Chilblains, also known as pernio, occurs when the small blood vessels of the toes go into spasm. This disease process results in redness, swelling, itching, and sometimes blistering of the involved toes. This is most commonly seen in cold, wet environments. For this reason, we have recently been seeing numerous cases in our offices.

Chilblains has more recently been associated COVID-19 when some patients, especially children, began to develop red, blistered toes after contracting coronavirus. This new condition is now referred to as “COVID toes”, but the exact correlation between coronavirus and chilblains is not well understood. Initially, it was thought to be the result of blood clotting disorders brought on by the virus. More recently, however, scientists have hypothesized that it is because patients who contract COVID-19 tend to isolate in cool, damp areas such as the basement of a home, and it is thought that these environmental factors may cause chilblains. Although chilblains can sometimes be associated with coronavirus, development of red toes with sores is not an indication to get tested for COVID if you are otherwise asymptomatic.

Diagnosis of chilblains is made clinically by taking a thorough patient history and performing a thorough physical exam. Because chilblains is a vascular condition, it may be more common in patients with a history of peripheral vascular disease or Raynaud’s phenomenon. When examining a patient with chilblains, the toes may be cool to touch, red or blue in color, and may sometimes have superficial sores or blisters.

First line treatment for chilblains is to avoid the environmental factors that cause it to occur. Avoid cool and wet climates, change socks frequently, and apply dry heat to the toes. For example, place a towel in the dryer then wrap is around the affect foot. If the toes are itchy or blistered, topical steroid cream may be prescribed to relieve symptoms. Topical vasodilators may also be prescribed to bring more blood flow to the affected toes.

Fortunately, with spring around the corner, these cases will decline. With warmer, dryer weather, these cases become self-limiting. In the meantime, however, do not hesitate to come in to be evaluated by one of the doctors of Advanced Podiatry. 

Metatarsalgia refers to any pain in the foot related the heads of the metatarsal bones. These bones are the long bones of the midfoot which lead up to the toes. While metatarsalgia is a common general diagnosis, there are various specific causes for the pain.

If one of the metatarsal bones is elongated or prominent, this may lead to increased pressure underneath the heads of the bone. This is most common around the 2nd metatarsal since it is the longest of these bones. Patient may experience focal tenderness to the area, and they may also develop a callus as a result of the increase in pressure.

There are other deformities of the foot and ankle that can lead to increased pressure under the metatarsal heads. A tight Achilles tendon will cause the foot to be more contracted and can create more pressure under the forefoot. Additionally, patients who have high arches will have metatarsals that come down at a steeper angle and therefore incur more pressure under their heads. 

Older patients may experience atrophy of the fat that is naturally present on the sole of the foot. Without this fat padding present, these patients may develop pain around bony prominences, especially the metatarsal heads.

Metatarsalgia can also result from injury to the soft tissue structures around the joint comprised of the metatarsal and its adjacent toe. These injuries can result from trauma or from overactivity especially in athletes.

Treatment of metatarsalgia is specific to the specific type of issue the patient may have. For individuals who have increased pressure around a metatarsal head because of a tight Achilles or an elongated metatarsal, an off-loading pad may be dispensed to decrease pressure to the area. Custom orthotics are an excellent treatment option since they too can decrease the pressure in the painful area under the metatarsal head, and they are specifically customized based on the patient’s foot type. If a callus is present in the painful area, it may shaved down to reduce pain. If there is a specific soft tissue injury that is causing pain, it may be treated with RICE therapy, orthotics, or anti-inflammatory medications.

While the vast majority of metatarsalgia responds to conservative therapy, surgery may be indicated in some patients. Those who have pain due to an elongated metatarsal may benefit from a surgical procedure in which the bone is shortened to reduce stress beneath the head of the bone. If there is damage to a soft tissue structure around the joint of the toe known as the plantar plate, this can also be repaired surgically.

While metatarsalgia is an all-encompassing diagnosis for forefoot pain, there are various possible reasons a patient may be experiencing this form of pain. Do not hesitate to make an appointment at one of our offices to be properly worked up and treated for metatarsalgia. 

As Dr. Vieira mentioned in his blog yesterday, Tiger woods was involved in a serious motor vehicle accident in California two days ago. Initially, news reports mentioned Tiger to have sustained serious injuries to both lower legs, the latest information however seems to indicate his right lower extremity was the primary source of injury.

Tiger was brought to UCLA Medical Center, a level one trauma center and underwent extensive emergency surgery on that right lower leg. Certainly, what they describe is a life-altering combination of injuries that will involve extensive recovery but overall does not seem life-threatening.

A statement was released by Chief Medical Officer at UCLA, Anish Mahajan MD, outlining some details of his operative management. I would like to dissect some of the statements to give better clarity. 

Dr. Mahajan’s statement is as follows, “TigerWoods suffered significant orthopaedic injuries to his right lower extremity that were treated during emergency surgery by Orthopaedic trauma specialists at Harbor-UCLA Medical center…”. “Comminuted open fractures affecting both the upper and lower portions of the tibia and fibula bones were stabilized by inserting a rod into the tibia. Additional injuries to the bones of the foot and ankle were stabilized with a combination of screws and pins. Trauma to the muscle and soft-tissue of the leg required surgical release of the coverings of the muscles to relief pressure due to swelling”.

This statement provides amazing insight as to the anatomical areas involved and what the initial procedures addressed. At first glance, we know the fractureswere comminuted, meaning not a simple break andactually  involved “shattering” of the bone into multiple small fragments. Obviously, this is more serious than a linear break of the bone and usually will involve a lengthier recovery. We know that the fractures involved the upper portion and lower portions of the lower leg, meaning he can have soft tissue injuries to the knee and/or ankle in addition to possible disruption of the cartilage in the ankle and/or knee. When a break exits through the ankle cartilage this is termed a “pilon” fracture and this will certainly be life altering for Tiger and may require future surgery.  We also know the fracture was “open” , meaning the bone did penetrate through the skin which significantly increases the chance for infection as debris from the car accident could enter the body and contaminate his leg. I am sure he is receiving the appropriate antibiotics and an extensive washout of the area was performed. They were able to stabilize the Tibia with a rod, a metallic implant that is inserted into the medullary canal of the bone, that will stabilize his fractures to allow for healing to start. This is good news for Tiger.

Also, his statement indicates Tiger woods had a condition called “Compartment Syndrome”. When he describes surgical release of the coverings of the muscles, this is known as a fasciotomy and the necessary treatment to release elevated muscle compartment pressures. Compartment Syndrome in addition to the fractures being “open” are both surgical emergencies in the orthopaedic world. If fasciotomy is not performed, the blood vessels to the muscles close down from excessive pressures and the muscles can actually die off very quickly.

Lastly, although there was not a great amount of detail, he may have sustained fractures to bones in the foot. It appears they were fixed with screws and plates but I cannot comment on which bones were involved.

We do know he is awake, responsive and recovering at this time and the surgery seemed to go well. Based on the information given, I know Mr. Woods is in good hands with a team of excellent specialists there at UCLA. I wish him a speedy recovery, one without pain and good function. I will keep our patients and followers updated with more details as they come in.