Author Archive

Painful Morton’s Neuroma

February 28th, 2011 by Dr.Murray

When I am treating a neuroma for a patient I am trying to quiet down an inflamed nerve that is causing pain.  The pain can be severe and often warrants fairly aggressive treatment. Other times the simplest form of treatment is all that is needed.  Switching to a wider width shoe and avoiding thick socks can often eliminate symptoms from a neuroma.  An open toe shoe or sandal works very well for many people with this problem.  This is often done in conjunction with a short course of an anti-inflammatory medicine.  If this works but not quite enough, the judicious use of a corticosteroid is often tried.  I try to limit the numbers of injections given to 2 or 3.  Steroid injections can be very effective in reducing the pain caused by a neuroma.  Again, we are talking about a condition in some people that hurts so bad they avoid putting shoes on and have eliminated most of their activity due to the pain.  Runners will stop running, dancers stop dancing and workers dread going to work.  In these cases the possible benefits from an injection far outweigh possible side effects.

Recently, I have had good results with cryotherapy, the freezing of the affected nerve, which desensitizes the area thus reducing symptoms.  Finally, their are those neuromas which do not respond to any of the above and hurt enough that excision is performed.  The results of excision are favorable.   I do the procedure at either Martha Jefferson Outpatient Surgery Center, Martha Jefferson Hospital or Augusta Health.  It is a 20 – 30 minute procedure that is done with a local anesthesia and IV sedation provided by an anesthesiologist.  Postoperatively rest and elevation is required for 2 weeks.  This is followed by 2 weeks of decreased activity and an open toe shoe or sandal.  Once successful treatment of the neuroma has taken place patients will get back to normal activity.

Post by Dr. Kevin Murray

Treatment Options For Plantar Fasciitis

February 23rd, 2011 by Dr.Murray

Plantar fasciitis remains one of the most common problems I treat.  I see plantar fasciitis in factory workers, teachers, nurses and athletes in great numbers.  These, and others, who are on their feet a lot are susceptible to this condition.  It is very frustrating to have and can be frustrating to treat.  It is technically an overuse injury.  The cause is usually multifactorial with the combination of foot structure, activity level, shoes worn, body weight frequently coming into play.  Several of the factors contributing to plantar fasciitis can be modified (activity, shoes worn) while others cannot (job requirements, foot structure).

For runners, tennis players, those who do aerobics or other impact weight bearing activity you usually have to take time off from your activity while being treated for this.  This is a time to cross train.  Swimming, bike riding, rowing machines, lifting weights on machines can usually be continued during treatment.

Shoes worn during treatment should be modified to include running shoes, good work boots or hiking shoes.  Shoes worn should have rigid soles with adequate shock absorption.  A key ingredient in shoes is a removable liner.  We can then put in either a very supportive over the counter orthotic or a custom made functional orthotic into the shoe.  This will provide extra support as well as shock absorption.  Going barefoot should be avoided as well.

If the change in shoes and inserts do not help more aggressive treatment will be needed. An x-ray will sometimes be taken to rule out a stress fracture.  A combination of taping, anti-inflammatories, orthotics, and corticosteroid injections might be needed to quiet the condition down.  It can take 6 months to a year for bad cases to respond to treatment.  Surgery is only considered when the above have failed to give relief.  When surgery is performed I do a partial release of the plantar fascia.  This can take several months to heal from.  As stated, the procedure is reserved for those not getting better with more conservative care.  For those who do need surgery you should know that the procedure works very well.

I had chronic plantar fasciitis in 1990 after the New York City Marathon and ended up being in the small group of patients not responding to care.  In 1993 I had a partial release done and have not had problems since.  Hopefully, you will not require this level of care but if you do we can help you.

Posted by Kevin Murray, DPM

Doctor, my shins are killing me!

May 15th, 2010 by Dr.Murray

“Shin Splints” is a common term for any exercise-related leg pain. The most common cause of exercise related leg pain is Medial Tibial Stress Syndrome (MTSS). Other frequent causes of exercise related leg pain in athletes are stress fracture or posterior compartment syndrome.
MTSS, a specific overuse injury, causes pain along the posterior inside & outside aspects of the lower leg. Athletes most commonly afflicted with this condition compete in track, cross-country, basketball, and volleyball. The incidence of MTSS in long-distance runners is reported as high as 16.8%. It affects females more than males. In our experiences it occurs frequently from training error and running on uneven surfaces.
There is no consensus on the cause. Some believe it is inflammation of deep fascia or strain of deep muscles of the leg. Others believe it is tearing of the leg bone-muscle interface. Yet, another theory is a stress reaction of the bone that has become painful.
The diagnosis is made by history, clinical exam and full consideration of the symptoms. Commonly, athletes will complain of pain at the beginning of a run that seems to subside during the middle but recurs at the end of the run. Some risk factors for MTSS are: excessive foot pronation (flat feet), tight calf muscles, foot/leg geometry and alignment, body mass, sex and age. Diagnostic exams can be utilized if other conditions are suspected and initial treatment program does not result in improvement.
As for most overuse injuries treatment involves cessation of the activity. Assumption of alternative forms of exercise should be utilized if competitive athletes want to remain in condition. Stabilization of the foot is essential if excessive pronation is found. Support of the foot will involve evaluation of shoes for wear. Replace if necessary. Foot orthotics should also be considered and made to specifications based of appropriate biomechanical foot exam and gait analysis. Anti-inflammatory medications are also helpful for pain control. Finally, a well directed range of motion, stretching and muscle recovery-rehabilitation-strengthening program should be started (see articles below).
If you suffer from shin splints or know someone who does make and appointment at Blue Ridge Foot and Ankle Clinic. We can help keep you “in the game.”
Further readings:

Know your athlete…Know your race

April 21st, 2010 by Dr.Murray

Effective treatment of the endurance athletes requires a basic knowledge of the rigors of the sport and training. You, the athlete, are best served when you have the confidence that your treating physician knows your sport as well as you do.
The Marathon covers 26 mile, 365 yards and was first run by the Greek messenger Phaedipides, who ran form the battle of Marathon to Athens. The Marathon race was started as modern Olympics event in 1896. There are more than 800 marathons in the world each year.
The 1st women’s marathon was in 1984 at the LA summer Olympics. Joan Benoit of the US won with a time of 2:24:52. Current Marathon World Record for males is 2:03:59, held by Haile Gebrselassie (Ethiopia), set a Berlin Marathon, Sep 2008. He is the first to break the 2:04 barrier. Current Marathon World Record for females is 2:15:25 held by Paula Radcliffe (Great Britain) set a London Marathon, Apr 2003.
The Ironman triathlon consist of: Swim 2.4 miles, Bike 112 miles, Run 26.2 miles and the World Championships are held each October in Kona Hawaii. The Ironman 70.3 triathlon consists of: Swim 1.2 miles, Bike 56 miles, Run 13.1 miles and the World Championships are held each November in Clearwater FL. The Olympic triathlon consists of: Swim 0.9 miles, Bike 24.8 miles, Run 6.2 miles. The Sprint triathlon consists of: Swim 0.5 miles, Bike 12.4 miles, Run 3.1 miles.
The Ironman triathlon is often referred to as the “World’s most prestigious one-day endurance event!” It was started in 1978 by a group of Navy Special Warfare SEALS based in Hawaii who had an argument about who was the fittest athlete. Navy Commander John Collins suggested that the best way to decide would be to combine the Waikiki Rough Water Swim, the Around Oahu Bike Race, and the Honolulu Marathon… It was said who ever finished would be called the “Ironman”. Gordon Haller won the first Ironman competition in 11:46:58.
Endurance athlete injuries are predominantly chronic/overuse, but and involve acute trauma as well. Most often, injuries are to skin, toenails, stress fractures, leg pain, and knee pain. Finding alternative activity for the endurance athlete is critical to recover from injury. Cross training such as aqua running, swimming, spinning, elliptical allows the athlete to maintain cardio-vascular fitness, while not causing further delay in healing.

Does your child experience heel pain?

April 13th, 2010 by Dr.Murray

If your child is experiencing heel pain,  he/she may have a condition known as Calcaneal Apophysitis (aka Sever’s disease).  It is typically present in children of ages 8-12 years who are physically active; usually gymnasts and soccer players. However and overweight child may also be at risk as the excess weight may cause extra stress and pressure on the calcaneal apophysis. This condition is basically an injury of the growth plate in the calcaneus (heel bone). The calcaneus forms a separate apophysis on the posterior inferior aspect which appears at 8 years and fuses around 14-16 years of age therefore this is rarely seen in older children/teenagers. During the time of growth, which is early puberty, the muscles and tendons in this area tend to be less flexible and any running and jumping activity may predispose your child to this condition. Your podiatrist may perform a squeeze test where you child will experience pain when the back of the heel is squeezed on both sides. They may also find that your child’s tendons have become tight. Your child may also walk with a limp or experience greater pain when on their tip toes. This pain may be present in one or both heels.
In an effort to prevent this, be sure that your child wears well-fitting, firm and supportive shoes to help maintain flexibility while your child is growing. A shock absorbent sole may also be helpful. Proper diet control may be necessary in the overweight child.
Treatment
-Reduce activity
-Well fitting, supportive shoes
-A soft cushioning heel raise to reduce the pull from the calf muscles on the growth plate
-Stretching before activity and Icing 20 mins after activity
If condition is more severe:
Be sure to consult your podiatrist
Custom orthotics may be recommended
Strapping/taping during activity to limit ankle joint range of motion
Medication to reduce inflammation may be prescribed
A cast may also be given for 2-6 weeks to give the calcaneal apophysis a good chance to heal.
This condition is self limiting and will go away once the bone has fully fused at about 16 years. However it can be really painful so treatment is necessary to relieve symptoms of it during the time of growth.
To Consult Dr. Murray and Dr. Chang about your child’s heel pain, book an appointment online today!

  • Posted in Children, Heel Pain
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Stress fractures can result from a number of reasons. Most common causes for stress fractures are decreased bone density, post-op complications from a foot surgery, and athletic training error / overuse injury in athletes, dancers, and “weekend warriors.” It typically occurs in the second metatarsal…. The longest of all central foot bones and the one subject to the most loading forces. Since the second metatarsal tends to carry more of the body’s weight during athletic and dance activities, the increase in pressure results in osteoclastic activity and compensatory osteoblastic activity becoming imbalanced.

Symptoms:
– Increasing pain in the midfoot
– Pain at rest
– Pain during activities
– Swelling on the dorsum of the foot
There is a lack of physical signs in making this diagnosis. Stress fractures cannot be seen on plain film x-rays until a few weeks later when healing begins. For this reason, when patients present with the associated signs and symptoms podiatrists often prefer the use of bone scans that typically reveal hot spots in the area of the mid-foot in patients with common stress fractures. CT’s and MRI’s are also helpful in pinpointing the exact location of the stress fracture.
Upon diagnosis, the hallmark of treatment is immobilization through a casting boot for up to 3-4 weeks. Follow this with progressive ambulation and support in customized orthotics or shoe padding for 4-6 weeks and an intermission of the associated activity to promote healing. For the competitive athletes that require a faster recovery time, podiatrists may consider a bone growth stimulator to expedite the healing process. Anti-inflammatory drugs are also given to assist in relieving the pain associated with these fractures. Conservative management is usually successful when treating stress fractures and surgery is rarely required. Use of menthol cooling gels, like Biofreeze, has shown to be helpful in alleviating pain.
More information can be found here:
http://www.aapsm.org/ct0398.html
http://www.foothealthfacts.org/what-is/ns_stress-fracture.htm

Treatment for Plantar Fasciitis

March 3rd, 2010 by Dr.Murray

This blog is a sequel to last week’s blog that discussed the epidemiology of plantar fasciitis. We will touch briefly on treatments/prevention used by podiatrists and discuss treatment pearls podiatrists tend to follow when athletes and dancers present to their office with plantar fasciitis.
Alternative Physical Activity is one of the first steps to treatment. It is important to change the cardiovascular fitness routine to one that avoids high impact on the plantar fascia. This means limiting running and jumping and pursuing swimming and upper body weights as an alternative method of cardiovascular fitness. This is often called a period of “Relative Rest”
Changing footwear is another critical treatment step. Barefoot and sandals should not be worn while trying to treat this condition, instead shoes with a slightly elevated heel and a strong mid-shaft insole, should be worn inside and outside the house. We favor the use of plantar arch strapping (taping) which proves to be very successful, especially in athletes and active people who want to maintain their busy lifestyle.
Home Therapy consists of stretching the heel cord to encourage healing, and massaging the foot to increase blood flow. Night splints are also indicated for plantar fasciitis as it maintains the foot in a passive stretch position to encourage healing. This prevents unwanted re-tightening of the fascial band during the night and reset of stretch receptors that trigger pain activation.
Customized orthotics is an important long term strategy in the management of patients with this condition. Additional adjuncts to expedite recovery include: physical therapy which proves to be useful in alleviating pain associated with plantar fasciitis, and anti-inflammatory drugs which are given to control pain when appropriate for the patient.
These conservative methods typically suffice when treating plantar fasciitis in up to 90% of people with this condition, however when not successful, corticosteroid injections are considered for the more severe cases. Along with these treatments, rest and the maintenance of a healthy weight can also limit predisposal to plantar fasciitis so it is highly encouraged. If pain persists and all conservative treatments are unsuccessful, surgery may be required to release tension on the plantar fascia ligament. We are also using the Topaz radio frequency coblation technique with great success on our patients. If you suffer from plantar fasciitis or know someone who does, Drs Murray and Chang, can offer complete evaluation and tailor an appropriate treatment plan designed around the persons needs.

Heel Pain

March 1st, 2010 by Dr.Murray

A very common complaint presented by patients to their podiatrist is that of heel pain. It is caused by a variety of conditions but this blog will discuss heel pain due to plantar fasciitis. Plantar fasciitis is the most common condition associated with heel pain, especially in athletes, dancers and individuals within the ages of 40-60. It causes a mild discomfort to an aggressive form of pain in the plantar aspect of the foot- in the area of the heel.

The plantar fascia ligament, illustrated in the picture below, runs between the calcaneus (heel bone) and the base of the toes and is defined as a strong connective tissue that helps in forming the arch of the foot. A person’s biomechanics, such as being flatfoot or having high arches can create a pressure on this tissue. Incorrect shoes or even physical activity as well as diabetes or arthritis can also impact this fascia. A surplus of exercise and physical activity, including excessive running and jumping can result in loss of elasticity and compliance overtime second to micro injuries. At the same time, individuals with inflammatory types of arthritis can unfortunately develop inflammation within the tendons consequently resulting in the same condition. While being overweight is a significant contraindication, walking or exercising in improper shoes can cause impairment in weight distribution considerably increasing the pressure on the plantar fascia. When overload occurs, microtears in the tissue present themselves, and the plantar fascia becomes inflamed, typically in its central band, resulting in what is known as heel pain.
Symptoms include:
Pain in the heel
Stabbing, burning, aching pain
Pain worse in the morning when stepping out of bed
Diminishing pain as the tissue “warms up”
Intensity of pain increases over a period of months.
Stay tuned for next week’s blog when we discuss ways to prevent, manage and treat plantar fasciitis.

  • Posted in Heel Pain
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Tips for Winter Runners

February 15th, 2010 by Dr.Murray

Keeping up with an exercise schedule during the winter can be difficult, as there are many obstacles faced by runners during the winter months. It is important to first and foremost dress appropriately for the weather wearing light layers of polypropylene or lycra under a wind/water repellent track suit. Hats that cover the ears are also extremely important as a lot of the body’s warmth is lost through the head, therefore it is crucial to conserve this heat. Gloves and thick absorbent socks are also imperative to prevent frostbite or poor circulation in the runner which can lead to a cascade of otherwise preventable problems. Proper winter running sneakers are essential to assist in the prevention of many slip and falls that occur on the ice or snow resulting in injured muscles or even broken bones. These shoes ought to be water proofed and one should also take into account the shoe size of their winter shoe, perhaps an increase in a half size to ensure the fit with the extra thick socks. For those who wear custom orthotics, one should consult his/her local podiatrist to customize an orthotic that would best fit their specific foot in the winter sneaker. Prevention of blisters and other shoe irritations should also be taken into consideration to ensure a comfortable workout experience. With the appropriate winter attire in place, the runner is almost prepared for his/her workout. But it is of high importance to properly warm up before facing the cold temperatures and even more important to warm down by stretching upon completion of the run. This protects the muscles from entering a sudden shock during the run and assists them in relaxing thereafter. One should be sure to keep his/her skin thoroughly moisturized and body well hydrated during these winter months while taking heed in the other precautions discussed, ensuring a safe and productive winter workout.

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