Psoriasis
Psoriasis is an systemic inflammatory disease that is caused by abnormalities in the immune system. In our practice, psoriasis commonly affects the bottom of the patient’s feet and manifests as a reddened-type rash with silvery scales or flakes of skin. The skin lesions are usually symmetrical. Psoriasis is commonly painful, itchy, inflamed, and can crack or fissure.
Psoriasis can also cause metabolic syndrome which causes patients to be more susceptible to diabetes, high blood pressure, high cholesterol and obesity. Psoriasis patients are more prone to having heart attacks and depression as well.
Psoriasis is commonly misdiagnosed as chronic athlete’s foot. Patient are commonly prescribed antifungal creams medications that do not end up working.
Psoriasis affects the toenails. The toenails will sometimes have little pits or divots. Sometimes the nails with be rough like sandpaper instead of smooth. The nails can have a tendency to come off. The nails can also have a dirty, brown appearance as if the nail was dipped in crude oil. The nails are often misdiagnosed as having fungus.
The patient will often have psoriasis in other places such as the knees, elbows, scalp and along creases in the skin folds such on the bottom or under the breasts. Oftentimes, the hands will manifest identically to the feet.
To diagnose psoriasis, a punch biopsy of the skin is most definitive. Once diagnosed, treatment can be started.
Treatments
Topicals
1. Topical corticosteroids – some topical steroids are very strong and some are not. Some stronger topical steroids are betamethasone, halobetasol, and clobetasol. These meds are typically only used for 1-2 weeks at the most. If they are used for a prolonged time period, it may cause the skin to become thin, develop stretch marks, and cause the skin healing to slow down. The lower dose topical steroids can be used for longer time frames.
2. Vitamin D Analogs – these medicines decrease inflammation and lessen the prominence of the skin lesions. Medications such as Dovonex and calcitriol are used twice daily. Taclonex is a combination of steroid with a vitamin D analog.
3. Topical calcineurin inhibitors – an ointment called Tacrolimus is usually combined with salicylic acid. This ointment locally affects the immune system to slow down the progression of the psoriatic lesions.
4. Keratolytics – skin creams with lactic acid, salicylic acid and urea are often used to decrease the amount of scaling and soften the hard skin.
5. Moisturizers – there is a large quantity of OTC and prescription moisturizers that can be used immediately after bathing to prevent recurrence of skin lesions and keep them at bay.
6. Topical retinoids – a medication called Tazarotene can be used once daily to decrease inflammation and decrease the amount of skin cell development at the site of the psoriatic lesions.
7. Coal tar – can decrease inflammation and itching. The downside to this product is that it has an odor, can stain the clothes and can cause sensitivity to sunshine.
8. Anthralin – research does not yet know how this product works
If you have psoriasis and desire treatment, please come see Dr. Silvers at Advanced Foot & Ankle Center in both McKinney, TX and Prosper, TX.
Call 972-542-2155 for an appointment today.
Pain in the Ball of the Foot
Almost every person at some point has had pain in the ball of their foot. Most patients don’t know that there is wide array of potential elements that can be factored as the cause of the pain. I am going to discuss a few of the possible cause of metatarsalgia. Metatarsalgia is a trashcan term. It encompasses all the problems that could potentially be cause the ball of your foot to hurt. Below is short list of common problems that can be classified under the term metatarsalgia and how we as doctors come to the conclusion of what you may have.
Examination
I first ask myself these questions.
1. What is the height of the patient’s arch – high or low?
If there is a high arch, the patient usually bears weight on the heel and the lateral ball of the foot, just behind the pinky toe.
If the arch is low, the patient usually bears weight on the medial ball of the foot, or the ball of the foot just behind the big toe.
2. Is there a bunion or hammertoes present?
If the patient has a bunion or hammertoes, patients will bear moreweight on the center ball of the foot.
3. Does the patient have a really long 2nd toe?
If the patient has a long 2nd toe, the patient will bear more weight to the ball of the foot just behind the 2nd toe.
The next thing I do is “push up” test. I apply a load with my hand to the ball of the foot and examine whether the toes straighten out or they remained curved or deviated or contracted. If this is the case, then there may be disruption at the joint capsule at the base of the toe.
I thoroghally examine the range-of-motion of each toe.
I then proceed to examine the spaces between the bones in the ball of the foot. These spaces contain the vessels, nerves and small muscles of the ball of the foot. I press from the top and botom in the spaces while at the same squeezing the sides of the foot together. Sometimes a nerve can be entrapped or squeezed abnormally between the bones and cause pain. Sometimes there can be a fluid filled sac called a bursa in the spaces and cause pain as well.
Next I press on the bones in the ball of the foot. If there is pain at the bases of the toe, just distal to the bones in the ball of the foot, the patient may have a inflammation of the joint capsule. Another test to examine the joints in the ball of the foot is called a Lachman test. The ball of the foot is held in place and the toe is pulled as a unit. This causes stretching of the joint capsule. If this test causes pain, it only reinforces that a joint capsule problem may be occurring.
X-rays are always taken to rule out bone deformities, stress fracture and to make sure the bones in the ball of the foot are normal lengths.
Diagnoses
Once the previous exams are performed, then I attempt to arrive at a diagnosis. The most causes of pain in the ball of the foot in order of most common to least common as seen in the practice are as follows :
1. Metatarsophalangeal joint capsulitis
2. Intermetatarsal space neuroma
3. Metatarsal stress fracture
4. Abnormal metatarsal length
5. Arthritis
6. Avascular necrosis of the metatarsal head
7. Tumors
I know these terms don’t mean much to patients, but feel free to look them up on the internet.
If you have pain in the ball of your foot, please come see Dr. Eric Silvers at Advanced Foot & Ankle Center in McKinney, TX and Prosper, TX.
Call 972-542-2155 for an appointment today.
How Are Puncture Wounds Treated?
Puncture wounds can hurt. They can vary from safety pins to needles and from toothpicks to knife wounds. The question is “How do we treat them at our office?” First, puncture wounds can be very difficult or very easy to fix.
An intensive history and precise account of the method in which the puncture wound occurred is taken from the patient.
X-rays are usually taken to rule out that a foreign body is still present inside the foot. Ultrasound can also be used to examine the foot for retained foreign body.
If it has been several days since the puncture wound occurred, an MRI may be warranted to rule out bone infection or an abscess inside the foot. Sometimes, a nuclear bone scan can also be used to rule out out or rule in bone infection.
X-rays can also rule out gas gangrene in the tissues.
Sometimes blood labs are taken to analyze the white blood cell count (high in infection and inflammation), electrolytes, and a few other markers called ESR and CRP (also high in inflammation and infection).
After this, the puncture site is often cleaned and prepped for foreign body retrieval. All abscesses or pus pockets are drained properly. All bad tissue is removed. If the foreign body is able to be sen, then it is removed. If the foreign body is very deep and unable to be retrieved in the office, then usually surgical intervention is taken and the patient is taken to the operating room for use of live x-ray for more a more intensive search for the object.
If MRI has shown that bone infection is present, then all necrotic or infected bone is removed fully.
Once the foreign body is take out, the wound is flushed with sterile saline.
Sometimes, the wounds must be left open to drain, especially if they are infected. If the wound is large, sometimes the patients have to be taken back to the operating room for closure of the wound after all infection has been drained out.
Patient are usually placed on antibiotics, either for prophylaxis or to treat a fully developed infection.
If you have a puncture wound, please come see Dr. Kory Williams or Dr. Eric Silvers at Advanced Foot & Ankle Center for treatment.
Call 972-542-2155 for a appointment today.
Does A Heel Spur Cause Plantar Fasciitis?
When people have plantar fasciitis or pain on the bottom of the heel or arch, they may feel a stabbing or sharp pain. Many people think they have a large heel spur tring to poke out the bottom of their heel.
In actuality, not all people who have plantar fasciitis have a heel spur. You must not correlate the size of a heel spur with the amount of heel pain present. Many patients walk into our office everyday with plantar fasciitis and have no remnants of a heel spur. Many patients walk into the office with a huge heel spur and have absolutely no heel pain. But there are people who fall in the middle and have plantar fasciitis and do have a heel spur.
Some think that the heel spur develops because of traction or pulling on the bone by the plantar fascia. This is completely false. In the foot, there are dozens of small tiny muscles, especially on the bottom of the foot. Research has shown that if a patient has a heel spur and dissection was performed on the patient’s foot at the site of the heel spur, it would show that the plantar fascia does not insert on the heel spur. Instead, about 2-3 tiny muscles in the bottom of the foot originate from heel spur. The plantar fascia actually inserts on the bottom of the heel bone just lateral or below the heel spur. Poor foot mechanics can cause greater muscle activity inside the foot and lead to the development of the heel spur.
What are the 2 most common things that can happen if the heel spur is taken out?
1. Possible stress fracture of the heel bone
2. Deep space infection in the surgical area
Overall, heel spur removal is seldom necessary in treating pain associated with plantar fasciitis. There is no correlation of the heel spur with the plantar fascia from an anatomic perspective. Many people get better from plantar fasciitis with conservative therapy while the heel spur remains present. According to the latest research, there is no evidence to support routine surgical removal heel spurs during the course of a plantar fascia surgery.
If you have plantar fasciitis and you are interested in having surgery on the foot, please come see Dr. Kory Williams or Dr. Eric Silvers at Advanced Foot & Ankle Center in McKinney, TX and Prosper, TX.
Call 972-542-2155 for an appointment today.
Lateral Ankle Sprains
It is thought that ankle sprains happen about 30,000 times per day and make up about 30% of all sports injuries. An estimated 60% of people who suffer from an ankle sprain never seek professional or podiatric treatment. Half of those people will develop chronic symptoms such as severe ankle pain, swelling, recurrent injury, and instability of the ankle.
Research has shown that low grade ankle sprains develop chronic symptoms just as frequently as high grade ankle sprains. This evidence shows that even mild sprains deserve professional attention.
There is huge debate on how ankle sprains should be treated. There are physicians who believe immobilization is the answer. There are others who feel immobilization is wrong. There are also other doctors who think surgery is the most appropriate answer to repairing severe sprains.
When comparing immobilization to mobilization or “functional treatment”, functional treatment has been shown as the best treatment. This proves true when looking return to work, return to sports, pain swelling, range of motion, and cost.
Early mobilization also reduces the degenerative effects of immobilization. Research has shown there is no benefit to immobilizing lateral ankle sprains and may doctors feel that immobilization should be abandoned except in select patients.
Is surgery the best option? Not always. Journals reveal that early mobilization still provides the fastest recovery of ankle joint mobility with the quickest return to sport. Surgery is only indicated when the individual continues to suffer from recurrent sprains and instability.
How do we treat lateral ankle sprains at Advanced Foot & Ankle Center?
First, if the sprain is fresh and there is a moderate to severe amount of swelling present, the patient is placed into a compression dressing such as an UNNA boot. An UNNA boot is tight compressive dressing comprised cast padding and calamine impregnated guaze. See the picture below:
If the swelling is minimal and no compression is needed, then depending on the severity of the sprain then one of two things is performed:
1. Support with an ASO Ankle Brace
2. Immobilization in a pneumatic walking boot
Once a short period of immobilization is performed, physical therapy may be implemented to increased range-of-motion, ankle strength, walking or running capabilities and balance.
If the patient continues to have severe pain regardless of immobilization or early mobilization via physical therapy, then an MRI may be warranted to examine the integrity of the ankle ligaments.
If the MRI is performed, and there is evidence of ankle ligament rupture, then surgical intervention may be implemented. Surgery repair of ankle ligaments will be explained in more details by the doctors in the office if warranted.
If you have suffered from chronic ankle instability or have suffered a recent sprain, please come see Dr. Kory Williams or Dr. Eric Silvers at Advanced Foot & Ankle Center for assessment and treatment.
Please call for an appointment today! 972-542-2155
Rheumatoid Arthritis of the Foot
Rheumatoid arthritis is a disease with inflammatory changes through out the connective tissues. It is generally a wasting disease with muscle and bone atrophy. Chronic inflammation causes damage to joint capsules and cartilage which are replaced with inflammatory tissue.
On x-ray, the cartilage is worn away, leaving no joint space and bone-on-bone grinding. The bone density lessens at the joint and the bone shows areas which have been “chewed up” from the inflammatory changes. Most joints end up becoming dislocated and have severity deformity.
Rheumatoid arthritis mostly affects the small joints of the foot. Therefore, most of the deformity lies at the toe or forefoot level. It can also be present in the hindfoot or ankle causing collapsing of the foot or ankle and causing a severe flatfoot deformity.
Clinically, most patients have severe pain after periods of immobility. Joints become very stiff and difficult to manuever. Pain and stiffness often subside somewhat after motion has proceeded and the joint “warms up.” Prolonged activity therefore thereafter can lead to worsening of pain.
Symptoms of rheumatoid arthritis can include weight loss, fever, coldness, numbness, tingling, fatigue and malaise. Common findings are symmetrical swelling of the toes, tenderness with touch, and pain with motion. The swelling is often spongy or rubbery. When there is limited motion for a prolonged time period, muscle wasting and joint contracture occurs. This is usually followed by joint fibrosis and fusion of bones. Sometimes, large nodules can form on the ball of the foot or on the toes. These are called rheumatoid nodules.
The diagnoses of rheumatoid arthritis is based on disease characteristics over time. Classic rheumatoid arthritis displays seven of the following symptoms, the first five presenting for at least 6 weeks:
- Morning stiffness
- Painful range of motion in at least one joint
- Swelling in at least one joint
- Swelling of at least one other joint
- Symmetrical joint involvement with simultaneous involvement of the same joint on both sides of the body
- Subcutaneous nodules
- X-ray changes typical of RA
- Positive blood test showinf rhematoid factor
- Joint fluid changes
- Changes in the structure of the joint capsule on microscope
Rheumatoid arthritis is a devastating disease causing severe changes in the feet. If you have RA, several things can be done to alleviate your pain.
Custom orthotics and braces
Orthotics can be custom molded to the feet to accommodate nodules and bony prominences. We offer accommodative orthotics that are very cushioning and can provide excellent comfort. Custom braces can e molded to your extremity to alleviate the most severe deformities.
Surgery
Oftentimes, surgery is very successful in alleviating rheumatoid foot pain. Excision of rheumatoid nodules, or straightening of digits or bunion deformities can be performed.
Please come to Advanced Foot & Ankle Center and see Dr. Williams or Dr. Silvers if you have RA and we will provide the utmost and highest quality care for your feet.
