Tuesday, November 27, 2012

Secrets 2 Stopping Heel Pain

A common foot complaint is pain in the bottom of the heel. This is often referred to as heel spurs or plantar fasciitis. It commonly is painful the first few steps in the morning or after rest. Heel pain tends to get worse the longer one stands during the day. 

It is caused by subtle changes in foot structure that occurs over time. These changes result in the gradual flattening of the arch. As this occurs a thick ligament (the plantar fascia) that is attached to the bottom of the heel and fans out into the ball of the foot is stretched excessively. This ligament acts as a shock absorber while walking. As the foot flattens it stretches. If it stretches too much it gets inflamed and causes pain. 

Over time the pull of the ligament creates a spur on the heel bone. It is important to realize that it is not the spur that causes the pain and therefore the spur does not need to be removed in most cases. This condition may also cause generalized arch pain called plantar fasciitis. This is an inflammation of the plantar fascial ligament.

A common factor that contributes to this condition is tightness of the calf muscles. Women who wear high heels and people who walk for exercise will often develop this problem because of the tightness that results in the calf muscle as a result of these activities. A non-supportive shoe also contributes to heel pain. Weight gain is another factor in developing heel pain.

Home Treatments for heel pain

Stretch, Stretch, Stretch and Stretch

Calf muscle stretching is very useful. The typical runners stretch by leaning into a wall is helpful. An alternative method of stretching is to stand approximately two feet from a wall. Facing the wall turn your feet inward so you are pigeon toed. Lean forward into the wall keeping your heels on the floor and the knees extended. Also keep your back straight and do not bend at the hips. Hold the stretch for 10 seconds and do the stretch ten times in a row. Do the stretching three times each day. Always stretch the calf muscles following any form of exercise.

Over the Counter Arch Supports

Wear a supportive sport or walking shoe. This can be supplemented with a good over the counter arch support, some of the time a custom made set may be recommended / required. 

Our doctor recommends the new balance sneakers

Oral Anti-inflammatory Medications

Medications like Advil, Naprosyn or Aleve may be of some benefit. Always read the medications directions and warnings before use and seek the advice of a physician. 

VISIT www.NaplesHeelPain.com


Professional Care

If the heel pain persists your foot doctor may suggest a cortisone injection, taping the foot to support the arch, night splints to stretch the calf muscles at night while you are sleeping or functional foot orthotics. Professional physical therapy program may also be required.    The Family Foot and Leg Center has the only integrated foot and ankle physical therapy clinic in the area.  We are very proud of our excellent , knowledgeable staff with over 32+ years of experience in physical therapy.  ESWT or shockwave therapy will help patients without the complications of surgery.  
 On occasion, surgery may be required to cure this condition.  

Saturday, November 24, 2012

Greatest Fear in Bunion Surgery Addressed

Greatest fear in bunion surgery comes from hearing stories about the pain and agony of someone who knows   of someone, who heard of someone, etc who had bunion surgery and it was the worse pain ever.
In the past foot surgery can be painful, but that is a thing of the past. 
How we now decrease the discomfort or even eliminate post operative pain is a multi pronged approach. 

1) preoperative IV NSAIDs or oral NSAIDs barring allergies and kidney issues
2) preoperative anesthesia with a nerve block despite the type of other anesthesia used such as Sedation or general anesthesia. 
3) careful incision planning
4) careful soft tissue handling to minimize trauma and collateral soft tissue damage
5) intricate closure of tissue to minimize bleeding
6) post operative long lasting anesthetic that can give up to 8 hours = of numbness.    
7) post operative steroid injection to decrease inflammation 
8) post operative pain medication both narcotics and none narcotics

Most of our patients report a pain scale of  zero to three out of ten (most pain) at their post operative visit. 

Thursday, November 15, 2012

Saving Limbs and Lives with Amniotic Stem Cells

Named a National Center of Excellence for Advanced Wound Care Technologies
Drs. Kevin Lam, Ramy Fahim and W. Drew Chapman of Family Foot and Leg Center
Naples, FL
239 430 3668

The Use of Amniotic Stem Cells in Wound Healing
Stem cells are a class of undifferentiated or “primitive” cells that are able to divide and differentiate into specialized cells of the body such as skin, bone, muscle cells, blood cells, liver cells, and the like. The two main types are embryonic stem cells and adult stem cells. Embryonic stem cells are derived from the inner cells mass of blastocysts of pre-implantation stage embryos. Adult stem cells are less controversial than embryonic stem cells because their production does not involve the destruction of an embryo.
It is now possible to take stem cells from the amniotic fluid and reprogram them to a more versatile state akin to embryonic stem cells. Using stem cells from amniotic fluid overcomes the ethical opposition to using human embryos as a source of cells.
Amniotic stem cells have a wide range of applications that can be used in research and treatment. A study confirms that the amniotic fluid is a good source of stem cells. This is seen to be more acceptable because this involves no genetic manipulation. Amniotic stem cells can differentiate into various types such as muscle, skin, bone, cartilage, cardiac tissue, nerves, and have a great potential in various medical applications.
Wound healing is a major health problem. Chronic wounds such as a leg ulcer, a foot wound caused by diabetes, and other slow healing wounds have a biological or physiological cause for not healing. Among diabetics, for instance, it is estimated that 15 percent of these patients will develop an open foot sore or diabetic foot ulcer. These chronic wounds have been difficult to cure.
Today, the use of stem cell therapy along in combination with medications and proper wound care can help encourage better wound healing. Stem cell rich materials injected into the area can allow for effective wound healing that otherwise can take considerably longer to heal or may not have healed otherwise. Amniotic stem cell treatments are now revolutionizing chronic wound treatments. Recent studies show that stem cell therapy can dramatically improve the condition of chronic and deeper wounds which would otherwise require more lengthy and expensive rehabilitation.
The healing activity of stem cells is due to their ability to separate into the different component cells of injured tissues as well as release growth factors that may encourage the formation of new blood vessels in the patient. It has been evident that these cells have the ability to multiply, integrate with the host tissue, and replace the damaged cells. Using amniotic stem cells in wound healing have sped up the rate of recovery and the results have been outstanding, saving limbs / lives. 

Post Moh's surgery for skin cancer.   Cancer free, now it is toe saving time. High risk for amputation skin cancer skillfully removed by Mohs surgeon now the challenge.   Day 0
Toe Saving Time after amniotic injection and matrix graft Day 14

Toe Saving time  Day 21
Complete healing at Day 45

Thursday, November 8, 2012

Pain in the Ankle / Subtalar Joint On Uneven Surfaces

When patients presents with this complaint a full radiograph of the ankle / foot is required to help.   Surprisingly the pain is usually not in the ankle joint, but rather a very little talked about joint called the subtalar joint.   This joint is below the ankle joint in the foot.  Testing for this is involves moving the foot in and out by grabbing the heel, called an inversion / eversion stress test.   Clinical exam will review pain in the outside of the foot right underneath the small ankle bone, fibula.       Subjective complaints from the patient can be burning, shooting pain and stiffness in the morning with difficulty with uneven surfaces.

Case below is a 72 year old RN presents for second opinion on her ankle pain.  She has been to other doctors to no avail. Xray below was taken.
Symptoms: Pain in the lateral foot below the ankle joint. Pain on uneven surfaces, stiffness and pain in the morning.   Manual test shows pain upon inversion and eversion of the isolated joint.  Patient did get immediate relief with 1% lidocaine into the subtalar joint.   

Preop Xray below. 

FFLC patient preop: note the malalignment on this view.  MRI confirmed swelling  and ligament  injury in the subtalar joint

Above shows the post operative Xray of a healed subtalar joint fusion. Noted the joint is realigned now and that there is a boney bridge present. No pain per the patient and able to go about her activities as an RN at full duty. 
Post operative protocol: 
8 wks of none weight bearing in a cast.  Then a cam boot for 8 wks with aggressive physical therapy. 

Discussion: Degenerative joint disease of the subtalar joint can be treated with NSAIDS such as motrin, aleve, etc.  Injection therapy with corticosteroids may be of help, but  a dislocation as presented in this case requires a subtalar joint fusion or the pain and instability will continue on a daily basis.

Below is a poem from a subtalar joint fusion patient.

Dr. Kevin Lam
Family Foot and Leg Center, PA
Naples, FL
239 430 3668


Tuesday, October 23, 2012

Kobe Bryant Foot Injury

Kobe Bryant sat out the Lakers' practice on Monday with a strained and bruised right foot.  He's officially listed as day-to-day. He may miss Wendnesday night game at the Staple Center against the Clipppers.

Saturday, October 13, 2012

Pierre Garcon's Toe Joint Injury.

Despite starting each of the past two games and making it through each unscathed, Washington Redskins wide receiver Pierre Garcon has yet to recapture the big-play form that he displayed during the first quarter of his team’s season-opening victory at New Orleans. Offensive coordinator Kyle Shanahan said that although it has helped having Garcon back on the field, he can tell the wideout remains less than 100 percent. In the season opener, Garcon – the Redskins’ biggest free agent acquisition of the offseason, signing a five-year, $42.5 million contract with $21.5 guaranteed – recorded four catches for 109 yards, including an 88-yard touchdown. On that touchdown play, Garcon injured his right foot, straining it near the ball of his foot. Garcon had to leave the game after only eight plays. X-rays revealed no breaks in the bone, but Garcon missed the next two games, and returned to action two weeks ago at Tampa Bay. But in the past two games, Garcon has combined for only four catches for 44 yards. (Washington Post)

Could this be turf toe as described by Dr. Brian Timm

Family Foot and Leg Center, PA
661 Goodlette Road, Suite 103
Naples, FL 34102

239 430 3668

Thursday, October 11, 2012

Yankee's Derek Jeter with bone bruise of the left foot

MLB injury list has Derek Jeter on there with a left foot bone bruise.  Bone bruises happens when there is a trauma to the bone, think of it as a punch delivered to the bone causing bone swelling.   The bone as an outer covering called the periosteum that carries blood to the bone and with a bone bruise, more blood is sent to the bone with healing factors to help heal this injury.   Can take up to 6-8 weeks for full resolution in most cases.
MRI's are useful as well as ultrasound can help detect this injury.

Dr. Kevin Lam
Director of Family Foot and Leg Center
Naples, FL

Tuesday, October 9, 2012

Posterior Tibial Tendon / Flatten Arches / Adult Acquired Flat Foot

If you have painful flat feet, you are not alone famous celebrities like: Kelly Osbourne, Gbenga Akinnagbe, Kim K. and many famous NFL, NBA athletes have flat feet. 

In the age of minimalist shoes and shoe makers such as vibrim, et al now concentrating on looks vs function, we are seeing a good amount of posterior tibial tendon injuries from mild to severe.     The posterior tibial tendon is a very important tendon that is the major supinator (holds up the arch) of the foot about the ankle.  When this tendon is injured inflammation starts, chronic inflammation can lead to tears and flattening of the arch.  There is a zone of hypovascularity behind the big ankle bone called the medial malleolus, this is where most tears are located. For some reason theres is the area of less bloodflow to the tendon.   Other areas of tearing and inflammation is where this tendon inserts into the navicular bone or to an accessory (extra) navicular bone called the os tibialis externum.   Chronic inflammation and tears can lead to a progressive flattening of the arch.  Hence one of our most common complaint is:" Doc my arch is falling and my ankle hurts."  Another complaint is the inability or difficulty in  walking up the stairs.   Ideally, we would like to see patients before the arch starts falling, once that process has started the tendon is already compromised.  

By MRI criteria the grading system as follows
Grade I: inflammation
Grade II: partial tears
Grade III: Rupture
For surgeons our grading system
Grade I: Inflammation
Grade II: partial tears
Grade III: Compromise of tendon with flexible collapse
Grade IV: Rigid flat foot deformity with compromised tendon

The area of red above shows the typical area of pain described by our patients upon presentation.  Palpation or touching of this area will reproduce pain.  
If you look from behind you will see the outward deflection of the heel along with "too many toes" sign when viewing the foot from behind.  In extreme cases patients can be have numbness in the foot from compression on the nerve that travels behind this tendon.   There is a tarsal tunnel where this important nerve runs in the medial ankle.    When the arch collapses the nerve is put under considerable stretch and pressure causing numbness / tingling.   A nerve conduction study can help to identify / quantify this phenomenon.

Conservative Treatment:
  • Immobilization with a boot or brace until tendon calms down
  • Physical therapy to strengthen the tendon and induce blood flow to the tendon
  • Orthotic therapy from your podiatrist or orthotist for mild to moderate cases
  • Gold standard for moderate to severe cases is the Ankle Foot Orthosis (AFO) which limited the ankle's pronation or flattening of the arch.  AFO such as a Richie, Arizona, Colorado, Stepwell, etc type braces.
  • TENS unit

Surgical Options:
Lateral column lengthening such as an Evan's calcaneal osteotomy where we place a bone wedge on the outside to bring the foot back under the ankle. This is the only procedure that can correct in all three planes of the foot. This is a very powerful procedure for adult acquired flat foot where the toes all point outwards in the typical "too many toes sign," when seen from behind.

NERD ALERT!   The Evan's is the only flat foot procedure that can correct in all 3 planes (views) hence it is a very powerful / useful procedure.

Preoperative eval for an Evan's Calcaneal Osteotomy.   Notice the red line forming the angle the foot is collapsed with increased Calcanceal Cuboid joint angle.  Greater than 5 degrees is abnormal on this view.

Post operative view 7 months later shows the proper alignment and a more normal looking foot. Notice the darkened wedge in the heel bone.  Problem solved at FFLC

Medial calcaneal osteotomy where the heel bone is cut and shifted medially (inside) to realign the heel under the ankle joint.  This comes in handy when there is a deformity of the heel bone itself or when the Evan's calcaneal osteotomy was not sufficient to correct the deformity.  Below shows a case of double calcaneal  (Evan's and the medial calcaneal slide) osteotomy used to fix an adult acquired flat foot deformity.
Preop notice how the foot goes out 
After notes how the foot is now straight. 
Preop of the same patient different view showing the collapse

Post op lateral view showing both osteotomies stabilized and the hindfoot well aligned. 
Subtalar joint implants or arthroeresis procedure is when an implant is placed into a hindfoot joint to stop the pronation or flattening of the arch.   This procedure is a quick fix for some patients with mild to moderate disease but it is not covered by insurances and is deemed experimental even though it has been around for decades.    Some surgeons use this as their primary procedure, I would disagree with that mentality.  Trivia: First subtalar joint implants were made out of penile implants, cut and shaved to fit in the subtalar joint.   Currently, they are made of stainless steel or titanium. Below, shows before and after xrays of a painful pediatric flat foot that was corrected with a subtalar joint implant.  Notice the metal circle holding up the arch of the foot. This was done in a 16 year old patient with painful flat feet and did not resolve with orthotics therapy.  Some doctors will do this procedure for every patient with flat feet, but my personal preference is to do this only for certain patients that can not undergo a true reconstructive boney procedure or those that only want a quick fix with realization that they may require a more detailed procedure later when skeletally mature.  

Triple /double  arthrodesis where we fuse 2 to  3 major hindfoot joints to create stability. Recent studies found this procedure to have the most satisfaction rating amongst patients.  I would agree with this when used for Grade III or IV deformities, or if the patient is obese.  Below you will notice the before photo of the ankle with the arch collapsed.   The bottom shows the proper alignment of the joints with the arch restored.  More often then not, an achilles tendon lengthening would be required as an adjunct to this procedure.
Case #1 : Preoperative Double  Arthrodesis with collapsed foot. 
Case #1 Post op with fixation intact and foot in proper alignment

Case #2 Preop Triple Arthrodesis Procedure, notice the collapse and arthritic formation  circled in red.  Patient had severe pain and collapse
Case #2: Post operative Triple Arthrodesis 3 years later without pain in the ankle or foot.

Tendon transfers may also be done. There is a tendon behind the posterior tibial tendon, flexor digitorum longus)  that can be easily transferred forward, or used to replace the entire posterior tibial tendon. Usually the tendon used is the flexor digitorum longus which is right behind the posterior tibial tendon.

The choice of surgical intervention  can be a combination of those above. Your surgeon should have preferences  from their past experiences.  Beware of surgeons who only do this or only that procedure for PTTD.  Different stages of the deformity requires different procedures and your surgeon should have experience with treating various stages and treatment protocols for each.

Custom orthosis usually a UCBL type of orthosis
Proper shoes with proper support such a new balance line with rollbar
Avoid heavy workout in minimalist shoes.


In stage one of this disease which is just tendonitis without any collapse or tendon weakness,  stem cell injections into the posterior tibial tendon can help regeneration of the tendon without the need for surgery.    Most of the time, a CAM boot may be required after the injection for up to 6 weeks to allow for proper tendon healing. www.topstemcell.com

Dr. Kevin Lam
Clinical Director of FFLC
Naples, FL 34102
239 430 3668 option 2 for schedling.

Pre and Post Operative photos are actual patients of Dr. Kevin Lam
Choosing the right surgeon for these complex cases can mean a difference of painfree living vs a lifetime of disability.  All rights reserved.  You may not use these pictures without written permission of Dr. Kevin Lam

Thank you viewers for making this my most popular blog, I will continue to update and refine!

Thursday, October 4, 2012

Joint Pain / Arthritis in the Big Toe

Often I would hear at the Family Foot and Leg Center here in Naples, FL, "Doc I have a bunion, or pain on the top of my foot around the big toe."  Technically the arthritis in the big toe can be called a dorsal (top) bunion.     As you can see from the xray to the side here there is a bump on top of the big toe joint.   There is also a lack of joint space in the big toe joint.
To the left here you'll see some spurring in the big toe joint.    The space is also narrowed.   Comparatively, look at the space between the 2nd metatarsal (long bone) and it's associated toe bone, there is a nice black gap in between, that gap is cartilage that is radiolucent (does not show on xray).
The condition is called, Hallux Limitus or Ridigus depending on the stage of the condition.  Causes range from: Post traumatic injury from soccer / football kickers, previous untreated big toe fracture, turf toe that caused joint injury, crush injury, poor choice of shoes or poor mechanics.
Your podiatrist will be able to tell you more about your cause.

Symptoms include: burning in the big toe joint, swelling, stiffness, deep throbbing pain, pain with change of weather, pain with bending the big toe joint.    Now one thing can be confused for hallux limitus is gouty arthritis, with gout youur joint will be red, hot and swollen and painful to even a bedsheet's pressure.    Hallux Limitus / Ridigus is more constant and consistent throbbing.    There are stages of Hallux Limitus, the case presented here is a Grade III where it is almost self fused.

Non surgical option will consist of using orthotics with a morton's extension, either rigid or made from cork.
Surgical options depend on the stage of the disease: injections, joint fusion, joint replacement.
Notice the top bump is gone
Joint space restored
The above real life case of Dr. Kevin Lam, the patient 5 years after a joint replacement with the arthrosurface implant. Patient remains pain free.    Not everyone is a candidate for this implant.  My personal criteria is 50 and over, good bone stock and people of mild to moderate foot activity.  If you are a 5 mile a day runner, you do not qualify.  Or if you are 30  years old, you do not qualify, etc.    Some doctors have stretched these rules.     Implants can be metal, silicone or a combination of such.    When you choose an implant make sure you realize that they may need to be replaced in 10 or 15 years, etc. Another surgery may be needed.

Fusion of the big toe has the best long term patient satisfaction according to new studies.  Our center offers that too but also gives our patient choices.   Fusion is great choice for active patients with debilitating pain. The end all procedure.  The decision should be between you and your doctor, get some opinions.   Beware of those that will tell you, I only fuse, or I only implant. There are choices and your doctor should be able to give you those choices and have the experience to guide you in the right direction.

Patient many years post arthrosurface implant, very happy about such, made a video about it and here it is.

Newest video with a full review and explanation about Hallux Limitus and Rigidus.

Dr. Kevin Lam
Family Foot and Leg Center, PA
 Naples, FL
239 430 3668

Wednesday, October 3, 2012

Panther's C Ryan Kalil / Santonio Holmes / Benson with Lis Franc's Injury

Cedric Benson now with Lis Franc's injury and out for 8 wks. Last time we saw this injury was with Santonio Holme's injury.   Another person to add to the Lis Franc's injury list:   C Kalil of the panthers has a left foot lis franc's ligament injury.   
THis must be a French Conspiracy on the football season. 

Find out more about Lis Franc's read on. 

Lis Franc's ligament is a small but important ligament holding the foot bones today, particularly the medial cuneiform to the base of the 2nd metatarsal (long bone).   Injuries to this ligament can be as mild as a sprain of the foot requiring 8 wks of a boot,  to fractures with dislocations that can debilitate the individual. Surgery is required if the pain does not resolve or if there is a large gap between the bones as noted below. 

Second opinion about Santonio Holme's foot injury reveals a Lis Franc's injury. Foot injuries can be devasting to the NFL player and can end your season like WR Santonio Holmes. How does this occur?  Mechanism can be from stepping on your foot, or you stepping down hard in an open hole causing the middle of the foot to buckle.   Can be seen in auto accidents where the person is pressing hard on the brakes to avoid a collision.   This can not only be season ending but career ending for some player, hope this is not the case for Santonio, only time will tell. 
LOOK at the Bottom of the first big bone (metatarsal) that is separated  from the 2nd big bone (2nd metatarsal)

Same foot as above with the area of injury enlarged.
You can see the separation better in the zoomed in picture.    This is a very serious foot injury that can career ending.  Not knowing the severity of his Lis Franc's injury, it is almost certain that he will always have some sort of pain or immobility from this.  Option for treatments involve, immobilization, prolotherapy,  Platelet Rich Plasma (PRP) injections, and even surgery.   Most patients will end up with chronic foot pain in that area that can develop degenerative joint arthritis over time thus requiring a fusion.    Below shows our technique for Lis Franc's Injury reduction.    There are numerous techniques from wires, screws, big halo's depending on surgeon's experience and preference.  Note that the goal of this surgery to realign the joints that are displaced.     

I certainly hope that this will not be career ending for Santonio, but these injuries can be very hard on a professional athlete and his foot will potentially never be the same. 

Disclaimer: These are not the xrays of Santonio's foot.     These are photos of an actual FFLC patient of Dr. Kevin Lam,  treated in Naples, FL. 

Dr. Kevin Lam
661 Goodlette Road, Suite 103
Naples, FL 34102

Sunday, September 30, 2012

Colts Vontae Davis ankle or foot sprain

Initial reports is that Colt's Vontae Davis suffered and ankle sprain.   How could this be confused with what his is confirmed with having now a foot sprain?  Very easily upon a cursory review.  Let's review the anatomy of the area.   There is a joint below the ankle joint that is intimately connected with a very important foot joint the, subtalar joint (STJ).  The illustration below shows the mechanism of injury that can be the source of either an ankle  or subtalar / foot sprain.
The subtalar joint is more clearly defined in the radiograph below:
As you can see the the two joints are very close to each other and sometimes an athletic injury can have one or both joints sprained depending on how the foot is planted and twisted.  Artificial turf that is unforgiving in regards to sliding can make things worse as the foot can be stuck in one position and the rest of the leg is twisted by the force of a tackle, etc.   During the high speed game of football, these injuries are hard to avoid if your foot is planted, then a tackle or ankle/ foot twist happens with the mechanism shown above.
Treatment is usually an immobilization boot, CAM BOOT, for 4-6 weeks with physical therapy. Physical therapy can consist of cold laser therapy, prolotherapy, ultrasound, estim, etc.

Dr. Kevin Lam

Friday, September 28, 2012

Heel Pain or Tarsal Tunnel Syndrome

Your feet is burning, aching and painful with every step.   Most common and often first diagnosis that comes to mind for physicians is Plantar Fascitis or Heel Pain Syndrome.   Let's step back a little bit and go up a little higher.    Those symptoms can also mean many other things, but one should look at the diagnosis of tarsal tunnel syndrome and / or medial calcaneal nerve neuritis.   With the advent of minimalist shoes, heel pain as well as tarsal tunnel syndrome has been more prevalent in my practice.   Just as carpal tunnel syndrome is caused by overuse and repetitive motion of the hands and wrist, the tarsal tunnel can be aggravated via overuse and unprotected repetitive motion.

Clinical diagnosis is key with positive a Tinel's sign, or shooting pain when the nerve is tapped with the finger of a practitioner about the medial (inside) of the ankle.     EMG and Nerve conduction studies can be done but they are very inaccurate for early stages of this condition.  These neurological tests will only pick this compression neuropathy up when the disease has progressed to involve some muscle wasting.   Clinical suspicion and evaluation is the key to a diagnosis.

Then there is a nerve that goes right to the bottom of the heel causing pin point tenderness, but this also there can be pain along the inside of the heel.  The nerve that supplies this area can be inflammed by trauma or chronic irritation.   Clinical exam is the key once again.  The medial calcaneal nerve is drawn below for illustration purposes.

If you have been treated for plantar fascitis but you continue to have pain and notice some burning pain along the side of the ankle, you just may have Tarsal Tunnel Syndrome and / or Medial Calcaneal Neuritis.
Therapy, injections, supplements such as: NeurX can help to control the symptoms.  If the symptoms persists you should consult with your Podiatrist.  At the Family Foot and Leg Center, we have a center for peripheral neuropathy excellence.   Surgery is often very successful if done early before nerve degeneration / damage.

Incision placement for Tarsal Tunnel Surgery

Initial incision into the tarsal tunnel, notice the bulging vein and nerve.
Compression caused by deep fascia that holds your tendons and muscles in place.
Patient above had surgery today with immediate relief of her heel and shooting ankle pains.  Updates will be done.  Post operative course will involve taking NeurX twice a day as well as immobilization for 2 weeks to allow for proper skin healing.   Followed up with use of a walking boot for another 2 wks.

Visit www.NaplesHeelPain.com for more information and stretching excercises for your condition. 

Wednesday, September 26, 2012

Effective Neuroma Treatments Without Surgery

Morton's neuroma is an inflamed nerve that causes pain, tingling and numbness in the ball of the foot. Many complain of a bunched up sock under the ball of the foot, while others complain of walking on a lump, a large pebble or a lamp cord. Some describe a "twang", like a guitar string, in the ball of their foot. The pain can dull in the ball of the foot or can be radiating, electrical, tingling or burning and shoot to the 3rd and 4th toes. The pain is worsened with tight shoes, standing, walking, hills and stairs and generally relieved by rest and removal of shoes.

The initial treatment for Morton's neuroma is to eliminate factors which may have caused or aggravated it. In many cases, tight shoes cramp the toes and press on the nerve, causing irritation, inflammation and pain. Over-pronation causes forefoot instability and excess movement of the long bones in the foot. This type of abnormal foot mechanics, in combination with soft, flexible shoes can cause a neuroma.
Icing the ball of the foot twice a day for 15 minutes and/or contrasting between hot and cold for 30 minutes each day will help decrease the inflammation. Anti-inflammatory medications, such as ibuprofen or naproxen, can also decrease the inflammation and the pain. A neuroma pad will help disperse forefoot pressure, decreasing irritation on the nerve. Steroid injections and nerve sclerosing injections may also be used.
When conservative therapy fails, surgery is recommended. Surgery involves releasing the ligament placing pressure on the nerve or removing the neuroma. When the neuroma is removed, permanent numbness at the toes will result, but toe function is not affected.
In a new study published in the Journal of the American Podiatric Medical Association, researchers found extracorporeal shockwave therapy to be a safe and effective treatment for Morton's neuroma. Extracorporeal shockwave therapy (ESWT) is a treatment which directs powerful sounds waves at an area of injury. The sounds waves create vibrations causing microtrauma to the tissues.

The body responds by creating new blood vessels and sending healing factors and inflammatory cells to the area to stimulate the natural healing process. ESWT has been used for the treatment of kidney stones for many years. In the year 2000, the FDA approved ESWT for the treatment of chronic plantar fasciitis, a painful condition in the heel. ESWT is not currently approved for the treatment of neuromas.
In this study, researchers divided twenty five patients with a Morton's neuroma, unresponsive to at least eight months of conservative therapy, to an active treatment group or a sham treatment group. Both groups were taken into the procedure room and given intravenous sedation and a local anesthetic. The active treatment group received extracorporeal shockwave therapy and the sham group received no treatment.

At 12 weeks following the procedure, the group with the extracorporeal shockwave therapy had significant pain reduction compared to the sham treatment group. Potential complications associated with extracorporeal shockwave therapy include bruising, pain, swelling, nerve damage and hemorrhage, but the incidence is less than 1%. This results of this study are encouraging and ESWT may prove to be an effective treatment alternative to surgery. But, this is a small study and further research is needed to evaluate the safety and efficacy of extracorporeal shockwave therapy for the treatment of Morton's neuroma.

FFLC has both the high energy and low energy modality for your care. Discuss with your doctor which is right for you. 


Fridman R, Cain JD, Weil L. Extracorporeal Shockwave Therapy for Interdigital Neuroma. A Randomized, Placebo-Controlled, Double-Blind Trial. JAPMA. Vol 99, No 3, May/June 2009