Query: Isolated Edema and Skin Changes of the Left Foot
I had a patient come in with an unusual complaint. I wonder if anybody out there can give me some ideas what I might be dealing with. The patient had a history of a midfoot stress fracture that was diagnosed by another doctor in April. She states that it became very swollen and the swelling never went away. She denies any pain at this time but states that no matter what she has tried, the swelling will not resolve. She has had some lightly compressive hosiery. She has tried massaging the area. She has rested and elevated the area without relief.
Isolated Edema and Skin Changes of the Left Foot
Evaluation of the patient's left foot shows significant difference from the right. Some violaceous changes of the left foot skin is noted compared to the right. The toes are swollen and the skin on the top of the toes is hardened. Palpation of the edema reveals no pitting. The consistency under the skin appears to be more like fat.
Other messages in this thread:
Query: Allergic to Orthotics
A patient returned for a follow-up visit post-orthoses dispensing and stated that he "must be allergic" to the orthoses as after a few days, his feet developed a pruritic rash. Other than the possibility of hyperhidrosis and/or a reaction to the glue utilized to adhere the Naugehyde top cover to the thermoplastic orthtoic material, I am at a loss to explain this. Can anyone provide a possible cause and perhaps even a "fix"?
Query: Severe Hyperhydrosis of Feet Affecting Bunion Surgery
I have a patient who is considering bunion surgery. On her initial exam, beads of sweat started forming and dripping from her feet within seconds of removing her shoes and continued through the entire appointment. She used to have this problem in her hands and feet. 30 years ago, all types of topicals were prescribed and used with no results. She had a surgical procedure performed which ended her hand perspiration, but not in her feet. My question is should the bunion surgery take place without addressing the hyperhidrosis? She is otherwise healthy, no meds, allergies or other relevant PMH, with no lower extremity vascular issues.
Query: Puncture Wound
A 13 year old female presented with a 3-4 week old puncture wound on her posterior heel. It is painful with no signs of infection. She was barefoot and stepped on a clean doorstop screw at a friend’s house. According to the patient, the screw only punctured superficially. Her PMH was unremarkable. The dermatological exam was unremarkable other than a local epidermal slough. There was no erythema or edema, and no signs of entry, but the area was very painful to direct pressure 2cm peripherally. X-rays were negative for any retained foreign body. I started her on Keflex, 250mg, QID and have her non-weight-bearing. Any other thoughts would be appreciated.
Query: Achilles Tendonitis with Partial Tears in a Professional Basketball Player
I’m seeking advice regarding best care for a professional basketball player who suffered an injury to his Achilles tendon. An ultrasound was done and the report said "tear of 50% of the Achilles tendon." He now is able to ambulate and play without pain; however, given the extent of injury, he asks whether he should have it surgically addressed. He also has flat feet that we intend to address with custom orthotics. His x-rays are unremarkable and the MRI report is as follows:
1. Low-grade partial-thickness interstitial tear of the Achilles tendon extending to its insertion. Mild tendinosis of the Achilles tendon.
2. Mild plantar fasciitis.
3. Mild scar remodeling of the medial and lateral ankle ligaments from chronic low-grade partial-thickness tear.
4. Tendinosis with possible low-grade partial-thickness tear of the peroneal brevis tendon.
5. Mild tendinosis of the posterior tibial tendon at its insertion. Mild tenosynovitis of the medial flexor tendons.
6. Moderate size ankle joint effusion.
Should he be evaluated for surgical intervention?
Query: Silicone Injections for Fat Pad Atrophy
Does anyone have experience with silicone injections for fat pad atrophy? If so, what has your experience been?
Frank DiPalma, DPM, Athens, GA
Query: Arthrogram of the 2nd MPJ
I am looking for instructions on performing an arthrogram of the 2nd MPJ. How much contrast should be injected into the joint? Any tips on imaging technique? I am looking for a plantar plate tear, planning to inject the joint with contrast, and have an MRI performed.
Stefan Lorincz, DPM, Minden, LA
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.
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.
I think this may be embolic, but did consider isolated vasculitis from the antibiotics. Any suggestions appreciated.
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