Podiatric Physicians Research Articles

Principles of Diagnosing and Managing Postmenopausal Osteoporosis for the Podiatric Physician

Osteoporosis is an asymptomatic disease until a fracture occurs. The prevalence of osteoporosis will rise with the aging of the population. Recent advances have led to more efficacious treatment options. Targeted screening, educating patients about preventive strategies, and providing appropriate treatment for those at high risk will allow physicians to reduce the enormous morbidity and mortality associated with osteoporosis.

Pulmonary disease: pneumonia, chronic obstructive pulmonary disease, asthma, and thromboembolic disease.

Although many medical problems are generally managed in concert with a general medical physician, it is important for the podiatric physician to be familiar with some of the major diseases of the lung. Pneumonia, an infectious process within the lung, is the sixth-leading overall cause of death. Antibiotic treatment, oxygen administration, and supportive care are the mainstays of its therapy. Chronic obstructive pulmonary disease presents as a spectrum from chronic bronchitis, with a greater inflammatory component, to emphysema, with a more significant destructive component. Asthma, often a more episodic chronic obstructive disease, is characterized by inflammation of the airways leading to their narrowing. The work of breathing is often increased in these diseases, and treatment is with combination therapies with a focus on smoking cessation. Thromboembolic disease, the occlusion of blood vessels with consequent interruption of blood flow, may occur in a patient with risk factors, especially after surgery. Treatment is with anticoagulation agents or in some cases with thrombolysis. Prophylaxis is key.

Infection and fever in the elderly.

The elderly make more frequent use of general podiatric medical services than the younger population. It is therefore important for podiatric physicians to become familiar with the general principles of infectious disease as applied to an elderly population, which is susceptible to a wider spectrum of disease with more subtle and unusual clinical signs and symptoms. This article reviews the diagnosis and evaluation of suspected infection, appropriate laboratory testing, patterns of specific infectious disease syndromes, and antibiotic use in the elderly.

Changes in plantar foot pressure with in-shoe varus or valgus wedging.

Varus and valgus wedging are commonly used by podiatric physicians in therapy with custom-made foot orthoses. This study aimed to provide scientific evidence of the effects on plantar foot pressure of applying in-shoe forefoot or rearfoot wedging. The plantar foot pressure distribution of 23 subjects walking on a treadmill was recorded using a pressure insole system for seven different wedging conditions, ranging from 3 degrees valgus to 6 degrees varus for the forefoot and from 4 degrees valgus to 8 degrees varus for the rearfoot. The results demonstrate that increasing varus wedging magnifies peak pressure and maximal loading rate at the medial forefoot and rearfoot, whereas increasing valgus wedging magnifies peak pressure and maximal loading rate at the lateral forefoot and rearfoot. As expected, the location of the center of pressure shifts medially with varus wedging and laterally with valgus wedging. However, these shifts are less significant than those in peak load and maximal loading rate. Timing variables such as interval from initial impact to peak load do not seem to be affected by forefoot or rearfoot wedging. Finally, rearfoot wedging does not significantly influence pressure variables of the forefoot; similarly, rearfoot pressure remains unaffected by forefoot wedging.

Complications of screw-fixated chevron osteotomies for the correction of hallux abducto valgus.

The surgical records of three podiatric physicians were reviewed to identify all chevron-type osteotomies performed during 2000-2001 for the correction of bunion deformity, and complications were reviewed for each. In the 95 cases identified, 15 complications occurred in 12 patients. Of these 15 complications, 4 were soft-tissue infections (4 patients), 4 were cases of painful hardware (3 patients), 4 were cases of second metatarsal head pain (2 patients), 2 were cases of cystic changes initially interpreted as osteomyelitis but later determined to be degenerative changes (2 patients), and 1 was a case of stiff toe (1 patient). There were no cases of avascular necrosis, hallux varus, or recurrence.

Acceptance Address APMA House of Delegates, Washington, DC: A Family of Podiatric Physicians

Acceptance Address APMA House of Delegates, Washington, DC: A Family of Podiatric Physicians

Relationship between "growing pains" and foot posture in children: single-case experimental designs in clinical practice.

Many young children present to the podiatric physician with the complaint of aching legs. Many of these children are clinically assessed as having a pronated foot posture. This foot posture is thought to be deleterious and is often treated with in-shoe devices such as triplane wedges or orthoses. Intervention aiming to reduce the amount of foot pronation in both stance and gait has been reported by parents and children to reduce, and in many cases eliminate, the episodes of aching legs. To test this theory and establish a degree of causality, a single-case experimental design was used in conjunction with age-appropriate pain scores for the children and independent parental ratings. Single-case experimental design is a useful research tool for the clinical practice setting that can identify cause-effect relationships and obviates large sample sizes. Eight complete single-case experimental designs were performed in the clinical setting. The in-shoe intervention proved efficacious for children with a pronated foot posture and aching legs. These findings may provide the impetus for a more rigorous examination of the possible relationship between pronation and "growing pains."

Fall-contributing adverse effects of the most frequently prescribed drugs.

The 200 most frequently prescribed medications in 2000 were reviewed for adverse effects that have the potential to cause fall injuries. The actual number of different medications reviewed was 169 after eliminating duplicates due to listing of medications by both brand and generic names. Of these 169 medications, adverse effects of documented traumatic injuries and falls were reported for 9.5% (n = 16). Four hundred forty-eight adverse effects were identified and organized into 13 broad categories representing drug-induced changes in nervous, circulatory, and muscular systems. These changes were reported for 157 medications reviewed (92.9%) and could result in fall injuries. The accompanying list of medications can serve as a ready reference for podiatric physicians and other health-care professionals when monitoring and counseling patients regarding the potential for medication-induced fall injuries, which are especially common in the elderly population.

Depression and chronic diabetic foot disability: A case report of suicide

Evidence at the scene of death and the postmortem examination led the pathologist to conclude suicide by intentional insulin overdose. The examination was conducted one day after the patient's death. The amount of insulin injected is not known, but levels of insulin in the vitreous gel were extremely high. While glucose and insulin are more stable in vitreous than in postmortem blood, the longer the delay between death and sample collection, the greater the uncertainty of the exact concentrations of substances at the time of death [42]. Patients with diabetes may have at their disposal the resources to end their lives; misuse of insulin and suicide by insulin overdose are presumably underreported events. Not only do diabetics have insulin available, but they may also have narcotics, tricyclic antidepressants or other drugs that are toxic at high doses. Even in the absence of depression, all patients with diabetes face multiple emotional issues related to the diagnosis and course of the disease. Diabetes often requires significant lifestyle changes, such as diet and physical activity, upon its diagnosis. Patients face the possibility of long-term, possibly debilitating, complications: vision loss, sexual dysfunction, and amputation. Any podiatrist who treats a large number of diabetic patients will encounter the situation of a patient at risk of losing a limb. A patient may consciously or unconsciously view amputation as punishment; limb loss interferes physically with bodily function and has extensive emotional consequences as well. It is important for patients to be involved with a healthcare team (including primary care physician, nurse educator, ophthalmologist, and podiatrist) that provides support throughout their lives [3]. As learned early on in podiatry school, podiatric physicians don't treat feet; they treat patients who have foot problems. It is as important to know when to refer a patient to the primary care physician or a psychiatrist for mental health complaints as it is to know when to refer a patient to an orthopedic surgeon for hip pain or to an ophthalmologist for vision problems. We do not propose that this patient's diabetic foot disease was the direct cause of his depression and suicide; however, the prevalence of depression in the general population and its even higher rates in patients with chronic medical illness require awareness of these problems by all members of the medical profession.

Diabetic foot care: podiatric physicians are the experts.

Diabetic foot care: podiatric physicians are the experts.

The biology, medical management, and podiatric implications of menopause.

Approximately 36 million women in the United States are in the postmenopausal phase of life, creating unique challenges for the provision of compassionate, comprehensive podiatric medical treatment. Long-term estrogen deprivation arising from menopause in association with age-related factors disproportionately increases the risk of ischemic heart disease, osteoporosis, and concomitant podiatric complications. This article discusses the physiologic basis of menopause, hormone replacement therapy and its effects on osteoporosis, and other podiatric implications of menopause. Podiatric physicians caring for larger numbers of peri- and postmenopausal women must formulate a comprehensive management plan for treating fractures that arise from a combination of estrogen-deprivation osteoporosis and abnormal foot biomechanics.

A Retrospective Analysis of 772 Patients with Hallux Limitus

In this retrospective analysis of 772 patients with symptomatic hallux limitus, 428 patients (55%) were successfully treated with conservative care alone; of these 428 patients, 362 (84%) were treated with orthoses. Corticosteroid injections and a change in shoes allowed 24 patients (6% of conservatively treated patients) and 42 patients (10%), respectively, to have less discomfort and return to previous activity levels. Overall, 47% of the patients in this analysis were successfully treated with orthoses. Surgical procedures were performed on 296 patients (38% of all patients) who did not respond to conservative care. In this analysis, 48 of the patients (6% of all patients) who did not respond to conservative care either refused surgery or were not surgical candidates. These data are intended to provide podiatric physicians with expected outcomes for conservative care of hallux limitus. The etiology, symptoms, conservative management, and surgical treatments of hallux limitus and hallux rigidus are also reviewed.

Lateral Intermetatarsal Angle: A Useful Measurement of Metatarsus Primus Elevatus?

The lateral intermetatarsal angle, a measurement of the sagittal plane angular divergence between the dorsal cortices of the first and second metatarsals of lateral weightbearing foot radiographs, was compared in 30 normal and 30 hallux limitus feet. The results suggest that the angle may be measured reliably and that although the measured angles are relatively small, a significant difference exists between the normal and hallux limitus subjects studied. Accordingly, the lateral intermetatarsal angle may prove to be a useful radiographic measurement to assist the podiatric physician in the clinical assessment of hallux limitus.

Normal values of plantar pressure measurements determined using the EMED-SF system.

Plantar pressure-measurement technology is being increasingly used by podiatric physicians and surgeons in both clinical practice and research. The authors present normal reference-range values for peak pressure, mean pressure, and pressure-time integral obtained from 30 healthy subjects using a two-step recording technique and the EMED-SF system, as background for proposed clinical trials. Normative data of this type are essential for clinical practice in the comparison of plantar pressure-measurement values of individual patients with those of normal, asymptomatic feet.

Fracture mechanics. A comparison study of torsional stress on bone.

Fractures that result from torsional loading of shafts in mechanical systems of nonbiologic materials generate a fracture line that forms a 45 degrees angle to an axis that is perpendicular to the direction of torsional loading on the shaft. As tension and compression are applied to these isotropic substances, the angle of fracture increases and decreases, respectively. Understanding how these forces, particularly compressive forces, generate elongation of a spiral fracture increases the ability to predict the extent of injury to bone. Fibular and metatarsal fractures are of primary importance to the podiatric physician, but any spiral fracture may be subject to torsional loading. Thus the principles stated here apply to the entire skeletal system. The purpose of this article is to provide a better understanding of the mechanics behind the causes and characteristics of fractures and to explore whether these same factors apply to the fracture mechanics of bone.

Wound-care resources on the Internet.

The Internet offers many resources in the area of wound and ulcer care that are of potential interest to podiatric physicians and students. This article provides an overview of World Wide Web sites that contain factual information, management guidelines, and illustrations pertaining to various aspects of wound and ulcer care. Web sites that emphasize preventive care are also reviewed. Because the prudent use of antimicrobial therapy is an important part of wound care, a few sites that offer antibiotic information are described.

Onychocryptosis associated with the treatment of onychomycosis.

With the advent of effective oral therapies for onychomycosis, there have been anecdotal reports of an increased incidence of onychocryptosis associated with the use of these new agents. The authors undertook a chart review of 100 consecutive patients treated for onychomycosis in a private medical practice to determine the incidence of onychocryptosis. A total of 37 of these patients (37%) developed paronychia ranging from simple pain to a severe inflammatory response with redness, drainage, and granuloma formation. Of these, 19 patients (19%) required surgical procedures to control onychocryptotic symptoms. Podiatric physicians should be aware that ingrown toenails may be an adverse consequence of effective treatment for onychomycosis.

Pedal manifestations of disseminated intravascular coagulation

Disseminated intravascular coagulation is a complex hemostatic imbalance associated with many disease states. The potentially lethal systemic consequences of this disease mandate that the podiatric physician obtain a complete detailed history in addition to proceeding with appropriate consultations from other specialties. If haste is utilized and surgical intervention is undertaken without careful consideration, a potentially fatal situation may ensue. A comprehensive case report highlighting the pedal presentation and complications, and an overview of this disease process are presented.

Location and indexing of articles written by podiatric physicians.

This study was undertaken to determine which biomedical journals contain articles written by podiatric physicians and in which indexing sources such articles are likely to appear. A survey was conducted of the 20 most frequently published podiatrist authors from a selected group of podiatric journals during the period from 1990 to 1995. Articles published by these authors during the study period were examined to determine where they had appeared. The MEDLINE database was found to contain the largest number of citations to articles written by these podiatric physicians. Both the Podiatry Index and Embase are also very good sources of citations to podiatric medical literature and should be used to supplement MEDLINE searches.

Chronic lateral ankle instability: Assessment of subjective outcomes following delayed primary repair and a new secondary reconstruction

Chronic lateral ankle instability is a condition commonly encountered by the podiatric physician. Chronic instability usually occurs after injuries to the lateral collateral ligamentous complex. The purpose of this article is to report subjective results of a retrospective study comparing delayed primary ligamentous repair and a new secondary ligamentous reconstruction. Our patient population includes 23 patients who responded to a detailed questionnaire. Three patients had bilateral ligamentous repair for a total of 26 ankles. Sixteen ankles underwent delayed primary ligamentous repair, while 10 ankles had a secondary reconstruction utilizing the authors' technique. The overall postoperative improvement was 90% in those with a delayed primary repair and 82% in those with the new secondary reconstruction. The average return to full activity for both groups was 10 weeks. Average follow-up for both groups was 12 months. The authors feel these results demonstrate that delayed primary repair and the authors' new secondary reconstruction both provide favorable clinical and surgical outcomes.