Does This Patient With Diabetes Have Large-Fiber Peripheral Neuropathy?

The Journal Of The American Medical Association, April 21, 2010 – Vol 303, No.15 1526-1532

Results:
Out of 1388 identified articles, 9 articles were on diagnostic accuracy and 3 articles were on precision of diagnosing large-fiber peripheral neuropathy. It was found that the most useful examination findings were vibratory perception with a 128-Hz tuning fork and pressure sensation with a 5.07 Semmes-Weinstein monofilament. Other tests that were included were deep tendon reflexes as well as dermatological exams, which were looking for the evidence of ulcerations or pre-ulcerative lesions.

Conclusion:
When diagnosing a diabetic patient with LFPN, a thorough physical exam along with a detailed patient history is needed. Abnormal results from the vibratory and monofilament testing alone or in combination help aid in the correct diagnosis of LFPN. Those tests, combined with ulcerations or pre-ulcerative lesions help make the precision of the diagnosis that much greater. Nerve conduction studies along with nerve biopsy and skin biopsies can provide additional valuable information as to the degree of nerve damage, as well as axonal degeneration.

Dr. Werber of inMotion foot and ankle specialists, has an expertise in diagnosing and treating diabetic sensory neuropathy, and patients with non diabetic peripheral neuropathy as well. We have biopsy techniques that are utilized in the office, and Dr. Werber is trained in performing nerve decompressions that may be contributing to the neuropathic pain.

Bruce Werber DPM, FACFAS

InMotion Foot & Ankle Specialists

Associate Professor Midwestern University
InMotion Foot and Ankle Specialists
10900 N. Scottsdale Road Suite 604
Scottsdale, AZ 85254
office phone 480 948-2111
inmotionfootandankle@gmail.com

www.inmotionfootandankle.com

nerve pain from increased pressure = tarsal tunnel syndrome

Tibial Nerve Decompression in Patients with Tarsal Tunnel Syndrome: Pressures in the Tarsal, Medial Plantar, and Lateral Plantar Tunnels. Plastic and Reconstructive Surgery, 124 (4), 1202-1210.

Scientific Literature Reviews
This article evaluates the pressure in the tarsal, medial plantar, and lateral plantar tunnels with the foot in various positions in patients with tarsal tunnel sydrome before and after surgical release of the tunnel roofs and inter-tunnel septum.

Methods:
Ten patients with tarsal tunnel syndrome underwent tibial nerve decompression for this study. Using an IntraCompartmental Pressure Monitor System, the tarsal, medial plantar, and lateral plantar tunnel pressures were measured before and after surgical release of the roof of each tunnel and the intertunnel septum. Each of these measurements was taken with the foot in neutral, dorsiflexion, plantarflexion, pronation, supination, and pronation with plantarflexion. The average of three readings in each position in every tunnel was recorded. An identical study was done on tweleve cadaveric models to compare these results with those of symptomatic patients.

Results:
Of the six foot positions tested, significantly higher pressures were found in the medial plantar (by 24 mmHg) and lateral plantar (by 26 mmHg) tunnels during pronation and all three tunnels had significantly higher pressures during pronation with plantarflexion compared to the neutral position. The pressure during pronation in the tarsal tunnel was significantly lower than with pronation with plantarflexion. Decompression of each tunnel significantly decreased the pressure in all positions except neutral where (p=0.01) Excision of the septum led to a further decrease in the medial and lateral plantar tunnel pressures during pronation. Although cadaveric models had similar pressure readings as the patients, the lateral plantar tunnels during pronation were significantly higher in symptomatic patients.

Conclusions:
This study demonstrates the need to release the tarsal, medial plantar, and lateral plantar tunnels and the intertunnel septum when performing a tibial nerve decompression in order to reduce the pressure in each compartment. Since the pressure is greatest at pronation or pronation and plantarflexion in each tunnel, it is suggested to control the amount of pronation, through custom orthoses, post operatively or as a non-operative treatment.

Dr. Werber at InMotion foot and ankle treats this problem with minimal incision surgery, quick recovery, good outcomes and will everything possible to treat the patients without surgery if at all possible.



Bruce Werber DPM, FACFAS
InMotion Foot & Ankle SpecialistsAssociate
Professor Midwestern University
InMotion Foot and Ankle Specialists
10900 N. Scottsdale Road Suite 604
Scottsdale, AZ 85254
office phone 480 948-2111
inmotionfootandankle@gmail.com
www.inmotionfootandankle.com

The Dreadmill: Common Causes of Stress Fractures

We all know what fractures are. Many of you have probably fractured a bone or two in
your lives. You fall out of a tree or get violently tackled on the football field and suddenly
you’re in the hospital and the doctor is telling you you’ve got a broken bone. While this
is easily understood by most, when prefaced by the term “stress”, people are often
confused when they’re told they have a fracture. It’s not uncommon for podiatrists to
hear this response after telling a patient they have a stress fracture: “but doctor, I don’t
remember any trauma to my foot”. While they may not recall any specific traumatic
event causing the fracture, the patient indeed suffered trauma significant enough to
cause a fracture, it just wasn’t the type of “trauma” everyone thinks of when discussing
fractures.

A stress fracture is a very small fracture in a bone, and is sometimes referred to as
a “hairline fracture”. These fractures can occur anywhere in the body’s 200+ bones;
however, by far and away the most common place to suffer a stress fracture is in the
foot. This is because the feet bear the weight of the entire body. Often times, stress
fractures are related to “overuse”, usually resulting from sports, overtraining, or sudden
increases in activity without proper conditioning. Sports like running, basketball, football
and even tennis are common activities where athletes develop stress fractures. While
participation in some activities put you at an increased risk for the development of stress
fractures than others, it is important to realize any physical activity where the foot is put
under high stress or subjected to repetitive forces and high impact landings can lead to
a stress fracture.

One common activity is running on the treadmill, or rather the “dreadmill”. When running
on a treadmill, at the same speed and the same incline setting for long periods of
time, you’re essentially taking your foot and slamming it over and over again on a hard
surface in the exact same spot. This is a good way to cause a stress fracture in your
foot. To prevent this, if you must use a treadmill, try changing the speed and incline
you run at frequently, so as to mimic running outside more closely. This way you’ll
constantly be adjusting how your foot strikes the ground, which dampens the stress
placed on any one spot in the foot.

Stress fractures are more common in women than men, for one main reason:
osteoporosis. This is compounded by two other common conditions in women: eating
disorders and irregular menstrual cycles. These two conditions contribute to the
development of osteoporosis, which can occur very early in life and should not be
considered a problem only in older women. Now, this is not to say men aren’t also
susceptible to stress fractures, because they can get them, it’s just important for women
to be aware of the increased risk of stress fractures.

The most common locations in the foot for a stress fracture are the second and third
metatarsals (long bones of the foot which run between the midfoot and the toes). They
can also occur in the heel and in a bone located at the top of the midfoot and in front
of the ankle called the “navicular”. Stress fractures in this funny sounding bone are

particularly difficult to heal because of inadequate blood supply.

Some common symptoms you may experience should you suffer a stress fracture are
pain that starts gradually, gets worse with weight-bearing activities and slowly gets
better with rest, possible swelling, tenderness to touch and possible bruising.

If you have a painful area in your foot, you can’t remember doing anything to hurt it
in the recent past, and you frequently participate in physical activities like the ones
described above or you’ve just started exercising more often, you should consider
seeing a podiatrist. He/she can perform a few simple tests in the office to rule out other
possible causes and will be able to pick up on a stress fracture, should that indeed be
what is causing you problems. Your doctor will be able to give you the proper treatment
and help you get back to your normal activities as soon as possible.


Bruce Werber DPM, FACFAS
InMotion Foot & Ankle Specialists
Associate Professor Midwestern University

InMotion Foot and Ankle Specialists
10900 N. Scottsdale Road Suite 604Scottsdale, AZ 85254
office phone 480 948-2111
inmotionfootandankle@gmail.com

www.inmotionfootandankle.com

Greek Health System Opts for Amputation as Money-Saver

This Saturday, one of Greece’s most respected newspapers, To Vima, reported that the nation’s largest government health insurance provider would no longer pay for special footwear for diabetic patients. Amputation is cheaper, says the Benefits Division of the state insurance provider.

The new policy was announced in a letter to the Pan-Hellenic Federation of People with Diabetes. The Federation disputes the science behind the decision of the Benefits Division. In a statement, the group argues that the decision is contrary to evidence as presented in the international scientific literature. Greece’s National Healthcare System was created in the early 1980s, during the tenure of Prime Minister Andreas Papandreou. Papandreou, an academic, won election under the slogan, Αλλαγ?, which is the Greek word for Change.

Bruce Werber DPM, FACFASInMotion Foot & Ankle SpecialistsAssociate Professor Midwestern UniversityInMotion Foot and Ankle Specialists10900 N. Scottsdale Road Suite 604Scottsdale, AZ 85254office phone 480 948-2111inmotionfootandankle@gmail.comwww.inmotionfootandankle.com

Preventing a 23% Medicare physician payment cut is one of several major tasks Congress faces when members return Nov. 15. The American Medical Association and dozens of other medical societies are reminding lawmakers that stopping the reduction before it takes effect on Dec. 1 is crucial to keeping Medicare sustainable.

The AMA, 65 national medical societies, and 24 state societies sent a letter to Congress on Sept. 29 asking members to stabilize Medicare physician pay, at least through 2011. Congress adopted short-term delays of the cuts several times in 2010, including once after contractors for the Centers for Medicare & Medicaid Services began to process Medicare claims with the cuts.

Bruce Werber DPM, FACFASInMotion Foot & Ankle SpecialistsAssociate Professor Midwestern UniversityInMotion Foot and Ankle Specialists10900 N. Scottsdale Road Suite 604Scottsdale, AZ 85254office phone 480 948-2111inmotionfootandankle@gmail.comwww.inmotionfootandankle.com

The State of the Economy Can Be Accurately Predicted by Women’s Shoe Buying Habits!

Bruce Werber DPM, FACFASInMotion Foot & Ankle SpecialistsAssociate Professor Midwestern UniversityInMotion Foot and Ankle Specialists10900 N. Scottsdale Road Suite 604Scottsdale, AZ 85254office phone 480 948-2111inmotionfootandankle@gmail.comwww.inmotionfootandankle.com

The State of the Economy Can Be Accurately Predicted by Women’s Shoe Buying Habits!

A skeptic you say? Here is a true story borrowed from an article in the Chicago Tribune by Barbara Brotman. Turns out there is good evidence that the Dow Jones Industrial Average can be predicted very well by the Nordstrom’s Shoe Index (my favorite shoe store as well!)

"The biggest swing in spending has been in retailers, such as Saks and Nordstrom, that target high-income consumers, a pickup that coincided with the rally in the stock market." — economist Michelle Meyer.

The science of economic analysis has taken a leap forward with the discovery of a new, highly accurate economic indicator: The Nordstrom Shoe Index.

Economists were intrigued to find that statistics on consumers' attitudes toward the economy coincided with the actions of a single consumer in Chicago. Taking a closer look, they found that they could track consumer confidence and its resulting influence on the nation's economy simply by following this consumer's interactions with the shoe department at Nordstrom.

The phenomenon came to light during a recent surge in consumer confidence. Barbara relates that she happened to be at Nordstrom buying eye shadow. Something, possibly a premonition of consumer confidence, drew her to the nearby shoe department. She began browsing high-heeled sandals, though she did not need a pair of high-heeled sandals, as her husband would later point out. But then she saw them: brown leather sandals with that thick-strapped look that stops just short of dominatrix, strips of leather accents in a fetching shade of salmon and a breathtakingly high heel.

She bought them.

The Nordstrom Shoe Index spiked.

The same day, the Dow Jones Industrial Average went up 21 points.

The purchase also mirrored the Conference Board's Consumer Confidence Index, which in April reached its highest point since September 2008.

Analysts noting the Nordstrom Shoe Index phenomenon were particularly cheered at the price the Nordstrom Shoe Indexer paid — $224.95. They reasoned that consumer confidence had to be surging pretty high for anyone to spend that much on a pair of sandals.

Moreover, the increase in the Nordstrom Shoe Index was accompanied by a high Lying to Spouse score. When her husband asked how much the sandals cost, the consumer claimed they were only $180. Though this still resulted in an increase in the Spousal Irritation Industrials, analysts noted that 20 percent represented an impressive level of lying, significantly above the routine 5 percent spousal lie discount.

However, stock market bears warned of a correction. And sure enough, within days, the Nordstrom Shoe Indexer began to have buyer's regret.

Trying on the shoes at home to defend the "$180" purchase to her spouse, she realized that the heel was so high as to cause intense pain, and not just because of the bunion problem. The heels threw her entire body onto the balls of her feet. She could barely walk in them.

For two days, she vacillated. (Really? Why do we do this to ourselves over cute shoes?)

In the same time span, the Dow Jones Industrial Average dropped 236 points

She brought the shoes into the office one day and tottered along a carpeted hallway, trying to decide whether she could take the pain. An economics debate broke out when several female colleagues stopped to say that her shoes were darling. Upon learning of the pain problem, some counseled her to be practical and return them. Others argued she should man up and wear them no matter how much they hurt because they were so white hot. (Pick some new friends!)

The Dow Jones, aka the Jimmy Choo, rose 49 points, apparently on hope of persuasion.
The direction of the nation's economy hovered in limbo as the Nordstrom Shoe Index progenitor agonized. Stock brokers chain-chewed antacids. Hedge fund managers gnawed on their fingernails. Institutional investors fanned themselves.

Finally, the indexer decided that she couldn't justify spending $224.95 on shoes she could wear only while sitting at her desk.

On Friday, she made the call: Back they would go.

The Nordstrom Shoe Index plummeted.

The Dow Jones dropped 173 points the same day. The Standard and Poor's 500 Index fell 20 points.

Some analysts use complex mathematical formulas to predict the behavior of the economy. Some stock-picking experiments have tried dart boards.

The Nordstrom Shoe Index, however, has earned its place in the economic indicator pantheon. A nation searching for signs of financial direction should consider this:

Barbara laments that she still want a pair of really cute, but lower-heeled, sandals.

Ladies…we all knew our shoe shopping habits were important, but now we know the economy depends on it!

Shop On!
as written by Dr. Crane

From Sewing to Surgery: A Brief History on Tailor’s Bunions

If you have a bunion on the outside of your foot, where the 5^th toe meets the 5^th metatarsal bone of the foot, you don’t just have a bunion, you have a Tailor’s Bunion. And if you have a Tailor’s Bunion, you can blame those who lived during the Renaissance period for your pain. You read that correctly, people who lived in the 14^th century were responsible, at least in part, for the profession that eventually led to the naming of the Tailor’s Bunion. First, a brief history lesson, then more about your condition.

During the Middle Ages, clothing was merely a means of concealing the body. Then came the Renaissance period, where people sought to accentuate the human form not only in the arts but in the fabric they wore on their backs. Gone were the days of wearing a loose robe that had been so easily created from a single piece of cloth. People began shortening, tightening, cutting, piecing, and sewing swatches of fabric together in an eventually successful attempt to bring into prominence the contours of the human body. This, ladies and gentlemen, marked the emergence of tailoring and, as a matter of fact, the birth of fashion itself. It is not too difficult to imagine that with a growing demand for shaped clothing, came also a growing need for someone who could shape the clothes. First came the “cutter”, whose job was to make the patterns. Then came the “tailor”, who did the sewing.

Now, fast-forward a few hundred years, and you could find tailors in every town or city, sitting crossed legged in their shops, sewing away at their newest conceived design. Consequently the outside of their feet, especially the heads of the 5th metatarsals, would be rubbed on the floor with such vigor that it began to hurt. They would go on to develop prominences, or “bunions” on the outsides of their feet, which was simply the body’s way of protecting itself. This is exactly how the Tailor’s Bunion got its name.

Your next question, logically enough, may be how is it that you can have a Tailor’s Bunion if you are in fact not a tailor, and perhaps you don’t even sit crossed legged. The answer is again related to fashion: inappropriate shoe wear. Just like it’s cousin, the bunion on the big toe, a Tailor’s Bunion can form as a result of wearing shoes with a tight toe box. Increased pressure of the foot against the inside of your shoes can, over time, result in the metatarsal bone moving and ultimately the formation of a bunion. In patients with wide feet, a Tailor’s Bunion tends to be one of the more common complaints because even though these patients have wide feet, they still tend to wear standard sized shoes, which leads to increased pressure on the sides of the feet, particularly the toe joints.

Whether you have wide feet, you’re a tailor who still sits on the floor crossed-legged, or you have a Tailor’s Bunion for some other reason, the good news is that this problem is most often completely curable. If you have pain associated with your bunion, you can use over the counter anti-inflammatory drugs and pain killers to help alleviate your pain. If your pain has persisted for a long time or if the drugs don’t help your pain, then your doctor may decide it’s time to recommend surgery. Wearing appropriate shoes is another important aspect of treating a Tailor’s Bunion. These special shoes, or any shoe geared towards people with wide feet, can be very effective in avoiding the development of a bunion or reducing the pain associated with bunions. These shoes are best used in conjunction with bunion pads, and in many cases can make your everyday activities much easier on your feet.

If you have a Tailor’s Bunion, you should consult your Dr. WERBER today to see what course of action is best for you to return to your regular activities, whether that be a physically demanding job, daily exercise or becoming the next big Design Star!

Bruce Werber DPM, FACFASInMotion Foot & Ankle SpecialistsAssociate Professor Midwestern UniversityInMotion Foot and Ankle Specialists10900 N. Scottsdale Road Suite 604Scottsdale, AZ 85254office phone 480 948-2111inmotionfootandankle@gmail.comwww.inmotionfootandankle.com