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Subungual Exostosis

A Subungual Exostosis is a bony projection which can arise underneath the toenail. They generally are a result of some form of trauma to the toe that results in the formation of bony irregularity or prominence. This condition usually affects teenagers and young adults, and is predominantly seen in females.

Causes of Subungual Exostosis:

The cause of Subungual Exostosis is unclear, however it is thought to occur as a reaction to:
– Constant irritation
– Previous Trauma
– Chronic Infection
– Inherited conditions such as multiple Exostoses Syndrome

Symptoms of Subungual Exostosis:

– Exostosis grows gradually over weeks and months
– It presents as a hard painful swelling under or beside the toenail, usually on its inner side.
– As it grows it presses against the nail, causing pain, which may be confined to the nail fold.
– With further growth, it separates the nail form the nail bed and erodes the overlying skin (making it prone to infections).

Treatment for Subungual Exostosis:

As the Subungual Exostosis continues to grow, it damages the surrounding tissue which causes a lot of pain to the toenail. The best treatment option is to remove the bony projection altogether, resulting in surgery. The procedure is done under local anaesthesia by your podiatrist. The Exostosis is removed, along with the attached nail bed. The surface of the underlying bone is scraped to ensure complete removal of the exostosis and to prevent its recurrence in the future.

 

Peripheral Vascular Disease

 

What is peripheral vascular disease?

Peripheral vascular disease (PVD) is the reduced circulation of blood to a body part other than the brain or heart. It most commonly affects the blood vessels of the legs and kidneys. It is caused by a narrowed or blocked blood vessel which is usually caused by arteriosclerosis. Arteriosclerosis is a condition where plaque builds up inside a vessel (also called “hardening of the arteries”). The plaque decreased the amount of blood and oxygen supplied to the legs or arms.

Risk Factors

The risk factors of peripheral vascular disease include:

  • Diabetes – this is the most significant risk factor
  • Smoking
  • High blood pressure
  • High cholesterol
  • Heart disease
  • overweight
  • Kidney disease
  • Stroke/CVA
  • Family history of peripheral vascular disease, stroke or coronary artery disease
  • Medical history of stroke, cardiovascular disease or heart attack

Symptoms

The symptoms of peripheral vascular disease include:

  • Painful cramping of the calves when walking. The pain intensifies with exertion and subsides with rest
  • Skin changes to your legs and feet (thinning, shiny, paleness)
  • Weak pulses in feet
  • Reduced hair growth on feet and legs
  • Wounds or ulcers on your feet that won’t heal or are slow to heal
  • Gangrene – tissue death from not enough oxygen getting to the tissues
  • Toenails that are thick and opaque
  • Numbness
  • Pins and needles
  • Numbness
  • Coldness of the affected body part

How can a podiatrist help?

Podiatrist’s can perform thorough vascular testing and may be the first health professional to detect any problems with the circulation. Podiatrists can perform ankle-brachial pressure index (ABPI) which is the ratio of the blood pressure at the ankle to the blood pressure in the upper arm. Compared to the arm, lower blood pressure in the leg indicates blocked arteries due to peripheral vascular disease. It is important to see a podiatrist for help with general nail care if you are unable to care properly for your feet yourself. A podiatrist can offer advice on preventing wounds and ulcers and how to prevent trauma to the feet as well as suggesting proper footwear to help with these issues. People with diabetes who are over the age of 50 should have an ABPI to compare the blood pressure in their feet and arms as they are more likely to get peripheral vascular disease.

Why podiatry is important in diabetes

 

Why is podiatry important in diabetes?

Diabetes is a chronic condition that effects the way the body metabolizes sugar often characterised by high blood sugar levels. Either the body does not produce enough insulin to store sugar as energy or the body resists the effects of insulin.

There are two main types of diabetes:

Type 1 diabetes, also called Insulin Dependent Diabetes Mellitus usually occurs in people under 30 years of age, but can occur at any age. In type 1 the insulin producing cells of the pancreas (beta cells) have been destroyed leaving no insulin available to help the glucose enter the body’s cells resulting in no energy and excessively high blood glucose levels. Represents 10-15% with diabetes

Type 2 diabetes, also called Non-Insulin Dependent Diabetes Mellitus (NIDDM). The beta cells of the pancreas are still producing insulin but it is ineffective in removing glucose from the blood stream. Usually occurs in people over 40 years of age, inactive, family history of diabetes and being overweight. About 85 to 90% of people with diabetes.

All types of diabetes are associated with high levels of glucose in the bloodstream. The clinical term for this is hyperglycaemia which leads to health problems

The two main health problems that can arise from hyperglycaemia are decreased blood supply and peripheral neuropathy.
Decreased blood supply and peripheral neuropathy may lead to leg ulcers, serious foot problems and limb amputation. It is estimated that amputation is 15 times more common in people who have diabetes than in people who do not.

Decreased Blood Supply

When blood sugar levels are poorly managed, the high levels of glucose causes inflammation of the blood vessels rendering them thicker and less flexible, also known as Atherosclerosis. As a result, it’s harder for the blood to flow through them. This is especially true of the smaller blood vessels that are so important for good circulation in the lower legs and feet. As an added concern, diabetics have a natural tendency toward higher cholesterol and triglyceride levels. Together, these problems put diabetics at a greater risk for Peripheral Vascular Disease.

Good blood supply is vital for adequate oxygen and nutrients to be carried throughout the body. This oxygen and nutrient supply is what allows our body to repair damaged tissue and fight against infection. Even the most minor cut or infection can be detrimental if blood supply is diminished.

↓ Decreased blood supply = ↑ Increased risk of infection

Peripheral Neuropathy

High levels of glucose are toxic to nerves resulting in nerve damage. Neuropathy in diabetics first affects the small nerve fibres in the feet resulting in tingling, itching, burning or shooting pain, loss of coordination, numbness or a complete lack of, sensation.

Neuropathy can affect the nerves that innervate:
• Sweat and sebaceous glands resulting in the loss of sweating and sebum causing the skin to be dry and prone to fissures
• Peripheral vessels leading to vascular rigidity and calcification resulting in decreased blood supply.

Peripheral neuropathy may also cause muscle weakness and loss of reflexes, especially at the ankle, leading to changes in the way a person walks. Foot deformities, such as hammertoes and the collapse of the midfoot, may occur. Blisters and sores may appear on numb areas of the foot because pressure or injury goes unnoticed. If an infection occurs and is not treated promptly, the infection may spread to the bone, and the foot may then have to be amputated. Many amputations are preventable if minor problems are caught and treated in time.

Why Visit a Podiatrist?

Diabetes Australia recommends visiting a podiatrist annually for a check-up or more frequently if your feet are at high risk.

Senior Foot Care performs comprehensive vascular (i.e. Ankle Brachial Pressure Index Doppler tests) and neurological assessments (i.e. monofilament) to assess if blood vessels and nerves have been damaged by diabetes.

Our Podiatrists will provide necessary treatment at the time of the consultation for nail care and skin problems such as corns, calluses or ingrown toenails or ulcer debridement and in more advanced cases recommend customised orthotics to offload pressure areas.

We can recommend appropriate footwear and stock a large range of Dr Comfort Footwear suitable for diabetics.

 

Paget’s Disease of bone

Paget's disease of bone

 

Paget’s disease of bone is a chronic condition that causes abnormal enlargement of the bone, causing the bone to thicken and weaken. The most common effected sites include the skull, spine, pelvis and the long bones of the upper arms and legs, however any part of the skeleton can be affected including the heel bone. Paget’s disease typically affects people over the age of 50 and tends to affect men slightly more than women.

Symptoms:

Symptoms of Paget’s disease may include:

  • Stiffness in joints
  • Constant fatigue
  • Aching in the bones
  • Pains becoming worse during the night
  • Bone shape deforming such as bowing legs
  • Affected areas are significantly warmer
  • Headaches and increasing head size (if the skull is affected)
  • Bone Fractures

Who is most likely to get Paget’s disease?

Although the cause of Paget’s disease is not quite known, risk factor seem to include:

  • Age – Paget’s disease is more common with increasing in age
  • Race – Those with Anglo-Celtic background are more likely to develop Paget’s disease of the bone, particularly those living in Britain, Australia, New Zealand and Western Europe
  • Genetics – In around 30% of cases there is a family history of the disease

Healthy bone tissue is maintained by cells known as osteoblasts (that build new bone) and osteoclasts (that remove old bone). In a person with Paget’s disease, the balance between these two groups of cells is disturbed with the osteoblasts becoming overactive and producing too much bone, leading to enlargement. This unusual growth means that the new bone tissue is weak and unstable.

Symptoms of Paget’s disease

Many people who have Paget’s disease do not realise as they only mild if any symptoms of the disease.

Depending on how severe the condition is, symptoms may include:

  • Stiffness in the joints
  • Painful aching in the bones
  • Aches and pains becoming more acute during the night
  • The bone appears bent or thickened
  • The affected site is significantly warmer than the rest of the body
  • Bowing of the leg bones (if the legs are affected)
  • Headache and increased head size if the skull is involved
  • Bone fractures

 

Complications of Paget’s disease

Paget’s disease can lead to further complications, such as:

  • Osteoarthritis in joints formed by affected bones
  • Broken bones that may occur with a fall or spontaneously due to the new bone growth being weak and fragile
  • Inner ear conditions such as tinnitus (ringing in the ears) or vertigo (a type of dizziness)
  • Deafness caused by pressure on the auditory nerves
  • Increased workload on the heart due to an increased number of blood vessels in the affected bones which leads to increased blood flow through the bones.
  • Numbness or paralysis caused by deteriorating vertebrae pinching the nerves in the spinal cord
  • Bone cancer of the affected area can occur, but this is rare

Diagnosis of Paget’s disease:

As most of the sufferers of Paget’s disease have no symptoms, the condition is often diagnosed when investigating another problem, often found during x-rays taken. The diagnosis of Paget’s disease can be confirmed via further x-rays, bone scans or by a blood test showing elevated alkaline phosphatase.

Treatment for Paget’s disease:

There is no cure for Paget’s disease, however symptoms can be helped by:

  • Drugs acting on the bones – such as bisphosphonates, are used to slow the progression of the condition. Bisphosphonates help the body control the bone-building process to stimulate more normal bone growth
  • Non-steroidal and anti-inflammatory drugs to relieve pain
  • Calcium and Vitamin D. It is best to discuss with your doctor as high amounts of calcium in the blood is often present in Paget’s disease and need to be monitored carefully as this can cause other medical problems
  • Surgery may be required to relieve pinched nerves or bone fractures or to replace a badly worn join
  • Exercise will help to maintain skeletal health and mobility in the joints along with strengthening the surrounding muscles. However as bones are weaker and more likely to fracture, certain forms of excursive will be inappropriate for people with Paget’s disease

Lest We Forget

Anzac

They shall grow not old, as we that are left grow old;
Age shall not weary them, nor the years condemn.
At the going down of the sun and in the morning
We will remember them.

Lest We Forget.

Arthritic Foot Care

jointpain

Definition: Arthritis can affect any of the movable joints in the feet. This can result in foot deformities such as enlarged swollen joints or toes becoming crooked and causing problems when walking in shoes.

Causes: In rheumatoid arthritis, the toes and the forefoot joints are the most commonly affected. These joints can become displaced and deformed and often the muscles and tendons shorten causing the toes to become hammer shaped or clawed. Pain associated with arthritic changes in the feet will vary with the type and duration of the condition. The pain may be acute as in the initial stages of gout, with the affected joints inflamed and swollen. The pain may present with morning stiffness and limited joint movement, which increases on weight-bearing in rheumatoid arthritis. Joint movements may be lost altogether due to bony deformity of the joints with osteoarthritis, resulting in limited movement and pain experienced with normal day to day activities. It is important to recognise that arthritis can affect other areas of the body, which results in poor posture and restricted movements. It is sometimes difficult for the feet to operate correctly as weight-bearing structures that support and propel the body forwards, when some of the key joints such as the hips or shoulders are affected.

Treatment:

CARE FOR YOUR FEET

Correct washing and drying of your feet is vital in maintaining foot health. It is most important to clean well between toes, lifting each toe and thoroughly clearing out any debris. Foot exercises are essential to help keep the joints moving and reduce joint stiffness that can make a person unsteady and liable to fall more easily. Nails should be cut regularly following the natural separation line of the nail plate and not cutting down at the corners. Corns and callouses if painful, can be treated professionally by a Podiatrist and pressure and friction over these areas can be relieved by protective devices such as tubular foam and other paddings. Cushioning soles can be used in all footwear to provide some shock absorption against all hard walking surfaces.

FOOTWEAR

It is important to buy footwear that provides the best advantages in protection, support and foot comfort for you. It is often a good idea to get yourself professionally measured and fitted with suitable footwear at least once a year. Shoes should be lightweight, flexible and allow the air to circulate around the foot. The ideal materials are leather and canvas, however most modern materials are well designed to accommodate feet. A good example of a lightweight shoe that can accommodate foot deformity is the common jogger or running shoe that is easy to put on and secure with laces or velcro straps to suit arthritic fingers. Shoes must have a broad deep toe box that will provide additional comfort and reduce frictional points that can cause corns and callouses. Heel height ideally should not exceed half an inch. Soles should have a non-slip grip pattern. Always choose the right shoe for the job – eg walking, gardening, etc. to protect the arthritic foot and support them during the activity.

HOW TO SEEK PROFESSIONAL ADVICE

It is important to discuss your mobility and foot care problems with your Podiatrist. Our Podiatrist can advise which service or professional support is most appropriate to your needs. Our Podiatrist, after assessing your foot function may recommend orthotics or insoles to help relieve foot pain and discomfort

Osteomyelitis

Osteomyelitis

Osteomyelitis : You may not have heard of it, but osteomyelitis is one of the most frequent foot infections in diabetics, accounting for 10-15% of mild infections and nearly 50% of severe infections. Osteomyelitis is an infection of the bone that is caused by a variety of microbes — most notably staphylococcus aureus. This infection affects roughly two out of every 10,000 people, and is especially prevalent among diabetics, sickle cell anemics, dialysis patients, drug users, the elderly, and people with weakened immune systems.

How Do People Get Osteomyelitis?

There are many ways a person’s bone can become infected, such as:

  • An open fracture, where the bone pierces the skin (evident in 47% of all cases)
  • Pneumonia or a urinary tract infection turns septic and gets into the bloodstream
  • Vascular insufficiency (which is especially a concern for diabetics)
  • A puncture wound that doesn’t heal right (1-6% cases)
  • A minor wound, which leads to blood clotting around the bone and infection
  • A minor wound, which leads to blood clotting around the bone and infection

Symptoms of Osteomyelitis Early symptoms include pain, tenderness, swelling, warmth, and fever. Many people become nauseous, uneasy, and generally ill-feeling. Sometimes pus drainage through the skin is visible. Excessive sweating, chills, swelling of the lower extremities, and limping have also been reported alongside osteomyelitis. A diagnosis can be made by a physician who will look for signs of tenderness and likely order blood tests/cultures. Other diagnostic indicators include needle aspiration, biopsies, and bone scans.

Treatment of Osteomyelitis Until fairly recently, the standard treatment for diabetic foot osteomyelitis was to scrape away infected portions of the bone during the open surgical procedure. However, more doctors are using antibiotics as a first course treatment to cause remission. The antibiotics rid the body of harmful bacteria in the bloodstream that may otherwise re-infect the bone. Aspiration (draining of infection using a needle) and biopsy sampling will ensure you are given the proper type and dose of antibiotics. Splinting or casting may be required to immobilize the infected bone and avoid further injury. In some cases, surgery is still required, but the prognosis is very good when using a combination of surgery and antibiotics. Very rare cases of chronic osteomyelitis may lead to foot amputation or squamous-cell skin cancer. Though rare, prompt medical attention is important when diabetics encounter any signs or symptoms of infection.

Cracked Heels, Callus and Heel Fissures

Dry, cracked heels can not only be unsightly, but can often be source of pain and embarrassment. The good news is that baby smooth heels are achievable with a little elbow grease and help from your podiatrist. Most minor cracked heels are able to be treated at home but for the best results our podiatrist’s can remove the dead skin from your feet in just 30mins leaving them soft, smooth and ready for sandals.

What are cracked heels?

Cracked heels are caused by cracking or splitting of the skin. This splitting may be due to dryness or thickening of the skin (callus). When the skin around the heels becomes thickened or dry, it loses its suppleness and elasticity, and can split under simple pressures such as that from walking. This can lead to unsightly, painful and even bleeding cracked heels. This can further be made worse in people who have a large fatty pad on the sole of their feet, which under pressure requires more elasticity in the skin to expand without cracking.

Causes of Cracked Heels

  • Skin type is often genetic. Some heels get very thick callus but don’t crack where as others have no callus at all but crack badly after a day on the beach.
  • Long standing at work or home, especially on hard floors
  • Increased weight which causes increased pressure on the heels causing callus. With increased weight the heel is also required to expand more and hence can often crack more.
  • Ill fitted shoes or sandals that don’t support the heels from expanding sideways under pressure.
  • Unhygienic circumstances or conditions as well a s fungal infections/tinea
  • Unhealthy, dry scaly skin that can be caused by climate, such as low humidity during dry summers or cold winters
  • Deficiency of vitamins, minerals, zinc and malnutrition.
  • Hormonal Conditions such as thyroid or estrogen imbalances.
  • Circulation problems
  • Diabetes where autonomic neuropathy leads to less sweating and thus less moisture

Note: in the elderly, callused or cracked heels may be a sign of increased pressure and can be a precursor to a bed sore. These cases should be assessed by a podiatrist before commencing any at home treatments

Podiatry Treatments

The quickest way to baby smooth heels is to visit your podiatrist who can safely remove the dead skin leaving you with healthy and flauntable feet. They can also provide you with information on what sort of creams are best for your skin type as well as rule out more serious reasons as to why your skin might be dry and cracking. In addition to cleaning the dead dry skin from your heels for you, your podiatrist may also be able to treat the underlying causes to your cracking as well as giving you the right advice on how to keep your heels in great condition.

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Onychogryphosis (Rams Horn Nails)

 onychogryphosisOnychogryphosis also known as “ram’s horn nails,” is a condition in which the toenails become thickened and the curve of the nails becomes more severe, making them difficult to cut and causing them to grow into a long, curved shape resembling a ram’s horn. The difficulty of trimming the nail is often exacerbated by neglect—one of the very things that sometimes brings the condition about in the first place. For this reason, the elderly are especially prone to onychogryphosis.

Symptoms of Onychogryphosis

To say that the toenail “thickens” does not adequately describe the more severe cases of this condition. In some of these cases the toenail indeed looks more like a horn than a nail; it is yellowish-brown in colour, and no longer flat, so trimming it with nail clippers or scissors is out of the question.

Causes of Onychogryphosis

The most common cause of this kind of nail growth is believed to be chronic neglect. Elderly people in particular can sometimes become absent-minded and indifferent to their health, causing them to become less conscientious about trimming their nails. (In some cases the task of nail trimming may become difficult for us as we get older, due to conditions such as arthritis.)

Another possible cause of onychogryphosis is pressure on the nail over an extended period, such as may be caused by poorly fitted shoes. This pressure causes the toenail to grow unevenly; one side of the nail grows faster than the other.

Other suspected causes of onychogryphosis include:

  • Trauma, such as a blunt-force injury to the toe or a laceration that damages the nail matrix
  • Peripheral Vascular Disease
  • Psoriasis
  • Syphilis
  • Ichthyosis, a skin condition that cause the skin to become dry, cracked, and easily damaged
  • Fungal infection

Complications of Onychogryphosis

If onychogryphosis is left untreated, the nail can eventually grow into the skin, causing pain and inflammation, and creating a risk of bacterial infection. Even if this does not happen, the unchecked growth of the nail can create an environment in which toenail fungus and other sorts of infections can appear.

Treatment of Onychogryphosis

Surgical removal of the toenail (also known as avulsion of the nail plate) is a common treatment for onychogryphosis, and in some cases your podiatrist may even recommend a permanent nail removal, which is accomplished by destroying the nail matrix. (The nail matrix is the layer of cells at the root of the nail responsible for producing keratin, the material the nail is made of. In other words, the matrix creates the nail and causes it to grow.)

The procedure for removing a toenail is simple—the podiatrist injects a local anesthetic into your toe and simply removes the nail. Following the removal of the nail plate, the next step may be the destruction of the nail matrix. This may be necessary if the condition is so severe (or has gone untreated for so long) that the nail matrix has been scarred and this scarring has permanently altered its orientation, making it impossible for the nail to ever grow properly again. A nail that is allowed to grow from a matrix that has been damaged in this way will continue to thicken as before and may not adhere properly to the nail bed.

If your podiatrist has determined that it is necessary to destroy the nail matrix after removing your toenail, he or she will coat the matrix with a chemical agent. This procedure is known as a partial or full matrixectomy, or permanent nail removal.

Cellulitis

 What is Cellulitis?

Cellulitis is a common bacterial skin infection. Cellulitis may first appear as a red, swollen area that feels hot and tender to the touch. The redness and swelling often spread rapidly. Cellulitis is usually painful. In most cases, the skin on the lower legs is affected, although the infection can occur anywhere on your body or face. Cellulitis usually affects the surface of your skin, but it may also affect the underlying tissues of your skin. Cellulitis can also spread to your lymph nodes and bloodstream.

If cellulitis is not treated, the infection might spread and become life-threatening.

Cellulitis Causes and Risk Factors

Cellulitis occurs when certain types of bacteria enter through a cut or crack in the skin. Cellulitis is commonly caused by staphylococcus and streptococcus bacteria. In 50 to 60 percent of cases, skin injuries such as cuts, insect bites, or surgical incisions are the cause of the infection.

You are at risk if you have:

  • Skin conditions that cause breaks in the skin, such as eczema and athlete’s foot
  • Trauma to the skin
  • Diabetes
  • Circulatory problems

Symptoms of Cellulitis

  • Cellulitis symptoms may include:
  • Pain and tenderness in the affected area
  • Redness or inflammation on your skin
  • Skin sore or rash that appears and grows quickly
  • Tight, glossy, swollen appearance of the skin
  • A feeling of warmth in the affected area
  • Fever

Symptoms such as drowsiness, lethargy, blistering, and red streaks could signal that cellulitis is spreading. If any of these symptoms occur, you should see your podiatrist immediately.

Treating Cellulitis

It is best to see your podiatrist if you are experiencing any of the above symptoms, for them to diagnose you and give you the best treatment options. Antibiotics will usually be prescribed after diagnosis. While taking antibiotics, monitor your condition to see if symptoms improve. In most cases, symptoms will improve or disappear within a few days. In some cases, pain relievers are prescribed. You should rest until your symptoms improve. While you rest, you should raise the affected limb higher than your heart to reduce any swelling.

Cellulitis should go away within seven to 10 days of starting antibiotics. Longer treatment could be necessary if your infection is severe. This can occur if you suffer from a chronic disease or if your immune system is not working properly. People with certain pre-existing medical conditions and risk factors may need to stay in the hospital for observation during treatment.

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