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By Dr. Kuvent, May 18, 2010 9:33 am

          You’re probably aware that heel pain is a very common problem affecting many people today. Countless products are made to support our arches and provide relief to our aching heels each year. Much of the attention is aimed at relieving the tenderness at the bottoms of our heels. However, one often-overlooked source of pain occurs at the back of the heel. This, of course, is where the Achilles tendon inserts and thus can lend itself to a wide variety of problems. One common source of pain which may occur alone or in conjunction with other forms of heel pain is called a “bursitis”.

          A “bursitis” is the technical term for inflammation and irritation of a bursa. A bursa is basically a small pad-like sack or cavity which contains fluid; almost like a small water balloon. Bursas are found at multiple locations within the human body where their primary function is to reduce friction between bones and tendons, tendons and ligaments, and other structures. A perfect example is found at the back of the heel. Because the Achilles tendon inserts at an angle along the top and back of the heel bone, a bursa in this location helps to prevent excessive rubbing and wear and tear which could otherwise damage the tendon.

          There are many causes of a bursitis including trauma, poorly-fitting shoes, arthritis, and sports injuries. The normal function and congested area in which heel bursas are found makes them naturally susceptible to injury and irritation. In many cases, the structure of the heel bone itself is such that there is an overlying prominence which puts even more pressure on the bursa and Achilles tendon. Patients with this problem usually have a dull, aching soreness over the top of the heel bone which is aggravated by shoe pressure. Women who are 20 to 30 years old are the most common individuals to encounter this condition as it is loosely associated with the wearing of high-heeled shoes. Nonetheless, males and other age groups may also be affected.

          As with any sort of structural disorder, a thorough evaluation is imperative, and this is where your local Chandler foot doctor can be of great assistance. Distinguishing between bony pathology, a bursitis, or an Achilles problem is critical. For this, your podiatrist may want to order some X-rays, an MRI, or other lab tests after first evaluating your heel in the office. The differential is huge and may include things such as rheumatoid arthritis, gout, Achilles tendon calcifications, various tumors, an infection, or even spinal cord problems.

          The standard of care for treating a bursitis is based on the severity of symptoms and is usually done as conservatively as possible. This may include shoe gear modifications, braces, prescription anti-inflammatory medications, aspiration, and steroid injections (which is done cautiously). If these treatments are ineffective, more invasive measures can be considered to excise the bursa in order to provide relief. If you have any questions, feel free to call today!

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By Dr. Kuvent, May 7, 2010 2:28 pm

          Even when they are perfectly healthy, kids have a way of drawing attention to themselves. As a parent or responsible caretaker, you also have a natural inclination to observe your children for their health and well-being in addition to their unique personalities. Occasionally, foot and ankle concerns such as flat feet may arise which can be tricky to pick up in a developing child. In these situations, thorough and professional evaluations can help ensure that more serious problems do not arise down the road.

          Due to the way that young children develop, they typically have different biomechanical standards than adults. These are based on their age, genetic makeup and other factors. For example, kids generally have more pliable soft tissues as well as a more pronated foot type which is normal until about 7 or 8 years of age. Of course, everyone is different, but there are also even more specific standard measurements for the heel position at particular ages. As a parent, there are a few things that you can monitor such as the sleeping and sitting positions, shoe wear, growing pains, and levels of activity of your child. Because young kids are not able to give a detailed description of their symptoms, subtle signs including a low threshold for physical activities can serve as a red flag that something may be wrong.

          One fairly common developmental abnormality is a foot which is rotated outwards on the ankle joint-essentially the opposite of a clubfoot. This is caused by intrinsic factors such as muscle imbalances and weak ligaments as well as extrinsic factors including a small uterus, increased fetal size, early walking and crawling, or simply ill-fitting shoes. The condition occurs in about 1 in 1,000 live births and may be a flexible or a fixed deformity. Generally, this condition will resolve with time, but in certain situations it should be treated early-ideally within the first year of life. The treatment most often involves manipulation of the involved extremity with splints or serial casting to rotate it back into a neutral position.

          Another condition which should be evaluated in young kids occurs when the heel position is fairly normal but the forefoot is deviated inwards. This also may or may not progress to become a painful deformity and thus require treatment. However, it is typically a milder deformity and thus may be effectively treated when the child is several years older.

          Other more obvious but serious abnormalities include a high-arched foot, a ‘rocker-bottom’ foot, or a foot with misshapen digits. These conditions warrant professional attention as soon as possible. If you have questions regarding these or any others affecting the feet or ankles of your child, don’t hesitate to contact your local Chandler podiatrist today. He can assist you in determining what is normal and whether any sort of intervention is appropriate. For all youngsters, it is important to start off on the right foot!

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By Dr. Kuvent, April 29, 2010 12:55 pm

Plantar fasciitis is a term that you’ve probably come across if you have dealt with heel pain in the past or have read much about it. Indeed, it is a major cause of symptoms, but unfortunately many patients and physicians often overlook the many other possible causes behind aching heels. One commonly misdiagnosed etiology is neurologic based heel pain.

          If you were to take a look at the anatomy of a human ankle, you’d notice that there are several major nerves running through the ankle and into the foot. At various locations these nerves branch to form even more nerves. Of course this is essential for our normal functioning as our feet not only contain many muscles but they are also very sensitive-which is a good thing! However, the space within the ankle and hind-foot is fairly narrow and occasionally one or more of those nerves can become compressed resulting in sore heels.

          One of the most common nerve entrapments creating heel pain involves a nerve which runs across the bottom of the heel towards the outside of the foot where it supplies a muscle of the 5^th toe. This nerve runs through a tight space where it can easily be compressed by a heel spur, the plantar fascia (central location of plantar fasciitis), and other structures. This type of pain is known as Baxter’s neuritis, and as opposed to plantar fasciitis, it will more often be painful following activities as compared to early morning or first-step pain.

          There are multiple other causes of neurologic pain in addition to a Baxter’s neuritis. For example, even irritation within the lower spine can create symptoms of pain at the heel. These symptoms may be difficult to distinguish from other causes, but it is generally more of a tingling, numbing, or burning sort of pain. Depending on your case, your local podiatrist may recommend several different diagnostic techniques after a thorough clinical exam if your pain is persistent. These may include X-rays, nerve-conduction studies, or an MRI to exclude any possible tumors or other space-occupying lesions.

          The treatment for neurologic heel pain depends upon its exact etiology and which specific nerves are affected. Initial treatments are often similar to those for plantar fasciitis and include the use of certain medications, mechanical supports, and anesthetic injections. If these measures are ineffective, surgical treatment usually involves a simple procedure in which a small incision is made at the bottom of the heel. The doctor then creates more space by removing some of the excess tissue which may be pressing against the nerve.

          In addition to nerve complications, there are many other possible causes of heel pain which should also be ruled out. If you have questions, feel free to contact your local foot doctor in Chandler today.

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By Dr. Kuvent,

          When you think of tumors you may think of cancer, and when you think of cancer, you probably don’t immediately think of the foot or ankle. However, there is in fact a very wide variety of tumors which do show up primarily in the foot and ankle. Thankfully, ten times as many of these lesions are benign as they are cancerous, but it’s still intriguing to note that 45% of soft tissue sarcomas occur in the lower extremity. One of the more common benign tumors of the foot is known as a “plantar fibroma”.

          Plantar fibromas are generally found in patients in their 20s, 30s, and 40s and are most commonly seen in men. About half of cases involve both feet, and they are more common in people with epilepsy, diabetes, and alcoholics with liver disease. Also, they are classically associated with a condition involving the hands in which the ring and small fingers are contracted forwards and are unable to be straitened. This is called a Dupuytren’s contracture. Of course, it’s important to remember that not all individuals with this condition fit these criteria.

          Essentially, plantar fibromas are thickenings of fibrous tissue within the plantar fascia which is a normal band of tissue that runs along the sole. These nodule-like thickenings are usually found towards the middle or inside of the sole, and they sometimes arise in non-weight-bearing areas making them asymptomatic. On the other hand, the lesions can grow to 2 cm in diameter, and although they are not cancerous, they can be locally aggressive leading to significant pain and discomfort when walking.

          A major key to properly managing plantar fibromas is achieving the correct diagnosis. This is because there are so many other possible tumors and lesions-both benign and malignant-within the foot and ankle. Your local Chandler podiatrist can help you in determining whether your condition is actually a ganglion cyst, an infection, hernias of the fat pad, tumors involving nervous tissue, a cancerous lesion, or indeed a plantar fibroma. In some cases, an MRI may be requested to help the doctor make this distinction.

          The treatment for plantar fibromas is based on the grade, size, and location of the tumors as well as the nature of your symptoms. Foot doctors like to start out as conservatively as possible by implementing certain medications, shoe-gear modifications, steroid injections, and other modalities before moving on to surgical intervention. In severe cases such as those involving pain, difficulty fitting into shoes, or a growing lesion, the doctor may recommend surgery to excise the lesion. There is a chance of recurrence, however.

          If you have symptoms of a plantar fibroma, such as painful ‘lumps’ on the soles of your feet, feel free to call and make an appointment today.

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By Dr. Kuvent,

Ulcers and other types of wounds are some of the most common problems that podiatrists deal with in the lower extremity. Part of the reason for that is because there are so many possible causes including diabetic ulcers, pressure ulcers, and blood-flow related ulcers as well as burns, traumatic wounds, and skin grafts or flaps. One unique treatment option that can be used in all of these settings is known as “negative pressure” or “wound vacuum” therapy.

          In short, wound vacuum therapy is an active but non-invasive form of therapy which uses controlled pressure over a wound to promote healing. This principle was actually first developed in 1841 when vacuum bells were applied to different body parts with the idea of drawing blood away from diseased organs! Later in the 1950’s, newer designs were developed and studies were carried out examining healing potential and how the body responded to changes in pressure. The most popular device today received FDA approval in 1995 and was approved by Medicare in 2000.

          There are several popular wound vacuum models in use today and a great deal of quality research has been done supporting their efficacy. The studies have shown that vacuum devices help by creating an ideal healing environment within the wound. They do this by offering protection and support as well as increasing local blood flow, removing excess fluid, decreasing bacteria, and promoting the formation of healthy tissue over the wound. Additionally, wound vacuum devices are shown to improve the success rates of skin grafts and flaps when they are necessary. Of course, vacuum therapy is not indicated in all wounds, and not every patient is a candidate.

          As already noted, there are several different wound vacuum models in use today. Many of the models include a foam dressing with a suction device which is specially applied over the wound. The dressing is then attached by a length of tubing and connectors to the actual battery-powered suction device. This device is usually small and lightweight and can travel easily with patients. It can be programmed to offer the proper amount of negative pressure in order to optimally heal the wound or wounds in question.

          Wound vacuum therapy is just one of many options available for the management of ulcers and other types of wounds. Your podiatrist in Chandler can tell you if this is an appropriate therapy for your condition and then help to manage that therapy effectively. Some wounds require constant suction while others require intermittent suction, and this can all be pre-programmed into the device. Vacuum therapy has proven to be an exceptional cost-saving measure in that it can help augment surgery, reduce the number of dressing changes, speed the transition to less invasive health care settings, and provide a treatment option to patients who are not ready for surgery. If you have questions, feel free to make an appointment today!

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By Dr. Kuvent, April 2, 2010 11:56 am

You’ve probably noticed that many television infomercials these days include attorneys who encourage us to seek compensation against various organizations in order to ‘get even’. In many ways, our feet are actually trying to do the same thing! Far from being rigid struts which simply absorb our weight, human feet are very dynamic structures which must work in a coordinated way and adjust to multiple factors in order to balance our bodies and keep us moving. Occasionally, problems in the back or middle of the foot may go unnoticed while forefoot symptoms may arise when trying to compensate for those imbalances.

          Some of the most common foot problems that you’ve probably heard about include bunions, hammertoes, corns, calluses, flatfeet, and other painful disorders. Many of these conditions are actually in part a response of the forefoot to abnormal mechanics in the rear-foot. With each passing step, the heel must first roll outwards a certain distance before rolling back inwards to stabilize the foot. This motion has a huge impact on the outcome of the forefoot, as different tendons will function atypically if the heel motion is abnormal.

          During the push-off stage of walking, the long bones of the forefoot must move downwards in order for the toes to bend properly. This motion is facilitated by those same tendons which are altered by the motion at the heel. Thus when the heel is unstable, the forefoot is also unstable, and forces from the ground can lead to the development of bunions, contracted digits, and other deformities. Just like a teeter-totter, the foot works constantly to balance our weight and to distribute ground forces equally.

          Of course, this ‘compensation’ is not simply one-sided. Sometimes, the deformity lies in the forefoot. For example, the ligaments holding the joints of the mid-foot may become loose or damaged, resulting in a misalignment or a lack of support to one side of the forefoot. In response, the hind-foot will usually compensate by altering it’s normal function to help off-load those high-pressure areas. Similarly, deformities within the shins, knees, or hips may also be mediated by motion at the heel. Sometimes, this compensation is adequate and sometimes it is not. Occasionally, the entire foot structure may change as a result.

          Your local podiatrist in Chandler is very experienced in treating and managing deformities of the foot and ankle which involve pathologic compensation issues. Again, this covers a wide variety of problems, so multiple treatment options may be considered depending on the nature of your symptoms. If you have any questions, feel free to make an appointment.

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By Dr. Kuvent,

          Most people have heard somewhere along the line of rheumatoid arthritis (RA) or osteoarthritis. These conditions have been previously described on this blog and can cause serious pain and damage to the joints of your feet and ankles. However, there are many other arthritic disorders that can also affect the lower extremities which is why a proper podiatric work-up can help to distinguish some of these conditions. Similar to RA, there are three fairly common diseases (along with multiple others) which also demonstrate similar inheritance patterns and tend to affect similar joints. These include Ankylosing spondylitis, Psoriatic arthritis, and Reiter’s syndrome.

          Ankylosing spondylitis, also called Marie-Strümpell’s disease, most often affects males. It typically begins when people are in their 30’s but often times the disease itself is not diagnosed right away because the early signs and symptoms are vague. However, these can include multiple manifestations including eye problems, stomach inflammation, and neurologic deficits. The classic finding, however, is lower back or buttock pain which tends to radiate down the thighs. In the lower extremity, symptoms can occur at the balls of the feet where degeneration and dislocation occurs at the joint. Symptoms may also arise in the heel where pain and inflammation occur at locations where tendons and bones connect.

          Psoriatic arthritis, as you can imagine, is closely associated with psoriasis although there are also other genetic, environmental, and immune system-related factors. The most common presentation involves the joints of the toes and results in widening at the joint space as well as joint destruction, toe swelling, and possible knee involvement. Interestingly, this disease also presents with unique nail changes; specifically the development of many small pits in the nails which may indicate the onset of the disease.

          Reiter’s syndrome is a form of reactive arthritis which occurs in response to an infection elsewhere in the body. The infection in question is usually either a urinary tract infection or a gastro-intestinal infection and thus often follows the contraction of a sexually-transmitted disease or the consumption of contaminated foods. Of course, this disease process includes many systemic signs, but in the lower extremity it exhibits symptoms similar to Psoriatic arthritis and Ankylosing spondylitis including swollen toes, nail changes, and heel pain.

          If you’re experiencing the symptoms of one of these conditions, your local Chandler foot doctor can be especially helpful. For one thing, there is a wide variety of other conditions including gout, RA, osteoarthritis, and lupus among others which will need to be effectively ruled out. Most of these conditions have different radiographic patterns which is helpful in that respect. Furthermore, if one of these conditions is diagnosed, your podiatrist has a huge role to play in the conservative and/or surgical management of your symptoms. Feel free to make an appointment today with any questions.

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By Dr. Kuvent, March 17, 2010 9:49 am

One of the most interesting aspects of the lower extremity is how many systemic diseases tend to show up in the feet, ankles, and lower legs. Diabetes is, of course, an obvious example, but there are also many diseases affecting the blood vessels which tend to show up in the lower limbs either before or during the time that they begin to affect other vital organs of the body. Many of these disorders will demonstrate predictable skin manifestations which help to offer clues about the underlying disease process.

          ‘Vasculitis’ is a general term referring to a state of inflammation or damage to the arteries or veins which transport blood throughout our body. There are many different diseases within this category which can affect different-sized blood vessels as well as different organs. However, many of the disorders result when the immune system causes damage to the walls of a blood vessel which in turn allows blood cells to leak out of these vessels. This can lead to skin lesions of the feet and lower legs which typically involve both extremities and may be severely painful.

          One important thing to keep in mind about vasculitis is that different conditions can present with a variety of different symptoms. Some diseases will involve painful blistering or ulceration of the skin while others will result in skin color changes, pain with walking, or nail pathology. Besides immune system malfunctions, other causes of vasculitis include infections, various types of cancer, and drug reactions. Similarly, the long-term and systemic prognoses of these diseases can vary widely. If left unchecked, some of these disorders may go on to cause blindness or other severe outcomes.

          Unfortunately, it isn’t possible to discuss each of the different vasculitis conditions here. However, if you would like a professional opinion, an appointment with your local Chandler podiatrist is certainly worth your while. He can perform several simple exams and help to sort out the possibilities in order to differentiate your symptoms from other possible skin or blood vessel disorders. Ultimately, he may recommend a biopsy to confirm the diagnosis before deciding on the appropriate therapy.

          While vasculitis may seem like merely an irritating rash of the feet or lower legs, in reality it is a systemic disease which can affect your joints, nerves, heart, lungs, kidneys, or GI tract. Therefore, early screening and detection is very important. The symptoms of the lower extremity may be just the tip of the iceberg.

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By Dr. Kuvent,

There’s a good chance that you’ve heard in passing of “carpal tunnel syndrome” and you may know that it is a painful condition which can affect the hands, wrists, and arms. There’s probably a smaller chance that you have heard of “tarsal tunnel syndrome” which is similar but in fact a completely different problem. Both of these conditions result when important nerves become entrapped or compressed in some way, but while carpal tunnel syndrome affects the upper extremities, tarsal tunnel syndrome affects the ankles, feet, and lower legs.

          Similar to the wiring in a house which must travel a certain distance to supply electricity, the nerves in our body must travel from our central nervous system (the brain or spinal cord) out to the distant parts of our body to supply electrical impulses. To accomplish this, one of the most important nerves must travel down the inside of the lower leg and course behind and below the bump or “malleolus” on the inside of the ankle before it enters the foot. While it’s not usually a problem, this inside area of the ankle also contains many other structures including tendons, ligaments, blood vessels, and bony structures. Occasionally, this congested area may become further compressed by a tumor, fracture, or other entity which creates an irritating pressure on the major nerve in that location.

          From tumors, lesions, and fractures to systemic diseases and biomechanical deformities, there are many possible causes of tarsal tunnel syndrome. Often times, there is no clear and specific cause which can complicate the diagnosis. However, the symptoms are fairly consistent which include burning, tingling, or shooting pains which may radiate either up or down the foot or ankle into the toes. This pain is often made worse with activities such as standing or walking and relieved with rest, although night pain is also not uncommon.

          A visit to your Chandler podiatrist is certainly a good idea if you’re experiencing these symptoms because he can help to determine whether tarsal tunnel syndrome truly is the cause of your pain. Many other etiologies are also possible such as a nerve root problem, peripheral vascular disease, tendon irritation, a heel spur, or a stress fracture. Once these other potential diagnoses are ruled out, you and the doctor can discuss the treatment options which will have the best chance of helping you. These can include certain medications, steroid injections, or specific shoe gear modifications before moving on to consider a surgical intervention to decompress the area.

          If a tumor or fracture is indicated during your evaluation, it may ultimately require surgery for a complete resolution of the problem and is yet another reason to schedule an appointment sooner rather than later.

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By Dr. Kuvent,

For most of us, losing fat is considered a goal, and something that many Americans strive for each year. However, when it comes to our feet, the reverse is true, and as we age the fat in our heels sometimes becomes thin and something to hold on to for as long as possible. Imagine driving a car in which the tire treads have worn thin, the air pressure is low, and the rims are nearly riding against the ground. The same principle occurs when the layer of fat beneath our ‘calcaneus’ or heel bone becomes worn down. Often times, this phenomenon is the cause for a great amount of heel pain.

          While it’s commonly thought that age is the cause of fat pad breakdown, there are also many other important causes and factors. Surgery, diabetic nerve problems, arthritic conditions, the use of steroids or steroid injections, and even a unique disorder known as Complex Regional Pain Syndrome can all lead to fat pad thinning. Of course, the way that we use our bodies can also play a big role. In the same way that cartilage tends to break down with overuse leading to knee and other problems, the cushioning fat pad of our heels can also wear out due to certain lifestyles, being overweight, or simply from genetics.

          Heel pain in general is a very broad topic which includes disorders of nerves, blood-flow, inflammation, metabolism, and even tumors. Therefore, it’s never a bad idea to visit your local Chandler foot doctor if you are having symptoms, because these other conditions can be properly ruled out. Fat pad atrophy may go on to cause stress fractures or various arthritic conditions, so a thorough evaluation including X-rays can indicate whether a more serious process is foreseeable.

          Much research is currently in the works regarding the injection of silicone and other synthetic materials to act as a near-natural replacement for fat pad loss. This may hold great promise in the future. For now, however, the gold standard of treatment continues to be specific shoe gear modifications, padding, and the use of customized inserts to provide optimal support to the heel bone. Feel free to discuss your best options with your podiatrist.

          Despite some of the natural changes that occur with aging, there are still some very viable options to keep you healthy and active. The best thing you can do for your overall well-being is to stay on your feet.