Treating Tendinopathy (Tendonitis) Using Dry Needling

What is dry needling?
Dry needling is a procedure used to treat tendinopathy more commonly known as tendonitis. It involves repeatedly placing a fine needle (about the size of an acupuncture needle) in to the abnormal tendon.

How does this procedure work?
Tendinopathy refers to failure of the normal healing process in a tendon leading to areas of abnormal tendon which generate pain. There is often a growth of abnormal blood vessels in and around the tendon. The dry needling procedure has 2 effects: it creates further mild trauma to the abnormal areas to encourage a better healing response and also damages the abnormal blood vessels resulting in small local bleeding in the tendon. Blood contains growth factors that promote tendon healing.

How is this procedure done?
You will be asked to lie on your front on the exam table. The skin over the tendon will be cleaned with antiseptic. Local anesthetic (numbing medicine) is then injected into a small area of the skin and tissues over the tendon. This stings a little at first, but then makes the skin numb. A fine needle is then passed through the skin and into the tendon. The fine needle can be painful when it passes through the tendon but is usually described as uncomfortable more than painful. Your doctor may prescribe you pain medicine that is to be taken prior to the procedure to minimize the pain.

How successful is the treatment?
This is a fairly recent option used to treat tendinopathy and therefore there are few large clinical trials available. However, current data shows that about 60% of patients with tendinopathy that have not responded to alternative therapies will respond well to this treatment, which is comparable to some operative procedures such as TOPAZ (a larger heated needle inserted in a similar fashion under anesthesia in the operating room. In some studies, the procedure was combined with injecting platelet rich plasma (PRP) into the tendon, but these results are similar to dry needling alone.

What risks are involved?
Risks are very uncommon:
1-There may be a temporary increase in pain for 1-2 days and a small amount of bruising. Taking anti-inflammatory medications helps with this.
2-There is a low (less than 1/1000) risk of infection.
3-There is a potential risk of tendon tear (rupture) with this procedure. Rupture is very rare but it is important that you follow the post treatment instructions to further reduce the risk of this occurring.

You should seek medical advice if:
• There is a sudden increase in pain in the Achilles tendon
• The procedure site becomes red.
• You develop a fever or a temperature.

What measures need to be taken to minimize tendon tear?
It is recommended that you wear a walking boot during this time to minimize the risk of rupture. Your doctor will give you clearance to begin walking without the boot and resume exercise activities, which is usually in about 3 weeks.

How long before I notice any improvements?
Some patients get benefit within the first week but it can take up to six weeks.

Will the procedure need to be repeated?
In about 50% of patients the procedure needs to be repeated at 4-6 weeks. This will be determined based upon your progress. Your doctor will work with you to determine the best treatment course, which may also involve alternative treatments such as cold laser therapy, ultrasound therapy and/or MicroVas therapy.

When can I return to work?
This depends upon the type of work you do. If your job involves mostly sitting, you will usually be able to work the next day. However if you have a physically active job, you may not be able to work for a week or more.

For more information call us at 972-542-2155

Ingrown Toenails Under Sedation Anesthesia

Advanced Foot and Ankle Center is committed to providing the highest quality care for our patients and this includes tailoring the treatment plan to fit each individual and their particular needs. Many patients are apprehensive about having their ingrown toenail removed due to concern of pain or discomfort during the numbing process and/or the procedure. This apprehension is very common and normal, particularly in the young and that is why Advanced Foot and Ankle Center along with Texas Star Anesthesia is proud to offer sedation anesthesia, administered by a board certified anesthesiologist, in the office for your ingrown toenail procedure.

What Is Sedation Anesthesia?
Sedation anesthesia, also known as twilight sleep, is a type of anesthesia where you are given medication that allows you to sleep throughout the procedure, while still breathing on your own. This differs from general anesthesia, where a tube is placed in the mouth to breathe for you. Sedation anesthesia is lower risk and the recovery time is shorter. The anesthesiologist monitors you throughout the procedure to ensure the highest degree of safety.

What Are the Benefits of Sedation Anesthesia in the Office?
• Your procedure will be done in the office where you are familiar and comfortable
• A lighter sedation is often administered which can reduce the recovery period
• Shorter waiting times than hospital based procedures
• Less paperwork and administrative overhead than hospital procedures

Frequently Asked Questions About Anesthesia
• Is it safe? – Yes. Sedation and anesthesia have a very strong record of safety.
• Is the anesthesiologist certified? – After completing medical school and residency, an anesthesiologist must complete a rigorous process of board certification. They are also required to undergo continuing education courses annually to ensure they are up to date on the latest developments in the field.
• Are there side effects? – Yes there are, but a vast majority of the patients have little or no side effects. Common side effects are nausea, vomiting, lightheadedness, stomach aches, and headaches. Discuss these with your podiatrist and anesthesiologist.
• Can I drive home after being administered sedatives or anesthesia? – After you have undergone a procedure involving sedatives and/or anesthetics you will be monitored at the facility to ensure full post op recovery. Though you may not feel the effects of anesthesia, there are residual effects that may not be apparent. Patients are advised not to operate a vehicle and/or heavy machinery for a 24 hour period after anesthesia or sedation. This is for your own safety.
• Is it important that I disclose my entire medical history prior to any procedure? – Absolutely. Podiatrists and anesthesiologists are medical professionals and their main purpose is to treat your symptoms so that you regain your health. Your medical history is confidential and is only disclosed to others with your permission. Treatment will vary depending on your state of health and knowing your health history is an important part of the treatment.

How Long Does It Take?
The ingrown toenail procedure is very quick, taking about 15 minutes to perform. Total recovery times vary and are dependent on how quickly your body recovers from anesthesia, but the total time is usually about 1.5-2 hours.

What Are the Risks of the Procedure?
The two main risks of having an ingrown toenail removed are bleeding and infection. Your doctor will give you antibiotics after the procedure to treat and/or prevent any infection. Sterile technique is also used during the procedure to ensure the lowest risk of infection. Bleeding is controlled during the procedure and is usually minimal afterward.

How Did I Get an Ingrown Toenail?
An ingrown toenail is a one of several problems involving the side of the toenail being trapped under the skin abnormally. This is caused by a few factors but usually is due to genetic inheritance. They are very common in children due to the rapid growth of the foot compared with the slow growth of the toenail. The trapped toenail leads to a cut in the skin and then an infection. If untreated the infection continues to grow because the nail blocks the healing of the cut, similar to a splinter in the skin that cannot get out.

What Is Done In the Procedure?
A wedge of the toenail that is trapped under the skin and a small portion of the visible nail are removed, allowing the cut to heal and the infection to drain. Depending on the level of infection, it is often possible to use a chemical to permanently stop the growth of the removed portion of the toenail, so that it does not grow back and cause another ingrown toenail. This can be done if the infection is not too advanced. If the infection is significant, the nail is allowed to grow back and if it causes another ingrown nail, a second procedure can be performed to permanently remove that portion of the nail.

What Is the Recovery Time for the Ingrown Toenail?
After the procedure you will have a bandage on your toe that you must leave intact for 24 hours. After that, the bandage can be removed for cleaning. You will generally need a bandage on your toe for at least a week to ten days depending upon the type of procedure and the person.

How Much Pain Will I Be In After the Procedure?
Your toe will be numb for 1-4 hours after the procedure. Pain is generally mild after the numbness wears off and can be controlled with over the counter medications. Most patients report that they have less pain the day following the procedure, and within a week to ten days most patients have minimal or no pain. Most normal activities can be resumed within 1-2 days of the procedure and this is based on your level of pain.

Moore Balance Brace Now Available

Many of the sensory inputs and postural controls to maintain ones balance decrease with age; increasing the chances of a fall. Studies show 1 in 3 folks over the age of 65 living at home, with current foot pain or disorders, will experience a fall causing an injury; injuries that could require surgery, nursing home intervention, or possibly be fatal.

· Falls and fall related injuries are the leading cause of accidental deaths in older adults.

· Fall related hip injuries alone account for deaths in 25% in those over 65 and 34% for those over 85.

· Half of the seniors who fall once will fall again.

· 40% of nursing home residents fall each year, some more than once.

· Fall related injuries occur more often than strokes and are preventable.

Click Here to Take A Quick Fall Risk Assessment Survey

When sensory information is missing or altered, cooperation and gathering of other sensory information by the brain is used to maintain balance and posture. Plantar cutaneous nerve firing plays an important role in the shaping of postural responses. The results of many studies show loss of plantar sensation is an important contributor to balance deficits and increased risk of falls associated with peripheral neuropathies.

The Moore Balance Brace (MBB) is a prescribed, custom made Ankle Foot Orthosis (AFO) often worn as a pair to help prevent falls and increase sensory information to the brain in order to maintain balance. The AFO brace has several ways it improves balance.

· The AFO brace stimulates cutaneous (skin) mechanoreceptors.

· It leads to additional nervous information sent to the brain and central processing center.

· The AFO brace custom manufacturing enables the brace to become another source of sensory information.

· Improves balance using conditions in which other sensory cues are eliminated.

The fact that the MBB is fabricated from a cast taken from the individual’s foot/ankle assures a perfect fit. The MBB covers part of the foot sole as well as the top of the foot. The ankle is stabilized medially and laterally (several inches above the ankle) thus providing for a significant amount of surface area of the foot/ankle to maximize skin mechanoreceptors.

The Moore Balance Brace has several key features to the custom design:

· Light weight

· No laces or latches that make it difficult for the senior to utilize

· Velcro latching that is easy to latch even after the shoe is on

· Fits comfortably into most shoes

· Some, but not too much cushion on the foot plate for comfort (avoiding a hard shell feel)

Moore Balance Brace· Posterior leaf design to aid in toe clearance

· Custom made to maximize somatosensory feedback

· Eliminates abnormal mechanics (frontal plane ankle motion) while allowing some ankle joint dorsiflexion to aid in a smooth gait

· Padded tongue to prevent rubbing/friction where the ankle is allowed to dorsiflex and plantarflex

· Correction for varus/valgus instability in manufacturing

The Moore Balance Brace is covered by most insurance companies, including Medicare, when used to treat conditions associated with risk factors for falls. The MBB is part of a long term solution to be used in combination with other fall prevention methods. Complete the following form to see if you or your loved one is at risk for a fall.

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 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.

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

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McKinney Office
4501 Medical Drive
Suite 300
McKinney, TX 75069

Prosper Office
221 North Preston Road
Suite C
Prosper, TX 75078

(972) 542-2155

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