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Lockport Footcare Center, PLLC
Harry I Zirna, DPM
Bunions (Hallux Valgus)
Bunion deformities are bony prominences which develop along the inside of the big toe joint. An inward drift or deviation of the long bone in the foot called the first metatarsal away from the 2nd metatarsal creates what is called a bunion deformity. The larger the separation or gap between the 1st and 2nd metatarsal’s, the larger the bunion deformity. As the bone becomes larger or more prominent, the great toe is pulled further toward the 2nd toe. This bony protrusion can result in shoe discomfort causing pain, redness and tenderness of the big toe joint. The longer a joint is allowed to function in an abnormal alignment, the more adaptive changes can occur. Occasionally, degenerative changes of the joint or bursitis can occur.
Treatment of bunions can include; shoe modifications, prescription orthotics, padding, oral anti-inflammatory agents, periodic cortisone injections or surgery to realign the malaligned bone.
Surgery often involves cutting through the deformed bone to correct the alignment and maintain the correction using pins, wires or screws. Surgery if chosen will often result in prolonged periods of immobilization and disability which a patient must thoroughly understand. There is often a period of stiffness associated with the big toe joint which will require time and effort to regain strength and motion.
Diabetic Footwear
Proper footwear is an important part of an overall treatment program for people with diabetes, even at the earliest stages of the disease. If there is any evidence of neuropathy, wearing the right footwear is crucial.
As a general rule, people with diabetes should choose shoes that:
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Accommodate, stabilize, and support deformities, such as Charcot Foot, loss of fatty tissue, hammertoes, and amputations. Many deformities need to be properly supported to relieve pain and avoid further damage.
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Limit motion of joints. Limiting the motion of certain joints in the foot can decrease inflammation, relieve pain, and result in a more stable and functional foot.
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Reduce shock and shear. A reduction in the overall amount of vertical pressure or shock on the bottom of the foot is desirable, A reduction of horizontal movement of the foot inside the shoe is also important to reduce shear.
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Relieve areas of excessive pressure. Any area where there is excessive pressure on the foot can lead to skin breakdown or ulcers. Footwear should help to relieve these high pressure areas, and reduce the occurrence of skin complications.
Prescription Footwear
Many diabetics need special prescription footwear.
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Custom-molded shoes: When extremely severe deformities are present, a custom-made shoe can be constructed from a cast or model of the patient's foot. With extensive modifications of in-depth shoes, even the most severe deformities can usually be accommodated.
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External shoe modifications: In these cases, the outside of the shoe is modified in some way, such as adjusting the shape of the sole or adding shock-absorbing or stabilizing materials.
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Off loading shoes: Immediately following surgery or ulcer treatment, special shoes may be necessary before a regular shoe can be worn.
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In-depth shoes: An in-depth shoe is the basis for most footwear prescriptions. It is generally an oxford-type or athletic shoe with an additional 1/4-inch to 1/2-inch of depth throughout the shoe. This extra volume accommodates inserts, or orthotics, as well as deformities commonly associated with a diabetic foot. In-depth shoes are usually designed to be light in weight, have shock-absorbing soles, and come in a wide range of shapes and sizes to accommodate virtually any foot.
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Orthoses or shoe inserts: Also known as orthotics, an orthosis is a removable insole which provides pressure relief and shock absorption. Both pre fab and custom-made orthotics or shoe inserts are commonly recommended for patients with diabetes and offer a high level of comfort and pressure relief.
Onychomycosis (Fungus Toenails)
Onychomycosis or fungus toenails is an infection of the skin and nail bed which can affect the fingernails and toenails. It can result in cosmetic changes such as thickening with discoloration (white, yellow, green, brown or black) of the nail, moldy odor, loose debris beneath the toenail. It is estimated that 35 million people in the US are afflicted with this condition. The condition has a genetic predisposition showing an autosomal dominant pattern in which the body has an inability to mount a cell mediated immune response to Trichophyton rubrum, a common organism involved in many of these infections. Several factors make an individual more susceptible such as general hygiene, daily repetitive use of the same shoe gear, hyperhidrosis (excessive sweating), community showers and pool decks. The condition becomes more prevalent with increasing age, diabetes and the presence of poor circulation. Diabetics are 2.8 times more prone to developing onychomycosis. In some instances chronic shoe pressure on a thick fungus toenail can result in a bacterial infection beneath the toenail which can lead to bone infections and possibly a digital amputation.
In addition to causing embarrassment, pain, and an unhealthy appearance of the toenail, nail fungus can also result in associated fungal infections of the skin such as tinea pedis (athletes foot), tinea cruris and tinea corporus. Nail fungus is contagious and can spread by close contact from one nail to involve other nails over time. In addition to causing difficulty in trimming and managing of toenails, advanced stages of the fungus toenails can occasionally cause pain in shoes making ambulation difficult. Fungus infections of toenails can be caused by a variety of different types of fungal organisms, such as dermatophytes (most common) Tinea rubrum and Tinea mentagrophytes as well as molds and/or yeasts 10% of the time . These organisms are commonly found in soils, carpeting, pet fur, shower stalls, public locker rooms, pools, hot tubs or poorly maintained hotel rooms.
Lasers work by destroying the fungal cell wall and thus causing death to the fungus. This is achieved by superheating the soft tissues (coagulation) containing the fungus by incorporating a high energy (peak power of 318 joules/cm2 or 15,385 watts per pulse) short duration micro pulse laser beam (0.65 milliseconds in duration).
Lockport Foot Care is now using a state of the art, best-in-class Nd:YAG 1064nm laser to treat fungus toenails. The Aerolase LightPod Nd:YAG 1064nm laser is the highest energy laser on the market capable of achieving the highest success rates in the industry (87%) after just two treatments, a significant advancement over older Podiatric Nd: YAG 1064nm lasers having only a 40-50% success rate after 3 treatments. When the Aerolase laser is used in combination with specially designed skin coolers, an advanced cold air technology which provides gentle cool air to the treatment site, the treatment becomes virtually painless. Lockport Foot Care is the only office in WNY offering the Aerolase laser and skin cooling system for your comfort.
Treatment results are NOT IMMEDIATE, as it takes anywhere between 4 to 10 months for the new non infected toenail to grow out. During this period of time it is recommended that patients follow a smart preventative care program to prevent reinfection during the waiting period which will be discussed after receiving treatment.
Learn how you can benefit from this revolutionary new treatment for fungus toenails and get sandal ready for the summer. Call Lockport Foot Care today at 716.874.1100 or 716.434.3338.
Laser Treatment of Nail Bed Fungal Infections
Do I need to treat the infection? No. Some patients choose to live with the infection and manage the condition by periodic debridement (trimming and reducing the thickness of the toenail) for comfort.
What treatment options are available for fungus toenails?
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Oral antifungals approved for the treatment of onychomycosis include; Lamisil (terbinafine), Sporanox (itraconazole) and Griseofulvin. Diflucan (fluconazole) is also occasionally prescribed particularly when yeast is felt to be the culprit. Although the oral medications often provide reasonably good success rates (approximately 70% for terbinafine)) they must be prescribed and monitored carefully. These medications require periodic blood tests to monitor liver function and can have various side effects (taste disturbances, alterations in blood counts) and also carry the possibility of drug – drug interactions.
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Topical prescription antifungals such as Penlac 8% (ciclopirox) lacquer, Jublia 10% (efinaconazole) topical solution and Kerydin 5% (tavarabole) topical solution can be helpful however the success rates will vary with the type of fungus and the degree of involvement. Most of the topical products are effective only in mild to moderate cases. The thicker the toenail, the less likely the topical products will be able to reach the site of infection. Ie: Penlac has been reported to penetrate 0.4mm through the diseased nail. Unfortunately, some fungus toenails can reach up to 8mm in thickness . There are also a myriad of home remedies and over the counter medications being promoted for treatment. When comparing success rates of any of these products it is useful to compare how the results are compiled.
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A mycological cure = the presence of a negative fungal culture and KOH test only while the toenail could still look discolored
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A complete cure = mycological cure + a normal appearing toenail
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The literature states the following results when comparing efinaconazole and tavarabole, the two newest topical agents used once daily for 48 weeks. A complete cure was achieved in (6.5 - 9.1%) of patients using Tavarabole and (15.2-17.8%) percent of patients using Efinaconazole.
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Permanent surgical removal of the toenail. This method can offer patients an avenue for pain relief as well as cosmetic cure however does involve a period of disability and is not always 100% effective.
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Laser treatment - the available literature reports cure rates of 77-90%
How does the laser work?
Lasers work by penetrating through the thickened, diseased toenail into the nail bed to create a coagulation effect by superheating the tissues. This process cleaves the fungal cell wall and effectively results in destruction of the fungus. One must wait for the nail to grow out (usually 4-6 months) before the disease free nail becomes evident. The laser has no adverse effects on normal surrounding skin.
What makes the Aerolase Nd:YAG 1064 nm laser different from other lasers on the market?
There are many FDA approved 1064 Nd:YAG lasers on the market for treatment of fungus toenails however the energy (Fluence) which they generate to penetrate the nail varies significantly. If a laser does not have enough power (fluence) to penetrate through the diseased nail, the effects will only be seen at the upper most surface and will not reach the deeper more active site of infection. The aerolase laser has developed a technology whereby it can generate a fluence (up to 1274 Joules/cm2) versus many of its competitors who are only able to achieve a fluence of 600 Joules/cm2. Aerolase laser uses a very short pulse width duration of 0.65 micro second. Success rates are reported to be between 77-90%.
Is the Aerolase laser treatment painful?
Some patients can experience mild discomfort however at Lockport Foot Care, we use a special skin cooling device to continuously cool the area during treatment to make the treatment virtually painfree. This allows a patient to receive the highest energy treatment available which translates into the highest success rates in the industry.
Is there any disability or complications associated with the procedure? Countless studies have shown that there are no post treatment side effects from this treatment. you can resume normal activities immediately following the procedure.
How long does the laser procedure take to perform?
Depending on the number of toenails being treated, treatment can take anywhere between 5 minutes for one toenail to 30 minutes for all ten toenails. The toenails are often trimmed prior to treatment if they are excessively thickened.
Are safety goggles required during treatment?
Safety is important to us. Laser light beams are not visible to the eye and can potentially cause damage to the retina. Therefore all people in the treatment room are provided with special laser eyewear that are designed to specifically block the dangerous wavelengths of light that can affect the eye.
Can the infection recur?
There is always a chance of reinfection if exposed to a new fungal source. Important information is provided following treatment to help prevent reinfection. SteriShoe ultra violet shoe sanitizers can be helpful to kill bacteria and fungus in your everyday shoes. Other common sense precautions can be helpful.
Can diabetics receive treatment?
Many diabetics can be at risk of vascular disease or nerve disease called peripheral neuropathy. Infections in and around the toes and toenails can become limb threatening problems in the aging diabetic. If the physical examination of an individual with diabetes demonstrates the appropriate parameters for healing, a diabetic may undergo this treatment.
What preparation needs to be taken prior to receiving treatment?
Toenails will need to be free of any nail polish prior to receiving treatment. This will need to be performed the day prior to the treatment.
Can the toenails be polished following treatment?
Yes nail polish can be applied immediately following treatment if desired.
Is the laser treatment covered by major insurances?
Unfortunately, this treatment is considered cosmetic and is not covered by insurance companies.
How much does the laser treatment cost?
The cost will vary depending on the number of toenails being treated. Please refer to our pricing schedule available in the office. All follow up visits (excludes treatment) are included in the pricing package for a period of one year from the date of the first laser treatment. Lockport Foot Care’s prices are very competitive and significantly lower than the national average. Payment options include cash, check, Master Card, Visa, Discover, debit card or Care Credit. In some instances, health savings accounts, or flexible spending accounts may also allow coverage.
Plantarfasciitis / Heel pain
Pain beneath the heel or arch when standing or walking is commonly referred to as heel pain or plantarfasciitis. This is a very common condition which often develops slowly and insidiously and frequently results in a progression in intensity if left untreated. Plantarfasciitis can be seen in patients experiencing a rapid weight gain, can occur following a trivial injury (such as a stone bruise), beginning a running program too aggressively, wearing flip flops or sandals for a prolonged shopping trip or walking or improper use of an inclined treadmill. Plantarfasciitis can often be seen in people showing weak structural integrity of their foot due to abnormal biomechanics. Classically the pain is worse after periods of rest, worse in the early morning or after long periods of standing or walking. The foot often shows no abnormal visual changes such as swelling, redness or elevation in skin temperature.
The plantarfascia is a strong connective tissue band which forms the base of the triangle in the foot, connecting the front of the foot (metatarsal heads) with the back of the foot (heel).
Diagnostic ultrasound is performed in the office and is a very cost effective method to directly image the plantarfascia allowing measurements to be taken at the point of insertion. The plantarfascia often becomes enlarged with inflammatory conditions such as plantarfasciitis. Ultrasound can easily confirm the continuity of the fascia and is helpful to identify any tears of the fascia or masses within the fascia. This can rapidly help rule out other causes of pain and determine the most effective treatment option for you.
Common treatment options often involve stretching exercises, night splints, heel cups, physical therapy manipulation with anti inflammatory modalities, ice and massage, oral anti-inflammatories, injectable anti- inflammatory medications such as cortisone injections, pre fab arch supports, prescription arch supports and in more resistant cases, radial shock wave therapy.
The overwhelming majority of patients completely respond to conservative, non- surgical treatments.
Some cases of heel pain are mistakenly identified and treated as plantarfasciitis when they may have a completely different etiology or cause. Some of these less common causes could include; nerve compression syndromes including tarsal tunnel syndrome or herniated spinal disc with radiculopathy; undiagnosed inflammatory arthritis, tumors of the plantarfascia, tendinopathy of the peroneus longus tendon, torn or ruptured plantarfascia, stress fracture of the heel, tumors of heel bone, just to mention a few.
Note: It’s always wise to first consult your doctor prior to initiating any treatment or taking any medication.
Extracorporeal Shockwave Therapy
Extracorporeal Shockwave Therapy or ESWT, as it is commonly referred to, is a non-invasive, non-surgical option for the treatment of intense and relentless heel pain associated with the chronic condition known as Plantar Fasciitis.
The Plantar Fascia is a strong ligament structure (tensile strength of 4000 lb/sq. inch) that helps to maintain the structure and arch of the foot. It extends from the base of the toes to the heel bone or calcaneus bone.
The Plantar Fascia is almost as wide as the foot and plays an important role in the support of the foot.
Plantar Fasciitis is the condition caused by overuse or injury. When the Plantar Fascia is strained due to overuse, improper shoes, or poor foot structure it gets irritated and tender. The resulting inflammation causes the symptoms of pain that include: a burning sensation on the sole of the foot, and recurring foot pain especially after getting out of bed in the morning or sitting.
Plantar Fasciitis is diagnosed by a Podiatrist, based on patient history and examination.
Research in ESWT that began in the 1980's has evolved into a treatment best suited for heel pain sufferers who have been unsuccessful in managing pain through the use of stretching, icing, orthotics, cortisone injections and conventional over-the-counter pain relievers. ESWT using the DolorClast® Method offers a high rate of success.
The treatment releases high intensity sound waves in the tissue being treated around the fascia nerve, near the heel. The chronic inflammation that was causing the pain becomes an acute inflammation and the body responds by increasing circulation and cellular metabolism around the affected soft tissue.
ESWT stimulates the body's own healing processes, by treating the source of the pain. ESWT using the Swiss DolorClast® Method, does more than mask the pain, it offers a successful, long term solution in eliminating the pain.
Prior to being treated with ESWT, patients must have been diagnosed with chronic Plantar Fasciitis for at least 6 months. Only after a patient's symptoms fail to respond to at least three conservative treatments should ESWT be administered. These conservative treatments can include cortisone injections, night splints, heal cushions, orthotics, non-steroidal anti-inflammatory drugs, and casting. In the past, surgery was the only option available when conservative measures didn't work. Today, non-invasive ESWT offers an alternative to surgery and successful relief from chronic pain.
The Swiss DolorClast® Method is intended to be used by patients who are 18 years of age or older who have symptoms of chronic Plantar Fasciitis that have lasted for 6 months or more and who have tried other conservative therapies without success.
How shockwave therapy works
If your doctor determines that treatment with the Swiss DolorClast® Method is appropriate for you, your doctor will palpate your heel to locate the area of greatest pain. It is there that the ESWT will be applied. Your feedback to your doctor will be important to locate the center of your heel pain. Coupling gel will be applied to your heel and treatment applicator will be held in contact with your heel. When the treatment begins, the shockwave impulses will be delivered at a low pressure, and then slowly increased to the target treatment pressure. This Method will allow you to adjust to any discomfort so that you will not need anesthesia to complete the treatment.
Application of the treatment protocol takes less than 5 minutes to complete.
Treatment with the Swiss DolorClast® Method requires you to undergo a total of 3 treatment sessions spaced 7-10 days apart in order to realize the maximum benefits of the treatment. Your doctor may also want you to return for a short follow-up visit to asses your response to the treatment. You should notice a gradual improvement in your heel pain over time. Significant improvement occurs over a period of 3 months, after your final treatment.
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