Hannah: Hello, everyone. Thank you for joining us for our educational webinar on common foot problems and how to take care of your feet. Tonight’s speaker is Dr. Ralph Napolitano, podiatrist and wound care specialist at OrthoNeuro.
Dr. Napolitano is a double board-certified podiatrist and wound care specialist physician specializing in medicine, surgery, and wound care of the foot, ankle, and lower leg. He is the director of wound care and healing at OrthoNeuro. Dr. Napolitano will answer questions following his presentation.
Dr. Napolitano: Thank you very much, Hannah. I appreciate that introduction.
So, all of us here in central Ohio, I think it’s safe to say we are smack dab in the
middle of winter. But spring is around the corner, and we’re going to talk about these common foot problems and getting your feet ready for the warm weather. So, I think we’re all ready for that. The question is: Will your feet be ready?
Podiatry is my specialty. Again, I’m part of the foot and ankle division here at OrthoNeuro. This division of medicine is devoted to the study of diagnosis and medical and surgical treatment of disorders of the foot, ankle, and lower leg.
So, we take care of a body region, not just an organ system of bones and joints. So, this lower extremity is what we’re stewards of, and taking care of all these things that can go wrong with that lower extremity.
Interestingly, in Ohio, we’ve retained a small part of a heritage profession called chiropody. This means we can treat skin and nail disorders of the hand. In my practice, I also treat fingernail fungus and sometimes an ingrown nail on the hand.
Podiatry is not new. It’s been around for a very long time, since ancient times. In ancient Egypt, carvings depicted at that time showed foot care. Hippocrates, the great scientist and early physician, described the care of corns, calluses, and skin problems.
Napoleon and President Lincoln also had podiatrists as well. The first Society of Podiatry was established in New York in 1895. Other countries soon followed.
Here are some interesting facts about feet:
This is a huge topic. There are lots of things that can go wrong with your feet. Our focus is on some of the more common things. And as we break out of the winter doldrums and take that spring break, we will discuss what these problems are, how to treat the problem, and prevention.
Now traumatology is a whole different subject; that’s something we’re not going to go into right now.
We’re going to start with our number one problem. These aren’t necessarily in any particular order, but of these 6 problems, these are the most common categories that we see in my field.
Skin problems of the foot: We’ll start with nail fungus—toenail fungus. Half of us will be diagnosed with nail fungus by age 70. Types of microscopic fungal organisms cause them.
Think about a microscopic plant, if you will. Signs and symptoms include nail thickening, a deformity of the toenail, discoloration, and sometimes a foul odor. And with that deformity, it can actually pinch into the skin.
Of special concern is this problem if you have some kind of immunocompromise. So, diabetes is certainly a very common condition we’re all familiar with. That’s a form of an immunocompromised circulatory problem. If you’re a cancer patient and are immunosuppressed, these are relevant conditions related to toenail fungus.
Left untreated, we see that the toenail can become permanently damaged, so it’s of utmost importance to treat this early on. This is what this looks like. We’ve probably seen this in friends or relatives.
The toenail is just slightly yellowed and slightly thick. We get this severe deformity as we get more progressive in the disease course. Left untreated, it’s hypothesized that the toenail root can get damaged beyond repair, even though we cleared the fungal infection itself.
I mentioned in my field, treating skin and nail disorders of the hand on occasion. The picture in the center of the screen shows a patient with fingernail fungus. So, we see this sometimes in people that work in industry and related professions where their hands are in wet, damp environments.
How do we treat this? It is an infection, so just like we would treat a bacterial infection with antibiotics, antifungals treat fungal infections. Topicals are another modality—next generations are now available. There are some very good ones that are just about as effective as oral. In fact, there are some out there that are on par with oral medications.
I’d like to point out that certain medications that they need to be on can affect the liver and other organ systems in some patients. Antifungals poorly have that propensity, so we have to be cognizant about taking oral antifungals, depending on your underlying conditions or other medicine other medications that you have.
Topicals essentially have no side effects, although sometimes you can get a little bit of irritation. That’s a small reaction that we’ve seen.
Now, in our practice at OrthoNeuro, we use a laser to treat toenail fungus. Lasers are used a lot in medicine. By using heat and light energy and manipulating those parameters, we can do lots of things, from taking care of toenail fungus to reducing scars to removing hair to taking care of vascular lesions or varicose veins.
What we have found is combination therapy to be very successful. So, different things in conjunction with each other certainly help clear this. So, doing laser together with possibly oral medication or topicals with the laser has shown to have this synergistic, excellent effect.
And I can’t stress enough: treating this early on is very important! Studies have shown that the earlier you get to this, the better your outcome will be to avoid that long-term problem and possible nail deformity we referenced.
Instead of going barefoot in public places, such as a gym shower floor, having your flip-flops there is just a good measure. Basic foot hygiene and nail care are good prevention. There’s absolutely nothing wrong with getting pedicures, but if you go to an establishment for the first time and it doesn’t feel right, it probably isn’t.
Of course, this is the livelihood of those that own these establishments, so they have to adhere to the cosmetology board, which is a dotted line to the health board.
Another thing I talk about in my practice is foot health and shoe and sock health—where our feet live. So, they live in shoes. This is one of the items of clothing that isn’t taken care of regularly.
Take care of your shoes to keep them fresh and sanitized—everything from simple sprays to ultraviolet shoe sanitizers. Socks—laundering them, which is certainly common sense. Add additives to your laundry, certain disinfectants, etc. All of that can be very helpful.
Now we’re talking about fungal infections of the skin—athlete’s foot. So, like toenail fungus, this is caused by common microscopic organisms throughout the environment. Signs and symptoms of this are scaling and cracking of toes of the soles of the feet and blistering.
Advanced cases can result in bacterial infection as well. Now, bacteria and fungi are kind of mortal enemies don’t play well together, but when unchecked, they can synergistically feed off each other in that environment.
So, toenail fungus can spread to the skin and vice versa. If you have an immunocompromise or underlying condition, if you’re diabetic or have immune problems, this can also be of special concern.
You can have a blistering type presentation called vesicular athlete’s foot or tineopetis, the more cresting kind, the dry kind, and inner trigonous between toes certainly—these are all presentations we see with Athlete’s foot.
Being a fungal infection, oral medications are used. But a shorter course is used compared to toenail fungus or fingernail fungus. Creams and ointments in combination with steroids sometimes.
Going back to toenail fungus, topicals traditionally haven’t been the most beneficial because having that medicine penetrate through that nail plate has been difficult. Where we’ve made a lot of advances over the past few years is the medication having vehicles to be able to penetrate.
So the medication formulas are able to penetrate to get into that toenail fungus. It’s not as difficult with respect to skin penetrants. So, creams and ointments are well suited for clearing the athlete’s foot. And we talk about shoe health also being necessary with shoe and sock health hygiene.
For prevention—not going barefoot in public spaces excessively. Talking about public pools, we’re not going to wear aqua socks all the time, and that has its shortcomings, too, because those garments aren’t suited for year-in, year-out use. Those should be cycled through every year or two.
So in a public pool situation, there are health issues. Pools are certainly clean and chlorinated, so there’s no reason to be overly neurotic, but just again, a bit of awareness is helpful.
Controlling perspiration is helpful, and all of the things we talk about preventing toenail fungus are applicable here with preventing athlete’s foot.
We’re still talking about skin problems, so plantar warts are virus infections that result in a cauliflower-like growth, usually on the bottom of the feet, but we can see them on the top as well. They can grow and become uncomfortable, especially if it’s on the bottom of the foot.
You see this more commonly in kids than adults, but we can see this at any age. If you’re immunocompromised, you have some other underlying health conditions, and if your immune system is a bit less optimal than someone that doesn’t have that, you can be more susceptible.
This is what these look like. Benign-type presentation on the left and a very profound presentation on the bottom right. These large cauliflower-like masses—we can certainly appreciate how that would be uncomfortable.
Treatment: topical medications, acid plasters over-the-counter things can work. However, you have to use these cautiously if you have diabetes or peripheral vascular disease because those acids can actually create chemical burns and are not the most appropriate if you have those underlying conditions.
Non-invasive procedures: we use a laser here as a reference. This certainly takes care of warts. Ultrasounds, some newer techniques, or traditional surgery, where we do excision.
Prevention: try common sense-type things like foot hygiene, drying your feet thoroughly, and controlling perspiration—we also talk about shoe and sock health. Pedicure awareness and all of that.
Now, I will say that plantar warts are fairly contagious. So, if someone has these in your household, be aware that they can, in fact, spread, so just kind of be cognizant about common shower areas and wiping things down.
Now we’ll move on to the appendage of the skin that we see tons of—ingrown toenails.
The fingernail and toenail is an appendage of the skin. This condition is a problem in which the nail curves and grows down and can actually pinch the skin and cause an infection. It can also be caused by trauma or the trimming of nails incorrectly.
A little nod to proper trimming of your toenails more straight across and not too terribly short because if you round them and trim them too short, they can pinch that skin as they grow in.
A little bit of nail anatomy: We see this most commonly in the big toe. You have the distal nail plate and the proximal nail fold, that skin there. And then, we have our medial and lateral nail folds, which are commonly affected areas that nails can curve around.
We say that’s a pincer nail. If it curves around a lot, we call that a trumpet nail, and that’s where it wants to pinch.
The picture in the center bottom of the screen shows what we call a granuloma, which is an infection of that soft tissue. On the side of the toe, you’ll see inflammation and redness—it’s quite painful. You can get drainage as well.
Up there to the right shows that incurvation can happen with nail deformity over time.
How do we take care of these? Well, we remove that offending nail border either temporarily, if it’s kind of a first-time offense, or if this becomes chronic, we can do a procedure where we actually kill the root of the nail on the side.
If we do that procedure, I am quite particular about maintaining a patient’s normal anatomy as best as possible. So, it’s really difficult to tell we did this once that little surgical area heals. You might know that the toenail is straight, but that incurvation piece is already taken care of, and it tends not to grow in.
There’s a small chance of recurrence, but you’re usually in the clear if we do that procedure. Antibiotics, topically and orally, can help support the healing process. And certainly, we discussed trimming your toenails properly. Avoid rounding them too much or trimming them too short.
Now, genetic predisposition, we see like in lots of things that affect the body. Some of us are just prone to this, but avoiding tight-fitting shoes or a pointed, narrow-toe box can certainly be helpful if you avoid those things to prevent ingrown toenails.
Now we’re talking about foot and toe deformity. So, common deformities we see are bunions and hammer toes. What are these? Well, bunions—that term comes from the word “turnip.” This is the formula of the great toe, which the toe turns in, and that first metatarsal head is more prominent.
The toe goes towards the midline of the body, creating this position where that metatarsal goes out. And this is a result of genetics and heredity, as well as an imbalance between the tendons that move the great toe up and down. We see this more common in women with flatter foot types.
If we look at a lady’s anatomy, things are a little bit more rounded with foot structure. Men have a more square-type foot structure. There’s a problem we’ll talk about later – arthritis – but women are more prone to subluxation or this imbalance with the hypermobility of this imbalance, and men are more prone to compression disorders.
The big toe turns in, resulting in the metatarsal head of the joint turning out or closer to the midline of the body. And this is what this can look like.
Progressive bunion deformities can result in overlapping second toes or underlapping second toes. This is certainly something you do want to address this before we see this significant problem.
Here are some radiographs showing this. On the right, it shows an actual dislocation of that second toe where the joint is what we call sub lux, so it’s in alignment but riding up there.
How do we treat this? If it’s mild symptoms, accommodating what you have, these are not surgical emergencies. But, keep in mind, these do not go away unless we fix the problem. So, inevitably, either you live with this or deal with it surgically.
Palliative measures, shoe gear, activity modification for inflammation, creams, anti-inflammatories, etc.
There are about a hundred different ways to fix a bunion. You can remove that medial portion of the first metatarsal head. You have to shift the bone either closer to the middle of the foot or sometimes towards the front of the foot, depending on the pathology level and type of recovery time.
Here are some before and after radiographs of a particular type of what we call distal bunion correction or osteotomy.
Prevention: wearing the right shoes certainly is a good start. Avoid shoes with narrow-toe boxes and excessively high heels. Arch supports and custom foot orthotics can help slow the progression but doesn’t put the bunion back. Genetics, of course, plays a role in all of this.
A part of what I do for our group is writing a blog called “A Step Ahead.” There’s related information here. I discuss shoe gear, how to measure your feet for shoes, and how to choose appropriate shoes.
A couple of hints here: Going towards the end of the day to buy shoes because your foot in dependency tends to be slightly increased in size. The rule of thumb when measuring your longest toe is the rule of thumb.
So, you want a thumbs nail width from the longest toe to the end of the toe box, which could be the first toe, or it could be the second. So, if it’s the third toe, you’re just a little different, but we love you anyway.
Moving on to hammer toes. This is a contracture, a bending of the smaller toe. So, a bunion deformity is a deformity of the great toe. Hammer toes are the littler toes, the second, third, or fourth and fifth toes, either in conjunction with each other or in and of themselves.
This is an imbalance between the tendons and ligaments surrounding the little toes, so the tendons that move the toes up are overpowered by the ones that move them down. Toes can rub in shoes resulting in corns, thickened pads on the top of toes, or calluses on the bottom of the feet. These can develop a sore, an opening where that thickened tissue can actually create a sore underneath.
Now, patients with sensation loss are of utmost importance for different reasons, especially in diabetes, which is common—we say peripheral neuropathy, where you lose that protective sensation. So, you might be rubbing in your shoe and not really realizing it and develop a significant infection.
Just like bunions, women tend to be more prone to this than men because of their foot structure.
This shows a hammertoe deformity in which you have this imbalance of the ligaments that pull the toe up versus the ligaments that pull the toe down. This is what this looks like in real-time. Here you can get overlapping or underlapping and significant problems.
You can treat this with a shoe and activity modification and prevent things from rubbing. These are not surgical emergencies, but they don’t get better unless they’re actually fixed surgically.
Some folks can live with this problem for several years, whereas for others, it’s really hampering their lifestyle.
So, like our bunion treatments, non-surgically, we can talk about palliation if we have inflammation here. Pain creams, even shoe modification, as referenced. And for corns and calluses, keeping that thickened skin reduced can certainly be helpful.
These pads can also be used as well. If someone’s not a surgical candidate or
they just want to take some time and treat things medically, they can do something like this.
Pretty common is what we call skeletal traction and toe surgery, where we use a percutaneous, meaning through the skin, through the toe, to keep things held in place temporarily, and those pins come out later. There are even implants and hardware.
This shows some combination of the bunion and hammertoe surgery, where the toes were corrected both at that great toe joint and the lesser joints.
Just like bunion prevention, wearing the right shoes of good quality, avoiding excessively tight shoes and narrow toe boxes. Genetics does play a role, so complete prevention may not be possible.
In referencing arch supports to control biomechanics, which can redistribute those ligaments and tendons and how they function, can help slow the progression of this deformity.
It’s time for arthritis. That’s a wear and tear or an inflammatory condition where joints wear out for different reasons. We all walk the planet. As referenced earlier, we’ll walk this Earth four times, maybe more, in our lifetime, so things do wear out.
We have two broad categories of wear and tear: non-inflammatory versus inflammatory. So, inflammatory conditions, such as rheumatoid arthritis, gout, and those variants—there are several subsets of arthritis. Joint pain, stiffness, swelling, deformity.
The foot joint that is most commonly affected is the great toe joint. I referenced men as being more prone to great toe arthritis. The ankle is certainly in the middle of the foot; these joints can be affected by arthritis.
It can look like this where you can get these nubby deformities of the great toe joint and even the middle of the foot. This is what this looks like on an x-ray. That ankle picture on the right shows this degeneration, where you have that talus bone which is an interesting bone.
If you make a fist, that’s kind of like the shape of your talus bone. It doesn’t have any muscle attachments, just ligaments connecting the two leg bones. You can appreciate that there are some compression of that leg down onto that ankle.
The picture on the left shows a very profound, very arthritic great toe joint where essentially there’s no motion at all. And the middle picture shows what we call a dorsal exostosis or bone spur, which prevents that great toe from moving up and down.
When we talk about modification and preventive measures, or palliative measures, shoe gear modification, certain shoes might not be the most appropriate for someone with advanced arthritis.Orthotics and arch support control those biomechanics.
And if you’re talking about inflammatory arthritis, controlling those underlying inflammatory processes certainly helps. So, gout, we see that more commonly in men, that’s inflammatory arthritis.
Anti-inflammatories, pain creams, steroid injections, and of course, surgery.
For great toe joint arthritis, we’re still not quite there with having a great implant. Some have shown some benefit, but you often either clean up the joint or fuse it. Now, fusing the great toe joint can be somewhat daunting and concerning because, well, how are you going to move that great toe and walk?
The truth is that you have a joint beyond that great toe joint. It’s what we call an interphalangeal joint, and that compensates. That’s where you’re able to get your motion, and this is a tried and true orthopedic surgery that we do.
Here are some examples of orthotics. These are custom-made orthotics that we certainly do a lot of that OrthoNeuro. The device in the center of the screen shows Morton’s extension. That’s a finger-like projection that helps prevent that big toe from moving, so that lever takes the pressure off of that great toe joint.
Here’s some arthritis surgery: I referenced implants or arthroplasty. We’ve made logarithmic advances in hip replacement and knee replacement.
We have a lot of options, but long term, there are some concerns. Now, it’s not to say we can’t do this, and a lot of times, we can get 20, 30, or 40 years out of such implants. But just the science isn’t quite there yet, hence my reference to fusing that joint instead.
That’s what this example is on the right. You can see that there’s a joint just beyond where those screws are that becomes the great toe joint. We put the big toe in a certain position, and it can accommodate common motion throughout the day.
And then that joint, just beyond where the screws are, becomes more flexible. Even if you’re a younger person in your 40s or 50s, this is a procedure that works exceedingly well.
So, wearing the right shoes certainly is helpful and controlling biomechanical abnormalities. And, if you have inflammatory arthritis, controlling those inflammatory processes can significantly prevent progressive joint damage.
Some medical foods, if you will, homeopathic things have shown some benefit, but the literature is a bit unfounded with some of those things.
Tendonitis is an inflammation of tendons or ligaments, weakness, or instability. So, repetitive overuse, depending on your job or sports, results in levers that move foot structures of foot structures and lower leg structures.
These can get inflamed and certainly can be damaged significantly, in which you can actually get a rupture. Overuse related to a more acute time frame is often the precipitating factor to tendonitis.
So, in the foot and ankle, our most common tendonitis problems are Achilles tendonitis and posterior tibial tendonitis. There’s a subset for those of you that have tuned in and probably are saying, “Hey, what about that other one?” and we’ll talk about that other one in a minute.
So, some anatomy here: The posterior lower leg shows your Achilles tendon that hooks on your heel bone. That posterior tibial tendon is in the middle of the screen—its job in life is to create the arch.
And over time, as we fight gravity again, walking this Earth many times, gravity makes everything fall. So, the flat foot will be the natural tendency. It doesn’t mean all of us will get flat feet as we age, but that’s the more common problem you see.
The high arch foot kind of defies gravity. There are several reasons why people can have high-arched feet, but there are two common tendon problems. That Achilles tendon on the back— that’s actually the strongest tendon in the body. That’s the motor that propels us with our feet and that posterior tibial tendon—our other common tendon.
So, there are anti-inflammatories and/or steroids and possibly injections for prevention and treatment. We must be very cautious when injecting the Achilles tendon or the posterior tibial tendon. That’s almost a last resort because the Achilles tendon, if it weakens and snaps; that’s obviously a big problem.
Steroid injections repeatedly can weaken tendon structures. Shoe gear and activity modification mobilization, and we use a lot of what we call protective mobilization. These are walking boots so that we can keep going throughout our day, but this prevents that foot from moving, so we can be active but still protected.
Controlling abnormal biomechanics and possibly orthotics, as referenced, is like some of the other problems. And if we have an imbalance that’s beyond repair, if we have a tendon that’s severely diseased, there is surgery.
There is tendon grafting, and there’s surgical repair, etc.
Now, talking about that other problem, the elephant in the room with this problem set is plantar fasciitis. This is inflammation of something that’s kind of like a ligament, something sort of like a tendon, but not really a fascia. It’s like a flat band that kind of connects different pieces and parts of the body.
So, in the foot, the plantar fascia separates your soft tissues, most on the bottom of the foot, from those structures deeper in the foot. So, our other muscles, ligaments, nerves, etc. We see this as a very, very common cause of heel pain.
So, pain with activities after rest—we say this is post-static pain or post-static dyskinesia. Pain in that bottom of the heel you go to sleep at night, and you get up in the morning, and upon arising, you continue to hurt. That’s because everything has sort of settled, and that inflammation settles in that area.
Then you get up, moving throughout the morning, and things ease up. We see this more in the flatter foot type as a predisposition to planar fasciitis. Think about maybe a bow and a bowstring. So you have your bow as your arch. If we flip it kind of over and the bowstring as the plantar fascia, when you pull or flatten out that bow pulls on the heel, and over time, that can cause inflammation. You even see some heels spurring, the dreaded heel spur. But we say that’s a result of the problem, not the cause.
So pulling on that heel causes this reactive inflammation. This gives rise to calcification, which gives rise to ossification; ergo, the heel spurs.
So, that pulling causes those changes that we see in x-rays. It’s a radiographic clue that that’s probably what’s going on. It’s kind of a chicken or egg story—what came first, the inflammation, not the spur.
There’s no surgical reason to remove a heel spur on the bottom of the foot because that’s again a result of the problem. There are surgical options to help with mechanics to release part of that ligament if need be, but most of the time, people get better with conservative things.
Other causes are shoe gear lacking arch support, overuse and flattening of the foot, certain activities and jobs, etc.
We see our Achilles tendon on the back in this picture, and on the bottom, we see this plantar fascia and ligament on the bottom. And here is where this likes to pull right there on the bottom, more so on the inside, pulling on the inside of the heel as we roll.
As we walk, we start on the outside of the heel and finish off on the inside of the foot and toe-off of our big toe. Another analogy here: think of this plantar fascia as sort of like a celery stalk, and those little fibers can actually pull and sometimes tear.
And that’s when we get this inflammation that we see. So, focusing on preventing the inflammation cycle and preventing it from coming back is a mainstay of treatment.
So why do we have this? In foot and ankle pathology, there is a lot to be said for an
inflexible foot. The Achilles tendon, as stated, is the strongest tendon in the body. It can also be tight, and your calf can be tight, so having a more flexible foot and getting it to what we call dorsiflex or moving up, we like to see it beyond just that 90 degrees straight. We like to see a few more degrees.
And if we don’t have that, we have a condition called equinus. With equinus we think of the Latin for horse and how a horse’s leg is. So, having this flexibility certainly helps prevent a lot of foot problems, including plantar fasciitis.
Anti-inflammatory steroid injections—we don’t hesitate to inject the plantar fascia. This is a very safe area to inject. Night splinting and wearing a device contraption at night, either while we sleep or while we have some downtime, helps with that flexibility preventing that equinus, as just referenced.
Active stretching, modalities, and ultimately surgery to release part of that or correct that contracture of the calf muscle. Other modalities include physical therapy. But we use steroid gel under ultrasound. We call this iontophoresis or phonophoresis.
There’s a procedure called extracorporeal shock wave therapy (ESWT). It has a terrible name that sounds awful, but it is a very novel technique that’s been around for a long time. For those of us who know someone or have experienced kidney stones, this is the same technique that they use to break up kidney stones.
In musculoskeletal medicine, this technique is used to break up inflammation, most commonly in the plantar fascia. We also see this for Achilles tendonitis, epicondylitis—which is elbow tendonitis, or even knee tendonitis.
So this outside-of-the-body shock wave therapy that’s done under local and can help break the cycle of inflammation. Most people get better by just conservative means as a reference.
For adjunctive procedures other than this plantar fasciotomy, we reference getting more motion with the Achilles, calf muscle, and gastrocnemius to correct those biomechanics.
This is a picture of what this extracorporeal shockwave device looks like. This is an office procedure that we do at OrthoNeuro occasionally. The machine comes with a technician that runs this.
I position the foot and anesthetize it locally. There’s no downtime. You’re a little sore afterward but a very excellent technique.
An endoscopic surgery will release part of that ligament here. For endoscopic surgery, you use a camera and instrumentation through small incisions to operate on a body part through these small windows into the body.
Arthroscopic surgery is through a joint. Endoscopics is through a body cavity or space, and this is an endoscopic plantar fasciotic.
One should wear supporter shoes and appropriate fitting shoes and orthotics as necessary. Activity modification, stretching, and maintaining a healthy lifestyle is important.
Next, we have nerve problems. Lots of things here. We can spend hours on this. But entrapment syndromes: we’ve all probably heard of carpal tunnel, which is entrapment syndrome of a nerve in the wrist.
In the foot and ankle, we have tarsal tunnel, which is like carpal tunnel in the foot and ankle. We have Morton’s neuroma, which is a pinched nerve between the metatarsal heads and the feet.
Also, a common condition is peripheral neuropathy, most commonly seen as a result of diabetic patients, along with standing uncontrolled diabetes. Still, it can be caused by other metabolic problems or medicines. So these include chemotherapy side effects, we say chemotherapy-induced peripheral neuropathy, metabolic conditions such as vitamin B12 deficiencies, thyroid problems, etc.
A bit of nerve anatomy here: That posterior tibial nerve is a bit of a misnomer because there is not an anterior tibial nerve. But this is our posterior tibial nerve. This is what gets entrapped when we have tarsal tunnel or carpal tunnel at the ankle.
And going more distal, you see those little nerves that are between the metatarsal heads that supply the toes. Think of the spinal cord as a circuit board. Larger nerves give rise to smaller nerves. All this is really an amazing feature of our bodies.
Anti-inflammatory steroid injections are utilized, topical pain creams, even shoe and activity modification, avoiding tight fitting shoes, rounded toe box versus a square or versus a more pointed toe box, controlling abnormal biomechanics, and also surgeries sometimes.
Using the carpal tunnel analogy and the wrist. Sometimes that those structures need a release that is pinching that nerve. Same thing in the ankle. Sometimes we have to release those structures.
You can have possibly what we call a space-occupying lesion in which a large varicose vein or even a tumor growth can be affecting that tibial nerve. Those can all be addressed surgically.
With Morton’s neuroma, sometimes we have to excise that small portion of the nerve which results in just a little bit of numbness between the toes, but of significance controlling the pain and getting rid of that is a small trade-off. You have sensations on the outside of the toes.
With neuropathy, if you’re having this as a result of diabetes or other things, controlling that underlying cause is very, very important. So side effects of medications, having appropriate blood sugar control if you’re diabetic.
Medications: Treat nerve pain, Gabapentin, tricyclic antidepressants(TCA’s)—all these can be helpful.
We’re not to the stage we can regrow nerve tissue. We’re getting closer, but when you have nerve damage that results in permanent, what we call Anesthesia, it’s hard to get that back. So sometimes, unfortunately, left untreated, in particular peripheral neuropathy and diabetes,
sometimes the effects can be permanent and significant.
So, here is a little bit of a wrap-up here on some preventive measures as we get into the warmer months, soon around the corner:
Thank you very much for your time. We have some time for some questions and answers.
Hannah: So, it looks like we have a few questions.
Can you have both toenail fungus and athlete’s foot at the same time?
Dr. Napolitano: Indeed, you can. You can have a synergistic pathophysiology where you can have one feeding the other. So, athlete’s foot can result in toenail fungus, and toenail fungus can result in athlete’s foot.
Skin infections tend to be much more catchy than nail infections. Nail infections take some time to develop, but they’re also more stubborn to get rid of. Plantar warts are fairly catchy. Athlete’s foot can be passed around a little bit more easily than toenail fungus, but yes, you can definitely have both.
Hannah: What is a beetle treatment for warts?
Dr. Napolitano: That’s a very good question. That’s Cantharone (Beetlejuice extract). In medicine, sometimes when you have a lot of treatments for something, that means either they all work very well or they all work kind of so-so. We see that with warts.
S, with plantar warts, sometimes you can growl at them one day, and they’re gone. Other times, we do everything short of blowing them up with dynamite, and they persist.
So Cantharone, that beetlejuice extract, is an injection. In my practice, we tend to use other things that are not as caustic or irritating. We do a lot of laser work with combination topical creams at compounding pharmacies.
Stomach medicine can be utilized for this. Tagamet, in the pediatric public population, was discovered to be antiviral. So that’s something now that we can use on occasion as well.
Hannah: How rounded is too rounded for toenail trimming? Do you recommend cutting a “V” in the middle of your nail to allow the nail to grow inward?
Dr. Napolitano: That’s a bit of an old wives’ tale. You really don’t want it to be pinching as it grows out. So this is not going to be the easiest to answer without a visual.
Just round it slightly so that the nail fold on the end is just a little bit visible. If you keep them totally square, that causes problems as well. Just where you can see a little bit of that nail fold on the inside or outside of that toenail, that’s kind of what we’re after.
Hannah: Is there a treatment for a bunion on my little toe?
Dr. Napolitano: Yes. That’s known as a tailor’s bunion. Tailors used to sit cross-legged. Then we get that irritation of that fifth metatarsal area. So as we correct the bunion of the great toe and shift things in, the same way is done to correct that bunion on the fifth toe.
Hannah: Can I wear heels after bunion surgery?
Dr. Napolitano: You certainly wear heels before and after surgery. Over time, wearing shoe gear that is not the most healthy can cause these problems to develop quicker and can result in recurrence.
So, for our lady patients, we usually recommend a smaller, chunkier heel. It doesn’t mean you can’t wear something higher from time to time. We referenced that equinus, that contracture of the Achilles, over time can result in all this sort of foot pathology.
So, keeping your foot in a high heel for days and weeks, months on end, or for years can result in that contracture of the heel. But, to answer this succinctly, yes, you certainly can wear high heels afterward. We suggest a lower heel that’s a little bit more robust on the bottom. It doesn’t mean it can’t be fashionable.
I come from an Italian family, and my great-grandparents were cobblers in Italy. So, I think my fate was cast from the get-go. So there were many shoe discussions growing up.
My one grandfather actually helped make Bess Truman’s wedding shoes during that era when it was very common to have shoe manufacturing all over the place in the United States.
Hannah: Can you fix a claw toe?
Dr. Napolitano: There are three flavors of hammer toes. For a claw toe, think of a bird’s claw, where you have contracture at the two little joints. For a mallet toe, think of a hammer. It has a contracture only at the distal joint. A hammer toe is where it’s straight on the end, but kind of hooved up in the middle.
It has a similar type of treatment where we remove a small portion of bone, letting the toe lie flat, doing some things with tendon work, and possibly using those little implants to help keep that toe in the correct position.
Hannah: If you fuse my great toe, will I still be able to run?
Dr. Napolitano: That’s a very good question. The short answer is yes. Now, if you have hopes of playing for the Celtics next year, we have to be cognizant that there are limitations.
This is a tried and true orthopedic procedure. We fuse that big toe in a certain position where you’re able to kind of get the best of both worlds. Sprinting is not going to be the same.
With very significant bunion deformities, sometimes we don’t have a choice. We have to fuse that great toe joint and balance things. In the middle of the foot, there’s another joint called the first metatarsal cuneiform joint.
There’s a bunion surgery called a Lapidus procedure, and a lot of times; this is a tried and true way to fix it. Just correcting things and having the best of both worlds that’s where we get into this fusion treatment for great toe arthritis or significantly advanced bunions.
Hannah: Is gout only limited to the great toe, and is gout curable?
Dr. Napolitano: So, gout is a condition in which your body makes either too much uric acid or doesn’t get rid of it. So we used to make more of a big deal about being an over-producer or under-excretor.
Certain foods can be triggers. Men are more prone to gout, and the overwhelming majority in the lower limb is the great toe because of how our anatomy is. However, gout is certainly not
restricted to just the great toe. The middle of the foot can be affected by gout.
The ankle and fingers can be affected. You can even get what we call gouty tophi, which is a term for these nodularities that can even poke through the skin. The crystallized and diseased tissue can actually come through.
So, although the great toe is most commonly affected, these other joints in the feet can become affected as well, men more so than women.
Some foods can be gout triggers, like cured meats, preserved meats, red meats, tomato sauce, and citric acid. Sometimes you may look at this food list and think, “Wow, I can’t eat anything.”
That’s not true. You just have to kind of figure out what is more insulting. Now, there’s medication to prevent attacks. There’s also medication to treat attacks.
What I usually do with my patients is if they have one or two attacks a year, we discuss if it is necessary to take preventive medicine throughout their whole life. If you have just one or two attacks, we treat that with anti-inflammatory medications, injections, or medicine designed to treat just a gouty attack.
If you’re getting three, four, or five attacks, especially around holidays when we’re eating, drinking, and being merry, then we talk about preventive measures.
Hannah: Can planar fasciitis spontaneously resolve, and how common is the surgery for the condition?
Dr. Napolitano: Most of the time it can be treated quite successfully non-operatively with stretching, controlling biomechanics, and addressing the inflammation.
Can it get better on its own? Well, if we want to just take a little nod to maybe spontaneous resolutions: just a little bit of stretching, a little bit of anti-inflammatory medication, and a little bit of help, then yes, it can get better on its own.
Jump-starting things with a little stronger anti-inflammation modality, such as a steroid by mouth or a steroid injection, really does move things along to getting better faster.
Hannah: Does diabetic neuropathy always cause permanent nerve damage, and is it preventable?
Dr. Napolitano: An ounce of prevention is worth a pound of cure. So, getting at nerve damage early on is very, very important. For diabetic patients, controlling that blood sugar as tight as possible is quite important for preventing permanent nerve damage.
If you’re diabetic, you could certainly have normal sensations throughout your life if you control your blood sugars as tight as possible and as best as possible.
If you have what we call painful neuropathy or painful diabetic peripheral neuropathy, we have medications to treat that pain and to treat that discomfort. Symptoms are related to a stinging, burning type of pain and weird sensations we call paresthesias.
Where we get into trouble is when we get anesthesia and have a lack of sensation. So, it’s a protective sensation. If we lose that, we don’t know what’s going on with our feet. That’s certainly a significant condition and a reason for significant concerns.
When we get to that stage, maybe as we move on with medicine, being able to regrow nerves to reverse permanent nerve damage or have anesthesia problems where we have that permanent nerve damage.
Hannah: It looks like that was our last question of the evening. Thank you, everyone, for participating in our first webinar of 2023. Our webinars this year are going to be on Tuesday nights at 7:00 pm.
If you have any more questions about how to keep your feet healthy, be sure to contact our team at OrthoNeuro. Our specialists in Columbus, OH look forward to giving you the peace of mind you deserve. Schedule a visit with us today!
