Scottsdale Podiatrist

New Information for Painful FlatFeet

2012-01-20T08:26:00.000-07:00

(Ivanhoe Newswire)-- Have you ever experienced the pain of flat feet? New insight may help millions of Americans who suffer from the painful condition.

Thanks to a team at the University of East Anglia a recent discovery was made that may help doctors understand what may be the cause of adult-acquired flat feet.

Flat feet are most common in women over 40 and are often left undiagnosed and untreated. Adult-acquired flat feet are caused from 'stretching out' a tendon that stabilizes the foot arch near the ankle bone called the tibialis posterior tendon.

Risks of flat feet include obesity, hypertension, and diabetes. Although the main cause of the actual stretching of the tendon is unknown, speculation that standing while wearing heels, or walking for long periods of time may be the cause.

Working with surgeons and scientists at Addenbrooke's Hospital, Cambridge, and the University of Bristol, the team showed that the structure and composition of tendon specimens had changed and found evidence of increased activity of some proteolytic enzymes. These enzymes can break down the constituents of the tibialis posterior tendon and weaken it – causing the foot arch to fall.

"Our study may have important therapeutic implications since the altered enzyme activity could be a target for new drug therapies in the future," Dr. Graham Riley, author of the Arthritis Research UK at UEA's School of Biological Sciences, was quoted as saying.

Further research is needed to find which specific proteolytic enzymes should be targeted and whether people could be genetically predisposed to tendon injuries of this type. New treatments could be 10-15 years away and the findings could lead to new drug therapy for flat feet and other common tendon conditions.

SOURCE: Annals of the Rheumatic Diseases, January 11, 2012

At InMotion Foot and Ankle, we have found a great solution for flatfeet caused by Posterior Tibial Tendon disfunction, we use a combination of ankle bracing, Extra Corporeal Shockwave Therapy (ESWT) with injection of moralized amniotic membrane and fluid, followed by aggressive home therapy.

Give us a call or go to ZocDoc.com and make an appointment with Dr. Bruce Werber

InMotion Foot & Ankle SpecialistsDr. Bruce Werber10900 N. Scottsdale RoadSuite 604Scottsdale, AZ 85254480-948-2111www.InMotionFootandAnkle.cominmotionfootandankle@gmail.com

Vitamin D deficiency in Diabetics with Neuropathy

2012-01-17T07:31:00.003-07:00

Article: Complications
Does Vitamin D deﬁciency play a role in peripheral neuropathy in Type 2 diabetes?
D. Shehab Department of Pathology, Faculty of Medicine, Kuwait University

Abstract

Aim Despite recent reports linking vitamin D deﬁciency with increased risk of diabetes mellitus and complications, there is limited data on patients with diabetic peripheral neuropathy. We aimed to evaluate the incidence and associations of vitamin D deﬁciency in 210 patients with Type 2 diabetes with and without diabetic peripheral neuropathy.

Results Eighty-seven patients had diabetic peripheral neuropathy and these patients had signiﬁcantly longer duration of diabetes and higher HbA1c. Age, gender, incidence of retinopathy and coronary heart disease were not signiﬁcantly different from those without neuropathy. Mean (SD) vitamin D was signiﬁcantly lower in those with neuropathy [36.9 (39.9) nmol⁄l] compared with those without [58.32 (58.9) nmol⁄ l] and 81.5%of patients with neuropathy had vitamin D deﬁciency compared
with 60.4% of those without. Vitamin D showed signiﬁcant (P < 0.05) correlations with total cholesterol, LDL-cholesterol and urine microalbumin : creatinine ratio. Binary logistic regression analysis showed that diabetic peripheral neuropathy was signiﬁcantly associated with vitamin D deﬁciency (odds ratio = 3.47; 95% CI = 1.04–11.56, P = 0.043) after inclusion of
potential confounders such as duration of diabetes, HbA1c and LDL-cholesterol.

Conclusion Vitamin D deﬁciency is an independent risk factor for diabetic peripheral neuropathy, and further studies are required to conﬁrm if Vitamin D supplementation could prevent or delay the onset.

InMotion Foot & Ankle SpecialistsDr. Bruce Werber10900 N. Scottsdale RoadSuite 604Scottsdale, AZ 85254480-948-2111www.InMotionFootandAnkle.cominmotionfootandankle@gmail.com

Spider Vein treatment with Laser Therapy ----

2011-11-30T11:08:00.001-07:00

What causes varicose veins and spider veins?

Varicose veins can be caused by weak or damaged valves in the veins. The heart pumps blood filled with oxygen and nutrients to the whole body through the arteries. Veins then carry the blood from the body back to the heart. As your leg muscles squeeze, they push blood back to the heart from your lower body against the flow of gravity. Veins have valves that act as one-way flaps to prevent blood from flowing backwards as it moves up your legs. If the valves become weak, blood can leak back into the veins and collect there. (This problem is called venous insufficiency.) When backed-up blood makes the veins bigger, they can become varicose.

Spider veins can be caused by the backup of blood. They can also be caused by hormone changes, exposure to the sun, and injuries.

How common are abnormal leg veins?

About 50 to 55 percent of women and 40 to 45 percent of men in the United States suffer from some type of vein problem. Varicose veins affect half of people 50 years and older.

What factors increase my risk of varicose veins and spider veins?

Many factors increase a person's chances of developing varicose or spider veins. These include:

Increasing age. As you get older, the valves in your veins may weaken and not work as well.
Medical history. Being born with weak vein valves increases your risk. Having family members with vein problems also increases your risk. About half of all people who have varicose veins have a family member who has them too.
Hormonal changes. Taking birth control pills and other medicines containing estrogen and progesterone also may contribute to the forming of varicose or spider veins.
Pregnancy. During pregnancy, there is a huge increase in the amount of blood in the body. This can cause veins to enlarge. Varicose veins usually improve within 3 months after delivery. More varicose veins and spider veins usually appear with each additional pregnancy.
Obesity. Being overweight or obese can put extra pressure on your veins. This can lead to varicose veins.
Lack of movement. Sitting or standing for a long time may force your veins to work harder to pump blood to your heart. This may be a bigger problem if you sit with your legs bent or crossed.
Sun exposure. This can cause spider veins on the cheeks or nose of a fair-skinned person.

Why do varicose veins and spider veins usually appear in the legs?

Most varicose and spider veins appear in the legs due to the pressure of body weight, force of gravity, and task of carrying blood from the bottom of the body up to the heart.

Compared with other veins in the body, leg veins have the toughest job of carrying blood back to the heart. They endure the most pressure. This pressure can be stronger than the one-way valves in the veins.

What are the signs of varicose veins?

Varicose veins can often be seen on the skin. Some other common symptoms of varicose veins in the legs include:

Aching pain that may get worse after sitting or standing for a long time
Throbbing or cramping
Heaviness
Swelling
Rash that’s itchy or irritated
Darkening of the skin (in severe cases)
Restless legs

Are varicose veins and spider veins dangerous?

Spider veins rarely are a serious health problem, but they can cause uncomfortable feelings in the legs. If there are symptoms from spider veins, most often they will be itching or burning. Less often, spider veins can be a sign of blood backup deeper inside that you can’t see on the skin. If so, you could have the same symptoms you would have with varicose veins.

Varicose veins may not cause any problems, or they may cause aching pain, throbbing, and discomfort. In some cases, varicose veins can lead to more serious health problems. These include:

Sores or skin ulcers due to chronic (long-term) backing up of blood. These sores or ulcers are painful and hard to heal. Sometimes they cannot heal until the backward blood flow in the vein is repaired.
Bleeding. The skin over the veins becomes thin and easily injured. When an injury occurs, there can be significant blood loss.
Superficial thrombophlebitis, which is a blood clot that forms in a vein just below the skin. Symptoms include skin redness; a firm, tender, warm vein; and sometimes pain and swelling.
Deep vein thrombosis, which is a blood clot in a deeper vein. It can cause a “pulling” feeling in the calf, pain, warmth, redness, and swelling. However, sometimes it causes no significant symptoms. If the blood clot travels to the lungs, it can be fatal.

Should I see a doctor about varicose veins?

You should see a doctor about varicose veins if:

The vein has become swollen, red, or very tender or warm to the touch
There are sores or a rash on the leg or near the ankle
The skin on the ankle and calf becomes thick and changes color
One of the varicose veins begins to bleed
Your leg symptoms are interfering with daily activities
The appearance of the veins is causing you distress

If you’re having pain, even if it’s just a dull ache, don’t hesitate to get help. Also, even if you don’t need to see a doctor about your varicose veins, you should take steps to keep them from getting worse

How are varicose veins diagnosed?

Your doctor may diagnose your varicose veins based on a physical exam. Your doctor will look at your legs while you’re standing or sitting with your legs dangling. He or she may ask you about your symptoms, including any pain you’re having. Sometimes, you may have other tests to find out the extent of the problem and to rule out other disorders.

You might have an ultrasound, which is used to see the veins’ structure, check the blood flow in your veins, and look for blood clots. This test uses sound waves to create pictures of structures in your body.

Although less likely, you might have a venogram. This test can be used to get a more detailed look at blood flow through your veins.

How are varicose and spider veins treated?

Varicose veins are treated with lifestyle changes and medical treatments. These can:

Relieve symptoms
Prevent complications
Improve appearance

Treatment options include:

Compression stockings

Compression stockings put helpful pressure on your veins. There are 3 kinds of compression stockings:

Support pantyhose, which offer the least amount of pressure. These also often are not “gradient” or “graduated.” That means they provide pressure all over instead of where it is needed most.
Over-the-counter gradient compression hose, which give a little more pressure. They are sold in medical supply and drugstores.
Prescription-strength gradient compression hose, which offer the greatest amount of pressure. They are sold in medical supply and drugstores. You need to be fitted for them by someone who has been trained to do this.

Sclerotherapy
Sclerotherapy (SKLER-o-ther-a-pee) is the most common treatment for both spider veins and varicose veins. The doctor uses a needle to inject a liquid chemical into the vein. The chemical causes the vein walls to swell, stick together, and seal shut. This stops the flow of blood, and the vein turns into scar tissue. In a few weeks, the vein should fade. This treatment does not require anesthesia and can be done in your doctor's office. You can return to normal activity right after treatment.

The same vein may need to be treated more than once. Treatments are usually done every 4 to 6 weeks. You may be asked to wear gradient compression stockings after sclerotherapy to help with healing and decrease swelling. This treatment is very effective when done correctly.

Possible side effects include:

Stinging, red and raised patches of skin, or bruises where the injection was made. These usually go away shortly after treatment.
Spots, brown lines, or groups of fine red blood vessels around the treated vein. These also usually go away shortly after treatment.
Lumps of blood that get trapped in vein and cause inflammation. This is not dangerous. You can relieve swelling by applying heat and taking aspirin. Your doctor can drain the trapped blood with a small pinprick at a follow-up visit.

There is a type of sclerotherapy called ultrasound-guided sclerotherapy (or echo-sclerotherapy). This type of sclerotherapy uses ultrasound imaging to guide the needle. It can be useful in treating veins that cannot be seen on the skin’s surface. It may be used after surgery if the varicose veins return. This procedure can be done in a doctor’s office. Possible side effects include skin sores, swelling, injection into an artery by mistake, or deep vein thrombosis (a potentially dangerous blood clot).

Surface laser treatments

Laser treatments can effectively treat spider veins and smaller varicose veins. This technique sends very strong bursts of light through the skin onto the vein. This makes the vein slowly fade and disappear. Not all skin types and colors can be safely treated with lasers.

No needles or incisions are used, but the heat from the laser can be quite painful. Cooling helps reduce the pain. Laser treatments last for 15 to 20 minutes. Generally, 2 to 5 treatments are needed to remove spider veins in the legs. Laser therapy usually isn’t effective for varicose veins larger than 3 mm (about a tenth of an inch). You can return to normal activity right after treatment.

Possible side effects of lasers include:

Redness or swelling of the skin right after the treatment that disappears within a few days
Discolored skin that will disappear within 1 to 2 months
Burns and scars from poorly performed laser surgery, though this is rare

Endovenous techniques (radiofrequency and laser)

These methods for treating the deeper veins of the legs, called the saphenous (SAF-uh-nuhs) veins, have replaced surgery for most patients with severe varicose veins. These techniques can be done in a doctor’s office.

The doctor puts a very small tube, called a catheter, into the vein. A small probe is placed through the tube. A device at the tip of the probe heats up the inside of the vein and closes it off. The device can use radiofrequency or laser energy to seal the vein. The procedure can be done using just local anesthesia. You might have slight bruising after treatment.

Healthy veins around the closed vein take over the normal flow of blood. The symptoms from the varicose vein improve. Usually, veins on the surface of the skin that are connected to the treated varicose vein will also shrink after treatment. If they don’t, these connected veins can be treated with sclerotherapy or other techniques.

Surgery

Surgery is used mostly to treat very large varicose veins. Types of surgery for varicose veins include:

Surgical ligation and stripping. With this treatment, problem veins are tied shut and completely removed from the leg through small cuts in the skin. Removing the veins does not affect the circulation of blood in the leg. Veins deeper in the leg take care of the larger volumes of blood. This surgery requires general anesthesia and must be done in an operating room. It takes between 1 and 4 weeks to recover from the surgery. This surgery is generally safe. Pain in the leg is the most common side effect. Other possible problems include:

A risk of heart and breathing problems from anesthesia
Bleeding and congestion of blood. But, the collected blood usually settles on its own and does not require any further treatment.
Wound infection, inflammation, swelling, and redness
Permanent scars
Damage of nerve tissue around the treated vein. It's hard to avoid harming small nerve branches when veins are removed. This damage can cause numbness, burning, or a change in feeling around the scar.
A deep vein blood clot. These clots can travel to the lungs and heart. The medicine heparin may be used to reduce the chance of these dangerous blood clots. But, heparin also can increase the normal amount of bleeding and bruising after surgery.

PIN stripping. In this treatment, an instrument called a PIN stripper is inserted into a vein. The tip of the PIN stripper is sewn to the end of the vein, and when it is removed, the vein is pulled out. This procedure can be done in an operating room or an outpatient center. General or local anesthesia can be used.

Ambulatory phlebectomy. With ambulatory phlebectomy (AM-byoo-luh-TOHR-ee fluh-BEHK-toh-mee), tiny cuts are made in the skin, and hooks are used to pull the vein out of the leg. Only the parts of your leg that are being pricked will be numbed with anesthesia. The vein is usually removed in 1 treatment. Very large varicose veins can be removed with this treatment while leaving only very small scars. Patients can return to normal activity the day after treatment. Possible side effects of the treatment include slight bruising and temporary numbness.

How can I prevent varicose veins and spider veins?

Not all varicose and spider veins can be prevented. But, there are some steps you can take to reduce your chances of getting new varicose and spider veins. These same things can help ease discomfort from the ones you already have:

Wear sunscreen to protect your skin from the sun and to limit spider veins on the face.
Exercise regularly to improve your leg strength, circulation, and vein strength. Focus on exercises that work your legs, such as walking or running.
Control your weight to avoid placing too much pressure on your legs.
Don’t cross your legs for long times when sitting. It’s possible to injure your legs that way, and even a minor injury can increase the risk of varicose veins.
Elevate your legs when resting as much as possible.
Don’t stand or sit for long periods of time. If you must stand for a long time, shift your weight from one leg to the other every few minutes. If you must sit for long periods of time, stand up and move around or take a short walk every 30 minutes.
Wear elastic support stockings and avoid tight clothing that constricts your waist, groin, or legs.
Avoid wearing high heels for long periods of time. Lower-heeled shoes can help tone your calf muscles to help blood move through your veins.
Eat a low-salt diet rich in high-fiber foods. Eating fiber reduces the chances of constipation, which can contribute to varicose veins. High-fiber foods include fresh fruits and vegetables and whole grains, like bran. Eating less salt can help with the swelling that comes with varicose veins.

Can varicose and spider veins return even after treatment?

Current treatments for varicose veins and spider veins have very high success rates compared to traditional surgical treatments. Over a period of years, however, more abnormal veins can develop because there is no cure for weak vein valves. Ultrasound can be used to keep track of how badly the valves are leaking (venous insufficiency). Ongoing treatment can help keep this problem under control.

The single most important thing you can do to slow down the development of new varicose veins is to wear gradient compression support stockings as much as possible during the day.

inMotion Foot and Ankle Specialists offer Superficial Laser treatment for the treatment of spider veins for the lower leg, ankle area and foot, we offer the Cutera laser system, minimize discomfort with direct cooling while using the laser, it is very effective in eliminating Spider veins in the lower leg and foot.

Warts (Verruca), fungal infected nails, and Scars can be treated with this laser system as well.

you can schedule a consultation with Dr. Werber

480-948-2111

inMotionFootandAnkle@Gmail.Com

www.inMotionFootandAnkle.com

InMotion Foot & Ankle SpecialistsDr. Bruce Werber10900 N. Scottsdale RoadSuite 604Scottsdale, AZ 85254480-948-2111www.InMotionFootandAnkle.cominmotionfootandankle@gmail.com

shin splints

2011-11-18T09:14:00.001-07:00

The fall high school sports season is winding down and winter sports is gearing up and with it is the prevalence of shin pain in athletes' lower legs.

Shin splints isn't a medical term, but it's the one everyone uses. The problem is shin pain can be one of three of four different medical conditions. Muscle soreness, tendonitis, stress fracture or compartment pressure are all possible causes of shin pain.

These problems usually are on the front, inside or outside of the lower leg calf muscle and Achilles tendon on the back of the lower leg aren't considered shin splint areas.

Almost anyone running or jumping can be susceptible to shin pain.

Usually doing too much too soon, or increasing intensity of running activities on hard dry ground, or hard surface conditions can cause discomfort.

Backing off somewhat, usually some ice massage or ice packs, also sometimes heat when indicated, can help the problem.
If these don't help, then a proper specific diagnosis is important. X-rays and MRI tests might be necessary to rule out a stress fracture.

Young growing bodies moving from middle school sports to high school might be doing twice the amount and intensity. If pain persists, get it evaluated. Often "intelligent rest" is needed.
What's interesting is that almost all persistent shin problems are foot related. Both pronated flat feet and the other extreme, high arches can be foot types that aggravate and perpetuate if not cause shin splint type conditions.

If the complaint is "every time my son or daughter gets really into the sports season their shin splints return" then check out the foot mechanics.

The shin muscles and tendons act as "the brakes" to slow down the foot, ankle and lower leg coming down from a jump or hitting the ground running. If the proper stability and alignment of the foot is off, then those lower leg muscles and tendons are overused or bones are stressed.

Shin splints are common in all ages in all running, jumping activities — one of the often referred to overuse injuries. Prescription in-shoe orthotics are very helpful when foot mechanics are involved.

Again, most persistent and resistant shin problems are foot related. Treatments often include physical therapy, anti-inflammatory medicine and strengthening exercises.

Being in the proper shoes is always important. Knowing the foot type, especially in running, is also important. Sports related podiatrists, therapists, trainers and a competent running shoe store all can identify foot types. You'd be surprised how many athletes at all levels are not in properly fit shoes. Get measured.

patient questions:
– I'm a 53 year-old jogger who's run 15-20 miles a week for over 10 years. I know I have pronated feet and have used the proper motion control shoes recommended by a running shoe store. My question is about my 2-3 year history of back problems. Can this be pronation related?

--- Yes it can and it's more common than you think. Have your foot mechanics checked by a sports podiatrist or therapist. Orthotics very often are helpful especially when combined with the proper therapy.

– My 13-year-old daughter dances hip hop and modern dance 4-to-5 days a week. Her dancing is very acrobatic and her heels have bothered her on and off for over six months. We've tried gel pads but still there's a problem. Her pediatrician says rest-anything else?

--– Large back of heel growth centers are susceptible to stress until growth is over (another 1 ½-2 years). "Intelligent rest" absolutely is important, but physical therapy, proper strapping, and inserts can help. Often foot type contributes to stress to the heels, so have her evaluated.

InMotion Foot & Ankle SpecialistsDr. Bruce Werber10900 N. Scottsdale RoadSuite 604Scottsdale, AZ 85254480-948-2111www.InMotionFootandAnkle.cominmotionfootandankle@gmail.com

orthotics, how long will they last, when to repair or replace

2011-11-17T10:59:00.000-07:00

How Do I Know if My Orthotics Need To Be Replaced?

Sometimes it is difficult to determine when custom orthotic devices need to be replaced. Here are a few simple ways to determine it its time.
-That pain you had reduced or cured with the device has made a comeback – I can’t think of a better reason to get your feet and devices checked
- Your device is held together with gorilla glue and cardboard – those home modifications just don’t do the trick

- If your orthotics wobble, you may fall down - motion in devices that wasn’t there before can lead to foot pain and instability
- The top cover is thinner than you remember – with time all materials will flatten and wear, if your top cover is paper thin or looks like a piece of foam Swiss cheese get it replaced.
- Cracks do not give character – cracks in the shell of the device can occur with prolonged use, glue is NOT the answer

- Added modifications are lost, loose or not providing the control or pressure relief they used too – just like top covers, modifications can flatten with time, and they can loosen or get lost
These are just a few subtle reminders of when you need to have your devices replaced. Obviously other problems occur. While most devices last for several years, most insurance companies replace a device yearly if problems with the device are noted, so don’t hesitate and stop by for an evaluation.

InMotion Foot & Ankle Specialists Dr. Bruce Werber 10900 N. Scottsdale Road Suite 604 Scottsdale, AZ 85254 480-948-2111 www.InMotionFootandAnkle.com inmotionfootandankle@gmail.com

golfers - ankle and foot pain, limiting swing potential

2011-11-09T20:12:00.000-07:00

Golfers have a unique set of injuries that can limit the enjoyment of the game, or make the game not so pleasurable due to poor form and shots. Many times knee and hip issues are directly related to the function of the foot and ankle. For example if the range of motion in the big toe joint is limited, then this will throw the alignment of the hip and knee out of position and will change your swing mechanics. If you have arthritis in the ankle , this will change and limit your ability to rotate your legs during swing, it will also alter your stance, you will need to unconsciously change the way you hit the ball.

How do we minimize or eliminate these problems, there are many new concepts in treatment for these problems. Lets look at some new technologies that allow me to get you back to improved function and better scores.

Heel pain our number one best seller, different types of orthotics and sets of exercises eliminate the need for injections of cortisone. For heel pain that has not responded to traditional therapy we now offer a combination of high energy shockwave therapy (extra corporeal shockwave therapy ESWT) with platlet rich plasma and or amniotic membrane and fluid. This new combination of therapies provides healthy viable mesenchymal stem cells and a flood of growth factors that stimulate your body to heal it self. This can be used for heel pain, tendon injuries, arthritic joints, diabetic wounds. The results we have seen in our studies have been frankly unbelievable.

What if your ankle joint is to far gone for the combination therapy mentioned above well in some cases we can do arthroscopic repair and implant new cartilage cells to reverse some arthritic conditions, as last resort we can know safely and reliably replace your ankle , just like hips and knees can be replaced. The same goes for your big toe joint.

It is no longer necessary to suffer, new technologies are here for you, don’t suffer, come in for an evaluation. We can discuss how to improve your foot and ankle function so we can improve your golf game, making you play better, improve your enjoyment of the game, maybe win a few more rounds. Dr. Werber offers convenient appointments, accepts most insurances, and patients without insurance.

InMotion Foot & Ankle Specialists Dr. Bruce Werber 10900 N. Scottsdale Road Suite 604 Scottsdale, AZ 85254 480-948-2111 www.InMotionFootandAnkle.com inmotionfootandankle@gmail.com

foot and ankle specialist, Scottsdale, AZ

2011-05-18T07:36:00.000-07:00

InMotion Foot and Ankle Specialists - Podiatrist Scottsdale AZ ...
From routine checkups to treatments for surgery, Podiatrist, Dr. Bruce Werber, DPM, FACFAS is equipped to handle all your foot & ankle needs. ...
www.facebook.com/InMotionFootAndAnkle?sk=app...

InMotion Foot & Ankle Specialists
Dr. Bruce Werber
10900 N. Scottsdale Road
Suite 604 Scottsdale, AZ 85254
480-948-2111
www.InMotionFootandAnkle.com
inmotionfootandankle@gmail.com

nail cancer - melanoma, check your fingers and toes

2011-05-18T07:34:00.000-07:00

Scottsdale doctor warns of nail cancer | Arizona State News.Net
Dr Bruce Werber says it is rare, but serious. According to Werber, nail cancer accounts for 15-percent of skin cancer cases. Although it is rare, ...
www.arizona.statenews.net/index.php?rid=45455804

InMotion Foot &Ankle Specialists
Dr. Bruce Werber
10900 N. Scottsdale Road
Suite 604 Scottsdale, AZ 85254
480-948-2111
www.InMotionFootandAnkle.com
inmotionfootandankle@gmail.com

nail cancer - melanoma, check your fingers and toes

2011-03-24T09:24:00.000-07:00

Nail Cancer: 2 Kalamazoo residents vow to raise awareness, and the survival rate, for rarely diagnosed melanoma

Published: Monday, March 14, 2011, 12:05 PM Updated: Monday, March 14, 2011, 12:08 PM

By Kaye Bennett

Mark Bugnaski / Kalamazoo GazetteArt Hoekstra, left, has a disease called acral lentiginous melanoma (aka nail cancer). Maria Drawhorn who also has the disease claims Hoekstra saved her life by suggesting that she should get diagnosed. They are working on an awareness campaign about this very rare disease. Hoekstra is wearing a Bob Marley shirt who died from acral lentiginous melanoma. Gazette / Mark Bugnaski

KALAMAZOO — Statistically, Art Hoekstra of Kalamazoo should never have gotten acral lentiginous melanoma.

That form of cancer, of the nail, is so rare that only about 80 people a year in this country are diagnosed with it, and those who get it are more likely persons of color, which Hoekstra is not.

But what really staggers the imagination is that Maria Drawhorn, also from Kalamazoo and a friend and colleague of Hoekstra, was diagnosed with nail cancer as well — thanks to Hoekstra’s persistent urging that she get a biopsy on a discolored fingernail.

Their shared diagnosis and professional experience in organizing projects have inspired them to spread the word. Their goal: To make sure that nail cancer is diagnosed early, like Drawhorn’s, rather than late, like Hoekstra’s.

Hoekstra, 61, is well known in Southwest Michigan as the longtime director of the Kalamazoo Deacons Conference, a Christian organization that serves the emergency needs of the poor. In 2001, after 21 years with the Deacons Conference, Hoekstra left that role and began working for local and national organizations to eliminate racism. Not long after this career move, Hoekstra’s experience with cancer began.

He had a 20-year history of toenail fungus — at least that’s what he thought it was. About seven years ago, he asked his physician about the nail on one of his toes, where the lesion looked darker and more discolored than the rest and he was not surprised to hear that it was just another case of fungus. He followed doctor’s orders and treated the nail, the fourth toe on his right foot, with an anti-fungal medicine. But he was prepared for a lack of results, since nail fungus is notoriously resistant to treatment.

Then, in late 2008, that nail got much worse. It ulcerated and began to bleed. Hoekstra’s doctor ordered a biopsy. The report came back on New Year’s Day 2009, when Hoekstra and his wife, Mary, were in Chicago, celebrating the holiday with their daughter Anna.

At that time, Anna Hoekstra, M.D., who is now 35 and a physician at the West Michigan Cancer Center in Kalamazoo, was doing a fellowship in gynecological oncology at Rush University Medical Center in Chicago.

She understood the implications of that biopsy report much better than her parents did. “I broke into tears,” she recalled. “I told him I was scared.”

She had never seen a case of nail cancer, but she’d seen enough cancers at that point in her career that she knew melanoma could be a deadly disease. Holiday or no, Anna Hoekstra began making phone calls on behalf of her father, lining up appointments with surgical and medical oncologists at Northwestern Memorial Hospital in Chicago. Within two weeks, Hoekstra’s toe had been amputated and a series of tests and scans began.

Courtesy Photo

When Hoekstra came home, he started chemotherapy at the the cancer center in Kalamazoo. His treatment with interferon continued until he had a transient ischemic attack (a “mini-stroke”), after which it was decided that he should be given a different chemotherapy drug, interleukin. But the interleukin treatment he needed had to be given at Northwestern, and he needed to spend a week in the hospital every time he got the drug. Its side effects sent Hoekstra to the intensive care unit multiple times.

By Christmas 2009, scans showed that Hoekstra’s cancer was continuing to progress and his doctors decided that the interleukin treatment wasn’t working for him. They put him in contact with the National Institutes of Health, to see if he qualified for any research protocols.

By this time, Hoekstra had lesions in his pelvis, kidney, stomach and brain. The brain lesions disqualified him from the NIH trials, so he focused once again on the treatment he could receive in Kalamazoo. Back at the cancer center, Hoekstra had stereotactic radiosurgery, “zapping the lesions with minimal damage to the rest of the brain.” This was followed by radiation to Hoekstra’s brain and abdomen, treatments which ended in May 2010.

Last June, while Hoekstra and his wife were vacationing in San Francisco, they saw a news story about a new drug that was being made available to patients with advanced melanoma.

Bristol-Myers-Squibb’s ipilimumab, a targeted T-cell antibody, is under review by the U.S. Food and Drug Administration. It has been shown to improve overall survival in adults with advanced melanoma and is currently available for compassionate use. (This means that a seriously ill patient may be given a new, unapproved drug if no other treatments are available.)

Encouraged by the news report and the feeling that there might be a chance in trying the new drug, the Hoekstras flew back to Michigan the next day.

Art and Mary Hoekstra weren’t the only people hurrying back to Kalamazoo because of ipilimumab. Hoekstra’s oncologist at the cancer center, Marcia Liepman, M. D., had been at an oncology convention in Chicago when she learned that ipilimumab would be available for compassionate use at Henry Ford Hospital in Detroit. Liepman came home and worked through the weekend to get Hoekstra enrolled in the protocol that would let him receive the treatment.

When the Hoekstras got home, they discovered that Liepman had succeeded in getting him into the study.

Currently, Hoekstra is in his second course of treatment with ipilimumab. Unlike other chemotherapy agents he’s tried, this one has extremely mild side effects, he says, and its infusion takes just an hour. Recent scans and an MRI have shown that most of his lesions are gone. After he completes ipilimumab treatment, he faces still more surgery.

Fighting cancer is “like a full-time job,” he says.

Mary Hoekstra and the couple’s three daughters take turns driving him to Detroit for his treatments. Busy as his medical condition keeps him, however, Hoekstra has kept up with his work on committees to fight racism. That’s when he noticed the middle finger on Maria Drawhorn’s left hand.

Drawhorn became involved in anti-racism initiatives when she worked at Kalamazoo’s YWCA, and she frequently works on projects with Hoekstra. He and Drawhorn were at a business lunch in early 2009, when he found himself staring at her fingernail, which was noticeably darker in color than the others.

Hoekstra remarked that Drawhorn’s use of nail polish was creative and, he recalled, “She said it wasn’t polish.”

He told her, “I wish you’d get a biopsy. It might be cancer.”

Drawhorn didn’t take his advice. But Hoekstra didn’t give up. “I’d try to pester her in ways that didn’t make her strangle me,” he said.

She was not concerned about the nail, which had been discolored since she was a toddler. “My mother thought it was from an injury, and the doctor thought it was a mole.” So she told Hoekstra, “It’s not the same. Mine’s always been there.” But, after six or eight months, Hoekstra wore her resistance down. Since she had an appointment with a dermatologist anyway, she decided to mention the nail so that the next time she saw Hoekstra, he would be pacified.

The dermatologist agreed to do a biopsy, which confirmed the lesion was indeed a melanoma. In November 2009, Drawhorn had part of the finger amputated, but tests showed she did not need chemotherapy or radiation, thanks to having found the cancer so early.

She will continue to see a physician for tests and, now that she knows she has this tendency, she will be diligent in monitoring any changes on her skin. She also plans to use sunscreen. “Being a person of color [Drawhorn is of Mexican ancestry] doesn’t make you immune to sun damage,” she said.

Although there is no conclusive evidence that sun exposure is directly related to nail cancer, the staff at the University of Michigan’s Melanoma Clinic advises patients that the body’s overall immune response to the sun can be related to the development of melanomas.

Since Drawhorn had the discoloration for more than 30 years, doctors told her there was no way of knowing whether it had always been malignant or if it had just recently become cancerous. The good part, they told Drawhorn, was how early she’d been biopsied. Her cancer was considered in situ, which meant that it hadn’t spread from the initial site; Art Hoekstra’s, by contrast, was a Stage IV by the time it was diagnosed.

Drawhorn credits Hoekstra’s persistence with saving her life — as well as with saving her from the complicated course his own disease had taken.

”My finger gets cold in the winter and I can’t type as fast as I used to,” she said, but other than that, physically she’s been minimally affected. Emotionally, however, cancer has taken a toll. “It made me re-evaluate every aspect of my life,” she said.

Drawhorn and Hoekstra are not convinced that both of them having such a rare disease is all that coincidental.

Drawhorn questions the accuracy of incidence figures: “I think the incidence is probably higher than we think,” she says.

Dr. Anna Hoekstra agrees; she said she expects the number of cases of nail cancer to increase as the disease gets to be better known. “Every time a diagnosis gets more attention, more cases are seen.”

Art Hoekstra says that the experience he and Drawhorn have shared is “a calling for us to tell our stories” and, in so doing, to encourage people to be more aware of this cancer.

As professional organizers, “We’re good at putting people together,” Hoekstra said.

And now they have this shared cause: To raise awareness among patients and healthcare providers, as well as nail technicians, because people who give manicures and pedicures are in a good position to observe the discolorations which are the hallmark of the disease.

This year, they launched a Nail Cancer Awareness campaign.

They’re off to a good start, lining up a list of not-for-profit organizations to act as partners, securing grants, creating posters and presentations with photos of typical nail cancer lesions, and speaking to groups around the community.

Hoekstra and Drawhorn aren’t afraid to think big. They hope that by May (Melanoma Month) of 2012, every doctor and manicurist in the U.S. will have seen the photos and be much more familiar with nail cancer. They have been in contact with Prevention magazine about a story on this disease.

Drawhorn said: “For Art to have cared enough to say something to me and encourage me to have [my finger] looked at. . . is an amazing story.”

It’s an amazing story that they both hope can be repeated many times to help protect others from this deadly form of cancer.

InMotion Foot & Ankle Specialists Dr. Bruce Werber 10900 N. Scottsdale Road Suite 604 Scottsdale, AZ 85254 480-948-2111 www.InMotionFootandAnkle.com inmotionfootandankle@gmail.com

How podiatrist contribute to great healthcare at lower cost to society

2011-03-19T09:40:00.000-07:00

Single podiatrist visit: $3.5 billion in US health care savings per year
If every American at risk for developing a diabetic foot ulcer visited a podiatrist once before
complications set in, the US health care system could save $3.5 billion in one year. Closing this
gap in podiatric care would reduce health care waste on preventable conditions, which
reportedly starts at $25 billion, by 14 percent.
This estimation is a projection based on findings from a Thomson Reuters study published in
the March/April 2011 issue of the Journal of the American Podiatric Medical Association.
The study’s numbers were based upon the American population that has either commercial insurance (116 million) or Medicare (46 million) in the Thomson Reuters MarketScan Research
Database. Sponsored by APMA and independently conducted by Thomson Reuters, the study
measured the health care records of nearly 500,000 patients with commercial insurance and/or
Medicare.
Publication in JAPMA, a peer-reviewed journal, validates these data for legislators, the media
and other health care professionals. APMA has created a variety of resources for members to
use as they communicate with these and other stakeholders about the study.
Read more: www.apma.org/podiatristvalue

InMotion Foot & Ankle Specialists
Dr. Bruce Werber 10900 N. Scottsdale Road Suite 604 Scottsdale, AZ 85254 480-948-2111 www.InMotionFootandAnkle.com inmotionfootandankle@gmail.com

running shoe controversy

2011-03-02T12:17:00.000-07:00

What kind of running shoe should I get to reduce my risk of getting injured?

The answer

For three decades, running shoes have been constructed to fulfill two basic missions: cushion your foot’s landing and control its “pronation” – the amount that it rolls inward with each step.

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“I was completely convinced that impact is something bad, and pronation is something bad, and I wanted to show that,” recalls Benno Nigg, a biomechanics researcher and co-director of the University of Calgary’s Human Performance Lab, who helped shape the original theory of pronation.

The initial studies were promising. Specialized running shoes, designed to address different degrees of under- or overpronation, could indeed reduce the impact forces shooting up through the legs of runners in lab testing. In the United States, sales of these high-tech shoes jumped from 25 million pairs in 1988 to 40 million in 2009, and growth was similar in Canada.

But there was just one problem: Running injuries didn’t disappear. While reliable statistics are hard to find, it appears that levels of common running injuries, such as plantar fasciitis, Achilles tendinitis and runner’s knee, have stayed roughly constant. Shoe researchers now face the possibility that the theory has been wrong all along – which would suggest we should either ditch shoes altogether, or look for simpler cues, such as comfort, to guide our shoe choices.

For Dr. Nigg, the realization came gradually. While study after study showed that shoes could manipulate impact forces, no one could produce any evidence linking these forces to injury rates.

The most telling test of the “pronation paradigm” came in a paper published last year in the British Journal of Sports Medicine by researchers at the University of British Columbia working with the Nike Sports Research Laboratory in Oregon. They studied 81 women enrolled in a 13-week training program prior to a half-marathon, dividing them into three groups based on their foot type and degree of pronation. But instead of fitting them with the “correct” shoe for their foot type, the researchers randomly assigned them to one of three types: neutral, stability or motion control.

“We were a bit nervous, because … if you see someone who is highly pronated, putting them in a neutral shoe may be a recipe for causing more pain,” acknowledges Michael Ryan, the study’s lead author, who is now a postdoctoral researcher at the University of Wisconsin.

He needn’t have worried. Twenty-six of the 81 women, or 32 per cent, reported injuries, but there was very little correlation between foot type, shoe type and injury rate. In fact, subjects who received the “correct” shoe for their foot type were even more likely to get injured or report discomfort than those running in the “wrong” shoes. More than half of the subjects assigned to motion-control shoes – the heaviest and bulkiest category for severe pronators – reported injuries, including all five of those with highly pronated feet.

Chris McDougall, author of the 2009 bestseller Born to Run, greeted the results with a blog post titled “Breaking news from Nike: We’ve been talking a lot of crap, and selling it.” In his view, the results were proof that we should be running barefoot, or at least in “minimalist” shoes that force us to mimic the gait of our caveman ancestors.

It’s not that simple, though. It’s true that minimalist shoes steer you away from the most common running mistake of overstriding (taking steps that are too long, so that your foot pounds into the ground far in front of your body instead of underneath your centre of gravity). But right now, barefoot running is at the same stage pronation-control shoes were in 1985: an intuitively attractive idea that makes sense, but hasn’t yet been tested. (Dr. Ryan and his colleagues are planning a follow-up study that repeats their previous experiment and also includes a minimalist shoe.)

In fact, numerous studies have found that training decisions – how far you run, how fast, how much recovery you allow – are far more important than shoes in predicting injuries. Those factors account for about 80 per cent of injury risk, according to one prospective study by Dr. Nigg’s group.

So where does that leave runners trying to choose a shoe? “The only thing we have is comfort,” Dr. Nigg says.

A decade ago, he and his colleagues studied 206 soldiers who were given six different shoe inserts and allowed to choose whichever felt most comfortable. There was no apparent connection between the soldiers’ foot types and the inserts they chose, but the number of injuries dropped significantly.

Dr. Ryan agrees: “The shoe should feel balanced. If it’s over- or undersupported, your lower leg muscles will have to work harder, which will make it feel less comfortable.”

As buying advice goes, that may seem a bit vague, but at least it’s simple – and until further studies are completed, it’s the best we’ve got.

Alex Hutchinson blogs about research on exercise at sweatscience.com. His new book, Which Comes First, Cardio or Weights?, will be published in May.

InMotion Foot & Ankle Specialists
Dr. Bruce Werber
10900 N. Scottsdale Road
Suite 604
Scottsdale, AZ 85254
480-948-2111
www.InMotionFootandAnkle.com
inmotionfootandankle@gmail.com

high heels and shoe inserts are they worth it

2011-02-24T15:39:00.001-07:00

High heels are high fashion. But the pain they can cause isn't pretty.

Makers of shoe insoles claim their product can help "prevent foot aches and pains, guaranteed" or provide "all-day comfort" and "cushion the entire foot area," so Consumer Reports Shopsmart put shoe insoles to the test, checking out four that cost between $8 and $13.

To test, 14 women tried each of the insoles in a pair of her shoes that had at least 2-1/2 inch heels, with some as high as four.

Jody Rohlena, with Consumer Reports Shopsmart, said, “The women did a lot of walking for this test. Each did a total of almost five-1/2 miles."

So what were the results? Not great for Dr. Scholl's for Her High Heel Insoles and Insolia high heel inserts. One woman who tested them out said. “My shoes didn't feel any more comfortable than they did without them."

Foot pedals Killer Kushionz did make shoes feel a little more comfortable. But the package says they are "not recommended to remove and reuse." Turns out the adhesive damaged some of the shoes.

Desiree Ferenczi said, “The whole lining is torn out and it looks really yucky now. It's not a nice shoe."

As for the Fab Feet three-quarter insoles from Target, they also made shoes a little more comfortable, but were easier to remove - although most of the women thought none of the insoles were worth the money.

When it comes to comfortable shoes, Consumer Reports Shopsmart says a big problem is people often buy shoes that are too small, selecting the size they've always worn.

But your feet change, so it's important to get measured each time you shop for shoes.

A good-fitting pair should have a pinkie's width between the end of your toes and the tip of your shoe.

InMotion Foot & Ankle Specialists
Dr. Bruce Werber
10900 N. Scottsdale Road
Suite 604
Scottsdale, AZ 85254
480-948-2111
www.InMotionFootandAnkle.com
inmotionfootandankle@gmail.com

Not the Deadliest Catch

2011-01-09T20:42:00.001-07:00

Not the Deadliest Catch

Today we’ll stray from the normal, fairly familiar foot issues to take a look at a relatively
rare cause of complications in podiatric medicine, that is, unless you’re a fisherman.

Catfish are the fifth most popular fish in the Western Hemisphere. In fact, there are over
3,000 different species of catfish worldwide, many of which are venomous to humans.
The feline-like fish possess venom glands in their “armpits” (the area just behind their
front gills), as well as glands in their dorsal fin (the one on top) and the pectoral fin
barbels (the fins on the sides). The fins are made of sharp teeth that can cut deep into
your skin, allowing for extensive tissue exposure and better absorption of the venom.
Again, soft-tissue infections caused by catfish envenomation are very uncommon to the
everyday podiatric medical office, but they do occur.

In the medical literature, most reported cases involve people stepping on, dropping or
kicking catfish and having a portion of the spine or fins embedded into their foot. Should
this ever happen to you, symptoms will include pain, redness, swelling, muscle twitches,
electric shocks and possible tissue death.

Due to the large diversity of the species, there is no definitive treatment regimen for
catfish stings. The most common treatments would include local wound care, removal of
any foreign bodies and antibiotic therapy.

The most important lesson to take away from this strange scenario is should you ever
find yourself stung or pierced by a catfish, whether at a farmers market or on the open
sea, don’t delay medical treatment. You should see your doctor immediately! Happy
Sailing!

InMotion Foot & Ankle Specialists
Dr. Bruce Werber
10900 N. Scottsdale Road
Suite 604
Scottsdale, AZ 85254
480-948-2111
www.InMotionFootandAnkle.com
inmotionfootandankle@gmail.com

2011-01-05T11:21:00.000-07:00

Foot Orthoses in the Prevention of Injury in Initial Military Training
A Randomized Controlled Trial

1. Andrew Franklyn-Miller, MBBS*†‡§,
2. Cassie Wilson, PhD‡,
3. James Bilzon, PhD‡ and
4. Paul McCrory, PhD†

+ Author Affiliations

1.
*Britannia Royal Naval College, Dartmouth, Devon, United Kingdom.
2.
†Centre for Health Exercise and Sports Medicine, University of Melbourne, Melbourne, Australia.
3.
‡School for Health, University of Bath, Bath, United Kingdom.
4.
Investigation performed at Britannia Royal Naval College, Dartmouth, Devon, United Kingdom

1. §Surgeon Commander Andrew Franklyn-Miller, Royal Navy, Centre for Human Performance, Rehabilitation and Sports Medicine Research, Defence Medical Rehabilitation Centre, Headley Court, Epsom, Surrey, KT18 6JW, United Kingdom (e-mail: afranklynmiller@me.com).

Abstract

Background: Overuse lower limb injury is common in incidence and morbidity. Many risk factors, gait related and biomechanical, have been identified, although little conclusive evidence has been found in terms of injury prevention to date.

Hypothesis: Orthoses, as produced by proprietary software interpretation of plantar pressures, are able to reduce injury rates in an “at risk” military population.

Study Design: Randomized controlled trial; Level of evidence, 1.

Methods: Four hundred military officer trainees were assessed by means of pressure plate recording of their contact foot pressures during walking. Participants were risk assessed and randomized to receive or not receive customized orthoses using the D3D system. Both cohorts were followed up for injury through their basic training at the 7-week point.

Results: The orthotic intervention group sustained 21 injuries in total (1 injury per 4666 hours of training), whereas the control group sustained 61 injuries in total (1 injury per 1600 hours of training) (P < .0001), thereby demonstrating an absolute risk reduction of 0.49 from use of the orthoses (P < .0001, chi square; confidence interval, 1.7, 2.4).

Conclusion: In this military trainee population, orthoses were effective in the prevention of overuse lower limb injury. This is the first study to identify a positive preventive role of orthoses.

InMotion Foot & Ankle Specialists
Dr. Bruce Werber10900 N. Scottsdale Road
Suite 604
Scottsdale, AZ 85254
480-948-2111
www.InMotionFootandAnkle.com
inmotionfootandankle@gmail.com

Flatfeet and children

2010-12-15T15:57:00.000-07:00

Feet Flat as a Board – Not Necessarily a Problem

If you think your flat-footed child could soon be at a disadvantage when it comes to keeping up with their peers in sports, think again. Children’s flatfoot is a very common concern among parents and is therefore a fairly regular reason for trips to the pediatrician. Treatment guidelines for children with flat feet happens to be a topic of hot debate in the medical community. While most parents want something done for their child, it is not always necessary. Many unknowing practitioners simply prescribe orthotics and arch supports, figuring since the child has a flattened arch they must need some form of support. Often times in the realm of pediatrics, part of practicing good medicine is knowing how to effectively work with worried parents in order to shed light on slightly hazy (but not crazy) concerns.

While the exact incidence of pediatric flatfoot is unknown, it is common. At birth, virtually all children are flat-footed. This is not painful to the child, who is many months away from walking on their tiny feet, and it generally resolves without any treatment. It is quite rare that any type of corrective measures need to be taken. That’s not to say that treatment is never needed for other underlying conditions, which is why it’s not a bad idea to bring your child to a podiatrist if you’re concerned about their feet. There are various conditions that can be problematic if left alone for too long, but again, these are fairly rare.

The first question you want to ask yourself is: does my child complain of pain in their feet? If the answer is no, then you probably don’t need to do anything until they are a little older. To give you an idea, it is considered completely normal for children to have flat feet until they are 7 or 8 years old. Now, if your child does experience pain in their feet, it may be time to go see the doctor.

Before you ask your doctor to prescribe your child inserts for their flat feet, please consider this: what you put in your children’s shoes is not as important as what you put in their mouths. A rapidly growing problem in America is childhood obesity. While celebrities and political figures actively talk about this problem in the media, more doctors need to talk about it in their exam rooms with their patients. Abnormally excessive weight places unneeded stress on growing feet, and according to many studies places the child at higher risk to developing severe foot-related problems both immediately and later in life. The foot is a very complex structure, and obese children experience changes to that structure which create instability while walking. When a child’s feet hurt, they’re less likely to exercise, so providing a healthy diet is a good way to either prevent your little ones from gaining excess weight or to help them lose weight if they’re already obese.

While obesity and flat-footedness are two different topics, they can be related. As always, it is important to see a podiatrist if you suspect you or your children are suffering from foot-related problems. Just don’t be surprised if they tell you your child’s flat feet are normal and no treatment is necessary.

InMotion Foot & Ankle Specialists
Dr. Bruce Werber
10900 N. Scottsdale Road
Suite 604
Scottsdale, AZ 85254
480-948-2111
www.InMotionFootandAnkle.com

inmotionfootandankle@gmail.com

2010-12-05T08:49:00.001-07:00

large prospective randomized controlled trial (level-1 evidence) that studied the effects of foot orthoses on the prevention of injuries in the feet and lower extremities of military officer cadets during their basic training (Franklyn-Miller A, Wilson C, Bilzon J, McCrory P: Foot orthoses in the prevention of injury in initial military training. A randomized controlled trial. Am J Sports Med, on AJSM PreView, 11/1/10). This study was performed at the Britannia Royal Naval College in Dartmouth, Devon, UK.

A total of 400 subjects were risk-assessed and then randomized into two cohort groups: 1) recruits that received customized foot orthoses, and 2) recruits that did not receive orthoses. Both cohort groups were followed up for injury through their basic training at the seven week period. Results from the study showed that the group of 200 cadets that received orthoses sustained 21 injuries in total (1 injury per 4,666 hours of training), while the control group (no orthoses) of 200 cadets sustained 61 injuries in total (1 injury per 1,600 hours of training) (P<.0001).

Therefore, this study clearly demonstrated that the group of military cadets that did not receive foot orthoses for their basic training were 2.9 times more likely to suffer injury to their feet and lower extremities than the group of military cadets that did receive custom foot orthoses before their basic training. This study will add significantly to the growing body of scientific evidence of the therapeutic benefit of foot orthoses for the prevention and treatment of foot and lower extremity injury.

InMotion Foot & Ankle SpecialistsDr. Bruce Werber10900 N. Scottsdale RoadSuite 604Scottsdale, AZ 85254480-948-2111www.InMotionFootandAnkle.cominmotionfootandankle@gmail.com

2010-11-30T16:12:00.001-07:00

MRSA, in my Foot?

Today, more Americans are developing MRSA infections than ever before. What’s
more, they are getting them from common, relatively minor foot problems like cuts,
cracks in the skin, athlete’s foot and ingrown toenails. While these infections are on
the rise, there also seems to be a number of quickly growing misconceptions about
MRSA. Most people recognize the term “MRSA”, but they don’t quite realize what it
really is beyond the fact it is serious. When asked to define MRSA, some patients say “a
frightening infection”, others say “flesh-eating bacteria” and still others simply don’t
know. First of all, flesh-eating bacteria is something different than MRSA. Now, while it
can be frightening, you don’t need to lose any sleep over MRSA tonight because we’re
going to cover it in the following paragraphs and after reading the facts, you should feel
more comfortable and less afraid should your doctor ever tell you that you have MRSA.

MRSA is simply an acronym for “Methicillin-Resistant Staphylococcus Aureus”. When
you break it down, Methicillin is a type of antibiotic and Staphylococcus Aureus is
nothing more than a type of bacteria. So, when put together, MRSA is just a type of
bacteria that is resistant to certain types of antibiotics. Unfortunately for us, there aren’t
a lot of good options for treating MRSA; however, fortunately for us, the ones we do
have can be very effective.

There are, generally speaking, two types of MRSA: community-associated and hospital-
acquired. These vary in ways other than the setting in which it is contracted, but
these differences aren’t necessary to explain in this setting. What you should know is
doctors have been diagnosing community-associated MRSA infections with increasing
frequency.

Staphylococcus bacteria, or Staph for short, are common. In fact, 1 in 3 people carry
these pesky bacteria. They live on your skin and in your nose and can be spread
through skin contact. When this bacteria becomes a major problem is when it gets
inside the body. Even minor tears in the skin’s surface open the door to bacteria and
infection. Common skin conditions such as athlete’s foot, calluses, corns, eczema
and psoriasis can create these open portals in the skin for bacteria to enter the body.
Walking barefoot increases the risk of cuts and puncture wounds. Here are a few simple
steps you can take to help prevent community-associated MRSA infections: Wash cuts
and cover them promptly with a bandage, see a doctor within 24 hours for any puncture
wound, never perform “bathroom surgery” to cut or dig out an ingrown toenail or foreign
body (like a splinter), and keep your feet clean and dry to prevent fungal infections like
athlete’s foot.

Hopefully you have a better understanding of MRSA now. The best thing to do if you
have an infected cut or scrape on your foot or ankle that doesn’t heal in a timely fashion
is to see a podiatrist and get it checked out.

InMotion Foot & Ankle SpecialistsDr. Bruce Werber10900 N. Scottsdale RoadSuite 604Scottsdale, AZ 85254480-948-2111www.InMotionFootandAnkle.cominmotionfootandankle@gmail.com

heel pain story

2010-10-22T11:22:00.001-07:00

A 51-year-old woman presented to the clinic complaining of left heel pain. On physical exam there was tenderness and soft tissue swelling of the posterior aspect of the left heel. Conventional radiographs of the left ankle were obtained in anteroposterior, lateral, and oblique views. They were essentially unremarkable, although the lateral view showed equivocal prominence of the posterior superior calcaneal tuberosity, along with subtle findings of increased density in the pre-Achilles fat (arrows, Figure 1). MR imaging was subsequently performed.

FINDINGS

Sagittal T1-weighted image (Figure 2) demonstrates focal decreased T1 signal within the pre-Achilles fat, as well as a prominent posterior superior calcaneal tuberosity (arrow). Sagittal proton density image (Figure 3) shows increased signal intensity in the pre-Achilles fat/retrocalcaneal bursa (arrow). Sagittal T2-weighted image (Figure 4) reveals mildly increased signal intensity within the distal Achilles tendon without evidence of a full-thickness tear. Axial T2-weighted image (Figure 5) better demonstrates increased signal intensity within the Achilles tendon (arrow) with associated retrocalcaneal inflammatory disease.

1. Left ankle, lateral view shows equivocal prominence of the posterior superor calcaneal tuberosity.
2. Sagittal T1-weighted image demonstrates focal decreased T1 signal within pre-Achilles fat and prominent posterior superior calcaneal tuberosity.
3. Sagittal proton density image shows increased signal intensity in pre-Achilles fat/retrocalcaneal bursa.
4. Sagittal T2-weighted image reveals mildly increased signal intensity within distal Achilles tendon without evidence of full-thickness tear.
5. Axial T2-weighted image better demonstrates increased signal intensity within the Achilles tendon with associated retrocalcaneal inflamma

Diagnosis

Haglund’s complex.

Discussion

Haglund’s deformity, commonly referred to as “pump bump,” is an enlargement of the posterior superior calcaneal tuberosity. Friction between the bony enlargement and Achilles tendon causes soft tissue inflammation, resulting in retrocalcaneal bursitis. This constellation of Achilles tendinosis, the bony enlargement, and retrocalcaneal bursitis constitute Haglund’s complex.¹ This condition is most commonly seen in young women who wear pump-style shoes. These shoes irritate the soft tissue by placing increased pressure on the bony enlargement. Other individuals who are prone to this condition include those with naturally high arches or a tight Achilles tendon.

Symptoms include pain at the Achilles tendon insertion site, erythema and swelling of the heel, and pain that is aggravated by dorsiflexion.

Initial treatment consists of conservative methods such as oral anti-inflammatory medications, heel lifts, ice, shoe modification, and calf-stretching exercises. Steroid injections are usually avoided in cases of Achilles tendinitis to avoid subsequent tendon rupture. If these methods are unsuccessful, surgery is considered.

MRI is the modality of choice in differentiating common causes of heel pain such as, but not limited to, plantar fasciitis, fracture, tarsal tunnel syndrome, bursal abnormalities, or tendon rupture.

Heel pain is a common complaint and many times can be managed conservatively. However, in cases where etiology is questionable and medical management is unsuccessful, MR imaging is useful in determining not only the diagnosis, but also the extent and severity of disease.

InMotion Foot & Ankle SpecialistsDr. Bruce Werber
10900 N. Scottsdale RoadSuite 604Scottsdale, AZ 85254480-948-2111
www.InMotionFootandAnkle.com
inmotionfootandankle@gmail.com

2009-04-12T16:25:00.000-07:00

Painful Bunions:

Leave the introduction describing bunions and picture intact and add:

Bunions vary in severity from a small bump on the inside of the foot to a large bump with severe outward deviation of the first toe(hallux) sometimes even causing impingement of the first toe onto the second toe. Just as the severity of bunions may vary, so does the range of surgical treatment options for correcting bunions.

Minimal to moderate bunion deformities often require that the surgeon perform a procedure that involves reshaping the bone at the base of the first toe called the metatarsal. Following reshaping , the surgeon then makes a cut in that bone which allows them to move that fragment of bone closer to the second toe and return the first toe to a straighter alignment, as it was prior to the occurrence of the bunion. The cut in the bone is then secured in place with medical grade screws.

Patients who undergo this type of procedure to correct their bunion can expect to spend 3-5 days with no weight bearing on the affected foot. This is followed by full weight bearing in a walking boot or cast for a period of 4-6 weeks. After approximated 4-6 weeks patients are able to return to normal shoe gear and return to regular daily activities.

You will need to be evaluated by your surgeon to determine the procedure that is best for you. More severe bunion deformities may require further surgery and longer periods of non-weight bearing on the affected side.

Please check back for updates that will include descriptions of surgical procedures for the correction of severe bunions.

InMotion Foot & Ankle Specialists
Dr. Bruce Werber
10900 N. Scottsdale Road
Suite 604
Scottsdale, AZ 85254
480-948-2111
www.InMotionFootandAnkle.com
inmotionfootandankle@gmail.com

silicon implant for painful foot lesions

2009-04-12T16:23:00.001-07:00

Injectable silicone (Corns, calluses, metatarsalgia)

Since we spend a large portion of our day upright, the bottom (plantar aspect) of our feet can experience a great deal of pressure. When you walk briskly, jog or run, your feet may experience greater than two times your total body weight. Many people often suffer from pain on the bottoms of their feet after prolonged periods of standing or walking. They may also experience painful corns or calluses of the feet which prevent them from wearing certain shoes or even walking barefoot.

Corns and calluses are formed by the body in response to areas of increased pressure. Increased areas of pressure develop as a result of losing the natural cushioning in your feet and exposing the underlying bone to repetitive stress from the ground called ground reactive forces. Cushioning in the feet is provided by subcutaneous fatty tissue. Subcutaneous fat diminishes as we age and over prolonged periods of continued pressure, similar to the wear on the soles of your tennis shoes. It can also be diminished in patients with diabetes or collagen vascular disease.

To date, there has been no way to replenish this loss of subcutaneous fat in the feet with the exception of injectable medical grade silicone. Inert medical grade silicone in very small amounts can be injected into areas of underlying corns and calluses to help restore a stable subdermal cushion between the skin and the bone. This often helps relieve pain and eliminate the corn or callus.

All drugs and medical devices have some degree of risk and these should be discussed with your physician prior to initiating any treatment regimen. The current level of scientific evidence supporting weight bearing pain relief far outweighs the associated risks.

Check back for a discussion on injectable silicone for use in preventing diabetic foot ulcers.

Bruce Werber DPM, FACFAS
www.arizonafeet.com

InMotion Foot & Ankle Specialists
Dr. Bruce Werber
10900 N. Scottsdale Road
Suite 604
Scottsdale, AZ 85254
480-948-2111
www.InMotionFootandAnkle.com
inmotionfootandankle@gmail.com

Success utilizing Silicon Implant for painful foot lesions

2009-04-12T15:07:00.002-07:00

We have had tremendous success utilizing this technique. 22 patients have had injections for painful foot lesions, that have been unresponsive to multiple alternative therapies.
Each of these 22 patients has had almost total to total relief utilizing this technique.

If you have a painful lesion, and need to have it cut down or you need to modify your shoes, or you are facing surgery to fix a painful lesion, let Dr. Werber evaluate you and consider the use of Silikon 1000 injection to resolve your problem

InMotion Foot & Ankle Specialists
Dr. Bruce Werber
10900 N. Scottsdale Road
Suite 604
Scottsdale, AZ 85254
480-948-2111
www.InMotionFootandAnkle.com
inmotionfootandankle@gmail.com

Injectable Silicone for Corns, Calluses, Metatarsalgia

2009-02-12T16:25:00.002-07:00

Injectable Silicone: Can It Mitigate Plantar Pedal Pressure?

Ambulation exposes the foot to a collaboration of focal pressure and repetitive stress, and ground reaction forces generated in response to weightbearing activities are the commonly responsible stressors.¹
The portion of the foot in contact with the ground varies during the stance phase of gait. Accordingly, the site of ground reaction force application varies, generally progressing from the heel at first contact to the hallux at toe-off.²
These forces contain vertical, anteroposterior and mediolateral components. However, the vertical force is much greater than the other two.³ Vertical forces can damage healthy tissue through compression and deformation. The mechanical stress generated by the anteroposterior and mediolateral components of ground reaction force are shear forces, which stretch and tear tissue.

The magnitude of ground reaction forces also varies over the course of the stance phase. Typically, the heel is in contact with the ground the first 64 percent of the contact phase while the forefoot is in contact the last 59 percent.¹ The amplitude follows a bimodal pattern with force initially rising at heel strike, decreasing as the foot rolls forward and then ascending a second time during toe-off.
The midfoot therefore experiences significantly less pressure forces than the heel and forefoot due to variations in the site of application and the magnitude of ground reaction forces. Consequently, the heel and forefoot are subjected to greater pressure, making these two areas susceptible to increased wear and tear.
Anatomically, the body accommodates this by providing plantar fat pads in these locations to assist with shock absorption. However, progressive loss of fat pad occurs due to structural anomalies (such as plantarflexed metatarsals and limited joint mobility); pathologic conditions (such as collagen vascular disease and diabetes); and normal age-related changes during the course of a lifetime.
In situations in which the patient is sensate, the resulting skin on bone situation is extremely painful, especially with ambulation. This severely affects the patient’s activities of daily living and quality of life.
In situations with insensate patients, continued normal ambulation can wear a hole in their skin, akin to normal patients wearing holes in their socks. Fat pad atrophy, regardless of the cause, is often associated with substantial emotional, physical, productivity and financial losses.^4-6

Understanding The Impact Of Fat Pad Atrophy And How Silicone Injection May Be Beneficial
It is well documented that plantar pressure is directly proportional to plantar tissue thickness.^7,8 Historically, physicians have treated corns and calluses with a myriad of palliative measures and more recently by surgical intervention.
Fat pad atrophy is common among people with collagen vascular disease and diabetes, particularly in the forefoot.^5,9 The loss of fatty tissue has been noted to be the fundamental mechanism associated with pressure related foot disorders.

Consequently, augmenting this high-risk area with an inert, viscoelastically robust substance such as silicone has the potential benefit to mitigate pressure. The commonly used unit for viscosity of fluids is centistokes (cs), with water having a centistokes value of 1. Silicone fluid used to replace soft tissue has a viscosity of 350 cs and one can easily inject this with a 25- to 27-gauge needle and a standard syringe.
The rationale for considering injectable silicone in the foot is that, regardless of the causes leading to increased digital or plantar pressure, there is an associated loss of subcutaneous fatty tissue. The development of essentially inert silicone fluids has provided the potential of augmenting the body’s own soft tissue via injection.
There is an injection procedure that allows physicians to implant silicone fluid to form a stable subdermal cushion between skin and weightbearing bone. The internal pad eliminates or reduces pain, and frequency of care for most patients. In cases of insensitive feet, this internal pad reduces the incidence of pressure ulcers.¹⁰
PodiaSil (Therapeutic Silicone Technologies) is a 350-cs injectable silicone that has been approved for marketing in Europe for the prevention of diabetic foot ulcers.¹⁰ Though previous studies suggest significant improvement in soft tissue thickness and subsequent profound reduction in plantar pressure, availability, production and medical/ legal factors have reduced the potential for widespread implementation.
Previous reports suggest a positive therapeutic use of liquid silicone injections in the foot to replace fat padding at callus sites, corns and localized painful areas.^5,10-12 To date, physicians have given more than 20,000 injections with anecdotal support of reduced callus formation, reduced diabetic foot ulcer recurrence and relief of localized pressure-related foot pain in non-diabetic patients.^9-12
Only minimal side effects have been reported. Unfortunately, this anecdotal evidence has been limited to a few centers.

What The Studies Reveal On Treatment Efficacy
Balkin injected silicone beneath corns and calluses in 1,585 patients, and gathered surgical and postmortem specimens for histologic analysis.¹⁰ Two pathology labs that studied the specimens noted no inflammation, infection, allergy or granulomas. Long-term clinical follow-up also found no evidence of significant adverse responses. Balkin concluded that medical fluid silicone appears to be safe, effective and stable biomaterial for treating weightbearing loss of plantar fat.¹⁰

Van Schie, et al., investigated the effectiveness of liquid silicone injections in the diabetic foot to reduce risk factors for ulceration in a randomized double-blind, placebo-controlled trial.⁵ A total of 28 diabetic neuropathic patients without peripheral vascular disease were randomized to active treatment with six injections of 0.2 mL liquid silicone in the plantar surface of the foot or the placebo treatment with an equal volume of saline.
Researchers noted no significant differences regarding age or neuropathy status between the two groups. All injections were under the metatarsal heads at sites of calluses or high pressures. The study authors measured barefoot plantar pressures and plantar tissue thickness under the metatarsal heads at baseline and at three, six and 12 months after the first injection.
Patients who received silicone treatment had significantly increased plantar tissue thickness at injection sites in comparison with the placebo group (1.8 versus 0.1 mm) and correspondingly had significantly decreased plantar pressures (-232 versus -25 kPa) at three months. There were similar results at six and 12 months.⁵
Physicians did note a trend toward reduced callus formation in the silicone-treated group in comparison with no callus reduction in the placebo group. The results of this study further confirm the efficacy of plantar silicone injections in reducing recognized risk factors associated with diabetic foot ulceration.
At a two-year follow up, researchers noted in the silicone group that the plantar tissue thickness, which had initially increased by an average of 1.6+/-0.9 mm at 12 months, remained increased at 24 months.⁹ However, the study authors found that the reduced peak plantar pressure in the silicone group at 12 months (-165.0+/-253.5 kPa) was lower at 24 months.
The reduction in the pressure time integral (PTI) in the silicone group did not reach significance at 12 months (-0.71+/-1.17 kPa/s). Although the PTI returned to baseline at 24 months for the silicone group, it was significantly increased in the placebo group (0.64+/-0.37 kPa/s).
This suggests that silicone may still exhibit some pressure-reducing properties after 24 months.⁹ The results indicate the cushioning properties of injected silicone are reduced at 24 months after the injection. This finding suggests that booster injections may be required in certain patients.
Studies are warranted to determine silicone’s efficacy to mitigate or prevent pressure ulcers because it appears to induce a relatively stable soft tissue prosthesis between skin and bone, and reduce the frequency of insensitive ulcer recurrence in the foot.¹²

What You Should Know About Fluid Migration
The migration of this silicone fluid remains the most significant, single adverse response ever since Balkin first reported silicone foot injection fluid drifts.¹¹ Despite findings that even relatively small amounts of silicone can migrate and, in rare instances, require surgical excision, it has long been assumed that fluid migration was due to over-injection.
One may see such movement as a thick silicone skin tag proximal to weightbearing metatarsal heads. At times, there may be a fine keratotic leading edge. These skin tags are essentially asymptomatic on bearing weight or direct palpation.
In one long-term study, from 1964 to 1995, 1,350 patients (986 female and 364 male patients with a mean age of 60.8 years) received silicone injections. The author of the study mostly injected over the soles but also performed silicone implantation in the lesser toes, the hallux, heels and bases of the first and fifth metatarsals.
Among this group, 885 patients received plantar injections beneath 1,879 metatarsal heads. Of these patients, 17 (1.92 percent) developed a soft to firm mass of migrant fibrous silicone tissue over the dorsum at 21 sites. Four patients had a single migratory site bilaterally. The study author noted that these complications occurred only with weightbearing and were painless upon firm palpation. (Balkin had reported this unusual response previously.¹³)
Balkin found that the earliest post-injection appearance occurred at 15 months and the latest at 13 years with an average post-injection appearance of five years. Four out of the 885 patients (0.45 percent) experienced sufficient discomfort in shoegear to warrant surgical removal, which was uneventful and without recidivation.

Migration from beneath a first or fifth metatarsal head tends to travel proximal medial or proximal lateral respectively. In all instances in which silicone migrated from plantar to dorsal, it followed implants beneath a second, third, or fourth metatarsal head. It is unknown why this type of migration was not observed or detected in earlier cases when larger amounts were injected. The 17 cases reported here received total amounts ranging from 0.4 to 4.1 mL (with a mean of 1.46 mL). Of the 17 patients with dorsal migration, 16 (94 percent) were women.
Aside from the lymphatic role in transporting silicone droplets, altered biomechanics induced by women’s shoes, which considerably increase forefoot pressure, appear to be contributory. Silicone implanted at metatarsal heads two, three or four may migrate distally or proximally as can a natural fat pad under weightbearing conditions.
Regardless of fluid migration, in most patients, the originally injected calluses remained improved or resolved, indicating that a further reduction of injected silicone might be desirable. Considering the inordinate forces to which feet are subjected, it may be impossible to prevent migration in every case.
In the study, the greatest amount of fluid injected into a patient at a single plantar site was 17.8 mL. This massive amount was 10 to 15 times greater than is currently suggested for a callus and is remarkable for its size and appearance. Yet over a 30-year course, it has remained asymptomatic.
Silicone migration following lesser toe implantation can also occur. Similar to plantar migration, such movement is infrequent and rarely symptomatic. Though silicone injections for a corn may make the toe appear fuller, there are no inflammation characteristics such as heat, redness, swelling or pain.
In several hundred treated small toes, a need for surgical excision of migrant silicone due to discomfort was rare (less than 0.5 percent). However, even in these rare cases, as with plantar migration, the original painful keratosis often resolved.

A Closer Look At The Histopathology Findings
The morphologic cellular responses and end fate of silicone have also been analyzed microscopically. In Balkin’s study, he noted 33 surgical biopsies and 124 postmortem specimens from 32 patients.¹⁰ Of these, 58 were digital and 66 were plantar. The earliest post-injection tissue examined was one month and the oldest was 29 years. Regardless of the time since injection, each specimen showed the presence of silicone.
Balkin noted the fluid was well retained at the deposit site by two essentially non-inflammatory tissue responses – histiocytosis and fibrosis.¹⁰ Histiocytes phagocytise foreign matter are part of the body’s scavenger system. The silicone is engulfed and retained within the histiocyte cell body as countless microscopic droplets.
The second key reaction to silicone fluid is that it stimulates the production of collagen fibers. The newly formed mesh of fibrous tissue acts like a web to further entrap and retain silicone fluid where it is deposited. Microscopic findings also show that numerous droplets envelop microneural and microvascular structures.
With thickening skin and encircling nerves with this resilient fibrous silicone coating, there is decreased neural impingement by the bone. This reduces stress and pain. Similar encircling of tiny blood vessels at pressure points appears to spare or protect vascularity via this cushioning mechanism.
This benefits patients who have neuropathic skin that suffers from pressure due to unrecognized callus or tight shoes. These patients are less likely to shift body weight as opposed to patients with intact nerves. Accordingly, these longer periods of unrelieved stress, when standing, walking or at rest, can diminish or stop local circulation.
Lymphocytes, eosinophils, fibroblasts or plasma cells are characteristic of chronic inflammation but one rarely sees these in silicone-injected tissue. Post-mortem specimen gathering has also afforded an opportunity to study inguinal nodes in 11 patients, including four in whom other lymph node systems were studied, as well as all major viscera.
Although the body does not reject silicone fluid, microscopic droplets are transported into the groin lymph nodes without clinical signs or symptoms. Other deep nodal systems and viscera revealed no silicone. Histopathologic findings suggest that injecting medical-quality silicone into the foot is a safe procedure.¹⁰

In Conclusion
Chemical and biomedical engineering advances have provided the healthcare industry with implantable polymeric biomaterials capable of repairing or replacing body parts. One such polymer, silicone fluid, can augment soft tissue and be remarkably well retained.
With regard to the lower extremity, this means that a quick, outpatient, injectable procedure can control or eliminate corns and calluses. When it comes to patients with diabetic neuropathy, this procedure can help eliminate the formation of ulcers.
The debate over the legitimacy of silicone as a safe tool for soft tissue augmentation has spanned well over half a century. Proponents concede that injections of questionable purity and/or of massive quantities have produced unfavorable outcomes. They assert that there are very few problems with “injectable-grade” silicone when experienced physicians perform the procedures.
Despite these claims, the literature is replete with disastrous outcomes following silicone fluid injection, often many years after the initial treatment.14 Unfortunately, as recently as 2006, reports in The New England Journal of Medicine and The New York Times failed to distinguish between the use of medical grade silicone injected by physicians trained in the microdroplet technique and the use of large volumes of industrial grade products injected by unlicensed or unskilled practitioners.¹⁵
Several independent evaluations and studies have found injected silicone fluid to be safe and effective as a facial dermal filler and as a soft tissue substitute for treating pressure induced foot disorders. Constant long-term patient review and extensive microscopic analysis have found no serious complications. No tumors or systemic responses were noted. Additionally, injected silicone does not impair healing nor impede venous or arterial circulation.
All drugs and medical devices have some degree of risk, and silicone foot injections are no different. The current level of scientific evidence supporting weightbearing pain relief far outweighs the risk of painless fluid migration or the rare need for surgical removal. For patients with diabetes, the fluid can prevent insensitive digital or plantar ulceration. With this capability, there is the extraordinary further potential of preventing toe, foot or leg amputation.
By breaking the chain of events of increased pressure leading to ulceration, physicians may be able to dramatically mitigate disastrous diabetic foot complications and their social and economic costs.
Further confirmation of these most favorable findings through official investigation, followed by silicone approval and appropriate use, could herald a new and exciting era in the history of foot care.

Dr. Wu is an Assistant Professor in the Department of Surgery at the Dr. William M. Scholl College of Podiatric Medicine at the Rosalind Franklin University of Medicine and Science in Chicago. She is the Director for Educational Affairs and Outreach at the Center for Lower Extremity Ambulatory Research (CLEAR) in Chicago.

Dr. Wu is also the Director of the National Center of Limb Salvage (NCLP) at the Advocate Lutheran General Hospital in Park Ridge, Ill.

Dr. Wu dedicates this article to Sol Balkin, DPM. She says Dr. Balkin, best known for his lifetime of research into the use of silicone in the feet, “was a warm
and compassionate practitioner who epitomized the highest values that a podiatrist could possess.”

References:

1. Wu SC, Crews RT, Armstrong DG. The pivotal role of offloading in the management of neuropathic foot ulceration. Curr Diab Rep. Dec 2005;5(6):423-429.
2. Van Deursen R. Mechanical loading and offloading of the plantar surface of the diabetic foot. Clin Infect Dis. Aug 1 2004;39 Suppl 2:S87-91.
3. Hamill J, Hardin, EC. Special Topics in Biomechanics. In: Kamen G, ed. Foundations of Exercise Science. Baltimore: Lippincott Williams & Wilkins; 2001:177-189.
4. Meijer JW, Trip J, Jaegers SM, et al. Quality of life in patients with diabetic foot ulcers. Disabil Rehabil. May 20 2001;23(8):336-340.
5. Van Schie CH, Whalley A, Vileikyte L, Wignall T, Hollis S, Boulton AJ. Efficacy of injected liquid silicone in the diabetic foot to reduce risk factors for ulceration: a randomized double-blind placebo-controlled trial. Diabetes Care. May 2000;23(5):634-638.
6. Boulton AJ, Kirsner RS, Vileikyte L. Clinical practice. Neuropathic diabetic foot ulcers. N Engl J Med. Jul 1 2004;351(1):48-55.
7. Abouaesha F, van Schie CH, Armstrong DG, Boulton AJ. Plantar soft-tissue thickness predicts high peak plantar pressure in the diabetic foot. J Am Podiatr Med Assoc. Jan-Feb 2004;94(1):39-42.
8. Abouaesha F, van Schie CH, Griffths GD, Young RJ, Boulton AJ. Plantar tissue thickness is related to peak plantar pressure in the high-risk diabetic foot. Diabetes Care. Jul 2001;24(7):1270-1274.
9. Van Schie CH, Whalley A, Armstrong DG, Vileikyte L, Boulton AJ. The effect of silicone injections in the diabetic foot on peak plantar pressure and plantar tissue thickness: a 2-year follow-up. Arch Phys Med Rehabil. Jul 2002;83(7):919-923.
10. Balkin SW. Injectable silicone and the foot: a 41-year clinical and histologic history. Dermatol Surg. Nov 2005;31(11 Pt 2):1555-1559; discussion 1560.
11. Balkin SW. Silicone injection for plantar keratoses. Preliminary report. J Am Podiatry Assoc. Jan 1966;56(1):1-11.
12. Balkin SW, Kaplan L. Silicone injection management of diabetic foot ulcers: a possible model for prevention of pressure ulcers. Decubitus. Nov 1991;4(4):38-40.
13. Balkin SW. The fluid silicone prosthesis. Clin Podiatry. Apr 1984;1(1):145-164.
14. Chasan PE. The history of injectable silicone fluids for soft-tissue augmentation. Plast Reconstr Surg. Dec 2007;120(7):2034-2040; discussion 2041-2033.
15. Narins RS, Beer K. Liquid injectable silicone: a review of its history, immunology, technical considerations, complications, and potential. Plast Reconstr Surg. Sep 2006;118(3 Suppl):77S-84S.
16. Zappi E, Barnett JG, Zappi M, Barnett CR. The long-term host response to liquid silicone injected during soft tissue augmentation procedures: a microscopic appraisal. Dermatol Surg. Dec 2007;33 Suppl 2:S186-192; discussion S192.
17. Prather CL, Jones DH. Liquid injectable silicone for soft tissue augmentation. Dermatol Ther. May-Jun 2006;19(3):159-168.
18. Orentreich D, Leone AS. A case of HIV-associated facial lipoatrophy treated with 1000-cs liquid injectable silicone. Dermatol Surg. Apr 2004;30(4 Pt 1):548-551. Additional Reference
19. Prantl L, Fichtner-Feigl S, Hofstaedter F, Lenich A, Eisenmann-Klein M, Schreml S. Flow cytometric analysis of peripheral blood lymphocyte subsets in patients with silicone breast implants. Plast Reconstr Surg. Jan 2008;121(1):25-30.

InMotion Foot & Ankle Specialists
Dr. Bruce Werber
10900 N. Scottsdale Road
Suite 604
Scottsdale, AZ 85254
480-948-2111
www.InMotionFootandAnkle.com
inmotionfootandankle@gmail.com

Have Foot Pain in Arizona, Call top doc Werber

2009-02-12T15:37:00.002-07:00

Dr Werber is Arizona's Top Foot Doc

InMotion Foot & Ankle Specialists
Dr. Bruce Werber
10900 N. Scottsdale Road
Suite 604
Scottsdale, AZ 85254
480-948-2111
www.InMotionFootandAnkle.com
inmotionfootandankle@gmail.com

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