Podiatry Management Online


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Query: Painful, Discolored Toe

A 62 year old, Caucasian female in apparent good health presented with a chief complaint of a painful second right toe, of several weeks duration. There is no history of trauma. Physical exam was unremarkable other than a Morton's foot with a significantly elongated second digit which is longer on the right foot than on the left. There is a bulbous appearance with a purple/red discoloration. The contralateral toe is normal. Radiographs display soft tissue edema, but no bony abnormalities and no evidence of gas or osteomyelitis. Could this be a bizarre presentation of Raynaud's or secondary trauma from distal shoe irritation due to the length of the toe?

Chuck Ross, DPM, Pittsfield, MA

Other messages in this thread:



Query: DVT Prevention in CAM Walkers  


What type of DVT prevention is recommended when we immobilize our patients, even in CAM walkers?


Jeffrey Klirsfeld, DPM, Levittown, NY



Query: Shoes for a Patient with Choreiform Movements


I have a new patient with choreiform movements of the extremities for the past 10 years. She was treated with atypical combination of antipsychotic medications when she was a teenager but is now on no medication. Her issues include pain in the toes and thick, dystrophy of the hallux nails due to constant trauma while not standing,


I am wondering how to recommend any closed toe shoes for her other than neoprene.  I would appreciate any recommendations.



Query: Recommended Cutoff for A1C for Surgery  


What is the recommended cutoff for A1C for surgical planning, even if the patient states they are “well controlled”?


Jeffrey Klirsfeld, DPM, Levittown, NY



Query: Strep Agalactiae Nail Infection


A 61 year old male presented with symptoms starting last fall. The condition started  as swelling around the nail. The nail becomes loose, with white purulence present. The skin sheds and has weeping. The remaining nail is very soft. In those affected digits, he is having significant arthritic symptoms. This started in a toe, then a finger, then a toe, etc.  (There are 7 digits affected).


Strep Agalactiae Nail Infection


He has tried: oral and topical anti-fungal, antibiotics, soaking in apple cider vinegar, and in dilute bleach, and has tried oral and topical steroids.  All treatments have alleviated some of the symptoms, but it is still progressing. Uric acid 6.7, ESR: 16, RF <10, CRP 3.1, CBC normal, ANA negative, fungal culture negative, cultured Strep agalactiae. Suggestions?



Query: Foot and Ankle Pain Post-COVID Vaccine


I have seen 4 patients who have developed increasing foot and ankle pain post-COVID vaccine. They seem to do worse after the second vaccine dose. Has anyone else had this experience?


Kaitlin Gonzales, DPM, Roselle, NJ



Query: Intermetatarsal Bursitis


I have a patient who developed a sharp pain "like walking on a pebble", with popping in the 3rd interspace after walking with ice cleats in late January. It appeared to be a typical Morton's neuroma but after no response to 3 cortisone injections along with tapings and met pads, an MRI was ordered. The only thing the MRI showed is some fluid in the interspace consistent with an intermetatarsal bursitis with no evidence of neuroma or other neurovascular abnormalities.  


The patient hasn't been able to walk much with very limited activities because of the pain.  Any ideas on how to treat an intermetatarsal bursitis conservatively?



Query: Inserts or Adjustments for an Arborist


I’m looking for advice and recommendations on shoes or inserts or adjustments to accommodate a healthy, fit 35 year old professional arborist. He uses Buckingham steel climbers for tree climbing which hits his medial plantar calcaneal tubercle, hurting it. He is already doing his stretching exercises, wearing orthotics with heel cutouts for off-loading, wearing an equinus brace, wearing a night splint, had a cortisone injection, which all helped. But he feels the steel is hitting the very spot that causes him pain.


I wonder if there is something that can be done to the steel, shoes, or orthotics to help minimize the pressure to his distal heel where it hits the straps on his work boots.



Query: Hallux Pain in a 97 Year Old Male


A 97 year old male presented with right hallux pain, mostly around the IPJ. The digit is hammered, with a small wound dorsal to the joint, but with no exudate. Cultures are negative, and x-rays were not suspicious for osteomyelitis. The is very obvious peripheral vascular insufficiency. I already have him on Trental, which has helped. I doubt any vascular surgeon would touch a 97 year old outside of an emergency.


Is nitro paste around the tarsal tunnel still used? I haven't read anything about it in many years. If so, how is it applied? How often? I know I can send him for an MRI or bone scan to further investigate osteomyelitis, but question whether, considering his age, a positive diagnosis would lead to a reasonable treatment .



Query: Post-Surgical Neuropathic Pain and COVID-19


In the last 3 months, we have noticed an increase in neuropathic pain in some of our patients who have undergone surgeries after receiving recent COVID-19 vaccinations. I assume this is an inflammatory response triggered by the vaccination. Has anyone else noticed this as well?


David Weiss, DPM, Henrico, VA



Query: Green Toenails


The patient is a 72 year old male who came to the office complaining of 10 green toenails. He has no history of new green interior shoes or green socks. He had been using topical Kerasal nail renewal 2x daily and states green color appeared subsequently. Certainly not pseudomonas nor candida. Not removable with alcohol swab. The green is easily removed on left foot with rotary sanding disc.


Green toenails


Before treatment, I suggested he wait until after St. Patrick's Day. Anyone else see this colorful side-effect? Kerasal’s main ingredients include propylene glycol, urea, lactic acid, sodium hydroxide EDTA. I personally use this product with no ill effect.



Query: Random Bruising on Feet


A 30 year old female presented with excruciating pain to her heels that runs up her calves. The pain would keep her up at night crying. She is otherwise healthy but 2 years ago, she was having pains all over and was eventually diagnosed with a connective tissue disorder, non-specific, by her rheumatologist. He put her on plaquenil. Because of all the pain she is having, throughout the years, he sent her to 14 different specialists. She doesn't have pain like typical plantar fasciitis or tendinitis or nerve pain like tarsal tunnel. Her feet are cold and changes color. It was thought that she has Raynaud's but her rheumatologist later dismissed it because of the pics she just sent me of the random bruising she would get. These are not necessarily the painful areas. They just appear out of nowhere.  


Random Bruising on Feet


Initially, I prescribed her nitro paste which helped her cold feet, but not the pain. I prescribed her a steroid pack. She said that was the only thing that seemed to have helped her pain and was a great relief to her, but about a month later, the pains came back with a vengeance. Any ideas of what she might have that would give her random bruisings? I'm planning to give her another steroid pack but to consult with her rheumatologist on maybe a more long-term steroid regimen.



Query: Turf Toe


I am trying to help a patient with turf toe. He injured his foot while playing rugby. He described being tackled and having the 1st MPJ severely extended. He was in a good amount of pain and self-treated his condition with the R.I.C.E. protocol. There was moderate pain when palpating the 1st MPJ, mostly around the plantar and lateral aspect of the joint. Mild to moderate edema was noted. Increased pain was elicited with dorsiflexion of the joint. Palpation of the sesamoid bones did not elicit pain.  


He does not want to have x-rays. His ability to ambulate seems to rule out severe ligament injury. Clinically, I would diagnose this as a stage one to stage two turf toe injury. I recommended rest and anti-inflammatories. I cast him for orthotics and will incorporate a Morton's extension to limit dorsiflexion of the 1st MPJ. I assume he can continue to wear this device even when he begins playing rugby again. Is there any other accommodation I should be incorporating into his orthotic? I educated him on the need to wear a rigid sole athletic shoe such as the Brooks Beast or New Balance 1540 when he is not wearing his work boots.



Query: Heel Pressure-Induced Injuries (Decubiti)


After more than 40 years in active practice, I still find decubiti challenging to treat. Off-loading continues to be a chore, and patient compliance is very difficult as well. I have experimented with various devices with a mixed array of results. I am wondering if these thoughts are universal.


Michael J Marcus, DPM, Montebello, CA



Query:  MIS Surgery on a Patient with Sickle Cell Anemia

I have always avoided operating on anyone with sickle cell (not trait) anemia. However, I would like an opinion from some of my colleagues on an unusual situation. I have a 16 year old patient who is having real psychological problems because of severe painful hallux valgus deformities. She is bullied, made fun of, and refuses to go to school because of her feet. The parents are all for having it done, though I explained the risks, and though I have not spoken to her PCP yet, he gave her a medical clearance. Does anyone have experience operating on a sickle cell patient, or should this be avoided at all costs. The procedure would be performed in an outpatient ASC using minimally invasive surgical techniques.



Query: Dermatitis or COVID-19?


A 29 year old  healthy female presented with this rash on top of her foot. She had a pedicure 2 days prior, where gel polish was removed with acetone wraps on her toes. Acetone did not contact the top of her foot. She felt immediate burning on the affected foot upon placing her feet in a basin of warm water. The lesions appeared almost immediately and became progressively worse. The other foot shows some very mild lesions.


Dermatitis or COVID-19?


The foot does not itch but is painful and tender. 1% hydrocortisone cream didn't help and caused burning. There is no cellulitis, lymphangitis, or lymphadenitis. She received the second Pfizer shot about 10 days prior. She developed reactions consisting of flare of cold sores, flare of eczema, mild fever, and fatigue that lasted 1-2 days. My question is could this be a reaction to the COVID-19 vaccine? I started her on antibiotics. If there is no improvement next appointment, I plan on a biopsy. I told her to call the phone number on the vaccine card about this possible vaccine reaction. Any thoughts would be appreciated.



Query: Intralesional Candida Antigen Injections for Verruca Plantaris


I have a patient with numerous bilateral recalcitrant verruca plantaris ask about treatment with candida injections. I have done some research, but wonder if anyone has experience with efficacy, side-effects, and could share your protocol and billing practice.


Karla Stipati, DPM, Saint Charles, IL



Query: Recommendations for Treatment of Raynaud's 


Since this winter has been colder than usual, a lot of my patients, especially females, are having issues with Raynaud’s changes to their toes. What are your treatments? Many of my patients are home (due to COVID) and not in shoes and socks as well.


Jeffrey Klirsfeld, DPM, Levittown, NY



Query: Nerve Entrapment


My patient is a 30+ y/o African-American lady who has had two previous tarsal tunnel releases with re-entrapment. Her PMH is unremarkable. Her previous surgical scars are heavy but not keloid. She has point tenderness distal to the tarsal tunnel where the nerve dives behind the muscle, mainly involving the medial branch. 


I have not used any nerve conduit for many years but I am considering it on this case. I have used GraftJacket as well as products to decrease formation of excess scar tissue but there is just nothing that I could say gives consistently good results. Suggestions and comments are welcomed.



Query: Prurigo Nodularis/Picker's Nodule


Recently, I surgically excised a skin lesion on a 62 year old well-controlled diabetic female. The pathology report came back: prurigo nodularis/Picker's nodule with underlying scar/granulation tissue and fat necrosis. Should I have any concerns as to the post-op course? It has been three weeks and healing has been uneventful.



Query: Non-Painful Bump on Ankle


This is an unusual incidental soft tissue finding in a 50 year old male who came in with painful retro-calcaneal pain. He recently noticed a non-painful bump on his ankle.


X-Rays of Non-Painful Bump on Ankle


He is on no meds and appears healthy. He has no history of parathyroid or other metabolic problems. Comments?



Query: Post-vaccination Dystrophic Toenails 


A middle-aged female presented with dystrophic toenails. She relates that she had COVID back in May with no cough but had a 103 degree fever for 2 days. She has the antibodies to COVID. She took the first dose of the Moderna vaccine about two weeks ago and got fever, chills, and pains in her leg that felt like they were "shooting out of her toes." 


Post-vaccination Dystrophic Toenails


Her symptoms lasted for two days. She had no trauma to the toenails, and did not change footgear. She is healthy with no meds and no allergies. There is no pain associated with the nail beds, and the rest of the nail seems to be attached to the nail bed. She contacted the CDC before the nails had this deformity, and is going to contact them again. Has anyone else seen this?



Query: Prescribing Protocol for Oral Antifungals


Has anyone changed their prescribing protocol for oral antifungals? I read a recent study where the authors did not see appreciable increases in liver enzymes throughout a 3-month course of Lamisil therapy. These patients did have higher than normal liver enzymes prior to starting the medication. If that is true and oral antifungals do not cause an increase in liver enzymes, then is there really a need to order a LFT prior to prescribing these medications?


Is anyone prescribing Lamisil (or any other oral antifungal) without first requiring a liver function test? Or, for that matter, prescribing oral antifungals to patients with already high liver enzymes (out of normal range)? This potentially creates a huge shift in how most of us practice. Are you aware of other studies with similar findings? 


Dave Williams, DPM, El Paso, TX



Query: Treatment for Nail Problem in an 8 Year Old


I have an 8 year old patient with hallux nails that grow into the distal tuft. I successfully phenolized the borders so that he no longer gets infections. 


Nail Problem in an 8 Year Old


I am asking for suggestions for care. How can I get these nails to grow over and beyond the tuft?



Query: Petechial Flexural Eruption and Digitate Papulosquamous Rashes?


In a recent Internet post by Eat This, Not That called "98 Symptoms Coronavirus Patients Say They've Had"---symptom number 64 as reported by JAMA Dermatology notes two types of rashes in some patients infected with the coronavirus:

                                          1.  petechial flexural eruption.

                                          2.  digitate papulosquamous rashes.


The post goes on to state "these skin conditions could occur at any time during and after infection and may contribute to the feeling of burning skin". The 98 symptoms were reported by what are now called "Covid Long Haulers", who may have had a severe or mild initial case of the contagion, but gets relapses of these symptoms for some time. About 10% of all clinical cases (not positive blood tests that have been conflated as cases) may be in that category. Can a dermatology maven out there translate these two descriptions into usable clinical images?


 Robert Teitelbaum, DPM, Naples, FL



Query: Amniotic Fluid Injections for Moderate to Severe Osteoarthrosis


I have a 57 year old healthy, female patient with right ankle trauma in 1987. Recent x-rays, MRI and CT resulted in the following conclusions: Mild posterior subtalar joint osteoarthrosis, severe talonavicular joint osteoarthrosis, mild calcaneocuboid joint osteoarthrosis, moderate navicular-intermediate cuneiform joint osteoarthrosis, moderate navicular-lateral cuneiform joint osteoarthrosis, and mild navicular-medial cuneiform joint osteoarthrosis. She is looking to avoid surgery, as her only real option is multiple mid-foot fusions. She has worn a Ritchie brace, undergone cortisone injections, and exhausted all traditional, conservative medical care. 


My question to my colleagues who have incorporated amniotic fluid injections and utilized them for a severe case is what were the results? I understand that everybody will respond differently. The patient is very open to the idea and I further believe that amniotic fluid will be more beneficial for her than PRP. With the multiple involved joints involved, the plan is for at least 4cc of fluid into multiple joints. The cost is not an issue, but I am curious what your experiences have been with its use for what I would consider to be a more extreme scenario than just PF, mild OA, neuroma, etc.

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