Podiatry Management Online


Podiatry Management Online
Podiatry Management Online



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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

Other messages in this thread:



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: 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?.



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?



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. 




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? 



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. 



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?



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"?



RE: Should we Prescribe Diuretics for Pedal or Ankle Edema?

From: Elliot Udell, DPM


From time to time, patients present to all of our office with complaints of pedal or ankle edema. In most cases, their internists will either prescribe support hose and or oral diuretics. In discussion with colleagues, there seems to be a split in opinion over whether we as podiatrists should prescribe oral diuretics when indicated. What are some of the prevailing feelings about whether podiatrists should prescribe diuretics for patients with pedal edema or refer them to the patients' primary care physician?


Elliot Udell, DPM, Hickville, NY



Query: Acquired Digital Fibrokeratoma


These toes belong to a 72 year old man with no significant past medical history who presented to my office recently. He states the lesions started in childhood and have been increasing in size; local treatment including what would appear to be cauterization has been unsuccessful. 


Acquired Digital Fibrokeratoma


Biopsy results are: “features suggestive of acquired digital fibrokeratoma”, so not horrible but not much help either. I'm wondering if anyone has seen a similar lesion and can suggest an effective treatment as he is eager to explore options. My thought is to simply excise the lesions and cauterize the wound bed; however, I am concerned about coverage and recurrence. 



Query: Pain in Left 2nd Toe Following Ingestion of Kit Kats


My patient is 69 year old with intermittent pain in the left second toe following consumption of several Kit Kats. He stated that he has eaten other chocolate products and has not had any similar reaction. His medical history includes Stage 3 chronic kidney disease, DM, and depression, but he is under treatment and control. His meds include Glipizide, hydrochlorothiazide, isosorbide, Losartan, and indomethacin. His labs are WNL. 


The first episode occurred a few months ago with a duration lasting 1-2 days followed by complete resolution.  I just thought this was a curious finding. I had never heard of anything like this. There are no biomechanical or LE issues and his regular care is for onychocryptosis. Has anyone ever seen this idiosyncractic reaction? 


Editor's note: The ingredients label of this product says that it contains  PGPR (Palsgaard4150) (an emulsifier). The FDA has deemed PGPR safe for humans as long as you restrict your intake to 7.5 milligrams per kilogram of body weight.



Query: Verrucae Hyperplasia?


A 59 year old female patient presented. Her PMH is only significant for hypertension and smoking. Nothing else would explain her foot conditions. Over the past year, she has developed bilateral hallux verrucoid-like lesions that are very painful. On her initial visit, I sent a partial thickness tissue sample. It was not deep enough to confirm as verrucae, but the pathologist labelled the lesion "suspicious". 


Hallux Verrucae Hyperplasia?


As you can see from the photo, the.overall size of the lesion is approximately 3cm x 2cm. Her previous few months of treatment by her PCP and another DPM have not helped at all, and little had really been done. I don’t think that cantharidin would be a good option for this area, but I am open to other options.  



Query: Minimum Age for Pointe Ballet


What is the recommended minimum age for dancers to start pointe ballet?


Hal Ornstein, DPM, Howell, NJ



RE: Plantar Cerebraform Collagenoma


I am curious if anyone has come across this unusual skin tumor. My patient is a 35-year-old who is very healthy. She developed the skin tumors about 10 years ago and they have been slowly growing. She relates that they seem to get worse every time she became pregnant,  or had a biopsy done. As you can see from the photo, she had a skin graft done years ago, and she relates that the tumors seemed to grow rapidly after the excision with skin graft.


Plantar Cerebraform Collagenoma


The diagnosis is plantar cerebraform collagenoma. The research I have done states that surgery is the cure. However, as you can see, these lesions are too numerous to excise. Fortunately, they are not painful to walk on. She's more concerned about the cosmetics. Any thoughts?



Query: Intractable Plantar Keratoma and Smoking


I've noticed that almost all of the patients that I treat for IPKs are cigarette smokers. Most of these patients also seem to have no causal relationship with plantarflexed metatarsals or elongation of the metatarsal within the parabola. Has anyone else noticed this relationship?


Thomas Nolen, DPM, Salem, IL



Query: Treatment for Severe and Painful Gouty Tophi


Due to chronic gout, this 80 year old retired dentist is non-ambulatory. The severe gouty tophi of both second digits (the symmetry has me stumped), the right much worse than the left, is becoming very painful.  


Severe and Painful Gouty Tophi


Any advice as to how to treat this condition surgically would be appreciated. This patient is followed regularly by his PCP and is taking allopurinol and colchicine for acute flares of pain; colchicine does not reduce pain of the second digits.
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