The subject matter presented was cutting edge from the world's most re-owned experts. Topics included nail tumors, reviews and update on recent literature and research involving the nails, nail surgery and nail pathology including onychomycosis (Fungal infections)

Take away points

• Diagnosis and treatment of nail tumors is under diagnosed
• A correlation between fungus from the toenails and fingernails
• Use of combination of urea and anti fungal topical creams prevent recurrence.
• Presence of yeast, hyperhidrosis (sweaty feet) and smoking inhabits a patients cure.
• Laser (near infrared) treatment very promising in treating fungal infections.
• Laser (near infrared) also promising for treating psoriatic nails.
• Recurrent infections should be biopsied to rule out malignancy.

The meeting was very insightful and beneficial. I look forward to continual participation with the Council on future studies and research.

Fungus infections of the nails are very common and it appears that the incidence is increasing. Fungal toenails are the most common dermatological infection of the foot.

Onychomycosis is the number one disease treated by podiatrist in the United States and is seen in 20% of individuals 40 to 60 years of age, 32% in individuals between 40-70 years of age and 50% in those over 70.

Fungus is contagious to others and it can spread to other locations in the patients body. Most believe nail trauma and exposure to fungus (i.e. shoes, spas, and family members) are the cause. Some researchers believe there is a generic predisposition that causes some people to have an immune sensitivity to these infections.

The most common organism found in most infections is T.Rubrum. The disease is characterized by a thickening of the toenail, debris under the nail plate, lifting of the edge of the nail, color change and odor.

Although the condition is most often painless, cosmetically it can be ugly and embarrassing. Most people seek podiatric care for a solution.

The treatment for onychomycosis involves five basic options:

• Debridment (reduction of the nail thickness)
• Topical medications
• Surgical removal of infected toenail
• Oral medication
• New laser therapy

Debridment does not treat the infection. It will reduce the thickness and may improve the cosmetic appearance, but must be done monthly as the normal nail grows out about (2mm) a month. Fungal nails may grow at twice the rate.

Surgical removal and destruction of the root ( matrixectomy) may be effective at eliminating the infection, but may result in other problems as the end of the toe is now unprotected without a nail. Most patients do not choose these options as it cosmetically is unappealing.

Topical treatments are many, however, most have from 5-20% success rate. Although many pharmaceutical companies are in search of a good topical solution, it is not here yet.

Oral medications have been very effective, however, they all have poor safety profiles including cardiac, liver and kidney concern that require monthly blood testing and monitoring by a physician. There are also reinfection risks.

Laser therapy is the newest technology int he fight against the dreaded fungus infection. High powered pulse lasers that target the fungus with usually one treatment. It does not require anesthesia has a clinical efficacy of 88%.

Once fungus is cleared there are proactive prevention measures that are strongly advised:

• Proper hygiene
• Keeping the feet dry
• Inspecting between the toes
• Shower shoes for public areas
• Breathable shoes
• Anti-fungal shoe sprays
• U.V. light shoe trees also help kill fungus
• Not sharing pedicure instruments
• Bring your own polish to salons
• Avoid repetitive trauma (tight shoes, picking at nails)

Research is suggesting a 40% urea cream combined with an anti fungal cream is the best topical option for preventing reinfection.

Women who frequently visit nail salons should be concerned that they are at potential risk for; athletes foot, fungal infections, warts, hepatitis, HIV, and MRSA.

Dr. Dorfman recommends some very basic guidelines:

• If you get the feeling that a salon is not clean- leave.
• Ask how they sterilize instruments( Heat autoclaves are the best method)
• Technicians should wear gloves and wash their hands between clients.
• Food and drinks should not be kept at the work station as this is a hygiene standard.
• If the technician has sores/cuts or warts leave.
• Watch the technician clean and disinfect the basin and whirlpool.
• Bring your own instruments and polish.

Some states have stricter standards than others, however, these standards are only good if they are enforced. It is your health and you have the right to observe and ask questions concerning these issues.

Thank you to all the wonderful East Ocean Podiatry patients and suppliers that donated socks to help the homeless. This drive far exceeded our wildest dreams. We collected to date 1450 pairs of socks. Some patients donated money, which we used to purchase underwear. Thrift stores cannot accept used undergarments so the Lord's Place was thrilled we were able to take care of another need. On January 29th we went with Dr. Dorfman while he treated the feet of about 45 homeless at the Lord's Place in West Palm Beach. We were able to give each of them several pairs of socks and underwear. A supplier donated some shoes and we were able to fit about half of our visitors with new shoes. We were also able to donate compression stockings, antifungal powder, ace bandages and foot creams provided by East Ocean Podiatry.

Because of the generosity of so many people the socks continue to come as does the cold weather. This past week we donated another 120 pair of socks to NE Focal Point in Deerfield Beach. They are not a homeless shelter, but work closely with the homeless in our community and other shelters. They said socks are in great need.

I can't imagine Dwight Freeney of the Indianapolis Colts playing on what has been described as a grade 2 ankle sprain of his right ankle.

Playing right defensive end requires excessive force on the right ankle as he tried to get around the end.

A grade 3 ankle sprain is one in which all 3 of the ligaments that would hold the ankle stable ( bone to bone stability) are torn. This usually fro a professional athlete means surgical correction.

If they send him out to play in the Superbowl it probably means a local anesthetic, lots of tape and a fitted in shoe hinged brace. Without feeling he can certainly have a career threatening result. This certainly brings up a whole host of medical questions.

Lets hope that Dwight chooses whats on his best interest, as it is only a game, be it the Superbowl , walking is not overrated.

Watch out as bacteria and fungi thrive in warm, moist places like showers, saunas, and whirlpools. Given the right conditions, these fungi, bacteria and viruses (Plantars warts) can survive for hours or even days on the surfaces.

Threats of athletes foot, fungal nail infections, warts and MRSA are possible.

How to keep your feet safe:

• Keep all sores covered with a bandage and never put an open sore in a hot tub.
• Never share shoes, socks or sandals with others.
• Wear sandals in the shower or sauna.
• Thoroughly wash and dry your feet especially between the toes, use a blow dryer or towel and an anti fungal powder.
• Rotate your sweaty shoes and allow them to dry out.
• Use a U.V. light is excellent for killing fungus.

The injury usually occurs when the foot is pointing down into the turf and someone lands on the heel.

In Ronnie Brown's case it was a season ending injury that required two tiny screws to help fixate the fractured and realign the joint, Ronnie should be good to play next season as he will be non-weight bearing in a cast for 6 weeks, and then the rehab will begin.

Researchers in Israel have succeeded in wiring an artificial hand to existing nerve endings. The smart hand, resembles a real hand in functions, sensitivity, and appearance. The technology is being applied to help build a bionic leg.

Symptoms are worse at night and usually lead to insomnia.

The cause is unknown but is seen most often in pregnancy, obesity, anemia, in smokers , diabetics, and those with kidney failure.

Treatment is directed toward the underlying illness.

Requip and Mirapex are the latest drugs used to treat RLS. other treatments that are helpful are cold baths, avoid caffeine, TENS therapy and acupuncture.

Although we all look at the Ethiopian elite runners who run barefoot, I would caution those who want to try this ; that the adaptions to this style needs to be a slow process. One would want to start once a week and run short distances. Gradually increasing a quarter of a mile per week for three to four weeks.

As a side note, I am seeing a lot of increased lateral column syndrome and peroneal tendinitis in runners who have bought into the now rage.

Bottom line, be cautious with new fads, for those of us who love running it is very frustrating to be sidelined with foot ailments.

- Dr. Dean Dorfman

Moderate intensity aerobic physical activity ( heart rate 40-60%) for a minimum of 30 minutes five days a week, or vigorous intense physical activity (60-80% heart rate) for a minimum of 20 minutes, three days a week.

As a podiatric physician, we can help guide patients in choosing the appropriate athletic shoe type, athletic sock, lacing techniques and supportive insoles/orthotics to help prevent injuries and keep you in the game.

Good news! there are better quality flip flops now being sold by companies like Orthofeet, Fit Flops, Chaco and Aetrex are at the forefront.

Watch out ladies! as high heels are becoming more in Vogue, Monsieur Louboutin will be introducing and 8-inch stilettos this fall!!!!

Diabetic with neuropathy need to take special care to examine their feet daily, keep them well moisturized, wear properly fitted shoes, and avoid going barefoot.

Treatments begin with well controlled blood sugar, healthy diet, exercise, and good hygine. More severe cases require oral medications which do not cure the problem but can mask the symptoms. These medications do not come with serious side effecrs and need to be take only in extreme cases.

A recent independent study from the Amnerican Council on Exercise shows that none of the "fitness shoes" tested helped the subjects burn more calories or exercise muscle groups more intensely than a typical running shoe while walking at a 3.0-3.5 mph pace on the treadmill.

Truth in advertising or just a current trend? You be the judge.

1) Force = Mass x Acceleration (Newton's Second Law)
This translates into the more you weight and the faster you run the more force is placed through your feet.

2) Forces which do not act uniformly on all parts (your feet) of a body will also cause mechanical stresses, a technical term for influences which cause deformation(damage) of matter (your feet).
This means that force created by your body while running is not spread out evenly throughout your body. It is unequally placed on certain parts of your lower extremity (feet), and this will cause damage of your feet as time goes on.

As humans run we usually contact the ground (strike the ground) in two common places, the rearfoot (heel) and the forefoot (ball of the foot). These two areas of the feet absorb force very differently as you are running. Most people who run long distances have heel strike involved in their gait(running pattern), while people who sprint do not have heel strike, they hit the ground with their forefoot(ball of their foot).
As stated early heel impact is very different form impact on the ball of your foot. Heel Impact leads to a rapid, high impact force about 1.5 to as much as 3 times your body weight (depending on your speed) This is equivalent to someone hitting you on the heel with a hammer using 1.5 to as much as 3 times your body weight. These impacts add up, since you strike the ground almost 1000 times per mile! Many running shoes make heel strikes comfortable and decrease the change of foot injuries because they slow the rate of loading considerably, reduce the force by about 10% and spread this force out over a greater area of the foot.
Barefoot runners that prefer "going shoeless", have to become accustom to striking the ground with the "ball" of there foot, not their heel, because force through their heel repeatedly will become very painful. Although you can train your body to run and contact the ground with mostly your forefoot "ball of your foot", the force of your body weight has to go somewhere and eventually you increase your chance of stress related changes to your feet, by not spreading out the forces evenly. If you have been a heel striker, it takes some time and work to train your body to forefoot or midmost strike, especially because you need stronger feet and calf muscles. Runners may be at greater risk of developing Achilles tendonitis when they switch from heel striking to forefoot striking, along with other conditions such as "Stress Fractures".
Another important point to bring up is that "Barefoot Running" does not protect your feet from the environment around you. Thick-soled shoes are much more forgiving when running over glass, sharp objects, and bacteria on the surfaces we run on. In conclusion, I recommend to run in proper athletic shoes, but with that said we live in a country where you can run with or without shoes, and if you happen to choose to run without shoes, rest assure that I will be here to help you if those foot or ankle problems eventually due "catch up with you".

Dr. Dominick Sansone - Foot and Ankle Specialist/ Surgeon

If you have any questions email me at dr.dsansone@gmail.com

If you have any questions related to this topic email Dr. Sansone at dr.dsansone@gmail.com or make an appointment at www.eastoceanpodiatry.com

If you have any questions related to this topic email Dr. Sansone at dr.dsansone@gmail.com or make an appointment for evaluation at www.eastoceanpodiatry.com

1) arthritis of 3 or more joint areas
2) morning stiffness
3) arthritis of the hand joints
4) symmetric arthritis
5) rheumatoid nodules
6) serum rheumatoid factor.

Evaluation for RA can be made by multiple different specialties in the medical field. Evaluation from a rheumatologist for long term treatment and monitoring is recommended, while surgical correction of foot and ankle problems related to the effects of RA are treated by a podiatrist (Foot and Ankle Surgeon). In the next blog we will focus on multiple treatment options for patients with pain and deformity related to the effects of RA, and the indications for surgical intervention and surgical procedures.

If you have any questions related to this topic email Dr.Sansone at dr.dsansone@gmail.com or make an appointment for evaluation at www.eastoceanpodiatry.com

Coming soon.