They may notice new faces along their routes as many others have taken up running due to gyms having limited capacity or closing permanently.

When restarting a running routine or developing one for the first time, preparation is of utmost importance. Most people will become disheartened due to injury or problems associated with lack of preparation. It is helpful to find a regimen that is appropriate for running experience level and current health restrictions. 

Choosing the right shoes for your feet, taking care of your shoes, and knowing how to care for common running-related foot injuries are important preparation steps for a successful running routine.

Before we unpack those steps, perhaps the most important advice for beginning a running routine is to start slow. Taking your time building up your endurance protects your body from injury. This can be especially difficult for experienced runners coming off a hiatus, but still equally important for new runners.

CHOOSING SHOES

 Your feet

Coming from a unique background of selling running shoes for 3 years before entering podiatry school at Temple University, I can tell you there is not a one-size-fits-all approach to shoe selection. Besides needing your appropriate shoe size, other considerations should be foot function (how well your foot absorbs the impact of running, also known as pronation level), mileage, and running surfaces. 

Determining the way your feet function is the most challenging task in the preparation phase. Most podiatrists can evaluate your feet and determine the level of shoe support you would require. Typically the three levels of support include neutral cushion, structured/stability, and motion control. 

Many local running shoe stores or certain chain running shoe stores, such as FleetFeet, offer a free fitting service that includes sizing and gait analysis to determine the type of shoe that is right for you. Most people will be able to fit into one of these levels of support but some may require an over-the-counter arch support to prevent injury. Some runners require custom-made orthotics with specific modifications built-in. Podiatrists also offer this orthotic fabrication service in their offices.

Q: Do we need to wear shoes when running? 

A: The trend for barefoot running has subsided mainly due to stress fractures and other repetitive high impact injuries illustrating that our feet are not equipped to sustain the impact of running on hard surfaces such as cement and asphalt.  

Your goals

Running shoes can be split into groups based on expected mileage. Entry-level running shoes are great for runners planning on doing less than 30 miles per week. Over 30 miles per week will require more costly high mileage shoes. There also has been a new level created deemed “super shoes”. Think of these as the flagship shoes that offer all the bells and whistles the company offers. This shoe is really only for people looking for all the extravagant features offered. However these "super shoes" are not necessary, even for high mileage training, nor will they guarantee successful training or prevent injury. A class of lighter-weight running shoes exists for those who complete races. These, of course, are optional as well, since you can still use your training shoes for races.

Your terrain

The surfaces on which you are running can also affect shoe selection. For running on roads, sidewalks, grass, and trails, standard running shoes typically will work well. For runners that primarily run on uneven, rocky trails, a trail shoe may be a better choice. Trail shoes are stiffer, have a thicker tread, and some are more water-resistant or water-proof. These features are not helpful for running on roads and sidewalks. Although it is possible to traverse these surfaces, it will not function as well as a standard running shoe.

SHOE CARE

It is a good idea to rotate between different shoes for two reasons. First, switching between two different shoe models can reduce repetitive motion injuries that may occur if the same pair of shoes are used every time. Second, giving your shoes time to recover between runs can replenish the elasticity of the cushioning system in the shoes, reducing injuries and extending the life of the shoes.

CHOOSING SOCKS

Preparing for a successful running routine also includes getting good moisture-wicking socks. Most of these socks are made from synthetic fibers although there are natural materials as well that have moisture-wicking properties, such as wool, bamboo, and even coconut. Moisture-wicking socks reduce blister formation and make your feet more comfortable when you're running. 

CARING FOR YOUR FEET

Blisters are a common occurrence with runners. To prevent them, you may apply a lubricant such as Body Glide to “hot-spot” areas. After a blister has fitness, as long as the blister has a clear yellow fluid, you can drain it at home. Be careful not to remove the skin of the blister. Cover it with a moist burn pad dressing such as second skin, but taking care not to completely occlude the dressing which will result in maceration of the skin. If there is blood in the blister or excessive pain, I recommend evaluation by a podiatrist.

Another common occurrence is “runner’s toe”. When the toenail rubs repeatedly it can create a pool of blood underneath the nail. It is okay to trim the nail aggressively to open the pocket of fluid up and to allow for drainage. The nail may also fall off on its own - which is okay. It will grow back! Again, if it is too painful, please see your podiatrist.

Any other injuries or foot problems, please make an appointment with your podiatrist. They can help treat your injuries and prevent recurrence so you can reach your exercise goals.

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