Experts Share Their Insights On Treating Neuromas
Painful foot neuromas are a common dilemma among podiatric patients and the neuromas appear to be increasingly more prevalent among runners. Samuel Nava, Jr., DPM, a Fellow of the American College of Foot and Ankle Surgeons (ACFAS), estimates that approximately 10 to 15 percent of his patients with neuromas are female runners. He notes that female runners who wear more narrow shoes at work and subsequently go running on hard surfaces may be at a higher risk for developing neuromas. Bruce Werber, DPM, a Fellow and Past President of ACFAS, says the majority of his neuroma patients are female but he believes that non-running footwear is the culprit in the majority of these cases. However, he has found that males with neuromas are more likely to be runners. Both DPMs emphasize the importance of addressing the patient’s footwear when treating neuromas. In addition to ensuring that patients are wearing proper running and work shoes, Dr. Nava says modifying the shoe with a wider forefoot can be helpful. He also recommends the use of padding via a neuroma pad and strapping/support. Dr. Werber notes that he may modify the shoe liner to facilitate biomechanical control. If this works, he will proceed to cast the patient for a functional orthotic. In regard to other conservative treatment options, Dr. Nava says using ice or contrast soaks after running can be beneficial. If this proves to be unsuccessful, one may consider NSAIDs, cortisone injections, physical therapy or immobilization. If footwear modifications fail, Dr. Werber says he will obtain an ultrasound to confirm the presence of a neuroma. If it is positive, he says he may utilize a series of ETOH and Marcaine injections. If the ultrasound is negative, Dr. Werber tries low-dye taping and several other techniques to “change the mechanics of the forefoot.” He adds that he also may consider physical therapy and will evaluate the effect of the gastrocnemius-soleus equinus. Obtaining High Success Rates With Surgery When conservative treatment fails, Drs. Nava and Werber have both had a significant rate of success with surgical procedures. Dr. Werber says he has had an 85 to 90 percent success rate with his primary surgical option, the Isogard™ System (Koby Surgical), which decompresses the interspace. Dr. Werber says approximately 5 percent of his patients who undergo this procedure experience some residual low grade discomfort and less than 1 percent have needed neurectomies. Dr. Nava has had a “very high” success rate performing neuroma excisions, emphasizing that more than 90 percent of his patients found improvement in their conditions. While he prefers a dorsal surgical approach, Dr. Nava notes certain other approaches, such as plantar incision and endoscopy, can be just as effective. When neither conservative treatment nor surgical decompression get results, Dr. Werber says he may obtain a MRI in order to obtain a more definitive diagnosis. In these cases, he will also evaluate these patients for the possibility of tarsal tunnel syndrome, sciatic nerve entrapment, a herniated disc or spinal stenosis. Re-Emphasizing Shoewear And Patient Compliance When it’s all said and done, both DPMs say ensuring patient compliance with footwear recommendations plays a key role in treating neuroma pain. Dr. Nava suggests providing patients with options for shoes that will help relieve their condition as opposed to exacerbating it. Like Dr. Nava, Dr. Werber works with his patients, putting the onus of healing on them and telling them if they want relief from pain, they must participate in the process. “Sometimes participation requires giving up on vanity for awhile and letting their bodies heal,” offers Dr. Werber. “The alternative is lost time from work and the inconveniences of surgery.” Predicting Charcot Risk: New Study Says Patient History And Neurologic Tests Are Key By Brian McCurdy, Associate Editor Obtaining a thorough patient history and performing simple neurologic tests are the best barometers for determining which patients are at risk for Charcot neuroarthropathy, according to a recent study in The Journal of Foot and Ankle Surgery (JFAS). Researchers tested 59 patients with diabetes, 41 of whom were Charcot-free and 18 of whom had chronic Charcot deformities. After evaluating the neurological and vascular characteristics of these patients with inexpensive handheld instruments, the authors found that a history of retinopathy (P < .02), nephropathy (P < .003) and previous foot ulcer (P < .01) were effective markers for predicting the risk of Charcot neuroarthropathy. The study in JFAS also determined that vibratory sensation (P < .001), deep tendon reflexes (P < .05) and 5.07 (10 g) Semmes-Weinstein monofilament test (P < .001) correlated highly to Charcot deformity in the lower extremity. Study co-author Lawrence Fallat, DPM, says the data from the study may help facilitate earlier detection of Charcot arthropathy. Dr. Fallat, a Clinical Assistant Professor within the Department of Family Medicine at the Wayne State University School of Medicine in Detroit, says the study is especially significant for patients with diabetes, who face a significant risk of Charcot-related complications. However, Dr. Fallat adds that this testing would be effective on other populations such as those with alcoholic neuropathy, a condition that can also cause Charcot deformities. Dr. Fallat says he was surprised about the lack of differentiation between the vascular examinations of both groups in the study. “The circulation was about equal in both groups,” explains Dr. Fallat, a Fellow of the American College of Foot and Ankle Surgeons. “Circulation was not a factor in predicting who would be likely to develop a Charcot foot deformity.” APMA To Host World Congress Of Podiatry By Brian McCurdy, Associate Editor When members of the American Podiatric Medical Association (APMA) gather in Boston next month, they will have some prestigious international guests. The APMA was awarded a bid to host the World Congress of Podiatry, sponsored by the Federation Internationale des Podologue (FIP), which meets every three years. “It’s going to bring together podiatrists from all over the globe,” says FIP President Ronald Lepow, DPM, who emphasizes it will be the largest gathering in the history of podiatry. “We expect it to be a great program.” Among the slated lectures by international speakers are “Impact of Podiatry on Low Back Pain: Experimental Approaches and Strategic Research” by Belgium’s Marc A. Bourgeois, PhD, and “The Prevalence of Foot Ulcers in Non-Diabetic Patients” by Ivan Bristow, MSc, who hails from the United Kingdom. Dr. Lepow says this is the first year the World Congress of Podiatry, which meets every three years in a member country, is being held in North America. The FIP began in 1947 but has seen particularly significant growth in recent years. When the United States joined FIP three years ago, Dr. Lepow said the federation consisted of 11 countries. By the end of the year, Dr. Lepow expects the FIP to number 50,000 members from 20 nations on five continents. Among the group’s goals are to bring together podiatrists from throughout the world and share research to enrich the profession. On June 1, the FIP announced the debut of international continuing education activities (CME/CPD) on its Web site. Editor’s Note: The World Congress of Podiatry, hosted by the American Podiatric Medical Association, will be held from Aug. 22 to 25 in Boston, Mass. For more info, go to www.apma.org or www.fipnet.org. In Brief Dermik Laboratories has launched an online resource on onychomycosis at the Web site www.penlac.com. DPMs can access information on managed care, patient education, diagnosis and complications associated with the disease. Tim Moran has been named Vice President of Marketing of OrthoNeutrogena of Los Angeles, Calif. He was previously the Director of Product Management for Dermik Laboratories. Kinetic Concepts, Inc. (KCI) has received the American Podiatric Medical Association’s (APMA) Seal of Approval for its V.A.C.® GranuFoam™ Heel Dressing. The advanced wound healing product is designed to fit the contours of the heel to aid in the treatment of chronic and difficult to treat wounds, according to KCI. Molnlycke Health Care, Inc. has been awarded a three-year contract from MedAssets HSCA for the latter company’s Tendra® wound management products, which utilize Safetac technology. The company says Safetac is a patented soft silicone adhesive designed for wound management dressings. Spectranetics Corporation has performed the first successful CLiRpath™ procedures using new Extreme® Excimer Laser Catheters, which were recently cleared by the U.S. Food and Drug Administration. The company notes that the CLiRpath™ Excimer Laser Catheters are indicated for use in the endovascular treatment of symptomatic infrainguinal lower extremity vascular disease where total obstructions cannot be crossed with standard guide wires. Collagen Matrix, Inc. recently announced that it has received FDA clearance on two new wound care products, the Matrix Collagen Sponge and Matrix Collagen Film. The company says the Matrix Collagen Sponge can be used to manage moderately to heavily exudating wounds and for minor bleeding. It notes that Matrix Collagen Film can be used as a primary or secondary dressing in managing wounds ranging from pressure ulcers to partial thickness burns. Physicians Web Pages has joined with Animator 2000, a CD comprised of 54 animated surgical procedures, and will offer physicians a method of educating their patients about common podiatric surgical procedures. Animator 2000’s original animations have been updated into the Windows format on a CD-ROM, and also are available for PDAs and Web sites.