Peace, Love, and Feet

Neuropathy

Diabetic neuropathy is one of the most paramount conditions affecting the lower extremity. It is the most common complication of Diabetes, affecting almost 50% of patients. Neuropathy is the loss of nerve function and affects sensory and motor nerves in the extremities. The number one risk factor is poor sugar control. The excess glucose in the blood leads to breakdown of nerves. Other risk factors include a long duration of diabetes, aging, high blood pressure, smoking, elevated cholesterol levels, and high consumption of alcohol. Symptoms involving the sensory nerves are numbness, tingling, burning, loss of balance, and pain and hypersensitivity at inappropriate times. Motor neuron loss causes weakness to the muscles in the foot.

Neuropathy in the diabetic patient must be treated. As commonplace as neuropathy is in diabetics, uncontrolled blood sugar accompanied by trauma to the foot can rather rapidly lead to ulcers, infection, amputation, and possibly death. However, if glucose levels are lowered, the progression of neuropathy is slowed. Without medical intervention, the patient’s duties are to exercise, eat a proper diet, wear diabetic shoes and keep feet clean, trim his or her toenails, limit alcohol intake, maintain a healthy weight, and cease smoking if applicable. Furthermore, a doctor can give the patient medications for pain. An anti-inflammatory can be used in the early stages of neuropathy, but this becomes ineffective as it progresses. Anticonvulsant and antidepressant medications are typically given to control pain. Besides the aforementioned treatment plans, neuropathy unfortunately has no cure and can only be lessened by treating symptoms of the condition.

Boulton A.J., Malik R.A. Diabetic neuropathy. Medical Clinic North America. Jul 1998;

82(4):909-29.

Studying for Part 1

I tried to start studying on May 7th. I’ve done one practice test and studied immunology and basic Path stuff since then. I’m working on antibiotics right now. I wanted to have so much more done by now. I think I’m so scared of failing that it’s paralyzing me. I have no motivation to study which is ironic. I don’t know how to kick start myself into doing this. I’m in a coffee shop right now on the verge of tears because I don’t know what to do. I don’t remember anything from the last two years. Am I that stupid? I probably crammed way too much the last two years. I definitely become more motivated when its a few days before an exam and I can just study for hours. But it’s hard to motivate myself when the test is 6 weeks away. Sigh.

Hoping this post is cathartic and will get me to study :(

Rheumatoid Arthritis

An autoimmune disease is one in which a patient’s immune system attacks his or her own tissues in the body.  A common autoimmune disease affecting the lower extremity is Rheumatoid Arthritis.  Symptoms occurring in the joints of the toes are often the first signs of the disease.  It is unknown how it is caused, but an environmental trigger is usually needed in people who are already genetically predisposed to autoimmune diseases.  Rheumatoid Arthritis should not be confused with Osteoarthritis, or the normal wear and tear of joints.  The autoimmune type of arthritis involves inflammation and stiffness of the lining of the joints.  This leads to destruction of the cartilage and surrounding ligaments, pain and calluses at the balls of the toes, and foot deformities such as bunions, claw toes, and hammer toes.  The disease eventually progresses to the rest of the foot, causing a collapsed arch, pain and instability in the heel, and pain in the ankle while walking up stairs.

Conservative treatment is used initially.  However, current treatment plans only relieve symptoms of the disease rather than stopping the progression of it.  Common medications include NSAIDs, which are anti-inflammatory, and DMARDs, which specifically treat Rheumatoid Arthritis and its inflammation.  Other non surgical treatments are limiting activities involving high impact on the feet, icing the affected area, orthotics or braces to minimize pressure and pain, and in-office steroid injections into the joint to decrease inflammation. Surgery should be considered if the extent of cartilage damage is severe enough for conservative treatments to cease working.  The most common surgical procedure is fusion of the affected joints with a screw or plate, used to treat severe pain.  A disadvantage of this, however, is that it causes a limited range of motion at the joint.  This is often the only option for a patient with a well-progressed disease.  

“Rheumatoid Arthritis in the Foot and Ankle.” OrthoInfo. Dec 2011. American Academy of Orthopaedic Surgeons. 14 May 2012. http://orthoinfo.aaos.org/topic.cfm?topic=A00163

Clubfoot

Clubfoot is often heard of occurring in developing countries, but it is actually fairly common in the United States, involving 1 in 1000 births.  This deformity can be genetic, but it typically develops randomly while the newborn is in the womb.  It is thought that the leg stops developing too early and there is defective cartilage found in the rearfoot, causing the deformity.  When the patient is born, he or she has shortened leg bones, atrophied leg muscles, and contractures in the calf muscles as well as in some of the ligaments in the foot.  This causes the toes to turn in with the front of the foot angled on its side, the big toe being furthest from the ground.  The foot also has difficulty flexing upwards, and the tibia bone becomes internally turned.  

The aim of treatment is to correct clubfoot as early as possible while maintaining correction until growth ceases.  Depending on the flexibility of the deformity, the patient may be treated conservatively with manipulation, casting, and splints.  Other more rigid deformities must be treated with surgery.  Conservative treatment is optimally started only two to three days after birth using splints.  This corrected position is maintained for many months.  

If infant does not respond to treatment within six weeks, he or she most likely will need surgery.  This is best performed when the infant is at least six months of age.  It is best not to wait to perform this surgery.  If the child becomes older than ten years, he or she will need to endure fusion of some joints in the foot, which is an extensive procedure mainly used to salvage normalcy in the foot shape.  After surgery regardless of age, the patient requires splinting for six to twelve months.  

Fortunately, 50% of clubfoot deformities in newborns can be corrected with surgery, and there is up to a 90% success rate with surgery.  Possible complications include infection, overcorrection, stiffness and limited range of motion, and recurrence of the deformity.  Discuss treatment options as soon as possible with a doctor if your infant has signs of clubfoot.  

Ippolito E, Ponseti IV. Congenital club foot in the human fetus. A histological study. J Bone Joint Surg Am. Jan 1980;62(1):8-22

Metatarsus adductus

The most common foot deformity that arises from birth is clubfoot.  However, many people are unaware of another congenital problem named metatarsus adductus, also known as metatarsus varus.  This deformity causes the toes to turn inward due to a deviation of the metatarsal bones.  One in one thousand newborns have metatarsus adductus, although it is slightly less common than clubfoot.  Causes include increased pressure in the womb, the premature ending of fetal development, abnormal insertions of muscle, hyperactive muscles in the leg, or a hereditary problem.  Besides the “pigeon toe” appearance, the actual foot also has a skewed shape, with a convex border by the pinky toe and concave border by the big toe.  The child, furthermore, has a higher than normal arch.  

Metatarsus adductus is typically diagnosed by x ray.  The angle in the midfoot between the 2nd metatarsal bone and the bisector of the intermediate cuneiform bone is measured, and an increased angle reflects the foot deformity.  An earlier diagnosis has many more treatment options, as well as more conservative options.  An infant of less than three weeks old is treated with soft tissue stretching and manipulation.  A child between the age of three weeks and twenty four weeks is serial casted.  Other conservative treatments include splints, braces, special shoes, orthotics, and a change in habits.  Surgery is considered if the child does not respond to conservative treatment, there is also a clubfoot deformity, or if the child is diagnosed after the age of six.  The type of surgery is decided on by age of the patient, severity of the deformity, and existence of other deformities.  

The most common soft tissue surgery is a release of the ligaments at the midfoot.  This is done for children between the ages of two and six.  Care after the surgery includes a cast for at least three months and watching for the development of flatfoot.  Unfortunately, this procedure has a 41% failure rate, but it is the best option for children in this age group.  Surgery on bone is not performed until the child is at least six years old.  The most common is procedure is a cutting and rotating of the metatarsals at their bases with screw fixation.  If your child has any of the above signs, talk to your doctor about treatment options for metatarsus adductus.    

Piraino, Jason. “Metatarsus Adductus.” PowerPoint presentation. Temple University School of Podiatric Medicine, Philadelphia, PA. 13 Mar 2012.

Reflection on 2nd year.

So. I’ll be out of the classroom for a few months. I’ll have review classes for boards in June and half of July, but at least those are review and don’t count towards a grade. I’ll have class from July 12th until end of December and then I’ll never have to step foot in a classroom again. Thank goodness. 

I think as far as this past year has gone, studying was not nearly as bad as 1st year. The fall had a lot of material…I mean we were taking like 40 something credits. But I stopped going to class for the most part and we only had like 12 exams the whole semester. So it actually wasn’t that bad. This semester was kind of a breeze. I think the only difficult part was going to class all the time except for pathology. 

I feel like I definitely know more about the foot lol. Sometimes I surprise myself when something spews out of my mouth and I realize I actually retained something. I guess I’ll be fine for clinic. Idk. I have issues with being wrong if someone asks me a question, especially if it’s in front of my peers. I just need to get over that FAST. Because I’m sure it will happen a lot, to everybody. I’m nervous to work with some of the clinicians, even though they’re all great. A few are more strict and may come off as mean. It’s just something you have to get used to in medicine. There’s actually a whole Wikipedia page on bullying in medicine :O Unfortunately, this is how students are taught. There’s a hierarchy in medicine, and the people above you are allowed to belittle you in order to teach you something. I have to be a tough cookie but at the same time not become a jaded miserable jerk. Luckily, I feel like it’s probably better in podiatry than…orthopedic surgery or something.

The non-clinic teachers sucked ass this year. Really badly. I feel like all they care about is their research and hate teaching us things…especially the path teachers. They were all awful. Worst class I’ve ever taken. I’m so relieved that class is over. If I had to break down hardest classes I’ve taken thus far…

• Most studying ever, ever, ever: LEA
• Hardest class to get a good grade in: Pathology
• Most conceptually difficult class to understand but not to get a good grade in: Pathomechanics

Interesting how grades don’t always matter. I did very very well in Pathomechanics, but I still have trouble understanding the main concepts of it. I worked really really hard in LEA, and some of his questions were ridiculous on the quizzes, but I ended up with a good grade that I deserved. And pathology…there was just no hope lol. I feel like any decent grades in that course were from studying old exams and review questions. Which is not learning. Sigh.

Anyways. My grades are pretty good, and I think I’ll stay afloat with some help from 4th years in clinic. I hopefully will pass boards, too. But I’m not thinking about that until after my birthday! Okay. Time to do something, anything. 

Charcot’s Foot

Charcot’s neuroarthropathy, commonly known as Charcot’s foot, is a common manifestation of Diabetes Mellitus. It is generally described as the nerve damage and bone breakdown in the foot, but it is much more complex than this vague definition. It begins with a tightening of the achilles tendon caused by poor control of sugar levels. This leads to decreased flexion of the foot upwards. Increased pressure on the toes causes a collapse of the midfoot. This is known as a rocker bottom deformity. The deformity causes degeneration of bone and skin, leading to ulcers and infection.

Charcot’s foot always begins with neuropathy, or nerve damage. As glucose levels increase, the blood vessels enlarge which decreases the ability for the blood to carry oxygen to the surrounding nerves. This leads to the neuropathy. Then there is a cycle of injury and repair. The injury is the active phase of the disease and is characterized by destruction of the joints and bones. After an injury, the healing phase occurs. Inflammation increases blood flow and there is resorption of the affected bone. Then the bone is repaired with the laying down of new bone, but unfortunately, this bone is easily traumatized and the process starts all over again. The third phase of remodeling can last for months to years and involves strengthening of bone and fusion of the joints.

Treatment of Charcot’s foot depends on the stage of progression as well as if there is infection present. With an infected ulcer, there must be antibiotics administered and debridement or removal of the infected tissue. A non weight bearing cast must be given to the patient during the active phase of the disease. Once the foot begins to heal, a walking cast can be used. After the healing phase is completed, a permanent brace is still necessary to prevent further trauma. Surgery is a last resort for Charcot’s foot and is only considered in the active phase when the cast becomes ineffective.

Nielson, David, Armstrong, David. “The Natural History of Charcot’s Neuroarthropathy.”Clinics in Podiatric Medicine and Surgery Vol 25 (2008): 53-62.

Osteomyelitis

Diabetics are prone to several types of infections. One common and serious infection is osteomyelitis, which is an inflammation of bone. Such a problematic condition eventually causes death of the bone and surrounding tissue, leading to amputation of the limb. Osteomyelitis is often chronic in diabetics and must be constantly monitored. It is commonly spread from a foot ulcer to the bone. Signs of an infection of an ulcer include discharge, swelling, redness, tenderness or pain, and warmth to touch. If not treated swiftly, this can most definitely progress to osteomyelitis. Risk factors include deep wounds, neuropathy, Charcot’s foot, poor blood circulation, poor control of sugar, and immune dysfunction.

The most common bacteria that causes osteomyelitis is Staph aureus. It is difficult to treat this type of bacteria because it is part of what is known as a biofilm. This is a community of bacteria protected by a matrix. The matrix is difficult to penetrate and so many antibiotics cannot damage the bacteria. The antibiotic, furthermore, must be able to also penetrate bone, which is the deepest tissue. The most common antibiotics given for osteomyelitis are penicillins and the closely related cephalosporins. If the patient has a penicillin allergy, Clindamycin or Vancomycin can be given. The antibiotic is usually administered with an IV in an outpatient setting. This is because the therapy must usually be done for a long time, and it also prevents gastrointestinal problems. Along with the antibiotic therapy, debridement or removal of the dead infected tissue must be done in order to break down the biofilm of the bacteria.

Especially when the infection becomes chronic, surgery may be necessary to treat osteomyelitis. Reconstruction of the limb is done in several different ways depending on the progression of the infection. Sometimes adjunctive therapy like revascularizing the limb or using hyperbaric oxygen therapy is useful. However, the best chance of a positive outcome is when surgery, debridement, and antibiotics are used collectively.

Rao, Nalini, Ziran, Bruce, Lipsky, Benjamin. “Treating Osteomyelitis: Antibiotics and Surgery.” American Society of Plastic Surgeons Vol 127 Number 1S (2010): 177S-

187S.

I’m not sure what else to write on this blog.

I feel like I have nothing special to write anymore and may hold off until June when I start clinic. Or maybe I’ll use it to vent about studying for boards. But we haven’t had too many exams this semester and the classes are pretty interesting but nothing to vent about lol. Except path which I did already. I do want to use this blog fo sho to talk about my experiences in clinic, provided I don’t violate HIPAA. Okay I guess that’s it.