Do you have a callus or a wart?

Many patients come into the office with painful lesions on the bottom of the foot. Some patients will have self diagnosed their condition and even begun a treatment regimen of topical creams, ointments, salves or even compound products (2 or more elements (medications) mixed into one).
Usually these products don't work or the patient is not seeing the results that they expect, so they appear in the office for a consultation.

Usually a scraping of the lesion with a scalpel blade is necessary to determine exactly what kind of lesion is on the foot. This scraping is usually not painful.
Different types of lesions:
Callus usually form in areas of pressure or friction. They usually appear yellow or gray.

Warts are viruses caused by Human Papilloma Virus (HPV). Warts have many different color variations such as gray, brown, or pink. Some have dark spots throughout or A single dark spot in the middle. Warts will not usually go away on their own if the immune system is weakened.

Treatment for calluses is usually shaving the lesion down and applying cream to soften them.

Treatment for warts usually consists of shaving down the lesion, freezing the lesion, applying Salicylic Acid and covering the lesion to prevent it from breathing. Laser therapy can even be performed.

My office can help you determine what lesion you may have and perform the appropriate treatment option. We also have a state of the art laser. Stop by for a consultation.

Morton's Neuroma

 

 

Morton's Neuroma

 

Morton's neuroma has been known by several other names: Morton's metatarsalgia, Morton's neuralgia, plantar neuroma and intermetatarsal neuroma)

Patients will often complain of  pain and/or numbness of their forefoot in between the 2nd and 3rd or 3rd and 4th metatarsals heads.  The pain is usually elicited by shoe gear (pain when the toes are pressed together inside of the shoe) or with a pressing motion (such as pressing on the brake during driving), or walking.

The term was first described by a Chiropodist Lewis Durlacher in 1845. Although it is a called a Neuroma, it is believed to be a perineural fibroma rather than a true tumor.

Although the best way to visualize a neuroma is by ultrasound or MRI, a standard x-ray may also be taken to rule out any trauma like a fractures or a bone lesion or arthritis. Standard x-ray will not typically show soft tissue lesions.

Ultrasound can also be used to guide therapeutic Cortisone injections to alleviate painful symptoms associated with the Morton's Neuroma.

 

Widely used forms of conservative treatments for Morton's Neuroma are orthotics and corticosteroid injections. An addition to traditional orthotic arch supports, a small foam or fabric pad may be positioned under the space between the two affected metatarsals. This pad helps to separate the metatarsal bones and create more space for the nerve so as to relieve pressure and irritation. Unfortunately it may cause mild uncomfortable sensations of its own, such as the feeling of having an awkward object under one's foot.

Corticosteroid injections can relieve inflammation and pain in some patients and help to alleviate the symptoms. However, the inflammation and pain recur after some weeks or months, and corticosteroids can only be used a limited number of times because they cause damage to the ligaments and tendons of the foot.

Sclerosing alcohol injections are also a treatment alternative if  other conservative methods fail. A direct injection of 4% alcohol can be placed into the area of the neuroma, causing toxicity to the fibrous nerve tissue.
Most often,  this treatment must be performed 2–4 times at 1–3 weeks intervals.

Another treatment modality of Morton's Neuroma is Radio Frequency Ablation. The effectiveness of the treatment is speculative.

Surgery is often the last resort and a procedure known as neurectomy (which involves removing the affected piece of nerve tissue), may be performed.
A postoperative scar tissue formation (stump neuroma) can occur in approximately 20% of cases, causing a return of neuroma symptoms

 

 

Oh No! I broke my toe!

Broken Toes

Oh No! I broke my Toe!

 

Many patients present to the office with suspected broken toes. Any toe can be broken but in my professional experience, the most commonly broken toes are the 4th or the 5th.  I'm not sure if it is because they are generally the smallest and therefore easier to break. But most patients state that they are the most bumped toes in the middle of the night.

Broken toes should not be confused with broken metatarsals which are the long bones of the foot that sit behind the toes.

 

 

Metatarsals

 

Toe

A broken toe is relatively quick to heal in a healthy patient. The standard protocol is rest, ice, compression and elevation. I also like to buddy splint the toes together (with a guaze in between prevent sweating between the toes, as shown in Pic 1), and the use of an offloading shoe.

There are times when a broken toe is very serious and that it when there is an open fracture (break in the skin). This type of fracture pushes the break through the skin which can allow bacteria to penetrate into the body.
This type of fracture usually requires a Tetanus shot, thorough cleaning of the wound, possible stitches (depending on the time frame of when the injury occurred and time of treatment) or surgical management.

Plantar Fasciitis

Plantar Fasciitis

Many patients present to the office with pain in the heels. Most patients describe it as a stabbing sensation that is worse in the morning and usually begins to improve as they walk around. They also state that the symptoms will return if they sit for an extended period of time.

Although I tell most of my patients that all heel pain isn't Plantar Fasciitis, majority of the time, it is. That being said though, when patients present to the office, I still get x-rays to help rule out a fracture, Tarsal Tunnel, or plantar fibromas.
Some patients present to the office with pain in the feet and heels which is originating from the back. So I always try to perform a thorough physical examination.

Q: So what is Plantar Fasciitis?
A: It is pain and inflammation of the Plantar Fascia

Q: What is a plantar fascia?
A: The plantar fascia is a band of ligaments that connects your heel bone to your toes. It helps to support the arch of your foot. If you strain the plantar fascia, it gets weak, swollen, inflamed and irritated. This often leads to pain of your heel bone or the bottom of your foot hurts when you stand or walk.

Q: How did I get this?
A: There are numerous reasons
-You have flat feet which cause the foot to roll inward toward the midline of the body when you walk. This is know as excessive pronation.
-You have high arches
-You are overweight
-Your shoes are worn out or don't fit well
-You spend large periods of time walking, standing or running on hard or uneven surfaces
-Your Achilles tendon or calf muscles are too tight

Q: How can I make this pain better?
A: There are several treatment options that I discuss with my patients
-Stretching with a towel or resistance band or stretching the toes against a hard surface such as a wall several times per day
-A steroid injection. I usually mix this injection with a local anesthetic to reduce pain. The steroid is to reduce inflammation, which also helps to relieve pain as well.
-Referral to physical therapy. There are several modalities that can be used to reduce the painful symptoms of plantar fasciitis and these usually help a lot of people
-Orthotics. The use of orthotics can help reduce the painful symptoms. The must be worn in a pair of good supportive shoes. Unfortunately, flip flops are not the type of shoes that orthotics can be worn in (#1 question asked by patients).
The cost of orthotics may not be covered by some insurance plans.
-Surgical management. I tell patients that this is the last resort. It is important to try to exhaust all conservative methods first before undergoing surgery.

Fun fact: There is 2 I's in Fasciitis. Although most people write it with only 1.

Gangrene of the lower extremity

Gangrene of the Lower extremity

Gangrene has both a Latin and Greek  origin which means "putrefaction" of tissues" and has no connection to the color green which is commonly thought.

Gangrene is a very serious condition that can be potentially life threatening. Gangrene usually arises from chronic conditions such as Diabetes and poor circulation or many years of smoking.

Types:
Wet: Occurs in moist areas such as the mouth, bowel, lungs, cervix, and vulva.
Dry: Usually arises due to a blockage of the arteries of the lower extremity. The appearance is purple or black with a sunken/ dried look
Gas: Caused by a bacteria called Clostridium Perfringens and it is a medical emergency because it can spread very quickly through the tissues of the body leading to Septecemia and toxemia.
Necrotizing Fascitiis: Gangrene of the deep layers of the tissue

Treatment options vary but usually entail surgical cleaning of the wound (debridement) , wound care, hyperbaric therapy, maggot therapy and antibiotic therapy, although amputation is necessary in most cases.

Foot masses: Clear Cell Sarcoma

Clear Cell Sarcoma

A significant portion of my practice involves the evaluation of soft tissue masses. The may be found in the forefoot, heel, ankle or lower leg. Majority of the lesions that I encounter are benign which means non-threatening or assumed to be harmless.

Not too long ago, a 48 year old, male patient presented to my office with a rapidly growing mass of the forefoot. The mass appeared and grew within a 6 month span. The patient had gone to see another physician who was injecting an alcohol solution into the mass to stop it's growth. The injections did not help and the mass continued to grow, pushing the involved and bones and soft tissue out of the way.

Upon the initial presentation to the office, the patient brought a copy of the  MRI report of the affected area. The MRI stated that there was a vascular (having a blood supply) tumor which was heteogenous (not uniform in structure) in nature.

The patient wanted the mass removed, so medical clearance was performed to get the patient cleared for surgery.  The mass was excised in its entirety and sent for evaluation by a pathologist. Due to the rare nature of the mass, it was sent to a Pathology specialist. The diagnosis was Clear Cell Sarcoma which is an extremely rare form of malignant cancer.

The patient was advised and referred to an Oncologist where preventative measures have been started.


History
Clear cell sarcoma (formerly known as malignant melanoma of the soft parts) is a rare type of cancer which usually affects young adults between 20 to 40 years old.
Sarcomas are cancers that arise within connective tissues, such as bone, muscle, fat, and tendons. Clear cell sarcoma tumors tend to grow attached to tendons in the limbs, especially in the feet and hands. They sometimes develop in the gastrointestinal tract, attached with the bottom layers of the skin, and in locations throughout the torso. Clear cell sarcoma is slightly more common in females than in males.
Recurrence is common.

Signs and Symptoms:
A slow growing, hard, deep lying mass that is usually painless until it grows very large. Clear Cell Sarcoma is usually found in the extremities and has a predilection for the knees, ankles and feet. The Sarcoma usually present in patients aged 20-40 and is equal amongst the genders.

Diagnosis:
Diagnosis is determined by physical examination in conjunction with X-rays, CT (Computed Tomograpy Scans), MRI (Magnetic Resonance Scans). In addition, a biopsy of the mass is extremely beneficial. If suspicion of metastasis, is suspected, A chest CT, bone scan  or PET (Positive Emission Tomography) may be ordered.

Prognosis:
In situations where the tumor is large in size and there is recurrence and  associated necrosis, the prognosis may be poor. The key factor in prognosis is the metastasis (travel from site of origin to another part of the body). The most common sites metastasis is the bone, lungs and lymph nodes.
Survival rates at 5 years  have been reported to be about 54% [1]. Ten and twenty-year survival rates are about 30% and 10%.

Pathology:
When viewed under a microscope,  these tumors show some similarities to traditional skin melanomas, [2]  Characteristically, they have solid nests and fascicles of tumor cells with clear cytoplasm and prominent nucleoli. [3]. The clear cell sarcoma has a uniform and distinctive morphological pattern which makes it distinguishable from other types of sarcoma.

 

 

Treatment:

Treatment of Cell Cell Sarcoma varies depending upon the location and the extent of the disease. Surgery is the first plan of action to remove the tumor. I would recommend the tumor be sent to Pathology. Radiation and in some cases, chemotherapy follows the surgery. Chemotherapy may or may not be initiated due to only a few cases responding effectively to Chemotherapy. 

[1] The Doctor's Doctor
[2], [3] Atlas of Genetics and Cytogenetics in Oncology and Haematology

Achilles Tendon Ailments

As the summer progresses, there has been an upsurgence of Weekend Warriors, which are people who are most active on the weekend. This has increased the number of sports related injuries, especially those of the Achilles tendon.
The Achilles tendon is the strongest and largest tendon of the body. Although it is so strong, it is extremely vulnerable to disease and injury. The Achilles tendon is extremely important as it plays a large factor in how we walk, jump, run by allowing us to spring up on our toes.


There are Several common ailments of the Achilles Tendon
1.Tendonopathy is a common term used to describe tendonitis or tendonosis (cellular damage of the Achilles tendon)
2. Tendonosis presents as a slight thickening of the Achilles tendon which weakens the tendon and makes it tendon vulnerable to injury or rupture. There is usually no inflammation associated with this condition.
3. Peritendonitis is similar to Achilles tendonitis, but inflammation and pain occur in the tissue surrounding the tendon, often two or more inches above the heel.
4. Tendonitis is when the ends of the tendon can be inflamed  due to frequent activity leading to pain and stiffness at the back of the heel.
5. Tears: Tears of the tendon can vary in size from extremely small to large They may occur suddenly during activity, or gradually over time with inciting factors such as causing pain, swelling, and impaired movement.
6.Rupture of the Achilles tendon may make a popping sound, followed by pain and swelling of the lower leg.
7. Calcaneal bursitis is when the fluid filled sac which cushions the Achilles tendon becomes irritated. This is felt most often with the shoes on as the most common contributing factor is low-riding shoes.

Treatment options can vary depending on the condition and extent of injury. Conservative therapy includes immobilization, physical therapy and rest. Surgical management is occasionally the treatment of choice.

A complete physical examination of Achilles Tendon ailments
 will be performed by Dr. Jacqueline R. Buckley in our Renton, Washington location