The Season for Acute Gouty Attacks has Arrived in Florida

As cooler temperatures have arrived at Central Florida Foot & Ankle Specialists the first cases of 'Acute Gouty Attack' are arriving in my waiting room. These patients are easily identified by their obviously painful gait, red, hot and swollen joints of the foot. The patients will describe having had no trauma and going to bed without pain or symptoms only to awake in the wee hours of the morning in significant pain.
This is do to the cooler temperatures and lower Intra-joint pressures of the foot allowing the precipitation of uric acid crystals into the joint. White blood cells then attack these perceived foreign bodies in an attempt to dissolve them with their potent enzymes. Unfortunately, they are not up to the task and they die, thereby spreading their inflammation causing enzymes throughout the affected joint.
Most patients improve quickly with a taper down dosing of Indocin, but the reason for the attack, a high blood uric acid level, must be dealt with to prevent recurrence of symptoms and eventual joint destruction. This intervention usually takes the form of medication to improve the kidneys capacity to excrete uric acid more efficiently. Reducing the patients intake of foods that break down into purines (the precursor of uric acid) is also helpful. Avoiding shell fish, which I find to be most frequently the culprit, is recommended. Dr. Vic McNamara

Transient Compartment Syndrome of the Feet

I have a proficiency in lower extremity sports medicine and would like to make some suggestions for identifying the cause of foot pain, particularly as it relates to gym work-outs.First try to identify the specific anatomical part affected and if the pain radiates in any particular direction from that spot. You will probably need your trainers help with this. Next identify what makes it better, such as rest, and what aggravates the pain or causes its onset. These facts will help a professional give you an accurate diagnosis and treatment regime.Other than the maladies mentioned above, a very common problem that I see and describe as Transient Compartment Syndrome, (TCS), is very common in the gym. The symptoms are of an exquisite pain, sometimes gradually building, in the mid and forefoot. The onset is with lower extremity exercise that has been underway for several minutes. It is aggravated by continueing the work-out and often causes numbness in the forefoot and digits. It ultimately can cause a person to stop their work-out. The pain resolves upon stopping the activity and/or removing their shoe gear. Often, treadmills, stairmasters and elliptical machines are particularly aggravating due to their causing the feet to remain in a propulsive phase of gait too long. The first treatment that I try for this (TCS)is very simple and never fails when my diagnosis is correct. First, be certain that your shoes fit correctly. (You can check my blog for instructions on how to do that.) Then, re-lace your shoes so that you skip the cross over of laces at the middle two holes and the tongue tether and continue lacing again toward the ankle. This prevents the typically overbearing lacing pattern that most modern athletic shoes have from depriving the intrinsic muscles and nerves of the foot of their blood flow as they swell and engorge with exercise. I hope this information benefits you. Dr. McNamara

The Pathogenesis of Metatarsal Stress Fractures

As seen with Dancing with the Stars Tom Delay, stress fractures of the feet most frequently occur in the long bones called Metatarsals. They start with either an impact to the bone sufficient enough to bruise the bone or with small repetative flexing forces being placed on these long bones. The slang term "march fracture" evokes a good mental picture of a soldier marching longer distances than he is used to and thus causeing a contusion (bruise) to the bone. As mentioned this is just the start of the process.
The next phase is the increased activity of bone cells called osteoclasts. The bone structure is continually in a state of turn over and these osteoclasts are responsible for removing weak or damaged bone. For a period of approximately 3 weeks after the initial injury these osteoclasts eat away the damaged bone thus making it gradually weaker. It takes this 3 week period for the rebuilding cells, called osteoblasts, to show up on the scene to begin the re-building process. However, if the person afflicted continues to be active the osteoblasts can not get the job done and a hair-line crack develops in the bone and this is the stress fracture. Only adequate rest of the injured bone will alow it to heal

Dr. McNamara's Foolproof Method for Fitting Shoegear

Now that you know what characteristics are important in a shoe to improve biomechanical function of your foot. What about shoe fit? After all if the shoe does not fit correctly then it can not function correctly.

When trying on a new pair of shoes after having vetted them for biomechanical correctness, check the fit by standing and follow the next three steps.

1.) Attempt to place your index finger between the heel counter of the shoe and the back of your heel. This should not be possible! If you can place one or more fingers there then sit back down and seat your heel into the heel counter of the shoe by tapping the heel back against the ground until the heel seats fully. Stand again and continue with step #2.

2.) Next, elevate your big toe in the shoe and determine if there is between 1/4" and 1/2" of distance between the surface of your toes tip and that of the shoes. Any more or less indicates an incorrect fit.

3.) Finally, while still standing, place your thumb to the side of your big toe joint on your shoe and your index finger on the side of your little toe joint. Pull the fabric on the top of the shoe together in a pinching motion. If a wave of pinched material forms as your fingers approach each other and eludes your ability to actually gather and pinch the material, then that is a perfect fit in width. If as pinching no wave of material forms, then the shoe is too narrow. If you are able to pinch any amount of material, then the fit is too wide.

A properly fiited shoe will help you in many ways, not the least of which is avoiding new causes of foot pain.

Keep on being active!

"Cankles" What is their cause?

"Cankles" are an interesting phenomenon. Most women are horrified buy the prospect of developing them and a few have elected to have me remove them. However, once the underlying pathology is understood, conservative measures can be helpful to reduce their size and symptoms.

Cankles are prevalent in women and men (John Madden reportedly has cankles of 38") of middle age. There is an inherited component in that our adipose (fatty) layer of tissue is passed on from our parents. Couple this genetic predisposition with Obesity and the phenomenon worsens. The final insult to the ankle fat pads, of which there are two to each ankle bone, one on the front and the other on the backside of the ankle, is the change in hormones that occurs with the onset of menopause. Every woman that has passed through this point of maturity realizes how their body has changed as particular fat distributions all over their body change shape.
There is one more aggravating factor, fluid retention, as fluid is retained in the lower extremity it gradually stretches these tissues and thus causes them to become larger, which in turn allows these fat pads to accommodate even more retained fluid. Therefore, they appear to grow when in fact they are only increasing their spatial volume.
At a later date I will discuss treatment options!

Shoe Gear That Assists Biomechanical Foot Function

A shoe has to do three things to help the foot function in a generally improved biomechanical manner. The foot has two primary functions, shock absorption at heel strike and propulsion at toe-off.
First, the shoe must fit correctly. I will discuss how to determine correct fit in the next installment!
Second, the shoe should have a rigid heel counter. That is the back, closed-in part of the shoe. This will allow the Sub-Talar joint to be controled in its tendancy to overpronate. Pronation is a normal and neccessary component of shock absorption, but you do not want it to continue into the mid-stance and propulsive phases of gait. You will test for this by putting one or two thumbs on the center of the back of the heel and push as hard as you can. The heel caounter should not deform in the least. If it does the shoe is not good for biomechanical control. It's only good for keeping tacks out of the bottom of your feet.
Third, the big toe joint must be allowed to bend upward as much as 90 degrees very quickly and efficiently to allow effective propulsion. Therefore, the shoe must provide a right angle bend at the precise spot on the shoe that corresponds to your big toe joint when in the shoe. You can test this by placing your open hands, one on the heel and the other on the toe, of the shoe and push them together while looking at the big-toe side of the shoe. The shoe should easily bend at a 90 degree angle at the location of the big toe joint, were it in the shoe. The shoe should not curve into the shape of a "C" or bend in the mid-foot area.
Next Topic: "The Proper Fitting Of Shoes"