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Posts for: February, 2021

By Dr David Ehrlich
February 27, 2021
Category: Foot Care
Tags: Metatarsalgia   

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. 

By Dr David Cheskis
February 25, 2021
Category: Others

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.

By Dr Aarti Kumar
February 25, 2021
Category: Toes
                                  In-toe (Pigeon Toe) Gait
Parents often bring their children in for an evaluation with podiatrists because of the way they walk. They commonly refer to their children as "pigeon toed". Pediatricians are usually the first to hear of this concern and will recommend the patient for a podiatry evaluation. 
In-toe gait refers to the turning in of the feet while standing and walking. Most times it is not painful and parents are concerned with the structure or their child falling during activity because of the malalignment. 
When it comes to evaluating in-toe gait, podiatrists will do a thorough examination in the office both walking and off weightbearing to see where the deformity is coming from. In-toe gait could come from the twisting of the thigh bone or femur, the leg bone or tibia or the long bones in the foot called the metatarsals. 
Twisting of the femoral bone is called femoral anteversion and it can lead to the knees causing a "knock knee appearance" along with the feet looking in-toe. This is mostly due to tight hip ligaments which can be addressed with a lot of stretching and physical therapy. Rotation of the leg bone or tibia is known as internal tibial torsion which can come from developmental formation or the way toddlers sit-specifically in the "W position". Finally, the long bones of the foot can be twisted in reference to the rearfoot known as metatarsus adductus. This is most common in babies/infants especially due to a tight in-utero position. If caught early, stretching and splinting is all that is needed to fix this. 
In-toed gait is a common condition seen in the pediatric population but if it goes untreated, it can be seen in the adult population as well. 
If you feel like you notice your child or yourself walking with your feet curled in, come into one of our offices and see our podiatrists for a biomechanical and gait examination. We look forward to helping you!

By Dr Evan Vieira
February 25, 2021
Category: Others

The sports world was shocked yesterday with news of Tiger Wood's terrible car wreck in California. Tiger has been recovering from his most recent, and 5th back surgery.  He was in California to host a golf tournament over the weekend and was on his way to do a presser. 

Unfortunately, the golf great suffered some very serious lower leg and ankle injuries.  Tiger's ankle was shattered into multiple pieces and bones broke through the skin.  This is called a comminuted compound fracture, and this is quite serious.  After the insertion of a rod, screws and other hardware into his leg Tiger is resting at the hospital as he has stated in a recent tweet.  
Many are wondering what the long term repercussions of such and injury will be.   It is impossible to say, however, they can be very serious.  Risks of infection, arthritis, failure to heal and chronic pain could all play a factor. Serious foot and ankle injures like this can truly be life altering, but Tiger is getting excellent care and has all his fans pulling for him.  
Get well soon Tiger!

By Dr Alan Greenberg
February 22, 2021
Category: Foot Care
Tags: Routine Footcare  

In today's world of fast paced, high tech,state of the art procedures and surgery, it is easy to overlook the importance of conservative palliative care, especially for those patients with diabetes and circulation problems. These patients have a compromised immune system and healing capacity.

Many patients have foot deformities which are subject to excessive pressure or friction within the confines of closed shoe gear. This increased pressure or friction can lead to undue stress to the underlying tissues, resulting in skin breakdown that could lead to ulceration, infection, and possible loss of body part, limb, or life if not addressed early by a qualified licensed podiatrist.

Palliative care reduces the excess pressure and stress to the tissues and can be accomplished in different ways.It can be done by debridement of excess dead skin, orthotics for the redistribution of the pressure forces associated with walking, or by devices that protect the vulnerable area when wearing closed shoes. If these issues are addressed by a nail salon or someone less than a qualified professional, the consequences could be quite severe. Patients should consult with their podiatrist for a proper care schedule and for maintaining healthy feet.

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