Dry, Cracked Heels. Is There a Solution?

After a nice warm summer filled with going bare foot and wearing sandals (both which are not recommended by podiatrists!) you have noticed thick callus build up around the back of your heel. The callus area is starting to become painful and you are noticing cracks in the skin. Why is this happening and what is the treatment?
First, let’s address why the callus builds up. Any callus anywhere on the foot forms due to excess pressure. The excess pressure could be due to an unsupportive shoe or most commonly due to biomechanical reasons, meaning due to the underlying bone structure. However, the most common reason for developing a callus around the rim of the heel is wearing a shoe without a back. Backless shoes (examples: sandals, clogs, etc.) allow the heel fat pad to spread out allowing for extra pressure all the way around the heel.  Once that skin thickens up and a callus forms it becomes more prone to cracking.

During the winter, the air becomes very dry due to running heaters. With the dry air the skin everywhere becomes drier. You may notice having to apply hand lotion or lip balm more frequently in the winter than summer, so you must also not neglect your feet. Apply lotion to your feet twice a day sparing in between the toes (applying lotion in between the toes is not recommended as it causes a build of moisture and can lead to a fungal infection). Excellent brands of foot cream are not limited to, but include:

  • Kerasal Foot Cream
  • CeraVe Renewing Foot Cream
  • Gold Bond Therapeutic Foot Cream
  • Eucerin Diabetics Dry Skin Relief
  • Amlactin Foot Cream

The creams will help to prevent cracking of the skin, which is known as a fissure. Fissures are painful and can be dangerous; especially, for the diabetic patient as it allows entry for infection. Diabetics should check their feet daily as a fissure or callus is a warning sign of being at risk for developing a wound. Vic’s Vaporub is VERY effective in treating these cracks.

The best way to have a callus removed is to see a podiatrist who can trim and smooth the callus with a sterile surgical scalpel. Never try to trim a callus yourself as you may accidentally cut yourself if using your own razor blade. In addition do not use the ped-egg if you are diabetic or have numbness in your feet as you may inadvertently cut yourself and have an open wound.

Once the callus is trimmed by a podiatrist, be diligent with applying lotion and wear supportive shoes. Doing these three things, will provide temporary relief and the callus will ultimately return, but not as quickly. Visit the Boulder County Foot and Ankle Clinic for further evaluation.

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I Have a Bunion but Don’t Want Surgery!

About 20% of the population either already has a bunion or is prone to developing a bunion, but first lets discuss what a bunion is and what causes bunions.

A bunion is a foot deformity that is characterized by having a large bump at the great toe joint (metatarsophalangeal joint) with the toe pointing outwards. You may have also noticed other associated deformities with bunions such as hammertoes, which are when the toes are in a flexed position, which can either be flexible, meaning they straighten out when standing, or rigid, which means the toes are flexed regardless of sitting or standing.  Also less common than hammertoes, some may notice what is called a bunionette, which is the same a bunion except the bump is at the 5th toe joint (metatarsophalangeal joint) and the 5th toe is turned inwards. Even though you can have these other deformities in conjunction with a bunion, it is not rare to just have an isolated painful bunion.

What causes bunions and these other associated forefoot deformities?

  • Genetics/family history.
  • Poor foot biomechanics, such as over pronation while walking.
  • Systemic conditions, such as Rheumatoid Arthritis.
  • Shoe gear.
  • Muscle weakness.

It needs to be made very clear that conservative management can work to address a painful bunion; however, conservative management will not get rid of the bunion nor make the bunion less noticeable. Conservative management can only relieve pain.

The most effective modalities of conservative therapy include:

  • Wider shoes to accommodate for the bump.
  • Shoes that are made of a flexible material to accommodate the deformity, so the bump is not rubbing against a stiff shoe.
  • A custom made orthotic to allow the foot to function in its most efficient position. Custom orthotics may help to slow the progression of the deformity, but as stated above will not get rid of the bunion.
  • Bunion pads to wear over the toe to cushion the bone and prevent rubbing in the shoe.
  • Bunion splints, only work in deformities that are flexible meaning that you move the big toe to back to its normal position and the bump seems to get smaller.
  • Anti-inflammatories may help if you have arthritis in the joint, which most people with bunions after many years will develop arthritis.

If conservative management does not improve your pain and you are having difficulty fitting into your shoe gear, it is time to consider surgical management. There are many ways to fix a bunion, but the first step is to have x-rays done on your feet to know, which type of surgical procedure would be most appropriate to fix the deformity. Depending on the type of procedure needed, will determine the post-operative course, such as how long you will need to be non-weightbearing, in some cases you will be able to bear weight after surgery. If you are suffering from bunion pain, schedule an appointment at Boulder County Foot and Ankle for further evaluation.

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Children’s Foot and Ankle Fractures

For children, especially those involved in sports, foot and ankle injuries are common.  In fact, five percent of all pediatric fractures are localized to the foot. In the foot, the most commonly fractured bones are the metatarsals.  The metatarsal bones are the longest bones in the foot and are located before the toe bones. Younger children have very flexible bones, so they are less likely to have a fracture; however, they are not exempt from sprains or contusions.  A contusion is a deep soft tissue injury.  Patients who have suffered sprains/contusions and fractures relate that the sprain or contusion may have been as or even more painful than a fracture.

Often times, children that are very involved in sports or young children who may have suffered an injury while misbehaving may not want to tell their parents that they are having pain. It is important to seek medical attention immediately if they are unable to bear weight, have significant swelling, bruising, and/or pain.

Radiographs will be taken to assess for any broken bones or other abnormalities.  If a complex fracture is noted on radiographs, more advanced imaging may be indicated, such as a CT scan or MRI.

The most devastating fracture pattern seen in a child can be one that crushes a growth plate, which means that the bone may not finish growing properly.  This type of injury is usually seen after jumping or falling from a high point. There is usually surgical intervention needed for these patients; however, it may not be done until they are skeletally mature.

Anytime, a bone is broken, patients are at risk of the bone not healing and progressing to a non-union. The risk of non-unions is higher in those that smoke cigarettes or continuously walk on their fractured foot. However, the risk of nonunion in the pediatric population is much less than adults. Other sequelae of a broken bones is developing arthritis, stunting growth of that bone, deformity, abnormal gait, and/or pain.

As mentioned previously, children’s bones are very flexible so it will usually take a
significant amount of force to actually cause a fracture. Luckily, for children they possess different bone and healing characteristics than adults, which makes
them more amenable to conservative treatment, as well as faster healing times.

For most pediatric fractures, even fractures that have been displaced, meaning the broken bone fragments are not perfectly aligned, will heal and re-straighten into anatomical alignment with 3-6 weeks in a non-weightbearing cast.  In adults, this is not true; if a fracture is mal-aligned it will not heal properly without surgery.

Some general tips if your child ever has any injury, remember the acronym RICE for after the injury. RICE stands for Rest (stop activity), Ice (ice 20 minutes on and 20 minutes off), Compression (use an ACE bandage to provide lite compression, if available), and Elevate the foot (use several pillows to get the foot above the level of the heart). RICE will help prevent swelling, which will ultimately help decrease pain. Also, never give your child Aspirin as it can cause Reye’s syndrome, which is characterized by sudden brain and liver damage. Children’s Tylenol is safe to help control pain if need, but it is best to seek medical attention immediately.

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The 411 On Ankle Fractures

Unfortunately, with the slippery conditions, ankle fractures are all too common during the winter months.  In fact, in the United States 250,000 patients will suffer from a broken ankle each year. Elderly women are at the greatest risks due to osteoporosis, which leads to weakening of bones. Once the bone quality has softened, even a small fall may result in a significant fracture.

If you are 1 of the 250,000 Americans that has sustained an ankle fracture this past year, you probably have already been to the Emergency Department. There, the doctor would have taken x-rays and/or CT scan to determine the extent of your injury. At that point, if you were told that your fractures were not lined up, the doctor will try to reduce (move the fracture fragments back in line) by pulling on the ankle; you would have been sedated for this part. If the fracture fragments can be re-aligned shortly after the injury, the prognosis will be better.

There are two broad categories of ankle fractures, stable and unstable. A stable ankle fracture, means that you would have only broken one of the two bones in your ankle, either the inside bone (tibia) or outside bone (fibula). It is more common to have just the outside bone broken (fibula) versus having just the inside bone broken (tibia). With a stable ankle fracture, surgery may be able to be avoided depending on the alignment of the fracture. If surgery is not needed you will wear a cast for 4-8 weeks and remain non-weightbearing during this time.

If you have an unstable ankle fracture, which means that both the outside (fibula) and inside (tibia) ankle bone are broken, you may require surgery to repair the fracture.  However, surgery may need to be delayed 1-2 weeks depending on how quickly you received medical treatment, which is why it is important to always seek medical attention immediately after an injury. Surgery cannot be done on ankle fractures that are too swollen or if blisters have formed. Surgery will consist of putting hardware, such as titanium plates and screws to hold the fracture fragments in line.  A commonly asked question regarding the hardware is will it set off airport alarms or store security systems and the answer is no. The surgery will take about 1-3 hours depending on the extent of the injury.  With the fractures aligned, the healing process will begin, which it takes 6-8 weeks for bone to heal.  During this time you will be non-weightbearing and in a cast. After healing, you will go through a course of physical therapy or at home exercises to regain your ankle range of motion and strength.

Complications of any fracture is non-healing, which the risk is significantly lowered with being a non-smoker and being 100% diligent in putting no weight on the ankle. Painful hardware, which this is not too complicated, because once the bone has healed, the hardware can be quickly removed in the operating room. Not every patient will have hardware that bothers them; often times patients forget that they even had a plate and screws put in their ankle. Lastly, with any injury, you can develop post-traumatic arthritis due to damaging the cartilage surfaces. There are various treatments for post-traumatic arthritis, but it can be lessened by not delaying treatment and the doctor will decrease it by re-aligning your fracture well either by casting or surgery. Be careful this winter and if you are 1 of the 250,000 unlucky people to take a fall go to the Emergency Department for further evaluation.

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Why Hospital Owned Physicians Will Drive Up the Cost of Healthcare

As most Americans are aware and many have already experienced first hand, the United States healthcare system has been undergoing major transformations. Not only has insurance coverage become more complicated, but also you may have noticed that your once private practice doctor now has their office within a large hospital system.

Why are physicians joining hospital systems versus staying in their independent office?

Many older physicians are selling their practices and working for hospitals or large health centers for several reasons. One of the primary reasons is that there are more resources available to them. For example, it is much easier to send a patient to get an MRI within the same building that they just had their appointment in rather than sending them to a satellite MRI office. It is easier for the patient too.

Joining a large mega healthcare group also provides constant stream of patients and job security. For younger physicians, looking to buy a practice can be a large financial burden. It is expensive to buy the office and equipment, but then to also employ staff.  Overall, there is decreased cost to the physician when a physician is employed by a hospital rather than paying to keep their private practice running.

Why is it beneficial for hospitals to buy private practices and then also pay the physicians’ salaries?

The main advantage for hospitals is more patients using the hospital facilities and imaging. Hospitals have tried this model in the past of buying up practices; however, at the time, it was not financially successful for hospitals. It is believed now that hospitals will make profit off of the mega healthcare groups due to the way that healthcare and insurance is setup.  It also is good for hospital reputation to have all specialties represented within the hospital.

Are having all specialties within in one hospital really a good idea?

One of the major cons includes cost.  You may notice that the price of your healthcare has increased and you may notice extra fees that you never had when you saw the physician in the private office. Unfortunately, one study that was released October 2014 showed a 10% increase in cost for patients to see a hospital employed physician versus private physician. As an example, the reimbursement for an X-ray in my office is about $36, while the same X-ray performed in a hospital setting is $300-600.  Surgery done at a hospital is approximately twice the amount as having it done at an ambulatory surgery center.  The cost of MRI’s and CT scans are another example where the hospital cost is significantly higher than a free standing facility. These are examples of why hospital owned physician groups and hospitals will drive up the cost of healthcare.  This cost is passed onto you, the patient.  Another frustration with major hospital systems is more difficulty with getting an appointment due to higher patient loads. Once you enter a major hospital system for your care, it can be easier to get lost within the hospital system and you may feel more like a number compared to when you saw the private physician in the office. With time, we will learn if these pros outweigh the cons.

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Why is Magnesium Important?

The body contains several major minerals and some trace minerals. Trace minerals are minerals that are found within the body usually due to diet, but are not vital for a healthy body. Magnesium is a major mineral meaning that it serves an important function in the body and is important to maintain overall health. Unfortunately, 70% of Americans are not getting the necessary amount of magnesium. The body needs an average of 25 grams of magnesium stored within the body to function normally; 25 grams is equivalent to holding 25 paperclips in your hand. We get magnesium into our body through our diet and usually do not have to take a supplement as long as we eat a healthy and balanced diet. The foods that are loaded with magnesium are the same foods that are loaded with high fiber; some examples include: leafy greens, beans, artichokes, and whole grains. Therefore, having a diet high in both fiber and magnesium are known to help relieve constipation.

However, magnesium is also very important to the body for other reasons. One of the most vital roles of magnesium is to maintain healthy bones. In fact, most of the magnesium in our bodies is stored in the bones. Many patients believe that calcium and Vitamin D are the two most important components to bone health, and while that is true, magnesium needs to be added to the mix. Women that are post-menopausal are at the highest risk of osteoporosis, which is a weakening of bone due to demineralization. Osteoporosis can reek havoc on one’s bones. It causes bones to break even when placed under normal amounts of stress; for example, a woman may walk one mile per day everyday for her entire adult life and then one day experience a stress fracture in her foot even though she has been doing that activity for years. A small fall in a patient with osteoporosis can also cause a catastrophic fracture.

Any magnesium that we bring into our body through our diet is sucked back out by sugary foods, such as soda, doughnuts, cookies, etc. or even coffee and tea. Also, patients with GI disease, alcoholics, type 2 diabetics, and the elderly are at risk for developing a magnesium deficiency.

Signs and symptoms of magnesium deficiency include:

  • Decrease in appetite
  • Nausea and vomiting
  • Tiredness and weakness
  • Numbness and tingling
  • Muscle spasms-may be a contributing factor to restless leg syndrome
  • Irregular heart beats

Just like anything in life though, too much magnesium can be dangerous as well. Patients with kidney disease should never take magnesium supplements as it may cause more damage to the kidneys than good to the rest of the body. Patients who are also taking antibiotics, water pills, proton pump inhibitors, and heart medications should also be careful when supplementing their magnesium levels with a pill as it may cause reactions with these medications. The maximum dose for an adult is 350mg of magnesium per day; however, consult with your healthcare provider before starting or changing any over-the-counter supplements.

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Trick or Treat, Smell My Feet

Halloween is coming up and the kids will be out in full force to get their sweet treats, so make sure your ready, so you don’t have to smell any feet. Two common foot conditions can be “scary” to some patients are:
1. Toenail fungus
2. Athlete’s foot/stinky feet

These two conditions are both caused by fungus. Usually patient’s present with both, but you can have one or the other. To begin, the most common cause of toenail fungus is trauma to the toenail. Trauma can consist of wearing shoes that are too tight, stubbing your toe, or dropping something heavy on your toes. The next most common cause is aging. As we age, the blood flow and your body’s ability to fight off infection may decrease allowing the fungus to successfully settle into your nail. So how can we get rid of fungus? Well, it is a slow process since it was a slow process for the fungus to begin growing there. There are topical medications that are harmless; however, the medication does not easily travel down to where the fungus is living. There are also oral medications with relatively low risks, such as Lamisil; however, the medication needs to be taken for at least 3 months. There is also laser therapy, which is a newer method to get rid of fungus, which has shown variable results. It takes 9-12 months for the big toenail to grow out and 6-8 months for the small nails, so it will take awhile to see results. Lastly, fungus does not usually pose any significant harm besides an unsightly nail, so there is antifungal nail polish that you can use to just cover it up in the event that all treatments fail.

Athlete’s foot is the number one cause for stinky feet. As the name suggests, athletes are more prone to getting this type of fungal infection due to showering in public showers where the fungus can be spread. In addition, athlete’s shoes are the perfect environment for fungus to grow. Fungus needs a warm, moist, and dark environment, such as an athlete’s shoe/sock. Athlete’s foot will present with symptoms such as burning, smelly, wetness in between the toes, scaling on the bottom of the feet, and itchiness. The same fungus as toenail fungus also usually causes athlete’s foot, but it is much easier and faster to treat than fungal nails. As with toenail fungus, there are also topical and oral medications that can be prescribed to help kill the fungus. In addition, to using the medications, it is very important to change your socks at least once or twice a day, especially if you have sweaty feet since fungus thrives in a dark moist environment. Also, if you are experiencing symptoms of athlete’s foot it is a good idea to wear shower shoes until the fungus has cleared to prevent spreading the fungus to your family members or teammates. There are several other skin conditions that can appear like athlete’s foot, so don’t be afraid to come to Peak to Peak Podiatry in Brighton, (720) 600-3380 or Boulder County Foot and Ankle (303) 442-2910 for further evaluation. Happy Halloween!

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