Podiatry Management Online


Podiatry Management Online
Podiatry Management Online



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Query: Bulbous Lesion on Distal Hallux


This is a 26 year old male with a growth tip of right great toe present for "a few years". It is getting larger. There is no history of pain or trauma. PMH: unremarkable. There is a bulbous firm lesion tip of hallux extending under the distal nail plate. X-rays reveal no osseus pathology.


Bulbous Lesion on Distal Hallux


A biopsy is scheduled before determining future treatment. If the lesion is benign, what is the best way to remove this lesion in order to close the likely large soft tissue defect?

Other messages in this thread:



Query: The Use of Amniotic Fluid or Stem Cell Injections for Polyneuropathy


Has anyone used amniotic fluid injections, stem cell injections, or other types of regenerative medicine in the treatment of polyneuropathy?  If so, would you please describe your results.


Richard Mann, DPM, Boca Raton, FL



Query: Metanx, Vitamin B6 and Diabetic Neuropathy


I recently prescribed Metanx for a patient with diabetic neuropathy. A few weeks later, the same patient was seen by a neurologist who apparently is a “top neuropathy specialist”. The patient showed the neurologist the bottle of Metanx and was told “it’s the worst thing you can take” and was told to throw it out. The neurologist stated that recent research has shown Vitamin B6, Metanx, is not indicated for diabetic neuropathy. To say the least, I was very surprised to hear that. I have been prescribing Metanx since it has been on the market. Is anyone aware of any recent research that Metanx, Vitamin B6, is contra-indicated for diabetic neuropathy?


Edward Orman, DPM, Perry Hall, MD



Query: Pyogenic Granuloma


This is a 53 year old diabetic female who is paralyzed from the waist down. She had a previous ulceration to the site. It healed with local wound care. Now, this lesion is present at the same site. Two separate punch biopsies were performed and the pathology report came back as a pyogenic granuloma.


Pyogenic Granuloma


The lesion measures 3 x 2.5cm. The skin is intact. Silver nitrate and phenol were applied to the site with minimal reduction of size. I would prefer not to surgically excise it due to her slower healing rate. Any suggestions?



Query: Unusual Unilateral Dermatitis


This 54 year old gentleman has a greater than 20 year history of dermatitis on one foot only. There has been no benefit from topical antibiotics, antifungal, or steroids. Biopsy results show spongiotic dermatitis, with no fungal elements on special stains.


Unusual Unilateral Dermatitis


The patient is otherwise very healthy and takes no medications. The dermatitis is very pruritic and the fissures become painful. Any thoughts or suggestions would be greatly appreciated.



Query: Embolic Phenomena


I had a 64 male non-diabetic patient being treating for endocarditis. He is on week 5 of IV ampicillin/rocephin. He developed an acute onset of pain and swelling in the left forefoot. The pain and swelling is going away but this is the appearance after 4 days. He still has a painful purpura type of skin in the first interspace. 


Embolic Phenomena


I think this may be embolic, but did consider isolated vasculitis from the antibiotics. Any suggestions appreciated. 



Query: Syndactyly


This 26 year old male presents with pain in his 4th toes bilaterally. The 4th digits are contracted and causing pain in shoes. He also complains of “big” 5th digits bilaterally. There is syndactyly of toes 4 and 5 bilaterally and of toes 2 and 3 right foot. He has no pain in toes 2 and 3 right foot and has no desire to address the syndactyly of the 2nd webspace right foot. He is interested in surgical remodeling of the syndactyly of digits 4 and 5 on both feet. X-rays reveal an extra middle and distal phalanx of the 5th digit bilaterally and an enlarged 5th metatarsal bilaterally. The decision has been made to release the syndactyly on digits 4 and 5 bilaterally, remove the extra middle and distal phalanx of the 5th digit, and perform hammertoe correction on the 4th digits. 


Syndactyly of toes 4 and 5 bilaterally


After excision of the extra middle and distal phalanx, how would you address the remaining distal phalanx? The thought now is to just leave it with the medial deviation. It will be okay in shoes and it is not bothering him. A wedge osteotomy of the proximal phalanx to provide a straighter toe may be warranted, but it is a relatively small bone and he has been living with this condition his entire life. The 5th digit is not painful. The hammertoe and de-syndactyly remodel are pretty straight-forward, but what about the excision of the extra middle and distal phalanx?



Query: Leukonychia Following Nd-YAG Laser Treatments


My patient is a healthy, middle-aged Hispanic female whom I have been treating for onychomycosis with an FDA-approved Nd-YAG laser. The onychomycosis had been resolving nicely on all toenails with the nail plate returning to normal thickness, color, texture, etc. When she later came in for a re-check, the nail plates on the hallux toenails only appeared white in color.


Leukonychia Following Nd-YAG Laser Treatments


I have used the same FDA-approved protocol for many years, but I have never seen this. I am sending in samples from the toenails for pathological analysis, but I’m curious if any of my colleagues have had a similar experience and, if so, what their experience(s) have been? 



Query: Gout in a Diabetic?


A 65 year old male with a history of type II diabetes presented last week with a red left 2nd digit. He reported no pain or wound and he had no recollection of any injuries. I thought it could be a bug bite and put him on doxycycline. The redness resolved in a day, but then the toe got swollen with a purplish hue to it. 


AP and MO views of swollen 2nd digit in a 65 year old diabetic


His circulation is normal. I took x-rays (above). I'm wondering if is gout? The bone deformity looks old, but corticol disruption at the base in the medial oblique view could be gouty change? Thoughts?



Query: Asymptomatic Bilateral Puntate Heel Lesions


A healthy 65 year old female presented the other day wondering what was on her heels. The lesions don’t hurt and are only noticeable when walking barefoot on hard tile floors. They developed over a three-year time frame. To her knowledge, no one else in her family has anything similar. Her hands are clear. She is presently taking Lipitor. 


Asymptomatic Bilateral Puntate Heel Lesions


I started her on 30% urea cream to soften the lesions and hopefully prevent problems. Any ideas as to the cause? What treatment besides debridement should be tried if these lesions were to become symptomatic? Is there anything I should have looked for that I didn’t?



Query: EMLA Cream


Does anyone use EMLA® (lidocaine 2.5% and prilocaine 2.5%) cream to numb the skin before minor procedures or injections? I treat the daughter of an elderly patient who would like a prescription to apply to the toes prior to having her nails cut. Any idea if this medication would be effective for that? Could it be used on a patient with painful diabetic neuropathy?


Richard A. Simmons, DPM, Rockledge, FL



Query: Unusual Lesion Medial to the Head of the 1st Metatarsal 


This 29 year old female presented with an extremely "painful bunion" for approximately one year. She is a performer with Disney in Orlando, but does not recall any trauma to the area. She saw another doctor who made her orthotics, which didn't alleviate the pain. 


Unusual Lesion Medial to the Head of the 1st Metatarsal


Physically, her foot appears to have a moderate bunion deformity which is extremely painful upon light palpation. I examined the x-rays and noticed a very unusual lesion medial to the head of the 1st metatarsal. It is very irregular in shape and not attached to the metatarsal. Any thoughts on further examination or diagnosis?



Query: Taste Disturbance with Lamisil


I’m curious to see how many practitioners have had patients report taste disturbance issues after taking Lamisil. I think this is an under-reported serious side-effect. How long does it take on average to resolve and are there any treatments other than stopping the medication and waiting it out? There is not much information in the literature on this other than patient blogs.


Lauri McDaniel, DPM, Union City, CA



Query: Sézary Syndrome


Does anyone have experience treating patients with Sézary syndrome? My patient, the first one I've ever seen with this condition, has weeping lower extremity edema and hyperkeratosis on the soles of his feet. Any input is appreciated.



Query: Relexa+ Shortwave Diathermy for Wound Care


I have a patient with a wound on his forefoot. This non-diabetic patient has an inoperable foot deformity, reduced circulatory status, and some loss of sensation. The patient wanted me to prescribe a Relexa+ shortwave diathermy device to assist with wound healing. I am not familiar with this form of treatment and I would like advice on whether or not to use it.


Edmond F. Mertzenich, DPM, Rockford, IL



Query: Xiaflex (Collagenase) for a Plantar Fibroma


Has anyone used Xiaflex (collagenase) off-label to inject a plantar fibroma in the foot? My orthopedic cohorts use it regularly for hands, with good results. One main problem is reimbursement (@$3,300 per injection), especially with off-label use.


Tip Sullivan, DPM, Jackson, MS



Query: Painful Tyloma Sub Calcaneus


I have a 24 year old African-American female patient with a 2-year history of painful 3 cm tyloma sub the right heel with no history of trauma. She has no health problems. She has normal skin lines upon debridement with a slight hyperchromia of the skin. 


Painful Tyloma Sub Calcaneus


Her physical exam was normal including gait and x-rays. A sonogram shows a 1.76x 0.70cm bursa sub calcaneus. Her MRI was negative. She still has pain after callus debridement, and  padding does not help. What is the possible etiology and treatment other than palliation?



Query: Posterior Calcaneal Spur


I have a healthy, active 73 year old female patient with chronic Achilles pain due to posterior spurring as seen on the x-ray below. All conservative care has been exhausted with the exception of custom orthotics; shoe changes with accommodation, cortisone, needling, soft tissue laser, and PT have been somewhat helpful, but the posterior spur remains the most symptomatic. 


Posterior Calcaneal Spur


I really don’t think the orthotic will be the difference maker at this point. Before she was referred to me for soft tissue laser, her previous DPM recommended surgical removal of the spur, but required removal of the Achilles to resect it. My question is: are there any new approaches or procedures that do not require TAL resection and the associated lengthy recovery?



Query: Shoes for Cavus/Met Adductus Foot


I have a patient, a nurse, who works 12-hour shifts at a group home as well as a number of shifts at a local clinic. She has significant pain in her cavus foot with severe met adductus, especially at her 5th met base. She currently wears Merrills, but wants other options.  


Cavus/Met Adductus Foot


I'm asking for community input on shoes for this foot type. Her pain is achy to sharp, mostly lateral 5th met base, cuboid, and arch. The patient has provided consent to publish photos. 


Pete Smith, DPM, Lancaster PA



Query: Popliteal and Saphenous Blocks


I have used popliteal and saphenous blocks regularly for post-operative pain control on an outpatient basis for many years. Typically, I do not like doing bilateral bunion surgery due to past experiences with complications, but agreed to perform bilateral procedures (after much begging and cajoling with promises of compliance) on a healthy young person needing only neck osteotomies. 


I have never done bilateral popliteal and saphenous blocks on an outpatient basis. I have not found any literature regarding the question except on inpatient cases and was looking for others' experience and thoughts on the matter. The patient will be in a wheelchair NWB post-op due to their living situation and due to the bilateral nature of the case.


Tip Sullivan, DPM, Jackson, MS



Query: Memory Foam Foot Syndrome


I would like to get some feedback on a phenomenon I have been seeing recently. I am calling it memory foam foot syndrome (MFFS). This is a compilation of foot symptoms that are associated with shoes that are lined with "memory foam" or products of a similar base. The patients are complaining about symptoms such as insertional and non-insertional plantar fasciitis, peroneal and posterior tibial tendinitis, and ankle and leg fatigue (shin splints) with activity. There is often irritation to the toes from trying to wear inserts in these shoes, which are overly padded. Although there is one popular brand which seems to be the main culprit, there are a number of different brands which have similar linings.


The problem stems from the fact that the shoes are purchased because they are "lightweight and spongy and supportive." That's fine for a while, but as people wear them for everything, including work and athletic activity, the memory foam breaks down, and without firmness in the soles, the fatigue and tendon/fascia symptoms start to develop, leading them to require professional help. Most people don't associate their symptoms with the shoes until after they are questioned about any changes in activity or footwear. At that point, it seems to come together. I know these shoes are very popular and for a house-type shoe they would be okay. Is anyone else seeing this in their practice? 


Timothy P. Shea, DPM, Concord, CA



Query: Post-Restylane Injection Complication


A 58 year old male presented with a painful corn on the inside of his little toe. Three months prior, a podiatrist treated the corn with an injection of Restylane dermal filler to the little toe, with temporary results. His toe is slightly bulbous and has a spongy (not hard) feeling and is excessively flexible. 


X-rays post Restylane Injections


The x-rays (DP & oblique) are quite disturbing in appearance. His past medical history is unremarkable other than kidney stones. The remainder of the x-rays are unremarkable. Is anyone familiar with the use of this dermal filler and is this a normal appearance post-injection? 



Query: Hyalgan Injections for Ankle Arthritis


Is anyone using Hyalgan injections for ankle arthritis? If so, what dose and how often?


Jay Callarman, DPM, Moses Lake, WA



Query: HIV Meds and Verruca


I think we all agree that warts occur with a greater frequency in people who are immunosuppressed. Among those are people with AIDS and or HIV infections. These days, I seem to be seeing more and more people on chronic long-term maintenance doses of medications for HIV infections. The question is: Do these long-term antiviral maintenance medications affect the incidence of warts in patients receiving therapy?


Tip Sullivan, DPM, Jackson, MS



Query: Drawing up Injectables in Advance


What is the storage timeframe for pre-drawn injectables such as lidocaine in a syringe?


Olga Luepschen, DPM, Sebring, FL 



Query: Treatment for Dystrophic Nails in 12 Year Old  Female


A 12 year old Hispanic female patient presented with bilateral dystrophic hallux toenails. Her parents report this has been present since birth. It is not painful. A Bako pathology report of the nail from 2 years ago revealed saprophytic mold. She was treated at that time with a 3- month course of oral Itraconazole, 100mg/day without improvement.  


Dystrophic Hallux Nails in a 12 Year Old Female


The patient now returns to the office interested in other treatment options. She would prefer to not have the nails permanently removed. Would oral Lamisil be a reasonable and safe option in a patient this young? Other thoughts?.