The Scoop on Toenail and Foot Fungus.

Tinea is a fancy name for fungus. There have been shown to be more than 80 different strains of fungus on the average person's foot with the highest concentrations being on the heel. These fungi live in a balance that isn't a problem until that balance is disturbed. People at risk for fungal infections include those with:

• Compromised immune systems (HIV, Diabetes, Oral Steroid use)
• Advanced age
• History of trauma to the toenail.  
• Poor blood flow in their toes. 
• Frequent use public/locker room showers (thus the term athlete's foot). 
• Poor pedal hygiene (improved hygiene has even shown to cure 35% of existing fungal skin infections).
• Genetically prone.  

ANATOMY INVOLVED

While tinea can get into the blood and cause systemic infections it most commonly affects the most superficial layer of skin, the epidermis, and the nail plates. The areas that are most resistant to treatment are the plantar foot and the nail plates due to the high amount of keratin which makes it difficult for topical medications to penetrate the structure.

THE EXAM AND DIAGNOSIS

Signs of a fungal infection of the skin, also known as athlete's foot or tinea pedia can include:

• redness (erythema)
• itchiness (pruritus)
• foul odor 
• macerated (white over-hydrated skin) or hyperkaratotic (dry callused skin) scaling
• fissures (cracking)

They present in three main patterns; interdigital, moccasin, and vestibulobullous(fluid filled blisters). Interdigital infections are usually more macerated while the moccasin pattern in more hyperkaratotic.

Research has shown that the most common fungal strains resulting in tinea pedis are Trichophyton rubrum and Trichophyton mentagrophytes (more aggressive strain). T. mentagrophytes has been shown to be more common in the younger healthier individual.

Signs of a fungal infection of the toenails, also known as onychomycosis, include:

• nail discoloration; yellow, orange or brown patches or streaks. 
• nail detachment from nail bed (onycholysis).
• subungual (under the nail plate) debris. 
• nail thickening
• nail crumbling

The "gold standard" method for diagnosis of pedal fungal infections is microscopic examination of skin subungual (skin under the nail plate) scrapings prepared in potassium hydroxide (KOH). The examiner can see hyphae. Today's podiatrists send these scrapings to a lab where they are read.

TREATMENT

Treatments for fungal infections include topical powders and creams for less severe infections and oral medications for more sever or resistant infections. Due to the resistive nature of onychomycosis (toenail fungus) the most effective treatments are oral medications. The downside of oral antimicrobial medications are that many have been shown to cause liver damage to a very small percentage of individuals. The internet is full of many home remedies and other remedies for treatment of toenail fungus (Vick's Vapor Rub, Colloidal Silver, Tea Tree Oil....). Due to the high number of these types of treatments and the low level of effectiveness I am not going to discuss all of them. The below list of medications that have been proven with varying degrees of effectiveness which I have put in order of effectiveness.

Topical Treatments:

• 2% Miconazole Nitrate Powder - Available Over the Counter
• 1% Clotrimazole Cream - Available Over the Counter
• 1% Clotrimazole Solution (better penetration into nail plate) - Available Over the Counter
• 1% Terbinafine Cream (Lamisil) - Available Over the Counter
• 1% Terbinafine Gel - Available Over the Counter
• 0.77% Ciclopirox Cream/Gel
• 8% Ciclopirox Solution (Penlac Nail Lacquer)
• 20% Urea Cream*
• 40% Urea Cream*
• Salycilic Acid*

*can be used with topical medications to soften the nail plate and callused skin improving penetration of medication.

Oral Medications:

• 250mg Terbinafine (Lamisil); liver enzymes from a blood test are also monitored while this medication is given to ensure that there is not irreparable damage occurring. 

Other Treatment Options

• Cleaning feet daily has shown to cure about 35% of cases. 
• Laser Treatment (for onychomycosis) is available and is very expensive. Its efficacy is still being investigated. 
• Toenail Avulsion (removal of toenail). In sever cases the complete removal either permanently or temporarily, is always an option. This options will prevent spread to other toes and is a sure cure. Toenails serve no real purpose beyond their aesthetic appeal. 

PREVENTION

The best option is to take proper precautions to prevent fungal infections from getting out of control in the first place. Most toenail infections begin as athlete's foot that has been neglected and the fungus gets into the nail. Once in the nail it is extremely difficult to cure and the fungus can damage the cells that cause the nail to grow making the nail thick and disfigured. Once a nail has become thick and disfigured the chances of being able to return to nail to its appearance prior to the infection if very low. Here are some suggestions as for prevention:

• Wash your feet daily with soap. Fungal spores are EVERYWHERE and washing them will decrease the amount on your feet and will remove the dirt and grim that harbors colonies. 
• Alternate shoes to allow them to dry out. The environment in your shoes (moist, dark, warm) is prefect for fungus to thrive so allowing your shoes to dry out will inhibit growth. 
• Wear well ventilated shoes, synthetic socks and use shoe powders occasionally to keep feet dry. 
• Treat fungal skin infections early on to prevent them from getting out of control and into the tissue that is more difficult to get to with medication like callused skin and toenails. 
• Avoid going barefoot in public area such as showers and pools. Fungal spores and live on for months to years. 

Hsu AR, Hsu J. Topical Review: Skin Infections in the Foot and Ankle Patient. Foot & Ankle International. 33(7):612-619, 2012 

Typical or Atypical Flatfoot in Children?

Photo by Kimber Hansen Photography

A common foot concern among parents is whether or not their child has flat feet and if it is an indication that the child will have problems further on down the road. Are there things that they can do as parents that can decrease the chance that their child will be unable to participate in sports and someday, maybe someday, become a collegiate or professional athlete if they want? I know I envision my kids running along side of me on various adventures someday in the future and the thought of my child growing up developing a deformity that  prevents this from happening scares me to death! (I am trying to empathize with you, but seriously I think about this).  Here is the low down on flatfoot deformity in children.



Flatfoot is common in children.

A child's structural support begins as cartilage, which is flexible and soft. This is true also in the foot. The midfoot, or the area above the arch, is one of the last areas of the foot to ossify, or convert to bone. Because of this it isn't uncommon for children to have less structure to their feet when they are young. This is often normal. A child's foot doesn't completely convert to bone until around the age of 7 yrs. That being said there are still times when concern is warranted.

There are times when it is wise to seek a professional's opinion on the matter.

• Pain. If the child is having pain that is preventing them from being a kid then they should be evaluated. .
• Difficulty walking and running. If your child is falling a lot more than others, walks with a limp, favors one leg over the other or is more apprehensive about getting up and running around than normal, the problem could be their feet.  
• Noticeable deformity. If things just don't look right when you compare the shape of your child's feet to other kids then an evaluation is advised. 

I know....these guidelines are so broad and gray. Many conservative parents want to get their child checked just in case. If you are on the fence about seeking medical attention a few more things that could put your child at risk for greater problems include obesity, family history of painful flat feet, history of trauma or sex (males are more at risk). If your child is on the low end of the scale you may consider just monitoring the situation because many times they will resolve on their own. If your child is presenting with one or all of the above symptoms a visit to a podiatrist should be considered to obtain treatment and rule out more serious problems such as Cerebral Palsy, Muscular Dystrophy, Skewfoot and Juvenile Idiopathic Arthritis.

Treatment is usually simple.

Often times simply just wearing supportive shoes or getting a kiddie-thotic(supportive insert) can reduce pain and discomfort and get them back into action. If a more serious condition is discovered then surgical intervention may be considered but this is not common.

There is no clinical proof that orthotics worn as a child prevent flatfoot in adults. 

I am not saying that wearing orthotics as a child won't prevent flatfoot, because it might, but it also might cause other deformities(probably not, but possible). There just isn't conclusive evidence currently that shows much benefit to a child unnecessarily wearing orthotics or supportive shoes. My best advice is to just let kids be kids. I personally plan on letting my kids spend the majority of their time barefoot and if they have pain then I will consider intervening. While I am not totally on the naturalist bandwagon (because there are a lot of illogical things that happen under the "Natural" banner), I do see some wisdom in allowing feet to function the way they evolved to (this statement is in no way endorsing barefoot running off the couch BTW). Also, remember the risk factors that I pointed out earlier. If your child is at increased risk then more frequent use of supportive shoe gear and possibly orthotics can be considered.

Maybe I would put my kid in these....baby climbing shoes!!!

Tapping into The Power of Fat

It is common Biochemistry knowledge that fat cells provide the most bang for their buck, giving 9kcal/g. Carbohydrates and proteins only offer 4kcal/g. For those of you good at math this is over double the BANG. The only problem is that our body normally uses this as a secondary energy source to carbohydrates. I recently read a paper by L. Burke et al that looked at the body’s ability to oxidize fat as an energy source and a lot of other interesting things about fat. They concluded that, “5 days of a high fat diet enhanced rates of fat oxidation during sub-maximal exercise despite increased CHO availability before and during exercise”.  Basically the way the body works is that it uses minimal amounts of fat along with glycogen (stored sugar) as energy. It isn't until most of the glycogen stores are gone that the body reverts into extensively burning fat as an energy source. By changing your diet to be high in fat and low in carbohydrates you are forcing the body to become better at using fat as an energy source by increasing the number of substrates necessary to do so. This concept was the basis for the famous Atkin’s Diet that was popular a few years back.  Burke discovered that after 5 days of the high fat diet, when they introduced carbohydrates back into the system the body still had significantly increased fat oxidation during exercise. This information could be extremely helpful in ultra-endurance activities because it would allow the body to preserve glycogen stores longer, using higher amounts of fat as it drains these stores. It would also improve the body’s ability to oxidize the fat once the body has depleted much of its stored glycogen and is relying more heavily on fat. 

L Burke et al. Adaptation to short-term high-fat diet persist during exercise despite high carbohydrate availability. Official Journal of American College of Sports Medicine. 2002

Walking the Biomechanical Runway

Depending on the reason for being there, it is not uncommon for part of your visit to the podiatrist to include a gait and biomechanical evaluation. Gait is the way in which someone walks, their swagger. The patient is asked to roll up their pants and walk back and forth, sometimes fast and sometimes slow. The doctor meanwhile intently watches until satisfied and has seen enough. The doc will then proceed to examine you from your hips to your toes, pulling, twisting and prodding on the way down.  During this ritual the doctor is obtaining information to formulate the treatment plan.  The cool thing about a biomechanical approach to the body’s problems is that the goal is to fix the underlying cause of the problem in a completely non-invasive way. Below are a few big concepts involved in a basic biomechanical evaluation.

Bill Cosby's gait evaluation.

1.       Supination and Pronation: These are probably terms that you are somewhat familiar with but let’s just make sure that we are on the same page. Supination is when the bottom of the foot is moving to face the midline of the body also causing the ankle joint to extend and the foot to turn inwards. Correct terms for these movements are inversion, plantarflexion and adduction. Pronation, the opposite of supination, refers to moving the bottom of the foot to face away from the midline of the body, causing the ankle to flex and the foot to turn outwards. Correct terms for these movements are eversion, dorsiflexion and abduction. The ability of the foot to supinate and pronate in necessary in the function of the foot during walking and running. These terms are also used to describe the foot's position while standing.

Figure borrowed from www.orthoticshop.com. 

2.       Asymmetries:  For the most part, the body was designed to be symmetrical, in movement and structure. Asymmetries lead to inefficient movements that put increased amounts of stress on the body’s structures often leading to breakdown, causing pain.

3.       Limited Joint Range of Motion:  Every time a joint comes to its end range of motion the soft tissue is potentially being stretched beyond the point at which it is capable of recoiling.  Abnormal end range of motion also can mean that you are having non-anatomical bone on transferred energy and motion that is not dissipated by the proper joint. Simply put, the jarring of joints is bad.

4.       Pronation Affects the Entire Body: Pronation, the lowering of the foot’s arch, causes the tibia to internally rotate and is a mechanism that the body uses to shorten an elongated limb. Try it. Stand up and try to pronate your foot while standing. The only way that you can do it is by internally rotating your leg forcing you into a knock-kneed type stance. This internal rotation translates up the leg all the way to the hip leading to tilting of the pelvis. This tilting affects the spine and up to the shoulders. This path of misalignment has been shown to cause a whole host of problems, including but not limited to: patellofemoral pain syndrome, iliotibial band friction syndrome, ACL injuries, sciatic pain, and lower back pain. Pronation also decreases the amount of upward bend (dorsiflexion) in the big toe which over time can lead to bunions and osteoarthritis. 

The Vitruvian Man, 1485. Leonardo da Vinci

Often times only parts of the exam will be conducted depending on the problem and each doctor has small differences in the way in which the information is obtained. Treatment recommendations to improve the biomechanics of the foot include strengthening specific muscles/muscle groups, orthotics and shoe types.

Traumatic Injuries vs Overuse Injures

Sports related injuries can generally be divided into two basic types of injuries, traumatic injuries and overuse injuries. Traumatic injuries, also known as acute injuries, are high energy forces that cause the breaking of bone and tearing of tendons and ligaments instantly. Causes of traumatic type injuries include falling, getting hit by someone or something, or proving something like hurling yourself off some cliff or ramp (you know who you are).

Traumatic injury potential.  Little Cottonwood Canyon, Utah, 2010. 

Hmmm..... Beaver Mtn. 2007

Traumatic injury potential. Porcupine Trail, Moab UT 2009.

Overuse injuries present over time. These injuries are more common and occur due to imbalance in the breakdown and remodeling of body tissues. The body is amazing at adapting to the many assaults that we put it through but can only adapt at a certain rate. No matter how hard we want to believe it, the phrase “The body can achieve what the mind can conceive” is only true given the proper amount of time for adaptation. Being able to distinguish between soreness, weakness, and injury will allow an athlete to push him/herself closer to their breaking point and over time raise the breaking point. Common overuse injuries include stress fractures and tendonitis.

Overuse injury potential. Gannett Peak WY, 42 mile car to car, 17hrs. 2010.

Overuse injury potential. Tetons WY, 2010

The most common and often most effective way of treating overuse injuries is to use the PRICE principle and NSAIDs. PRICE stands for Protect, Restrict Activity/Rest, Ice, Compress, and Elevate. Common NSAIDs, meaning non-steroidal anti-inflammatory drugs, include Ibuprofen, Advil, and Naprosyn.

Overuse injuries can be very frustrating because they can take a long time to heal. The best ways to prevent getting an overuse injury are:

·         -Ease into workout regimens. The “Weekend Warrior” mentality of being inactive all week and then going 100% on the weekend puts an individual at the greatest risk for problems.

·         -Correct form. Get instruction on correct form if needed. There are tons of options online on how to do just about anything if you don’t have a mentor or trainer.

·         -Use correct gear. You don’t need to go crazy but a good pair of well fitted shoes goes a long way, and gear is awesome and any excuse to buys some is always a good idea!

·        - Listen to your body. Pain is there for a reason. Be careful about toughing it out. 

If you are not having improvement with the use of PRICE therapy principles and NSAIDs after about 4-6 weeks more intensive diagnostic evaluation should be considered which include x-ray, MRI or bone scan. 

MRI

X-Ray

Bone Scan