Why is it so important?

Nerve damage, poor circulation and trouble fighting infections, can make foot problems very serious for people with diabetes. The goal of the CDFE is to identify any changes in your feet, prevent problems and reduce the risk of amputations.

How Diabetes Can Affect the Feet

• Diabetic neuropathy. Because of the abnormal increase of blood sugar, nerves that supply sensation to the feet can be damaged. This decreases the feeling of pain in the feet.
• Diabetic vasculopathy. Diabetes can affect the blood vessels of the feet, causing them to narrow, and reduce blood flow to the feet.
• Structural changes. If the foot receives less nutrients and oxygen, the bones and joints will weaken, causing the foot to flatten or toes to curl, creating new pressure areas that could cause the skin to break down.

Why Should You Be Concerned?

Patients with diabetes are more likely than others to have problems with their feet. The American Diabetes Association reports that the amputation rate is 10 times higher in persons with diabetes, but these rates can be decreased 45-85% with a comprehensive foot care program.

To all our patients:

• Did you know that foot problems are a leading cause of infection in a diabetic?
• 20% of all diabetics admitted to the hospital, are admitted for foot infections

The American Diabetes Association’s “2010 Standards of Medical Care in Diabetes” statement on diabetic foot care “requires” an annual comprehensive diabetic foot examination to assess all lower extremity risk factors. To provide you with the best possible diabetic foot care, we are instituting these recommendations into our practice, effective immediately.

We are advising all of our patients with diabetes to schedule a Comprehensive Diabetic Foot Exam (CDFE), so that we can perform the necessary non-invasive testing examination to meet these requirements. (This exam should only take about 15-20 minutes)

This exam will not include the treatment of corns, calluses or nails.

Please remember to bring with you a list of all prescription medications that you are taking, and any shoes/insoles that have been provided through the Medicare Therapeutic Shoe Program. If you are not part of this program, please bring in shoes that you would typically wear.

You should of course continue to be monitored by your primary care physician, as your condition warrants, and as always, we will coordinate your foot care with your regular physician.

Thank you…

Jerold Fleishman, D.P.M • Timothy Downs, D.P.M. • Edward Carver, D.P.M. • Caroline Gauthier, D.P.M.

Bunions are enlargements of the joint at the base of the big toe—the metatarsophalangeal (MTP) joint—that form when the bone or tissue at the big toe joint moves out of place. Bunions are a symptom of our foot’s development due to the way we walk, our inherited foot type, our shoes, or for other reasons. Although bunions tend to run in families, it is the foot type that is passed down—not the bunion. Since the MTP joint
carries much of the body’s weight while walking, bunions can cause extreme pain if left untreated. Podiatric medical attention should be sought at the first indication of pain or discomfort.

Stress fractures are tiny or incomplete cracks in a bone often caused by overuse. Stress fractures occur most frequently in the foot and ankle and can be caused by a number of factors. An unusual increase in activity causing strain in the foot (fatigue fracture) is one of the most common causes, while weak bones (insufficiency fractures), are caused by medical conditions such as osteoporosis, can also be a factor. Medications such as steroids can lead to stress fractures, as can a sudden increase in activity levels. All of these causes can and should be evaluated by your podiatrist when you notice pain or swelling, which are the
symptoms of a stress fracture.

A neuroma, also referred to as a “pinched nerve,” is a painful condition involving irritation and/or thickening of the nerve tissue between the toes,most commonly the 3rd and 4th toes. The condition brings on pain, a burning sensation, tingling, or numbness between the toes and in the ball of the foot. Your podiatrist can offer a number of treatment options for a neuroma.

Ingrown nails are a common ailment seen by podiatric physicians. An ingrown nail is one whose corners or sides dig painfully into the soft tissue of the toe, often leading to irritation, redness, and swelling. Usually,
toenails grow out straight, but sometimes one or both corners or the sides will curve and grow into the flesh. The big toe is the most common site for this condition, but other toes can also become affected.

Ingrown toenails may be caused by any one or more of the following: improperly trimmed nails, shoes that are too tight, trauma, and activities with repeated pressure on the toe (such as running or kicking). There are other causes as well, but this painful condition can usually be eased with one or two visits to your podiatrist’s office.

Women may also have a tendency to develop blisters, corns, calluses, and heel pain. All of these conditions can be treated by your podiatrist, and a number of treatment options are available. Once we all realize that our feet don’t have to hurt, life will be that much more enjoyable, ladies.

New Technology in Foot Care

Podiatric medicine and surgery are changing rapidly, as is all of medicine. Doctors of podiatric medicine now use the latest technology both in their offices and in the hospitals to diagnose and treat foot and ankle problems. These technologies are changing the face of medicine, and your doctor can provide you with more information.

Ultrasound for diagnostics – While x-ray is still in use in most podiatric medical offices, ultrasound is another diagnostic technique available to your podiatrist. This non-invasive technology allows better visualization of soft tissue structures such as tendons and even allows evaluation of joints in motion.

Orthotic scanning – In the old days, your doctor may have taken a plaster cast mold of your feet to fashion orthotics specifically for you. While this is still done successfully in some offices, new technology allows your podiatrist to scan your foot with an electronic device that captures the necessary data to construct your custom foot orthotics. The electronic scan is then evaluated by the podiatrist and sent to an orthotics lab for
processing. In just a few weeks, you’ve got a new pair of custom foot orthotics, molded and designed specifically to correct your particular condition.

ESWT – Non-invasive procedures like ESWT (Extracorporeal Shock Wave Therapy) are now available in the office or surgical center of your podiatric physician. Used to treat heel pain unresponsive to standard treatment options, ESWT can be used in several ways, and is usually administered with anesthesia. ESWT may be a treatment option to consider prior to proceeding with open surgery for chronic heel pain. ESWT has few complications that can be considered minor compared to those of open heel surgery. Ask your DPM for more information.

Surgical Implants – Knee and hip replacements are now common in medicine for the treatment and care of arthritic and painful joints. Many people are unaware, however, that there are joint “replacements” for the foot and ankle. For patients with arthritis and those with joint damage secondary to trauma, both high-grade plastic and metallic implants are being used to replace, joints in the foot and ankle. If you are dealing with the daily pain of an arthritic joint, ask your podiatrist about these implants. What’s next? Fungal toenails are very common and podiatrists treat this condition with an arsenal of weapons. However, currently under consideration by the FDA is a laser treatment that will resolve the fungus. Ask your podiatrist for more information on this promising new treatment.

Stretching before exercising is one way to make sure you are warmed up and ready to go.

• Consider purchasing new shoes for your new level of activity. It’s important to have your feet measured, and then choose an athletic shoe that fits your sport. Make sure to break in any new gear appropriately, and ask your podiatric physician for recommendations for your particular needs.

• Take care of your feet. Examine them daily for signs of blisters, corns, and ingrown nails. Take a few days off your new activity if you see signs of any of these problems.

• Visit your podiatrist periodically to discuss your foot and ankle concerns or just for a check-up before starting a new routine.

•Watch your sun exposure. As the weather improves and our feet are more exposed, it’s important to remember sun-screen. The tops of feet are one of the most commonly sunburned areas.

• Seek immediate care for any foot or ankle problems. Spring is a great time of year for renewal, but don’t let your over-eagerness get the best of you. Take the time to enjoy and take care of those two very important assets—your feet.

With spring on the horizon, we are all looking forward to warming up our bodies for increased activity levels. To make sure that your feet are fit for spring, we offer the following suggestions.

• When starting a new exercise routine, or when ramping up your current one, make sure to ease into that new routine..

Click here to learn about New England Foot & Ankle of Chelmford, Newburyport

New England Foot and Ankle, PC is proud to announce that Dr. Timothy Downs, DPM has been elected Chief of the Department of Podiatry of Lowell General Hospital. Dr. Downs’ mission as Chief of Podiatry is the continuation of excellence in patient care and the promotion of foot and ankle specialists in the community. We are very proud of his accomplishment and strongly believe that his expertise will benefit the community.

October 7, 2009

Bethesda, MD – The average American’s foot pain often gets in the way of daily activities. Perhaps no group suffers from chronic foot pain more than those who are constantly on their feet. According to the American Podiatric Medical Association’s (APMA) 2009 foot ailments survey , 44 percent of respondents said they spend at least four hours standing every day. Additionally, nearly 78 percent of Americans have experienced foot problems as a result of wearing uncomfortable or ill-fitting shoes.

"The excess strain put on the legs and feet of those standing for long periods of time can take a massive toll on the body—especially for those working in the health care community," said APMA President Ronald Jensen, DPM. "Without the proper footwear that provides necessary support to the ligaments and joints of the feet, these individuals are subject to a host of ailments that can lead to chronic problems such as metatarsalgia—a pain and inflammation in the ball of the foot.”

Excessive standing and walking on hard surfaces like concrete can also increase the incidence of foot problems. However, many footwear companies create products that are specifically made for those who “work standing up.” The following footwear products, designed specifically for those who make a living on their feet, have been granted APMA’s Seal of Acceptance. The Seal of Acceptance Program recognizes products which have been found beneficial to foot health and of significant value when used in a consistently applied program of daily foot care and regular professional treatment:

Crocs Work Shoes. The familiar, comfortable feel of Crocs is also available in a professional-looking shoe that conforms to workplace standards. Featuring a closed toe and heel design, as well as arch support and a foot bed that promotes circulation, the Crocs Work Shoe is a top choice for many health and service industry professionals across the country.

Dansko’s Acadia and Stapled Collections . Dansko’s new Acadia collection (pictured) features distressed leather uppers, a removable triple density molded EVA insole and slip resistant out-sole. With a lightweight base and lower profile, this collection is perfect for the active woman. Additionally, the company’s Stapled Collection features a rigid construction and key features that promote good foot health, including a rocker bottom and full arch support.

The Timberland Company - Timberland PRO. Timberland’s PRO Renova series of work footwear—which includes the Professional, Provider, and Caregiver (pictured)—is designed specifically for those at work in the health care community. The Professional Series features Timberland PRO Anti-Fatigue technology, a rocker profile, and an anatomically shaped oblique last for all-day comfort.

For a complete listing of work footwear products that have been awarded the APMA Seal, visit www.apma.org /workfootwear. For more foot health information, visit www.apma.org.

Founded in 1912, the American Podiatric Medical Association (APMA) is the nation’s leading and recognized professional organization for doctors of podiatric medicine (DPMs).  DPMs are podiatric physicians and surgeons, also known as podiatrists, qualified by their education, training and experience to diagnose and treat conditions affecting the foot, ankle and structures of the leg. The medical education and training of a DPM includes four years of undergraduate education, four years of graduate education at an accredited podiatric medical college and two or three years of hospital residency training. APMA has 53 state component locations across the United States and its territories, with a membership of close to 12,000 podiatrists. All practicing APMA members are licensed by the state in which they practice podiatric medicine. For more information, visit www.apma.org.

Today, a Chelmsford, MA foot and ankle surgeon urged obese adults to seek immediate treatment for chronic, activity-limiting foot and ankle problems to foster compliance with physician-directed exercise programs.

“It’s unfortunate obese adults get caught up in the vicious cycle of avoiding physical activity due to foot or ankle pain, thereby permitting cardiovascular disease and other life-threatening conditions to worsen as a result,” says Dr. Jerold H. Fleishman, DPM, FACFAS, a member of the American College of Foot and Ankle Surgeons FACFAS in Chelmsford, MA. “For example, in many cases, chronic heel pain occurs from carrying too much weight. Left untreated, it becomes an impediment to physical activity and meaningful weight loss.”

Dr. Fleishman says there’s no reason foot or ankle pain should stop obese patients from exercising. The first step toward breaking that vicious cycle is an evaluation by a foot and ankle surgeon.

According to the ACFAS consumer Web site, FootPhysicians.com, many causes of foot pain can be relieved without surgery through stretching exercises, orthotics and athletic shoes with good shock absorption and support. If a bunion, heel pain or other condition requires surgery, patients can participate during their recovery in non-weight-bearing activities, such as riding a stationary bike, swimming or weight training.
For those moderately to severely overweight, Dr. Fleishman says a thorough physical examination is mandatory before beginning an exercise program.

“Once cleared by your physician to begin exercising, don’t try to do too much too soon. Follow a gradual routine until your body adjusts to the stress of regular physical activity,” HE says. “For example, I counsel overweight patients to avoid working out on treadmills or elliptical machines to minimize pounding and stress on their joints.”

Shedding excess pounds helps diabetic patients control their disease, but Dr. Fleishman notes many who experience foot ulcerations and vascular problems caused by diabetes might think they shouldn’t exercise.
“Every diabetes patient needs regular foot exams to check for possible sore spots and assess nerve sensation,” says Dr. Fleishman. “And with proper diabetic foot care and the right footwear, most patients can follow an exercise regimen that is safe and appropriate for them.”

To Contact Dr. Fleishman’s visit www.nefootankle.com

Timothy M. Downs, DPM, FACFAS, says those symptoms may be caused by a condition called diabetic peripheral neuropathy, or nerve damage. Neuropathy in the feet can lead to permanent numbness, deformities such as bunions and hammertoes, and dry skin that cracks open and won’t heal.

“Diabetic peripheral neuropathy is not only painful but dangerous,” says Dr. Downs, a Fellow of the American College of Foot and Ankle Surgeons with offices in Chelmsford, MA,. “It’s a leading contributor to foot ulcers in people with diabetes.”

Burning, tingling and numbness in toes can also be symptoms of thyroid problems, nutritional deficiencies, back problems and pinched nerves in the ankles. In the United States, diabetes is the leading cause of peripheral neuropathy and can lead to further foot complications.

Out of the 23 million Americans with diabetes, one in four has not been diagnosed. Some people learn they have diabetes only after seeing a doctor for burning, tingling and numbness in their toes and feet. Many people already diagnosed with diabetes are not familiar with neuropathy’s symptoms. According to FootPhysicians.com, even diabetic patients who have excellent blood sugar control can develop diabetic neuropathy.

Medications can treat pain caused by neuropathy. However, nerve damage cannot be reversed.

“When you have diabetes, especially diabetic neuropathy, a minor cut on your foot can turn into a catastrophe,” says Dr. Downs. “The statistics on diabetic ulcers are sobering.”

Twenty percent of diabetes patients who develop ulcers will require an amputation. Patients who are black, Hispanic and Native American are twice as likely as whites to need a diabetes-related amputation. Half of all people with diabetes who have a toe or foot amputation die within three years. The annual cost for diabetic ulcer care in the U.S. is estimated at $5 billion.

For more information on foot problems such as diabetic peripheral neuropathy, contact Dr. Downs at www.nefootankle.com.

Changes in diet, including overindulging in certain foods and beverages, can cause gout attacks this time of year, says Jerold H. Fleishman, DPM, FACFAS. Dr. Fleishman is a member of the American College of Foot and Ankle Surgeons (ACFAS) with offices in Chelmsford, MA.

Gout attacks are extremely painful. They are caused when uric acid accumulates in the tissues or a joint and crystallizes. This most commonly occurs in the big toe joint. Dr. Fleishman explains this is because the toe is the coolest part of the body and uric acid is sensitive to temperature changes.

He says foods that are high in purines contribute to uric acid build-up. He recommends that people prone to gout attacks avoid purine-rich items such as shellfish (shrimp, crab, etc.), organ meats (kidney, liver, etc.), red meat, red wine and beer.

Gout can be treated with medications, diet changes, increasing consumption of appropriate fluids, and immobilizing the foot. In some cases surgery is required to remove the uric acid crystals and repair the joint.

For contact information visit www.nefootankle.com

With the observance of National Diabetes Month in November, Timothy M. Downs, DPM, FACFAS, a member of the American College of Foot and Ankle Surgeons with offices in Chelmsford, MA, reminds residents with diabetes that following simple foot care tips can reduce their risk of toe, foot or leg amputations.

People with diabetes are 10 times more likely to have a lower limb amputated than people without diabetes, according to the American Diabetes Association. Dr. Downs says the disease can cause poor blood circulation and nerve damage in the feet, making them vulnerable to developing ulcers, infections, deformities and brittle bones.

The ACFAS consumer Web site FootPhysicians.com provides these foot care tips for people with diabetes:

·    Inspect feet daily for injuries that could lead to dangerous ulcers.
·    Gently wash feet in lukewarm (not hot!) water.
·    Moisturize feet, avoiding the area between the toes.
·    Never trim corns or calluses; this can lead to serious infections.
·    Inspect the inside of shoes before wearing.

People with diabetes must always be vigilant, says Dr. Downs, and see a foot and ankle surgeon at the first sign of trouble. Early treatment can keep diabetic foot problems from progressing, and reduce the risk of amputations.

To contact Dr. Downs, www.nefootankle.com.

Jerold H. Fleishman, DPM, FACFAS says the ankle joint is vulnerable to serious injury from hard falls on ice.

“Ice accelerates the fall and often causes more severe trauma because the foot can go in any direction after slipping,” he says.

Dr. Fleishman is a member of the American College of Foot and Ankle Surgeons (ACFAS) with offices in Chelmsford, MA, and Newburyport, MA. He adds that in cases of less severe fractures and sprains, it’s possible to walk and mistakenly believe the injury doesn’t require medical treatment.

“Never assume the ability to walk means your ankle isn’t broken or badly sprained,” he says. “Putting weight on the injured joint can worsen the problem and lead to chronic instability, joint pain and arthritis later in life.”

Some people may fracture and sprain an ankle at the same time, and a bad sprain can mask the fracture.

“It’s best to have an injured ankle evaluated as soon as possible for proper diagnosis and treatment,” says Dr. Fleishman.  “If you can’t see a foot and ankle surgeon or visit the emergency room right away, follow the RICE technique – Rest, Ice, Compression and Elevation – until medical care is available.”

According to the ACFAS consumer Web site, FootPhysicans.com, even though symptoms of ankle sprains and fractures are similar, fractures are associated with:

·    Pain at the site of the fracture that can extend from the foot to the knee
·    Significant swelling
·    Blisters over the fracture site
·    Bruising soon after the injury
·    Bone protruding through the skin—a compound fracture, which requires immediate attention!

Most ankle fractures and some sprains are treated by immobilizing the joint in a cast or splint to foster union and healing.  However, surgery may be needed to repair fractures with significant malalignment to unite bone fragments and realign them properly.

Dr. Fleishman said newly designed surgical plates and screws allow repair of these injuries with less surgical trauma.

“With newer bone-fixation methods, there are smaller incisions to minimize tissue damage and bleeding and accelerate the healing process,” he says.

Dr. Fleishman recommends scheduling an appointment with his office if you have injured your ankle in any way.

“If you fall on an icy spot and hurt your ankle, the best advice is to seek medical attention immediately,” he says. ”This aids in early diagnosis and proper treatment of the ankle injury and reduces the risk of further damage.” For contact information please reach me at www.nefootankle.com.

These popular boots typically feature tall, spiked heels and narrow, pointed toes.

“Wearing high-heels makes you more unstable when walking or standing on dry surfaces, let alone slippery ones like ice or snow,” says Dr. Downs. “A stylish low-heeled winter boot is a lot more fashionable than a cast and crutches.”

Dr. Downs also recommends women scuff-up the soles of new boots, or purchase adhesive rubber soles, to provide greater traction.

Falls from high-heeled winter boots can lead to a number of injuries, depending on how the woman loses her balance. If her ankles roll inward or outward, she can break her ankles. If her ankle twists, ligaments can be stretched or torn, causing an ankle sprain. According to the American College of Foot and Ankle Surgeons consumer Web site, FootPhysicians.com, broken and sprained ankles can be present at the same time. Dr. Downs is one of 6,000 ACFAS members.

“This time of year I see a variety of broken bones occurring in patients who have slipped on the ice,” says Dr. Downs. “These include broken toes, metatarsals, heels and ankles.”

Dr. Downs urges women hurt from slips and falls in high-heeled winter boots to contact his office in nefootankle.com for prompt evaluation and treatment. In the meantime, immediately use the “R.I.C.E.” method – rest, ice, compression and elevation – to help reduce swelling, pain and further injury.

“Delaying treatment can result in long-term complications such as chronic ankle instability and pain, arthritis, or deformity,” says Dr. Downs. “Even if you’re able to walk on the injured foot, pain, swelling, or bruising indicates a serious injury.”