Dr. Michael Hercules Theodoulou, D.P.M.

This is not an uncommon disorder resulting from excessive dryness of the skin associated with barefoot walking causing this local fissuring. Clearly avoidance of being barefooted is critical. I recommended skin emollients or lotions to prevent this fissuring and cracking. There are multiple products available over-the-counter which are useful for this. I do oftentimes recommend a product such as ammonium lactate lotion or cream that can be obtained with a 5% strength over-the-counter and a 12% strength with prescription.

Diabetes is an endocrine disorder that results in impaired glucose metabolism. The persistence of elevated blood sugars can impact multiple organ systems that frequently can be reflected in injuries to the lower extremities and feet. Diabetes can impact peripheral circulation, sensation and immune response to injury including the presence of infection. Diabetic
feet require special attention by medical practitioners who have a keen appreciation for subtle changes that may portend future complications. Reduced ability to palpate pulses in the feet, diminished or absent hair growth, sluggish capillary return, altered skin temperature can suggest reduced blood flow. Reduced appreciation for tactile sensation to light touch, sharp stimulus, vibratory appreciation can suggest reduced feeling. Inability to mount an appropriate immune response to local microbial contamination can result in severe infection. For these reasons, diabetics are encouraged to have a periodic evaluation by a foot specialist. Depending on the identified risk presentation, the frequency of visits will be determined by the specialist.

Ingrown toenails can be effectively managed during an ambulatory visit at a specialist clinic. A common procedure performed is the removal of the affected nail margin with chemical cauterization of the nail matrix utilizing phenol (an acid solution). This is done under a digital local anesthetic block. The acid solution destroys the cells of the matrix responsible for regenerating the nail in this region preventing recurrence. Recovery from this procedure is usually very quick with recommendations of warm water soaks frequently with Epsom salts and maintenance of local bandage for 10 to 14 days. In the event the ingrown nail has associated infection which prevents the use of phenol, the offending nail spicule may be removed under a digital anesthetic block and you may be given a short course of oral antibiotic to assist in resolving the infection. In this latter circumstance, the nail will likely regenerate and there may be the future risk of recurrence.

Inappropriately maintained soaking tubs, instruments, or anything else that comes into contact with our skin and associated structures does pose risk for infection. The number one method to prevent the spread of infection in hospital settings is appropriate cleansing of hands and use of universal precautions to include gloves. Translated to soaking tubs, if facilities do not appropriately cleanse and disinfect between patron use this can cause the spread of infection. Breaks in our skin can allow for contamination and infection. Individuals who are immunocompromised are that much more susceptible and at risk - example diabetics, elderly. I would casually observe cleansing procedures of the facility that you use for pedicures. I would also ask management how instruments and tubs are cleaned and disinfected between customers. If not satisfactory, I would avoid obtaining services from them. If you have any open or recent cuts or wounds to the feet, I would avoid pedicures until they are fully healed.

I prefer the word corrected versus removed when dealing with bunion deformities. It is a misconception that this represents bone overgrowth although that can occur as part of the deformity. This in fact is a deformity where the long first metatarsal bone deviates away from the other lesser metatarsal bones with reciprocal inward deviation outward deviation of the great toe to the lesser toes. This is in fact deviation of joints and not a true intrinsic deformity of bone. Its correction surgically can be achieved with corrective bone cuts to realign the metatarsal bone or selective fusions involving the deviating joints.

Heel spurs are typically appreciated at two sites - on the inferior or bottom of the heel and posteriorly or back of the heel. Both are intimately related to the attachment of soft tissue with the insertion of the plantar fascia on the bottom and the Achilles tendon at the back. The development of bone prominences represents repetitive strain and microtrauma at these
attachment points resulting in acute micro bleeding with secondary calcification and ossification of the soft tissue. Over time these prominences enlarge and can be appreciated on plain film radiographs and clinically with visible and palpable presentation when discussing those of the back of the heel. Commonly these spurs are can be managed conservatively without surgical intervention. Particularly bone spurs associated with the plantar fascia. In both cases, it is believed the pain generator is not the bone spur, but the acutely or chronically inflamed or degenerated connective tissue. Most cases of plantar fascia/heel spur pain resolve with good conservative care of appropriate footwear, arch support or heel cushion, program of stretching and judicious use of anti-inflammatory medication. When surgery is indicated, the bone spur is frequently not addressed and it is simply the plantar fascia that may be partially released or selectively debrided with ultrasound guidance. Posterior heel spurs are a little more challenging and may require removal if they become large enough to interfere with footwear and the counter of the shoe rubbing on the back of the heel. In both cases, anesthesia is frequently afforded with plantar fascia procedure requiring at a minimum local anesthetic to the area and potentially IV sedation. The posterior heel spur being more invasive frequently requires sedation with a regional block or general anesthetic.

Clearly excessive cold exposure to the extremities can produce pain. Our body tends to shunt blood to vital organs when in the cold leaving extremities such as hands and feet vulnerable. Prolonged cold exposure can produce conditions such as Chilblains, a reversible thermal injury of tissue to advancing degrees of frost bite that in extreme cases can cause death of tissue. There are certain conditions that may predispose an individual to increased cold sensitivity such as Raynaud's disease or phenomenon. Individuals with this may have an underlying connective tissue disease or simply develop increased spasticity of the small blood vessels particularly to the fingers and toes in response to cold exposure. The reduced blood flow prompts the pain. It is important to note that the chemicals and salts applied to the roadways and sidewalks lowers the freezing point of water. Persistent immersion of feet in puddles with lower than freezing water temperatures can heighten risk for injury. Prevention is to keep extremities warm with appropriate layering of socks and use of footwear resistant to water. If extremities should get wet, it is best to dry as soon as possible.

Bunion deformities represent a progressive misalignment of the great toe with deviation developing between the bone of the great toe and the corresponding metatarsal bone. This deformity is most often a consequence of familial or genetic predisposition and affects women more than men. The deformity may also develop from local trauma to the area. Finally,
different types of arthritis may be a contributing factor to its presentation to include osteoarthritis and rheumatoid arthritis. If you are suffering from other joint discomfort beyond the great toe or have other systemic complaints it would be prudent to be medically evaluated. Bunion deformities typically become more painful if there is developing arthritis within the joint as bump pain alone can be relieved with appropriate foot wear that minimizes compression to the area.`

This bulge may represent many things from a misaligned bone to new growth of bone or soft tissue. Given that you have identified this presentation and it is clearly creating symptoms of pain, this should be evaluated by an appropriate specialist. At the least some type of imaging should be considered. Initially x-rays are obtained but if these do not suggest derangement of bone or joint other forms of imaging can be considered to include musculoskeletal ultrasound and MRI.

Swelling of the lower extremities can result not just from inflammation, but also due to fluid retention.Inflammation in fact is a form of fluid leaving the vascular system and entering into the interstitial tissue through capillary leakage due to reaction from injury whether acute or chronic. Swelling or peripheral edema can also result from excessive fluid resulting
from organ issues related to kidney, heart, liver; or local vascular issues frequently seen with venous insufficiency or lymphedema. If this swelling does not remit as anticipated with current medical management, I do believe it is important that further investigation occurs to determine why the swelling in your feet persists.

Recurring ankle sprains may result from functional or structural dysfunction. Functional suggests that there is no significant structural weakness that permits the ankle to rotate excessively. It may result from weakened surrounding musculature particularly the peroneals when dealing with inversion sprains (most common when ankle roles out) or can also
suggest proprioceptive dysfunction. Nerve endings around our joints that allow us to appreciate spatial relationships of our anatomy and appropriately adjust if placed in awkward positions. Structural dysfunction results from true ligament disturbance by tear or attenuation or bony deformity that drives our ankle to rotate inappropriately. There are situations that ankle instability arises from both functional and structural deficits.

Ingrown toenails are an incurvation of a nail corner resulting in local pain and inflammation of the surrounding skin. These frequently affect the great toe. If allowed to persist they can become locally infected with increasing redness, drainage and exuberant granulation tissue. In the early stages these can frequently be managed with local medical care hi performance of warm water baths with antibacterial soap or Epsom salts. If permitted to advance and not getting better oftentimes these do require surgical removal. On occasion systemic antibiotics are also given by mouth.

Flat feet are a common presentation represented by reduction of the in step vault, outward rotation of the heel, and in more severe cases the fore part of the foot turned out on the rear part. This is often referred to as overpronation. When symptomatic this type of foot posture benefits from good mechanical support. Generally in the running shoes we speak of motion control or stability. Structure of the shoes include a rigid sole with firm counter and lace up. Briefly shoes that represent this include new balance, Asics, Brooks, Saucony in running type shoes. Casual walking shoes include Clark, mephisto, Ecco.

Calluses typically represent a reaction of the skin due to overloading or excessive pressure. Relieving pressure by soft insoles, shoe modification can be quite beneficial. Mechanical reduction of the calluses with a pumice or callus stone after bathing can be also helpful. We ask particularly patients that may be compromised with diabetes, peripheral vascular disease or peripheral neuropathy to refrain from any type of medicated acid type callous remover as this may cause injury to the skin causing and healing complications.

Ingrown toenails can impact quality of one's life due to pain and repeated infection. If this is a recurring problem a minimally invasive office-based procedure under digital anesthetic can be performed to excise the involved nail margin with destruction by surgical excision or cauterization with medicine of the nail matrix to prevent recurrence. This can be a very gratifying procedure for those who suffer from repeated episodes.

The audible sound coming from soft tissue in joints often times is a benign process but if it is related to associated pain or dysfunction to the area may define underlying pathology that requires investigation and potential treatment. Given your history of trauma I would suggest that there is some ongoing process that needs further evaluation. I would caution the use of any type of cortisone injections around the Achilles tendon as this has demonstrated potential risk for rupture. I would encourage evaluation by a specialist well trained in and foot and ankle issues for a proper evaluation to include necessary imaging such as x-rays and it indicated advanced imaging such as MRI or CT scan. Based on this hopefully a definitive diagnosis can be made with prognosis and treatment options

Bone enlargements or growths are not uncommon findings, particularly with toes. These may represent simple degenerative spurs or in fact, may represent small benign bone tumors. One frequently encountered is identified as an osteochondroma. This does represent a benign overgrowth of bone with cartilage surface. Treatment of these bone groups is based on symptomatology and impact on local function and pain. Clearly, if there are any concerns regarding appearance based on radiographs, then an excisional biopsy is always recommended. Further, if one cannot obtain relief or improved function by offloading the affected area with the appropriate footwear or digital padding, then surgery is the most effective treatment, as these enlargements will not spontaneously regress and there is no medical management that will allow for dissolution of the overgrowth of bone.

The diabetic foot is not a disease entity unto itself, but is a description for potential concern regarding complications of the lower extremity and foot-related to the diabetic state. Hyperglycemia or elevated blood sugar can impact multiple systems and thereby tissues that can impact foot presentation. Of notable concern is the circulatory and nervous system.
Diabetics are prone to diseases of these systems resulting in poor circulation and loss of nerve function that may leave an individual susceptible for injury to include wounds as well as bone and joint trauma. It is for this reason that we recommend to our diabetics vigilant regular examination of their lower extremities and feet to include visual examination and manual palpation. Stringent glycemic control is the mainstay of care, but when complications do develop immediate attention by a specialist well-versed in the diabetic foot is critical to prevent significant sequelae. Patients with identified compromise to include neurologic and vascular of the lower extremities warrant regular examination by such a specialist and in fact hygienic care to include management of nail disorders and skin disorders is typically covered by insurance with the understanding of this risk.

Bunion deformities represent truly a misalignment of the great toe joint. This joint is comprised of the proximal phalanx of the great toe and the first metatarsal bone. The deformity is considered principally to be familial in etiology but can be worsened by environmental factors to include activity, trauma and foot wear. As there is progressive misalignment of the joint deterioration or ankylosis of the joint can occur. Unfortunately, this deformity is initially best managed with activity modification, shoe modification and analgesics as required and used judiciously. Much of the advertised bunion splints did not produce any sustainable reduction of deformity. Ultimately, if this deformity impacts your quality of life, then surgical correction is warranted. There are a myriad of different surgeries available based on clinical and radiographic presentation.

There are a variety of neoplasms or new growths that can occur affecting all tissues of the human body. Firstly it needs to be established where the growth presents. On the skin these can result from neoplasm, infection, trauma. Viral infections consistent with HPV present as warts. Altered cellular activity of the skin can produce benign and malignant skin lesions. We evaluate these lesions based on presentation of color, size, shape and border presentation. Traumatic injuries can produce hypertrophic scars and keloids. Deep to the skin and subcutaneous tissue soft tissue masses and elevations can represent cystic lesions such as ganglions, fatty tumors known as lipomas. Beyond the subcutaneous layer around joints we can develop tumors of the joint lining or synovial tissue. Again these can be benign or malignant. Fast-growing lesions that are painless are concerning. These can represent sarcomas. Finally lesion of bone can develop. Again this can result from altered cellular activity resulting in new bone growth and palpable prominence. Given all of this as a potential I would recommend evaluation by a medical specialist with appropriate workup to include imaging as indicated.