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06/05/2017    

QUERIES (CLINICAL)


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:


08/22/2018    

QUERIES (CLINICAL)


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? 

08/15/2018    

QUERIES (CLINICAL)


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?

08/14/2018    

QUERIES (CLINICAL)


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?

07/30/2018    

QUERIES (CLINICAL)


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

07/27/2018    

QUERIES (CLINICAL)


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?

07/26/2018    

QUERIES (CLINICAL)


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

07/23/2018    

QUERIES (CLINICAL)


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.

07/17/2018    

QUERIES (CLINICAL)


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

07/11/2018    

QUERIES (CLINICAL)


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

06/23/2018    

QUERIES (CLINICAL)


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?

06/20/2018    

QUERIES (CLINICAL)


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?

06/13/2018    

QUERIES (CLINICAL)


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

06/07/2018    

QUERIES (CLINICAL)


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

05/21/2018    

QUERIES (CLINICAL)


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

05/17/2018    

QUERIES (CLINICAL)


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? 

05/02/2018    

QUERIES (CLINICAL)


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

04/30/2018    

QUERIES (CLINICAL)


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

04/18/2018    

QUERIES (CLINICAL)


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 

04/17/2018    

QUERIES (CLINICAL)


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?.

04/09/2018    

QUERIES (CLINICAL)


Query: Chronic Sesamoiditis with Plantar Plate Lesion


 


A 40-year-old active female who used to do a lot of walking and cycling has had chronic sesamoiditis for three years. During that time, she has had ongoing treatment with all sorts of physical therapy for tibial sesamoiditis, including home use of a bone stimulator daily for 3 months -- all to no avail. In the past 3 years, there have been moderate remissions with exacerbations but never has it been pain-free. An MRI showed an intermediate grade plantar plate lesion/tear medial to the 1st proximal phalangeal base.


 


Her rigid pes cavus foot type has been properly addressed with well cushioned orthotics that closely approximate her high arch with forefoot valgus posting, a first met head cut-out and lots of cushioning under the sesamoid with thicker accommodation around it. She wears them daily in good running shoes. She has seen a number of orthopedists in various places, including the Cleveland Clinic, and is now contemplating a sesamoidectomy by an orthopedist who apparently "does a lot of them.Given that there is no sesamoid fracture, would a sesamoidectomy be a good idea?

04/04/2018    

QUERIES (CLINICAL)


Query: Painful Vesicular Rash on Hands and Feet


 


A 2 year old male developed red vesicular painful rash on the palmar and plantar surface of his hands and feet which started 5-6 weeks ago and seems to be getting worse. Initially, the hands improved, but the rash has returned. There is no history of oral/throat rash, fevers, or other symptoms to indicate hand, foot, and mouth disease.. 


 













Painful rash on palms and soles



 


His parents deny new shoes, socks, detergents, changes in environment/routine. There is no family history of eczema, psoriasis, dermatitis, etc. Cortisone was applied without improvement. I am currently using clobetasol. Input would be appreciated. 


 

03/05/2018    

QUERIES (CLINICAL)


Query: Rapid Onset of Sweaty Feet in a Diabetic


 


I had a patient come in this week who is in his mid-twenties. He has been an insulin-dependent diabetic since age 5. He's about 80 pounds overweight. His chief complaint is sweaty, smelly feet that started only a month ago. My usual first line of treatment is to use an over-the-counter antiperspirant spray on his feet. This did no good. 


 


He changes his shoes frequently so I don't see that this is caused by any pair of shoes. Has anyone heard of a hormonal aspect to hyperhydrosis? 

02/14/2018    

QUERIES (CLINICAL)


Query: Treatment of Verruca in Patient Taking Blood Thinners


 


I would apreciate suggestions for a patient with 2 large warts (1cm lateral 3rd toe and 2cm sub 1st met). The patient is on two blood thinners, and cannot have excisions. The lesions have been frozen by a dermatologist without success. I have used laser treatment, Cantharone plus, and salicylic acid (Veraciti). She has used vinegar and Mediplast. There has been minimal improvement. I would like to know if anyone has used other treatments with success. 

01/17/2018    

QUERIES (CLINICAL)


Query: Dystrophic Heel Pad in a Rheumatoid Patient


 


I was just wondering if anyone has come across this in practice and has any insight as to treatment. The patient is a 50 year old woman who is planning on surgical correction of her painful hammertoes, but also has what she considers unsightly, but non-painful dystrophic heel pads. She enjoys vacationing with her family and she avoids wearing sandals or showing her feet on the beach because of the heels. The the right is worse than the left and they have a cleavage line posteromedially with a somewhat thickened heel pad that is slightly mobile, non-painful to palpation. 


 













Dystrophic Heel Pad in a Rheumatoid Patient



 


X-ray shows a radiolucent ovoid area in the right foot only, which may be consistent with a rheumatoid nodule. I have not obtained further soft tissue studies, as my initial recommendation to the patient is to not address them surgically, since there is no pain, and surgery to resect the nodule or hypertrophic pad itself may leave her with scar tissue or painful neuritis. The patient, however, would still like to see if there is anything she can do.


 


Some of my online research has shown use of GraftJacket for augmentation of painful heel pad atrophy, but nothing specifically for this condition. Does anyone have experience with injection therapy, surgery, or other means to improve this condition?

12/29/2017    

QUERIES (CLINICAL)


Query: Dissolving Foreign Body?


 


A year ago, I took an x-ray of a patient's foot which revealed an unrelated (to the chief complaint) metallic foreign body (FB) that appeared to be a pin. The FB was 2 cm in length and below the calcaneus, entering  plantarly and angled dorsal medially. A year later, she presented with a chief complaint of heel pain. A second x-ray revealed the continued presence of the FB and palpation revealed it to be the source of pain. It had not moved from the original views.


 


Due to the patient's work schedule, removal was scheduled in two months. When the patient came in for removal, I took another x-ray with a grid to determine its exact location. To my shock, the FB was gone. It did not appear in any portion of the foot or ankle area. She also had no pain, but she thought it was because she was avoiding a lot of weight on the heel. She was asymptomatic when I had her walk barefoot on the floor and carpet.


 


Re-examination of my x-rays revealed the initial FB to be relatively solid. The x-ray taken a year later revealed very tiny indentations on the sides of the FB almost serrated. I surmised it was beginning to break down. My question is, "Has anyone had this occur, and what might the object have been, as metal is not likely to have "dissolved"?
Surefit


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