Tuesday, July 29, 2014

Malignant Melanoma on the Leg at www.NaplesPodiatrist.com

Patient of the Family Foot & Leg Center, PA in Naples FL was seen for a trauma of the other foot, trauma taken care of in surgery, but he had a dark spot on the other leg.   Started about 5 years ago after he had scrapped his leg on an object and started bleeding.  No history of cancers, etc in the family.  He was not even sure he should have even brought this small problem up to me. Given the pattern of this and that he was not born with this lesion a 3 mm punch biopsy was done.   Behold the report came back malignant melanoma.  Instant referral to a dermatologist and general surgeon was made for more definitive care and diagnostics.   Malignant Melanoma on the foot is the 2nd deadliest cancer a man can have, this is in the leg not much better.

Possible treatments can involve a below knee or above knee amputation depending on spread of this disease.

Update:Patient's melanoma is the superficial spreading kind which is very much on the surface.  Dermatologist removed a majority of it and then an oncological surgeon removed the rest along with a lymph node biopsy. 
Patient's leg  and life saved. 

Wednesday, July 23, 2014

President Barack Obama has Right Heel Pain


Heel Pain is the most common problem seen by #podiatrist, not even the president is immune.
NaplesPodiatrist.com   this is one of the most common none surgical  problem that we see.

 A few reasons why:

1) We are poorly educated about shoes by the media and pop culture. What is cool is not the best for you.

2) Lack of flexibility and stretching of achilles. Even in martial arts schools, running teams, they neglect this area of the body. Achilles is the biggest tendon in the body!

3) Weight, though not President Obama's issue, this does weigh heavily in why we are seeing so many heel pain patients. Want to know more about heel pain or stretching visit:
Naples Heel Pain Page

Pediatric Flat Foot & Pain, what you should know

I still hear from some patients that they have no idea where to turn for pediatric flat foot / flatfeet advice.   The video above is a great resource as well as the videos below highlighting the problems kids go through with their feet.      Not all pediatric flat foot deformities are surgical cases.  In fact, most are treated conservatively.     But true surgical cases must be managed by those with extensive experience and training for such.  Here is link to a flow chart as recommend treatment protocols by the American College of Foot & Ankle Surgeons.

Dilemma on talking to patients about weight issues contributing to foot / ankle pain

Funny, as a physician we are supposed to make sure our patients stay healthy and free of aches and pains. Obesity is a big issue in some areas and when it is the cause of our patient's problem, most will not listen or even criticize the doctor via email for, "How dare you tell me to lose weight when all I had was pain all over my body and feet, which is why I came to see you in the first place. I did not pay for you tell me to lose weight." This email caused me to reflect on my role as doctor or learned friend. In my years of practice, I have had the most pleasure not correcting a clubfoot or reconstructing an unusable limb due to trauma to one where the patient can walk on it, no. The one case that brought me the most pleasure was a 350 pound man with collapsing ankles and flattening feet / arches in a disease known as posterior tibial tendon dysfunction. I have known this wonderful gentleman for 2 years, every time he comes in is the same complaint, doc my ankle hurt I'm having problems walking on it, can you please do surgery on me. For 2 years I refused to do surgery on this fellow and the main reason I gave him is that if I did surgery on him, it would fail due to his weight. The goal for him was to lose 100 lbs or I would not operate on him. Don't get me wrong, I did treat the fellow with medications, braces and physical therapy orders as a temporary solution. The final straw for him was when his pain returned this year, I referred him to a weight loss physician as well as getting him a custom Ankle Foot Orthosis commonly known as AFO. He lost 40 lbs with the doctor and discovered that he was eating for pleasure and living to eat instead of eating to live. Suddenly his foot / ankle pain is gone and he is happily wearing his brace. With all this talk about the ACA, obamacare, ACO's, how about a good dose of self responsibility. Most physicians are too busy these days to help monitor weight loss, etc. They would just say lose weight, see you at your next checkup. Or write a pill for your type II diabetes is  much faster and easily accepted by patients nowadays vs a good prescription of diet change and workout regimen with a trainer. If I had to do it again would I tell this obese female who sent me an email degrading my doctoring skills to lose weight? Of course I would, she will go from doctor to doctor who will bandaid her problem if at all possible. Or seek gastric surgery only to fail without proper mental / psychological preparation. Having trained at a center where they did a lot of bariatric surgery, I can tell you that counselling is essential as the mentality towards foods have to changed and reprogrammed. Food is an addiction and must be treated as such in order to succeed.

Eat your veggies, keep a healthy weight, lifestyle, don't smoke, drink in moderation all the stuff your grandmother would tell you.

Tuesday, July 22, 2014

What you need to know about Spurs in the Achilles Tendon

Most common complaint for this problem is a pain in the back of the heel and stiffness.  Or even a bump on the back of the heel.    The xray below shows an unfortunate patient with two types of spurs in the back of the heel that can cause a problem with the achilles.  Not to mention a large spur on the bottom that is currently not symptomatic.    

Red: is the Haglund's deformity AKA pump bump, common in old fashion days when pumps were popular and the back the pump rubs against the back of the heel bone.  

Orange arrow: points to the spur within the achilles tendon.  As you can see there is a shadow of the achilles noted in the back of the heel bone.  It is also very inflammed in nature as noted with the thickness noted in this xray.   MRI's are more telling of the actual tendon inflammation, injury and likely partial tears of the achilles.   By the time a patient presents to me with these xray findings they have been having pain for some time already.  

Not all patients with these xray findings will require surgery. Conservative care with anti inflammatories, physical therapy, shockwave therapy, massage therapy can help the condition, but if the pain persists beyond conservative care, surgical care will be required.

Below shows an xray of the same patient 2 weeks post operatively.
Notice the two noted spurs have been removed and staples in place for skin closure.
No pain at the 2 weeks mark and able to stand on the foot, not walk yet, but can stand.  Will allow range of motion at 4 weeks, then therapy and a boot to be used at 6 wks.   7/22/2014, stay tuned /subscribe for updates as the patient heals from her successful surgery.

Office Based Surgery Suite as cost savings to patients, insurers, government

Did you know that the most expensive part of your surgery is not your surgeon?
It is the facility such as the hospital or surgery center, that cost can be as high as 10 times your surgeon's fees.    With all this talk about cost savings and need for medicare and patients to save money the trend is towards office based surgery suites.  They are based out of the surgeon's office and is certified by the state department of health.   This significantly brings down the cost of surgery procedures by eliminating the highest cost in the equation for surgical procedures.  This allows the surgeon /physician to control the cost of the extraneous expenses and the patient gets the best value.   You still get the same care, anesthesia, etc, but at a fraction of the cost.    The one big barrier to this model of care is that when implants are being used, such as screws, wires, joints, insurance companies are not paying the office suites for these thus possibly passing the cost to the patient.   In most cases even if the cost of implants are forwarded to the patient, office based suites still is a great value vs other facilities.    As our healthcare system goes through these changes we should see more OBS sites.

Lateral ankle ligament surgery what you want to know

Tore some ankle ligament?    This is a story of an active male that had lateral ankle ligament reconstruction elsewhere and is here for a 3rd opinion.

Problem:  wound would not close and drains as well as continued unstable ankle.

How solved: removed all prior internal stitches (fiberwire) none absorbable that were used for the ligament repair.    Flushed / power washed the site with 300 liters of pressurized saline to clean any bacteria out.  Sent patient to infectious disease for powerful intravenous antibiotics for 6 weeks.   Repair with none braided smooth and absorbable antibacterial suture with amniotic tissue graft used for reinforcement due infected tissue that had to be removed.

Discussion:  Infections happen even in the most skilled hands and seemingly sterile environments.   Microbes are all over the place. I have steered away from certain braided none absorbable sutures now due to increase incidence of bacterial colonization.    Braids can hide bacteria better & also presents a barrier for antibiotics to get through.     Lateral ankle ligament reconstruction is not very difficult to do, most patients have enough of their own tissue nearby that can be rotated to reconstruct ligaments.

Secrets to Buying Shoes For Back to School

Can not believe it is back to school shopping again for SouthWest Florida Schools.

Let us look at the proper way to assess and buy shoes for your child to avoid foot , heel, or ankle pain.

Many of the problems we see in kids can be avoided with the proper fitting shoes and proper length.

Having a child that is in his growth spurt, I know it can be challenging in keeping up the size of shoes in kids.

Timeline for replacement can be anywhere from 3 months to 6 months depending on activity of the child, weight, etc.

Wednesday, July 16, 2014

Arthroscopic Ankle Fusion by Dr. Kevin Lam

Frank discussion about ankle fusion and this technique to achieve such.

Fusion of the ankle can be complicated and difficult to heal from with up to 50% nonunion rates (failed fusion) depending on technique.     Arthroscopic fusion is greater than 90% fusion rate according to studies mostly from lack of dissection, keeping nerves and blood supplied intact and mostly the anatomy also is intact during this type of fusion.    

With the advent of percutaneous intermedullary rods and external fixation techniques most ankle fusions do not need to be opened.

Tuesday, July 15, 2014

Rainy Season & Fungi growth on ur feet 5 things you need to know

  1. Air out your shoes / socks, do not keep them on too long if you happen to step on a puddle
  2. Dry / scaling feet or cracks between the toes, smelly, time to see your podiatrist
  3. Diabetics with redness or cracks in the feet must see a doctor or risk infections and amputations
  4. Rotate your shoes have at least 2 pairs to alternate daily humidity and wet weather is a great breeding ground for fungi
  5. As a preventative, you can use baby powder or foot powder between your toes every day to keep the sweat from becoming a problem. 

If you ignore your fungal infection, you can colonize bacteria and cause a bacterial cellulitis that can be life threatening and difficult to treat, even requiring IV antibiotics at times. 

Monday, July 14, 2014

5 Things you want to know about MRSA in Jujitsu, karate, gyms, etc.

5 Things you want to know about Methicillin Resistant Staph Aureus.

1) Staph Aureus is all around us, on our skin, desktops, phones, etc.   MRSA is just a variant of this bacteria that is resistant to methicillin a form of beta-lactam antibiotic aka penicillin family.

2) MRSA starts out as a bump on the skin / boil, blister, etc.

3) Can go deeper through the skin to the fat, muscles and blood where it can be deadly

4) Only way to identify is through cultures taken at the doctor's office or hospital.  In fact, most patients in the high risk category such as immunocompromised or diabetics, that are admitted to hospitals nowadays are assumed MRSA infection until otherwise noted

5) There are newer oral antibiotics that are effectively treating MRSA, IV antibiotics is still the quickest way to get the antibiotics into your system for limb or life threatening situations.

5 ways to avoid or pre diagnose MRSA

1) Nasal Nares cultures:   taking a culture of the nasal passages can determine if the person is a carrier and if so a regimen if antibiotic application and bathing in selective solutions can help

2) Wash your hands frequently, and use hand sanitizers.

3) Make sure you wipe down and pre-wipe all equipment at the gyms

4) Jujitsu or karate uniforms must be clean at all times, jujitsu more so then karate. No badge of honor for sticky yellow uniform that is supposed to be white.  Use long rashguards to avoid skin abrasions.

5) Mats or other contact surfaces must be cleaned and disinfected with anti MRSA solutions.

When you have a skin rash, infection, make sure a culture is taken and empiric (broad spectrum)  antibiotics are started immediately, can be a matter of limb and life loss.

Remember Kevin Randleman's Staph infection? Vinny Magalhaes had to step out of Metamoris 3 lineup due to this infection.

Not to say, do not practice contact sports for I love Brazilian Jujitsu and Karate, you and the gym should take precautions against MRSA.   As a medical student and even as a resident back in late 1990's, MRSA was not as common.   How does this happen, where and when did this happen that MRSA is so common?

One big blame is the overuse of common antibiotics like penicillins, bacteria generations are way shorter then humans and through true Darwinian concepts, one bacteria forms resistance and thrives while others are killed.    The overuse of antibiotics is one major cause.    We actually need bacteria on our skin to keep a balance as well as bacteria in our gut for proper food digestion, not all bacterias are bad.    

Hospitals , nursing homes and jails are big source of community acquired MRSA due to both population density and antibiotic usage.

Dr. Kevin Lam

Monday, July 7, 2014

10-15 year old with foot pain

Typically the parents bring in the patient with foot pain that they have tried to treat at home with motrin, etc and the patient's pain is the same or worse.     At about the ages of 10-15 the child will undergo massive growth spurts and the growth plate can become inflammed from the counter pulling of muscles / tendons, etc. Added to the fact that this is also the age where most kids become active and serious into sports, karate, etc. Two common diagnosis for kids of this age group is:

  • Severs Disease  inflammation of the heel growth plate.  I see this in basketball players and karate students.     Best way to treat this at home is to do achilles stretching, wear proper shoes and heel cups.   If these fail, then a visit to your local podiatrist would be in order.  Below is a film about stretching, for more resources, visit www.Naplesheelpain.com
  • Os Vesalium Syndrome: Swelling and pain the base or back of the #5 metatarsal base (bone on the outside of the foot.    Stretching, rest, Ice.
  • OsGood Schlatter disease:   Pain in front of the knee where the patellar tendon inserts into the tibia.  Patients will complain about knee pain typically in the 10-15 year old age group. Stretching the hamstrings and quads will help this condition as well as Rest, Ice, and topical anti inflammatories. 
Lesson in all this is that with increased activity and growth the child needs a consistent stretching program to avoid these problems as well as bone spurs when they are adults. 
Tight muscles , tendons, ligaments are the reason why heel spurs, bone spurs are formed in the lower extremity.   Proper training programs requires proper stretching programs to coincide. 

Stretching instructions

Below talks about Pediatric Heel Pain

Below talks about how to buy shoes for your child.

  • Second most common foot pain in a child of this group is Os Vesalium syndrome.  

Hope you find this informative and ask questions. What do you want to know? 
Dr. Kevin Lam,DPM, FACFAS
239 430 3668

Tips to control foot odor / fungus

Summertime is here and if you live in SWFL you will notice the humidity.   We are seeing more cases of athlete's feet , aka tinea pedis, aka fungal infection of the feet / toe/ nails.
Steps you can take to control, avoid such

  • spray your shoes / sandals with lysol and allow to air for 24 hours, also alternate shoes, sandals
  • if you sweat a lot, use antifungal foot powder spray to keep odor and fungus at bay
  • wash socks in color safe bleach
  • do not wear wet shoes! Dry them out completely before wearing
  • pay attention to between your toes,   toe jam = dead tissue that can be a breeding ground for fungus
Fungus is a tiny organism that lives off your skin cells.   Infections starts with mild itching, scaling of the feet.   Worsening infections can lead to bleeding, pain and severe odor.  Once there is a crack in your skin, the skin is open for bacteria to enter and cause bacterial  infection called cellulitis.    

Diabetics, people with peripheral neuropathy or PAD (peripheral arterial disease) should not try to treat this themselves.   

When all else fails see your podiatrist as soon as possible to prevent further complications.

Sunday, July 6, 2014

Urial Hall UFC 175 toe dislocation: wins decision

Uriah Hall fought his heart out like a warrior on UFC 175 even with a dislocated 2nd toe joint.  Just from analyzing the photo attached,  it looks like the toe was dislocated at the proximal interphalangeal joint of the second toe.  Biomechanically  it looks like the bunion & the tailor's bunion did not seem to help Mr Hall in his fight. It looks like the second toe is taking way too much force as the bunion joint is not moving or supporting the spin secondary to the alignment from the bunion.

When a fighter throws a roundhouse kick or a spinning kick there is a lot of circular force going through the support leg and toes. Typically the toes will fan out to act as disc brakes and help to control the fighter's momentum and balance. This is where the bunion joint is stuck and the second toe takes way too much lateral force as the person is spinning.   Treatment for an exposed bone in any situation would be treated as if the patient has osteomyelitis, it is assumed a bone infection. Whenever a bone is exposed to air or touches an object it also assumed infected. Most likely treatment in this case will be 6 weeks of intravenous antibiotics, surgical flushing and closure of the second toe with possible pinning, his career will not be in jeopardy for this warrior.  He will not be fighting or training anytime soon at least within the next 6 weeks  with this kind of injury.  I certainly hope he will  read my blog about minimally invasive bunionectiomies and get that taken care of during this medical leave.

Disclaimer: I am NOT Uriah Hall's  Doctor,  just speaking as an avid ufc fan and spectator looking at this photo of the injury.   

Dr. Kevin Lam
2389 430 3668
In the above pictures you you see the tremendous force being placed on the 2nd toe naturally during a kick and in this photo of my foot, my big toe joint is working.   Imagine that force on the second toe by itself.  Video below shows the lateral force that the toes undergo while doing a kick. 

Friday, July 4, 2014

Strokes of your Feet?

Stroke of the Feet?
Strokes are caused by a blockage in the artery going to the brain.  When brain tissue is devoid of blood it starts to die to  put it simply.   Your feet can have a stroke, well sort of.      It is not technically called a stroke in the feet but rather Peripheral Arterial Disease or P.A.D. This can happen over time, or via an acute embolism. 
Over time the artery can narrow due to genetics, cholesterol, smoking history, unhealthy diet, diabetes, etc.
The arteries first will stiffen, then plague will form within the wall of the artery to cause narrowing, the narrow passageway of blood becomes more a problem below the knees when the arteries narrow and gets narrower quickly into the foot.   
Acute embolism happens when there is a clot / plague in a big artery up in the belly or even closer to the heart.   This ball of plague will get logged in a narrow artery downstream in the leg , ankle or foot.   Vascular surgeons and interventional radiologists now have a great way to open these clogs via a small rotation burr in the artery, "laser" (picture Dr. Evil),  or a small hook, just like fishing out a clot.   Previously, a bypass surgery where vein or graft is used to replace the clogged artery was more commonly done.  Nowadays more surgeons are going to the endovascular (inside vascular structures) procedures.  The endovascular revolution has made it possible for patients to get revascularization, blood flow back to the region of previous dead or suffocating tissue.    This will not save every limb or toe but can potentially save a person's leg or life.  
Your team of doctors should include a podiatrist, why? I always tell my patients if you lose your toes or feet we lose our business, jokingly of course but we do have an incentive to try and save what we can, either via prompt refer to a vascular colleague or proper wound care protocols.
Overall, the patient needs to take personal responsibility for the reason why they have P.A.D.   If you are a diabetic, smoker with high cholesterol and still continue such lifestyle after,  your foot / ankle is as good as gone.   One infectious doctor who is an avid hunter told a patient you might has well take a gun and shoot the other foot off, gross? insensitive?  Perhaps as doctors it does frustrate us when we see patients continue to harm themselves with things that only they can change, a pill or surgery can't change it all for you.

Below is a clinical picture of dead toes just prior to scheduling amputation.   Symptoms are uncontrollable pain , cold feet and lack of warmth in the feet.
Patient lost 3/4 of his foot to smoking, diabetes, etc.  Patient requested amputation vs trying to save the foot utilizing hyberbaric oxygen treatment as an option.

Dr. Kevin Lam
239 430 3668

Things You need to know about Stroke adult and pediatrics

Stroke - Know The Risks and Signs

Know Stroke!
-- 4th leading cause of death in the U.S.
-- 795,000 people in the U.S. suffer strokes each year
-- Strokes are responsible for 133,000 deaths each year
-- Stroke kills more than twice as many American women every year compared with breast cancer deaths
-- More women die than men from stroke
-- Women suffer greater disability after stroke than men
-- Incidence of stroke among African Americans is nearly double that of Caucasians
-- Incidence of stroke among Hispanic Americans is higher than that of Caucasians
Lifestyle Changes
-- Keep blood pressure controlled
-- Avoid all tobacco products and second-hand smoke
-- Eat healthy diets containing 5 or more servings of fruits and vegetables per day
-- Exercise, be active!
-- Lose excess weight
-- Keep cholesterol controlled (ideal LDL <100mg/dl)
-- Reduce sugar intake/ control diabetes
Recognize Stroke Symptoms (F.A.S.T.= Face, Arms, Speech, Time)
-- Sudden and severe headache
-- Sudden vision changes or difficulty seeing out of one or both eyes
-- Sudden dizziness or difficulty walking
-- Sudden confusion or difficulty speaking
-- Sudden numbness or weakness of the face, arm or leg
Remember, ANY age group is at risk!

Wednesday, July 2, 2014

Surgical Pediatric Flat Foot Discussion

Minimally Invasive Bunionectomy and Tailor's Bunionectomy

Surgery For Chronic Ingrown ToeNail

Ingrown toenails are not only painful but can lead to toe amputations in diabetics or even life threatening blood infections that can land you in the ICU or worse.    Those are extreme cases but an ingrown toenail can harbor severe bacterial infections that can lead to bone infection.    The bone is very close to the surface and once bacteria touches the bone then it is treated as a bone infection.

Ingrown nails show a 50% hereditary factor.   If it runs in your family you may want to consider a permanent side removal as shown above.  Local anesthesia is administered, the offending nail is removed then a chemical  NaOH or Phenol is used to "kill" the root aka matrix.

Often people do not realize that podiatrists can do such services for you.   If you have an ingrown nail see a podiatrist.   While antibiotics will calm the infection down, the removal of the offending border can often times negate the need for oral antibiotics.