Services

Arthritis

Arthritis is a condition of inflammation and wearing out of the cartilage and lining of the joints. The joints usually become stiff and swollen due to increased fluid. The most common type of arthritis is osteoarthritis which is a wearing out of the joint surfaces. Unlike rheumatoid arthritis which is a connective tissue disease where there is an inflammatory process that attacks the joints and causes destruction and deformity.

Athletes Foot

This is a skin disease caused by a fungus. Because there is buildup of moisture in shoes this provides a warm dark environment which makes it easy for fungal growth. In a high-risk patient such as a diabetic or one with peripheral vascular disease this can lead to skin breakdown and secondary bacterial infection. Quite often over-the-counter medications are helpful. Shoes and socks need to be changed frequently and antifungal foot powder can be utilized.

Bunions

One of the most common conditions that we treat at Penobscot Family Foot and Ankle Center of Maine are bunion deformities known as hallux Valgus. This is seen as an enlargement of the big toe joint which can become inflamed and painful. This makes it difficult to wear normal foot gear. This is actually a dislocation of the great toe joint. Many times this can be treated conservatively with padding and shoe modifications. Surgical correction of the deformity is quite often necessary and is performed on an outpatient basis.

Bone Spurs

Bone spurs are bony projections that develop along the edges of bones. They are called osteophytes. They usually form around joints because of the wear and tear of osteoarthritis. They may occur at an attachment of tendon or fascia to the bone and these are known as traction spurs. Most of the time bone spurs did not require treatment and may go undetected. If they are symptomatic they can be removed surgically.

Corns and Calluses

We commonly see corns and calluses in our practice. They are areas of thickened skin that developed to protect an area from irritation or friction. They are usually formed by rubbing or excess pressure against a part of the foot. They may form over a foot deformity. They are meant to protect the skin but when they become thick they act as an irritant. These lesions are commonly pared down and protected with padding or shoe inserts. In a foot with decreased feeling they can cause ulcerations.

Diabetic Foot Care

When you have diabetes it can increase the risk of developing a wide range of foot problems, often because of two complications of the disease: nerve damage (neuropathy) and poor circulation.

Diabetic peripheral neuropathy usually develops slowly and worsens over time. Many times patients will have this condition before they are diagnosed with diabetes.

Patients with foot deformities such as hammer toes and bunions are prone to develop ulcerations because they cannot feel sores on their feet. Many patients will also develop thickened or ingrown toenails.

It is important for those patients who are at high risk to have regular visits with their podiatrist.

At Penobscot Family Foot and Ankle Center of Maine we carry a full line of diabetic extra depth footwear with heat molded and custom inserts. For eligible patients Medicare will cover these shoes and inserts.

Diabetic Infections and Ulcerations

Because of the decreased sensation secondary to peripheral neuropathy and commonly occurring peripheral arterial disease the diabetic foot is quite prone to developing infections. Infections usually occur secondary to ulcerations. The oil glands in the diabetic foot may stop functioning and this makes the skin more dry and apt to crack or fissure.

The diabetic may not be able to mount an inflammatory response to an infection which allows more rapid spread of the process. Quite often this leads to cellulitis and abscess formation requiring hospitalization and surgical treatment.

Regular inspection of the diabetic foot by the patient and or their family can help to avoid serious infection or subsequent amputation.

Flat Feet (Pes Planus)

This condition results in a foot that has the appearance of not having an arch. Usually this is not symptomatic. Many times this is because the arch never fully develops. It is estimated that 20 to 30% of the general population have this condition. In adults flat feet may develop following an injury or simple wear and tear and stretching out of the tendons and ligaments around the foot and ankle.

Many times this will cause an awkward and painful gait. Some children are born with a rigid flat foot. Flat feet may contribute to problems in your ankles and knees and may cause or exacerbate backpain.

Most often the symptomatic “excessively pronated “or flat foot is treated with custom molded biomechanical orthotic devices. Prefabricated devices are also commonly utilized. At Penobscot Family Foot and Ankle Center of Maine we find that it is necessary at times to fabricate a custom made foot/ankle brace to control the very symptomatic severe flatfoot. Sometimes surgical intervention becomes necessary.

Fractures

Fractures may occur from direct trauma or from chronic repetitive stress. A stress fracture is a small crack in a bone. Quite often these develop from repetitive overuse from high-impact sports like running or basketball. In a non-athlete they are more common in people with softer bones such as those with osteoporosis. The mechanics of the foot may predispose someone to a metatarsal fracture.

When muscles become overtired they cannot absorb shock and it is transferred to the bones. The most common areas for a stress fracture are in the second and third metatarsals, navicular bone and heel bone or calcaneus. The pain usually will worsen the more that you are on your foot and commonly there is some swelling.

Stress fractures are treated conservatively with rest and a stiff shoe or a removable walking cast. Most will heal within 6 to 8 weeks.

Traumatic fractures are commonly seen following a fall from a height or with an ankle sprain. It is common to fracture the heel bone and the fifth metatarsal. The bones of the ankle are susceptible to fracture following a sprain. Quite often surgical intervention is necessary to fixate the fracture. Fractures of the toes usually heal without treatment but it is suggested that they be evaluated professionally as sometimes treatment is needed.

Fungal Toenails

Toenail fungus is an infection beneath the surface of the nail caused by fungi. The disease is characterized by a progressive change in the toenails quality and color. The nails become quite thickened and are sometimes very hard or very brittle. This is seen more commonly in older individuals but can occur in children.

At Penobscot Family Foot and Ankle Center of Maine we routinely see patients who are unable to trim their own toenails. Oral antifungal medication is sometimes utilized as well as topical antifungal oil preparations. Eradication of this problem can be difficult. Sometimes it becomes necessary to permanently remove a toenail which is a simple office procedure.

It is important for high-risk patients to seek podiatric care for this problem as ulcerations can occur beneath the nail.

Hallux Rigidus

Hallux Rigidus is an arthritic disorder of the joint located at the base of the big toe. The joint may become quite enlarged making it difficult to wear shoes. It causes pain and stiffness in the joint and it becomes increasingly harder to bend the toe. At Penobscot Family Foot and Ankle Center of Maine this is one of the most common arthritic conditions that we treat. Often times this is confused with a bunion deformity which is more of an enlargement and deviation of the joint.

Common causes of this deformity are faulty function and structural abnormalities of the foot that can lead to osteoarthritis in the big toe joint. Other times it may be caused secondary to trauma.

Nonsurgical treatment involves shoe modifications, orthotic devices, anti-inflammatory medication, cortisone injections and physical therapy.

Quite often surgical intervention is necessary. This may involve simply removing bony enlargements or fusing the joint. Some physicians utilize joint implants.

Hammer Toes

Hammertoe is a contracture or bending of one or both joints of the second through fifth toes. This abnormal position can put pressure on the toe when wearing shoes causing problems to develop. They usually start out as mild deformities and get progressively worse over time. Initially they are flexible but as a person ages they become rigid and symptomatic.

The most common cause of hammertoe is muscle/tendon imbalance resulting in structural change in the toe. They may be aggravated by ill-fitting shoes. Quite often they are inherited.

Nonsurgical treatment involves padding and trimming of corns and calluses as well as change in footwear, splinting and strapping of the toes. When the toe becomes rigid and symptomatic surgical intervention is commonly utilized. This involves removing or fusing a part of the joint in the toe and relaxing or rebalancing the tendons. Pins, screws and implants are utilized to hold the toe and a corrected position.

Surgery is performed on an outpatient basis.

Heel Pain – Plantar Fasciitis

Heel pain is most often caused by plantar fasciitis. It may also be caused by a stress fracture, tendinitis, arthritis, nerve irritation or bone cyst or tumor.

Plantar fasciitis is an inflammation of the band of tissue that extends from the heel to the toe. Most often it is secondary to faulty foot mechanics. It is more common in a high arch foot which has a tighter fascia. Sometimes a heel spur will develop but it is not the cause of the pain but an indication that there is abnormal pulling on the fascia.

Most often symptoms occur following the use of flexible poorly supporting shoes. Typically there will be pain upon arising in the morning or after sitting for a while. The pain may ease with walking. The pain usually occurs at the bottom of the heel but may extend into the mid-arch.

Conservative treatment involves stretching the calf and hamstring muscles. Avoid going barefoot. It is important to ice the heel and use a stiff shank supportive shoe as well as arch supports. At Penobscot Family Foot and Ankle Center of Maine we carry a full line of inexpensive prefabricated arch supports. Sometimes custom molded orthotics are necessary. We usually recommend the use of a night splint and elastic arch band. Women may find relief wearing a higher heeled shoe. Corticosteroid injections can be very helpful.

If someone fails conservative treatment we commonly perform a surgical plantar fascial release which is almost always curative. There is no need to remove the heel spur.

Plantar fasciitis is the most common foot injury that we see.

High Arch (Pes Cavus)

Cavus foot is a condition in which the foot has a very high arch. Because of this an excessive amount of weight is placed on the ball and the heel of the foot when walking or standing. This may represent an inherited structural deformity or may be caused by a neurologic disorder such as cerebral palsy or stroke. If this appears to be worsening over time is necessary to determine if there is an underlying neurologic disorder or other medical condition.

The arch will appear high even when standing. Quite often this is associated with the formation of hammertoe and calluses on the bottom of the ball of the foot. This foot may become unstable and it is more likely to suffer an ankle sprain.

Usually this is treated with custom foot orthotic devices and shoe modifications. Sometimes a brace is necessary to keep the foot and ankle stable especially if this is occurring along with foot drop. Sometimes surgical intervention is necessary.

Ingrown Toenails

An ingrown toenail is a common condition in which the corner or side of one of your toenails grows into the soft tissue of that toe. This can result in pain and swelling. Quite often these become infected.

At Penobscot Family Foot and Ankle Center of Maine ingrown toenails are one of the most common conditions that we treat. It is especially important to treat this condition in a patient that has diabetes, peripheral arterial disease or is immunocompromised.

Many patients are just unable to cut their toenails because of orthopedic problems or visual problems. Those patients are routinely seen for foot care. Commonly these toenails are curled and often thickened or have a fungal infection. We often see this in adolescents and teenagers who may cut their toenails improperly.

If this is a chronic problem we can usually remove the affected side of the toenail with a simple office procedure that does not require an incision. Patients can shower the next day. It is not necessary to miss work or school following the procedure. Antibiotics are utilized to treat any infection.

Ankle Pain and Injuries

Ankle pain is quite often seen following an ankle sprain but it can also be caused by ankle instability, arthritis, gout, tendinitis, fracture, nerve compression such as tarsal tunnel syndrome, infection or improper mechanical alignment. It can be accompanied by swelling or redness and is worsened with walking.

It is quite common to see ankle pain secondary to tendinitis of the posterior tibial tendon on the inner side of the ankle or of the peroneal tendons on the outer side of the ankle. This is usually associated with faulty mechanics.

Conservative treatment involves immobilization, anti-inflammatory medications, physical therapy and injection therapy. A variety of ankle braces are often utilized. It is important to seek medical attention to obtain an accurate diagnosis.

Morton's Neuroma

A neuroma is a thickening of nerve tissue usually caused by chronic irritation. The most common neuroma in the foot is Morton’s neuroma which is usually located between the third and fourth toes. The nerve becomes thickened because of fibrosis secondary to mechanical irritation. Patients with other forefoot deformities such as hammer toes and bunions are more likely to experience a neuroma. Symptoms usually include tingling, burning or numbness with a sharp pain that quite often radiates into the third and fourth toes. It can occur between any of the toes.

At Penobscot Family Foot and Ankle Center of Maine conservative treatment includes padding usually with a metatarsal pad as well as icing, orthotic devices, activity modification, wider shoes with a lower heel. Injections of cortisone and local anesthetics and sometimes alcohol are utilized.

Surgical intervention is required for patients who do not respond to nonsurgical treatment and are experiencing chronic discomfort. Usually the nerve section is excised. This does leave permanent numbness between the third and fourth toes but this is usually not a problem. Rarely a neuroma can recur following surgical excision.

Sprains/Strains

Any joint in the foot or ankle can be sprained. One of the most common ankle joint injuries is the “ankle sprain”. They are very common athletic injuries. It is the most common injuries seen in basketball players. The lateral ankle sprain occurs when the foot inverts or turns inward. Usually this involves injury to a ligament most commonly the anterior talofibular ligament. Commonly the patient will feel or hear a pop. Swelling and bruising occurs shortly after the injury. And sometimes it is quite difficult to walk on the affected foot. This can become a chronic problem.

It is quite common to also sprain the midfoot and sometimes this is associated with a dislocation of the midfoot known as a Lis Franc’s fracture dislocation. This is a serious injury often requiring surgical repair.

X-rays are usually obtained to make sure there is no fracture. It is common to fracture the fifth metatarsal during an ankle inversion sprain. A grade 1 sprain involves ligament stretch, grade 2 involves partial tear of the ligament and grades three involves a completely torn ligament.

The medial ankle or eversion sprain is possible but it is much less common and usually involves a more serious mechanism of injury.

Immediate treatment involves “RICE” rest, ice, compression, and elevation. Sometimes a seemingly simple ankle sprain can lead to chronic problems. It is therefore important to seek medical attention.

Sometimes chronic problems can occur such as fractures of the cartilage or osteochondritis, tendon tears and nerve injuries can occur as well. It is important to rehabilitate the ankle following an injury with strengthening and proprioception exercises.

Tendinitis

A tendon is a tough yet flexible band of fibrous tissue. Tendons connect your muscles to bones. When a muscle contracts it pulls on the bone to cause movement. Although there are hundreds of tendons throughout our body there are a small handful of tendons that commonly cause problems. Some of these occur in the foot and ankle. Most tendon injuries occur in an area known as the watershed where there is a poor blood supply. This makes it difficult for the body to deliver oxygen and nutrients necessary for tendon healing.

Most of the tendon injuries that we see in the foot and ankle are related to overuse or improper biomechanics. There will be pain directly over the tendon and pain with movement. Often time’s the tendons will become swollen.

The most common tendon injury seen in the foot and ankle involves the Achilles tendon. This is the large tendon that attaches to the back of your heel. Quite often the tendon will become swollen a few inches up the leg from where it attaches to the heel bone. This usually means that the tendon is degenerating and some of it is tearing and turning to a gelatinous material. This is known as tendinosis. This is the area where the tendon may rupture completely or partially. This is usually seen in middle-aged weekend warriors. Sometimes steroids or quinolone antibiotics have been linked to Achilles tendon rupture. Other tendons that we commonly see injured are the posterior tibial tendon on the inner side of the ankle or peroneal tendons on the lateral or outside part of the ankle. The tibialis anterior is a muscle in the front of the ankle that attaches to the top of the foot and this may become degenerated and sometimes ruptures. With the advent of MRI we can see longitudinal tears in tendons with degeneration that is commonly associated with tendon injury.

Treatment involves correcting any biomechanical abnormalities. Physical therapy modalities are quite often prescribed. Rest and immobilization are utilized if necessary. Correcting muscle imbalances with stretching and in the case of the Achilles tendon emphasis is placed on eccentric stretching exercises. Anti-inflammatory medications are often utilized.

In the case of acute rupture or severe tendon degeneration surgical intervention is necessary.

Trauma

Foot and ankle trauma is extremely common no matter how young or old you are. This commonly involves fractures, torn ligaments and tendons, sprain and strains, puncture wounds and toenail trauma. Quite often patients are seen with fractures or torn tendons without realizing how serious the problem is. Long-term foot and ankle pain is often linked with ignored trauma.

The most common foot trauma that we see are toe fractures, metatarsal fractures, calcaneus fractures,ankle fractures, ankle and midfoot sprains, tendon tears, sesamoid injuries, hematoma, foreign bodies and lacerations.

Many of these injuries are referred from the emergency department. Patients with diabetes will quite often have injuries that they will not notice such as burns and blisters. It is important for those patients to make sure that they wear shoes whenever they are up and around.

Quite commonly the more severe foot and ankle trauma requires the expertise of a specialized trauma surgeon and we frequently make those referrals.

Plantar Warts

A wart is a small growth on the skin that develops when the skin is infected by a virus. Warts can appear anywhere on the foot but they usually appear on the bottom or plantar aspect of the foot. They are caused by direct contact with the human papilloma virus (HPV). The wart may resemble a callous and it may have tiny black dots in it.

No matter what the treatment they can be very difficult to get rid of. If they are not symptomatic we usually suggest no treatment as they will almost always resolve on their own. If they are symptomatic they can be treated with cryotherapy(freezing), salicylic acid topical medications, hyfrecation(burning off), laser removal, topical irritants such as Cantharidin which causes the skin to blister, duct tape which works as an irritant creating an immune response by the body, drying agents used topically and topical medications used to treat skin cancers.

Depending on the location of the wart and symptomatology along with the patient’s input we decide on what treatment will work best. We usually suggest spraying the shoes with Lysol, changing socks frequently and eating foods rich in vitamin A.

There are skin cancers that can mimic plantar warts such as verrucous carcinoma therefore if a wart is enlarging and does not go away it should be looked at.

Wound Care

The most common wounds that we treat are related to diabetic foot ulcerations. These occur in approximately 15% of patients with diabetes and are usually on the bottom of the foot. 6% of patients who develop a foot ulcer will be hospitalized for infection or ulcer related complication. Approximately 14 to 24% of patients with diabetes who develop a foot ulcer will require an amputation. Foot ulceration precedes 85% of diabetes related amputations. Diabetic ulcers are preventable.

Most of the diabetic wounds that we see involve sensory neuropathy and some degree of vascular insufficiency. They are commonly related to foot deformity and excessive irritation from footgear. Treatment is aimed at preventing infection, “offloading “or taking pressure off of the area, removing dead skin and tissue called debridement, applying medication or dressings to the ulcer and managing proper blood glucose control.

In recent years the importance of understanding and treating the physiology of the wound environment has dictated how we treat chronic wounds. This new information has led to the formation of a new and large industry which provides dressings, medications and modalities which promote and enhance wound healing.

Hyperbaric oxygen therapy is another modality which is utilized at St Joseph Hospital’s wound clinic. In addition there are many skilled wound nurses that treat chronic wounds on patients in their homes.

Tailor's Bunion

Tailor’s bunion or bunionette is a prominence of the fifth metatarsal bone at the base of the little toe. There usually is a bump right where the toe attaches to the metatarsal bone. This can become quite inflamed and irritated. It is called a Tailor’s bunion because centuries ago Tailor’s sat cross-legged with the outer edge of their feet rubbing on the ground.

Most often this deformity is caused by an inherited faulty mechanical structure of the foot. The fifth metatarsal begins to drift laterally and the foot becomes wider. Quite often there is a seam in the shoe right at this point which can further irritate the bunion.

Conservative treatment includes shoe modifications and pads. Occasionally a bursa will form that can be injected. Surgery is considered when pain continues despite trying the previously described measures. Sometimes the bone can be just shaved down or it may need to be broken and reset in a corrected position.

Foot Odor

Closed shoes and sweaty feet can lead to some pretty powerful foot odor. If you’re prone to smelly feet try to wear sandals when possible for better airflow. Rub cornstarch or anti-perspirant directly on the soles of the feet, wear moisture wicking socks and avoid wearing the same shoes two days in a row so they can dry out. A quick spray of Lysol in your shoes knocks down the bacteria that cause the odor. If you are not diabetic you can try soaking your feet in lukewarm water with Epson salt or a solution of dark tea to help dry them out. There are topical medications that are available and may be helpful for you.