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Post tibial block for deep ennucleation

Discussion in 'General Issues and Discussion Forum' started by mburton, Nov 25, 2009.

  1. mburton

    mburton Active Member

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    Hi there y'all!

    Help please?
    I am treating a woman in her 40s with 2 or 3 fibrous planter HDs and heavily fissured heels. She can hardly walk with the pain from these HDs; in 40s, smokes, red hair, fair skin which reacts badly to most of the emollients/urea-based creams I have suggested. She can't excercise so is putting on weight and increasingly depressed. Her feet are spoiling her life. The only footwear she can tolerate is very thin pumps which are truly awful, and she cannot tolerate socks.

    She soaks her feet before coming to see me and I can reduce as much as she can tolerate. I have given her a post tib block twice now to aid reduction and this has worked really well.

    I would value any suggestions for alternative treatments or shared experience of using blocks for ennucleation. My inner self is not happy about doing it too often, especially with her propensity for allergic reaction vis the creams.

    Please be gentle - I'm a newbie!
  2. drsarbes

    drsarbes Well-Known Member

    Hi Mo:

    PLANTAR HD's with heel fissures.
    Red hair and fair skin (Odd combination!!! haha)

    Are these painful lesions under any particular metatarsal head(s)?
    Accommodative orthotics would be the logical treatment, if these are caused
    by a plantar flexed metatarsal one could surgically elevate the offending metahead.

    I think a bit more information might help get a better picture of your patient's pathology.

  3. G Flanagan

    G Flanagan Active Member

    i would agree with Dr Arbes that after enucleation orthotic therapy should be introduced, however should these be IPK's in relation to a met head maybe a referral to your local pod surgery department for assessment maybe useful. In relation to the frequent use of post tib block's, how often do you see her?
  4. Ella Hurrell

    Ella Hurrell Active Member

    There's your problem! Can't find any literature on the subject - my theory is purely anecdotal - but the patients who have these types of "hypersensitive" corns tend to be smokers in my experience. If they can give up, it seems to resolve a lot of the pain?! Weird I know, and you'll never get her to believe you! Anyone else agree with me? I would also be thinking of a way to offload the areas orthotic wise, but it sounds as if her footwear is not going to accommodate much?
    Last edited: Nov 25, 2009
  5. mburton

    mburton Active Member

    Hi guys, thanks so much for your interest. It's pretty amazing to have worldwide advice so quickly!

    Re HDs. She has had them since she was 17 and they are getting more & more problematic. Worst is a NV corn distal to the L/1st MPJ, other HDs on L/5th MPJ, R/1st MPJ, apices of L2nd and 4th. Deep fissuring on heels and thick fibrous callus B/1st planter IPJs. Sounds like a cavus foot but there is too much oedema normally for it to be obvious(she has a bit of heart trouble) and to be honest I don't usually have the time (NHS....) to do a biomechanics assessment as well as reduction of HDs.

    However, I have booked her in to our new foot posture index clinic in a month or so (local pod surgery department - you jest! Maybe in another decade!))and I have suggested to her that appropriate footwear will be required to accommodate insoles to help her. Maybe she will co-operate this time.

    Re post tib blocks. I did one in June and another last week.

    Re smoking. I totally agree and that's why I mentioned it. My own clinical experience has been that it appears to affect the elasticity of the skin. I would also suggest that it appears to affect the more anxious patient, but that's no doubt why they smoke anyway!
  6. Griff

    Griff Moderator

    Hi Mo

    What is a Foot Posture Index Clinic??

  7. mburton

    mburton Active Member

    It's a biomechanics clinic - new approach we're trying out.
  8. Post tib block for this seems rather sensible to me. After all they offer it at the dentist for painful proceedures (not post tib blocks... you get the point).

    Or even, if you're in a hurry and depending on location, a squirt with ethyl chloride and a local infiltration with a 30 Gauge needle. I've found there is a difference in patient experience between a 27 and a 30.

    Maceration padding and offloading insoles will also increase comfort time between visits.

  9. Interesting, why is it called the foot posture index clinic?
  10. Graham

    Graham RIP

    If you are using a post tibial block you may as well do an electro hyfrecation of laser Treatment to reduce the dermal scarring and neurovascular elements. Followed by good accommodative/functional orthoses
  11. Julian Head

    Julian Head Active Member

    I would also suggest biomech assessment but also xrays to see what the met heads are doing.......try orthoses but if no great improvement then pod surgery is the way forward. Where are you based? Must be able to refer somewhere via the GP....

    Electrodessication may help a bit but if the underlying anatomy is causing the problem your success will be limited

  12. SarahR

    SarahR Active Member

    Agreed. I also heard this from a colleague when I just graduated. I've had a few neurovasc/painful corns go from deep and nasty and difficult to debride, resistant to offloading to being pretty much asymptomatic with proper management (CFOs/regular debridement) after patients have quit. Difficult getting people to quit for good though. And for some reason to convince some smokers to get orthotics?? Hmm... Though my demographic was crap for orthotics regardless.

  13. LuckyLisfranc

    LuckyLisfranc Well-Known Member

    I see "smokers corns" in new patients at least every couple of months. They are yellow-ish, and typically macerated deeper down, and exquisitely tender. They are frequently misdiagnosed.

    Craig Camasta has described these in one of the Podiatry Institute updates a few years back. A good research topic for an honours or post grad student. There is a mountain of evidence regarding the effects of smoking on skin, in combination with friction/inflammation.

    These are intractable lesions that usually respond poorly to offloading and are very painful to debride. I frequently use local anaesthesia infiltrations or regional blocks for them.

    They generally dissappear within 1-2 years of smoking cessation (anecdotal experience).

  14. barry hawes

    barry hawes Active Member

    Hi All,

    Could these lesions be porokeratosis? Given the chronicity and degree of pain associated with enucleation I would include it in the DDx.

    Barry Hawes
  15. dgroberts

    dgroberts Active Member

    If she has oedema and crap shoes then she would probably benefit from referral to an orthotist. They will provide good quality TCI's too.

    Sounds like she's not doing herself any favours in terms of lifestyle.

    Another option would be use of Podospray, works very well with painful HD's.

    On a similar note, everyones mentioning surgery. I have a chap that comes in every 4 weeks with a huge build up under the L4 and R5th met head, not corns just huge amounts of hyperkeratosis. I've referred him all over the place, even for a surgical opinion but they just sent him on his way. Can you surgically re-align met heads successfully?
  16. bob

    bob Active Member

    Yes, but there are a variety of factors that need to be taken into consideration prior to offering a patient surgery. Diffuse keratosis over a couple (or more) met heads is not (in my experience) generally responsive to surgery.

    Even if a patient is a reasonable surgical candidate from a medical and social perspective, lesser metatarsal surgery for plantar corns offers no absolute guarantee of success. Aside from all the standard risks of surgery, it is unfortunate that you might end up chasing the problem to another met head following surgery.

    'Smokers corns' without the presence of and underlying bony abnormality would not be something I'd be too keen to offer surgery for. Simple excision of the corn is an option and on the rare occasions that I have performed this, I have always told the patient that there's a high chance of recurrence or possibly fibrous corn formation in the scar. Interestingly, the histopathology report often comes back with viral elements within the corn.

    Debridement under local anaesthetic is pretty good at prolonging periods between appointments and I've even had some success in totally resolving these (used to use this in combination with granuflex and orthoses). Smoking cessation advice might help and is going to be good for the patient anyway.

    If you have access to x-ray, I'd recommend using a radio-opaque marker on the lesion (to remain on during the x-ray - don't let your radiographer pull it off) and request an axial view of the MTPJs along with your weightbearing DP and oblique. This will aid any potential surgical planning and give you an idea of the relation of your skin lesion to the underlying bony architecture.
  17. drsarbes

    drsarbes Well-Known Member

    Bob's post brings to light the problem here; we don't have a proper diagnosis.

    Once you determine what the pathology is (HD doesn't make the grade) and what the underlying etiology is ("smoker's corn isn't on the list) then you can rationally decide on a proper treatment.

    When terms like "fibrous plantar HD" are used it's pretty much useless as far as having us (as readers of a post) visualize what exactly you are describing.

  18. bob

    bob Active Member

    Steve - do I detect a note of frustration in your post? Ha haa. This seems to be a frequent occurrence on podiatry arena - when presenting a case, it's rare to provide a diagnosis or differential diagnosis on here. :dizzy:
  19. matt cichero

    matt cichero Welcome New Poster

    I absolutely concur with the smoking link...yes Camasta's work on this was quite revealing. I'd be recommending she start a stop smoking program ASAP before putting scalple to skin if she was coming to me for a surgical solution. Stay with all the conservative care for now.

    If she can follow your instructions and the lesions still don't go away then at least a surgeon will know she is compliant and would be more inclined to offer options.

    You'll be doing her a huge favour anyway and providing wholistic care.
  20. Johnpod

    Johnpod Active Member

    Many of the problems reported are due to poorly developed scalpel technique and lack of blade skill. Tibial blocks are decidedly OTT. Smoking is an excuse - not a cause of the lesions. Dead tissue is dead tissue, dead from whatever cause, and cuts just as readily.
  21. Graham

    Graham RIP

    I disagree. I have had a number of clients with these lesions who were smokers. On quitting thier lesions diminished significantly and their pain improved immensely. There appears to be an inflammatory component with may be exacerbated by smoking perhaps increasing nurition and callus formation.

    Unfortunately, with severe neurovascular lesions the drag of the blade does elicit some movement on the underlying dermal adhesions and is often more painful to reduce than a "regular" corn. IMO
  22. bob

    bob Active Member

    Oh dear! By the same logic, it would be easy for anyone to accuse you of not being able to perform a tibial nerve block. Lets not turn this thread into an attack on any of the suggestions posted. Your contribution could be summarised as "use good scalpel technique" - this would be a bit more positive (and hopefully goes without saying in the first place).
  23. Johnpod

    Johnpod Active Member

    If it went without saying, I would not feel the need to say it! What drag of the blade?

    Positive would be a description of a 'severe neurovascular lesion'
  24. Paul Bowles

    Paul Bowles Well-Known Member

    If it is dead tissue (as you described it John) where exactly is the vascular or neurological component?

    I am yet to see a "neuro-vascular helloma durum" (as mentioned) at any point in my career.

    Smoking is most definitely, without a doubt a contributing factor as Matthew has so elegantly put it. Camasta's write up on these lesions is pretty definitive. Reduction in smoking will reduce the discomfort associated with the lesion, if not eradicate it completely. These are not entirely mechanically related. Barry also makes a great point - is it something else - Porokerotosis? Punctate Keratoderma?

    Accusing Podiatrists of "poorly developed scalpel technique and lack of skill" - No wonder you post anonymously on these forums!!! :eek:
  25. Johnpod

    Johnpod Active Member

    I'm with Dr Steve on this one, a Neurovascular HD is not a true pathological description of the lesion.

    I also concur with you, Paul (same experience) that I too 'have yet to see a neurovascular Heloma durum'.

    If an HD is in fact a mass of dead tissue (dead because it has been denied its blood supply), then a neurovascular HD cannot exist.

    If the tissue is dead, it cannot have vascularisation
    If the tissue is dead it cannot have innervation.

    The converse is also true - tissue that has innervation and a blood supply cannot be dead i.e. it cannot properly be described as an HD, vascular HD or neurovascular HD.

    That these lesions bleed or hurt when enucleated cannot be attributed to included blood vessels or nerves - they bleed or hurt due to the close proximity to blood vessels and nerves. Blood vessels or nerves can only be present in the dermal papillae that underlie the lesions.

    These can be obliterated/eradicated by an application of the 95% silver nitrate caustic pencil. This precipitates the protein of the dermal papillae, causing them to die. They are included in the stiff, black eschar that results and falls away 7-10 days after application.

    As a clinician of twenty years standing and having taught scalpel work for 15 years I have to say that scalpel use is generally poor and the skill is certainly not endemic within us, just because we call ourselves podiatrists. The skill does not come with the title.

    If smokers hurt more it may be because their nerves are all 'a-jangle'. Perhaps that is why they smoke? And smoking depresses appetite. Perhaps they suffer some form of malnutrition?

    Yes, I post anonymously, as do many others. But I do have my principles and as a practising and teaching degree holding clinician of many years standing I am prepared to debate and defend my beliefs so long as the discussion remains on a professional level. That is what the forum allows. I had thought that that is what the forum is for.
  26. LuckyLisfranc

    LuckyLisfranc Well-Known Member

    Respectfully, Johnpod, I must disagree.

    Intractable plantar keratosis (IPK) is something we were all taught about. Usually the throwaway line was that these were due to a 'dropped metatarsal' or some such fictitous thing. Neurovascular corns were also bantered around. I too have seen no such thing.

    However, since spending a week with Craig Camasta when he was around a few years ago (plus time with other podiatric surgeons), I have come to realise there is a discreet entity known as a "smokers corn" that is unlike anything previously accurately described in the podiatric literature.

    I posted an image of a classic case on this thread here. An indigenous Australian with chronic IPK lesions, who happened to be a heavy smoker and resistant to any other forms of mechanical offloading. Would attend almost monthly and go through quite significant discomfort whilst these lesions were enucleated by minute dissection.

    I have put everything from silver nitrate to phenol on these lesions. It makes little impact at all until smoking is ceased.

    I believe this to be a clinical entity that is underdescribed and poorly appreciated, and atypical to all other *closely* similar lesions on the foot. They are easily identified once familiar with.

    In fact, I can make a bold prediction that I am 100% correct in identifying a smoker by the visual appearance of these things alone, without any other information.

    I only wish these had been described better when smoking was "in fashion".

  27. Johnpod

    Johnpod Active Member

    Hi Lucky,

    I appreciate your posting and am genuinely interested in your observations. Having looked closely at the image you have posted I cannot see anything that I have not seen a thousand times. There appear to be no special features that make this a 'smokers HD' that I can detect from the image. Can you help me to appreciate and understand the special characteristics of this new species hitherto unrecognised and unknown to science?

    Always looking for something new - don't want to think that there's nothing new out there - certainly not a closed mind.
  28. drsarbes

    drsarbes Well-Known Member

    I checked your link and the photo demonstrating the "smoker's Corn" is very nice.
    Thank you.
    So WHY is this a "smoker's Corn"?
    I assume the patient smokes? IS that the connection?
    Does the patient have any other vices we can blame this on other than the fact that it's under the second metathead and perhaps you've come across the "fictitous dropped metatarsal" !!!!!

    I saw a patient last thursday with an achilles tendinitis, however, it was a bit more painful than I usually see and, during my history I discovered that the patient is a vegetarian - SO, I DEDUCED (being the cleaver clinician that I am) that there must be a relationship - thus I coined the term

    fitting I thought.


  29. Johnpod

    Johnpod Active Member

    The image to which the link on Lucky Lisfranc's post 26 leads demonstrates a plantar HD - nothing more. The foot shows vascular insufficiency (red colouration and blue viens post 1st met head). The foot is subject to forefoot-disrupting hyperpronation, evidenced by HAV and retracted lesser toes. The 5th ray is abducted and is probably hypermobile (callus blade on 5th) and plantar callus sub 5th met indicates frontal plane instability rotation. The short first ray is incompetent (bears little weight - hence small amount of callus beneath 1st met head) and the long second metatarsal is having to compensate for loss of first ray function. This is the reason for the lesion in question and explains all callus masses present, including that on the medial aspect of the hallux.

    The lesion is directly beneath the 2nd met head, exactly where it would be if the second metatarsal was functioning to compensate for 1st ray deficiency. There is no abnormal inflammation present, no swelling. A hard central nucleus is obvious, surrounded by callus, the depth of which is indicated by the darkness of the lesion. Nucleus and associated callus must all go - every fraction of it. All dead skin is yellow. Any dead skin at depth might be moist (macerated).

    This foot would benefit from pronation-limiting orthotic correction which would also improve 1st ray function and release the retracted lesser digits. I would probably add a shaped metatarsal bar to elevate the central mets.

    It may be that the patient has a penchant for liquorice, but this does not become a liquorice corn. If the sufferer enjoys the effects of nicotine, the lesion does not become a "smoker's corn" - except in the sense that it occurs (in this case) in the foot of a smoker.

    Interested to read drsarbes confession (being the cleaver clinician that he is). Just confirms that scalpel skill is sadly not as highly developed as it might be.
    Nice one Steve:)
  30. Paul Bowles

    Paul Bowles Well-Known Member

    Give a man a hammer and all he can do it push nails.......
  31. LuckyLisfranc

    LuckyLisfranc Well-Known Member

    OK, I can talk the talk with biomechanics too...but this is not the point. I have treated these types of IPKs for years with all manner of fancy orthoptic variables.

    Yes, Steve - a history of smoking is not evidence of causality. In my observations, not all smokers seem to get these lesions either. I am not sure why, but a distinct subset of smokers seem to be prone to them - so I am not sure what other variables are at play here.

    My final comments are just to reiterate the following observations, in case anyone has an open mind to this argument (and because the page will get logged on Google and this might help someone one day):

    Clinical appearance; discreet solitary hyperkeratotic lesions, typically under MT heads and bony promineces. Resemble heloma durum, except for a yellowish tone to the lesion, and closer to the dermal junction these become quite white, macerated and exquisitely tender. Rarely seen in non-smokers. Little discernible improvements with orthotic/mechanical offloading. Often improve/resolve within 1-2 years of smoking cessation.

    Given there is no real evidence in the podiatric literature to support these observations from me (and a range of clinicians with more experience than I), I will politely step away from the conversation now, and bid you all the best. Hopefully an enthusiastic researcher may take a closer look at this one day.

  32. Johnpod

    Johnpod Active Member

    ...but give a man a scalpel and he can bring relief to thousands - if he can use it properly, that is.

    Cheers Paul

    ...and Lucky, "Given there is no real evidence in the podiatric literature to support these observations" - that is exactly the point. Biomechanics is the answer; Tissue stress theory, Davis's law.

    All the Best
  33. LuckyLisfranc

    LuckyLisfranc Well-Known Member

    I tried to quit this thread but couldn't resist that last bit of bait.:D

    Considering that cigarette smoking is a known trigger for psoriasis and hyperkeratosis within the mouth, I thought the following quote might be of interest...

    As Paul obliquely suggested; sometimes its not just about using bits of plastic inside shoes. Given we don't have access to cost-effective punch biopsy testing for podiatrists in most parts of the world (and much of a pool of talent in dermatopathology), it will no doubt be a long time until some podiatric studies can investigate this properly within the foot.

    All the best, and I'll try to sign out properly this time.

  34. Unfortunately picking up a scalpel may not be the answer either:
    In our study published in the British Journal of Podiatry in May 2005 pain scores at six weeks following treatment showed no statistically significant difference from the pain scores taken immediately prior-to scalpel debridement (p>0.05). This means that the subjects who received debridement were no better off in terms of perceived pain than when they first came in for their initial assessment. Of greater concern, is that almost one third of the subjects (32.5%) in this group reported higher pain levels at six weeks post-scalpel debridement than they had reported prior to treatment
    Timson, S., Spooner, S.K. (2005) A comparison of the efficacy of scalpel debridement and insole therapy in relieving the pain of plantar callus. British Journal of Podiatry, 8(2):53-59. Previously, Colagiuri et al. have reported that the appearance of nearly 25% of calluses deteriorated with scalpel debridement http://linkinghub.elsevier.com/retrieve/pii/016882279501050N.

    There is little doubt that scalpel debridement of plantar callus provides an immediate reduction in perceived pain from the lesion, however, in the longer-term insoles seem to be more effective when these modalities are compared in isolation.
  35. Paul Bowles

    Paul Bowles Well-Known Member

    ....with many return visits and the addition of bent plastic earning said man/women an extremely healthy turnover!

    Give the patient however a small piece of education (i.e. STOP SMOKING) and said issue may indeed improve with little or no cost. Lets see for a minute - continue smoking and wear plastic/have multiple debridements yearly and most likely develop secondary complications including respiratory illness, vascular disease etc.... OR stop smoking, reduce lesions and stay healthy. Tough decision!

    Is there a medical negligence case there somewhere?

    You measured the patient when they first presented (in pain) then measured them again six weeks later when they were in pain again? Would it have not made more sense (and been far more palatable) if you had measured pain at weekly intervals following callous debridement?

    For what reason? Was any data collected on their activity post debridement, footwear etc.... Maybe they felt so good one week after their initial treatment they could then walk more easily to the corner store on multiple occasions to pick up a few packets of "bungers"

    I do in fact recall an Honours project from the University of Western Sydney some years ago that found debridement + innersoles was indeed the most effective means of pain and pressure relief. I think Dr Tony Redmond may have had something to do with supervising that particular study....

    Regardless, I doubt any of these studies categorized lesions into aetilogies such as mechanical, traumatic, pathology etc....and this would be a major failing of all the research to this point (Please Simon correct me if I am wrong I have not read the full article - would love to if you could attach it as a .pdf though cheers!)

    I do love your work Simon but in this case you are comparing apples with watermelons in this thread at this stage.....did you ask a control group to stop smoking and see what the outcomes were? Was data even collected on smoking in this population?


    I am afraid the issue here is not orthoses or scalpel, as these are merely band aids to the symptoms - The real issue is what are these lesions and does smoking assist with their appearance/location/pain reduction in any way? Stopping/reducing smoking may not be a band aid, it may be part of the solution! Like Tony, Matthew and many others have mentioned I have clinically seen these lesions improve and even resolve after cessation of smoking in patients - that doesn't mean I am right though!

    Reading through this thread again, I wonder how many people dispelled the issues related to smoking and bone healing prior to any research on the topic?

    Ok, I am ready to have my "ass" handed to me by Simon :D. Fire away!
  36. bob

    bob Active Member

    Simon - I'm sure others may pitch in querying the quality of the scalpel work used to debride the callus in your study. Did those providing the treatment treat discrete 'corns' or was it diffuse plantar callus? And if it was diffuse plantar callus, did they leave a feathered finish with their 11 blade that was 'cheated' to a better finish with a Moore's disk and a fistful of flexitol? I only really want to hear an answer to the first question ;)

    LL - shame you're leaving the thread as I think I know the type of lesion you're talking about. As I said earlier, whenever I've excised these lesions and sent for histology, they often come back with signs of virally infected tissue. I'll see if I can track down a histology report, but it's a good while since I've done this.

    In addition to the above, I recall most patients that I've seen with this type of lesion were female, aged 35-60 and have a history of depression (taking citalopram, etc...). There are a variety of factors that could be correlated to their presentation and I admit I don't really know the true cause, only that the type of patient presents as above, the lesion has been incredibly resistant to a plethora of conservative options and the patient reports minimal relief from standard debridement by a variety of clinicians with varying levels of experience. X-rays usually show the lesion is not intimately related to an underlying bony abnormality and my colleagues specialising in biomechanics can't always help. Thankfully, I haven't seen one of these for a while, but I can acknowledge their existance (I think!) :D
  37. drsarbes

    drsarbes Well-Known Member

    Hi John POD
    Yes, very very "cleaver'!
  38. Johnpod

    Johnpod Active Member

    Hi Steve,

    That's ok, I understand that you were suffering from some sort of vegemata dysplasia (misplaced vegetable) at the time!

    Isn't humour wonderful?!

  39. aclarkmorris@aol.com

    aclarkmorris@aol.com Welcome New Poster

    The use of podospray is may well be helpful in this case and should enable you to debride more than with scalpel alone with out the use if a tib post block. I have found it useful (especially on anxious patients) albeit a bit messy.
  40. bob

    bob Active Member

    Fair point. I know of other practitioners offering this service to some of the patients I previously did the tibial nerve blocks and debridement on. My main problem with the podospray is the aerosol effect. Do you know of any studies into this? The patients I saw reported improved short-term relief from the podospray when compared to routine debridement. Generally, they reported an initial increase in pain following debridement under anaesthetic followed by a more prolonged period of relief when compared to podospray. Shame I didn't get my act together and design a research study on it at the time. Sorry.

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