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Medically Guided Shopping ™

Using Medically Guided Shopping™ to select the right products for plantar fasciitismedically guided shopping - plantar fasciitis

I was working with a patient this morning, discussing one of the more common problems that a foot doc sees in practice – plantar fasciitis.  At the conclusion of the discussion, I printed the plantar fasciitis knowledge base article in Myfootshop.com’s foot and ankle knowledge base, and gave it to the patient.  This accomplished two goals of the patient visit.  First, printing the article helps confirm the points discussed in the patient visit.  The patient can take the article home and read it in the leisure of their home.  Second, printing the article satisfies MIPS requirements for physician Meaningful Use.

But then the patient said, “So, do I just go to WalMart for those heel lifts?”  That’s when I explained to her how Medically Guided Shopping™ works.  How do you find the right diagnosis and the right product?

  • Step 1 – Navigate to www.myfootshop.com/articles and click on the location where it hurts
  • Step 2 – Research the conditions specific to that region of the foot and make your diagnosis.
  • Step 3 – Evaluate the products selected by our medical staff (always located at the bottom of the condition article) specific to that condition.
  • Step 4 – Make your purchase.

Finding the right product for foot and ankle conditions is easy when you use Medically Guided Shopping™.

Jeff  

Dr. Jeffrey Oster
Jeffrey A. Oster, DPM 

Medical Director
Myfootshop.com  

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May-Thurner Syndrome

Differential diagnosis for unilateral, left leg edemaMay-Thurner Syndrome

I saw a 53 year old female today for left ankle pain and chronic left leg swelling.  Swelling was pitting, meaning that with digital pressure to the skin, when you pull away, your finger leaves a divot, or pit in the skin.  Pitting edema classically describes fluid retention in the legs, commonly called venous stasis.  But this case was unusual.  The swelling was only in the left leg. 

What is the significance of unilateral vs. bilateral edema?  Bilateral edema is by far more common and signifies a fluid overload of the body.  With standing or dependency of the legs, the legs will swell with fluid edema.  An important characteristic of fluid retention and lower extremity swelling is that fact that the edema is found in both legs.

What could cause unilateral swelling of the left leg?  Fortunately this patient was familiar with her diagnosis and has been thoroughly evaluated by vascular medicine specialists.  This patient presented with May-Thurner Syndrome which is a compression syndrome of the iliac vein.  The iliac May-Thurner venous compressionvein is found in the lower pelvis and is the final vein of the lower extremity that feeds into the vena cava, the primary vein that returns blood to the heart.  In cases of May-Thurner Syndrome, swelling of the legs is exclusive to the left leg due to the unique anatomical, arterial-venous complex found in the lower abdomen.  May-Thurner Syndrome is caused by compression of the left iliac vein by the right common iliac artery. 

It’s interesting to note that May-Thurner Syndrome is due to the alignment of the vena cava (venous return to the heart) and aorta (arterial supply to the legs).  You can see from the attached picture how the anatomical arrangement of the arterial tree is superficial to the venous return.

Treatment of May-Thurner syndrome is primarily fluid management with diuretics, compression hose and venous ablation of the superficial veins of the left leg. 

Jeff  

Dr. Jeffrey Oster
Jeffrey A. Oster, DPM 

Medical Director
Myfootshop.com  

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Foot and Ankle Resources for Providers

Foot and ankle educational resources for patients

How to guide for providers – using the Myfootshop.com foot and ankle knowledge base

As a health care provider, how can you use Myfootshop.com’s foot and ankle knowledge base to benefit your patients?  There’s two ways that are really quick and easy.

  1.       During patient visits.

Ever get stuck trying to educate a patient about anatomy, body planes or the bone structure of the foot?  A picture can be worth a thousand words.  Here’s some fast references you might want to use on your laptop to help patients.

X-rays of the foot and ankle

Spatial orientation

Muscles of the lower extremity

Nerves of the lower extremity

  1.        Conclusion of the patient’s  visit

It’s easy to satisfy Meaningful Use requirements with foot and ankle knowledge base pages.  Here’s a few quick links to some of our more popular foot and ankle knowledge base page.

Plantar fasciitis

Achilles tendinitis

Saddle bone deformities

Hallux limitus

PTTD

 

All articles are open source meaning that you are free to share articles with your patients.  Simply print the article at the conclusion of your patient’s visit and you’ve not only helped your patient understand your recommendations, but you’ve also checked just one more box off the MIPS list.

Jeff  

Dr. Jeffrey Oster
Jeffrey A. Oster, DPM 

Medical Director
Myfootshop.com  

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Foot Drop - injury to the common peroneal nerve

Foot drop – trauma and treatmentCommon peroneal nerve

Contusion of the common peroneal nerve resulting in foot drop

I saw an interesting case of post-trauma foot drop (peroneal palsy) this week.  The patient was a 24 y/o female who described falling against her car and hitting her right leg on the license plate.  She presented to the emergency department for a small laceration of the lateral knee.  She also described the inability to lift her foot while walking.  The laceration was dressed in the ED and the patient referred to me for follow-up.

The patient is of healthy BMI, good health and an everyday smoker.  Upon examination she showed a well healed laceration of the lateral right knee.  Muscle strength testing was strong on the left leg noting dorsiflexion, plantarflexion, inversion and eversion all 4/4 with resistance.  The injured right leg though showed 4/4 plantar flexion with 2/4 inversion and eversion.  Dorsiflexion was present but limited at 1/4.  Findings were suggestive of an injury to the common peroneal nerve.  Sensation of the top of the foot (distribution of the common peroneal nerve) was intact.  Gait exam noted adequate but weak dorsiflexion of the right foot in swing phase of gait.  The patient did relate two falls since the injury due to instability of the ankle.  Percussion of the injury site noted a positive Tinel’s sign to the dorsal right foot.

Anatomy of the common peroneal nerve

Nerves of the lower extremityThe common peroneal nerve is a branch of the sciatic nerve that wraps around the lateral aspect of the knee just below the head of the fibula.  The common peroneal nerve branches into the superficial and deep branches.  The deep branch supplies the innervations to the two dorsiflexors of the ankle, the extensor digitorum longus and the tibialis anterior muscles.

Innervation of the extensor digitorum longus and tibialis anterior by the deep branch of the common peroneal nerve enables dorsiflexion of the foot at the ankle.  Dorsiflexion at the ankle is an important part of the biomechanics of walking.  In the swing phase of gait, when the foot is not touching the ground but swinging forward at the hip, the innervations of these muscles lifts the foot so that it doesn’t drag on the ground.  Injury to the common peroneal nerve results in foot drop or ‘palsy’.  Inability to lift the foot at the ankle necessitates lifting of the leg at the hip and low back to complete a cycle of gait.

Neuropraxia of the common peroneal nerve

Injuries of peripheral nerves are broken down into three primary types by the Seddon classification of peripheral nerve injuries.  My patient sustained the mildest of injury called neuropraxia.  Neuropraxia should respond in weeks to months as the nerve regains its ability to send both motor and sensory signals.

Treatment of peroneal palsy

What was interesting in this particular case was the fact that the laceration was several centimeters proximal to the common peroneal nerve.  This knowledge was comforting in that we could assume that there was not a direct laceration of the common peroneal nerve.  Palpation of the nerve at the head of the fibula produced a tingling sensation in the top of the foot called a Tinel’s sign.  A positive Tinel's sign meant that the common peroneal nerve was intact.

The initial injury was treated with ice, elevation and compression.  Since the common peroneal nerve was found clinically to be intact, there was no need for surgical exploration or reapposition of a lacerated nerve.  Physical therapy has been helping with muscle strengthening, preserving existing muscle strength while the nerve regenerates.

How quickly will the nerve regenerate?  There are a number of variables in this case that include;

  • Age of the patient
  • Smoking status
  • Severity of the injury to the nerve

Based on our clinical finding this week, I think the patient will go on to a full recovery. 

Jeff  

Dr. Jeffrey Oster
Jeffrey A. Oster, DPM 

Medical Director
Myfootshop.com  

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Adjacent segment disease secondary to correction of Charcot deformities

Charcot joint treatment pearls..

In my blog post last week, I discussed how fusion of one joint increases load to adjacent joints resulting in early onset of pain and arthritis.  This accelerated deformation of the joint is called adjacent segment disease.  Speaking of adjacent segment disease…

I was at a limb salvage seminar today and had a number of great conversations related to reconstructive surgery and limb salvage.  A big topic of conversation was Charcot joint surgery.  The thread that connected these conversations was that there is no clearly defined ‘correct’ way to treat Charcot arthropathy.  Is surgery best?  Is conservative care better?  There really are no guidelines for care, but it seems that these conversations with my peers are the guide posts that best sum up care.

Here’s a couple of important topics that bubbled up during the day.

  1. If you surgically fuse a Charcot joint, expect adjacent segment disease at the next proximal joint.  This stands to reason in that the load that was once distributed across two joints is now distributed across one.  That increase load in a fragile foot will certainly lead to a greater incidence of Charcot arthropathy.
  2. Don’t treat stage 1 Charcot joints with fusion.  Eichenholtz defined the four stages of Charcot arthropathy.(1)  In stage 1 where the foot is hot, active and weak, primary fusion is a poor choice.  An external frame to support the foot is the best way to protect the foot from deformation.  Total contact casting is the next best alternative.
  3. When you’re using an ex-fix frame to treat Charcot joints, expect three problems.  What will those problems be?  It’s hard to say.  Just expect three.

Great to be able to joint with peers today to discuss these complex foot and ankle challenges. 

Jeff  

Dr. Jeffrey Oster
Jeffrey A. Oster, DPM 

Medical Director
Myfootshop.com  

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  1.        Clin Orthop Relat Res. 2015 Mar; 473(3): 1168–1171.