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

Athlete's foot is a representation of a superficial skin infection produced by mold like fungi that are environmentally acquired. It is noted to be contagious. Environments that tend to be warm and moist are quite conducive to this type of fungal growth. The majority of these infections are produced by a class of fungi known as dermatophytes. They are sensitive to many topical antifungal products that are readily available over-the-counter. These do respond quite favorably after a few days to a
few weeks of use. Good hygienic care of the feet to prevent exposure to environments conducive to this type of mold-like growth is critical specifically gym showers, pool decks and other areas of high traffic. It must be appreciated that there are other types of dermatitis that can produce similar findings of athlete's foot to include redness, scaling, itchiness and if your condition does not respond timely to traditional anti-fungal preparations it may be of benefit to have the skin eruption or rash evaluated by a medical provider. Skin scraping can be performed painlessly to determine if there are presence of fungal elements. If sterile you may be suffering from a noninfectious dermatitis that may better respond to other treatment such as topical steroids or lotions.

Unfortunately, structural deformities of the feet, particularly bunions, are found to have a familial predisposition. They are more common in women. There are no long-term studies suggesting ability to inhibit deformity development with orthopedic bracing, exercises, shoe modification, or medication. We do appreciate environmental factors that may accelerate deformity presentation both in severity and symptoms. These include inappropriate foot wear, increased physical demands of loading to include
excessive body weight, injury, and concomitant disease states (often those that affect the musculoskeletal system, such as arthritis, connective tissue disorders, metabolic bone disease, etc.). Things we can do to minimize foot deformity impact on our quality of life - make sure shoes are well-fitted, accommodate foot structure well, and have limited heel height; maintain a healthy body weight; regular exercise that does not cause reproducible pain to the feet particularly over areas of deformity; and monitoring for any other associated signs such as developing joint pains to include feet and elsewhere in the body. Although feet may not always be aesthetically beautiful regarding deformity presentation, the more important aspect is that they are pain free and allow us to remain mobile and active. When dealing with these deformities, the latter must always be considered paramount.

It is extremely challenging to define what is a normally functioning foot from the standpoint of anatomic appearance. Ultimately, it is one that allows an individual to perform activities without pain or dysfunction. The appearance or presentation of flatfoot does not necessarily condemn an individual to disability regarding performance of activities such as running. In fact I treat many patients for other reasons with underlying flatfoot that has never been symptomatic. This can also be said for the opposite presentation of a high arched foot. With that said, if you have found limitations of pain or dysfunction particularly with athletic activity this needs to be evaluated. My general first consideration is whether the deformity is what we call supple or rigid in nature. Supple deformities are flexible in nature with collapse of the foot that can be reduced to some degree with manipulation. The arch can often be reconstituted with support. These individuals do exceedingly well with good supportive foot wear and orthotic insole, whether this be custom or prefabricated.

Individuals suffering from diabetes can be at risk for complications involving the lower extremities and particularly the feet. As a disease, diabetes can produce injury to the peripheral nerves and circulation. This may leave the patient with impaired sensation and poor blood flow. Secondary findings can include dermatologic changes such as nail thickening, dryness of skin, and risk for infection. We often do not encourage palliative hygienic self care for maintenance of nails, trimming of calluses/corns in these individuals as local injury can lead to significant problems. Health care providers, particularly the specialty of podiatry, are highly knowledgeable in the management of the diabetic foot. Screening by a podiatrist can establish a risk stratification by assessing circulation, nerve function, structural deformity and skin integrity. A patient with diabetes demonstrating compromise in any of these areas would be best cared for on a periodic basis by a foot specialist. The value of these services has been recognized by insurance payers to include Medicare and is a covered benefit when criteria is met.

Any persistent pain or swelling to the ankle following injury exceeding more than 7 days does warrant evaluation by a medical professional or specialist. Sadly, the ankle sprain has often been overlooked as a minor musculoskeletal injury that is frequently self treated. By experience, study, and literature, these ankle injuries can cause individuals persistent problems up to 40% of the time 6 months following trauma. The ankle joint is an extremely confined joint with multiple tissues that can be injured to
include bone and cartilage, ligament, tendon and nerve. With this in mind, your injury may warrant more aggressive initial protection than simply a soft wrap and limited activity. Followed by this period of appropriate protection you may also benefit from formal physical medicine and rehabilitation in order to achieve a more expedient restoration of ankle function and reduce the likelihood of chronic issues.

It will be extremely difficult to provide you a credible cause for this pain without more information. When evaluating a patient's complaint, clinicians must assess the nature of the pain (aching, sharp, burning, etc), location (in your case what part of the foot), duration of symptoms etc.

Leg swelling or peripheral edema is produced by expansion of fluid within the surrounding tissues. Generalized swelling results from increased fluid pressures across the capillary beds, reduced capillary oncotic pressure or increased capillary permeability. Sodium or salt retention by the kidneys can also produce swelling. It is not uncommon for diabetics to have some level of kidney disease. It may also be compensatory in response to reduced arterial blood volume resulting from heart failure and liver disease. Peripheral swelling can also result from poor blood circulation particularly related to venous blood flow. There are drugs that can influence organ systems specifically heart, liver and kidney that can also be associated with swelling. When looking at swelling of the legs, we often characterize the presentation as nonpitting or pitting. By their own name presentation, pitting swelling produces a dimpling effect when the tissues are pressed on with gradual expansion back to their swollen state. Pitting swelling is frequently related to the previously mentioned organ disease. Non-pitting edema does not produce a dimpling effect and may be associated with vein insufficiency or chronic lymphedema. Any type of acute single leg swelling should always raise the possibility of blood clot such as deep vein thrombosis that needs to be acutely evaluated. Given the history as presented, I do believe this swelling more than likely is related to her diabetes and potential impact on other organ systems by the disease itself or medications that are required. Elevation of the extremities can be extremely beneficial when sedentary to help manage the expansion of fluid out of the vascular system. It is imperative that the cause of the swelling be established in order to provide an effective treatment. This would be best handled by your primary care physician who can assess current medications, obtain appropriate laboratory studies, and assess organ systems.

The big clinical question is whether there are any perceived skin changes associated with this feeling. Meaning is there any type of rash, skin eruption, skin breakdown. Clearly if this does manifest then some type of dermatologic disorder is most likely the cause of your problem. This can include both infectious and noninfectious. From an infectious standpoint, the most likely cause is a fungal infection or athlete's foot they can be readily treated with many over-the-counter topical antifungals. Noninfectious disorders can include areas of eczema, contact dermatitis, psoriasis. These disorders may be best treated with a topical steroid. If it is simply drying out of the skin then a good skin lotion or emollient may be warranted. If there are no overlying skin changes then we must consider other systems that may be prompting the sensation of a raw feeling and numbness. Most likely this is some type of neuropathic process. Given the focal nature as described without any evidence of radiating type presentation both into the leg or distally into the foot this may simply present as a compression irritation of nerve distributing into this area.

Without original diagnosis that warranted the arthroscopic procedure, I cannot provide you appropriate reason for the recurrent ankle pain. Ankle arthroscopy is generally performed in order to survey, repair or perform ablation of disease process to the joint. We perform arthroscopy to assess the joint and help diagnose pathology. If possible, we repair disease through arthroscopic approach.
Conditions frequently managed include chronic inflammation of the joint lining and scar formations, addressing injuries of the cartilage surface, managing ligament damage. In advanced arthritic disease states, we can use arthroscopic technique to fuse the joint. Unfortunately, diseases of joint can be progressive. We try to manage disorders for the here and now and hopefully provide sustainable outcome through minimally invasive technique, but there are disorders that can persist or relapse. My recommendation for you is to return to your surgeon
and be re-evaluated.

A corn represents an area of thickened skin overlying areas of bone prominence. Generally speaking corns are utilized to describe this thickened tissue on the tops of our digits. This is in contrast to what we refer to similar type skin hypertrophy on the bottom of the foot where we describe these as calluses. This is a benign presentation typically and does result from focal irritation of normal skin from the underlying bone prominence and overlying foot wear or weightbearing surface. The most appropriate treatment is to relieve pressure from the skin. This can be done externally with digital padding or modification of foot wear to minimize the local irritation commonly with a larger toe box shoe. There are available over-the-counter acids that can help reduce the keratotic buildup but these should be used with caution and should never be used if you are a diabetic or suffer from peripheral vascular disease or poor sensation to the feet. If the condition does not respond to concerted conservative management then correction of skeletal deformity such as hammertoes through surgical means may be warranted to relieve the problem and prevent recurrence. This should only be considered if appropriate conservative management has been attempted.

The heel bone known medically as the calcaneus is an extremely unique bone critical for the function of the hindfoot and the ability to appropriately load weight onto the foot. It possesses articular facets on its top surface to form a complex joint with the overlying bone known as the talus that we refer to as the subtalar joint. Distally it also has a joint that articulates with the tarsal cuboid bone of the mid-foot. The broad body of the calcaneus posteriorly also serves as an insertion for the largest and
strongest muscle tendon complex of the body appreciated as the Achilles tendon. There are multiple ligamentous attachments to this bone that maintain the stability and structure of the foot and ankle. Interestingly, with its significant need for weightbearing load, it is not terribly well designed structurally to do this. It has a thin cortical shell with significant medullary space and we frequently correlate this to almost like an egg with a hard shell and soft yolk in the middle. Fractures of this bone can become challenges depending on the mechanism of injury as well as the anatomic involvement. Broadly speaking we can speak of fractures that involve the complex joint surfaces and those fractures that do not. Not knowing the type of fracture that you have suffered makes it difficult to tell you whether surgery is indicated or not. Fractures that do not involve the articular surface and are considered nondisplaced body type fractures frequently do not require any surgery and heal quite readily given the nature of the bone. Those fractures that we refer to as intra-articular or joint involving that cause displacement and compression of the heel bone remain somewhat controversial in their treatment. For years, a conservative approach was considered given potential wound healing complications associated with surgical exposure. More recently, with an
evolution of surgical techniques, there has been greater interest in recommendation for anatomic reduction of these fractures to restore the gross normal anatomy of the heel bone speaking of its height with in length. Fractures that do involve the subtalar joint surfaces do have high risk for posttraumatic arthritis that may produce prolonged disability and require ultimately surgical fusion of this joint. Given the challenging nature of these fractures and the risk for long-term disability, these do require evaluation by a specialist well-versed in their management. If you have any concerns regarding your healing and treatment recommendations, I would highly encourage a second confirmatory opinion.

There are many reasons for developing peripheral swelling or edema. This swelling can represent inflammatory reaction due to overuse syndromes and injuries of the musculoskeletal system, arthritic or rheumatic disorders, infectious, tumor, vascular and fluid exchange processes of the tissues due to electrolyte imbalances and other organ disease processes to include kidney and liver function.

Clinical history is critical to assisting in what may be the potential cause. Frequently asymmetric or single leg swelling is representative of a local process of the extremity. When there is bilateral (both limb) involvement, this more than likely represents a systemic or generalized process. It is also critical to understand whether there is associated pain with the presentation. Painful peripheral swelling of joints can represent rheumatic processes. It is also extremely important to identify how long the swelling persists and what is done to relieve the presentation. Given you describe yourself as an 18-year-old girl who appears to be healthy and active as this presentation is developing after running or workout sessions, then the more likely factors appear to revolve around musculoskeletal disorders. Medical evaluation should include basic laboratory studies, radiographs of the ankles and a good physical examination of the involved anatomy with subsequent studies as required to determine the cause of this presentation.

Rotational injuries of the ankle can present as mild, moderate, and severe. For many years the poor ankle sprain has been considered to be of a limited problem that resolves with appropriate rest. Interestingly the ankle joint is the most frequently injured joint of the body and can create persistent problems in up to 40% of the cases 6 months following the injury. Appropriate early treatment is absolutely critical.

There are many reasons to suffer from morning pain and stiffness involving the musculoskeletal system. Oftentimes referred to as a gelling phenomenon, the connective tissue that makes up much of the structure of our bones, joints, ligaments and tendons are impacted by reduced perfusion of blood while we sleep particularly to the extremities. If there is underlying disease process this appears to be heightened as we get up in the morning. A common disorder that impacts the heel is a condition known as plantar fasciitis. This is an inflammatory degeneration of the broad fascia/ligament on the bottom of the foot that is a dynamic stabilizer of the foot and maintenance of the instep. At its proximal attachment into the heel bone we can produce inflammatory irritation. A common complaint of patient suffering from this disorder is something we refer to as post static dyskinesia. Meaning after being sedentary or sleeping the first few steps are quite painful and stiff until there is increased perfusion to the area and there is a gradual relief of pain. This is akin to the athlete who sustained an acute injury while playing their sport but continues to play without initial significant impact. Once taken off the court or playing field the connective tissue begins to tighten up. Morning pain and stiffness can also be the result of joint disease to include arthritis. This is also a common complaint that is heard with stiffness and pain to the involved joints. Given that you have been suffering from this for 1 year, it would
be most appropriate to seek medical evaluation and a determination as to the potential cause for these complaints. Plantar fasciitis is a readily treated disorder with appropriate stretching, shoe and activity modification, heel lift or supportive over-the-counter insole and will improve. Unfortunately arthritic disorders are more challenging and may require greater and more prolonged management in order to achieve an improved pain and functional state.

Increased body mass is a significant factor to overuse processes of the musculoskeletal system particularly the lower extremities. It has been determined that with walking and running we can produce pressure loads of approximately 5-1/2 times our body weight in the ankle and 2-1/2-3 times in the knees. When you consider the small surface areas particularly attributed to the ankle joint we can appreciate why this joint is the most frequently injured joint of the body. Further there are no tendinous
attachments to the talus which is the bone that resides within the ankle mortise and as a result the stability of this joint complex is based on bony architecture and surrounding ligamentous support. Clearly exercise is critical for good health to include cardiovascular, musculoskeletal and even mental but we must be cautious and understand the limits of our body and appreciate the activity and its pressure that it is exerting through the skeletal system. I have frequently advised patients with notably
higher BMI to begin with appropriate dietary restriction under physician guidance and begin weight loss in this fashion prior to engaging in high intensity activities in an effort to further lose weight through caloric burn. Alternative exercises that do not put excessive pressure on the lower extremity joints to include use of a stationary bike, aquatic exercise are a great initial means to do this. As body mass improves with weight loss then increased exertional activities such as higher intensity walking and running can be initiated with reduced risk of injury.

Your subjective symptoms of a prickling feeling on the bottom of your great
toe randomly is most suggestive of some type of peripheral nerve process.
More than likely it is local and effects one of the cutaneous or skin
nerves in the area. Given that you do not describe any radiating
presentation to involve other parts and it is quite limited in its area of
involvement this appears to be a benign focal irritation. Since you do not
describe any type of overlying skin eruption or rash, I do not believe
there is any type of skin disorder that may similarly present with this
type of feeling. I do not believe any formal evaluation or treatment is
required other than observation. Clearly if symptoms become more constant
and begin to involve a greater area of the foot this would warrant some
type of medical evaluation. There are systemic causes for what we
described as peripheral neuropathy to include diabetes and other metabolic
disorders, nutritional vitamin deficiencies, metal toxicities, traumatic or
entrapment and many that are simply idiopathic, we simply do not know the
cause. Best recommendation at this time is to simply keep a close eye on
the process and make sure there is no appreciated worsening.

there are potentially many reasons for the cause of a general dull ache to
the big toe. These can include musculoskeletal problems, vascular and
neurologic. From a musculoskeletal consideration one would have to consider
arthritic processes that cause joint pain. This may have resulted from old
trauma, repetitive mechanical injury or systemic cause for arthritis.
Vascular complications can include arterial insufficiency. Unfortunately
tobacco misuse has caused identified diseases of the peripheral arterial
system which can cause insufficiency and secondary pain. We also frequently
appreciate this in our diabetic population as this disease also impacts
peripheral circulation.Finally nerve processes can also produce chronic
pain. There are many reasons for peripheral neuropathy to include the
previously mentioned diabetes. There can also be nerve compression and
previous nerve injury. Regardless, if this pain is chronic and has not
found to improve on a timely basis or in fact has been worsening, it would
be best advised to seek specialty medical care in order to have a good
examination to include potential x-rays and other necessary laboratory
studies to better understand why he may be suffering from this discomfort.

Orthotic appliances are used to treat biomechanical and structural dysfunctions of the human foot and lower extremity. An appropriate diagnosis is always critical to achieve a most efficacious response. This can only be done by seeing an experienced provider in the management of these disorders. With that said, there are many common conditions that can be
readily identified by the consumer (patient) and achieve satisfactory results with an off-the-shelf insert. These conditions include flat feet, plantar fasciitis (heel pain), arch pain/fatigue and metatarsalgia (pain in the ball of the foot). There are many products that can be purchased at local retail stores that will provide similar benefit to that of a custom foot orthosis without the cost in handling these presentations.

Sadly nails can become disfigured and "scarred" with any type of trauma to include ingrown nail surgery. This can be very challenging to restore. It is possible you acquired a secondary fungal infection. Nail specimen can be obtained to assess for fungal presence and appropriately treat with the best option being an oral systemic. I have also found that with several nail growth cycles which take 6 to 8 months one can appreciate return of an improved toenail. So you may simply want to be patient and perform good hygienic management of nail trimming and see if with time things improve.

It is a frustrating disorder and unfortunately no definitive treatment to guarantee return of your normal nail appearance.