Dr. Michael Hercules Theodoulou, D.P.M.

Toenail fungus or onychomycosis can be very difficult to resolve. This is based both on the nature of the organism as well as the anatomy that is involved. Fungal care is essentially achieving an infection free state of the tissue. Clinical care is achieving similar outcome, but with restoration of normal-appearing anatomy. Unfortunately clinical cure can be far more difficult to achieve. Our nails are considered part of the integumentary system which includes the skin. Not unlike the skin any type of trauma be physical or infectious may cause scarring. Chronic infection with a fungus can cause scarring of the nail plate that does not permit for regeneration of a normal healthy appearing nail. Currently all treatments be it with medication, laser therapy, light therapy and surgical removal all have demonstrated limited clinical cure rates. At present the most effective treatment is an oral systemic agent, but again clinical cure rates remain somewhat low and there is a high degree of recidivism.

Your great toe pain may result from different types of pain generators. This can occur at the skin and nail level if there is incarceration of the nail. This can also result from more deeper problems to include bone and joint. If there is no gross deformity of the toe in appearance or function and it appears to be mostly related to the toenail, incarceration of the nail edge cannot produce focal tenderness. Typical signs include increased redness and swelling of the skin fold. Advancing degrees of infection can start demonstrating local discharge and exuberant granulation tissue. If pain persists for greater than 72 hours it would be best to have medical evaluation.

Fungal infections are produced by molds that live within her environment. There are different types of molds that can produce this infection. Typically involving the human skin and nail these represent dermatophytes. #1 is to maintain good hygienic principles in the care of your feet to include appropriate cleansing and drying of the feet, changing of socks and shoes on a regular basis and allowing the feet to air. If there is acquired infection there are many topical antifungal creams, solutions and sprays that can be applied. Most commonly these need to be used for at least 3 to 4 weeks if it is skin involvement. Nail involvement is far more challenging as it does not readily absorb or permit for penetration of antifungal products.

Infection by fungal organism can be somewhat challenging to resolve depending on tissue that has been infected. Infections of the skin frequently refer to as athlete's foot can be addressed with good hygienic management of the feet with cleansing and drying and regular changing of shoes and socks. One can also consider Epsom salts soaks which are good
antimicrobial solutions as well as distilled white vinegar soaks. Infections of the nail can be addressed with the cold salve Vicks vapor rub as this does contain camphor oil which has been shown to have inhibitory effect on fungus.

Excessive drying and cracking of the skin can result from many factors. These can include environmental, dermatologic, endocrine/metabolic, and normal aging. Environmental can include reduced humidity which commonly occurs in the winter. Dermatologic can include infectious and noninfectious such as athletes foot, contact dermatitis, nummular eczema, and atopic dermatitis. Endocrine/metabolic disease can present with dry skin in the conditions of diabetes and thyroid disorder. Normal aging is as explained. The basic tenet of dermatology suggests if it is wet, dry it and if it is dry, wet it. Use of daily emollients or creams to hydrate the skin is very important. Excessive bathing is extremely drying to the skin as it strips the normal oils that maintain hydration. If there is a concern for noninfectious inflammatory dryness use of topical corticosteroids may be helpful. If there is a suggestion of infection due to fungal elements then anti-fungal creams should be considered.

Fungal infection of the nail can be very challenging to achieve clinical cure, meaning elimination of infection and restoration of anatomy to normal appearance and structure. Fingernails and toenails are part of the integumentary system. Not unlike our skin they can be traumatized and scarred. Trauma can be from local injury or infection. All treatments for fungal nails including medical, surgical, laser, and photo therapy have shown difficulties in achieving and maintaining clinical cure. Without question, the most effective treatment are oral systemic agents taken over a period of months. Although mostly safe, there are risks to introducing anything into our body. Many of these drugs are metabolized by the liver and on rare circumstance can produce toxicity. Like anything else, one can suffer a hypersensitivity reaction to the medication. Less effective are topical agents, none of them showing great clinical cure rates with high recidivism. Personally, I recommend home remedy of Vicks Vapor Rub. Camphor oil has shown fungal inhibition. The vehicle of the rub also softens the nail to make it more amenable to cutting and filing. There are studies supporting its use with understanding it must be regularly applied for 48 weeks.

Typically, we identify heel spurs inferiorly (on the bottom) and posteriorly (the back). In both circumstances, the etiology of the bone growth relates to insertion of tendon, fascia and muscle cause constant passive strain on the bone. A law of medicine known as Wolf's law suggests that when bone is placed under force or strain, there can be generation of new bone growth along that force. Heel spurs on the bottom of the heel are usually produced by tension from the plantar fascia. Resistant cases that do not respond to concerted conservative care of at least six months may be amenable to more aggressive intervention. Recent study and experience suggests that removal of the inferior heel spur is not necessary with treatments focused to the plantar fascia that can include balistic ultrasound, coblation therapy, and limited surgical release of the fascia in small open or endoscopic approach. Posterior heel spurs can be more challenging as their prominence may impact use of foot wear with pressure being induced by the counter of the shoe. Those resistant to conservative care may require surgical excision of the spur and debridement of the degenerated Achilles tendon insertion with reattachment. Although an effective treatment, this surgery does carry a long recovery typically 6 to 9 months before pain relief is identified and function restored.

Bunion deformities can be challenging to address both non operatively and operatively. Over the past century of modern medicine, there has been well over 100 surgical procedures identified for the correction of this deformity. The number of procedures suggests we may not have identified one single procedure that produces a sustainable outcome in every instance. Every deformity is unique to the individual, and its management must be specific to the circumstance particularly regarding its etiology and manifestation. In other words, it is not a one size fits all approach regarding procedures performed. Over the past 5 to 10 years we have gained a greater appreciation for the multiplanar nature of the deformity. Many
procedures directly served as a translational correction, which means, cutting and shifting the bone over. Unfortunately, this fails to address the rotational deformity that is appreciated. There has been a greater emphasis in recent years to address both the translation but also the rotation of the bone. We have embraced again treating the deformity at the base of the metatarsal where it forms a joint with the midfoot cuneiform bone. By fusion this joint we can derotate and move the bone over and maintain it in this corrected position. It is essentially placing a crooked building straight again on its foundation. The advent of newer orthopedic plates and screws have allowed this procedure to gain significant traction as the need for prolonged immobilization and limited weight bearing has been mitigated. Ultimately, the success of the surgery not only depends on the selection of a correct procedure for the particular circumstance, but the native tissue of the individual. Meaning the preservation of correction requires the individual to have healthy tissue to support prolonged repair. If this is not the case, then success may be limited, and other options should be considered to include nonsurgical treatment or joint fusion of the great toe.

The most common reason for heel pain is repetitive overloading and strain of the fascia on the bottom of the foot. It is believed this is the pain generator and not the presence of a bone spur that may be identified radiographically. The plantar fascia represents thick bands of connective tissue that support the instep. There are many factors that may contribute to injury of this tissue including acute and chronic. Acute tears and strains can occur due to sudden overloading. Most commonly this occurs over time and is influenced by environmental factors such as prolonged standing and walking on hard surfaces, poorly supportive footwear and intrinsic factors such as elevated body mass index, poor foot mechanics particularly over-pronated or flat feet, and tight Achilles tendon. The mainstay of therapy is to negate those factors. Reduce activity that aggravates the condition, support the instep vault, and performance of stretch exercises for the tight calf and Achilles tendon. Medical support can include the use of anti-inflammatory medication if needed and formal physical therapy. This
is commonly a self-limiting condition that may take several weeks to months to recover. If pain does not improve, seek a medical opinion.

Plantar warts represent a subtype of the human papilloma virus (hpv). They are environmentally acquired. As such, your skin can in contact with the virus which found opportunity through local break to develop infection and the identified lesion(s) that now present. The best way to avoid relapse is to minimize future exposure by using foot wear in places that may have likelihood for surface presence of the virus, such as gym showers, pool decks, etc. You may also wish to periodically spray shoe or sandal with surface disinfectant that is good for viruses as well such as Lysol disinfectant spray.

The active ingredients in Vicks Vapor Rub are camphor, eucalyptus oil, and menthol. Camphor oil has been shown to demonstrate fungal inhibition compared to other oils and as such has been recommended as a home remedy as an antifungal. With that said, its inhibition of fungi has been demonstrated in species which are not typical to those that produce the
common athlete's foot or nail fungus. Further, it is formulated as an ointment based product which occludes and moistens skin which is more hospitable for fungal growth. There are studies demonstrating improvement in nail fungus when used for up to 48 weeks applied several times a day to affected nails. With all of this in mind, there are many readily available
over-the-counter antifungals available that specifically address those organisms that commonly produce athlete's foot, and I would encourage their use over Vicks.

Unfortunately, there is very little evidence that external bracing will correct a bunion deformity. Not dissimilar to the analogy with eyeglasses, the brace only serves to correct while used. Bunions are a most commonly a familial (hereditary) disorder with a tendency to progress. It is a structural instability of bone and joint. Its progression may be limited by adjustment of environmental factors such as footwear and activity, but the ability to restore anatomic alignment can only be achieved with surgery.

This may be treated medically at first by performance of warm water baths with soap or epsom salts. Appropriate hygienic trimming of the nail by cutting straight across and not trimming into the edges. If redness worsens with increased pain or development of discharge or exuberant granulation tissue, then system antibiotic may be required and potential surgical excision of the offending nail edge in order to achieve resolution.

Depending on the procedure performed, the postoperative protocol may vary. With the traditional technique of partial nail removal and chemical cauterization of the nail matrix, local care with warm water baths incorporating Epsom salts or similar is performed until local discharge resolves. A clean bandaid or similar should be kept over the area when foot is enclosed in shoes. After 7 to 10 days most people can return to activities without restrictions. I would avoid any pedicure procedure for 4 to 6 weeks.

Morton's neuroma represents chronic inflammation with secondary scarring (fibrosis) around the nerve sheath or lining. It typically affects the common intermetatarsal nerve between the 3rd and 4th toes. Its cause may be traumatic, biomechanical induced, environmental (poor foot wear to include high heels, tight toe box), rheumatic (underlying arthritic disorder), and
idiopathic (no defined explanation). There are a variety of treatments to include shoe modifications, foot orthos with metatarsal pad to relieve pressure from the area, physical therapy, nerve block with corticosteroid, and finally surgery for either decompression or excision. There are other less investigated procedures to include ablations of nerve with chemical or
thermal probe and shock wave treatment.

Initial management includes shoe modification, metatarsal pad with or without supportive insole, activity modification and judicious use of anti inflammatory such as ibuprofen if permitted. If this does not produce improvement, I would recommend x-rays to rule out differential causes of pain to include stress fracture, joint disorder. Other imaging techniques for neuroma include ultrasound and MRI. If definitively neuroma then consider nerve block with cortisone and physical medicine. If this all fails, you may need to investigate more invasive treatment such as surgery and if this does not appeal to you some of the other less investigated approaches mentioned.

Bunions are indeed a deviation of the long first metatarsal bone and the corresponding phalangeal bone of the great toe. There is a progressive inward deviation of the long metatarsal bone while the great toe reciprocally begins to point toward the lesser toes. Over time with repetitive pressure to the area, there may be some development of new bone growth or if secondary arthritis develops due to malalignment of the joint. It is for this reason when surgically corrected, the bone cannot only be cut away, but some type of realignment procedure is required. Bunions are principally a familial or hereditary condition.

Although the cause of bunions can involve environmental, traumatic, and event systemic arthritic factors, the most common reason is familial or genetic. There is a notable genetic predisposition for women. What does this mean for prevention? It is quite challenging to impede progression. With that said, there are management measures that can be done to assist in the relief of localized pain and dysfunction without aggressive intervention such as surgery. Shoes with limited heel height not to exceed two inches with larger toe box to minimize compression is a great start. If there are identified overall biomechanical factors contributing to its presentation such as over pronation of the foot, orthotics controlling these factors may be of assistance. The marketed bunion splints have no evidence-based medicine or scientific support for the restoration of foot anatomy or retarding progression, but they may assist in local pain relief. Ultimately, if pain or dysfunction notably impacts the quality of life and failed these nonoperative measures, then surgery may be required.

Corns under the nail, or medically referred to as subungual keratomas, develop not dissimilar to other identified corns. There is excessive pressure borne on the nail bed resulting in thickening and keratinizing of the nail bed epithelium or skin. These are challenging to eliminate as they are protected by the overlying nail plate. Frequently, a portion of the nail may need to be removed to gain access. This may be done under local anesthesia if it is too sensitive to be done without anesthetic. As this is not a frequent area to develop these lesions due to protection from the nail plate, it may be wise to biopsy the presentation if there is any suspicion that this is not keratinized skin (abnormal coloration, irregular borders, altered appearance of the surrounding nail bed skin, etc.). If there is any appreciation or local deformity, it may be wise to also obtain an X-ray to rule out a not uncommon bone growth or exostosis that develops on the distal phalanx that can contribute to these lesions (subungual exostosis or osteochondroma). If this is present, the bone enlargement may also need to
be reduced and biopsied.

Optimizing a patient's health before any type of surgery, particularly elective surgery is absolutely critical. With regards to musculoskeletal surgery, there are comorbid conditions that may influence the outcome and any acute complications that may occur. Glycemic or blood sugar control is absolutely critical from the standpoint of wound healing, reduction of
secondary infection risk, and bone healing. Elevated blood sugars impact healing at the cellular level and influence compromised immune response. Blood sugars can be monitored acutely with finger sticks and getting a snapshot understanding of current control, but more frequently, we utilized a test known as the hemoglobin A1c to get a better understanding of her overall glycemic control over an extended period of time. Although there is no consensus, we do appreciate that a hemoglobin A1c representing normal glycemic control is ideal. In my own practice, I typically utilize an A1c of 7.5 mg/dL as a cutoff point for elective surgery. As a side other factors that are looked at particularly when it comes to bone and joint
surgery include the health of the bone from the standpoint of vitamin D as well as social factors such as smoking, which can also impact wound healing and bone healing.

Appropriate hygienic care of the feet is particularly important in those individuals who suffer from diabetes. Cleansing with warm water and antibacterial soap on daily basis is important. It is critical to dry the feet well after bathing particularly between the toes. Replacement of skin moisture is also important with appropriate lotions or creams as diabetes can have impact on the normal regulation of skin moisture resulting from autonomic neuropathy. Refrain from daily water soaks as this can be extremely drying to the skin. Monitor for any cracks or fissures that can result in skin breakdown and potential site of infection. If concerned about skin presentation of the lower extremities, please consult a medical
specialist such as a primary physician, dermatologist, or podiatrist.