FAQ Category: Foot

As you have discovered, managing blood sugar levels isn’t the only problem facing patients with diabetes. Over time, nerve damage and other complications such as collapse of the arch in the foot can occur. This condition is called Charcot midfoot arthropathy. Charcot is the name of the physician who first discussed this problem.

Ulceration, fracture, dislocation, and deformity associated with the Charcot foot can be serious problems to deal with. There isn’t an easy answer to treatment. Conservative care is always the first-line of treatment. Bracing, casting, or shoe inserts called orthoses are a few of the ways patients can get help before ulceration or fracture occur.

Sometimes surgery is needed to fuse the midfoot. This gives the patient a stable foot to walk on — one that doesn’t break down and form ulcers. It’s true that patients with diabetes may be at increased risk for complications from surgery (any type of surgery). This could be any of the problems you mentioned (along with a few others!).

But with the right kind of care, you could end up with a stable foot and ankle that will support your weight and allow for standing upright and walking independently. A fusion procedure has its risk but with good surgical technique and proper patient compliance with postoperative instructions and rehab, the potential benefits usually far outweigh the risks.

Diabetic ulcer healing can be a real challenge for patients and families alike. Sometimes, despite all efforts, the diabetes works against the patient and the ulcer progresses. Surgery can’t be done with an open wound like that because of the risk of infection.

The physical therapist can offer a combination of treatment interventions that work together to overcome the delayed healing effect of the tissues. The first step is always to make sure the patient is experiencing good, stable (daily) control of blood sugars. This is accomplished through medication, diet, and exercise. Of course, with severe foot deformities and open wounds, exercise can be difficult. But it’s not impossible. That’s what the therapist will help you figure out.

Proper foot care is part of the big picture. With ulcers already present, the task is to keep them from getting worse or adding new ones. Foot care includes a wide range of activities such as daily inspection, protection to minimize trauma, and reduction of weight bearing. This is the piece that the patient is responsible for and compliance is essential for a good result.

Anyone with loss of sensation from nerve damage called peripheral neuropathy is advised to avoid soaking the feet. There is a danger of burns and prolonged exposure to warm water leaves the skin susceptible to fungal infections. Whirlpools and hot tubs are not allowed and baths are not advised (showering may be best). Bathing and soaking remove the protective barrier from the skin and can lead to other infections, especially if there are cracks from dry skin due to decreased circulation.

The therapist will also teach your husband how to control activity levels and decrease shear forces on scars from previous ulcers (if there are any). Orthoses (molded shoe inserts) are often used to redistribute or move pressure away from a blister, sore, or other area of pressure. Soft, moldable orthoses are preferred to the rigid orthoses used by patients with other types of foot problems.

The therapist will find the best off-loading techniques for the treatment of neuropathic ulcers. For example, total contact casting (TCC) is one very effective way to treat neuropathic plantar ulcers.

Total contact inserts (TCI) and metatarsal pads can be used to reduce stress on the bottom of the foot, thereby preventing skin breakdown and ulceration. The TCI reduces excessive pressures on the bones of the foot by increasing the contact area of weight-bearing forces. Metatarsal pads act by compressing the soft tissues around the metatarsal heads. By doing this, the pads take direct pressure off the metatarsal heads.

This is just a partial list of things the therapist can offer you and your husband. It may be best to seek the services of a therapist already working in a diabetes clinic or diabetes education center (or otherwise specializing in this area). But if this is not available in your area, then ask around and find someone who is tuned in to the special needs of the patient with diabetes.

Tendon ruptures of the tibialis anterior are uncommon. That makes it tough to study and come up with effective treatment guidelines. The tibialis anterior is the muscle along the front of the lower leg that dorsiflexes the foot. Dorsiflexion means the tendon pulls the ankle up toward the face.

Surgery is suggested in order to restore a normal gait (walking) pattern. Surgery may also be done to avoid a foot deformity. Conservative (nonoperative) care is more likely for older, inactive adults or when treatment has been delayed for three months or more.

For elderly patients who can’t handle surgery because of other health concerns, bracing and physical therapy may be in order. The therapist will evaluate current muscle function and determine whether or not an exercise program would help. In some cases, electrical stimulation may be needed to help stimulate muscle contractions. The goal is to strengthen the muscles around the ankle that can substitute for the damaged one.

A special brace that will assist ankle dorsiflexion (pulling the toes up towards the face) can help with the foot slap commonly seem with this condition. Without the strength of the tibialis anterior to pull the ankle up, the foot slaps with a noticeable sound when the foot hits the floor. Some patients end up compensating by picking the foot up higher to avoid tripping. This gait pattern is referred to as a steppage gait.

You are right to be concerned about this problem. Preventing falls is an important way to avoid further complications. Seek out the services of a physical therapist for this problem. Addressing it sooner than later is the best way to go.

A chondroma is a cartilage-producing tumor. It is usually benign, meaning it doesn’t spread to other parts of the body. It is not likely to cause death. Most of these tumors occur in the tubular bones of the fingers and toes.

Extraosseous means outside the bone. Chondromas don’t usually invade the soft tissues around the bone, but they can. When this happens, the type of chondroma is a chondroma of soft parts. This type of chondroma can affect the nail bed, synovium (joint lining), or other areas around the joint.

Some extraosseous chondromas occur right next to the bone. These are referred to as juxtacortical chondromas. Regardless of where these tumors develop, they usually cause pain, local swelling, and an obvious mass (bump under the skin). They are slow-growing and may be present for years before becoming bothersome enough to see a doctor.

Any adult of any age can be affected. There doesn’t appear to be any difference in the number of men affected versus women. Juxtacortical chondromas tend to develop in younger adults between the ages of 18 and 26, but again, anyone of any age can develop this type of chondroma.

When someone has arthritis of the foot, it can be difficult to treat because it’s hard not to use your feet. If medications and nonsurgical treatments don’t work, the next option is likely surgery. But to be able to rest the foot well enough for good results, the person must be able to move around without weight bearing and this usually means crutches. If someone doesn’t have strong enough arms or good enough balance, this can be difficult, if not impossible. Even if your father was to use a wheelchair after surgery, you do need strength in your arms to propel the chair.

It may be that this is one reason your father’s doctor is talking about exercising and increasing strength. The best bet is for your father or you, if your father permits, to ask the doctor the reasoning and what specifically you can be doing to increase the chances of a successful surgery.

If you’re having surgery in the middle part of your foot with hardware (pins), it sounds like you injured the tarsometatarsal joints, which is where the bones in your foot all seem to join up.

If the fracture is unstable, meaning the bones have moved, then surgery is usually the chosen treatment. In cases like arms and legs, the hardware is usually left in because of the type of bone and the part of the body affected. But, with the foot, the motion of the feet, the pressure on the ball of the feet and the joints when taking every step, can eventually cause the hardware to break due to fatigue. This can cause even more problems.

Some doctors do leave the hardware but this is a decision best left between you and your own surgeon.

If you did break the tarsometatarsal joints several years ago and the bones didn’t heal back in proper alignment, it’s entirely possible that you are developing arthritis in that area. This is one reason why doctors recommend surgery for this type of injury, even if the displacement or bone movement is minimal.

Extracorporeal shock wave therapy (ESWT) is a newer form of nonsurgical treatment for chronic plantar fasciitis. It uses a machine to generate shock wave pulses to the sore area. Patients generally receive the treatment once each week for up to three weeks.

It is not known exactly why it works for plantar fasciitis. It’s possible that the shock waves disrupt the plantar fascial tissue enough to start a healing response. The resulting release of local growth factors and stem cells causes an increase in blood flow to the area. Recent studies indicate that this form of treatment can help ease pain, while improving range of motion and function.

There’s even a more specific type of ESWT being tested for this condition. It’s called radial extracorporeal shock wave therapy (rESWT). rESWT applies vibrational energy at a specific point of tenderness. The force of the vibration spreads out over a larger area. The pattern of vibrational energy released looks like the shape of a megaphone. Treatment is directed at the painful region rather then at a painful point.

The shock waves are applied to the bottom of the foot using a special hand piece that directs the energy at the point of maximum tenderness. FDA approval studies have found the treatment to be both safe and effective. Some patients report feeling increased pain during the procedure. A local injection of a numbing agent can be used to help reduce or eliminate this sensation.

However, a few studies have had results that suggest the local numbing agent might reduce the benefit of the shock wave therapy. Most patients offered this pretreatment pain reliever do not accept it.

Plantar fasciitis is a painful condition affecting the bottom of the foot. It is a common cause of heel pain and is sometimes called a heel spur. Plantar fasciitis is the correct term to use when there is active inflammation.

Plantar fasciosis is more accurate when there is no inflammation but chronic degeneration instead. Acute plantar fasciitis is defined as inflammation of the origin of the plantar fascia and fascial structures around the area. Plantar fasciitis or fasciosis is usually just on one side. In about 30 per cent of all cases, both feet are affected.

The natural history of this condition is that left alone (untreated), it will eventually go away on its own. Another term for this kind of response is to say that plantar fasciitis is usually self-limiting. That’s why many studies using a placebo (pretend treatment) get good results no matter how it’s treated.

But sometimes, the problem lasts a long time. When it doesn’t go away, doctors say it’s recalcitrant, which means it’s chronic. The painful symptoms limit movement and function, which can reduce quality of life. Finding a way to treat patients with chronic plantar fasciitis is important.

There are many ways to treat this problem. Some of the conservative (nonoperative) approaches include antiinflammatory drugs and pain relievers. Nonpharmacologic intervention include steroid injection, stretching, night splints, ultrasound, ice, massage, electrotherapy, and/or orthotics (shoe inserts).

The use of radial extracorporeal shock wave therapy (rESWT) has been studied, too. Shock wave therapy is a newer form of nonsurgical treatment. This form of treatment can help ease pain, while improving range of motion and function. It uses a machine to generate shock wave pulses to the sore area. Radial shock waves spread the force of the vibration out over a larger area compared with deeper, more focused ESWT.

Patients generally receive the treatment once each week for up to three weeks. It is not known exactly why it works for plantar fasciitis. It’s possible that the shock waves disrupt the plantar fascial tissue enough to start a healing response. The resulting release of local growth factors and stem cells may cause an increase in blood flow to the area, which in turn, fosters a healing response.

If your painful symptoms don’t start to resolve on their own, ask your doctor about trying some of these ways to treat the problem. Finding the right method or combination of treatment approaches may take a period of trial and error before success is achieved.

The goals of treatment and management of gout are twofold: (1) end acute attacks and prevent recurrent attacks and (2) to correct the excess uric acid in the blood
called hyperuricemia.

Nonsteroidal antiinflammatory drugs (NSAIDs) work well for most patients to reduce the pain and inflammation of an acute attack. Once in a while, a steroid injection into the joint is needed for an especially acute attack.

Allopurinol is a drug that can prevent or lessen future gout attacks by slowing the rate at which the body makes uric acid in cases of excess uric acid production. This is taken on a consistent basis, not just when an attack is coming on.

Other medications can be used to lower uric acid levels in the blood by increasing the amount of uric acid passed in the urine. These pharmacologic agents must be taken on a continuous basis to maintain a lower concentration of uric acid in the blood.

Once the acute attack has been relieved, the hyperuricemia may be treated, especially in the case of recurrent attacks of acute gouty arthritis or chronic gout. This requires lifelong management, and compliance is absolutely necessary. Dietary changes, weight loss, and moderation of alcohol intake are all important. Controlling the hyperuricemia is the key to preventing this disease from becoming chronic and disabling.

Although these drugs can prevent and/or treat painful gouty attacks, they don’t work for everyone and they often have nasty side effects. And many patients have other health problems (e.g., diabetes, hypertension, kidney disease) that make it impossible to take the current drugs for gout.

So there’s a call for safer, more effective therapy for gout. What’s on the horizon right now? Well, the European Commission (like the U.S. Food and Drug Administration) has approved a new therapy called febuxostat. It lowers uric acid slowly enough to avoid flaring up the gout. It isn’t processed by the kidney, so it’s possible patients with kidney disease may be able to take it. But it is metabolized by the liver. Anyone with a liver problem or who abuses alcohol may not be able to take this drug.

When all else fails, there is a rather expensive ($8,000 per dose), but effective enzyme treatment (pegylated uricase) that may be helpful for rescue therapy. Rescue therapy refers to the patient with extreme, uncontrolled, and very painful gout for whom nothing else has worked. Once the worst of the problem has been treated, the patient can be switched to something else (one of the more standard treatments available).

Scientists continue to explore all avenues of possibility in seeking a way to prevent, treat, and/or manage gout. As new biologic agents are developed for other inflammatory conditions, these will be tried with patients who have gout. The hope is to find something that works quickly in order to offset the high cost of most new drugs.

Shoe wear can be an extremely important item of clothing in the older adult — and not just from a sense of fashion. Studies show that almost half of all falls are linked with the type of shoes worn at the time of the fall.

Slippers and heels double the risk of falling in older people. Combining slippers with high heels hasn’t been investigated. But even younger adults are at risk of fractures from shoes with a high or narrow heel. And walking barefoot isn’t any better. The risk of falling also increases with bare feet (and especially wearing just socks).

Most older adults fall when their balance is challenged, and they can’t regain their center-of-balance. A recent study of shoe type has shown the benefit of a comfortable, low top, lace-up Oxford shoe. They may not be the height of fashion, but they will reduce the risk of falls and disabling fractures in anyone 65 or older.

Sharing these statistics may help your mother appreciate the seriousness of the problem for all older adults. But she may respond more favorably if she hears it from a valued friend or trusted health care professional.

You may want to consider discussing your concerns with people in both these categories and see what happens. Hopefully, with education on this point, more older adults will modify their shoe wear before a fall leads to a traumatic injury.

Studies testing walking ability on flat surfaces and uneven surfaces in a variety of shoe types have been done. Special motion detector equipment has been used to record three-dimensional (3-D) movement data of the entire body. Young adults and older adults have been tested and compared. In one study, six different shoe types were tested in both age groups on flat and uneven ground.

One of the shoe types included was a lace-up type Oxford shoe with a high collar (high-top). When wearing the soft soled shoes or shoes with a high collar, adults of all ages have a larger shift in their center-of-mass and base-of-support (from side to side). High collar shoes also reduce the margins between center-of-mass and base-of-support from front to back.

Possibly more important than shoe wear, older age (over 65) is a major factor in balance, stability, and falls related to shoewear. For example, older adults have poorer visual contrast sensitivity. This refers to seeing differences or changes in floor/surface color or design (e.g., seeing where bathroom floor tiles end and side of tub begins).

They also had less sensitivity on the bottom of their feet and decreased knee strength compared to younger adults. Older adults were more likely to take shorter steps, walk slower, and spend more time with both feet on the ground at the same time.

When out walking or hiking on uneven ground, give your parents time to navigate the distance and the terrain. Provide walking sticks for everyone so that the older folks don’t feel singled out and as if they need a cane. The extra contact of the sticks with the ground increases ground reaction forces and sensory feedback to the brain. This can help when balance is challenged and reduces the risk of falls (and thus injuries from falls).

Osteochondral lesion of the talus (OLT) refers to damage to the talus after an ankle sprain. The talus is a bone in the ankle between the calcaneus (heel bone) below and the tibia (shin bone) above.

The bottom of the tibia forms a dome over the top of the talus. With OLT, a piece of cartilage from the talus gets pinched by this dome. In more severe cases, a fragment of cartilage breaks off the talus. In the worst cases, the fragment is floating free in the joint space.

The first step for you may be to see an orthopedic surgeon (if you haven’t already done this). The fact that you know you have OLT suggests you’ve already taken this step and received a diagnosis.

Most studies support an initial treatment of conservative care. A physical therapist will work with you to mobilize the joint and decrease pain and swelling to restore motion. A program of flexibility and strengthening exercises is usually prescribed. Expect a four-to-six month period of rehabilitation.

If your symptoms are not improved (or not improved enough), surgery may be advised. There are several ways to treat this condition surgically. For example, holes can be drilled in the talus where the fragment has broken off. This procedure is called microfracture. It stimulates new growth of fibrocartilage. Or the loose piece of cartilage can be removed (excision) with smoothing of the bone where the piece has broken off. And some patients may have both excision and drilling.

The type of surgery performed is usually selected based on the severity of the condition. Mild cases of OLT with an intact joint cartilage have a better chance for a positive outcome. More severe injuries with disruption of the joint cartilage can degenerate with deterioration of the initial results.

Once the surgeon is able to determine the location, type, and size of lesion, then specific treatment can be planned.

There are many studies comparing various methods of treatment for Achilles tendon rupture. The two main methods are surgical repair and nonoperative treatment with rest, immobilization, and antiinflammatory drugs.

There are pros and cons to both management techniques. The main advantage of surgery compared with nonoperative care to repair the torn Achilles tendon is a lower rerupture rate. But the rates of infection, scarring, and nerve injury is much higher for surgical repair.

There is some suggestion that the complication rate after surgical repair of a ruptured Achilles tendon will continue to decline over the next few years with improved surgical technique. Surgeons can use minimally invasive (MI) methods. This allows for much smaller incisions and less disruption of the intact soft tissues.

After surgery, the patient can wear a special brace called functional bracing. The brace allows the individual to walk, exercise, and train for sports. Recovery is faster and return to work and sports occurs sooner. The risk of rerupture and other complications is low with bracing.

Nonoperative care is usually by casting or splinting to immobilize the leg. The foot is held in a position of slight plantar flexion (toes pointing down). This takes the pressure off the healing tendon. There is no risk of nerve injury as there would be with surgery. But recovery is delayed due to weakness of the injured calf muscle.

The first step in making the treatment decision is to see your doctor. A medical exam is needed to determine the severity of injury. Your activity level, sports and recreational involvement, and work or occupation may also influence your decision about which way to go with treatment.

When surgery is not an option, conservative care must be used to help bring about tendon healing without rerupture. Nonoperative care is usually by casting or splinting to immobilize the leg.

The foot is held in a position of slight plantar flexion (toes pointing down). This takes the pressure off the healing tendon. There is no risk of nerve injury as there would be with surgery. But recovery is delayed due to weakness of the injured calf muscle.

If it has been a while since the injury and there is still pain, recovery may require an extensive period of rehab. A physical therapist can help guide you and your son through this process.

Special care must be taken to protect the healing tendon from rerupture while strengthening the muscle. Most people with Down Syndrome have fairly low muscle tone, which will complicate matters. With a heart condition, if there is any loss of circulation to the feet, healing can be further delayed. The use of any brace, splint or cast will require extra skin care to prevent pressure ulcers or other skin breakdown.

There are many variables in the treatment of Achilles tendon rupture. Because of this, there is no clear agreement on the best practice for this condition. Some experts suggest early rehab after injury.

Animal and limited human studies seem to support this idea. Tension placed on the healing tendon and calf muscle seems to help build blood supply and strength in the injured area. Putting weight on the leg and foot help provide the tension needed.

And studies comparing the use of a cast to immobilize the foot with free range-of-motion and weight-bearing showed better function with motion and weight-bearing. The patients went back to work and sports sooner when early weight-bearing was started.

One potential problem with early weight-bearing is the risk of increased pain and discomfort when standing or walking on the injured side. Patients can use a crutch or cane to help offload that foot until enough time has passed to ensure comfort with weight-bearing.

Whether to start rehab first and then consider surgery if treatment fails or to have surgery right away followed by rehab remains an individual decision. The surgeon gives the patient all the factors to consider and his or her best judgment. The patient must choose accordingly.

It may be helpful to know the results of a recent study from Canada. Patients with Achilles tendon rupture all had surgery. Then one group had early weight-bearing while the other group waited longer to resume weight-bearing activities. Early mobilization brought about faster return to function. Patients also reported better quality of life in the first six weeks. There was no difference in results measured six months later.

This may depend on the type of treatment you have and how soon in the recovery process you have to return to work. Most tendon ruptures take a minimum of six weeks to heal enough for the kind of walking and standing your job requires. If surgery is needed, then the process can take longer.

Studies in animals and humans have shown us that early tension and load through the Achilles tendon can actually help the healing process. Weight-bearing seems to stimulate increased blood flow to the area. Putting weight on the leg also improves muscle strength as healing takes place.

Safety is an important consideration. In your case, both your own personal safety and your patients’ safety are factors. You must be far enough along in the rehab and recovery process to be able to function safely in the extended care facility where you are working.

It’s likely your employer has some basic criteria to guide your return. Following these guidelines will help ensure both your own safety and the safety of the clients under your care.

Not yet. Stem cell studies are still fairly limited because of federal financial restrictions on stem cell research. Most of the stem cell research being done is with private funding. The focus has been on destructive diseases such as multiple sclerosis, Parkinson’s disease, and cancer. Scientists are only starting to investigate the use of stem cells for less benign conditions such as musculoskeletal injuries.

The theory is that supplying stem cells to an arthritic joint or degenerative tendon can bring healing. The stem cell signals the body to improve collagen organization in the tendon.

Animal studies show positive benefit of stem cells for tendon repair. But much more research is needed before this will be applied to humans. Long-term effectiveness must be proven. More information is needed about potential adverse side effects.

If you’ve made a bet, I’m afraid you’ll have to pay up. The Achilles tendon runs down your calf to your heel. It allows you to move your foot, mostly to point down, stand on your toes, push off when you’re about to run, and so forth.

The majority of Achilles tendon ruptures, or tears, do happen around the ankle area, as that seems to be where they are must susceptible, but tears can occur anywhere along the tendon, from top to bottom.

While only a doctor can diagnose you by examining your leg and listening to your history, the symptoms you describe do suggest that a ruptured Achilles tendon is a possibility.

The signs and symptoms of a ruptured Achilles tendon include:

– Pain, possibly severe
– Swelling near your heel
– Inability to bend your foot downward
– Inability to stand on your toes on the injured leg