Non Surgical

non surgery foot and ankle procedures

HEEL SPUR/PLANTAR FASCIITIS PAIN
This is a very painful condition, possibly the most common foot complaint seen in industrial areas such as Northwest Indiana where people spend a great deal of time working on concrete surfaces. The 26 bones in the foot have to function as a shock absorber and as a propulser, both different and separately with each step. The plantar fascia, which means “bottom elastic” in English, is basically a rubber band that attaches on the bottom of your heel and runs to the five toe joints. Its job is to not allow the foot to over collapse the arch and pull the foot back into rigid position before propulsion. If the 26 bones you inherited don’t function as well as they should, this fascia will be microscopically stretched and will sustain very tiny microscopic tears throughout your life. These tears will be so small that you won’t recognize or feel them, however, they take eight weeks minimum to heal and during that time the same pathomechanics that caused the tear continues to aggravate during its healing and causes scarring. Eventually these tiny microscopic islands of scar tissue accumulates in the fascia and it no longer looks like the 3 mm thick flexible rubber band that it was when you were younger-it usually is about 6 mm thick when patients experience symptoms-which makes it 100% thicker and scarred. When the patient sits down, stands still, sleeps in bed for hours, or drives for any timeframe after walking or working and then gets up and begins walking again, the fascia refuses to stretch, and the weight of your body forces it and it tears the wallpaper off the underside of your heel microscopically which creates excruciating pain and over time will generate a heel spur.

This is easily the most frequent new patient complaint that presents in our office, and can be treated conservatively, non-surgically. We have the technology to evaluate and diagnose with digital weight-bearing radiographic evaluation, ultrasound of the soft tissue fascia and FluoroScan to confirm the alignment of the rear foot joints. Flexible strapping of the arch and anti-inflammatories followed by casting for custom orthotics-arch supports-after confirming that your insurance company covers them-and the patient usually is back feeling much better within a week and working and playing pain-free. With our thorough diagnostic testing, we find that most patients’ insurance companies cover orthotics on a regular basis. Of course, we will do all of the precertification with your insurance as a courtesy to you the patient.

PLANTAR WARTS-VERRUCA
These are very common and very annoying and very painful lesions usually found on the weight-bearing surfaces of the foot, associated with puberty, hormone fluctuations and stress. They are caused by a very common virus which resides on the skin of most people and needs the right conditions, mainly stress on the immune system to allow the virus to replicate in the skin and create a wart. Therefore, we commonly see this problem in puberty aged young people.

If the warts are are small they can be treated with topical application of medication. It should be remembered that they like irritation and friction and therefore treatment with topical should be reserved for small lesions only. If the number or size of the lesions is large, then painless laser hyfrecation under gas sedation at the surgery center, under local anesthesia, achieves an excellent result with one day off work or away from school.

NEUROMAS
Neuromas are a very painful affliction of the front foot around the toe joints-with pain, tingling, numbness, electric shock sensations happening individually and all at one time-often manifesting with such foot pain that the patient feels they may have broken a bone. And the number one differential diagnosis of neuromas is a stress fracture.

The cause of this problem again is instability in the 26 bones in the foot-inherited. At the moment of propulsion one of your feet is bearing weight only on the toe joints and you are pushing down with a force equal to 1 1/2 times what you weigh to lift yourself off the ground against gravity and simply take a step. The other foot at that moment is flying through the air getting ready to land on the heel. If the forefoot is unstable then the metatarsal bones which make up the foot component of your toe joint jiggle and the nerves that pass between them become irritated and inflamed and this process snowballs into a swollen scarred nerve- a neuroma. It is not a tumor as some doctors will call it, but more of a scar tissue inflammatory process that can be very painful.

The good news is that if recognized and diagnosed early, conservative treatment with functional arch supports-orthotics-can be almost completely successful in managing the problem

Occasionally, steroid injections administered painlessly and sometimes even alcohol treatment to destroy part of the nerve can be utilized to return the patient to normal activity and painless activity. Surgery on neuromas should always be considered a last resort, due to the high percentage of stump neuroma postoperative complications-a problem which can be more painful than the original neuroma. Therefore, once again, exhausting all conservative therapy before surgery is always good medicine.

FLAT FEET/EXCESSIVE PRONATION
The foot has two functions and they must be performed with each step. Absorbing shock is the first step and with a very flexible hyper prone aiding-flatfoot-this job is performed almost too well. The arch collapses excessively, the foot actually torques inward and the leg rotates internally more than it should. The foot now cannot become rigid for propulsion and body momentum forces the foot to propulse in this flexible unstable position and this causes almost all 33 joints in the foot to sustain abnormal tension, compression and twisting. Over time, this will create bunions, hammertoes, heel spurs, plantar fasciitis, ankle damage and further up the leg – the medial meniscus will be worn almost completely by age 45 and the pelvis tilts forward to help the ball and socket joint at the hip allow the leg to do this abnormal inward rotation and that causes low back pain.

All of this can be avoided-in spite of the patient age-with a very small implant and a 35 min. surgical procedure which is basically painless. Patients can walk on the foot at one week postop and will immediately notice that they have a”new” foot.

Dr. Fedorchak has personally done this surgery on over 1400 patients and it continues to be his favorite surgery-because I have told every parent of the patient and every adult patient that the surgery can be 100% reversed if they don’t like it. We have never had to do that. But it certainly is a wonderful thing to tell parents that you can change their child’s foot dramatically for the better and they have very little to fear from the surgery because it can be reversed. Dr. Fedorchak has even done this surgery on his own oldest daughter when she was 4 1/2 years old. Patients in this practice age from 4 1/2 years old to 75 years old and have delighted in the benefits of this surgery.

HIGH ARCH/CAVUS FOOT
People who inherit a very high arch tend to have the chronic complaint of feeling as if they have “weak ankles”-because the foot lands in such an abnormal lateral heel position that the ankle is exposed and suffers microscopic sprain with every step which ultimately causes chronic damage to the lateral ankle ligaments as well as the ankle joint. Additionally these patients quite often suffer from dramatic hammertoe deformities and bunion deformities because of the forefoot’s attempt to grab the ground with each step and make up for the loss of stability suffered by the hyper rigid foot. The real problem here is the rigidity, which steals the shock absorption function from the foot and causes 150% of what the patient weighs to be transmitted up into the ankle, knee, and hip and lower back and create severe degenerative arthritis at an early age.

This is a foot that needs to be addressed conservatively at least and probably surgically and there are ways with outpatient surgery to bring this foot around to a normal function. One of the first things that needs to be done with this foot-is utilization of external shock absorption shoes to prevent the severe damage to the ankle, knee, hip and lower back joints from the foot’s inability to absorb shock.

Quite often these patients are very good at sports and running and therefore feel that the rigid foot is a blessing-it comes with a high price.

ATHLETES FOOT-TINEA PEDIS
Athletes foot is a fungal infection caused by normal fungus and bacteria on the skin of the foot increasing in population secondary to excessive sweating-hyperhidrosis-or change in skin pH-acid-base balance of the skin-which can both be secondary to physiological changes in the body or can be related to a change in environment.

The skin on the foot represents some of the thickest epidermis-dead skin layer-on the body and this can create lots of depth for the fungus and bacteria to hide. We lose our dead skin layer every 30 days and it is replaced by new epidermis-of which 99% is dead-keratinized tissue

Therefore, it is important to identify and diagnose the problem correctly and then even more important to treat it with not only the appropriate antifungal topically but for the correct length of time. Since the skin is replaced every 30 days a normal treatment should last at least 90 days to ensure that the antifungal gets to the very bottom layers of the epidermis-the dead skin-and eradicates the fungus

Oral antifungal medications should only be used in severe circumstances as it can have serious long-term life-threatening damage to your liver and other organs

EXCESSIVELY SWEATY FEET-HYPERHIDROSIS
Some people are born with more sweat glands than are needed and other people have nervous or endocrine problems which can create excessive sweating in the feet. Quite often this is associated with excessive sweating in the hands as well

For the feet, this can create psychological, embarrassing problems where people are prone to not removing the shoes because they leave a path when they walk in the bacteria and fungus normally found on our skin increases in population and can create odor. Additionally this hyperhidrosis creates an excellent environment for fungal infection of the toenails-onychomycosis-and athletes foot-tinea pedis

The good news is that a topical cream application for two or three weeks on a daily basis can address this problem and reduce the number of sweat glands permanently-therefore eliminating the excessively wet socks, foot odor, toenail fungus and athletes foot

GOUT
Gout is a metabolic disease, which means it’s related to the individual production of each of your cells. Your body is constantly reproducing and replacing cells throughout your lifetime. Your red blood cells which carry the oxygen to your body are entirely replaced every 120 days. So all of the red blood cells in your body four months ago are gone and have been replaced by an entirely new group of red blood cells. This requires an incredibly specific recycling plant to ensure that cells are made properly and timely.

Think of a long assembly line where all of the workstations are manned by veterans of many years and suddenly a brand-new employee shows up at one of the workstations. Things are going to turn over a little bit slower at that workstation. If your body does not have enough of a particular enzyme-then uric acid does not get converted and recycled into the next step on the assembly line as quickly as it should and that buildup of uric acid creates the formation of crystals in your blood which under a microscope look like icicles with a point at either end. When the uric acid level reaches a certain amount in your blood these crystals were icicles find their way into your great toe joint on 1 foot and manifest as incredible pain-as if shards of glass were stuck into the cartilage of joint and when you move the toe it feels just like that.

Along with being extremely painful, gout can lead to gouty arthritis and complete destruction of the affected joint. Therefore it is extremely important that the patient be evaluated by foot and ankle specialist who is familiar with this problem and can recognize the arthritic problems, keep a record of the joint presentation through digital videography and treat the metabolic disorder by giving the patient the enzyme they need to change uric acid into the next product along the assembly line.

It is very important that the patient continued this medication for the rest of their life and if they do the chances of having gout attacks and debilitating complete destruction of the joints and foot is very, very minimal.

RHEUMATOID ARTHRITIS-RA
Rheumatoid arthritis is one of several diseases considered at this time to be called connective tissue disorders. Medicine is still not sure where to put these diseases and so they are lumped together. The common denominator is that the body attacks itself. The immune system cannot differentiate between bad external invasion and the internal makeup of your body. In the case of rheumatoid arthritis it attacks the ligaments in joint capsule which are the stability for the joints. If these are attacked and damaged than abnormal range of motion is allowed and that creates structural damage to the joint cartilage and visible deformity to the patient. It is also extremely painful.

Every rheumatoid arthritis patient should have a custom functional orthotic. The disease weakens and destroys the structural integrity of the joints and then secondarily the joint cartilage becomes damaged and extremities become deformed. With 1 1/2 times what you weigh coming down on your foot with every step you take, you need all the support you can get. If your body is destroying some of that natural support through damage to the ligaments and joint capsule then external orthotic support is absolutely necessary to prolong alignment and limit pain.

DIABETIC NEUROPATHY
Diabetes is a terrible disease that affects both children and adults. It affects the body’s ability to regulate individual cell metabolism-sugar-and leads to dysfunctional and permanently damaged cells which then create problems for the patient.

The example that I like to use for patients in my office to understand diabetes is a very simple. You fix yourself dinner and you sit down and you eat and you mechanically fill your stomach and satisfy the first part or half of digestion. Then the food you ate is broken down in your stomach and dissolved from your small intestine into your bloodstream as sugar, fat and protein. The protein is used for bones and hair-the two by fours of your body. This fat goes around her waist for cold winter night. And the sugar is the gasoline that every one of your cells runs on. So the sugar goes around and around in your bloodstream and your pancreas recognizes this and produces insulin to allow the sugar to pass through the cell walls and into each of the cells that make up your body. If the insulin fails to be made properly and timely than the sugar continues to go around and around in the blood and it builds up on the walls of your arteries and narrows them and it passes through the kidneys and is excreted in the urine. None of the sugar is benefiting your cells. And so now the cells that are most fragile and must be set on a regular basis become damaged or die. Brain cells, peripheral nerve cells, your retina. It is often said that diabetes won’t kill you directly but it will leave you with both legs amputated and very poor sight and praying to die.

When the peripheral nerves are damaged they do not function properly and send abnormal messages to the brain and patients suffer from diabetic neuropathy. This is a very debilitating and painful disorder and needs to be addressed by many specialists simultaneously. Endocrinologists, neurologists and podiatrists should be involved simultaneously to slow down or stop the progression of the disease and to work in concert to reverse the symptoms.

All diabetic patients should be wearing a functional custom-made orthotic.

FRACTURE TREATMENT AND REPAIR
Fractures of the toes, the foot and ankle all come in varying degrees of severity. Some of them can be so mild as to require simply a shoe gear modification. But others can be much more devastating.

First of all it is important to see a specialist of the foot and ankle to ensure that all anatomic and physiological function of the fractured bone is understood completely from a weight-bearing standpoint as well as the location of tendon attachments. If there is a tendon attachment close to where the fracture has occurred, and the emergency room doctor is not familiar with the anatomy of that attachment it could have devastating effects as the fracture will move during the healing process-4 to 6 weeks-and can seriously distract from the healing. This can end up in abnormal bone formation, chronic pain, and failure of the fracture to heal.

Also location of the fracture as regards joint surfaces can be very important to long-term impact and excellent healing. This is very commonly seen in the midfoot, rear foot and ankle, where emergency room and urgent care physicians may not appreciate the severity of the damage or even have the equipment-FluoroScan and Ultrasound-to evaluate the fracture location properly.

Sometimes, the severity and location of the fractured mandate that conservative therapy i.e. cast and crutches will not be enough and surgical intervention Open Reduction Internal Fixation-the use of screws and plates-becomes necessary to ensure proper alignment and proper joint function and preservation of the joint. Quite often a fracture through a joint can be missed and becomes devastating later.

POSTERIOR HEEL PAIN-ACHILLES TENDON INSERTION BUMP-“PUMP BUMP”-RETRO CALCANEAL EXOSTOSIS
This is a very painful bump of bone which gets larger with time at the insertion of the Achilles tendon on the back of the heel. Quite often it is associated with a curvature of the heel-calcaneal varus-which creates an abnormal pull on the Achilles tendon insertion on the back of the heel bone-calcaneus-and causes bony overgrowth and pain and eventually inability to wear certain shoes and to walk.

Like most bio mechanically caused problems in the foot and ankle if addressed early with proper diagnosis and conservative non-surgical treatments such as orthotics it can be slowed or completely stopped in its natural progression.

Sometimes, due to severity or to the amount of time it has been allowed to grow, surgical repair is necessary and can be performed on an outpatient basis.

ACHILLES TENDON RUPTURE AND REPAIR
The Achilles tendon is the largest tendon in the body and is required to create enough force to lift your body weight multiplied by 150%, off the ground with every step you take.

Tendinitis and partial tears as well as complete rupture of the Achilles tendon need to be diagnosed and evaluated by an expert .

Quite often slight tears, tendinitis, etc. can be treated conservatively with below the knee cast for six weeks

If surgical repair is necessary it should be performed by someone who is Board-Certified and does this kind of surgery on a regular basis-Dr. Fedorchaks’ office provides that quality of care

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