Atopic Dermatitis

Atopic dermatitis is a pruritic disease of unknown origin. It is is an inflammatory, relapsing, non-contagious and pruritic skin disorder.

The disorder is characterized by eczematous lesions, dry skin, and thickening of the skin.


Atopic dermatitis may be associated with other atopic diseases such as asthma, allergic rhinitis, urticaria, acute allergic reactions to foods.

The skin affected by atopic dermatitis reacts abnormally to irritants, food, and the environment. The skin becomes red, flaky and itchy.

It is a familial and chronic disease and the symptoms can increase or disappear with time.

Causes:

Genetics - A family history of atopic dermatitis is often common.

Infection - The skin atopic dermatitis is colonized by S aureus. This can cause a flare of atopic dermatitis.

Hygiene - Hygiene may be a cause for atopic dermatitis.

Climate - Atopic dermatitis flares occur in different climates. Heat and cold are poorly tolerated.

Differential Diagnosis:

Contact Dermatitis - A localized rash or irritation of the skin caused by contact with a foreign substance

Lichen Simplex Chronicus- A skin disorder that leads to chronic
itching and scratching


Nummular Dermatitis - A form of eczema that is characterized by round-to-oval erythematous plaques

Psoriasis - A common skin condition that causes skin redness and
irritation

Seborrheic Dermatitis - An inflammatory skin disorder that causes scaly, flaky, itchy, red skin

Tinea Pedis - A dermatophyte infection of the soles of the feet and the interdigital spaces


Lab Studies:

Skin scraping for pathological exam may be helpful to exclude tinea pedis.

Biopsy may be helpful to show an acute, subacute, or chronic dermatitis.


Medications/Treatments:

Anti-inflammatory agents provide relief of inflammation of eczematous lesions.

Topical steroids are the mainstay of treatment

Mild topical corticosteroid - Hydrocortisone ointment 1%

Medium strength topical corticosteroid - Betamethasone valerate

Immune Modulators are medicated creams that are used for the treatment of atopic dermatitis.

Tacrolimus


Pimecrolimus 1%


Moisturizing -
Patients usually benefit from lukewarm soaks followed by the application of a moisturizer.

Other treatments -

Both hydroxyzine and diphenhydramine provide relief from itching. Antibiotics are used for the treatment with infection caused by S aureus.

New Blog Location!

We just wanted to let you know that we're in the midst of combining all of our blogs (Roanoke Foot Doctor, Blacksburg Foot Doctor, and Botetourt Foot Doctor) into a bigger, better one - if you'd like to keep following us and stay updated on all the fun foot facts and articles, please update your bookmarks to http://shenandoahpodiatry.blogspot.com.

Thanks for reading, commenting, and of course visiting our offices!

Dedicated to your happy feet,

Nancy Ann Ballhagen
Administrative Assistant, Blacksburg Office

Low Heels = High Style, Less Pain?

Kitten heels have appeared on the fashion scene, and fashionistas are rejoicing in the most comfortable footwear trend in quite a while! These shoes, a morph of stilettos and flats, offer the sophisticated look of high heels but with less discomfort. Kitten heels may have had their stuffy days, worn in bland styles in the workplace by 1980s working women, but the new styles are far from frumpy. In candy colors, pretty peep toes, or toughened up with hardware, these shoes are fun and, compared to last year's sky-high stilettos, comfy.

The New York Times is raving about this smart new style. “They give you the posture. They give you an elegant attitude right away,” says Giovanna Battaglia, fashion director of Italian Vogue accessories mags Vogue Gioiello and Vogue Pelle.

Low heels may be high on style, but how healthy are they for your feet? The real answer is all in how you wear them. While they give the wearer less immediate pain than high heels, there is still little support in most ladies’ dress shoes, even low-heeled or flat ones. Check that your dress shoes have sufficient arch support; if they don’t there are plenty of comfy (and stylish) orthotic options available in the foot care section of your local shoe store or drugstore. Some will fit invisibly into peep-toe or open-toe shoes; others are printed with fun patterns that you'll want to show off. Also, let your feet rest! Put your feet up or go barefoot when you get a chance, and wear more supportive footwear out in the yard, when running errands, etc.

In our offices we often see patients with foot pain due to wearing improper shoes constantly for long periods of time. You can prevent painful foot conditions if you make smart choices for your feet!

Cross Country Barefoot Encounter

Did you hear about the guy walking across the country barefoot?? Yes, you heard me correctly. Ron Zaleski is trudging across the US - BAREFOOT - to raise awareness about the need for mental counseling for all military personnel.

As a former military man himself, he is attempting to collect 1 million signatures for his petition along his back roads route to the west coast. The petition calls on Congress to mandate mental counseling for all military personnel.

Tuesday August 10 (just last week!) he passed through good ole' Buchanan, VA. Such a huge cause trampling right through our back yards. Our very own Roanoke Times had a chance to catch up with Mr. Zaleski and get an update on his journey.

Ron is giving everything he has to this cause including the health of his poor tootsies! Rex Bowman from the Roanoke Times reported that his feet were a "mess of broken skin and calluses." Not exactly the prettiest of mental pictures. He should definitely have stopped by to see us while he was in town. ;-)

Well, I just wanted to share with you a little about the barefoot walker's journey. If you'd like to follow him on his cross country trek, check out his website www.thelongwalkhome.org.

For more information visit our website www.roanokefoot.com

VT Foot Fumble

It was grim news for VT Football fans when they heard Nick Becton, starting left tackle, sprained one of his right toes. He is going to be on the sidelines for an undetermined amount of time and there is no guarantee he will be able to be back on the field for Sept. 6th - the big season opener against Boise State.

For those of you thinking - "Toe sprain? He's seriously out for that? Walk it off man!" Here's the definition of a "sprained toe" according to Aurora Health Care. "A toe sprain is caused by a partial tear of the ligaments that support a toe. Ligaments are strong bands of tissue that connect bones to each other." Now it sounds a little more serious than you thought, huh?

Toe sprains can be caused by any number of things, from stubbing your toe to suddenly stopping a run and causing your toe to jam into the front of your shoe. And people MOST at risk for this type of injury are people playing sports, dancing, moving on rough ground, or people with poor coordination or the tendency to be clumsy.

If you think there is any possibility that you may have a sprain of any kind, you need to immediately see a doctor. They will need to run tests and determine a course of treatment which will definitely include rest from whatever activity lead to the injury.

Check out this site for more info on this particular injury. Toe Sprain

You can also check our our website if you are not sure what is causing your foot discomfort or pain. We have some great info on several different common ailments that may be the culprits. Shenandoah Podiatry

Unhappy Feet

No, this is not a parody of the popular cartoon children's movie with the tap dancing penguins. It actually has more to do with the fact that fall sports are kicking off - literally, and as a former soccer player myself, we don't always listen to what are feet are telling us.

“Athletes will play through a level of pain in their feet that, if they felt it in their knees or their shoulders, they’d be hammering at a surgeon’s door,” says Glenn Pfeffer, the director of the Foot and Ankle Center at Cedars-Sinai Medical Center in Los Angeles. Aching feet are the “forgotten stepchild” of sports injuries, he adds.

He's absolutely right! When I read that, it took me way back to high school. I remember first hand how much I paid for ignoring my own foot pain.

I played an entire game in high school with an aching pain in my right foot, but I didn't even let it phase me. I was completely focused on the win. This was one of the biggest games of our season against our rival team. All I could think about as we were getting ready to take the field was my dad's favorite "motivational" (I use that description loosely) saying. "Walk if off girl, walk it off. Be a champion." So that's just what I did. Only instead of walking, I was running, pivoting, kicking, and juggling all at full speed, for about 2 hours. Probably not the best choice I had ever made, then again I was a teenager.

By the end of the game, my adrenaline was through the roof because we had one by one goal when we were not the favored team. I couldn't even feel the pain anymore. It was the best feeling in the world...until I took off my cleats and socks. My foot was swollen to twice it's normal size and there was extensive noticeable bruising. Oops!

To make a long story short, I had just played that game with a navicular fracture. A bone in the middle of my foot was broken and I had no idea. Apparently, it was due to forcing too much stress on my foot without enough recovery time. I was also told that it appeared that the fracture was severely worsened by playing in that game. Had I been responsible and listened to what my body was trying to tell me and sat that game out, I may have gotten to finish out the season only missing a few games for recovery. Since I played, I was forced to sit on the bench the rest of the season and I missed indoor tryouts for the winter season.

We really don't think too much about what are bodies are trying to tell us. Especially our feet since most of the time we attribute our discomfort to walking too much, wearing the wrong shoes, or just being plain old tired. Of course, sometimes those things are true, but if you truly enjoy being active or playing sports, do you really want to be taking that risk?

I came across an article today from the NY Times that might be of some use. It explains just how serious this lack of "listening" to our feet really is. They use Kobe Bryant as a prime example. In 2004, he had a serious struggle with plantar fasciitis, which is an extremely painful heel condition. Can you imagine being a basketball player, worth millions, and having to play the game of your career with crippling pain in your feet? I sure can't (partly because I'm a terrible basketball player and no ever paid me to play soccer - but that's beside the point.)

If you're an athlete, a parent or friend of an athlete, or even a person that just likes to got out and start pick up games I strongly encourage you to check out this article from the NY Times. And next time your feet are trying to tell you something from way down there...LISTEN UP!

Freiberg's Infraction

Freiberg's Infraction is a condition that affects the lesser metatarsal heads. The most common affected location is the second metatarsal followed by the 3rd 4th then 5th. This condition is also known as AVN (avascular necrosis). Freiberg's Infraction causes a loss of blood supply to the metatarsal head. The condition occurs at the metaphysis of the bone where the nutrient artery of the bone supplies the distal metatarsal. This results in a collapse of the metatarsal head. The condition is more common in females and usually occurs between ages 10-18 and can occur in adulthood.


Classification

Smillie’s classification (1967)


Stage 1: Subtle fracture line through the epiphysis.
Radiographic changes at this stage may be subtle.

Stage 2: Central depression of the articular surface.

Stage 3: Central depression leads to medial and lateral projections at the margins. Plantar hinge remains intact.

Stage 4: Central portion frees from the intact plantar hinge, forming a loose body. Fractures of the medial and lateral projections are present.

Stage 5: Flattening of the metatarsal head with secondary degenerative changes.


Contributing Factors:

Freiberg disease in adolescents is thought to be due to growth disturbances of the epiphysis or apophysis.

• Vascular insult- an injury of the blood supply to the metatarsal head
• Traumatic insult- a single acute injury or multiple repetitive injuries

Symptoms

• Local pain and Tenderness that usually increases with activity
• Stiffness
• Limping

Differential Diagnoses

• Metatarsalgia
• Morton neuroma
• Stress fracture

Treatment

Non Surgical:

• Stiff Soled shoe or Post Op Shoe
• Non weight-bearing cast
• Short leg walking cast or CAM boot
• Rest /Activity modification
• Steroid injection
  

Shoe Modifications:

• Metatarsal pads
• Rigid shanks
• Rocker bottom

Surgical Treatment:

• Simple debridement

Osteotomies:

• Dorsal closing wedge osteotomies- reorients the plantar intact cartilage to articulate with the proximal phalanx.
• Shortening osteotomies- metatarsal overloading of the is reduced

Arthroplaty

• Total joint arthroplasty- Utilizing an implant

Tarsal Tunnel Syndrome

Tarsal tunnel syndrome is a condition that is caused by compression of the tibial nerve or its branches.

Tarsal tunnel syndrome is analogous to carpal tunnel syndrome of the wrist.

The tarsal tunnel is a narrow space that lies on the inside of the ankle.

The tunnel is covered with a thick ligament called the flexor retinaculum.

Structures within the tarsal tunnel include:

-Arteries
-Veins
-Tendons
-Nerves

Tarsal tunnel syndrome is a compression on the posterior tibial nerve.

This syndrome produces symptoms anywhere along the path of the nerve.

Possible symptoms include:

-Tingling
-Burning
-Numbness
-Shooting pain
-Paresthesias

Contribute Factors to Tarsal Tunnel:

-Soft tissue masses:
Lipomas-is a benign tumor composed of fatty tissue
-Tendon Sheath Ganglia:
Neoplasms- is an abnormal mass of tissue as a result abnormal proliferation of cells
-Nerve tumors
-Varicose Veins

Work up:

Tinel sign- Percussion of a nerve with radiation of pain along the course of the nerve.

The doctor may order any of the following tests to help with the diagnosis:

-Electromyography (EMG) - A technique for evaluating and recording the electrical activity produced by skeletal muscles
-Nerve conduction velocity (NCV)
-Magnetic resonance imaging (MRI)- In cases of suspected soft-tissue masses and other space-occupying lesions
-Ultrasonography
-Radiography

Conservative Treatment:

-Rest
-Ice
-Non steroidal anti-inflammatory drugs-to help reduce pain and inflammation
-Immobilization- Restricting movement of the foot by wearing a cast or cam boot
-Physical therapy
-Injection therapy
-Orthotic devices. To control any abnormal bio mechanics of the foot









-Surgical Therapy

Tarsal tunnel release surgical intervention may be needed if conservative therapy fails to alleviate pain and symptoms. This procedure is used to decrease pressure on the posterior tibial nerve. Any space occupying lesions may also be excised.

Anodyne Therapy

Diabetic neuropathies are neuropathic disorders that are associated with diabetes mellitus. These conditions are thought to result from diabetic microvascular injury involving small blood vessels that supply nerves

Neuropathy can present itself in a number of different ways including; numbness, pain, loss of feeling, weak muscles.

These symptoms can lead to secondary problems including difficulty with walking, balance and activities of daily living.


Anodyne Therapy is a treatment specifically for peripheral neuropathy. It works by relieving pain and/or increasing circulation in the area where the patient is experiencing pain.


The only contraindications are for pregnancy and active malignancy, according to the company.

How it works

The Anodyne Therapy System uses monochromatic infrared energy (MIRE) to release nitric oxide from the patient’s red blood cells.

Anodyne Therapy utilizes the healing power of infrared light to stimulate increased nerve function and blood flow to decrease pain and improve feeling

This form of treatment is usually given in addition to physical therapy

Anodyne Therapy is completely painless

The program usually involves 10-24 therapy sessions and may include:

Stretching and strengthening exercises

Dynamic and static balance exercises

Massage and the use of other therapeutic modalities for pain

Sensory integrative techniques

Tailor's Bunion

Tailor's bunion is as an acquired lesion that causes chronic pain and swelling over the outer aspect of the distal foot. It is also known as a bunionette and is characterized by a painful prominence on the outer aspect of the foot in the area of the fifth metatarsal head.

These types of lesions were often seen on tailors with a cross-legged sitting posture. The posture resulted in pressure being placed on the lateral side of the foot.

Causes

Extrinsic causes - Commonly chronic

• Tailors' posture
• Footwear

Intrinsic causes

Structural Abnormalities

• Lateral bowing of the metatarsal shaft
• Enlargement of the metatarsal head
• Congenital splayfoot

Presentation

• Symptoms - Painful keratoses on the outer, bottom, or top aspect of the metatarsal head.

Imaging Studies

• Weight-bearing x rays of both feet
• Vascular studies are important with patients who have questionable circulation

Treatment

Conservative

• Padding
• Shoe modification
• Orthotic devices
• Anti-inflammatory medications
• Corticosteroid injections

Surgical Treatment

• Can be treated with simple removal of osseous bump when there is no evidence of anglular deformity
• With an angular deformity or a deviation in the bone is present an osteotomy (cut in the bone) is made and held together with a screw. The level of bone cut varies with the level of the deformity.

Possible Complications

• Malunion- Incomplete union or union in a faulty position
• Nonunion- A nonunion occurs when a broken bone does not heal
• Nerve Injury
• Joint pain and stiffness
• Symptomatic hardware
• Infection
• Recurrence

Diabetic Education

General Education for Diabetics:

Avoid any at home care for nails and calluses

Avoid constrictive bandages

Avoid open toed or opened back shoes

Be careful with adhesives and tape on the diabetic insensate foot

Buy shoes at the end of the day when the feet are the largest

Check the bath temperature before submerging the feet

Diabetics with impaired vision need someone to inspect there feet daily

Do not use chemical substances for removing corns or calluses

Dry the feet and between the toes thoroughly after showers

Inspect the feet and toes daily for any lesions

Inspect the shoes for objects before placing on feet

Never walk barefooted

Professional nail care at a podiatry office with regular visits

Protect the feet from sunburn

The use of a high toe box to accommodate hammertoes

The use of an insert to accommodate any lesions

The use of shoes with a wide toe box with extra depth

The use of water based lotion daily without moistening between the toes

Wear a shoe with an appropriate fit to avoid friction which can cause blisters

Green Nail Polish?

I am mother to a four month old, which means I am diligent about what chemicals come into my house.(or actually are not allowed!) Every day, I strive to keep my family healthy and chemical free. We use natural household cleaners, buy organic veggies, recycle and even started composting. In my podiatry practice, I have started looking for ways to recommend less chemicals to my patients.

After months of pedicures and continuous application of nail polish you may notice your toenails getting dry and brittle. This damage to the nail is caused by the formaldehyde found in most commercial nail polishes. Not only does commercial nail polish contain formaldehyde (a found carcinogen!) but also toluene (toxic to liver and kidneys) and DBP (causes birth defects).

Podiatrists, Dr. Adam Cirlincione and Dr. William Spielfogel have together created safer solution. It all started when Dr. Cirlincione's wife was pregnant and he was researching the harmful toxins contained in most nail polishes. Dr.'s Remedy Enriched Nail Polish is toxin free and enriched with tea tree oil and garlic bulb extract, which are naturally occurring anti-fungal, antibacterial, and healthier for the nail. If you are looking for a healthier alternative for keeping your nails pretty this sandal season, consider Dr. Remedy's.

Dedicated To Your Healthy Feet,

Dr. Jennifer Feeny

Psoriasis

Psoriasis is a common, chronic, relapsing, inflammatory skin disorder. Psoriasis has a genetic basis and can affect the skin the nails and also joints.

Psoriasis has a tendency to wax and wane.

Flares can be related to systemic, environmental factors, or infection.





Psoriasis most commonly manifests itself on the skin of the elbows, knees, scalp, and lumbosacral areas.



Most psoriatic nail disease occurs in people with clinically evident psoriasis.


Psoriatic arthritis is a chronic inflammatory arthritis that is commonly associated with psoriasis.



Frequency

Approximately 2-3% of people are affected by psoriasis

At least 5% of patients with psoriasis develop psoriatic arthritis

Sex

Psoriasis is slightly more common in women than in men


Symptoms of Psoriasis

The surface of psoriatic lesions often has a layer of dead skin cells that appear as silver scales.

Erythematous(Red) scaly area which can have a sudden onset.

Scaling plaques that itch.

Lesions may be vesicular.

Joint Pain.



Joint Findings

Sausage Digits

Enthesopathy- An inflammation of the insertion points of tendon into bone.

Tendonitis


Nail Findings

Oil drop - a translucent, yellow-red discoloration in the nail bed resembling a drop of oil beneath the nail plate.


Pitting- Pitting is a result of the loss of cells from the surface of the nail plate.


Beau lines- These lines are transverse lines in the nails


Leukonychia- Leukonychia is areas of white nail plate.


Onycholysis Onycholysis is a separation of the nail plate from its attachment to the nail bed.



Causes


Psoriatic lesions are caused by an increase in the skin cells turnover rate.

Genetic factors- Approximately 40% of patients with psoriasis or psoriatic arthritis have first-degree relatives who are affected.

Psoriatic nail disease may be due to a combination of genetic, environmental, and immune factors.



Differentials

• Seborrheic dermatitis
• Onychomycosis
• Squamous cell carcinoma
• Nummular eczema
• Lichen planus
• Lichen simplex chronicus
• Pustular eruptions

Arthritic Differentials

• Gout
• Osteoarthritis
• Rheumatoid arthritis
• Septic arthritis

Work Up


Radiographs of affected joints can be help differentiate the type of arthritis.

Psoriatic arthritis- The diagnosis is based primarily on clinical and radiographic findings.

Nail biopsy- A nail biopsy may be obtained to confirm the diagnosis of nail psoriasis



Laboratory studies

Rheumatoid factor (RF)- negative

Erythrocyte sedimentation rate (ESR)- usually normal

Uric acid level- May be elevated in psoriasis





Treatment

Skin Lesions

Topical corticosteroids- Used to reduce plaque formation.


Coal tar- Coal tar is an inexpensive treatment that is available over the counter in shampoos or lotions for use in widespread areas of involvement..

Keratolytic agents- Used to remove scale, to smooth the skin, and to treat hyperkeratosis


Psoriatic arthritis

Nonsteroidal anti-inflammatory drugs- (NSAIDs)

Disease-modifying antirheumatic drugs (DMARDs)

Anti–tumor necrosis factor (TNF)-alpha medications.

Nails
Avulsion therapy -can be used as an alternative therapy for psoriatic nail disease.

Gout

Gout is a common disorder of uric acid metabolism. It is a medical condition that usually presents with recurrent attacks of acute inflammatory arthritis. Gout is caused by cellular reaction to uric acid and can lead to deposits of monosodium urate crystals in soft tissues and joints.



Types

Primary gout - May occur alone. Accounts for about 90% of cases of the disease.

Secondary gout- May be associated with other medical conditions or medications. Accounts for about 10% of cases of the disease.


Frequency
Approximately 1% of the general population have gout.

Sex
Predominance- 90% male


Symptoms

Gout is associated with considerable pain.

Acute episodes of gout may incapacitate a patient.

Involved joints typically have the following symptoms: swelling, warmth, erythema, and tenderness.

The first metatarsal phalangeal joint is most commonly affected, however other joints can be involved such as the ankle or the knee.


A tophus deposit may develop in the ear.


Causes

Conditions that may cause acute changes in the level of uric acid and may precipitate a gout attack:

• Hyperuricemia
• End-stage renal disease
• Alcohol ingestion
• Disorders that cause high cell turnover with release of purines
• Over consumption of foods high in purines
• Underexcretion of uric acid - renal insufficiency

Long Term Effects

Untreated chronic tophaceous gout can lead to severe joint destruction.

Deposition of uric acid crystal in the kidneys may produce renal failure or obstruction.


Differential Diagnosis

Cellulitis- A severe inflammation of dermal and subcutaneous layers of the skin.

Gonococcal Arthritis- Is caused by infection with Neisseria gonorrhoeae.

Calcium Pyrophosphate Deposition Disease- Is a type of arthritis caused by the deposition of calcium pyrophosphate crystals.

Rheumatoid Arthritis- Is a chronic systemic inflammatory disease that affects the peripheral joints.

Psoriatic Arthritis- Is a chronic inflammatory arthritis that is commonly associated with psoriasis.


Laboratory Studies

Synovial fluid- The physician may aspirate the involved joint to rule out an infectious arthritis and to confirm a diagnosis of gout.

Serum uric acid.

Uric acid in 24-hour urine sample.


Imaging

Routine radiographs reveal punched-out erosions or lytic areas with overhanging edges. These finding are not acute.



Treatment

Acute gout

• Indomethacin- is the traditional Nonsteroidal anti-inflammatory drug (NSAID) of choice for acute gout.
• Colchicine.
• Corticosteroids- May be indicated in those patients who do not tolerate NSAID or Colchicine.

Chronic gout

• Probenecid- For patients who are hypoexcreters of uric acid.
• Allopurinol- For patients who are over producers of uric acid. Allopurinol reduces the generation of uric acid in the body.
• Uloric- Prevents uric acid production and lowers elevated serum uric acid levels.

Diet

Patients with gout should avoid beer and hard liquor. These elevate levels of uric acid and may precipitate attacks of gout.

High purine foods should be consumed in moderation:

• Kidney
• Liver
• Meats
• Shellfish

Shoes that are creating their own path in our world: Part 2

Simple Shoes

This shoe company has come along way since opening in 1991. The Simple shoes that we know and love today are not at all the same shoes from the 90’s. For about 13 years Simple was just like every other shoe company out there. But in 2004 Simple Shoes had an epiphany and decided to take on the challenge of providing eco friendly shoes to the public. They started small with 2 different styles in 2005 called their ‘Green Toe’ collection. These shoes where a hit and as soon as the ball was rolling for Simple there was no stopping it. Over the past few years Simple has produced with even more shoes that incorporate natural and sustainable materials into their products. In 2006, Simple set a new goal to become a 100% sustainable company. This was a huge step for any company, and a very exciting one at that. In 2007, they took it one step further (we didn’t think it was possible!). Simple shoes started to use recycled materials as well as products found naturally in our world. So now, old tires can gather dirt on people’s feet instead of in a dump. To learn more about Simple Shoes visit www.simpleshoes.com.

Shoes that are creating their own path in our world: Part 1

Tom’s

Tom’s are extremely colorful with many different patterns, but this is just a bonus. The best thing about these shoes is that you get two for the price of one! Deals are great aren’t they!! What is even better about this deal is that one pair of shoes goes to you and one pair of shoes goes to a child who doesn’t have any shoes to call their own. Tom’s was started in 2006 by Blake Mycoskie. His inspiration came from seeing children without shoes on his visit to Argentina. A little known fact is that many diseases can be picked up from the ground by being absorbed through the skin on the feet. Another concern is puncture wounds especially when medical treatment is not readily available. These things are not acceptable when there is something we can do about them. So, when Blake came back to the states he got very busy. During his first year in business he gave 10,000 shoes to children all around the world. Tom’s have become increasingly popular over the years. Their expansion has been exciting and inspiring. As of April 2010, Tom’s have given approximately 600,000 shoes to children all over the world! To check out Tom’s shoes online please visit www.toms.com.

Tinea Pedis

Is a fungal infection of the skin that causes scaling, flaking, and itch of affected areas. It is also known as Ring Worm or Athlete's foot.

Symptoms
The symptoms of athlete's foot or tinea pedis typically include itching and burning of the feet.

The skin may peel or crack with or without any associated pain.

Commonly the rash is localized to the soles of the feet.

Sometimes the flaking skin may spread to the sides and tops of the feet in a moccasin distribution.


The digital interspases may have some moisture, peeling, redness and flaking as well.



Types of Tinea Pedis


T rubrum is the most common cause for tinea pedis.

Trichophyton mentagrophytes, and Epidermophyton floccosum are other causative organisms.




Vesicular tinea pedis-
Usually caused by T mentagrophytes.
This type is characterized by painful, pruritic vesicles most often on the instep.






Interdigital tinea pedis-
Usually caused by T rubrum seen more in hot/ humid environments
This type is characterized by redness, maceration, fissuring, and scaling between toes. It is also associated with itching





Chronic hyperkeratotic tinea pedis-usually caused by T rubrum.
This type is characterized by chronic redness on the bottom of the foot or sides with scaling.




Risk Factors

• A hot, humid, tropical environment
• Prolonged use of footwear
• Hyperhydrosis- Sweating
• Certain people may have a genetic predisposition to the infection

Work Up

In suspected tinea pedis a KOH (potassium hydroxide) staining may be ordered by the doctor for fungal detection by obtaining a sample of the flaking skin

Fungal culture- may be performed to confirm the diagnosis of tinea pedis. A culture can be used to identify the fungal species.



Treatment

Tinea pedis can be treated with topical or oral antifungals. Some topical medications are over the counter. Topical agents are generally used for 1-6 weeks


Examples of Topical Medication

Topical Imidazoles

• Clotrimazole 1% (Lotrimin)
• Econazole 1% cream (Spectazole)
• Ketoconazole 1% cream (Nizoral)

Topical Pyridones

• Ciclopirox 1% cream (Loprox)

Topical Allylamines

• Naftifine 1% cream (Naftin)
• Terbinafine (Lamisil)

Oral Antifungals

Considered in patients with extensive chronic hyperkeratotic or inflammatory/vesicular tinea pedis

• Terbinafine (Lamisil)
• Itraconazole (Sporanox)

Prevention

• Keeping your feet clean and dry
• Avoiding prolonged moist environments
• Disinfecting old shoes
• Periodic use of anti fungal foot powder in the shoes

Morton's Neuroma

Is a painful benign fibrotic enlargement of one of there common digital nerves. It is caused by a shearing force of the adjacent metatarsal bone. It most commonly affects the third common digital nerve. Morton's Neuroma is found to be more common in females. This may be related to the type of shoe gear often worn by females. It is most common in the 4th - 6th decade.


History

Obtaining an accurate history is important to making the diagnosis of Morton's neuroma.

Common Findings

• Pain in the forefoot and corresponding toes adjacent to the neuroma
• Pain is usually described as sharp and burning
• Pain may radiate proximal
• Numbness and tingling often is observed in the toes adjacent to the neuroma
• Intermittent pain
• Massage of the affected area may give some relief
• Narrow tight high-heeled shoes aggravate the symptoms
• Patients may feel as though they are walking on a wrinkle in there sock

Exam

• Firm squeezing of the metatarsal heads with one hand while applying direct pressure to the dorsal and plantar interspace with the other hand may elicit radiating pain.
• Mulder Sign - A silent palpable click produced by the lateral squeeze test. The neuroma moves between the metatarsals.
• Passive and active bending of the toe in an upward direction may aggravate symptoms.
• Sullivan's Sign - Toes adjacent to the affected interspace splay apart on weight bearing.

Imaging

• Ultrasonography
• MRI

Differential Diagnosis

• Stress fracture of the metatarsal
• Rheumatoid arthritis
• Hammertoe
• Metatarsalgia- plantar tenderness over the metatarsal head
• Neoplasms
• Metatarsal head osteonecrosis
• Freiburg osteochondrosis- characterized by interruption of the blood supply of a bone followed by localized bony necrosis.
• Ganglion cysts
• Intermetatarsal bursal fluid collections

Treatment

Treatment strategies for Morton's neuroma range from conservative to surgical management.


Conservative

Bio mechanical

• Orthotics

Medications

• Injections- Corticosteroid- Anti inflammatory agent
• Alcohol sclerosing- Causes a chemical neurolysis of the nerve and used as an alternative to surgery for Morton's neuroma
• NSAID's- Non Steroidal Anti Inflammatory such as Ibuprofen or Naprosyn
• Tricyclic Antidepressants- Amitriptyline(Elavil)
• Anticonvulsants- Neurontin (Gabapentin)
• Pregabalin (Lyrica)
• Duloxetine (Cymbalta)

Rehabilitation Program
Physical Therapy

• Cryotherapy-Cold Therapy- Cold may be applied using an ice bag or a cold pack
• Ultrasonography- Sound waves that are transferred to a specific body area via a round-headed probe. The sound waves travel deep into tissue, creating gentle heat. The heat helps relieve pain and inflammation
• Deep tissue massage
• Stretching exercises
• Phonophoresis- Has been used in an effort to enhance the absorption of topically applied analgesics and anti-inflammatory agents through the therapeutic application of ultrasound

Surgical Intervention

• Neurectomy- When conservative measures for Morton's neuroma are unsuccessful surgical excision may be beneficial

Diabetic Peripheral Neuropathy

Diabetic Peripheral Neuropathy is the presence of symptoms and/or signs of peripheral nerve dysfunction in people with diabetes after exclusion of other causes.
Neuropathies are characterized by a progressive loss of nerve fibers

Noninvasive Testing

• Nerve conduction studies and Electromyography- A test commonly used to evaluate the function and the ability of electrical conduction of the motor and sensory nerves.
• Quantitative sensory testing
• Autonomic Function Tests
• Monofilament testing - If the patient does not feel the wire at 4 or more at 10 testing sites- the test is positive for neuropathy

Pathophysiology of Diabetic Peripheral Neuropathy

Result from vascular disease:

• Endothelial dysfunction
• Deficiency of myoinositol-altering myelin synthesis
• Chronic hyperosmolarity-causing edema of nerve trunks
• Increased sorbitol and fructose

Diabetic Neuropathy can contribute to Structural foot deformities

Hammertoes

Bunions

Metatarsal deformities

Charcot foot

Eventual tissue breakdown

The symptoms of peripheral neuropathy include the following

• Hyperesthesia-Is a condition that involves an abnormal increase in sensitivity to stimuli of the senses.
• Paresthesia- Is a sensation of tingling, pricking, or numbness of a person's skin. It is more generally known as the feeling of "pins and needles".
• Dysesthesia-It is defined as an unpleasant, abnormal sense of touch, and it may or may not be, considered as a kind of pain.
• Radicular pain-Is pain "radiated" along the dermatome (sensory distribution) of a nerve due to inflammation or other irritation
• Anhydrosis-Means lack of sweating.

Peripheral Neuropathy Signs

• Loss of sensation in the foot- Results in repetitive stress
• Injuries and fractures
• Loss of vibratory and position sense
• Loss of deep tendon reflexes
• Trophic ulceration
• Foot drop

Treatment


Diet

• Patients with diabetic neuropathy should develop a realistic diet for lowering blood glucose. This should be guided by a nutritionist or doctor

Medicines widely used to help with painful symptoms

• Selective serotonin and norepinephrine reuptake inhibitors- example:Duloxetine (Cymbalta)
• Tricyclic antidepressants- example: Amitriptyline (Elavil)
• Anticonvulsants- example:Gabapentin (Neurontin)
• Pregabalin (Lyrica)- FDA approved for neuropathic pain associated with diabetic peripheral neuropathy or postherpetic neuralgia.
• Capsaicin cream (Capsacin)- A natural chemical derived from plants of Solanaceae. This is a topical medicine and is the active component of chili peppers.
• Neuremedy (Benfotiamine)- For the nutritional management of peripheral neuropathy.

Obese children are more prone to leg, ankle, and foot injury.

A new pediatric study reveals that obese children are more prone to leg, ankle, and foot injury than other children their age. Dr. Wendy J. Pomerantz of Cincinnati Children’s Hospital in Ohio and several of her colleagues studied the patient records from the emergency room in their hospital from January 2005 to March 2008. They noticed some very interesting trends. About 30% of obese children in their study had suffered from lower extremity injuries verses the 18% of normal weight children. On the other side of the spectrum the study showed that 15% of the normal weight children suffered from head injuries compared to 10% of the obese children. The study showed that over weight children often had a longer recovery time than other children. They also found that ankle sprains where twice as common among obese children as other children their age. Although the researchers didn’t have the information explaining how these children became injured the group hypothesized that obese children are more vulnerable during walking or running while normal weight children have an easier time playing sports that carry the risk of head injury.

Of course parents want to protect their children so these numbers might scare some parents into not letting their children be active. But this is not what the study was meant to do. We want children to be active but we want them to be safe about it. Obese children (just like adults) should ease into exercise and sports instead of jumping right in.

Pomerantz’s steps following this study are to figure out why these numbers are slated this way and try to find some protective measures to help keep children safe.

5 warning signs of foot problems in children

Foot pain in children is not something to be taken lightly or ignore. Sometimes it is hard for children to tell their parents when they are having foot troubles. Perhaps the child was born with a foot abnormality so their gait, though abnormal, seems normal to them. Or, a child may feel embarrassed about how their feet appear so they don’t want to bring it up. So, it is very important for parents to keep an eye on children's feet to keep them just as healthy as the rest of their body. Remember these feet have lots of miles ahead of them!!

Here are five things to look out for that might indicate your child is having foot pain or problems.

1. If your child is having trouble keeping up with other children~ If your child frequently lags behind other children in sports or other physical activities this could be due to flat feet causing the leg muscles to tire more easily. The muscles and feet become tired easier because the feet are not functioning as efficiently as they could be.

2. If your child suddenly stops wanting to participate in activities they enjoy~ If your child is suddenly not participating in their favorite activities this could be due to heel pain that is common in children ages 8-14. Heel pain can be caused by repetitive stress that occurs while playing sports. Too much strain can lead to pain and inflammation in the growth plate at the back of your child’s heel.

3. If your child is reluctant to show you their feet~ If a child notices a change in their feet they might be embarrassed or nervous that the change could lead to a trip to the doctors office. Start making it a habit early to check your children's feet for discoloration of the skin or nails, growths, calluses, redness, swelling or ingrown nails. Seek podiatric help for any of these signs of a problem.

4. If your child trips or falls often~ Although children are often clumsy while they are getting used to their body, repeated clumsiness can be a sign of in-toeing, balance problems or neuromuscular conditions.

5. If your child tells you they have foot pain~ Sometimes we get lucky and our children will tell us that their feet hurt. If this happens be thankful and take them to see a podiatrist right away. It is never normal for children to have foot pain and since they are growing all the time foot pain should not go overlooked. If injuries cause pain or swelling for more than a few days see a podiatrist asap.

Even if no symptoms are present and your children don’t complain of foot pain it is a good idea to get a yearly check up to make sure that the feet are growing properly.