Ouch!! Ingrown Nails

Now that the weather is starting to cool off and it is back to school, we are out of the sandals into our tennis shoes and work shoes. You or your child may notice that you are having some pain by your big toenail. This is a very common season to see patients in the office for ingrown toenails, as switching over to a closed toe shoe may be causing pressure on the nail causing it to become ingrown.  The big toe is the most common toenail to become ingrown because it is usually the one that pushes up against a shoe and experiences the most trauma caused by shoes.

There are many other causes for ingrown nails, which include:

  • Trauma caused to the nail
  • Kicking sports, such as soccer
  • Ballet
  • Fungal toenails
  • Pedicures-nails should always be trimmed straight across and never shaped
  • Tight fitting shoes

The symptoms of ingrown nails include:

  • Pain by the nail border
  • White discoloration of the skin where the nail is poking in
  • Redness surrounding the nail
  • Blood, pus or other colored drainage
  • There may be some increase in red tissue that bulges from where the nail is irritating the skin-this is called paronychia and is a common sign of infected ingrown nails

If you are experiencing any of these symptoms, you may get temporary relief from soaking your toe in warm Epsom salt water and wearing open toed shoes. However, for the pain and possible infection from the ingrown nail to resolve, you will need to see a podiatrist to remove the nail border or entire nail depending on the severity of your ingrown nail. It is very important that you do not become a “bathroom surgeon” and try to pull the nail border out yourself as this may cause more pain and may introduce bacteria causing an infection.

At the office, I will be able to assess your nail and recommend which type of removal is best. The first step of the procedure, which patients say is the worst part, but overall is not that bad, is injecting your toe with numbing medication; it is similar to getting a shot, but then once your toe is numb you won’t having any pain from the procedure.  You will not have to be sedated for the procedure and it will only take 15 minutes or less. I will then remove either the offending ingrown nail border or the entire toenail may need to be removed depending on the severity. Also, depending on how often you get ingrown toenails, you may want to have the nail border or the nail never grow back if it is on ongoing problem for you. If your toenail is infected, I will prescribe a 10-day course of antibiotics, which will clear the infection.

There are very few if any complications from removing an ingrown nail, so if you or your child are experiencing an ingrown toenail please visit the Peak to Peak Podiatry (720) 600-3380 in Brighton, or Boulder County Foot and Ankle (303) 442-2910 for further assessment.

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I’m Reopening!!

I’m please to announce that I am reopening my practice in Brighton beginning Wednesday, October 8th.

PLEASE NOTE NEW PHONE NUMBER:   (720) 600-3380

LOCATION:  606 S 4th Ave.  Brighton, Colorado

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Identifying and Treating Baseball Injuries

Baseball is one of the fastest growing youth sports in America.  In general, it’s also one of the safest sports as the injury rate is 2-8%.  In 2012, there were over 250,000 injuries requiring a trip to the emergency room.  Most injuries are acute–that wild pitch that hits a player. Baseball injuries to the foot and ankle include such things as sprains, tendonitis, fractures, bruises, dislocations, nail injury, and heel pain. 

Ankle sprains are one of the most common injuries not only in baseball, but all sports.  The starting/stopping, jumping, and side to side movement will cause sprains. Even sliding into a base can result in a sprain as something has to give and it’s not the base. The most common risk factor is a previous ankle sprain.   Managing an ankle sprain right after injury is critical t the success of healing.  The old adage of RICE (Rest, Ice, Compression, Elevation) should be changed to PRICE with the P being protection. Stretching, bracing, taping, balance program are all ways to prevent a sprain.  Ankle sprains can be a serious injury leading to loss of practice and game time so don’t ignore the significance of one if it does occur. 

Tendonitis, which is considered an overuse injury, can occur anywhere on the foot, but is most common in the achilles.  Pain on the back of the heel or above the attachment is the location of achilles tendonitis.  Chronic pain and inflammation can lead to a rupture, which is a bad injury.  Rarely in youth athletes will one see a tendon rupture, but for that weekend warrior type, it can be very common injury that often requires surgery. 

Discolored toenails are another common baseball injury.  Purple or black discoloration under the toenail is a sign of some type of trauma–a pitch that was fouled off, stepped on by another player, or even a baseball cleat that is too small.  Generally, if more than 50% of the nail is involved, the nail is going to come off. Sometimes the blood can be drained if caught early so not to lose the nail.

One of the most common injuries I see is heel pain in kids 8-14.  Often called Sever’s disease or apophysitis.  While not exclusive to baseball, any cleated sport whether its baseball, soccer, football, etc, can lead to this.  Pain is present with activity and usually relieved with rest.  Rarely is there swelling or redness.  If you squeeze the heel and there is pain, it’s usually Sever’s, which is inflammation of the growth plate in the heel bone.  Stretching, icing, anti-inflammatories, heel cups/cushions are options, but often times, an orthotic from a podiatrist is needed for rapid resolution of the symptoms.  With proper treatment, and early identification of symptoms, treatment can result in no loss time of practice or games.

While this blog wasn’t intended to be all inclusive, some of the more common injuries I see were covered.  There are several other types of injuries that can, and do occur.  If concerned, don’t hesitate to contact a sports podiatrist to be evaluated.  At Boulder County Foot and Ankle, we treat all kinds of sports injuries whether its running, baseball, soccer, football, basketball, etc so don’t hesitate to contact us with any type of sports injury.

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What is a Coalition in a Foot?

A coalition is the union of 2 bones in the foot. The two bones will be fused by boney, cartilaginous, or fibrous tissue. This union will prevent the normal range of motion that the foot requires.
Why does this happen?
There are two theories; the most accepted theory is that during development, for an unknown reason there is the failure for the embryonic tissue, which will eventually become bone (called mesenchyme) to divide properly. However, it has been found that pedal coalitions are inherited meaning if one of your parents has a coalition you have a high chance of having one too. The other theory is that the additional little bones in the foot called ossicles fuse into the joint spaces causing the bones that make up the joint to be “glued” together.
Who gets pedal coalitions?
Both adults and children can have pedal coalitions. However, the symptoms will not usually present until age 6. This is because this is when the bones start to harden (ossify) and the foot will become more rigid, so if the foot is rigid and the joints are not working properly, due to a coalition, it will be painful. Adults that begin having symptoms of coalitions usually get them due to arthritis, trauma that changed the coalition, and/or infection of the bone. On-the-other-hand, you may have a coalition and never know due to not ever having symptoms.
What are the symptoms of coalitions?
• A dull aching pain usually near the ankle
• The pain is worsened by activity, walking or running on uneven ground, and/or standing for many hours
• The pain is relieved by rest
• An inability to turn your foot to the outer edge (inversion)
• Your foot may appear flat when standing
• You may notice spasms in the peroneus brevis muscle; this muscle begins in the outer aspect of the leg and inserts on the outer aspect of the foot
How will the Boulder Foot and Ankle Clinic determine if you have a coalition?
The most common way to diagnose pedal coalitions is by using advanced imaging. First, a baseline x-ray will be taken. Only bone shows up on an x-ray, so this may not show if a coalition is present, since there are the cartilaginous and fibrous tissue coalitions as well as the boney tissue type. So, since x-ray does not show cartilage or fibrous tissue, imaging such as a Computed Tomography (CT) scan or MRI is needed in order to see the fused joint. In addition, the podiatrist will be able to measure your range of motion. If there is decreased range of motion, this may indicate coalition. The podiatrist will also be able to find the site where you have the most pain, which may also lead to the diagnosis.
What is the treatment for coalitions?
There is non-surgical treatment for coalitions, which is effective in about 20-30% of all cases of coalitions. These non-surgical treatments include:
• Shoe modifications and orthotics
• Physical therapy
• Non-steroidal Anti-inflammatory medications
• Immobilizing the foot with a cast
Non-surgical treatment will usually take anywhere for 1-3 months for you to have improvement of symptoms. If symptoms do not improve, you may need to have surgery to re-open the joint and get rid of the coalition. There are several procedures that can be done. For further evaluation, schedule an appointment at the Boulder County Foot and Ankle.

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If Your Bone Isn’t Healing, Then What?

There are many scenarios where you may need a bone stimulator. Some of these include:
• A non-healing broken bone, especially if you have one of the following conditions listed below, which will drastically increase the risk of a bone not healing.
• Diabetes, Rheumatoid arthritis, vascular disease, immunosuppressive medications, tobacco usage, or alcoholism.
• Surgery that used pins and screws to fix a bone
• Charcot arthropathy
On average, under ideal conditions a bone takes 6-8 weeks to heal. However, the above situations and conditions may lead to a delay in the bone healing process or may not allow the bone to heal at all. In these cases, a bone stimulator should be utilized. The following are frequently asked questions about bone stimulators.
What is a bone stimulator and how does a bone stimulator work?
• A bone stimulator is a device that can either be surgically implanted near the broken bone or it can be worn over a cast. The bone stimulator functions to help bone heal. Exactly how bone stimulators work is complicated, but can be easily summarized. There are three different types of stimulators, which include electric current, electromagnetic, and ultrasound devices. All three work similarly by activating and increasing the necessary bone growth factors and cells needed for bone production. The amount of time a bone stimulator is worn varies between the different types of device. Some devices therapy is for 24 hours where other devices may only need to be worn for 20 minutes per day.
When would I need to use a bone stimulator?
• Bone stimulators are not usually prescribed to patients until there is no bone healing seen. Most patients will receive a bone stimulator if a broken bone is not healed within 3 months and has not shown any signs of healing. Bone stimulators are very expensive and insurance companies will not cover them unless there are signs that the bone is not healing.
Does the bone stimulator hurt or does it make noise?
• Bone stimulators are painless; it is the broken bone that is painful. Bone stimulators are silent and may only make noise to let you know that the therapy session has ended.
Do I still need to where a cast if I am using a bone stimulator?
• Yes. In order for bone to heal and heal in proper alignment, the two ends of the one must remain still. If you are putting weight and walking on the broken bone the ends will be moving and no new bone will be able to form, despite wearing a bone stimulator. In addition, the weight may cause the boney ends to become displaced, which will increase the gap and the amount of new bone needed to heal the fracture.
Is there scientific evidence that bone stimulators work?
• Yes. There is an abundance of research that has shown that all of the different types of bone stimulators are effective with helping bone heal that previously was unable to heal on its own. In fact, on average, the healing rate with a bone stimulator is about 90%. There has been no research that has shown one type of bone stimulator that is superior.

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Frequently Asked Questions After Foot Surgery

Having surgery on your foot will change your daily routine drastically for a short time. Here are many questions that patients have asked in the past when having to face surgery.
Will I be able to walk after the surgery?
• This is highly dependent upon the type of surgery. Some surgeries may require you to not bear any weight for 4-6 weeks where other less complicated procedures may only require you to bear weight with wearing a surgical shoe or walking boot.
Can I drive after having surgery done on my right foot?
• Immediately after surgery, no you will not be able to drive due to the type of anesthesia that is used. So have a ride arranged to pick you up from the surgery center. After the surgery on the right foot, you should never drive as a cast, surgical shoe and walking boot are all large and will cause you to hit the brake pedal while hitting the gas. In addition, when wearing these devices you will not be able to move your ankle downwards to properly hit the pedals. Also, putting the weight on your foot may cause pain and lead to improper healing.
When should I do for pain and when should I start taking pain medication?
• It is recommended to stay ahead of your pain the day of and after your surgery, so it is best to follow the instructions on the scheduling of your pain medication. However, after 3 days, for most procedures, you can begin to wean yourself off of the pain medication. In addition, to taking pain medication, your pain can be reduced by keeping your foot elevated above the level of your heart after surgery, especially the first couple days. By elevating your foot, you are helping to prevent swelling, which will help to prevent pain. You can also ice the foot to help decrease inflammation. If you are wearing a cast, put an ice pack behind your knee to help cool the blood going down into your foot.
When will I be able to put weight on my foot and get back to my regular activities?
• This will depend on the type of surgery you have. However, for most foot surgery, involving bone, 6-8 weeks will be needed for the bone to heal properly. If the bone is not healing you may need a bone stimulator. If the surgery, did not involve the bone, and only soft tissue you should be able to return to activity sooner than 6-8 weeks.
When will I get my stitches out and is it painful to have them removed?
• A surgical incision in the skin takes approximately 2 weeks to heal. Stitches will usually be removed at 2-3 weeks. Removing stitches is not painful, but some patients say that removing them feels like a small pinch. Most patients say that it usually feel better after the stitches have been removed.
What do I do if my cast or bandage got wet?
• You should not shower the foot after surgery and if you do it is best to get a cast cover. Cast covers should be used during bathing and if going out in the rain. For bathing it is best to wear the cast cover and for extra safety precautions dangle the foot outside of the bathtub, especially since the cast cover may leak. If your cast or bandage does become wet, you should call Boulder Foot and Ankle Clinic, because the cast or bandage will need to be changed. If you ignore it, you increase your risk of infection at the site of surgery.
Any questions prior to surgery will be answered by Dr. Yakel, at Boulder Foot and Ankle Clinic prior to having surgery.

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Restless Leg Syndrome

If you find your thighs, legs, and feet needing to move around when you are resting or especially at night when you are trying to fall asleep, you may have Restless Leg Syndrome (RLS). RLS is a neurological disorder, but many people believe that their lower extremity movements are not a serious enough to talk to their doctor. However, it has been reported that RLS impacts 10% of adults within the United States population. Unfortunately, RLS may keep you awake at night and drowsy during the day, which ultimately may affect your relationships and ability to perform well at your job. Below are some frequently asked questions about RLS.

What are the symptoms of RLS?

Many patients described the sensations in their legs as the following:

  • Throbbing
  • Creepy and crawly
  • Twitching
  • Itchy sensations
  • Burning pain
  • Strong urge to move legs
  • Temporary relief from sensations by moving legs

These sensations are most commonly present when lying down to go to sleep at night; however, can also be present during the day when sitting still or trying to take a nap.

What is the cause of RLS?

No one cause has been pinpointed for RLS. However, there are several possible etiologies, which include:

  • Peripheral neuropathy, which is commonly associated with diabetes or alcoholism. Peripheral neuropathy is characterized by numbness, tingling, and burning pain in the feet, which is the result of nerve damage.
  • Pregnancy results in many hormonal changes and most pregnant women, who experience RLS, will have it during their third trimester.  Many women say that their symptoms have disappeared after giving birth. Overall, women are twice as likely to have RLS than men.
  • Kidney failure causes iron deficiency and electrolyte imbalances, which may lead to RLS.
  • Genetics. Fifty percent of the patients who present with RLS explain that they also have a relative who has or has had the same symptoms.

Will I need a sleep study for RLS to be diagnosed?

No. Most of the time RLS can be diagnosed based upon your symptoms. It will be helpful if you keep a log of when you experience the symptoms, descriptions of the symptoms you experience, and if able, how you get rid of the symptoms.

Is there treatment for RLS?

Yes. There are simple ways to decrease the symptoms of RLS, which include:

  • Warm baths and massage, may help in order to relax the leg muscles.
  • Apply heat and cold packs to your legs; many patients find alternating between the two temperatures helps more than just doing one or the other.
  • Exercise and stretching during the day; doing gentle stretching before going to bed may also help to minimize symptoms.
  • Do not drink caffeine, alcohol, or use tobacco products before going to bed as these can exacerbate symptoms.

There are also medications that your doctor can prescribe in order to treat RLS. In addition, your RLS may be due to underlying health problems, electrolyte imbalances, or iron deficiency, so if this is the case, it will be important for the underlying cause to be treated in order to resolve RLS. RLS can be treated, so it is important to seek medical attention, so you can return to getting good sleep and having productive days. 

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