Toenail Fungus

The most common cause of yellowed, thick and /or deformed toenails is a fungal infection of the toenail. The fungus that infects the nail, most commonly, is the same fungus that causes athletes foot. It tends to be slowly progressive, damaging the nail to a greater and greater degree over time. The infection usually starts at the tip of the nail and works its way back. It usually is not painful and often not noticed until it has gotten well established. A single toenail or any number of nails can be affected. It can also occur on just one foot. Over time, the nail becomes thickened, crumbly, and distorted in appearance. Sweaty feet contribute to the initial infection process and contribute to its spread. The fungus prefers an environment that is moist, dark, and warm, which is why it affects the toenails much more often than fingernails. It does not spread through the blood stream. The infection limits itself to the nails and skin. It is often found in association with areas of dry scaly skin on the bottom of the foot or between the toes. The dry scaling skin is frequently found to be chronic athletes' foot. It is not highly contagious, and family members are almost as likely to contract it from some other source as they are from the family member who has the infection. Keeping common showering areas clean is recommended, and sharing shoes should be avoided.

Diagnosis

Not all thicken or yellowed toenails are caused by a fungal infection. Injury to a toenail can cause the toenail to grow in a thickened or malformed fashion. This can be due to an established fungal infection or may be due to the damage caused to the nail root when it was injured. In these instances, treatment with anti-fungal medications will not correct the malformed nail. Other causes of thickened toenails are small bone spurs that can form under the toenail and psoriasis. Taking a scraping of the toenail and culturing it makes the diagnosis.

Treatment

It is best to treat the condition as soon as it is noticed. In early cases, over the counter medications may be sufficient. It is also important to treat any concomitant athlete’s foot that may be present. In more advanced cases, a prescription medication may be needed. There are effective topical, oral medications and lasers available for the treatment of fungal toenails. If sweating feet are a problem, changing shoes and socks during the day is recommended. There are some topical medications available that help to reduce the sweating of the feet. On occasion, your doctor may recommend removing the toenail.

Peripheral Neuropathy is a nerve condition that affects the arms, hands, legs, and feet. The most common form of peripheral neuropathy is due to diabetes.  People with diabetes have an abnormal elevation of their blood sugar, and lack adequate insulin to metabolize the blood sugar. As a consequence, the blood glucose (sugar) abnormally enters certain nerve tissue and damages the nerve. This can occur in any type of diabetes.  The nerve damage that occurs is considered to be permanent.  As the nerve damage occurs, the protective sensations are affected. These include a person's ability to determine the difference between sharp and dull, hot and cold, pressure differences, and vibration. These senses become dulled and/or altered. The process begins as a burning sensation in the toes and progresses up the foot in a "stocking distribution". As the condition progresses, the feet become more and more numb.   Some patients complain of their feet burn at night, making it difficult to sleep. The feet may also feel like they are cold, however, to the touch, they have normal skin temperature.  Treatment for peripheral neuropathy is, for the most part, directed at the symptoms of the condition. Vitamin B12 injections may be helpful if the patient has a vitamin B deficiency. There are certain oral medications that may ease the burning pain that can be prescribed.
Different supplements that can be taken to improve nerve nutrition and nerve ending regeneration. These supplements can take several weeks to months to take effect. Dosage may need to be altered as well as other supplements added. Topical ointments, magnetic therapy and electical stimulation are alternative forms of treatment but results are varied and difficult to quantify.

The Achilles tendon is the largest tendon in the human body. It is located at the back of the ankle joint and can be felt as a large, cord-like structure attaching to the back of the foot. Since tendons serve to attach muscles to bone, the Achilles tendon also attaches the large calf muscles, the gastrocnemius and soleus, to the back of the heel bone, the calcaneus.

The muscle mass and strength of the gastrocnemius and soleus muscles are greater than all of the other muscles of the lower leg combined. Therefore, the pull of these muscles on the Achilles tendon is very large since these muscles help balance the body while standing, push the body forward during walking, spring the body forward during running, and spring the body upward during jumping. Because of the large amount of stress which the Achilles tendon is subjected to during running and jumping activities, the Achilles tendon is prone to injury.

The most common form of injury to the Achilles tendon is called Achilles tendonitis, which is an inflammatory condition causing pain in the Achilles tendon. Achilles tendonitis generally occurs in people who are active in sports activities. Types of sports that commonly are associated with Achilles tendonitis are basketball, tennis, running, football, soccer, volleyball and other running and jumping sports.

Achilles tendonitis tends to occur more frequently in older athletes than in younger athletes. As a person ages into their thirties and especially into their forties and fifties, the ligaments and tendons of the body tend to lose some of their stretchiness and are not as strong as before. This predisposes older individuals who are active in running and jumping activities, to tendon injuries such as Achilles tendinitis. However, Achilles tendonitis can also occur in teenagers who are very active in running and jumping sports.

Diagnosis

Achilles tendonitis is diagnosed by a history and physical examination of the patient who describes pain at the back of the ankle with walking and/or running activities. The pain generally will be associated with an increase in running or jumping intensity or frequency. It is also often associated with a change from running in a thick heeled shoe to a thin heeled shoe, such as going from training shoes to racing flats and/or racing spikes in cross-country and/or track. The pain from Achilles tendonitis is often so severe that running is impossible and even walking is uncomfortable.

During the physical examination, the podiatrist will feel and push lightly around the Achilles tendon to see if it is tender or has any irregularities in its surface. Achilles tendonitis may cause the tendon to be thickened in areas, may cause swelling of the area around the tendon, and can even feel like the tendon has a painful bump on it. In addition, the person with Achilles tendonitis will limp while barefoot, but walk more normally with heeled shoes on. X-rays are not helpful in diagnosing Achilles tendonitis but may be taken to rule-out other pathology. MRI scans are only indicated if a partial or complete rupture of the Achilles tendon is suspected by the podiatrist.

Treatment

Achilles tendonitis generally responds very well to conservative treatment as long as it is diagnosed and treated early. Surgery is rarely indicated unless the Achilles tendonitis is particularly severe and chronic, or if the tendon has ruptured completely.

Initially, the podiatrist may treat the Achilles tendonitis by putting heel lifts into the patient's shoes. In addition, the patient may be asked to avoid barefoot walking or walking in low-heeled shoes. Non-steroidal anti-inflammatory drugs (NSAIDS) such as ibuprofen (Motrin, Advil) and naproxen (Naprosyn, Aleve) may also be prescribed to calm the inflammatory process in the tendon. Icing may be suggested to help decrease the inflammation and pain in the tendon. Stretching exercises for the calf muscles may also be given to the patient to help loosen the calf muscle and Achilles tendon so that the tendon is not under as much stress during normal daily walking activities. The stretching should not be done however if it causes pain in the Achilles tendon.

Initially, the patient with Achilles tendonitis will be asked to modify their activities to decrease their running and jumping activities and do alternative physical activities, such as swimming, which don't put as much stress on the Achilles tendon. As the tendon starts to feel better, the podiatrist will allow a gradual return to normal running and jumping activities. If normal return to activities is not possible within a few weeks, then many times the podiatrist may additionally prescribe physical therapy and/or functional foot orthotics to help the tendon heal more rapidly. The foot orthotics generally are used during both the sports activities and walking activities to allow for more normal foot and Achilles tendon function. If the physician is concerned about a partial tear of the tendon the patient may be placed in a below the knee cast. It can take several weeks or even months for the tendon to heal depending upon the severity of the injury to the tendon. It is not uncommon for a patient to return to activities too quickly and re-injure the tendon. Careful monitoring of a return to full activity is important and the patient must have patience during this period of time.

Laser for toenail fungus working well

Hyperblue laser for toenail fungus has been working well to reduce stubborn fungal toenails. This procedure causes minimal discomfort and easy to perform. Results have been very encouraging over the last 2-3 years.

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Platelet Rich Plasma

I have been using platelet rich plasma (PRP) in my office and I have had good results. So far I have used it for posterior tibial tendinitis, plantar fasciitis and even diabetic neuropathy. I was surprised by the improvement in my diabetic patient with neuropathy. He had about a 50% reduction in symptoms in 1 month.

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