Pascal Dupuis

Most of the people that read my blog know I love to watch ice hockey, and also know that I especially like the Pittsburgh Penguins.  Today, the Penguins announced that winger Pascal Dupuis has a a "blot clot in his lung."  This is more specifically a pulmonary embolism.   A few months ago, I blogged about how American Idol contestant, Michael Johns, lost his life due to a pulmonary embolism.

The Penguins say that Pascal had chest pain and was evaluated and the embolism was found.  He apparently had a blood clot in his leg (DVT = deep vein thrombosis) that traveled to his lungs.  A DVT in the leg is, in and of itself, not the problem.  However, it can cause very painful leg swelling and inflammation.  The problem is if that blood clot breaks away and travels to the lungs it can be deadly.  Most people would go to the ER if they had trouble breathing, but people need to take sudden painful swelling in the leg just as seriously.  Immobilization after injury, as well as being seated for long periods of time (eg, a long airplane trip), can be a couple of the common causes.

Pascal will be unable to play hockey for at least 6 months as he will need to be on anti-coagulants, or blood thinners, for at least that time to prevent further clots.  As most of you know, hockey is a contact sport and blunt trauma and blood thinners are not a good combination.

The Penguins say that Pascal should be able to return to hockey.  Unfortunately, however, this is his second blood clot.  One has to wonder if he would want to risk coming off anti-coagulation as he is obviously prone to developing thrombi in this body.  I guess time will tell, but either way, he will have to closely watch for developing symptoms for the rest of his life.

Let's Play Hockey!

For a hockey fan like myself it is the greatest time of the year.  (OK, so maybe second greatest if your team makes the playoffs).  The season officially begins tonight and tomorrow my favorite team, the Penguins, and the local team, the Lightning, begin the season.  Because of this occasion, I feel it is appropriate to post my previous hockey blogs.

http://donaldjadamovdpm.blogspot.com/2013/06/alex-ovechkins-broken-foot.html

http://donaldjadamovdpm.blogspot.com/2013/03/kris-letangs-broken-toe.html

http://donaldjadamovdpm.blogspot.com/2013/02/erik-karlssons-achilles-laceration.html

http://donaldjadamovdpm.blogspot.com/2013/01/ice-hockey-is-back.html

http://donaldjadamovdpm.blogspot.com/2011/11/ice-hockey-and-foot-injuries.html

The Passing of Michael Johns

I was saddened to read that a few days ago, former American Idol contestant, Michael Johns, had passed away due to a blood clot after twisting his ankle.  I do not watch American Idol much anymore, but back in 2008 I rarely missed an episode.  I do remember Michael Johns competing.

At 35 years old this is a tragic loss.  Fortunately, blood clots after twisting an ankle leading to death are very rare.  However, blood clots in the legs are not uncommon.  The clot in the leg is not what is fatal but instead it is the blood clot "breaking off" and traveling to the lungs that can lead to death.  This is called a pulmonary embolism.

How do blood clots form in the legs?  Well, there are large veins in the legs and when a person does not move his or her legs for a long period of time there is no muscular activity to help the blood return to the heart.  This blood can then pool in a vein in the leg causing a deep vein thrombus (DVT).

I am not sure of the facts but it seems that Michael Johns twisted his ankle and it was causing him severe pain.  It was too painful to move and he probably stayed off of it.  A blood clot formed and likely traveled to the singer's lungs.

This could have been possibly prevented if the singer sought medical advice.  A possible sign of a DVT is severe calf pain and swelling.  If this happens seek medical attention right away.  An ultrasound can be done to determine if a DVT is present or a blood test called a D-dimer can be done to see if a clotting process is present.

RIP Michael Johns.  Hopefully, some good can come out of this tragedy by educating people on the dangers of this condition.

New Office Renovation

People are hard at work completing the final touches on the new podiatry building on the campus of Absolute Healthcare.  I am very pleased with the new spacious office.  I find it very welcoming and am excited to start caring for my patients in this beautiful building.

5 common things medical professionals can overlook with treating the foot and ankle

To continue my "5 things" thoughts from earlier in the year, I want to focus on some of the things I see that medical professionals can commonly overlook when treating foot and ankle issues.  This list includes some things that I, myself, might not always have noticed at first glance as a podiatrist.

1) Poor circulation:  There is a common misconception, especially with general medical practitioners, that if one can feel a pulse and the foot is warm then the circulation is OK.  I have seen many patients that I have diagnosed with peripheral vascular disease in the lower extremity that has been overlooked by some pretty well-trained and respected clinicians.  Often times, these patients are told it is just their neuropathy or arthritis.  I always become suspicious when a patient admits cramping at night, when they have been or are a smoker, and when they have a history of cardiac bypass and stenting.  A simple doppler test that is abnormal can give an indication to me that can be followed up by other studies.

2) Stress fractures:  A stress fracture in the foot (usually a metatarsal) is often overlooked.  These can be "hairline" fractures caused from injury or non-traumatic simply from a change in activity.  Problem is, normal everyday x-rays usually do not show an early stress fracture.  These are read as negative by radiologists who do not have an opportunity to examine the patient.  (These studies are, in fact, negative most of the time).  I have treated true painful stress fractures for several weeks diagnosed clearly by MRI that not once showed up on regular x-rays.  If a patient comes in with a swollen foot more painful after activity, I tell my patients, "if it looks like a duck, and quacks like a duck, it's probably a duck."  In other words, if I think it is a stress fracture due to what I see, I can do little wrong by treating it as such with immobilization.  Usually, if a stress fracture is caught earlier it resolves more quickly.

3) Not giving an injection when appropriate:  With a lot of conditions we treat, injections are very helpful.  I often see, and was guilty of this earlier in my career, doctors with-hold injections in favor of conservative treatment.  This is fine, if after discussion with the patient, that is what is desired.  However, I have seen people who do not mind injections come in with severe heel or acute arthritis inflammation that have went to other doctors and were given very little treatment.  If appropriate, an injection of a corticosteroid can quickly and safely give a patient great relief.  There is nothing wrong with giving an injection on an initial visit if indicated.

4) Giving an injection when inappropriate:  On the other hand, I have seen injections given when they likely maybe should not have.  Fortunately, it is rare to cause significant harm from giving an injection, but doing so may delay resolution of the condition or frustrate a patient because other treatment is often not given and only temporary relief is gained.  A stress fracture is a perfect example.  A quality practitioner will often get a negative x-ray and inject a painful foot.  If a stress fracture is present, the corticosteriod can delay healing if injected in the area of the fracture.  Also, I have seen injections in areas that are debatable for injecting.  A good example is a tendon.  Corticosteroids can increase the risk of tendon damage and rupture.  Thankfully it is not common, but, in my opinion, conservative immobilization can often heal these patients without taking this risk.

5) Not advising a patient on footwear:  Especially here in Florida, flip-flops and flimsy shoes are common all year.  I have seen patients treated by more than one other doctor when no one talked to the patient about his or her shoes at all.  Many foot and ankle problems will not resolve if people do not at least change their shoes or shoe wearing habits a little.  Sometimes a change in shoes to something more supportive will be all it takes to alleviate foot pain.

So there is my list of "5 common things medical professionals can overlook with treating the foot and ankle."  Please keep in mind that good practitioners disagree on how to appropriately treat many conditions.  I do not make this list to criticize, but instead just highlight some things I have learned throughout my over 10 years of experience as a podiatrist.

MRSA from an Ingrown Toenail

A local football player is battling MRSA for the 2nd time.  The Tampa Bay Buccaneers have confirmed that their guard, Carl Nicks is again being treated for MRSA.  Media sources indicate that the initial cause was an ingrown toenail.

MRSA is an infection of Staph aureus that is found to be resistant to the antibiotic Methicillin.  The media makes the population fearful of MRSA but we do have antibiotics that can fight it.

Additionally, ingrown toenails can become bacterially infected and MRSA can be the cause.  It is important to point out, however, that most ingrown toenails can be treated in the office through excision and oral antibiotics.

As is true with most foot problems, any pain or problems are easier to address earlier rather than later.  I do not know what happened with Carl Nicks but I suspect his ingrown toenail became so infected that the bone in the toe got infected necessitating IV antibiotics.

The moral of the story: If you think you have an ingrown nail, see a podiatrist as soon as you are able for treatment.

Tom Hanks Makes an Announcement

Earlier this week, on late night TV, Tom Hanks announced that he has been diagnosed with diabetes.  He talked about lifestyle changes he needed to make and also a little about how the disease effects the body.  I have had a few patients over the years that presented with foot problems that lead me to suspect that he or she could be a diabetic.  The patient usually knew something wasn't quite right but was completely unaware that this disease was present.

One of the earliest signs of diabetes in terms of the foot would be numbness or tingling.  Diabetes is a disease of high blood sugar and this high blood sugar can cause several problems with the body.  Diabetic neuropathy is caused when nerve fibers are damaged by the high blood sugar.  This can be uncomfortable as a bothersome numbness in the feet but also can lead to pain.  Besides the discomfort, this loss of feeling can but a patient at risk for injury.  For example, a stone in the shoe can cause a sore.  A person without diabetic neuropathy would remove his or her shoe and remove the stone, but a diabetic patient may not even know that there is a stone in his or her shoe.  Left in the shoe the stone can lead to a sore or ulceration.

If you think you have diabetes you should see a physician for testing.  Symptoms are not just tingling in the feet but also weight loss, increased thirst, and increased urination.

5 things people do wrong for their feet

I was recently talking to a close colleague who is an internal medicine physician.  As people who read my blog know, I like to blog about sports injuries and celebrity foot problems.  However, this doctor was interested to know what I believe are the most common things people do wrong with regards to caring (or often times, not caring) for their feet.  I thought about it, and in my 10+ years of experience I had an answer, I thanked my colleague for the question and immediately answered it.  I think this information is worth sharing.

5 THINGS PEOPLE DO WRONG FOR THEIR FEET:

1) Ignore foot pain:  Many patients think that pain in their feet will just go away.  It could, but odds are it will get worse if not treated.  For example, heel pain can affect how you walk as a patient can often compensate by walking differently due to the pain.  Walking differently can lead to tendon pain in the other ankle or in a different part of the painful foot.  Additionally, pain in the foot or ankle is often inflammatory in nature.  Inflammation that is allowed to worsen can often be much more difficult to resolve than when treated earlier.

2) Going barefoot:  Especially down south, many people do not like to wear shoes.  However, this can have significant consequences.  Of course, there is always a chance of injury without the protection of footwear.  Cuts and scrapes can be especially harmful to a patient with poor circulation or feeling in his or her feet.  Additionally, when one goes barefoot there is no support.  This can lead to tendonitis as tendons work to support a foot that a shoe should be supporting.  I often hear, "going barefoot is natural."  I counter this argument by replying "what is natural about concrete?"  You do best in a man-made supportive shoe when walking on this man-made surface.

3) Wearing flip-flops:  In Florida, these shoes are a year round favorite.  In other parts of the country, they come out when the snow thaws.  However, these shoes, especially the really flat flimsy ones, are just as bad as going barefoot.  They offer little support or protection for the foot.  It is hard, as people love these shoes, but at least try to get one with a rigid sole and even an arch.  A small heeled wedge sandal is much better than a flimsy flip-flop.  However, a trip to Disney World is probably best enjoyed in a sneaker.

4) Using medicated pads or callus remover:  I am fine with padding that can be bought in the drug store, as this can be a good conservative treatment for some foot problems.  However, any padding that says "medicated" can be very harmful.  Medicated pads usually contain salicylic acid.  Yes, real acid that damages skin.  The acid can not select the "good" tissue from the "bad" callused tissue and I have seen infections from using these products.  Unfortunately, in a few diabetic patients, I have seen the use of these pads lead to bone infection and toe amputation.  A callus is more than just something that can be removed easily as there is often an underlying deformity leading to this hardened uncomfortable skin.

5) Doing "bathroom surgery":  We likely have all done this.  A toe can be a little sore and we "dig out" a toenail in our bathroom using a dirty pair of toenail clippers or whatever object available.  This can lead to a bacterial infection needing antibiotics.  Again, as with medicated padding, I have seen bathroom surgery lead to amputation.

This is my list of 5 things people do wrong for their feet.  Podiatrists are trained to treat almost all foot or ankle problems.  I welcome new patients who are experiencing any foot or ankle pain.

Kobe Bryant's Scar

There has been a lot of talk recently regarding Kobe Bryant's quick recovery from his achilles tendon surgical repair.  Not to down-play this recovery, but being a physician who has performed several achilles tendon repairs, I noticed something about this scar.  When looking at it, I notice that it is obviously healed well, but I also notice that the scar stops further up on the ankle.  To me, this means that he likely didn't require a more complex repair that often involves some detachment of the tendon from the heel bone.  In this case, the repair, though still very successful, has a much longer recovery time.  This is because hardware is often used to reattach the achilles tendon to the heel.  In this case, the patient must partake in a much more gradual return to activity, especially to perform at the high level needed to play in the NBA.

If you have any achilles tendon problems, keep in mind that it is important to address them and not wait.  Patients who wait have a much higher chance of needing surgical correction.

A Stress Fracture from Golf?

Yes, it is true.  The best swimmer in the world injured his foot, not by kicking a pool deck, but from golfing.  I read the article and found that it wasn't actually from golf itself but from walking the golf course.  Apparently, Phelps walked something like 20 miles over the course of the tournament.  This lead to the injury, a stress fracture of his foot.

There is a lesson in this for all of us.  A stress fracture can occur over time.  It does not have to be a single instance.  In fact, in my experience, Phelps is a perfect example of what can lead to a stress fracture.  It is usually when we walk too much or wear a new or ill-fitting pair of shoes and are too active that leads to stress on the bone.

A stress fracture can lead to a swollen foot that is very painful to walk on.  It does not always even show up on x-ray but left unchecked can lead to a complete break in the bone (usually a metatarsal).  This can be much more difficult to treat and may even require surgery to repair.  Therefore, it is important to see your podiatrist right away with any foot pain.

Something to Celebrate

As a podiatrist, I read with interest a recent study that shows a drastic increase in lower extremity diabetic amputations.  The study was published in this month's Foot and Ankle International.  The study pointed out when looking at Medicare claims from 2000-2010, lower extremity amputations decreased 28.8%.  I am wondering if this is related to the 143.3% increase in the treatment of foot ulcers in the same time period.  Also interesting is that amputations at the upper and lower leg level are down 47% while partial toe amputations increased 24%.  (Sometimes a toe amputation is needed to be done by a physician like myself to prevent the infection from getting worse).  To me this means podiatrists are saving feet and legs.

This is a big deal on many levels.  First, it saves money.  Lower extremity amputations cost our health care system a lot of money.  Second, it improves patients quality of life.  Obviously, having a limb amputation is a big deal and can lead to other problems.  Earlier studies have found that a lower extremity amputation has a mortality rate of 50% within 5 years.  So one can argue that saving some one's limb, saves some one's life.

I am proud to have a hand in all of this and excited to continue to help bring down the level of amputations in my community.

Blame your parents for your bunions?

As a podiatrist, one of the procedures I perform most is correction of bunion deformities.  This is a deformity in which the great toe turns out and creates a bump on the inside of the foot just below the great toe.  If conservative treatment fails, surgery is an option for many patients.

A study came out last month that suggested this deformity is inherited.  In my opinion, however, it is more complex than this.  I believe your foot type can be inherited (ie, flat or high arch) and this foot type can lead to deformities.  For example, a young lady can have a foot type that she "inherited" from her father but she gets bunions unlike her father because she wears tight high heels that can lead to easy development of a deformity based on her inherited foot type.

I believe, the environment does come into play.  Another example would be a flat flimsy foot.  An individual with this foot type who wears flip flops all the time may develop a much more severe bunion than someone who wears a supportive shoe and insert most of the time.

Just like other medical risks such as heart disease it is likely that most bunions can be prevented with the proper decisions and care.  You should see a podiatrist if there are any concerns you have a bunion or believe you are developing one.

NBA Playoffs: Full of Foot & Ankle Problems

I have admitted before that I am not a huge NBA fan but could not avoid the news recently as several players have made the news with foot and ankle problems.

First off, Tiago Splitter of the Spurs sprained his left ankle earlier this week in game 3 against the Lakers.  Radiographs were reported as negative, but to me that doesn't mean much as a bad ankle sprain can be very painful and needs treated appropriately.

To a Chicago news station this week, Joakim Noah stated that "plantar fasciitis sucks."  This is a very common condition I see, and I am sure many of my patients will relate.  However, with the right treatment we can help most people significantly.

Chicago's first round opponent, the Nets, also apparently has a player suffering from plantar fasciitis as well.  Joe Johnson received a "cortisone injection" for plantar fasciitis earlier this week and Johnson admitted that this was very helpful.  When appropriate I can also give injections as part of my treatment.

As I often say you do not have to be an athlete to suffer from these conditions.  Come see us at Spring Hill Podiatry with any foot or ankle problems.