Memory foams are foams that have “memory” to rebound to their original thickness and density when non-weight-bearing. The higher durometer ones, such as midsoles and outsoles of footwear (40 durometer and above on the ‘Sure A’ scale) do not pack down, or bottom out. Most memory foams we use for insoles are made of 15 to 25 durometer polyurethane such as PPT and Poron.
These are highly successful in distributing cushioning over the entire foot in proportion to forces from above and below. Skechers markets their “memory foam’ shoes that do not fulfill the above criteria. They use a much softer material than described above.
I agree with Dr. Shea. Shoes with memory foam insoles bottom out quickly. Some that are new just flatten out. They don't seem to have the resilience or density needed for ambulation. It is not the same as a memory foam mattress, where the weight is distributed over a large surface (our body). The weight distribution to the foot needs more resilience through the "gait cycle", which memory foam doesn't seem to provide. I tell patients that they make good house slippers to soften the hard tile floors but don't have the qualities of a running shoe. I cut several running shoes longitudinally to demonstrate those qualities and then discuss orthotics.
Alas, Dr. Shea, you are not alone. I too have seen an increase in the number of patients I am diagnosing, specifically with either plantar fasciitis, and/or associated peroneal tendinitis in non-athletic patients who either walk for exercise, walk their dogs, walk the grandchildren, or just do their activities of daily living, wearing the shoes you are alluding to.
It seems to be almost always women in my practice who purchase these types of shoes and have these specific issues. However, I relate the issues more to the "non-structured" outer soles of the shoes, rather than...
Editor's Note: Dr. Gurnick's extended-length letter can be read here.
This appears to be Radiasse as the filler in question. It has calcium hydroxyapatite and is the only filler that shows up on x-ray. I have not used a filler in this location. It appears that there is a lot of filler in a small space and that may have caused the complication. For a fifth toe corn, I suspect you would use a very small amount of filler and it appears that too much filler was used. I suspect you can use too much and that may affect the vessels to the toe. We generally use fillers on the plantar aspect of the feet under the metatarsal heads.
This is lollipop toe syndrome (LTS) caused by 1. too much Restylane injected into the toe (way too much in this case) and 2. not padding the injected site with an aperture pad post-injection. All of the Restylane migrated to the tip of the toe instead of staying over the lateral head of the proximal phalanx. It may take 6-12 months to absorb.
Dan Michaels, DPM, MS, Frederick/Hagerstown MD
RE: Cell Phone Causes Toe Fracture
A patient came in with a swollen erythematous distal 2nd toe. Last night, her cell phone fell vertically onto her toe. There is small avulsion/chip that was sheared off the lateral condyle of the base of the distal phalanx of the 2nd toe.
Cell Phone Causes Toe Fracture
Since she has a Morton's type foot, she is getting more pain than usual at toe-off.
Regarding Dr. Callarman's query about Hyalgan in the ankle... I co-authored an article we published in Foot and Ankle International regarding the efficacy of Hylgan in the ankle joint. The article was published with Dr. Roy Altman, our former Chief of Arthritis and University of Miami faculty member. Drs. Altman and Moskowitz published one of the original multi-center trials of Hyalgan for osteoarthritis in the knee and is a gold standard article.
Please also note that there is another fine article published in JBJS regarding the same by Dr. Tom Chang. I hope this helps answer some of the questions raised.
Has Synvisc been approved for joints other than the knee? If not, it is an off-label use which is 100% legal; however, insurance companies may not pay for it and this is an expensive injection. Does anyone have any experience with injections of Synvisc in joints other than the knee with regard to insurance re-imbursement?
I have no experience with Hyalgan, but I used Synvisc One in the military population for ankle and 1st MPJ osteoarthritis. It’s a single injection instead of a series. It comes pre-loaded in a 6cc syringe, I use 6cc into the ankle via a 22 gauge needle every 6 months. Use 1cc for hallux rigidus/limitus.
Whether HIV or meds that are used to treat HIV cause a lack of resistance to the virus that causes warts is a good question. Unfortunately, asking that question to most readers of PM News might not give us the answers we are looking for. Why? Many people will not tell a podiatrist or dentist in private practice that they have AIDS. Only on rare occasions do patients tell me that they are being treated for AIDS. I suspect that many more have the virus but don't want to divulge that aspect of their medical history.
The same holds true for other sexually transmitted diseases. In the last 20 years, not a single new patient has told me about any medical history of having being treated for a sexually transmitted illness. Am I to think that these diseases do not exist in my community? Podiatrists working in hospital settings where "the truth" cannot be hidden might be in a better position to answer Dr. Sullivan's question.
I had a previous patient with similar clinical findings. The patient was 12 years old. Both he and his parents were educated on what I believed to be a fungal condition. The patient was treated with PinPointe laser as well as oral terbinafine, and topical anti-fungals. The patient and his parents were reminded about the importance of parent/patient compliance.
Pre- and post-treatment photos
I rarely remove a nail plate. I’ve improved so many dystrophic nails very simply. As I tell all my patients, it just takes time, patient compliance, and good physician care.
I would like to thank Dr. Shavelson for sharing with the readers the condition of "disappearing nail bed (DNB)". It was a condition I was previously unaware of. Having said that, I do have concerns regarding some of his statements. 1) He states for this condition that the etiology is not primarily infection. In the study he linked us to, I don't see where it stated that. I did see that 36% of DNB in toenails did indeed have fungus, 17% had nail trauma, and 18% a history of prior surgery.
2) Shavelson continues that "continuing to treat as fungal or saprophytic is 'reckless'." If a nail biopsy or culture reveals fungus or mold, then it would NOT be reckless to include this in your treatment paradigm. 3) Shavelson continues to point out the great toe is especially long and parenthetically mentions shoe etiology. The original posting revealed the child was born with the problem.
Referral to a dermatologist would be my first course of action. Pending that consultation result, I would consider a total simple avulsion with regrowth expected. Although we are generally taught to the contrary, I've seen many nails grow back much improved without any medicinal intervention.
Notice that her toenail is short and the distal digital soft tissue is bulbous (pathognomonic). You should notice that her hallux is especially long (shoe etiology). I also detect signs of a flexible forefoot foot type that is serving as underpinning etiology needing treatment that need to be confirmed. If the patient has peroneus longus atrophy or a weakness in the lateral compartment of her legs, the diagnosis will be made.
These toenails need debridement in addition to attention to the other factors mentioned above. A referral to a dermatologically-dedicated DPM is an option. The patient and her parents will thank you.
I think that Lamisil 250 mg Qd x 3 months with LFT monitoring is a good treatment option along with topical Jublia with or without a total nail avulsion Discuss all possible side-effects with the child's parents .
John J. Brummer, DPM, NY, NY
Part of wisdom is knowing what you do not know. Refer this child to a pediatric dermatologist. By virtue of the inquiry, it is likely you are not experienced in this area. You have completed your job by making an appropriate referral to someone with more experience with this pathology.
The cause of the dystrophy of this nail will never be found. If it was present at birth, maybe the trauma was intrauterine or it's even possible that the nail matrix was oxygen deprived; whatever the exact cause, the nail matrix now outputs an abnormal nail plate. The nail plate is not only abnormal in appearance but in all probability is and always will be susceptible to fungal, saprophytic, and bacterial infections.
In my experience, the use of systemic or topical antifungal agents will not cause a normal appearing nail to grow. There may be some who advocate steroid injections into the nail matrix, but in my experience, they are of little benefit. I understand the psychological effect that an abnormal nail may have on her, but the only solution would be to remove the nail and use cosmetic nail replacements periodically, or routinely file the nail to a normal thickness and paint the nail. Sometimes, conditions are not resolvable.
I am not sure why a bone stim was used for sesamoiditis, but I will let others comment on that as I don’t see the correlation, nor do I understand physical therapy for this. She has a “rigid pes cavus” which gives you the possible etiology of her condition. Address the cavus and her pain may also go away. Certainly a gastroc, TAL, Bauman needs to be considered for the equinus as well as a DFWO of either the first met, or cuneiform, or a Cole midfoot osteotomy if it's global, but I have no idea how severe her cavus is.
Rather than removing the sesamoid(s), you can consider removing just the plantar 50% of the sesamoid by planing with a sagittal saw, and leave the articular cartilage. Brace with proper orthoses.
The posting informs us that the patient used a bone stimulator for three months to no avail. The posting also states, an MRI revealed there was no fracture. Hence, it makes sense the bone stimulator didn't work as there was no fracture to treat. The posting indicates an orthotic was made but the assumption is this didn't work out so well as the patient still has the on and off again pain. The poster is questioning the orthopedic doctor's proposal of a sesamoidectomy in light of the fact there is no sesamoid fracture.
I don't think the sesamoid has to be fractured in order to remove it. I don't think heel spurs have to be removed when people have heel pain yet many of my colleagues remove them. What you do have is a positive finding of a intermediate tear of the plantar plate. My question to you is has there been any form of treatment to attempt that as the cause of pain? Afterall, it is a positive finding, one not addressed by the bone stimulator or the orthotics described.
Does the lateral and/or sesamoid view show hypertrophy of the tibial sesamoid? If so, I would plane that off and immobilize the foot in a post-op shoe with 1/2" felt extended out under the met heads to eliminate ground-reactive force under the toes for 4 weeks, then transition back into footgear with an orthotic. The constant overload from a cavus foot type can cause hypertrophy of the bone here. Also consider a TAL if this is a factor.
Consider avascular necrosis (AVN) in your differential diagnosis. I would get an MRI with and without contrast. You're describing a younger, active female with a high arch. This is a classic presentation for AVN, in my experience. I've taken out a fair number of these (I just did one 2 months ago in a situation similar to yours), and they invariably do very well. The symptoms resolved in all cases....and there was no side-effect of developing a bunion...so far.
Painful rashes are not common. This child needs to be evaluated for cardiovascular problems/vasculitis. Once ruled out, then a skin biopsy would be appropriate. Hand, foot, and mouth would be the first consideration, but is usually self-limiting. I would get on the phone with the pediatrician and seek referral to a pediatric cardiologist and/or rheumatologist.
My son is a pediatric dermatologist at the University of Virginia. I sent him this case and photo from PM News. His differential diagnoses include: neutrophilic eccrine hidradenitis, erythromelagia, dyshidrotic eczema, and mercury poisoning. He recommends consulting a pediatric dermatologist of course!
The painful rash on the hands and feet of a two year old likely represents a Cocksackie A 15 viral infection, otherwise known as hand, foot, and mouth disease. He should be seen by the pediatrician and have his throat and mouth examined. This infection is generally self-limiting and extremely common in that pediatric age group.
Consider Aldara (iImiquimod 5%). This is a cream that is applied topically on a daily basis and has to be continued for about four months -- and sometimes longer. While it doesn't kill the wart, it does boost the immune system locally so that the verruca does not survive.
Over the years, I have used laser on verrucae and in those cases when the lesions recurred, I have found the Aldara worked nicely to clear them up. So much so, that in many cases, I'll prescribe it as a first line of treatment rather than laser surgery, especially with children. It is an expensive prescription and patients have to stick with it, which most don't seem to mind, since they usually have had the verruca for such a long period of time to begin with. There is also a slightly less potent version called Zyclara (imiquimod 3.75%) which the drug reps seem to feel works equally well and is a bit less expensive.
I've used the Bleomycin treatment for verrucae for about 15 years now and think of it as my primary treatment course for adults with normal immune systems. With this treatment, I've seen an approximately 98% success rate with the added benefit that if the person has multiple verrucae, treating just the one lesion will allow resolution of all of them in the course of 5-6 weeks.
The procedure entails using the body’s own immune system to kill the wart and follows the path of driving some of the warty material into the dermis, where the body will identify it and raise killer T-cells to the HPV (I, II, IV). As these circulate throughout the body, any place with a wart will...
Editor's note: Dr. Secord's extended-length letter can be read here.
You stated that these two lesions are lateral 3rd toe and 2cm sub 1st met. These are classic locations for an IPK, which may be the reason previous treatments have failed. When treatments are not working, take a biopsy.
Just because a patient is on blood thinners does not necessarily mean they can not have these excised. Proper technique, not going too deep and applying a topical coagulant and compressive dressing can suffice, and consider using a tourniquet along with epi in your injection (but not in the toe). Some may disagree with this, but I have performed surgery on patients on blood thinners, and they too have done well.
Working on the assumption that these are in fact warts, when I have had resistant lesions that have not responded, I resort to injections of Candida albicans extract. Give the patient an Rx. It will cost them about $175 and they can bring it to the office (and make sure to keep it refrigerated). You can get 3-4 treatments out of a 1cc vial. The technique is easy (although can be painful and can be readily found on-line. Basically, use 0.3cc weekly with a tuberculin syringe. I have done this about six times in my career, and it has always worked. Look for clearing by six weeks after initial treatment.
Charles Morelli, DPM, Mamaroneck, NY
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