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Podiatry House Calls

Fungus Toe nails  -  Ingrown Toe nails  -  Heel Spur/Plantar Fasciitis  -  Warts  -  Corns/Callous  -  Diabetes  -  Ulcers

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Fungus Toe Nails - Onychomycosis
Fungal Nails are an unsightly infection of the nails, causing thickened, brittle, yellow, discolored and sometimes painful nails. It is difficult to cure. It is caused by one of several microscopic organisms, similar to those that cause Athlete's Foot (dermatophytosis) These are plant like organisms that thrive in a dark, warm, moist environment, such as within shoes and stockings. They grow in the nail bed, beneath your nails, and live off Keratin, the protein in the nail. The condition usually begins toward the far end of the nail and may cause white or yellow-white areas that appear to be rotten or dead. If the infection continues to the base of the nail, it can invade the nail root (matrix) and cause the nail to grow thickened and deformed. Many people complain of a foul odor associated with this condition. It can also spread to other nails. The fungus can also spread to the adjacent skin surrounding the nail.
It may not be painful in the beginning, and may only look slightly different than the normal nails. Later, the nail may begin to show small patches of white or yellowish-tan color and may become brittle and split. As it progresses, the nail becomes thicker and deformed and may begin to grow at an angle and become an Ingrown Nail. Pain develops, due to the ingrown or thickened nail deformity, and becomes aggravated by pressure applied by shoes. Inflammation can develop due to this pressure and a secondary bacterial infection may occur, leading to more pain. Even without inflammation, shoe pressure on the fungal nails can cause pain, making it difficult to walk or stand for periods of time. This can also influence one's involvement in day to day activities.
First of all, the doctor will do a physical examination to determine if there is a fungus present and not some other kind of medical condition. After determining the type of fungus, treatment may range from topical solutions to oral, systemic medications. The nails may be trimmed and reduced with an electric grinder periodically, and you may be asked to participate in some way at home. Fortunately, oral medications are now available that have proven very effective in curing these difficult infections. These medicines reach the nail through the blood stream and create a barrier between the old infected nail, and the newly formed nail, effectively killing all living fungus organisms.. The medications are taken for about three months. During that time, they penetrate into and saturate the growing part of the nail. Even after you stop taking the medicine, the medicine that has gotten into the nail continues to treat the nail from inside for another six to nine months, until a healthy nail has completely grown out. Although these medications are safe, there are some side effects in a small percentage of patients and they require a blood test to monitor blood levels. Your doctor will discuss the advantages and disadvantages of oral therapy and other alternatives with you, to determine the most appropriate treatment in your situation.
You may be asked to treat the insides of your shoes, which have become contaminated by the fungus. This is to make sure that the new healthy nail doesn't become contaminated by any fungus hiding in the shoe. To prevent the fungus infection from coming back, the best offense is a good defense. We must control moisture and create a drier environment for your feet. Use powder in shoes, to absorb perspiration. Also, if you have been cutting your nails too deeply, or treating an ingrown nail on your own, this may have allowed the fungus to grow under the nail. Use
DaniPro anti-fungal nail polish.

Ingrown Toe Nail
An ingrown nail occurs when a portion of a toenail on either side of the toe turns downward and presses into the skin. Nails normally are nearly flat, with just a slight arcing downward at the borders. When the border of the nail is turned downward, it begins to injure the skin.
Patient's usually feel pressure and eventually pain, as the hard and sharp nail edge creates further injury. Shoes that apply pressure to the toe increase the pain. If an infection develops, the pain becomes intolerable.
In advanced cases, where pain, swelling, redness or obvious infection is present, seek the attention of a doctor.
In the most minor cases, the podiatrist will simply cut the nail to shorten it, and show you how to cut the nail in the future, to prevent ingrowing of the nail again. In more severe cases, but not those in which an infection hasn't developed, the podiatrist may gently remove the ingrown portion of the nail. This affords considerable relief, but is temporary. After a few weeks, when the nail grows long again, it may again grow in. In cases where the nail has grown in repeatedly, or more critically, when the nail edge has penetrated the skin and caused an infection, the podiatrist will perform a minor procedure called an Ingrown Nail Correction or Matrixectomy. The podiatrist will gently numb your toe, reshape the nail edge and finally, apply a medicine which will, in most cases, permanently prevent the nail edge from growing improperly again. 

Heel Spur-Plantar Fasciitis
A pain has developed at the bottom of the heel, and it has gotten worse. The patient was not aware of having had any injury that caused it. While  the following information can be helpful, the only way to get a  definitive diagnosis is to have an examination by your Podiatrist. There are many causes of heel pain which must be ruled out.
It feels like a dull ache most of the time, but when the patient first gets out of the bed in the morning, or when getting up after sitting for a period of time during the day, the pain in the heel is impressive. It almost feels like the heel has been bruised, from falling on a rock barefoot, but it is worse.
It is better to rest the heel as much as practicable. When you are off your feet, the injury is healing and getting better. When you are standing, without any foot support, the heel is getting injured further. When you are standing when wearing orthotics (foot supports) and well supportive shoes, the injury decreases dramatically, but usually is not eliminated altogether. So, during the treatment period, if you have the choice of sitting or standing, sit !
First, we need to protect the bone from the pulling of the plantar fascia. We do this by using some kind of in-shoe arch supporting device. Some patients will find relief from an over-the-counter pairs of insoles such as the
Spenco PolySorb Insoles. Others may need a custom made orthotic (foot support). They come in pairs, one for each foot. If you must wear Flip flops or sandals I highly recommend Spenco PolySorb Total Support Sandals for Women or for Men. Next, we encourage the patient to stretch the tissue on the bottom of the foot. Three times a day, sit erect with the legs extended and loop a belt, scarf or towel around the forefoot. Pull the forefoot toward the upper leg. Expect to feel a mild pulling sensation at the back of the leg and in the arch. Stretching should not be done to the point of pain. This position is held for 30 seconds, and is repeated 3 times. The 3 repetitions at 30 seconds, 3 times-a-day is easy to remember. I highly recommend using a Night Splint to keep the area stretched overnight. This will help alleviate the pain first thing in the morning. Because of the risk of stomach upset, non-cortisone anti-inflammatory medication can only be used for some patients and only for a short period of time. In addition to the above, we begin an aggressive course of physical therapy and cortisone injections. For physical therapy, the doctor may employ ultrasound, galvanic stimulation or any of a number of anti-inflammatory modalities in the office or at the offices of a physical therapist. The most effective way for physical therapy to work is if it is applied regularly, at least three times a week.  Cortisone injections are usually done at weekly intervals, and most cases require 1-3 injections. The skin can be desensitized before the injection with a cold freezing spray designed to provide brief anesthesia. The injection is done from the inner side of the heel, not from the bottom.
Recurrence is rare after treatment, if the patient continues to employ good mechanical foot control by continuing to wear orthotics and good
supportive walking or athletic shoes.  

Plantar Warts-Verruca Plantaris, Plantar Warts
A plantar wart is a small skin lesion that resembles a callus and is found on the bottom of the foot or toes. The term "plantar" doesn't mean only farmers get them. "Plantar" means they occur on the bottom surface of the foot. It is usually under 1 cm diameter, but can occur in clusters and be much larger. Sometimes a single larger wart is surrounded by many smaller warts. In this case, they are called mosaic warts. 
A plantar wart feels like a lump under the foot. They are only painful is they are squeezed or pinched from side to side, or if you bear direct weight on them. Warts on other parts of the body, such as the hands, grow elevated above the skin's surface. We bear weight on warts on the bottom of the foot, so they get flattened and pushed into the skin. Most people liken this to walking with a rock attached to the foot, as the thickened callous tissue becomes hard and painful as it gets bigger.
All warts are caused by the Papilloma virus, a slow growing virus which invades the skin. The viruses are common in all of our environments and they don't readily grow on intact skin. But if there is a break in the skin, like a scratch or thorn penetration, this gives the virus the opportunity to get in and start growing. The virus particles can spread from the main wart, along the cutaneous (skin) nerves, to begin growing remote or satellite warts at a distance from the original site. If enough of this spread occurs, mosaic warts result.
Your doctor has a number of choices for treating your Plantar Wart. Unfortunately, warts are stubborn entities and even the best methods  for removing them allow a high rate of re-occurrence, around 15%.  He/she may choose to use medication that is stronger than what is available at the pharmacy. This can speed up the process. Depending on the size and number of warts, treatment can take from 1 - 12 months before the wart is completely gone, and like any infection, all parts of it must be completely eliminated, or it will grow back.  An additional option is to physically remove the wart at one time, surgically, with a spoon like instrument called a curette. The healing time is from 2-4 weeks, depending on the size. 

Corns and Calluses
A corn is simply an area of hard, thickened skin that can occur on the top, between, or on the tip of the toes. A callus is similar in nature, but is larger and usually occurs across the ball of the foot, on the heel, or on the outer side of the great toe. Corns and calluses are often mistakenly considered a "skin" condition. They are actually the visible sign of an underlying "bone" problem.
Calluses and corns quite often have painful nerves and bursal sacs (fluid-filled balloons that act as shock absorbers) beneath them, causing symptoms ranging from sharp, shooting pain to dull, aching soreness.
Corns and calluses form due to repeated friction and pressure, as the shoe (or ground) rubs against a bony prominence (bone spur) on the toe or foot. The skin thickens in response to this pressure, in order to keep you from getting an open sore or blister. Small amounts of friction or pressure over long periods of time cause a corn or callus. Large amounts of friction or pressure over shorter periods of time cause blisters or open sores. Corns can be due to a buckled or contracted toe position called a hammer toe. Often toes curl under the neighboring toe (especially the smallest toe) causing corns to form.  A poor choice of shoes can aggravate corns and calluses, but often it is not the "sole" cause. (No pun intended.)
After an initial history and physical exam of your feet, x-rays may be needed to tell the whole story and determine why corns and calluses are
developing. Your doctor is the expert in trimming down these areas of thick skin and will often apply comfortable padding to these painful corns and calluses. Special padding devices and materials may be available only from your doctor for your use at home. Medication for inflammation may be utilized to treat the underlying injury and sometimes a cortisone injection into the underlying bursal sac will be
recommended to rapidly reduce pain and swelling.  Changes in shoe-wear may be recommended. A prescription custom-made device called an orthotic might be made to wear inside your shoes, to redistribute pressure more evenly across the ball of your foot. A pad placed in your shoes (called a metatarsal pad) may help reduce your contracted hammer toes and relieve pressure on the ball of the foot as well. Often corns and calluses will have to be trimmed on a regular basis to prevent them from hurting. Eventually, you may desire corrective foot surgery by your podiatrist to straighten curled or contracted toes for corns or elevate and shorten metatarsals for calluses. Often such surgery represents a short term inconvenience to your lifestyle, but will not require any lengthy period of rest or inactivity. 

Diabetes-Diabetes Mellitus
About one in five people with diabetes will enter the hospital for foot problems. Foot problems are leading causes of hospitalization
for the 16 million persons in the United States with diabetes mellitus accounting for expenditures of hundreds of millions of dollars annually.
It has been estimated that 15% of all diabetics will develop a serious foot problem at some time, which can potentially threaten their limb or even their life. The most common of these problems are infection, ulceration, or gangrene (death of the tissue) which can lead , in the most severe of cases, to amputation of a toe, foot, or leg. The good news is that most of these problems can be prevented through regular podiatric visits, patient education, daily foot inspection and care, proper footwear, and early recognition and treatment of any suspected trouble areas. This can only be accomplished with active participation in your own care along with the help and guidance of your foot specialist. People with diabetes can develop a variety of foot problems. Even ordinary problems can quickly get worse and lead to serious
complications. Foot problems most often happen when there is nerve damage in the feet or when blood flow is poor. Inspect your feet every day, and seek care early if you do get a foot injury.
What Causes Foot Problems in Diabetes?
It is well established that the longer a person has the disease, the greater is the incidence and severity of complications of diabetes mellitus. Although good control of blood sugar and blood pressure are extremely important in maintaining your optimum health, other factors can be
important in the development of diabetic foot disorders.  Foot problems in persons with diabetes are usually the result of three primary factors :
Neuropathy (diminished sensation), poor circulation, and a decreased resistance to Infection.  

Neuropathy can generally be defined as a loss of sensation or alteration in sensitivity in the feet and legs. There may be a diminished or absent ability to detect painful sensations such as a pinprick or the heat of sand at the beach in the Summer or hot water. Your ability to detect the tightness of a shoe might also be affected. Neuropathy can prevent the recognition of injuries to the feet and permit them to remain untreated for lengthy periods of time. Continued walking on the injured or infected foot results in further trauma and injury.
Sometimes neuropathy can be painful and quite distressing, especially at night when you are trying to sleep. Painful neuropathy usually causes burning or sharp shooting pains in the feet. It is even possible for some people to have painful neuropathy in combination with an
actual loss of external sensation as described above. Neuropathy can also cause muscle weakness in the legs and feet. This might give rise to such conditions as "foot drop", where the foot cannot be raised at the ankle when walking. Other common deformities associated with this might be hammertoes or bunions; these are often also associated with corns or calluses.
Poor circulation
People with diabetes often have varying degrees of circulation disorders to their legs and feet due to atherosclerosis and blockage of arteries. Common symptoms of peripheral vascular disease are cramping in the calf or buttocks when walking. Temperature and color changes in the feet, in addition to loss of hair and thickening of toenails, might also be attributed to circulatory changes. Poor circulation results in reduced blood flow to the feet. Adequate delivery of oxygen and nutrients, which are required for normal maintenance and repair, is then restricted. This becomes critical when the foot is injured, infected, or ulcerated, since healing will be impaired or will not occur at all. Long a major cause of lower extremity amputation, peripheral vascular disease can now be frequently corrected by vascular bypass
operations in the legs. This is similar to those operations performed in the heart for blocked arteries.
Infections are often a problem in persons with diabetes, since they have difficulty fighting off bacteria that enter the skin from cuts or other wounds. This is due, in part, to certain deficiencies in the activity of white blood cells. Apparently, uncontrolled high glucose levels impair normal immune responses to bacterial invaders. The result can be an overwhelming infection in the foot. Without the ability to feel pain or without the ability to deliver white blood cells to the site of injury, infections can frequently become serious in a short period of time. The first sign of such serious infections might be very high blood sugars or flu-like symptoms. Unfortunately, fever is often absent or delayed in diabetic foot infections. Therefore, when you develop a fever, proper attention must be given to your situation immediately. Infections are the most frequent reason for hospitalizing diabetic patients and can progress to bone involvement in a relatively short period of time. Deep infections almost always require some type of surgery for treatment, so it is best to catch these problems early and avoid this serious complication. Special deformities can occur in persons with neuropathy and very good circulation. A Charcot joint, resulting from trauma to the insensitive foot, causes the foot to collapse and widen. This very destructive condition is often first heralded by persistent swelling and redness, increased warmth in the affected foot, some mild to moderate aching, and an inability to fit into your usual shoes. If this should occur it is extremely important to stay off your foot and immediately see your Podiatric physician. Neglect of this complication can lead to continued collapse of the foot, progressive deformity, and subsequent ulceration.
Footwear Guidelines
Shoes are meant to protect your feet, not to hurt them. Therefore, shoes must always fit comfortably, with adequate width and depth for the toes. If a shoe is hard to put on, then don't wear it. It is most likely too small for your foot and can cause serious damage, especially if you
have neuropathy or poor circulation. Shoes should preferably be made of leather, which will easily adapt to the shape of your feet over time, as well as allow your feet to "breathe". Athletic shoes, jogging shoes, and sneakers are usually an excellent choice, as long as they are well fitted and provide adequate cushioning. In some cases, your Podiatrist may recommend "extra depth" shoes or custom molded shoes to accommodate unusually shaped or difficult to fit feet. Also, special insoles or custom orthoses may be prescribed, to provide cushioning and support. Always check your shoes for foreign objects or torn linings before putting them on. Each day you should wear two or three
pair of shoes, so that one pair is not worn for more than four to six hours. New shoes should be worn only for a few hours at a time, taking care to inspect your feet for any points of irritation. Socks should be well fitted without seams or folds and should not be so tight that your circulation is stopped. Well padded socks can be very protective, as long as there is adequate room in your shoes for them. Above all else, do not walk barefooted . Avoid wearing open - toed shoes or sandals until you have discussed this with your foot doctor. At the beach or pool, however, these might be acceptable, as well as neoprene "aquatic shoes".
Footcare Guidelines
Inspect your feet daily for blisters, bleeding, and lesions between toes. Use a mirror to see the bottom of the foot and heel. Do not soak your feet. Avoid temperature extremes - don't use hot water bottles or heating pads on your feet. Wash daily with warm , soapy water and be sure to dry them well, especially between the toes. Use a moisturizing cream or lotion daily, but avoid between the toes. Do not use acids or chemical corn removers. Do not perform "bathroom surgery" on corns, calluses, or ingrown toenails. Trim your toenails straight across and file them gently. Have a foot doctor treat you regularly if you cannot trim them yourself without difficulty. Call your foot doctor immediately if your foot becomes swollen, red or painful. Stay off your foot until you see your doctor. Don't smoke. Learn all you can about your diabetes and how it can affect your feet. Have regular foot examinations by your foot doctor and be sure to remove both shoes and stockings at each visit with any doctor. 

Ulcers-Slow Healing Wounds
When using the term ulcer, we are generally referring to breaks in the normal integrity of the skin. Ulcers are skin wounds that are slow to heal and are classified in four stages, according to which layers of skin are broken through.
Stage 1 ulcers are characterized by a reddening over bony areas. The redness on the skin does not go away when pressure is relieved.
Stage 2 ulcers are characterized by blisters, peeling or cracked skin. There is a partial thickness skin loss involving the top two layers of the skin.
Stage 3 ulcers are characterized by broken skin and sometimes bloody drainage. There is a full thickness skin loss involving subcutaneous tissue (the tissue between the skin and the muscle.)
Stage 4 ulcers are characterized by breaks in the skin involving skin, muscle, tendon and bone and are often associated with a bone infection called osteomyelitis.
How an ulcer feels is dependent on the underlying cause of the ulcer. For example, one of the more common types of ulcers is seen in patients with diabetes, who have loss of sensation in their feet. In this type of ulcer, there is little if any pain, due to a condition called diabetic neuropathy. In fact, diabetics typically get this type of ulcer because they've lost their protective pain sensation. Another common ulcer is due to loss of arterial blood flow to the leg, resulting in ischemic ulcers that can be very painful. So you can see that it very important to have any break in the skin properly evaluated and the lack of pain is not always a good initiator as to the severity of the problem.
Ulcers occur due to different reasons, so it is very important to determine the underlying medical problem that caused the ulcer. There are essentially four main reasons people get ulcers on the foot.
Neuropathic: This is when a patient has loss of sensation in the feet. It is commonly seen in people with diabetes but it can be caused by other reasons such as chronic alcohol abuse. These ulcers are generally seen under weight bearing areas and often will begin as a callus or a
Arterial: This type of ulcer is due to poor blood flow to the lower extremity. This type of ulcer can be very painful and are usually found on the tips of toes, lower legs, ankle, heel and top of the foot. They can very easily become infected.
Venous: This type of ulcer is due to compromised veins. Veins are the vessels that take fluid out of the legs and back up to the heart. Veins have small valves that allow blood to flow only one way, back up to the heart. The valves normally block the tendency for gravity to pull the blood back down to the legs. Sometimes the valves leak or cease to work at all. If the valves do not work, then the fluid pools down in the legs, causing swelling. This swelling leads to increase pressure in the venous system, producing discoloration of the leg and eventually this lead to ulceration. They are commonly seen around the inside of the ankle and are slow to heal.
Decubitus: This type of ulcer is caused by excessive prolonged pressure on one area of the foot. The most common place to see this
type of ulcer is in a person confined to bed and they occur on the backs of the heels.
The best thing you can do for an ulcer is to have it looked at by your doctor, as soon as you can. The earlier that the ulcer is treated, the better chance you have at healing it.
The first thing that will be done is to inspect the wound. The doctor is looking for signs of infection, location of the wound, the color of the tissue in the wound. This is all done to determine the best treatment for that wound. Often the doctor will refer you to another specialist, such as a vascular doctor, to check your circulation. If you are a diabetic, he will want to consult with your diabetes doctor, to make sure that your blood sugar is under control. Once the cause of the ulcer is determined and all the necessary referrals are made, treatment of the ulcer can begin. The treatment will be tailored to the individual ulcer and it is often difficult to predict how long it will take an ulcer to heal. Ulcer care is best treated by a team approach, involving a few different types of doctors.
Yes. The best prevention is treating the underlying cause of the ulcer. That means if you are a diabetic, check your blood sugar daily and inspect your feet every day. If the reason for your ulcer is due to swelling in the legs, then you need to wear support stockings and keep your feet elevated as much as possible.
Ulcers can be a very debilitating problem, causing pain and disability. The best treatment is preventing the ulcer from ever occurring. If it does occur, have it checked immediately by your doctor.