Rashes & bumps... What to do when you're just not quite sure.

As an APRN that specializes in foot and ankle conditions, I face a very similar clinical reality as my colleagues in primary care... Disorders of the skin.  The skin problems that I most often see are related to fungal infection and warts.   But every once in a while I am presented with a much more interesting and unique dermatological challenge.  In fact, I will present to you a patient case that just happened last week.

A 10 year old caucasion female is referred to my by her pediatrician for "wart removal" of a solitary plantar wart on her plantar medial heel that has been evident for the past 3 months.  The lesion grew over a section of skin that her mother said previously had a birth mark.  The lesion measured 6mm in diameter and was raised.  It had a pink-brown pigmentation and the borders of the lesion were smooth.  It did not have a rough "warty" appearance.  After taking a medical history and evaluating the lesion, I recommended that we biopsy the lesion.  I choose to do a simple 2mm punch biopsy (after numbing under the lesion with a marcaine with epinepherine mixture).  I sent the specimen to my Dermatopathologist, BAKO Pathology and 2 days later had a diagnosis... Spitz Nevus.  I referred this patient to my partner, Dr Paul Krestik, for a complete excision of the lesion. 

Spitz Nevus (Click for video information) 

Additional Information on Spitz Nevus

I believe that there are at least two major take home messages from the case above.  First, as APRN's we need to biopsy more lesions.  Why send our patients out to dermatology for biopsy when it can be simply and effeciently done in our own office?  Second, an excellent Dermatopathologist is a very important member of your clinical team.  After trying several different pathology companies in my practice, I have concluded that BAKO Pathology is the premiere. 

If you are not comfortable doing simple punch and shave biopsies in your office, I would challenge you to find a continuing education course on the topic and gain some confidence and skill in this area.  I will do a brief educational primer on these techniques in the near future.

You've got to know your anatomy...

One of the most important aspects of being an excellent clinician is simply knowing human anatomy.  As advanced practice nurses, we spend many years in school and clinical practice becoming experts in diagnosing and treating a wide variety of health systems.  However, I find that with many primary care providers, APRN's included, often do not devote enough "educational energy" on the foot and ankle.  The human foot and ankle is a complex mechanical structure containing more than 26 bones, 33 joints (20 of which are actively articulated), and more than a hundred muscles, tendons, and ligaments.^[1]   



Foot and Ankle Anatomy Resource

Considering the variety of conditions that manifest in the foot and ankle, it is essential to become a competent clinician in this arena and that will involve an investment of time and energy.  Is it worth it?  Absolutely.  Musculoskeletal conditions of the lower extremity comprise a significant percentage of patient encounters in primary care.  As a nurse practitioner, I am acutely aware that our patients trust our judgement and look to us as their health care expert.  Although I realize that it is impossible to become a highly skilled specialist in all facets of health care, it is our responsibility to continue to grow and learn as providers.

How many hours over the past year have you invested in studying the anatomy of the foot and ankle?  Have you been to any continuing education courses on this topic?  Are you willing to put the "educational energy" into learning a new area for your clinical practice?

If so, I would recommend that you start off by simply doing an online search for anatomy of the foot and ankle.  You may find an additional excellent online resourse HERE.

"Rocker Bottom" shoes... Are they just a passing fad?

There are a variety of these types of "toner" or "rocker bottom" shoes available on the market today.  From Skecher's Shape-Ups to Reebok's EasyTone, my patients often ask me if these shoes are worth trying.

Skecher's Shape-Ups

Several of my patients have shared with me their personal journey with the "toner" shoes.  From the 80 year old lady who struggled to use them, only to be saved from an inevitable fall by the use of her walker, to the Cracker Barrel waitress who is "certain" that she only continues to work because of these "incredible new shoes".  

With such a variety of opinions and experiences, I believe that any clinician recommending the purchase of "rocker bottom" shoes needs to consider the following...

"Normal gait biomechanics"are definately altered with these shoes.  A few foot conditions may benefit from the short term use of these shoes.  The "rocker bottom" does effectively offload the forefoot, which may help with forefoot pain related to capsulitis or Morton's neuroma.  The shoe may also provide a stretch of the plantar fascia that may help to alleviate the symptoms of plantar fasciitis.

"Rocker Bottom" shoes can lead to instability and falls.  According to the Consumer Reports health report there were more reports of injuries with these types of shoes then any other in 2010.  Here is an example of a Skecher's lawsuit over the Shape-Up shoes causing stress fractures.

"Rocker Bottom" shoes have not proven to provide the health benefits that they have advertised.  In fact there is currently a Skecher's class action lawsuit over unfounded claims of health benefits.

In conclusion, I have choosen not to recommend "rocker bottom" shoes for my patients.  What will you decide?

Performing a Nail Surgery

The spring and summer months bring flowers blooming, family picnics and a flare up of those pesky ingrown toenails.  With the renewed commitment to exercise after taking the winter season off, you can plan on the incidence of complications and infections related to ingrown toenails increasing.   The question is how to appropriately and effectively manage this very painful problem.

For a quick primer on Onychocryptosis click HERE!

One of the first questions is whether it is best to perform a simple slant back procedure, partial nail avulsion without chemical matrixectomy, partial nail matrixectomy or a total nail matrixectomy.

For a simple, first time ingrown toenail with paronychia you might consider doing a simple slant back procedure with a topical anesthetic spray and a small nail cutter.  Necessary instruments are listed below.

For nails that are chronically ingrown or damaged I would recommend considering a more permanent procedure. 

For diabetics that are poorly controlled or any patient with vascular compromise, I would caution the use of a chemical matrixectomy.  

As to the question of Sodium Hydroxide verses Phenol for chemical of choice, I choose Sodium Hydroxide.   I have used both chemicals in the past but have found that the tissue damage and irritation with Sodium Hydroxide is less then with Phenol.  This study published by the NIH comparing the Sodium Hydroxide and Phenol Matrixectomy showed significantly reduced healing times with Sodium Hydroxide use with comparable long term success rates.

Click HERE for Video of Partial Sodium Hydroxide Matrixectomy

Click HERE for Video of Post Op Nail Surgery Day 14

 Click Here for a Printable Post Op Nail Surgery Patient Instruction Sheet

Evaluating Gait and Recommending Athletic Shoes

What type of athletic shoe should I buy?  Is there really that much difference in the brands?  Why do manufacturers like New Balance, Brooks and Asics have such a variety of choices?

When considering an answer, it is important to be educated on a couple of things.  First, you need to understand the different components of an athletic shoe.   Please visit the "Anatomy of a Shoe" link provided by the American Academy of Podiatric Sports Medicine for an excellent explanation.

Next, you need to assess your patient's gait.  Do they have neutral pronation, overpronate or underpronate?  The following video links will help you become comfortable making this assessment.

 Click for Video explaining Neutral Pronation

Click for Video explaining Overpronation

Click for Video explaining Underpronation

Back to the original question ... what is the best athletic shoe?  When making suggestions to my patient's, I follow the recommendation list provided by the American Academy of Podiatric Sports Medicine.

Personally, I have worn Brooks tennis shoes for the past few years and really like them.  Brooks has a wonderful interactive "Shoe Advisor" section to help you choose the perfect style for your unique needs!

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Placing a Digital Block

One of the most important aspects of performing any surgical procedure is the ability to achieve appropriate anesthesia. During my first few years in practice, I tried a variety of techniques attempting to discover the most efficient, painless way to perform a complete digital block.

If you will follow these steps, I am confident that you to will get great results.

1. Apply a topical preparation to the site of the digit that you will be placing the injection. I use this compounded topical (Benzocaine 20%, Lidocaine 6%, Tetracaine 4%) Allow the topical to stay in place for at least 15 minutes prior to the injection, although optimal time would be 30 minutes.

2. Mix 2.5cc of 1% Lidocaine Plain with 2.5cc of 0.5% Marcaine Plain and add 0.2cc-0.4cc of 8.4% Sodium Bicarbonate (helps decrease the stinging sensation with the injection). Don't use to much Sodium Bicarbonate, as this will decrease the effectiveness of the anesthetic.

3. Clean the application site with alcohol.

4. Spray the injection site with a 'cold freeze' topical spray (see my blog post on 'Placing a Plantar Fascial Injection for a link to the product that I use)

5. Inject approximately 1 1/4cc of the mixture into all 4 areas around the digit. You will essentially be making a ring of anesthesia around the digit of choice.

Check out my Demonstration Video

  

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The "Orthotic" Sandal

"My feet are killing me..." "The heel pain is back..." Such common complaints of my patient's as they inevitably transitioned from wearing orthotics throughout the winter months into flip-flops for spring and summer.  For years I struggled with this scenerio.  I tried (unsuccessfully) to use the basic logic of "cause and effect" but to no avail.  Patient's were frustrated and so was I.

Is there a sandal that's affordable, functional & attractive enough to help with this problem?  I searched for several months to find a product that met my criteria.  I ordered a variety of samples, from different manufacturers, that claimed to be the "most supportive and comfortable."

Finally, I found the Spenco Total Support Sandal.  These "Orthotic" Sandals retail for $40.00 and are worth every penny!

Spenco Total Support Review for "Nature Lover's"

Spenco Total Support Review for "Athlete's"

Spenco Total Support Review for "Everyone Else"

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How to Treat Plantar Fasciitis

Tips for a Successful Cortisone Injection

For this injection I recommend a 27 gauge needle that is 1 1/4" in length.  I use 1cc of Lidocaine Plain, 5mg of Kenalog, 2mg of Dexamethasone Phosphate, 0.3cc Sodium Bicarbonate (for your patient's comfort).

I also highly recommend using a topical "cold freeze" prior to the injection.  This decreases the pain of the initial injection and also minimizes your patient moving their foot in the beginning of the procedure.

I would suggest this inexpensive but very effective product manufactured by
medique pharmaceuticals.

Lastly, It is worth having a medical assistant help hold your patient's leg (right at their knee and above the ankle)

  

It is also important to have your patient stretch, ice and massage the plantar fascia.  Here is a link to a printable patient education handout that you can utilize in your practice.  Patient Education Instructions

Finally, many of your patient's will require the use of a supportive shoe insert.  Some individual's will need a custom orthotic but many will do great with a high quality pre-fabricated device.  Please do not send your patient to the local discount store to purchase "gel pads" or heel cups.  I highly recommend the Pro Powerstep orthotic.  This pre-fabricated insert is supportive & easily transitioned into.  Your patient's will be very pleased with this product.  The wholesale pricing is under $18.00 and the inserts retail at $40.00.

ProTech Powerstep Orthotics

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Making my way to the AANP National Conference

I am excited to return to the AANP National Conference in Las Vegas to present a session on "Diagnosing and Treating Common Foot and Ankle Conditions".  The opportunity to speak at such a well respected conference is one that I highly value.

My journey as an APRN began in 2000 when I graduated from the University of Kentucky.  I achieved my certification as a FNP with the ANCC (I was young and did not know any better...)  Upon graduation the career opportunities in the Central Kentucky area were limited.  But I only needed one opportunity to open and a few weeks after graduation I was offered a full time position in a growing podiatry practice.  In talking with several NP's and fellow students I was advised that I may inevitably be hurting my career opportunities by taking the position.  After all...  Who had ever heard of a NP working with a podiatrist.  Was it even legal in Kentucky?  Did I know enough about the foot and ankle to effectively care for patients?

After doing the research, I found that it was legal to work in collaboration with a DPM and since I have never been one to follow the path of least resistance, I accepted the position.  As far as having a knowledge base that would allow me to be an excellent foot and ankle clinician, that would come years later as I have spent several hundred hours of self study to gain the experience and confidence that I have today in treating many common and complicated foot and ankle pathology.

In speaking with many Nurse Practitioners, Physician Assistants, Physical Therapist and MD's/DO's, I have come to the conclusion that adequate training and education in foot and ankle care is missing in our educational experience.  With this blog, I hope to introduce you to some interesting case studies, offer effective and research based practice guideline suggestions and provide video education on performing common foot and ankle procedures.