First of all know this. Doctors do not make follow-up appointments because they “want to see you”. They make follow-up appointments because they “need to see you”. Need as in necessity. Meaning there is an indispensable need that follows a logical requirement for another evaluation and management of your ongoing condition. There may be several reasons for this.
- to monitor your medications
- to assess improvement or worsening of symptoms
- for continuity of care
- to remove and/or apply dressings for wound management
- to discuss diagnostic tests and develop a follow-up care plan
- to check for reoccurrence
Physicians treat patients based on medical necessity and must have supporting documentation for your care. If there is no need for further treatment your Doctor will discharge you from the practice. Until then periodic appointments are essential to the desired outcome of your treatment and not following up with a scheduled appointment can compromise your care.
Patient’s who routinely miss their appointments without notifying the office staff also effect other patients who may have been waiting to schedule an appointment as well as staff efficiency and wasted resources. Don’t be a “no show” (intended appointments that were not canceled or rescheduled). All healthcare providers would much prefer that you cancel your appointment or reschedule than just not show up. Most office staff and physicians would say that to forget is forgiven but habitual “no shows” (repeat offenders) create havoc in the schedule and time spent in additional documentation and concern regarding interruption of care.
A well-regarded physician schedules follow-up appointments because he/she needs to see you. Not to make more money, buy a bigger house or satisfy big drug companies by writing more prescriptions. If they do then you should find another healthcare provider and value their time as much as part of a healthcare team committed to caring for you.
Meteorologists are noting that Pyeongchang in 2018 might be the coldest Olympics since 1994 in Lillehammer, Norway. The athletes, coaches, course workers, photographers and spectators are being advised to take precautions against the cold and the serious potential of frostbite.
Frostbite is a dangerous cold-weather condition that can happen to anyone, from the most experienced winter athlete and outdoorsman to your neighbor shoveling her driveway. Frostbite can result in various degrees of skin damage from an irritation to blistering to permanent tissue death. The hands and feet are particularly susceptible to frostbite because the body is busy working hard to keep the internal organs warm.
Frostbite starts by producing a burning, tingling sensation in the exposed areas. This is followed by numbness in the affected area (toes or feet) and changes in skin color, from pale or red to bluish-gray or black and feel hard to the touch. Children, the elderly, and diabetics are more prone to frostbite because of the size of their extremities or poor circulation. Severe frostbite may necessitate amputation of the affected toe(s), or possibly the entire foot. Other consequences may include
- Frostbite arthritis , a condition resulting from damage to the bones and cartilage
- Permanent numbness or other nerve damage
- Increased susceptibility to frostbite in the future
You can avoid frostbitten feet by taking a few precautions. Wear warm, moisture-wicking socks, layering thick socks over thin ones to help trap heat. Wear warm, waterproof winter boots out in cold temperatures and limit how much time you spend in the cold.
Why early diagnosis and treatment of traumatic injuries is important.
Traumatic injuries cause damage to the cells that make up the soft tissues. These damaged cells release chemicals that cause an inflammatory response characterized by pain, localized swelling, heat, redness and a loss of function.
Too much of an inflammatory response in the early stages of an injury can delay the healing process making it longer to return to normal activity. Early attention and treatment can minimize the inflammatory phase of an injury, so that the overall process of healing can begin.
The sinus tarsi is an opening on the outside of the foot between the ankle and heel bone. It is often referred to as the “eye of the foot” because it opens towards the outside of foot. STS (sinus tarsi syndrome) was first described by Denis O’Connor in 1957 as a problem that can occur after an inversion ankle sprain or due to a “pinching” or impingement of the soft tissues in the sinus tarsi due to a very pronated (rolling in) foot.
Patients typically present with localized pain in the sinus tarsi region with a feeling of instability aggravated by weight bearing activity. Inverting the ankle or moving it into a position where it is turned inwards like it would go with an ankle sprain can cause severe pain. Patients may feel instability in ankle joint especially while walking on uneven surfaces and repetitive strain can aggravate the condition.
Medication and therapies that reduce swelling and inflammation are recommended as well as correction of any underlying biomechanical problems that contribute to the way the ankle bones move restricting the space in the sinus tarsi channel. Strengthening exercises for the ankle are suggested and helpful. When treated early, the outlook for recovery is good but without appropriate, early intervention the condition can lead to chronic pain.
Lift, shift, push, pull – construction work is a physically demanding job and most of the work is done on the move. So it’s understandable that those who work in construction come home with aching feet.
According to the Center to Protect Workers’ Rights, ankle and foot injuries are among the most commonly injured body parts for construction workers. Going up and down ladders, stairs and scaffolding and lifting heavy objects all day can create problems likes strains, sprains and bone bruising. Torn ligaments, overuse injuries, plantar fasciitis and broken bones account for loss time on the construction site. Maintaining balance and equilibrium to prevent falls and accidents are important as well as recognizing what can be done to minimize risk and prevent on the job injuries of the lower extremities. Here are a few best practices for proper care and prevention of foot and ankle injuries.
- Invest in well-made boots and if necessary prescription orthotics to compensate for any structurally abnormalities that can contribute to underlying foot problems.
- Treat minor problems before they become major problem. Yes, arch and heel pain is important, but don’t ignore your toes. Your big toe withstands 40 to 60% of your body’s weight so any injury or problem can have a big impact on your gait and ability to move effectively.
- Don’t ignore persistently swollen or numb feet, burning and tingling. These can be signs of a neuropathy, which diabetics are especially susceptible to.
- Infected or ingrown nails may develop into a cellulitis,a potentially serious bacterial skin infection that can rapidly spread to other parts of the body. Cellulitis appears as a swollen, red area of skin that feels hot and tender.
- Continued pain with activity. If your feet only hurt while you’re active, you could be suffering from a stress fracture. Without proper treatment, stress fractures can easily turn into broken bones.
We live in a society of immediate gratification. Waiting a couple of extra seconds for an Internet page to load feels like an eternity. A culture of impatience over slow website loads or less than same day delivery. We’ve come to expect things so quickly that when faced with an injury patients become easily frustrated when they are not healing as fast as they think they should.
Soft tissue injuries, muscle or connective tissue injuries often develop over time. There may be an incident of trauma, an accident, pop or accompanying fracture, however many are caused by repetitive stress, pulling forces that ligaments must resist and overtime are extreme enough to damage softer blood vessels and nerves. Long before breaking under a strain, tissue often gets “sick”, overused. Once that happens, the tissue loses the ability to tolerate even minor stresses. If these structures do become injured, their limited blood and nerve supply results in a longer recovery and healing period.
An evidence-based study of ankle ligament healing after an acute ankle injury showed that it took at least 6 weeks to 3 months before ligament healing occurred. However, at 6 weeks to 1 year after injury, a large percentage of participants still had “objective mechanical laxity and subjective ankle instability”. Alterations in the biology and biomechanics of the injured body part not only effect it but effect those structures surrounding it so that healing the area depends on contributions from multiple body systems . Physical condition, underlying medical problems, poor muscle balance, inflexibility and lack of tissue strength influence the time it takes a body to heal. You have to almost completely stop challenging the tissue, or it will never have a chance to recover.
Rebuilding, remodeling and recovery from injury takes time. Accepting the time it takes and giving your body (including the proper nutrition) what it needs to protect, heal, repair, and recover isn’t easy to do if you are a determined athlete, career-driven professional, a relied on caregiver or parent. The art of healing depends on rest and mobility. Patients need to work with their healthcare provider to find a happy medium and the time needed to do so.
Over the last several years clinical correlation studies have shown the below normal Vitamin D levels (hypovitaminosis D) may contribute to a variety of health problems. Cited sources have described Vitamin D deficiency as a “worldwide epidemic” with an estimated one billion people having inadequate levels of vitamin D in their blood, and deficiencies can be found in all ethnicities and age groups. Yet it is an often overlooked component in the treatment of foot and ankle injuries and chronic foot and ankle pain.
In the foot and ankle, stress fractures of the metatarsal bones and ankle may be seen in those with Vitamin D deficiency, as well as generalized foot pain. The prevalence of Vitamin D deficiency has been identified as one of the most common causes of fragility fractures and poor fracture healing. Healthy amounts of vitamin D are a critical factor in orthopedic healing and the healing of reconstructive surgery of the foot and ankle.
As specialists in the foot and ankle we see a variety of bone, joint, musculoskeletal and neurological problems of the lower extremity with systematic manifestations such as diabetes, arthritis and other metabolic disorders effected by low levels of Vitamin D. Patients with various –itis (inflammations) such as capsulitis and persistent and recurring tendonitis often test in the lower limits of normal for optimum levels of Vitamin D. Inadequate dietary intake, a lack of sunlight exposure, certain metabolic disorders and disorders that affect your body’s ability to absorb vitamin D can result in a deficiency. With an increasing knowledge of the health consequences of low levels of Vitamin D, doctors can benefit their patients by identifying those who are deficient and require therapeutic supplementation.
Artists tell me that second to hands and the face, feet are one of the areas sculptors often have trouble with. Like hands they are very complex structures with lots of bones, articulations and surface textures. The anatomical details of the foot and ankle realistically treated are difficult to make with all the essential parts in the right proportions.
Traveling in Italy I’m always amazed at the artistic renderings of the human foot. Many paintings, frescoes, mosaics and sculptures pay a great deal of attention to the foot. As a physician and surgeon that specializes in the treatment of the foot and ankle I’m always interested in the art and design of what Leonardo da Vinci called ” a masterpiece of engineering and a work of art . . . the human foot”.
Here are a few monumental feet that reflect the art and appreciation of this essential yet often overlooked part of the human body.
The first is a statue known as Lo Spinario, or Boy Plucking a Thorn from the Foot. It is located at the Musei Capitolini in Rome (a copy is in the Uffize gallery in Florence). Also named Fedele (faithful) because it was thought to represent a Roman messenger boy who completed his mission despite having an injured foot. Listed as one of the 10 Sculptures One Must See When in Rome, the statue has been copied many times and can be found in various places including the Metropolitan Museum of Art. The next monumental foot is truly monumental, the foot of the statue of Emperor Constantine II in the courtyard of the Palazzo dei Conservatori also at the Musei Capitolini in Rome. The foot is part of fragments of body parts from the Colossus of Constantine a 40 foot monument commissioned by the Emperor to honor a military victory.
Dawn and Dusk, two sculptures on the tomb of Lorenzo de’ Medici in Medici Chapel of San Lorenzo in Florence. Dawn (6 feet 8 inches in length) and Dusk (6 feet 4 3/4 inches in length) gracefully spread themselves along the edge of the sarcophagus. There are other monumental figures on the tomb of his brother Giuliano (Night and Day). Together they are considered to be some of Michelangelo’s best works.
Dawn and Dusk Medici Chapels – Florence
Night and Day Medici Chapels – Florence
When I first saw the IceMan I was on a road trip to Bolzano with my Italian cousins. After traveling through most of Tuscany and Umbria my cousin Lidia and her husband Roberto turned their Lancia north and said “you must go to the Dolomiti and while we are there you will see the Iceman”.
The Dolomites are some of the most impressive mountains in the world. Formed 200 million years ago they are part of Italy’s Sudtirol. Bordering on Austria and Switzerland, the Italian Alps of the Trentino Alto-Adige region combine food, customs and language to create a unique taste and travel experience that is often overlooked by conventional tourists. Besides wutrzel, Bozen beer and stinco di maiale (braised pork shanks) you will be able to see Otzi, one of the world’s best known and most important mummies and one of the most famous tattooed men in the world. Also known as the Iceman, the mummy was discovered in the Ötztal Alps of Italy’s South Tirol in 1991 by two hikers who found the back of a human figure jutting out of the ice and melt water in a rocky gully. The Iceman is on display at the South Tyrol Museum of Archaeology in the city Bolzano (South Tirol, Italy).
Almost perfectly preserved in the snow and ice Otzi’s body was dated between 3500-3100BC and provided a unique study of Copper Age culture and early medicine. Over the years examinations (including x-rays, CT imaging studies, DNA analysis and a full-scale autopsy on the thawed body) have revealed much about his life and death including the state of his health.
More than 50 tattoos made up of small lines and crosses were found on various parts of the Iceman’s body (on the ankle joints, wrists, knees, Achilles tendon and lower back). Small incisions along meridians of the body rubbed with charcoal. Together with findings from medical examinations they leave unmistakable signs that these tattoos may have been related to numerous pathologies. Various studies mention a genetic marker for cardiovascular disease, lactose intolerance, Lyme’s disease, intestinal worms and arthritis and several diagnostic features of musculoskeletal conditions in the Iceman lead to the possibility that tattoos may have been used as a location of chronic pain. As there is evidence that Otzi had a traveling medical kit of natural Alpine folk remedies it would not be unusual for him to use tattooing along accupressure points as a therapeutic treatment in an attempt to relieve the joint pain that must have bothered him on his glacial trek.
Click on the Iceman’s Photoscan to see the complete mapping of the tattoos via high definition photos.
You might have noticed that when Steve Holcomb competed in the Bobsled Event at the Sochi 2014 Winter Olympics he had a black tattoo-like strip of tape across the back of his leg. Holcomb strained a calf muscle during an early heat and wasn’t certain he’d be able to continue. He somehow got past the pain and won a bronze medal 24 hours later.
Holcomb’s training and determination kept him going with a little help from a black strip of tape on his calf that I instantly recognized as a kinesio taping. I first learned about this elastic therapeutic tape from my cousin who is a physiotherapist in Italy. After spending time with physicians in Milan to learn about foot and ankle care in the European healthcare system, I traveled to Portogruaro near Venice to visit my cousin Marika who practices physiotherapy; professionals who provide treatment to develop, maintain and restore physical movement and function. She introduced me to kinesio taping and described it as a technique to help protect and treat failure of function in muscles, tendons and joints.
As a Podiatric physician and surgeon I have used various taping and strapping techniques for a variety of biomechanical and functional problems so I was very interested in learning more. Coming out of research in kinesiology, the science behind muscular and skeletal movement, kinesio taping attributes its efficacy to the activation of the neurological and circulatory systems. Developed in 1979 as a muscle treatment by Japanese chiropractor Dr. Kenzo Kase, the taping method is said to gently lift the layers of skin and attached tissue covering a muscle to allow blood and other body fluids to move more freely in and around that muscle and effect healing.
Notice the italicized said. The ability of the tape and technique to provide support for muscles and joints, improve blood flow and reduce inflammation, all while enabling full range of motion sounds like a magic bullet for physicians and therapists who treat neuromuscular and orthopedic problems but the reviews on its efficacy are mixed. A 2012 meta analysis published in the journal Sports Medicine reviewed 10 studies on kinesio tape and found that current research on its benefits were inconclusive. Others have found it to be helpful. Many professional and Olympic athletes use and praise kinesio taping as evidenced by the pink, black and blue strips worn like medical tattoos at sporting events all over the world.
The tape itself is primarily made of cotton (you can wear it in the shower or pool) with a 100 percent acrylic adhesive that is hypoallergenic and latex free and a single application can last 3-4 days. I have used kinesio taping in selected cases and found it to be worth looking into meaning that as a physician specializing in the medical, surgical and orthopedic treatment of the foot and ankle and podiatric sports medicine, I’m always open to learning about any technique that sustains or improves the well-being and full functioning of the extremities.
A point to note. The success of this type of treatment depends on the tape and the technique meaning that the quality of the product used and the skill and knowledge of the physician and/or therapist applying it is of paramount importance. Do not waste your time and money trying to apply the tape on your own. Certified Kinesio Taping practitioners and physicians who make the proper diagnosis and apply the proper technique are necessary. As in any other medical problem an inaccurate diagnosis can lead to further problems and delayed healing.