Complications of an ingrown toenail

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A lovely 70 year old female presented with a toe infection on-going for a few days. She relates having an ingrown nail causing her pain and was subsequently removed by a podiatrist. 

She is a diabetic and admits to going back to work after the procedure. Several days later I was called to see her in the emergency room. See far left image. There was increasing redness, swelling and purulent material draining out the nail bed. Her prognosis was bleak. 

I didn't know if the toe could be saved but I told her I would try. I worried that if we did nothing, the infection would spread affecting other parts of her feet. So we wheeled her into surgery right away. 

Paying close attention to the blood source to the toe, an incision was made down the middle and the infection was gently cleared out with a curette. The wound remained open to allow further drainage. She was admitted to the hospital for IV antibiotics and debridement was performed daily until I was comfortable that the infection was controlled. 

Several weeks later, she is doing quite well. 

Complications of an ingrown nail is rare but the risk is still present, especially in patients with diabetes. It is important for patients to feel comfortable in addressing any problems they have after a procedure immediately with their doctor and equally important for the doctor or their medical assistant to be available as well. Don't take any procedures lightly and as you can see here, complications are real but if dealt with in a timely fashion, prognosis can be good. 

 

"I think I have an ankle fracture. Now what?"

XR of an ankle (fibular) fracture

XR of an ankle (fibular) fracture

Breaking any bone in your body is frightening. Not only does it hurt but fear of surgery and long term disability is on everyone's mind. My husband recently missed a step going down stairs, he was holding the dog's leash in one hand (and she was pulling) and his cell phone in the other (I don't see how this was a good idea to start with). His foot turned under him and ... SNAP! He heard and felt a pop, called me immediately and fortunately for him had concierge service from his favorite podiatrist. He told me "I think I fractured my ankle."

Luckily my office wasn't too far from where he was so I was able to drive him to the office and get xrays immediately, bypassing the emergency room. Of course, the whole time he was very scared that he would need surgery. He himself is a general surgeon and runs around all day and night going between patients traveling to different facilities and stands for long periods to operate nearly everyday. His job, like many others, requires him to ambulate independently without pain. So, what was next for him?

His xrays were negative for an ankle fracture. But what was that audible pop and the immediate bruising and swelling? He may have torn one of the lateral ankle ligaments but since he was not a professional athlete, I advised him to take the following protocol seriously so he can heal optimally without surgery, the acronym R.I.C.E. protocol is appropriate here:

1. REST - I realize many working people don't know how to do that. He was given a walking boot to protect the ankle and was instructed to wear it during working hours, then take it off when sleeping or driving. Functional recovery (continued protected movement) is important in ankle sprains. In the evening, he was to do passive range of motion exercises, drawing out the alphabet with his foot. Too much immobilization could stiffen the ankle and weaken the leg slowing down recovery. 
2. ICE - this will decrease the swelling
3. COMPRESSION - I applied an elastic ACE wrap to help with the swelling
4. ELEVATE - raising the affect leg above the heart while at rest will also decrease swelling

(or P.O.L.I.C.E. - Protect, Optimum Loading, ICE, Compression, Elevation)

He only took a few ibuprofens in the beginning but went straight back to work the following day taking it slow. Of course I'd occasionally find his boot laying around the house every now and then while he was at work, so you can say he was doing fine. After 6 weeks he felt pretty normal and went back to working out and running comfortably.

By the way, if it was an ankle fracture, that doesn't necessarily always mean surgery. Allow your surgeon to make the diagnosis and discuss treatment plans with you. The sooner you seek treatment, the better off you'll be. 

 

 

Elderly Foot Care

The age at which a person is considered "elderly" may vary from culture to culture but it has been accepted (in the US) to be those of age older than 65. October 1 is International Day For Older Persons so I wanted to share some insight about elderly foot care from a podiatrist's perspective.

A large portion of my practice focuses around the elderly and here are some important issues to consider.

1. Gait imbalance - There are many reasons for gait imbalance and some can be easily addressed with orthotics, braces, walking assistance aid (walker, cane). Other times, physical therapy is needed to improve joint mobility and conditioning to prevent falls. Podiatrists can determine whether or not your feet is the cause of your imbalance and make recommendations.

 What I would highly recommend for prevention of falls at home (that I learned in my gerontology class from medical school) is GET RID OF LOOSE RUGS around the house and loose cable wiring also. These can lead to tripping and falling, which can have disastrous results in our geriatric population.  

2. General foot care - Common problems seen in elderly feet:
- Dry feet that may crack and is too hard for patients to reach to apply lotion
- Painful corns and calluses
- Thick and discolored toenails that are difficult to trim
- Circulation issues including cold feet, pain at rest that feels better when the legs are dangling, or intermittent claudication (pain with walking short distances)
- Osteoarthritis and joint stiffness
- Hammertoes and bunions are progressive deformities that worsen with time and can be very painful

Many of these issues can be treated by a podiatrist with simple procedures performed in the office the same day as your appointment.

3. Undiagnosed depression - Often times, patients seek medical help but they often hide their depression, either from chronic medical conditions or loneliness. Since podiatrists see a lot of elderly patients, we work closely with your primary care doctors to discuss social issues that affect this vulnerable population.

For more information on Geriatric Care, please visit https://geriatricscareonline.org/

Photo by Rawpixel Ltd/iStock / Getty Images

Photo by Rawpixel Ltd/iStock / Getty Images

Pregnancy and Foot Pain

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I'm at the age where a lot of my friends are getting pregnant and many have suffered from foot pain near their last trimester. I've put this together with you in mind ladies:

Why do my feet hurt?
Carrying around extra weight from your growing fetus adds pressure to your feet. Even in patients who are not child bearing but experience an increase in weight gain will suffer from foot pain. Many patients have told me once they were able to lose weight, or had their baby, they had less foot and ankle problems. 

Why did my shoe size change?
During pregnancy you're more likely to retain water and so your feet will swell up. That is why you may notice your regular shoes are fitting more snug than you remember. Many moms-to-be opt for sandals that are not as restrictive. 

I think my feet are changing shape too! Is this normal?
Unfortunately yes. With increasing weight and a hormone called relaxin that is produced during pregnancy to loosen the pelvic ligaments, it also affects ligaments throughout your body including your feet. The arch may flatten out which is why you see the changing shape. 

What can I do to get relief?
- Sometimes, rest is best! Kick off your shoes and elevate your feet as much as possible to decrease the swelling. 
- Give yourself a home spa treatment with Epsom salt foot soaks. Add aromatic oils like lavender to help you relax. 
- Exercise regularly to improve circulation and for overall health.
- Drinking a lot of water and limiting salt intake will decrease water retention. 
- My favorite recommendation of all time: massage! You can use a frozen water bottle to roll under your arches or have someone massage your feet.  

You deserve to relax and be pain-free. After all your amazing body is building a baby in there! If you have more questions, feel free to click on the button below to email me. 

Maybe you need orthotics

Custom orthotics come in a variety of styles and are custom designed to suit your foot and ankle condition

Custom orthotics come in a variety of styles and are custom designed to suit your foot and ankle condition

What are orthotics?
These are removable inserts that are placed inside your shoes which help to correct structural abnormalities that many people have in their feet. Structural abnormalities, such as flat feet or high arches, can result in abnormal pressure distribution and eventually pain. 

What common pathologies are orthotics helpful for?
The most common reason I prescribe orthotics is heel pain but there are many reasons to have orthotics, including back and knee pain. Take a look at the next county fair you go to, what are people mostly wearing? Flip flops, canvas shoes, maybe even flat dress shoes I bet. When you need to walk short distances, these shoes are fine. But if you're spending the day walking and standing on your feet for longer than you're used to, you really need supportive arches, whether it be a high quality shoe or custom orthotics, to prevent sprains and strains.

Do insurances pay for orthotics?
Many insurances pay for custom orthotics performed by a foot and ankle specialist. When they don't, I would still recommend over the counter orthotics, something that does not fold in half and fits your arch well and maintains it. High quality ones are sold exclusively in a podiatrist's office. 

Do I need orthotics?
Many people I see have demanding jobs that require them to stand on their feet for over 6 hours at a time with minimal rest. This can put a lot of strain on your feet. I have prescribed orthotics to people who have recurrent or constant pain and many do well with it. There is a small fraction of people who either don't like it or can't tolerate it at all, but since there are so many ways to create it, I often suggest having them evaluated by a foot and ankle specialist. Sometimes a small modification can help.

Coffee Chat with Dr. Tea

Here is where I write down my thoughts, less educational, more intimate. 

Have you ever wondered who your doctor was outside his or her lab coat? Like, what are they into? Do they all drive nice cars? What are their true values in life? What makes them crazy? What makes them love their job? I won't attempt to answer all these questions, but let's see where this takes us.

Are you an introvert or extrovert?

I'm more of an introvert than extrovert who enjoys reading, writing and quiet time. It is easier for me to write out how I feel than it is to say it. Becoming a doctor has challenged me in that now I have to push the words out of my mouth in front of patients, colleagues and staff in order to be an effective communicator. I admit I still struggle with this at times. Often times, my words don't work but I'm fortunate enough to have staff who can read my mind (or predict my next move). That is an amazing skill. 

How does that affect you as a doctor who sees over 20 different people everyday?

I also like balance. Periods of introversion must be broken up with human interaction, just like periods of wakefulness needs sleep to recharge. I truly enjoy being in small groups of friends whereas in larger groups I tend to feel drained. I value my energy reserve and there is a finite amount in a day, so I am also very picky about how I spend it. That also means I am straight to the point with my patients and thorough about explanations. There's no sugar coating important facts that need attention. I have patients who find my honesty refreshing, there are others who'll choose to never see me again. I am ok with that.

What useful thing have you learned in practice that you didn't get in training?

Don't bother trying to please everyone! You simply can't and having accepted this has given me the freedom to be exactly me and stay true to my values, which is honesty. I want patients who get that, I think that has helped increase the quality of patient-doctor relationship, ease nervous patients, while providing clarity in treatment options. Since I am spending most of my waking hours with patients, I have to make it count so I have to hang on to my core values, which in turn helps my sanity.

What values have you learned along the way that has helped the way you practice?

Empowering people around me is something I value greatly. I will rarely tell patients what to do. They always have choices: do nothing or consider my advice or consider someone else's. I treat everyone like adults and each individual chooses their own destiny. Some like the easy route, others prefer the more difficult one. The choice is yours as it always has been.

If you enjoyed this content, I thank you for being here. I hope to hear from you as well. 

 

 

What to Expect at Your Podiatrist's Appointment for Ingrown Nails

My previous post gave you some pointers on preventing ingrown toenails and when to seek professional advice. Here is what you can expect at your podiatrist's appointment.

1. A history and physical exam will be performed. What I check for is how good your circulation is, possible causes for the irritation (nail salons, shoe wear, genetic deformities, etc) and how bad the ingrown nail is. 

Removing an ingrown nail can be done with minimal discomfort. Only the offending border is removed with little noticeable deformity. Pain is relieved the same day.

Removing an ingrown nail can be done with minimal discomfort. Only the offending border is removed with little noticeable deformity. Pain is relieved the same day.

2. You will be offered the following options:
- Do nothing: In mild cases, some suggestions to prevention will be reviewed. 
- Avulsion (in-office small procedure): We have a better angle at seeing your toenail so we can perform a slant-back of the offending nail with sterile nail nipper. In some cases we'll inject a numbing medication to provide optimal comfort.
- Matrixectomy (also an in-office procedure): This will permanently prevent the nail from growing back (95% chance of success). You will be given a numbing injection, followed by removal of the nail border with sterile instruments, and a chemical is used to burn the nail root so it does not grow back. Many people tolerate this procedure and are able to walk out of the office without pain. Limited activities is recommended for the first week.
- Rarely will going to the operating room be necessary. 

What is offered on your first visit will depend on you and your insurance. A discounted cash price is also available. 

 

Home remedies for ingrown nails

Photo by robertprzybysz/iStock / Getty Images

Photo by robertprzybysz/iStock / Getty Images

I have to admit, I am a huge fan of home remedies because I don't always have the luxury of seeing a professional and mostly because I don't want to. (I'm human too!) I know many of you feel the same, which is why I wanted to share with you some insight on ingrown nails, things you can do at home and when you should definitely see a specialist. 

PREVENTION
It is better to prevent than to cure. Prevent ingrown nails by cutting the nail straight and rounding the sharp corners with a nail file.

A few patients have told me they read somewhere that creating a "V" notch would help. I'll save you the trouble and tell you it does not. Straight is great.

Also, too much digging into the corners will cause the skin to thicken and introduce bacteria so you may not want to do that. 

Poorly fitted shoes with narrow toe boxes can add pressure on the nail. Choose wider shoes or sandals if irritation is occurring. 

HOWEVER
If you are developing an ingrown nail, simple things that can be done at home include:
1. Epsom salt soaks - this will relieve the inflammation. Take a basin of warm water, add 1/2 c Epsom salts, soak for 10-15 minutes. This will soften the nail and you can use a sharp ended filer to gingerly lift the nail corner.
2. Topical ointments - such as antibiotic ointment will also help soften the nail

SEEKING PROFESSIONAL HELP
Too often I see antibiotics prescribed erroneously. An ingrown nail that presses into the skin, maybe even cutting it, is best treated by removing the irritation. You'll want a professional to do this for you to avoid worsening infections. I've removed a lot of ingrown nails without prescribing any antibiotics because the source has been removed, saving you the inconvenience of antibiotic side effects, possible resistance and mostly saving you time from pain. Sometimes antibiotics are needed, most times they are not. Let a professional help you with that.

If you have chronic ingrown nails and want it to be removed permanently, podiatrists can help with that. I will follow up on next week's blog on what you can expect during a nail avulsion/matrixectomy procedure. 
 

If you would like to make request an appointment with Dr. Tea, click on the button below.

August is Back to School Shoe Shopping

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What an exciting time it is going back to school and mostly, back to school shopping. Here are some pointers on what to look for when buying new shoes:

1. Not all shoe sizes are the same! For example, a size 8 from one company may fit differently from another. Make sure the length of the shoe fits the longest part of your foot. For some, it may correlate with the big toe and some others the second toe will be longer. Make sure there is room for every toe and wide enough to prevent blisters.

2. Cheap shoes may cost you in the long run. While it may be tempting to go for the budget friendly shoes, sometimes these are constructed very cheaply and can cause unnecessary foot pain. Make sure the shoe has some cushion inside and does not easily fold in half. Cheaper shoes may not last as long as higher quality shoes. The investment is worth it.

3. Consider orthotics or shoe inserts. If you are suffering from foot pain, orthotics may help provide better support and reduce the pressure on your feet. Keep in mind, some orthotics will not fit all types of shoes and vice versa.

Learn more by visiting your local foot and ankle specialist who may be able to recommend custom orthotics in qualified patients. 

Patient Diagnosed with Diabetes, Takes Control

A cheesy title, I agree. But I wanted to share this story because it is a bit of an inspiration that I know many of you, including myself, appreciate hearing from time to time. 

As you know, my specialty is foot and ankle problems. When I see a problem, I like to fix it. When there is a broken ankle, I want to fix it. When I see a wound, I want to heal it. This is my area of expertise. Having 10 years of experience secured, I am able to process problems fast. Sometimes too fast. But I admit, I still have human errors.

A young kind lady presented to me with complaints of heel pain. She was recently diagnosed with diabetes and admits knowing she is overweight. She was very scared of this diagnosis so decided to be proactive and take classes at the gym. She had never worked out much before but had seen the consequences of diabetes since it runs in her family. She is terrified of losing her legs from the complications of diabetes. She tells me she is working out a lot and is worried that her heel pain won't go away and that it might stop her from losing weight. I empathized. 

Of course, in my mind, I'm thinking about an algorithm. Here's a problem, here's how to fix it. I started going through the routine of educating her on plantar fasciitis and how it can be aggravated by being overweight, having a certain foot type, change in level of activity, etc. She started silently crying so I stopped my babbling and asked her why is she so sad?

To me, there's a problem, here's how to fix it. To her, it's me telling her to stop activities meaning she may not be able to lose the weight and also meaning she is not in control of her health. My human error was not realizing what I said could mean several different things to patients. 

She tells me, "I don't want to stop working out, I am doing so well right now and losing weight. It makes me feel good to go to class and dance."

I felt bad for making her feel like she had to give up something that makes her feel good about herself, working out. I reassured her stopping does not mean quitting, it's really just a short break and your body is telling you, please take a break! If you have foot pain, you can't ignore it. You'll start to walk differently to compensate and that can throw your whole body off, you may even hurt other parts of your body. 

I gave her a treatment plan, created custom orthotics, and she is back on track to staying healthy. She recently just told me, "Dr. Tea, I feel amazing. I've lost 15 pounds. My self confidence is up, I feel good about myself, I am really happy and hope my friends will join me to being healthier."

Sound like something from a commercial doesn't it? Except I don't have anything to sell. Just a story that I hope inspires you that something so simple like walking that extra mile, taking a fitness class, eating better, and practicing these things on a day to day basis, may be just enough to change your life. Small actions, big rewards.