Nonsurgical Retrospective: Part 2, Forefoot |
Hello again and happy upcoming Valentine’s Day to all of you romantic "soles." Sorry — I couldn’t resist. Anyway, in the last issue, we talked about the importance of conservative or nonsurgical care in podiatry, reviewing some advantages and disadvantages. I urged those of you steel-handlers who think you’ll be in the OR 9-5 every day to consider the nonsurgical ways in which you’ll help your patients. This is important since you’ll be spending much of your time in the office. To that end, let’s talk about a select number of pathologies and some of the nonsurgical methods to treat them. For those of you seasoned veterans who have great tips and pearls, please write in and foster those of us who haven’t been around as long. For those of you in residency, write in with your pearls as well. Very few of us are exposed to as large a number of great ideas on a daily basis as you residents are. Share the wealth! That’s what PRESENT is all about.
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Jarrod Shapiro, DPM
PRESENT New Docs Editor
Joined Mountain View
Medical & Surgical Associates
of Madras, Oregon July 2008
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A couple of quick issues. First, you can’t short cut a good history and physical. LISTEN to your patient. Often they’ll tell you their diagnosis. Second, I try to think of a differential diagnosis during the physical exam and rule out those other diagnoses. For example, lesser MTP joint pain is often misdiagnosed as a neuroma. Yes, it’s common. I see it from my referring docs all the time. Third, with all of the diagnoses listed below, my initial treatment is education. Every patient deserves to know what they have, why, and how you’re going to treat it. Fourth, as I mentioned previously, these methods are my personal choices and may differ in style or substance from others. I’m not advocating that you adopt my choices, only that you consider them.
Let’s get to it!
Toenail Complaints — I’m pretty typical when it comes to onychocryptosis and paronychia. I’ll perform P&A’s with a very rare surgical matricectomy. I use phenol instead of sodium hydroxide, primarily because that’s what I did in residency. However, I’m planning to give NaOH a try. I’ll let you know how it goes. I’m also liberal with partial wedge resections for the older individual (especially PAD patients) and those with clearly distal inflammation. I don’t use oral antibiotics unless it’s clearly infected and frankly cellulitic. Get rid of the offending nail border, and you’ve eliminated the cause of the paronychia, and created a very happy patient.
Morton’s Neuroma — I usually start with radiographs to rule out fractures and joint issues and review the mechanics. I start my treatment with education, an anti-inflammatory, metatarsal pad, activity as tolerated, shoe changes (ex. wider toebox, antipronation shoe), massage, and sometimes Biofreeze. If improved, then I recommend orthotics. If not better after 2-3 weeks, I’ll recommend either a steroid injection (both therapeutic and diagnostic) or begin alcohol sclerosing therapy, which is remarkably successful.
Hallux Valgus — Education is most important here. Patients learn they will not reverse the bunion without surgery, but the symptoms may be relieved through nonsurgical methods. I usually recommend orthotics, padding, shields, wider shoes, and the occasional injection. For the older at risk population, I’ll recommend Ambulator shoes with the neoprene vamp and toebox.
Hammertoes — I only occasionally see patients with hammertoes that complain of actual toe pain. Unless the toe rubs on shoes or forms helomata, they’ll generally complain about metatarsalgia symptoms. For the toes, I’ll try crest or buttress pads, silicone toe sleeves, and splints. For metatarsalgia, I’ll try met pads and orthotics before surgery. I’ve read about silicone injection, which sounds like a fantastic idea. Due to the past silicone controversies, I’m going to wait for formal studies before I start this treatment.
It should be as clear as the large nose on my face that this is not an exhaustive list of either pathologies or treatment options. I always try to remain open to new therapies, which keeps practice on the nonsurgical side more interesting. The above list is probably common to the majority of podiatrists, but for those of you interested in a specific pathology not listed, write in and start a conversation.
For those of you who have questions or comments, please write in. I like my own opinion, but the real fun and usefulness of this editorial is your thoughts and concerns. Write in and be part of the community!
Best wishes...
Jarrod Shapiro, DPM
PRESENT New Docs Editor
[email protected]
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