Nail Changes in Systemic Disease

(Hutchinson’s Sign in melanoma)

An important aspect of the clinical exam for podiatrists is the careful examination of the toenails as well as the fingernails. A variety of systemic diseases can appear in both the hands and feet, and analysis can often lend itself to revealing an underlying systemic condition. The following is a brief list of some of the changes to the nail and fingers and toes, as well as the underlying conditions associated with the changes.

• Nail Clubbing – This is a condition that is caused by a thickening of the soft tissue beneath the proximal portion of the nail plate (the area closest to the knuckle, or the distal interphalangeal joint). A specific finding of nail clubbing is to put the two index fingers next to each other, with the nails facing each other. If the distal interphalangeal joints of the two fingers touch, and the distal end of the nails do not come in contact with each other, it may indicate clubbing of the digits. Nail clubbing is most commonly associated with pulmonary disease, such as emphysema, cystic fibrosis, lung abscess, pulmonary fibrosis, and bronchogenic carcinoma. It is also commonly seen in inflammatory bowel disease, celiac disease, and cirrhosis of the liver.

• Nail Pitting – Most commonly associated with psoriasis, nail pitting is a series of small, punctate depressions in the nail. It is caused by a defect in the layering of the nail plate as it grows out of the nail matrix. Nail pitting may also be seen in systemic diseases such as Reiter’s syndrome, connective tissue disorders, sarcoidosis, and pemphigus. A localized dermatitis may also cause nail pitting, if it disrupts the normal growth of the nail plate.

• Koilonychia – Also termed “nail spooning”, koilonychia gives the nails a spoon-like appearance, with a central depression of the nail plate. It may be due to repeated chemical exposure or trauma to the nail, but is also associated with a variety of systemic conditions. Hemochromatosis and iron-deficiency are two of the conditions that the clinician should be suspicious of when koilonychia is found. Koilonychia can also be a normal variant in the infant child, which usually resolves with age.

• Onycholysis – This is a separation of the nail plate from the underlying nail bed, most commonly at the distal end of the nail, and usually caused by trauma, warts, onychomycosis, or as a finding of psoriasis. However, in the absence of these explanations, it may be associated with hyperthyroidism. When onycholysis is seen in hyperthyroidism, the condition is termed “Plummer’s nails”.

• Leukonychia – Any whitening of the nail in a random, non-linear pattern may be termed leukonychia. It is a very common finding in the nails of both children and adults. Many people will have several white spots on one or more nails, that grow out with time. These are benign lesions that are of no consequence, are believed to be caused by random microtrauma to the nail matrix. A whitening of one or more nails in a linear fashion that parallel the lunula (the half-moon shaped lighter portion at the proximal end of the nail) may indicate a number of systemic disease, and should be evaluated by a physician.

• Longitudinal Linear Lesions – Darkened lesions that run longitudinally along the nail should always be shown to a clinician. Benign lesions must be distinguished from melanoma, which can be seen growing underneath the nail plate. Unexplained darkening in a longitudinal pattern along the nail plate should be considered malignant until proven otherwise with a biopsy.

This is simply a brief listing of some of the changes seen in the nail and surrounding tissues associated with a variety of systemic diseases. Always let your doctor know of any recent changes to your nails.

Central Florida Foot & Ankle Center, LLC

101 6th Street N.W.

Winter Haven, FL 33881

Phone: 863-299-4551

www.FLFootandAnkle.com

Dog Eats Toe, Saves Owner’s Life

Strange news from Grand Rapids, Michigan today as a Jack Russell terrier saved its owners life after gnawing off the man’s big toe.

Yes, you read that correctly.

Forty-eight year old Jerry Douthett’s dog, Kiko, sniffed out an infection that had been growing in Jerry’s toe for several months. The wound had been the result of a small sliver that Douthett had attempted to remove himself by cutting at it with a knife. What ensued was a serious infection that would swell greatly over time, and eventually would spread to the underlying bone.

Douthett’s wife, a registered nurse, recognized the infection as possibly related to diabetes, and urged her husband to seek medical attention. After weeks of delay, Jerry would finally be forced to heed this advice.

The canine-amputation resulted in a hospital visit that would uncover Jerry’s type II diabetes, as it was undiagnosed at the time. Doctors removed what was left of the gnarled and infected toe at the hospital.

Kiko had been sniffing at the wound for quite some time, but was finally able to rid his owner of the infected toe when Jerry came home from a bar. Jerry had drank several beers and margaritas, and fell fast asleep upon arrival. Jerry would wake up later to a missing toe and pool of blood in his bed.

"The toe was gone," said Douthett. "He ate it. I mean, he must have eaten it, because we couldn't find it anywhere else in the house. I look down, there's blood all over, and my toe is gone."

What Kiko was able to sniff out is unfortunately a fairly common situation in the diabetic foot. A loss of pain sensation in diabetic peripheral neuropathy can allow someone to have a serious foot infection without much pain. This is also what would help Kiko chew off the toe without causing too much pain. Combined with the diminished immune system of the diabetic patient, this sets up a dangerous situation.

Now that Douthett is out of the hospital, he has sworn off drinking and is trying to take better care of his health. This starts with working to control his diabetes.

For diabetic patients, it is crucial that they check their feet for open wounds or areas that look like the skin is breaking down. These areas can quickly become infected. For a person with diabetes, something as simple as a hangnail could turn into a big problem. Jerry Douthett learned this in a difficult way.

Central Florida Foot & Ankle Center, LLC

101 6th Street N.W.

Winter Haven, FL 33881

Phone: 863-299-4551

www.FLFootandAnkle.com

Rickets

Rickets is a softening of the bones in a child, sometimes referred to as childhood osteomalacia. It is caused by a decrease in calcium absorption, most commonly due to a decrease in activated vitamin D.

Vitamin D is an essential component of calcium metabolism in the body. Activated vitamin D allows for the absorption of calcium from our diet. Without it, much of the ingested calcium in our diet passes through the intestines without being absorbed and utilized by the body.

The activation of vitamin is a complex reaction that is activated by UV light, in particular UV-B from the sun’s rays. A certain amount of exposure to sunlight is required to generate activated vitamin D everyday. In an adult, it takes approximately 15-20 minutes of direct sunlight on non-protected fair skin to generate approximately 10,000 IU of vitamin D everyday.

In children, however, the amount of time required to activate an appropriate amount of vitamin D is unknown and is difficult to measure. Factors such as age, skin tone, body mass, geographical location and season will all play a role in altering the total. In children, 400 IU of vitamin D are required daily to prevent Rickets and to maintain a healthy level of calcium in the body. It has been shown that children with darker skin pigmentation may require 5-10 times as much sunlight exposure as fair skinned children to activate the daily requirement of vitamin D.

Children aged 3-18 months are at a particularly high risk for the development of rickets, because their bones are growing rapidly at this point in development. High risk groups include children that are strictly breastfed, children with darker skin pigmentation, and children with very limited exposure to sunlight.

In developed countries like the United States, the incidence of Rickets is extremely low (approximately 1 in 200,000 will develop the condition). However, in the developing world, it remains as one of the more common conditions attributable to malnutrition. A lack of vitamin D in the diet is to blame; foods rich in vitamin D include eggs, butter, fish liver oils, fortified milk, and oily fishes such as tuna, herring and salmon.

Symptoms of rickets are due to a lack of calcium, most notably the skeletal deformities that result from the softening of the bones. This includes the classic bow-legged appearance of the tibia and femur, cranial and spinal deformities, and costochondral swelling (swelling along the ribs at their attachment with the cartilage, also known as “rachitic rosary”). Other symptoms include muscle weakness, growth disturbances and failure to grow, dental problems, bone pain, and an increase risk of fractures.

The Indoor Air Quality Act of 1989 reported that Americans spent roughly 93% of their day indoors, which only further compacts the problem of limited sunlight exposure and the development of rickets. Due to the modern lifestyle of developed countries, as well as campaigns to limit sun exposure due to its influence on developing various forms of skin cancer, it is predicted that the incidence of rickets may rise in the future. This has already been observed in Western countries.

Treatment of rickets may be multi-faceted, but includes supplementation with activated vitamin D as the mainstay. Increased exposure to sunlight may be recommended in some cases, though the risk of skin cancer from over-exposure warrants a word of caution. In cases where skeletal deformity has developed, accommodative bracing, orthotics, and other devices may be used.

Central Florida Foot & Ankle Center, LLC

101 6th Street N.W.

Winter Haven, FL 33881

Phone: 863-299-4551

www.FLFootandAnkle.com

Ingrown Toenails

Ingrown toenails can be an excruciating experience. They happen when the nail grows into the skin around the toe, and can lead to a tremendous amount of pain, or even infection.

The best way to avoid getting an ingrown toenail is to cut your nails straight across, without rounding off the corners. When the corners of a toenail are trimmed, they have a tendency to grow back into the skin.

If you have diabetes, nerve damage to the legs and/or arms, or are otherwise prone to infections, do NOT try treating an ingrown toenail yourself. This can lead to serious complications. If you fall into this category, you should consult with your podiatrist or primary physician immediately.

If you’ve got an ingrown toenail and it’s starting to turn red, or if there is pus coming out of the skin, it is most likely infected already. In this situation, your doctor may prescribe antibiotics, as well as trim out the offending nail border. This can be done in several different ways.

Often, a podiatrist may cut out the entire border of a nail. This is especially done in situations where an ingrown toenail is a recurring event. By removing the entire border of the nail, the chances of the nail growing back into the skin are very low.

When the entire border of the nail is to be removed, your doctor will first numb the area with a local anesthetic. This is to ensure that you have no pain during the procedure. The procedure is fairly quick, and it involves cutting into the nail and removing a small piece.

The root of the nail is often removed as well. The idea behind removing the root of the nail is that this is where the nail grows from. If the root of the nail is gone, then the nail will not be able to grow into the skin. Thus, the problem of the ingrown toenail is solved.

Many people have a problem with recurring ingrown toenails. The key is to prevent infection. Infection of an ingrown toenail is known in the medical community as a paronychia. Paronychia is usually a problem that will go away with treatment, but can evolve into a more complicated situation if left untreated. This is particular true in someone with a compromised immune system, such as a diabetic patient.

In the diabetic patient, the immune system is not functioning at full capacity. The same may be true for patients that are on oral steroids for rheumatoid arthritis or other systemic disease. For these patients it is especially important to seek treatment right away.

Central Florida Foot & Ankle Center, LLC
101 6th Street N.W.
Winter Haven, FL 33881
Phone: 863-299-4551
http://www.FLFootandAnkle.com

Varicose Veins

Podiatrists are known to treat the foot and ankle and leg. To the average person, it seems like the typical problems a podiatrist is limited to are bunions and warts. The common conception is that their expertise is confined to the foot in the areas of the muscle, bone and skin.

However, podiatrists are well-versed in many aspects of the foot, ankle and leg – nervous system disorders, musculoskeletal pathologies, dermatopathologies and vascular anomalies! Varicose veins are one such anomaly that is quite common in the population.

What are veins? Veins are a type of blood vessels that take the blood from different parts of the body TO the heart. They only function in ONE direction. The one-way direction is due to the one-way valves that are within the vessels. Varicose veins arise when the valves are malfunctioning. When a valve stops working properly, blood which was destined to the heart starts to flow back towards the legs (or other extremities). The blood is now going in the opposite direction it was supposed to be going! As a result of this backward blood flow, pressure in the veins starts to rise and causes varicose veins! Varicose veins are essentially veins that are receiving so much pressure that the start to expand and engorge. The elastic properties of the vein allow for it to expand due to pressure and it thus it protrudes out of the skin.

There are a variety of risk factors which can cause the veins to start swelling due to the pooling of blood.

A. Family history is one factor – you may genetically have valves that are incompetent;

B. Occupation – standing on your feet for greater periods of times increases venous pressure

C. Obesity

D. Pregnancy

E. Age – with increased age, vessel function starts to deteriorate

Varicose veins are not usually painful but you may feel a deep ache in the area. Swelling and discoloration may also be noted in the area of the engorged veins. The color starts out reddish and may turn to brown with time. The most common complaint is the fact that these veins just look ugly! If untreated, skin erosions can occur; this may progress to venous stasis ulcers which have a poor ability to heal! If you find that you do have varicosities, don’t hesitate to see your podiatrist! They have the knowledge and expertise to guide you to a solution and prevent this medical condition from becoming worse!

Central Florida Foot & Ankle Center, LLC

101 6th Street N.W.
Winter Haven, FL 33881
Phone: 863-299-4551
http://www.FLFootandAnkle.com

Small Girls and Tall Heels!!

Every little girl has tossed on a pair of her mom’s high heels, doused herself in red lipstick, put on a string of pearls and topped off her ensemble with a floppy oversized hat! It is one thing to play dress up; however, it’s another thing when infants or little girls are seen wearing high heels for any period of time!

Many women are already well-aware of the damaging effects of heels on the feet. Heels themselves are a hazard for walking because they alter your center of gravity. In addition, all of your body weight which is meant to be distributed evenly across your feet is now on the ball of your foot. The ball of your foot is not designed to bear your weight and does not function well in terms of shock absorption. So the impact of the forces from the ground and the body weight from above leading to pain called metatarsalgia!

Other conditions that can occur with heels are Morton’s neuromas, corns, calluses, bunions, and hammertoes. The damaging effects of heels are not just limited to feet either! Heels affect your posture by pushing your hips and spine out of alignment! The knees are also prone to injury because heels place additional force on the inside of your knee! The calf muscles may shorten and tighten as a result of excessive contraction needed to adjust to the angle of high heels.

Many podiatrists are concerned with the advent of celebrity moms dressing their children in high heels and being seen in public. High heels are ill-advised in adults and the implications on children can be even more devastating. The bones of a child are not yet fully-formed or fully-calcified; bone formation in the foot in particular partly relies on how the forces are transmitted. The wearing of high heels alters these normal forces and can affect the normal ossification pattern of the bones! And remember, foot problems will not be the only problems that will arise from wearing high heels too early. Knee, hip and back problems can occur due to the change in the body’s center of gravity as a result of high heels. These are not problems young children should ever have! One way to AVOID these musculoskeletal problems is to delay wearing heels as long as possible! Talk to your podiatrist about the implications and possible complications of wearing high heels at any age!

Central Florida Foot & Ankle Center, LLC
101 6th Street N.W.
Winter Haven, FL 33881
Phone: 863-299-4551
http://www.FLFootandAnkle.com

Rocker-Bottom Shoes for Health

The popular shoe company Skechers has recently added a new line of shoes to their repertoire. The Skechers Shape-Ups promise to help improve fitness, lose weight, and improve posture and muscle tone. They even claim to help improve circulation and reduce cellulite. But do they work?

The Skechers website offers evidence from a clinical case study that was performed to assess the effectiveness of the shoes. The study does show an increase in gluteal muscle strength, as well as weight loss and a decrease in percentage of body fat. While this study only points to one small group of wearers, a larger study is being developed to investigate the usefulness of the shoes.

The shoes work by having a contoured, rocker-bottom sole. The shape of the sole helps promote muscle use of otherwise underused muscles, such as the extensor muscles on the front of the leg. Using the muscles that are normally neglected would help to strengthen and tone, as well as burn extra calories.

The shoes also come equipped with a heavy layer of cushioning built in, which is supposed to help alleviate the stress referred up the leg and into the ankles, knees and hips. The soft landing and improved heel-to-toe motion gives a feeling of walking in sand.

Concern has been expressed, however, that the shoes limit the movement of muscles whose function is normally maximized while walking. This may throw people wearing the shoes off balance at first, something that the training video addresses on the Skechers website.

While it is innovative, the technology behind the Shape-Ups shoes is hardly new. The company MBT has been selling a similar version, which has always been heavier and much pricier than the Skechers version. Reebok also has a shoe designed with a rocker-bottom.

Podiatrists and other doctors originally used the rocker-bottom design as a therapeutic device for patients, particularly those with arthritis in the joints of their feet. The rocker-bottom helps immobilize those joints

Whether these shoes will have a great impact on your health may or may not matter. The fact that someone is willing to spend over a hundred dollars on a pair of walking shoes means that they will be more likely to use them. The extra muscle stimulation that someone gets from wearing these shoes may be minimal, but the idea that they are walking more often is a sign of good health.

Central Florida Foot & Ankle Center, LLC
101 6th Street N.W.
Winter Haven, FL 33881
Phone: 863-299-4551
http://www.FLFootandAnkle.com

No More Heels in the Workplace!?

Current events: In the United Kingdom, there is some political controversy over high-heeled shoes! British unions passed a motion stipulating that women are not confined to wearing heels at the workplace; they have the right to wear comfortable shoes! And as usual, most media outlets over-exaggerated the declaration!

The Society of Chiropodists and Podiatrists introduced a motion asking workplace employers to partner up with Health and Safety representatives and trade unions. Risk assessments of high heels should be conducted by these organizations and in where the footwear poses a health hazard, initiatives should be put into place to replace them with comfortable shoes.

The motion set forth by the Society of Chiropodists and Podiatrists just sets a standard that women should not feel that high heels are the only choice of footwear and that the prevailing medical opinion is that they should be avoided in occupations where prolonged standing is involved.

The Society has been quoted to say that, “this [high heels] is a serious issue for women in the workplace, and we at the Society of Chiropodists and Podiatrists want to ensure women workers are never forced to wear high heels which we believe can lead to foot health problems in the short, medium and long term.” In addition to the motion, members of the Society advocate the use of sensible shoes which have heels no more than one-inch high. Specifically, the safety guidelines they issued said that “heels should have a broad base and be no higher than 1.5 inches... if worn for long stretches no higher than 0.8 inches.

The motion advanced by this society was not just a random act; there is plenty of evidence that high heels are economically counterproductive and a hazard to health. Women have lost nearly 2 million days of work a year through lower extremity disorders and many of those lead to foot operations. Too high of heels end up causing long-term foot and back problems! The Society has said that “wearing high heels can cause long-term foot problems, such as blisters, corns and calluses, and also serious foot, knee and back pain. More needs to be done to raise awareness of this problem.”

Central Florida Foot & Ankle Center, LLC
101 6th Street N.W.
Winter Haven, FL 33881
Phone: 863-299-4551
http://www.FLFootandAnkle.com

Feet: His and Hers?

There are many variables that are incorporated in the study and treatment of feet such as shoe gear, activity level, and family history of foot pathologies. However, there has been increasing evidence that a fundamental variable has never been considered or often overlooked: gender.
At the microscopic level, men and women are different in terms of their chromosomes. Yet, those microscopic entities translate into enormous physiological differences ranging from hormonal influences to bone structure. Why is it that the difference between male and female feet is not taken into account when evaluating the health of feet?

What aspects of women’s feet differ from those of men’s feet?
The same basic anatomic structure of the foot holds true between the genders. All the bones, ligaments (connective tissue that links bone to bone), muscles, blood vessels, and nerves are present in the same location.
A study conducted on 300 men and 500 women of the armed forces of the United States revealed that there are inherent anatomical differences between males and females. It was found that the men had longer metatarsals, longer arch length, and a narrower forefoot. In addition, differences were noted at the ball of the foot, big toe and the length of the outer border.
As a result, these differences may also influence strength, flexibility of the ligaments, and proprioception (position sense).
Another scientific study also determined that the foot-to-body ratio is higher in males than in females. In other words, males have a longer foot length than that of a woman of the same height. That same study also used magnetic resonance imaging (MRI) to study join components such as surface area and the amount and nature of the cartilage. It was demonstrated that males had significantly increased thicker cartilage and their joints encompassed more surface area than that of women.

What do these findings mean?
These studies illustrate that women’s feet are not just smaller replicas of men’s feet and the surface of gender difference has only been scratched. The implications of these differences on locomotion and foot health can only be determined with further study!

References

Daniel M. T. Fessler, Kevin J. Haley, and Roshni D. Lal
Sexual Dimorphism in Foot Length Proportionate to Stature
Annals of Human Biology 2005 32: 44-59

Roshna E. Wunderlich and Peter R. Cavanagh.
Gender Differences in Adult Foot Shape: Implications for Shoe Design
Med and Sci in Sports and Exercise 2001 33: 605-611

Central Florida Foot & Ankle Center, LLC
101 6th Street N.W.
Winter Haven, FL 33881
Phone: 863-299-4551
http://www.FLFootandAnkle.com

APMA demands retraction of Arizona congressman’s statements

John Shadegg, a Republican congressman from Arizona, recently referred to podiatry as an "esoteric demand that most people don't have or don't need," equating the field to such alternative medicine practices as acupuncture and aromatherapy. The American Podiatric Medical Association has fired back at the congressman, demanding a retraction of the remarks made.

In a press release issued Friday, APMA President Ronald D. Jenson, DPM, said “It is appalling to find someone who serves on the House of Republican Health Care Task Force so uninformed about the podiatry profession and the valuable role of a podiatric physician in the delivery of essential medical and surgical foot and ankle care. We are on the front lines of diabetes management. Without our services and comprehensive diabetes foot care, lower-leg amputations would soar”.

These figures that Dr. Jenson points to include the $19 billion spent in 2007 on the care of diabetic foot ulcers alone. It is estimated that up to 85% of non-traumatic lower extremity amputations could have been avoided by the early detection of such conditions by a podiatric physician.

Podiatrists are often the first to detect diseases such as peripheral vascular disease, deep vein thrombosis, and diabetes, all of which are potentially life-threatening illnesses. To equate podiatry to alternative medicine choices such as acupuncture and aromatherapy is a slap in the face to the thousands of podiatrists in this country who have completed a four-year education in addition to a residency training program. Stumbling through an interview and throwing around rhetoric like this, as Mr. Shadegg has, is a great misstep and epitomizes the misinformation that opponents of healthcare reform have been spreading in the past few months.

Beyond the press release issued on Friday, the APMA has taken further action to set the record straight. APMA president-elect Kathleen M. Stone, DPM, is demanding a personal meeting with Congressman Shadegg, and is sending letters to Arizona newspapers. The APMA will also encourage the podiatric medical school at Midwestern University in Glendale, Arizona to extend an invitation to the congressman to tour the facilities and learn more about the profession.

Healthcare reform has been making prominent headlines all summer. It is important for people following the news to know what is real, and what is not real. Facts are easily blurred by sensationalism and rhetoric. To have a true understanding of what healthcare reform means, it is important to do plenty of research on the topic. A great article was recently published in the New York Times, called “A Primer on the Details of Health Care Reform”. If you are interested in learning more about the topic, this is a good place to start.

Central Florida Foot & Ankle Center, LLC
101 6th Street N.W.
Winter Haven, FL 33881
Phone: 863-299-4551
http://www.FLFootandAnkle.com