Neuropathy, Nerve Pain

Posted on November 23, 2016 by danpreece

Neuropathy

 

Neuropathy can be a life changing and overwhelming condition for some of our patients.

The causes are varied but the most common include diabetes, back injuries, tarsal tunnel syndrome, chemotherapy, idiopathic causes, vitamin deficiencies, thyroid concerns etc.

As podiatrists, we are concerned with the preservation of your feet and therefore the prevention of wounds subsequent infections and the common result of amputation of toes and/or the foot.

Image result for neuropathy

When dealing with neuropathy, the first step is to identify the cause.  We run a large panel of blood tests to rule out the most common metabolic causes.  Nerve conduction or PSSD testing can help diagnose nerve entrapment issues.   Another common test we use is called Sudoscan.  This is a simple test that demonstrates the sweat glands response in your skin to a small electrical stimulus.  This helps us determine if the small nerves / autonomic nerves of your extremities are involved.  If they are, it is very likely that Diabetes may be the cause of your neuropathy.

In general, if the causes of your neuropathy have been identified and dealt with (ie better blood sugar control, vitamin deficiencies remedied, back/spine evaluated, entrapped nerves released etc), then we move on to treating the nerve pain directly.

There are two main medical treatment options.  Either we make the pain improve with oral pain medications or we try to improve the nerve health itself and therefore the pain and numbness.

Covering the pain to allow for better sleep, exercise and ambulation may involve drugs such as lyrica, gabapentin, cymbalta, duloxetine etc.  Theses are not normally habit forming and can be used long term.  Narcotic coverage of this kind of pain is a last resort.

The other medical treatment is focused on helping the nerves to recover and improve function.  The most common prescription we use is Metanx.  This is a patented highly concentrated Vitamin combination that has been shown in repeated studies to improve sensation, bloodflow, wound healing and reduce pain involved with neuropathy.

Our current protocol is to test the nerve function with Sudoscan and have patients take the Metanx twice per day for six months at which time we test again with the Sudoscan.  If quantifiable improvement can be demonstrated we encourage the patient to keep taking Metanx and to be retested in the future.  As long as improvement in nerve function can be seen, our hope is that enough feeling will be developed in the feet to help patients feel any wounds or infections starting early enough that we can intervene long before amputation enters into the picture.

Our goal is zero amputations, and by restoring nerve health and close monitoring we hope to achieve this lofty goal.

When neuropathy appears, patients are at risk of many complications.  Below you can read about the valuable role a Podiatrist can play in the prevention and treatment of foot and ankle complications.

QUALITY OF CARE
Duke Study:
• Persons visiting a podiatrist and/or a lower-extremity clinician specialist within a year before developing all-stage complications were between 23 percent and 69 percent less likely to have an amputation compared with individuals who visited other health professionals.
• Podiatrists provide a unique and valuable service that is distinct from the services that allopathic and osteopathic physicians provide, and provide the highest benefit to those persons at risk of lower extremity complications as a consequence of diabetes.
• Conclusion: Care by a podiatrist and/or a lower extremity clinician specialist in the year before the lower extremity complication diagnosis reduced the potential for undergoing lower extremity amputation, suggesting a benefit from multidisciplinary care.
Thomson Reuters Study:
• Podiatrists see patients who are sicker and have more comorbidities.
• Among non-Medicare patients with foot ulcer, those seen previously by a podiatrist had a 20 percent lower risk of amputation and a 26 percent lower risk of hospitalization compared with patients not previously seen by a podiatrist.
• Among Medicare eligible patients with foot ulcer, those seen by a podiatrist had a 23 percent lower risk of amputation and a 9 percent lower risk of hospitalization compared with patients not previously seen by a podiatrist.
• Conclusion: Care by podiatrists prior to the first evidence of foot ulcers in patients with diabetes prevents or delays lower extremity amputations and hospitalizations.

Dan Preece DPM  & Darren Groberg DPM

Foot and Ankle Specialists

801-532-1822

www.saltlakecitypodiatrist.net

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Medical Expenses Financing

Posted on November 25, 2015 by danpreece

Our main focus at the Salt Lake Podiatry Center is to get you feeling better as quickly as possible.  We offer the most advanced Foot and Ankle surgical and clinical treatments available.  To help with the financial worries that medical care can create, and to allow you to focus primarily on healing, we are pleased to offer the option of Care Credit Financing if the need arises.

www.carecredit.com/

Salt Lake Podiatry Center P-LLC

Dan Preece, DPM  &  Darren Groberg, DPM

Office: 801-532-1822, Fax: 801-532-7544
Address: 144 South 700 East SLC, UT 84102-1109
                
     Foot & Ankle Specialists
Posted in Wound Care Clinic | Leave a comment

Plantar Warts

Posted on October 7, 2015 by Darren Groberg

**Any treatment options discussed below may be “off label” use and should only be attempted under the supervision of an appropriately trained physician.**

Warts, specifically Verruca Plantaris have been on my mind of late since 2 nasty little ones decided to “pop” up on the bottom of my right foot.  They aren’t painful fortunately but have the potential to become so.  Since I treat them on a daily basis I feel it is time to update the blog world on new treatments that I have recently implemented for my patients as well as myself and their success rates.

Verruca Plantaris:

A plantar wart is a wart caused by the human papillomavirus (HPV) occurring on the sole (Latin planta) or toes of the foot.   This infectious process is usually picked up by walking barefoot on a contaminated surface or by using shoes and socks contaminated by someone else who has the infection.

Plantar warts are almost unknown in habitually barefoot cultures and people. This is because walking barefoot for extended periods of time strengthens the skin and keeps it dry and uncompromised as well as wearing off the virus through friction on the soles of the feet, preventing infection.  While infection occurs in an estimated 7–10% of the US population, plantar warts tend to affect only 0.29% of people who have never worn shoes.  Though I am not recommending we all shuck our shoes for good (see post on barefoot running), it is interesting that a little barefoot time will get you the viral infection, and a lot of barefoot walking will actually help prevent it.  I often go barefoot and it is for that reason that my little warts have stayed little and have allowed me to avoid treating them for quite some time.  That being said there are about a thousand reasons to not  go barefoot in the environment most of us find ourselves in today including, infection, laceration, warts, puncture wounds, painful callus, skin fissures etc.

wart

Look closely at the picture above.  You will notice black dots within the wart that are actually tiny capillary buds that have clotted off.  You’ll also notice that the skin lines spread out and become wavy around the wart.  If you could squeeze the wart from side to side it would be quite painful.  These three classic signs in the diagnosis of plantar warts.  A large number of patients come into my office convinced they have a wart that needs to be removed when in fact it is just a thick callus that has become painful (which is also treatable).

We recommend having warts treated as soon as they are found.  The simple fact is that small warts are easy to treat and larger warts can be quite challenging and painful to treat.

Treatment Options:

Several studies have been published (J Cutan Aesthet Surg. 2011 Sep;4(3):188-91.) showing the effectiveness of Bleomycin injections into small warts.  Most of these studies showed >90% cure rate.

Bleomycin has been demonstrated to be very effective for warts smaller than a dime.  You do have to deal with a painful thick lesion after injection which needs to be removed within a week or two of the injection but it rarely results in scarring or recurrence.

Bleomycin has been and continues to be our primary treatment for small to moderate sized warts in our office.  For over 2 years we have used a small device called a madajet which was developed for the purpose of numbing small, superficial areas of skin for dermatological procedures.  It works better in our opinion at distributing bleomycin into a wart than does an injection.

madajet

The limitations of Bleomycin injections are two fold.  It does leave a painful and sometimes deep wound, so if you inject a large area this becomes a big problem.  Second, Bleomycin is a chemotherapy type drug and larger amounts can result in nausea and vomiting among other side effects.

Large warts or Mosaic Warts are another matter and can be uniquely challenging.

Large Plantar Wart

I like to approach larger warts from several angles at once.  I have had great results in the toughest of situations (over 20 warts on a single foot) with the combination of using oral Zinc Sulfate, foot powder/drying agent and topical DNCB.  All three of these have been demonstrated to cure warts on their own without painful scarring, however, their success rates are not as high as Bleomycin injections so they are combined for best results.

DNCB (dintrochlorobenzene) activates the immune system helping the body to fight the wart from within where ever applied.  This can be a potent treatment option and needs to be monitored by your doctor.   Zinc Sulfate enhances the immune system’s ability to fight warts and can be effective as the only treatment.  Warts tend to prefer moist skin types and a good drying powder aids in changing the environment of the skin.

Even though DNCB has been an effective treatment option in my clinic I have certainly had patients who did not respond to it at all.  For this reason I am always looking for other systemic treatment options.

A new treatment option which I have used very successfully with multiple patients when dealing with many warts of varying sizes is Tagamet.  Yes that’s right I said Tagamet.  For those of you out there who suffer from acid reflux or GERD you are likely familiar with this oral medication.  What you may not know is that is has been studies for at least 10 years and used to treat plantar warts.  The dose that you take is much higher than for treating stomach issues (30-40 mg/kg daily) and runs for 8-12 weeks.  This is clearly an off label use of the drug but has been found to be safe.  Recent studies show it is slightly more effective in pediatrics than adults but I have seen good results for both.  Worse case scenario it has resolved enough warts that we were able to proceed with treatments like Bleomycin.

Other Options:

– Liquid Nitrogen:  effective in other parts of the body where the skin is much thinner.  I have found that the freezing agent just doesn’t work as well on the thick skin of the sole of the foot and require many treatments if it is effective at all.

– Laser Removal:  can leave painful scarring and has a fairly high recurrence rate.

– “Bug Juice”:  moderate results, often warts are resistant.

–  Surgical Removal:  carries with it a risk of scarring which can be as painful/annoying as was the wart but can be very effective if done right.  I reserve this for a last resort treatment.

–  Duct Tape:  has actually be demonstrated to work for smaller warts, “occlusion” activates the body’s ability to fight the wart.

– Compounded Topical Creams: a combination of 5 Fluorouracil, salacylic acid, urea etc that has been shown to be effective killing the warts.

Please feel free to contact us at anytime for an appointment to be evaluated and treated or even just to ask us whatever questions you may have.

Darren Groberg, DPM

Salt Lake Podiatry Center P-LLC

Dan Preece, DPM  &  Darren Groberg, DPM

Office: 801-532-1822, Fax: 801-532-7544
Address: 144 South 700 East SLC, UT 84102-1109
                
     Foot & Ankle Specialists
Posted in Wound Care Clinic | Leave a comment

Neuroma (pinched foot nerve)

Posted on January 22, 2015 by danpreece

Neuromas:

Neuromas are generally described as a pinched nerve at the base of the toes.

neuromaPain, numbness, burning and tingling are all terms patients use to describe what they are feeling in the ball of the foot, the toes or the general region.  Radiating pain is often described as traveling out into the tips of two specific toes.

Onset:

Patients usually describe pain as starting after a change in activity, new shoes, new exercise program or some large event.  They often have discovered that going barefoot or wearing flimsy shoes exacerbates the pain.  Athletes talk about the pain showing up after a specific amount of running or biking etc.  Pain can come and go spontaneously but normally becomes a permanent fixture after enough irritation and damage to the nerve has occured.

Treatment:

The first line of attack is to decrease inflammation and injury to the nerve. This can be accomplished by wearing stiffer soled shoes combined with inserts or orthotics in the shoes that distribute pressure into the arch and away from the ball of the foot.  The inserts can be augmented with felt/foam padding as needed.

Icing, resting, ibuprofen or other NSAIDS can be useful if used carefully and routinely.

Steroid injections can be very helpful in decreasing the inflammation around the nerve tissues, causing softening/atrophy of surrounding tissues etc.  Many patients find that one or two injections helps relieve the pain for good or for over a year.

The next level of treatment is to damage the nerve enough that it no longer can send pain signals to the brain.  Neurotherm, Coblation etc are options available and are normally procedures carried out in the operating room under local anesthesia using ultrasound to locate and either freeze otherwise damage the nerve.  Success rates vary by Dr, but most report around 70% success rate.

Surgery:

If all else fails, then surgical removal of the nerve is the last option.  Studies have shown that an aggressive approach with the nerve being resected as far back as possible will give the patient the longest and most pain relief period as possible with over 90% success rates.  It is possible for the nerve to grow back or grow into a “stump neuroma” either of which may require repeat of the surgery, however this may take years to occur and is best prevented by tracing the nerve as deeply into the foot as safely and practically as possible.

Surgery has risks such as infection, hematoma, chronic pain and other complications.  These complications are relatively rare and recovery from surgery usually involves 2-3 weeks of wearing a post op shoe and bandages until sutures are removed.  Scar tissue and swelling can take several months after that to resolve to the point of being pain free.

 

We always suggest exhausting conservative options prior to surgical interventions are attempted.

Dan Preece, DPM

 

Salt Lake Podiatry Center P-LLC

Dan Preece, DPM  &  Darren Groberg, DPM

Office: 801-532-1822, Fax: 801-532-7544
Address: 144 South 700 East SLC, UT 84102-1109
                
     Foot & Ankle Specialists

 

 

Posted in Neuroma | 3 Comments

Dr Preece & Dr Groberg to join the IMC Wound Care Clinic faculty!

Posted on February 27, 2014 by danpreece

Dr Preece & Dr Groberg have been invited to join the faculty of the IMC Advanced Wound Care Clinic. They will be staffing the IMC clinic on Tuesday mornings and afternoons respectively. This is a great opportunity for them to merge the expertise they have gained in lower extremity wound healing with the resources of the IMC wound clinic to help patients with difficult chronic wounds.

Congratulations!

 

IMC Wound Care Clinic:

5171 S Cottonwood St. Murray, UT.   801-507-9310  (building one, third floor)

 

 

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Diabetic Foot Care and Monitoring

Posted on October 25, 2013 by danpreece

Diabetic Foot Care & Monitoring

As a resident training in the Salt Lake City VA Hospital, I was exposed to the full gamut of diabetic foot wounds, infections, amputations and at times as a result, the loss of life.  Diabetes is a systemic disease that leaves no corner of the human body untouched, least of all the foot.

Below I will provide an extensive list of situations to avoid and tips on protecting your feet if you are suffering from numbness / neuropathy from Diabetes or any other type of nerve disorder that might leave your feet at risk.

  • Check your feet at least morning and night for blisters, thick calluses, redness, swelling, warmth etc.  Even if you can explain the symptoms, you probably should have a podiatrist take a look.  A small amount of warmth and redness can spell disaster in some situations.  The most common sign of possible problems to come is a thick callus on the heel, ball of foot or tips of the toes.  The thick callus becomes to stiff and the underlying skin can begin to break down into blisters and later wounds.
  • Never put your shoes on before shaking them out and feeling inside for anything that could have punctured the sole including nails, needles, screws, pins etc.  I have seen patients who have neuropathy walk around all day with a marble, watch and even an golf ball in the shoe, sustaining serious damage.

download

  • Never check the temperature of bath water with your foot.
  • Never walk around in your home or outside without a thick soled shoe that would prevent most punctures.  I can’t tell you how many times we have x-rayed feet and found needles inside the foot that the patient had no idea was there.
  • Never go barefoot.  I have seen severely burned feet just from walking across a wooden deck in the summer that resulted in amputation.
  • Have at least a yearly check up with a quality podiatrist.  Some of my more brittle diabetic patients have to be seen monthly or even weekly to keep them out of trouble.  A recent study out of Duke, showed that having a podiatrist involved in the care of a foot wound will reduce your chances of major amputation down the road by 25-30%.
  • Wear quality shoes, hopefully diabetic shoes.  If you are on Medicare, they will pay for one pair of shoes and 3 sets if inserts each year.

diabeticShoes

  • Where white socks.  If you begin to bleed from a wound or puncture, you’ll notice it much quicker than if you are wearing darker colored socks.
  • Keep dry skin moisturized.  Cracking skin can open the door to infections.  Keep wet and moist skin from getting too dry or it too will break down into blisters and wounds.
  • Get it checked out.  A simple blister, callus or red spot can end up being a major problem.  A good podiatrist normally will tell you to please come in to be examined.  Small problems normally can be kept small, whereas larger problems cannot be reversed at times.

Remember that diabetes will and can affect your blood flow, your immune system and your sense of feeling.  This puts you at risk for wounds, infections and slow healing. Our goal is to protect your feet from even the smallest problems.

As always, please feel free to contact our clinic with any questions or concerns or to make an appointment.

 

Dan Preece, DPM

 

Salt Lake Podiatry Center P-LLC

Dan Preece, DPM  &  Darren Groberg, DPM

Office: 801-532-1822, Fax: 801-532-7544
Address: 144 South 700 East SLC, UT 84102-1109
                
     Foot & Ankle Specialists
Posted in Diabetic Foot Care | Leave a comment

Ankle Arthroscopy / Scope, Joint Arthritis

Posted on July 11, 2013 by danpreece

Arthroscopy of the Ankle for Arthritis and Related Issues

Ankle sprains, ankle fractures, flat feet and many other foot problems can lead to damage within the ankle joint.  Much of this damage can be fixed with a surgical procedure called an ankle arthroscopy or ankle “scope”.   In short, the surgeon introduces a small camera 2.7 mm or 4.0 mm wide into the front of the ankle through a very small incision and through a second equally sized incision places instrumentation to clean up the ankle joint and repair damaged structures.

Ankle Scope 2

Osteochondral Defects (OCD)

OCD’s show up commonly after ankle fractures or bad ankle sprains.  The surfaces of the ankle joint bang into each other causing cartilage and/or underlying bone to die or degenerate leaving a “pot hole”.  Pain from this problem often feels like sharp shooting pain that hits you at certain moments while walking, especially on uneven terrain.  If pressure is applied just right to the defective area, pain can be excruciating.

osteochondral defect ankle

Treatment normally starts with a simple steroid injection into the ankle joint for two reasons.  One reason is the anti-inflammitory effective of the injection that for some patients can bring long lasting relief, the other reason is for diagnostic purposes.  Often with the injuries that lead up to the OCD, there can be surrounding tissues outside the ankle that become injured.  The local anesthetic injections into the joint helps rule out sources of pain outside the ankle.  If most of the pain is relieved from an ankle injection of local/steroid than chances are that the space within the ankle is where surgical attention should be focused.

Stable shoes, ankle braces and custom foot orthotics all can be very helpful in limiting the pain associated with an OCD, however,  surgery is often required.

If all else fails, an ankle arthroscopic procedure can be used to accomplish several things.  Joint synovitis almost always accompanies OCD’s.  Synovitis resembles tentacles of scar tissue that hang within the joint and become painful when pressure or stress is applied to them.  Some describe their appearance as “crab meat” and is removed with a mechanical devise called a shaver.

ankleSynovitis1

If an OCD is found, which is normally confirmed by MRI prior to surgery, then several options are available depending on the size of the lesion.  Generally, if the hole is less than 1.5 cm, drilling the surface bone to create bleeding can help the body repair the damage with a new layer of fibro-cartilage.  If the defect is larger, then the problem can be fixed with cartilage grafts either taken from the patient or a  donor such as with Zimmer’s Denovo product.

-denovo-hero2

Recovery times depend on the extent of the repair carried out.  If a simple clean out is performed, the patient may walk in a CAM boot immediately.  If OCD drilling and cartilage filling is done, then the patient is required to be non weightbearing for 3-6 weeks followed be a rehab protocol.

Dr Groberg and Dr Preece are accomplished arthroscopists and have performed these procedures many times in training and in practice in the Salt Lake area with very good outcomes.

When damage within the joint becomes to extensive for these joint salvage measures, the discussion turns to ankle joint replacement or ankle fusion depending on the situation.

Please contact our clinic with any questions you may have or to schedule an exam to hear what options may be available for you.

 

Dan Preece, DPM

 

Salt Lake Podiatry Center P-LLC

Dan Preece, DPM  &  Darren Groberg, DPM

Office: 801-532-1822, Fax: 801-532-7544
Address: 144 South 700 East SLC, UT 84102-1109
                
     Foot & Ankle Specialists

 

Posted in Ankle Pain / Scope | Tagged , , , , , , , | Leave a comment

Verruca Plantaris / Plantar Wart

Posted on February 18, 2013 by danpreece

**Any treatment options discussed below may be “off label” use and should only be attempted under the supervision of an appropriately trained physician.**

Warts, specifically Verruca Plantaris have been on my mind of late since 2 nasty little ones decided to “pop” up on the bottom of my right foot.  They aren’t painful fortunately but have the potential to become so.  Since I treat them on a daily basis I feel it is time to update the blog world on new treatments that I have recently implemented for my patients as well as myself and their success rates.

Verruca Plantaris:

A plantar wart is a wart caused by the human papillomavirus (HPV) occurring on the sole (Latin planta) or toes of the foot.   This infectious process is usually picked up by walking barefoot on a contaminated surface or by using shoes and socks contaminated by someone else who has the infection.

Plantar warts are almost unknown in habitually barefoot cultures and people. This is because walking barefoot for extended periods of time strengthens the skin and keeps it dry and uncompromised as well as wearing off the virus through friction on the soles of the feet, preventing infection.  While infection occurs in an estimated 7–10% of the US population, plantar warts tend to affect only 0.29% of people who have never worn shoes.  Though I am not recommending we all shuck our shoes for good (see post on barefoot running), it is interesting that a little barefoot time will get you the viral infection, and a lot of barefoot walking will actually help prevent it.  I often go barefoot and it is for that reason that my little warts have stayed little and have allowed me to avoid treating them for quite some time.  That being said there are about a thousand reasons to not  go barefoot in the environment most of us find ourselves in today including, infection, laceration, warts, puncture wounds, painful callus, skin fissures etc.

wart

Look closely at the picture above.  You will notice black dots within the wart that are actually tiny capillary buds that have clotted off.  You’ll also notice that the skin lines spread out and become wavy around the wart.  If you could squeeze the wart from side to side it would be quite painful.  These three classic signs in the diagnosis of plantar warts.  A large number of patients come into my office convinced they have a wart that needs to be removed when in fact it is just a thick callus that has become painful (which is also treatable).

We recommend having warts treated as soon as they are found.  The simple fact is that small warts are easy to treat and larger warts can be quite challenging and painful to treat.

Treatment Options:

Several studies have been published (J Cutan Aesthet Surg. 2011 Sep;4(3):188-91.) showing the effectiveness of Bleomycin injections into small warts.  Most of these studies showed >90% cure rate.

Bleomycin has been demonstrated to be very effective for warts smaller than a dime.  You do have to deal with a painful thick lesion after injection which needs to be removed within a week or two of the injection but it rarely results in scarring or recurrence.

Bleomycin has been and continues to be our primary treatment for small to moderate sized warts in our office.  For over 2 years we have used a small device called a madajet which was developed for the purpose of numbing small, superficial areas of skin for dermatological procedures.  It works better in our opinion at distributing bleomycin into a wart than does an injection.

madajet

The limitations of Bleomycin injections are two fold.  It does leave a painful and sometimes deep wound, so if you inject a large area this becomes a big problem.  Second, Bleomycin is a chemotherapy type drug and larger amounts can result in nausea and vomiting among other side effects.

Large warts or Mosaic Warts are another matter and can be uniquely challenging.

Large Plantar Wart

I like to approach larger warts from several angles at once.  I have had great results in the toughest of situations (over 20 warts on a single foot) with the combination of using oral Zinc Sulfate, foot powder/drying agent and topical DNCB.  All three of these have been demonstrated to cure warts on their own without painful scarring, however, their success rates are not as high as Bleomycin injections so they are combined for best results.

DNCB (dintrochlorobenzene) activates the immune system helping the body to fight the wart from within where ever applied.  This can be a potent treatment option and needs to be monitored by your doctor.   Zinc Sulfate enhances the immune system’s ability to fight warts and can be effective as the only treatment.  Warts tend to prefer moist skin types and a good drying powder aids in changing the environment of the skin.

Even though DNCB has been an effective treatment option in my clinic I have certainly had patients who did not respond to it at all.  For this reason I am always looking for other systemic treatment options.

A new treatment option which I have used very successfully with multiple patients when dealing with many warts of varying sizes is Tagamet.  Yes that’s right I said Tagamet.  For those of you out there who suffer from acid reflux or GERD you are likely familiar with this oral medication.  What you may not know is that is has been studies for at least 10 years and used to treat plantar warts.  The dose that you take is much higher than for treating stomach issues (30-40 mg/kg daily) and runs for 8-12 weeks.  This is clearly an off label use of the drug but has been found to be safe.  Recent studies show it is slightly more effective in pediatrics than adults but I have seen good results for both.  Worse case scenario it has resolved enough warts that we were able to proceed with treatments like Bleomycin.

Other Options:

– Liquid Nitrogen:  effective in other parts of the body where the skin is much thinner.  I have found that the freezing agent just doesn’t work as well on the thick skin of the sole of the foot and require many treatments if it is effective at all.

– Laser Removal:  can leave painful scarring and has a fairly high recurrence rate.

– “Bug Juice”:  moderate results, often warts are resistant.

–  Surgical Removal:  carries with it a risk of scarring which can be as painful/annoying as was the wart but can be very effective if done right.  I reserve this for a last resort treatment.

–  Duct Tape:  has actually be demonstrated to work for smaller warts, “occlusion” activates the body’s ability to fight the wart.

– Compounded Topical Creams: a combination of 5 Fluorouracil, salacylic acid, urea etc that has been shown to be effective killing the warts.

Please feel free to contact us at anytime for an appointment to be evaluated and treated or even just to ask us whatever questions you may have.

Darren Groberg, DPM

Salt Lake Podiatry Center P-LLC

Dan Preece, DPM  &  Darren Groberg, DPM

Office: 801-532-1822, Fax: 801-532-7544
Address: 144 South 700 East SLC, UT 84102-1109
                
     Foot & Ankle Specialists

Posted in Warts / Verruca Plantaris | Tagged , , , , , , | 1 Comment

Heel Pain in Adolescence

Posted on February 13, 2013 by danpreece

Heel pain in the arena of Foot and Ankle specialists is like the common cold for a Primary Care physician.  The vast majority of the time it is diagnosed as Plantar Fasciitis and is on the bottom of the heel, usually at the instep.  It can however be a variety of other diagnoses including insertional achilles tendonitis, retrocalcaneal bursitis, or neuritis just to name a few.  In Adolescence, heel pain is also quite common but is rarely any of the above mentioned.

The most common diagnosis in athletically active youth, roughly between the ages of 6-13 is Calcaneal Apophysitis or Sever’s disease.  Sever’s Disease, here after referred to as SD was initially described by Sever in 1912.  Historically it was most often seen in adolescent boys who were involved in a variety of sporting activities.  Times have changed and girls are participating just as actively in athletics and are subject to the same pathology.  The usual presentation is pain in the back/bottom of the heel that is aggravated by activity and resolves to some extent with rest.

Example of an open growth plate.

Example of an open growth plate.

 

 

Example of Achilles and Plantar fascia insertions.

Example of Achilles and Plantar fascia insertions.

 

Sever’s Disease is not a disease in the sense of an infection or other chronic pathology but is an injury/irritation of a growth plate.  The Calcaneal growth plate or growth plate in the heel bone has attachments from the achilles tendon and the plantar fascia.  Pull from either or both of these structures can cause enough motion within the apophysis or growth plate space to create irritation and inflammation which can be quite painful and limiting.  This can start when the growth plate is still wide open but is more often seen as the growth plate starts to close further limiting its ability to move with the traction of soft tissue attachments.  It was believed by Sever that fractures within the growth plate were the source of the discomfort.  When looking at a growth plate that has started to close it can appear to be fragmented into 2 or 3 pieces.  It has since been proven that this is the normal appearance of a closing growth plate.

The disease itself is self limiting and will resolve regardless of treatment once the growth plate has fully closed.  Depending on the age of the youth at onset this could be a problem for many years.  Treatment has always been aimed at managing the pain as well as the inflammation.  This is done with the rest, ice, non steroidal anti-inflammatories like ibuprofen, stretching, taping, heel cups, heel lifts and orthotics.  In severe cases, cast or walking boot immobilization is used.  Each of these have differing levels of efficacy but in my experience orthotics are the golden treatment or the silver bullet.  I am not talking about your run of the mill over the counter Dr. Scholls shoe insert.  These definitely have their place in the world but not here.  Custom molded orthotics made from a mold taken of the youths foot will provide the necessary control and support to stop the pain cycle.  We can safely report over 85% of patients who are able to get back to sports and other activities as long as they wear the orthotics in supportive shoes as directed.

As  previously mentioned, both the achilles tendon and the plantar fascia have attachments to the growth plate.  Increased activity  with sports, coupled with slight irregularities in normal gait like pronation cause micro atypical motion/trauma within the growth plate.  This motion/trauma is the source of the pain.  When the youth is casted in a neutral position the resulting orthotic allows them to function in that position, thus controlling the motion and stopping the pain.  A proper custom orthotic will completely resolve the SD in a matter of weeks and the youth will be able to regain full activity without limitations.  I treat many painful pathologies and deformities in the feet with custom orthotics.  Very few respond as well as does SD.

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Another pearl to add when treating SD is a thorough assessment of their cleats.  If you look on the bottom there is often a posterior spike which is positioned anatomically directly below the growth plate.  Getting a new cleat without a spike in this area or simply grinding down the spike on the old cleat will also significantly reduce impaction trauma and irritation to the area.

If you or your child has SD and you have been told to deal with it and manage the symptoms when they come and eventually it will resolve on its own don’t settle for it. A simple, custom orthotic can and will be a game changer.  We cast patients for these devices in our offices and can have them ready for fitting in 2-3 days.

Any questions, thoughts or comments are always welcome.

 

Dr. Darren Groberg, DPM

 

Salt Lake Podiatry Center P-LLC

Dan Preece, DPM  &  Darren Groberg, DPM

Office: 801-532-1822, Fax: 801-532-7544
Address: 144 South 700 East SLC, UT 84102-1109
                
     Foot & Ankle Specialists
Posted in Heel Pain in Adolescense/ Sever's Disease | Tagged , , , , | 1 Comment

Custom Orthotics / Shoe Inserts

Posted on November 13, 2012 by danpreece

Custom Foot Orthotics /Shoe Inserts

The foot is the foundation of the body and if the foundation is not supported correctly the ankles, knees hips and back can be directly affected.  Many diagnoses can be treated with orthoses including Plantar Fasciitis, Shin Splints, Hallux Limitus (big toe arthritis or decreased motion), arch pain, foot fatigue, flat feet, high arches, knee pain and calcaneal apophysitis (heel pain in children and teenagers), achilles tendinitis, limb length discrepancies etc.  Combined with a sturdy shoe, the orthotic can support the foot in a neutral position and afford the wearer pain relief and comfort.

The Salt Lake Podiatry Center has been creating and fitting custom foot orthotics in our office for 70 years.  We have adopted and modified the technique first described by Richard Schuster a sports medicine Podiatrist who practiced in NY treating large numbers of runners.  For the last 35 years our clinic has provided the Utah Jazz basketball team and other professional and semi-professional athletes with orthotics and shoe recommendations creating one of the lowest foot and ankle injury rates in the NBA.

Our clinic also provides custom inserts and shoe ordering assistance for those who qualify for Diabetic Shoes to help prevent ulceration and wounds.  Medicare will pay for one pair of shoes and three pairs of accommodative inserts each year if certain criteria are met (Diabetic with vascular or sensory issues).

Fabrication: 

We begin the fabrication process by taking a plaster mold of the patients feet.  The entire bottom of the foot is captured in a neutral semi-weightbearing position, or whichever position the Doctor desires the patient’s orthotics to hold them in depending on the problem being treated.  In my training I had the opportunity to see many different casting methods and fabrication processes demonstrated and this version consistently provides the most comfortable and effective orthotic therapy.
 

 

 

 

 

 

Once the casts have been allowed to dry and harden for 24 hours, they are ready to be filled with plaster to create the positive mold.

 

The positive molds are corrected of any defects and modified as needed.  They are then placed in a vacuum press and covered with heated polypropylene and allowed to cool.

The cooled polypropylene orthotic is then ground down to size and specified length depending on the problem being treated.  This process takes about 2-3 days.

 

 

 

 

At this point the patient is encouraged to wear the orthotics for 1-2 two weeks to become accustomed to the fit and feel of the device.  Heel posts and top-covers can then be added with offloading areas with foam or cork as needed for comfort and treatment purposes.

 

 

 

 

This entire process is labor intensive and can take up to 3 days.  We currently charge $375 for a pair of orthotics and $200 for multiple pairs.  Our experience has shown that they will often last and be quite functional for up 10 years if not longer.  If you add up the cost of buying cheaper over the counter orthotics for $30-50 every 3-4 months, the price begins to even out and you get a much more effective product.  We have found this form of orthotic to be the most effective at relieving a variety of foot problems.

The cost of the orthotics also includes the follow up visits necessary to modify and fit them to the patient until a high level of comfort is reached.  We of course offer a full money back guarantee if the patient is unhappy with the end result, all we ask is for the orthotics and casts be returned.

If you are in need of  custom orthotics, please contact our clinic 801-532-1822.  Teenage athletes who may need several orthotics made over the years may receive a 25% discount if you mention this post.

Diabetic Shoes:

We also provide Diabetic shoes and 3 pairs of inserts as covered by Medicare each year for Diabetic patients.  We use a three layer insert for cushion and custom fit that can be placed in a large variety of Diabetic approved shoes that are extra depth.  The molds are made from impressions captured in foam boxes.

 

 

Please call our office with any questions or concerns you may have regarding custom orthotics or diabetic shoes.

 

To schedule an appointment please call 801-532-1882 or go to our clinic’s website at: www.saltlakepodiatrist.net.

 

Dan Preece, DPM

 

Salt Lake Podiatry Center P-LLC

Dan Preece, DPM  &  Darren Groberg, DPM

Office: 801-532-1822, Fax: 801-532-7544
Address: 144 South 700 East SLC, UT 84102-1109
               
     Foot & Ankle Specialists

 

 

 

Posted in Custom Orthotics and Diabetic Shoes | Tagged , , , , | 5 Comments