Complications of Diabetes

Diabetes is an increasingly common disorder in the United States and around the world. Chances are someone close to you has some form of diabetes. The United States Department of Health and Human Services has predicted that there will be over 30 million people with diabetes by the year 2020, which is now only 6 years away.

The frequency and severity of complications in diabetes is tied to the length of time with the disease as well as how controlled the blood sugar has been. On average, a person has a high blood sugar for 3 years before diagnosis and treatment.

Diabetes is a disease that, if managed well, can have few or no complications, and a person can expect to lead a full and healthy life. However, there are serious and sometimes fatal complications of diabetes when it is not well managed, and many of these issues affect the feet including wounds, infections, peripheral neuropathy, Charcot neuroarthropathy, dry skin, fungal infections of the toenails and vascular disease. Each of these complications can be encountered individually, but many times several problems are combined.

Wounds
Wounds are most commonly found on the bottom of the foot in people with diabetes, but they can be found in other locations as well. Wounds on the bottom of the foot are caused by a combination of pressure, fragility of the skin and loss of proper feeling due to neuropathy. The wound occurs because there is excess pressure on an area of the foot, usually at the ball of the foot, and it is not noticed because of the decreased feeling in the foot. This pressure causes death of the living layer of skin and over the course of 1-2 days, a wound opens. There is often drainage from the wound and redness around it, and it sometimes also gets a callus (aka corn).

Often the wound is first noticed by a family member or when blood or drainage is noticed on the sock. It is very important that the wound be treated by a physician as soon as possible to prevent worsening of the condition, which includes the wound getting larger and/or deeper and infection. Redness, swelling, increased drainage, red streaks up the foot, fever, chills, nausea, vomiting and/or night sweats are the signs of infection, and if these are experienced it is important to seek immediate medical attention.

Most wounds are treated with a combination of debridement (cutting away of all the dead tissue), antibiotics to help prevent infection, and bandaging. It is very important that the cause of the wound be identified so that it can be removed. In the case of a pressure wound on the bottom of the foot, wearing a special shoe to take the pressure off is initially needed. This is followed by wearing prescription diabetic shoes to remove the pressure from all areas on the bottom of the foot, which helps to prevent new wounds in the same area of different areas.

Wounds can also occur in other areas, such as around the ankle. These wounds are usually due to damage to the blood vessels, causing the skin to become weak. There is often a lot of leg swelling as well. Damage to the blood vessels is accelerated due to high blood sugars, and it usually starts before the diagnosis of diabetes is made.

Infections
Infection is a common problem in diabetes because the immune system is affected by high blood sugar. The immune cells are damaged when blood sugars are above normal, making them slower in identifying infection and slower to attack it as well. A slow immune response also affects the time it takes to heal, since the immune system is an important part of the healing process.

As discussed earlier, wounds are a common problem in diabetes and because the immune system does not function normally, infections and poor healing can be a significant problem. Redness, swelling, increased drainage, red streaks up the foot, fever, chills, nausea, vomiting and/or night sweats are the signs of infection, and if these are experienced it is important to seek immediate medical attention. If left unchecked, deep infections can lead to severe complications which can be life-threatening, including need for amputation of the toes, foot and/or leg. If caught early, oral antibiotics and proper wound care can effectively treat most infections.

Peripheral Neuropathy
Neuropathy is a loss or decrease in sensation due to high blood sugar and compromise to the blood vessels that supply the nerves. It begins at the tips of the toes and progresses up the foot in what is called a “stocking glove” style, which means it affects all the nerves of the foot as though a sock is being put on. Not everyone with diabetes will get neuropathy, but it is very common.

The severity of neuropathy is tied to the length of time a person has had diabetes and how well the blood sugar has been controlled. Symptoms can range from a feeling of tingling, mild numbness or mild burning pain all the way to severe burning pain and complete numbness in the feet, and everything in between. These symptoms, when mild to moderate, can be somewhat reversible with better control of blood sugars. However, more severe forms are often permanent to some degree, emphasizing the importance of prevention of neuropathy.

The treatments for neuropathy are mostly geared at reducing symptoms, and including over the counter vitamins and prescription medication. Vitamins, such as Neuremedy, can help to improve the function of the nerves, reducing the neuropathic process. There are several medications that have shown some great improvement with numbness and burning pain, and these include gabapentin and pregabalin.

Because of the decrease in sensation, as discussed earlier, diabetic shoes are extremely important in preventing pressure wounds and infections that can lead to serious complictions.

Charcot Neuroarthropathy
This disorder, usually called Charcot for short, is caused by neuropathy and can lead to severe breakdown of the bones of the foot. This bone breakdown creates severe instability in the foot and can cause open wounds in a very short period of time. The breakdown in the bone is caused by many fractures in the bones, that are not felt because of the loss of feeling in the feet.

There are various forms of treatment for Charcot, including casting, walking boots and surgery. In many cases, surgery is necessary to stabilize the broken bones and allow for proper healing. As with neuropathy, prevention of Charcot is centered around proper blood sugar control, diabetic shoes and close monitoring by a foot and ankle specialist.

Dry Skin
While not a serious complication of diabetes by itself, dry skin can lead to open wounds with severe cracking, which can lead to infection. Diabetes causes dry skin because it causes abnormality of the sweat and oil glands in the skin, causing them to not work correctly. In some cases this try skin can be severe and lead to fissuring and cracking that can be painful and lead to infection.

There are many treatments available for dry skin including Idonia and Lantiseptic creams.

Fungal Infections
Fungal infections are very common in diabetes because of the decreased ability to fight infection. Fungus on the foot (athlete’s foot) can cause cracking, especially between the toes, leading to bacterial infection in some cases.

More commonly the toenails can become infected with fungus, leading to thickened, discolored, cracked, brittle and painful nails. Once the fungus gets in, it can be difficult to eradicate it. Fortunately however, there are many treatments including creams, nail polishes and oral medications for treatment.

Vascular Disease
Vascular disease, or disease of the blood vessels, is a very common problem in diabetes. The high blood sugar and high blood pressure cause damage to the vessel wall, which causes narrowing and hardening of the vessels, decreasing blood flow. This damage is especially common in the very small blood vessels that carry blood to the toes and fingers. It also causes damage to the large vessels.

Unfortunately, there are no treatments currently to repair the small vessel damage, and this can lead to significant problems with wounds and wound healing. However, the large vessels can often be repaired using a variety of surgical techniques, which increase blood flow to the feet and legs. A vascular specialist evaluation is needed for proper treatment.

In conclusion there are many types of problems related to diabetes that can cause significant problems if untreated. But with treatment, most of these issues can be well managed for many years.

Ankle Fractures

Oh the weather outside is frightful,
And I slipped and broke my ankle…
And now there’s a place I must go
To the doc, to the doc, to the doc

This is a problem I’ve seen many a time during bad weather, especially when ice storms come. It doesn’t take a lot to break your ankle due to its design, but fortunately many types of breaks are not as bad as you think. In fact, some forms of ankle sprain are more painful and swell more than certain types of fractures in the ankle and they can take longer to heal.

However, many of the types of fractures that occur from a slip and fall can be serious and some require surgery. It is therefore important to take swift action and get a proper diagnosis. The diagnosis is made with clinical exam and with x-rays. Occasionally an MRI or CT scan may be required. Usually a broken ankle is swollen, bruised, painful when touched or moved and difficulty or inability to walk on it. An important study done in Canada showed that 97% of people with serious broken ankle were not able to put any pressure on it. X-rays will show a fracture of one or both of the lower leg bones and the location and severity of these breaks determine the type of treatment that is necessary.

The least severe form of an ankle fracture is called an avulsion. This is where one or more of the ankle ligaments pulls off a small piece of the bone as it tears. This can occur on either the tibia (big lower leg bone) or the fibula (small lower leg bone) and usually are not serious, though a cast or boot with non-weight bearing may be needed.

Fractures farther up the bones are more serious and almost always need to be casted with non-weight bearing. The period of non-weight bearing depends on the location of the fracture but is usually between 4 and 8 weeks, which is the length of time required for bone to properly heal and become strong enough to bear the weight of the body.

Certain fractures of either bone require surgery to correct them. This is needed in these cases because the ankle joint becomes unstable and the fractures will not heal properly and/or will heal in poor position. Repair of these fractures involves a combination of screws and sometimes plates to return the ankle to a more optimum position. Surgery is then followed by a period of casting and non-weight bearing. If allowed to heal without surgery, these types of fractures can lead to severe arthritis that occurs within a few years or less. As with any fracture, the risk of arthritis to the joint increases as a result of the injury. Poor treatment can accelerate this process greatly in some cases.

There are also several associated injuries that can occur along with the fracture and they include damage to the ligaments and tendons around the ankle joint as well as damage to the ankle joint itself. A chip fracture of the talus (the ankle bone) is a very common injury along with a fracture of either of the lower leg bones and it needs to be properly diagnosed and addressed. It is sometimes necessary to surgically repair this injury, even if the ankle fracture itself does not need surgery. Tears to most ligaments do not usually need surgery, but tears of many of the tendons do, either at the time of the injury or later down the road.

After the period of casting and non-weight bearing, a period of weight bearing in a walking boot is usually needed and can last from 2-6 additional weeks. After that, physical therapy is usually recommended to improve strength and motion of the joint and surrounding muscles and ligaments. Your doctor will help guide you in these expectations depending upon the type of fracture.

Whether a simple or complex fracture, the doctors at Advanced Foot and Ankle Center are experienced in treating these injuries with precision to get you back to your life as quickly and effectively as possible.

Ankle Arthritis

Arthritis is a common ailment that millions suffer from in the United States and around the world. The most common form is osteoarthritis which is caused by the wear and tear of joints over the course of years. This is also known as degenerative joint disease. It is most common in the fingers, wrists, hips, knees, ankles and toes. The signs and symptoms are pain and stiffness in the morning that eases with motion within an hour’s time, aching or throbbing with activity and/or throbbing at night with joint swelling, heat and redness. Although nearly all seniors will have arthritis in some of these locations, it is not limited to the older population. Improper alignment of joints can significantly accelerate this process and lead to substantial arthritis early in life.

Other forms of arthritis include rheumatoid arthritis, post traumatic arthritis and reactive arthritis. Rheumatoid arthritis is caused by a genetic condition that attacks most of the joints of the body and causes an accelerated and severe degeneration of the joint. It causes weakening of the cartilage (which allows for smooth motion of the joints), leading to quickly deteriorating joints. Post traumatic arthritis results after a fracture or other severe injury. The damage to the cartilage, as a direct result of the injury as well as the poor alignment of the joint that can result, cause a speedy breakdown in the joint, causing pain and inflammation. Reactive arthritis is an uncommon disorder that is as a result of other conditions, such as irritable bowel syndrome or certain types of bacterial infections. Its results are sometimes reversible but in the case of irritable bowel syndrome, it can lead to a quicker breakdown of the cartilage.

Ankle arthritis is a very common disorder. The anatomy of the ankle is unlike any other joint of the body. It is a complex relationship between the talus (the ankle bone) and the tibia and fibula (the two lower leg bones). All three bones interact with one another to allow both the common hinge motion most commonly associated with the joint as well as a subtle side to side motion that allows for a more efficient walking pattern and adaptation for unstable walking surfaces. Unlike other joints, such as the knee or hip which have large muscles crossing them for greater stability as well as very large and strong ligaments, the ankle joint has no muscles that cross it. The ankle also has a few ligaments that are not as strong as other joints. Because of the design of the ankle, it is more prone to injury and is the most commonly sprained joint in the body. More frequent injury makes the ankle very prone to earlier and more severe arthritis.

Ankle arthritis is diagnosed by clinical exam and x-rays. Clinically there will be pain and swelling of the joint with a decrease in the amount of motion and in severe cases grinding or popping when the joint is moved. On x-ray there will be a smaller joint space, formation of bone spurs and changes in the density of the joint.

There are essentially 3 levels of ankle arthritis, classified as mild, moderate and severe, and each has a different strategy for treatment. For mild arthritis, usually anti-inflammatory medications by mouth and/or with topical creams help to effectively manage the pain and swelling. Decreasing high impact activities along with proper shoes and in some cases shoe inserts will help to decrease the risk of the arthritis getting worse.

Moderate arthritis is also treated with anti-inflammatory medications. Ankle braces and in some cases an injection of steroid into the joint can help significantly. There are also surgical options with this level of arthritis and an ankle arthroscopy, where a camera is inserted into the joint with a small incision, can be used to help decrease the inflammation and help repair damaged cartilage. Small spurs that have formed can also be removed with this method. The recovery time or an ankle arthroscopy is very short, with limited time away from work, making it a very good option for a large majority of patients.

Severe arthritis, or end stage arthritis, has more limited options. The main goal is to decrease pain and maintain function of the foot and mobility of the patient. Prefabricated or custom ankle bracing can work for many people with end stage arthritis. However, in many cases, some sort of surgical intervention will eventually be needed to allow better function and allow activity with less pain. Ankle arthroscopy can be an option in some cases of severe arthritis, however it is used as a method of “buying time” and the effects are most often temporary. Full surgical intervention at this stage is in the form of ankle joint replacement or ankle joint fusion. Unlike knee or hip joint replacement, ankle joint replacement has limited usefulness currently. Due to the relatively small size of the ankle joint, in addition to the poor stability of the ligaments and tendons as discussed above, ankle joint replacements do not have the longevity that a knee or a hip replacement does. By comparison knee and hip joint replacements can last for more than 15 years on average, where ankle joint replacements last about 7 years on average. An ankle joint fusion, though it sounds extreme, is a very good option for patients with end stage arthritis. Though the ankle joint has no motion after a fusion, the surround joins pick up some of the slack and most people have normal or near-normal walking, allowing them to resume the activities of daily life.

No matter what the cause or what stage of arthritis you are experiencing, the doctors at Advanced Foot and Ankle Center are very experienced in treating these conditions, using the most up to date techniques to decrease pain and improve the quality of your life.

Advanced Foot and Ankle Center
Eric M. Silvers, DPM
Robert A. Hadfield, DPM
972-542-2155

Ankle Sprains and Ankle Instability

Ankle sprains are one of the most common sports injuries and statistically the most common musculoskeletal injury seen in the emergency room annually. But, despite their frequency, ankle sprains are one of the most commonly under treated injuries. How many times have you heard someone say, “it’s just a sprain, I will be OK” and then they limp along their way?

Our athletic culture in many ways has come to think of all types of sprains as unimportant injuries that one can “play through” and be OK. But the truth is, frequent and severe ankle sprains can lead to a lot of chronic pain and problems, which in some cases can require surgical correction.

An ankle sprain is caused when there is a severe and abrupt turning of the ankle with the body weight being carried through the foot while it is turned inward. This causes a very large stretching force on the ankle ligaments, causing them to tear. Unlike the knee or the hip, which have very large muscles that cross them that assist in stability, the ankle has no muscles crossing it, and it relies heavily on tendons and ligaments to keep it stable. Also unlike other joints, there are two leg bones, the tibia and fibula, that are responsible for holding the joint together along with the talus (ankle bone). The knee and hip have only one bone on each side of the joint, and therefore are more stable. The knee also has large internal ligaments that are very strong to hold it together and the ankle does not have these. So, because the ankle has a difficult and somewhat unstable design, it is very prone to injury.

There are many different systems of classifying ankle sprains and many of them are needlessly complicated. The most commonly used system is 3 grades, which correspond to severity and number of torn ligaments. There are 3 ligaments on the outside of the ankle that hold it together. A grade 1 sprain, which is the most common, is a tear of 1 ligament and is classified as mild. A grade 2 sprain is a tear of 2 of the ligaments and is moderate to severe. A grade 3 sprain is a tear of the first 2 ligaments combined with injury to other areas such as the tendons or the ankle bone. A tear of all 3 ligaments is extremely rare.

The treatment for standard ankle sprains depends on severity but rest, ice, compression and elevation are key with all types. In grade 1 sprains, usually immobilization in an ankle brace or walking boot is sufficient to allow for proper healing. In grade 2 sprains, usually a period of non weight bearing is needed, followed by a walking boot. The treatment for grade 3 sprains depends on the other injuries present and usually requires casting and in some cases surgery.

A high ankle sprain is a little different than the classic type and can be very debilitating if not diagnosed and treated correctly. It involves a tear of the ligament between the two leg bones, causing instability in the joint. These are often treated as classic sprains and they can lead to long term chronic pain. A high ankle sprain usually needs a longer time of non weight bearing followed by longer in the walking boot and can sometimes require surgery as well.

Frequent sprains are common in certain foot types and can lead to chronic ankle instability. This condition is often as a result of under treatment or no treatment with frequent sprains. The recurrent tearing of the ankle ligaments causes them to heal in a lengthened position, causing a loose ankle that feels unstable and causes pain when stressed. This instability also creates higher risk for injury to other areas of the foot and ankle including tears of tendons and damage to the ankle bone. Treatments for chronic ankle instability include orthotics, ankle braces and in some cases surgical correction to tighten and strengthen the ligaments.

It is important to remember that rolling your ankle is not “just” a sprain and appropriate and timely treatment is necessary to avoid chronic ankle instability and greater injury.

COLD LASER IN MCKINNEY TEXAS

COLD LASER IN MCKINNEY TEXAS

Advanced Foot and Ankle Center is proud to introduce to our practice Cold Laser therapy. We currently us the K-Laser Cube 4 unit. This laser uses four different wavelengths to target various tissues at different depths. Results to date in our practice have been exceptional and our patients have been very happy with the outcomes.
There are several physiologic and biological effects of cold laser therapy as outlined below.

1) Accelerated Tissue Repair and Cell Growth: Laser light therapy increases the energy available to the cell so that the cell can take on nutrients faster and get rid of waste products. As a result, cells of tendons, ligaments, bones, nerves and muscles are repaired faster.
2) Faster Wound Healing: Laser light stimulates fibroblasts which are the cells that aid in wound healing. Laser light is effective in open wounds, burns and scars.
3) Reduced Fibrous Tissue Formation: Laser light reduces scar tissue formation following tissue damage from cut, scratches, burns or surgery by inducing production of normal type 1 collagen.
4) Reducing Inflammation: The anti-edemic effect of laser light causes vasodilation and activates the lymphatic drainage system and thus decreases swelling.
5) Analgesia: Laser light affects nerve cells in a way that blocks pain from being transmitted. Thus this decreases pain.
6) Improved Vascular Activity: Laser light increases the formation of new capillaries in damaged tissue that speeds up the healing process, closes wounds quickly and reduces scar tissue.
7) Increased Metabolic Activity: Laser therapy enhances enzymatic activity within the cell, facilitates oxygen delivery from the bloodstream into the reparation chain, and increases cell membrane permeability. Thus the damaged cells are repaired and regenerate faster.
8) Improved Nerve Function: Laser light speeds up the process of nerve cell reconnection and increases the amplitude of action potential to optimize muscle action.

At Advanced Foot and Ankle Center, Dr. Eric Silvers and Dr. Robert Hadfield use the cold laser to treat Plantar Fasciitis, Achilles Tendonitis, fractures, neuropathy, edema, acute pain, metatarsalgia, plantar fibromas, hypertrophic scars in addition to many other foot and ankle conditions.

To schedule a consultation to be evaluated for laser therapy, please call our office at 972-542-2155.

Understanding Flat Foot

Growing up, my mom often told me I had her arches and my dad’s toes. I always thought it was a strange observation but once I became a Podiatrist I realized that she is right. Unfortunately for me, I got the worst of both worlds. It is true that your foot type is genetic, although it is not as cut and dry as getting your mom’s arches and your dad’s toes. It is often more complex inheritance but looking at your parents’ feet can be a crystal ball into the future of your own.

There are several different types of flat foot. There’s the pancake type that make a kid “heavy footed” when they walk. There is a flexible type, where the foot appears to have an arch when sitting, but then it disappears with standing. There is also a type called adult acquired flat foot, where there was a normal arch, but has since collapsed, sometimes over a short period of time. Of these, the flexible flat foot is the most common and is fortunately the most responsive to treatment.

With all of these types of flat foot, other sometimes serious conditions can develop as a result. The arch of the foot is designed to carry the burden of the body’s entire weight when standing, and transfer that force through the rest of the skeleton evenly, while absorbing shock, and creating a lever to push off of for quick and efficient walking. When the arch collapses, these processes do not work correctly. Consequently, the other joints of the foot and leg can become misaligned and lead to pain and arthritis. Bunions, hammertoes are common conditions associated with flat foot. Ankle, knee, hip and back pain/arthritis are also very common.

Flatfoot conditions lead to bunions because of a change in the way the foot pushes off. Instead of the arch holding up the foot and transferring the force through the big toe evenly, when there is arch collapse the foot turns outward, leading to pushing off the side of the big toe. Since the big toe joint is not designed to push off in this way, the big toe joint gradually gets more and more dislocated, leading to a bunion. Hammertoes result from the tendons having abnormal pull because the arch collapses. This abnormal pull gives certain tendons more advantage to pull harder, which causes them to gradually curl. As the toes become more curled, it leads to early arthritis and less ability to straighten them, eventually leading to pain.

Pain and arthritis in other joints of the body, including the ankles, knees, hips and back are as a result of poor shock absorption. Some flattening of the arch in normal walking and running is needed to absorb shock. When the foot is already flat, less shock absorption from the foot is possible, which allows more of the shock to be transferred up the leg into these other areas. The knee has special cartilage, known as the meniscus, that is also designed to absorb shock. But, since the foot is not doing its job correctly, the meniscus gets broken down more quickly.

Determining which type of flatfoot you have is done with clinical examination, x-rays, and analysis of the way you stand and walk and sometimes an MRI. Understanding the individual mechanics of each patient’s individual feet helps to make a custom plan designed specifically for you.

What can be done to avoid these painful conditions? There is not one blanket answer that will cover them all, but there are many conservative therapies aimed at maintaining the arch, providing shock absorption and helping to prevent the further development of bunions, hammertoes and arthritis in the joints of the foot and leg. Wearing proper shoes is a key in this conservative therapy, along with orthotic devices aimed at maintaining the arch, are essential in this process. Children are especially responsive to these therapies because orthotic devices can help assist their feet in growing into a more proper alignment.

If conservative therapies are not enough, there are surgical options for correction as well. These consist of implants to realign the joints, transferring and/or lengthening of tendons and cutting of bone to correct the angles of the bones and joints. Surgery to correct a flatfoot is a last resort option in most cases, but can be very beneficial with the right timing to prevent bunions, hammertoes and arthritis over the long term.

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