My Blog

Posts for: May, 2020

By Colorado Foot and Ankle
May 28, 2020
Category: Foot Care
Tags: Toenail Fungus  
Onychomycosis is the technical term for toenail fungus. It’s when fungus gets under the nail and causes an infection. You’ll notice that the nail changes color and starts emitting an odor. If left untreated, the infection can spread to the other toes and even the fingers. The best thing to do is to schedule an appointment with your local podiatrist. 
What Causes Toenail Fungus?
Your feet are vulnerable to fungi and bacteria due to their location on the body. This is especially true if you go barefoot in damp areas like locker rooms, showers, and swimming pools. Your feet come in direct contact with these pathogens. An injury to the nail bed also opens your body up to infection. Even the smallest cut provides an opening for bacteria. Other possible risk factors include pre-existing medical conditions like immune-deficiency, diabetes, circulatory problems, and other chronic illnesses. 
Podiatry Treatment for Toenail Fungus
Schedule an appointment with your podiatrist right away when you notice differences in the appearance of your toenail. This includes any thickening, discoloration, or deformity. Your podiatrist will first need to make a diagnosis before treatment starts. This is done through a simple lab test. 
The first line of treatment includes oral and topical antifungal. Topical antifungal medication or cream is applied directly to the nail. Oral antifungal is taken just like regular medication. These are also more effective. You will take the oral antifungal for approximately three months.
For severe cases, patients require surgery. That’s why it’s so important to seek treatment from your foot doctor right away. They can help you before it gets to this point. Otherwise, your podiatrist performs a temporary removal of the nail. This gives your doctor space to evenly apply the topical antifungal.  
Toenails that don’t respond to any treatment need permanent nail removal. This eliminates the fungal infection while getting rid of the damaged nail.
At-Home Solutions for Toenail Fungus
There are a few things you can do at home to help treat your toenail fungus. A strict cleaning regime can relieve mild infections. Patients have found success in filing off the white marks and then applying over-the-counter antifungal agents. These do not stop infections from coming back, which is why we encourage patients to seek treatment from a medical professional.

By Colorado Foot and Ankle
May 20, 2020
Category: Foot Issues
Tags: Morton's Neuroma   Neuroma  
Morton's NeuromaA podiatrist can help you with a variety of conditions that affect the feet, including Morton’s neuroma. A neuroma is the thickening of nerve tissue in the body, with Morton's neuroma specifically happening in the ball of the foot. It’s caused by an irritation in the nerve between the third and fourth toes. Patients experience pain while walking, with a burning, tingling, or numbness. 
Developing Morton’s Neuroma
There isn’t any known cause for Morton’s neuroma. There are a few factors that can increase your risk though. These include: 
  • Trauma or injury to the foot, damaging the nerve and resulting in swelling.
  • Improper footwear, like shoes that squeeze the foot together. High heels also increase pressure on the vulnerable areas.
  • Recurring stress to the feet through repeated physical activities or exercise. This is common with patients who are constantly on their feet due to their job. 
  • Deformities of the foot, like a high arch or flat foot. These lead to instability throughout the foot. 
The most important thing that your podiatrist recommends is wearing comfortable shoes. You don’t want anything that squeezes or hurts. Always wear athletic shoes when engaging in any physical activity. 
How to Treat Morton’s Neuroma at Home
Start by finding shoes that give your toes lots of room and are easily adjustable. The soles need to be shock-absorbent and thick. This keeps the pressure off the feet. You should also invest in shoe inserts or soles recommended by your podiatrist. Lastly, pay attention to your feet and their pain levels. When your Morton’s neuroma starts to act up, take a minute to rest. Take off your shoe and massage the area. An ice pack brings down the swelling too. 
Talking to Your Podiatrist
You should schedule an appointment with your podiatrist as soon as you experience foot problems. Morton’s neuroma gets worse without treatment. Identifying the neuroma early on can prevent needing aggressive treatment options like surgery. 
For early forms of Morton’s neuroma, changing your shoes is enough to relieve your symptoms. Your podiatrist’s goal for early treatment is to relieve pressure from the affected area. After going through a physical examination and having X-rays done, your podiatrist creates a treatment plan that works for you. 
There are a few different options that can work for you:
  • Taping and padding: This is a special type of tape and bandages that you place on the bottom of the foot. This helps with your symptoms. 
  • Orthotics: These are the custom shoes that your podiatrist can create for you. 
  • Medication: Cortisone injections reduce the pain and inflammation in the foot. Anti-inflammatory drugs also reduce your swelling. 
  • Surgery is the last resort for treatment. The procedure is done on an outpatient basis. The injured nerve is removed and recovery takes a few weeks.

Outcomes in all of medicine, but especially wound care, go beyond the physical clinical presentation. Accordingly, the panelists discuss unique mental, social and emotional challenges wound care patients may face, and share their experiences and opinions on how best to provide support and care.


What mental, emotional or social challenges do you feel patients with chronic wounds may encounter in relationship to their condition? Why?


Chronic wounds can certainly be a large burden on patients due to the necessary complexity of care, says Jacob Fassman, DPM, FACFAS, CWS. He adds that transportation issues and financial burdens of frequent visits are also very impactful. Both Dr. Fassman and Kazu Suzuki, DPM, CWS identify possible patient embarrassment from malodorous wounds, or needing to ask for help from family and friends as sources of distress and isolation. Both doctors also agree that pain management needs pose a significant challenge for wound care patients.

“Having chronic pain for months or years, let alone undergoing an amputation, can be devastating to one’s mental health,” says Dr. Suzuki. 

Citing the work of Beattie and colleagues, Valerie Marmolejo, DPM, MS says a perceived lack of control and loss of self are significant aspects of the psychosocial health ramifications of a diabetic foot ulcer (DFU).1 For example, Fejfarová and Jirkovská note that weightbearing restrictions impact the patient’s ability to perform daily activities, including work-related activities.2 Dr. Marmolejo says this may have a negative impact on a patient’s attitude and self-confidence.1-6


How might these patient challenges pose further treatment challenges for the clinician?


“A key component in treating a patient with a chronic wound is to know that negative emotions will be involved,” says Dr. Marmolejo. 

The panelists agree that patients may express these negative emotions in a variety of different manifestations and behaviors. Patients may direct fear and anger at the provider, explains Dr. Marmolejo. She says it is important to understand the underlying reasons for these behaviors and still try to build a positive patient-provider relationship.

Patients with depression may not keep scheduled appointments, which challenges the provider to adequately and promptly address their condition, according to Dr. Suzuki. In addition to appropriate referrals to psychiatric professionals, Dr. Suzuki emphasizes awareness of pain management options. 

“I do my best to be proactive about pain counseling and management as there are many pharmacological interventions,” says Dr. Suzuki. 

For pain management, he notes that he would have patients start with acetaminophen around the clock (maximum 3,000 mg per day in divided doses) and use narcotic medication (such as tramadol, hydrocodone and oxycodone) for breakthrough pain. Dr. Suzuki says adjunctive pain medication options may include gabapentin, pregabalin (Lyrica®, Pfizer) and duloxetine (Cymbalta, Lilly). He adds that many of his patients also self-medicate with CBD supplements.

When it comes to pain control interventions, Dr. Fassman cautions providers to be aware of unwanted side effects such as somnolence, confusion or even addiction. 

Dr. Fassman adds that clinicians should carefully weigh and balance non-clinical issues such as transportation challenges and large or repetitive copays when formulating an appropriate treatment plan that still prioritizes positive outcomes.


What strategies have you employed to prevent or address psychosocial issues during wound treatment? 


“I try to be direct and concise with patients who have chronic wounds,” says Dr. Fassman. “I will utilize phrases such as ‘It is essential, Ms. Jones, that you keep your appointment with me next week,’ or ‘It is critical you control your blood sugars in order to heal the wound and prevent you from losing your foot.’” 

Dr. Marmolejo relates that taking into account a patient’s psychosocial health is important and begins with a thorough assessment of a patient’s level of education, employment history, history of alcohol, tobacco and drug use, how the patient interacts with his or her social network, the patient’s knowledge and perception of how his or her comorbidities affect health, the patient’s goals of treatment and reasons for previous treatment successes and failures if applicable.1,2,5,7

Dr. Suzuki explains that he strives to be as empathetic and positive as possible during interactions with patients. He adds that close communications with primary care doctors and the patient’s family may also be helpful. Judicious use of antidepressant medications and help from psychiatry colleagues may also be worthwhile, maintains Dr. Suzuki.  


Do you have any interesting case examples from this population to share with readers? 


Dr. Suzuki shares a case of a woman in her mid-40s with chronic leg wounds over 10 years due to thalassemia (a genetic blood disorder that causes anemia), resulting in multiple hospital admissions. He notes the patient is clinically depressed and only presents for appointments every other week or so. He relates that he sees this in other patients that deal with chronic, lifelong diseases. While some of these patients manage reasonably well, Dr. Suzuki says others experience hopelessness and neglect their medical conditions.

Dr. Fassman relates seeing a recent patient with a chronic, plantar foot ulceration. As an attorney, the patient found it challenging to be able to offload appropriately as he had to be in court and meetings, etc. The patient unfortunately developed a limb-threatening infection, which required hospitalization a few days before a planned vacation out of the country. The patient adamantly expressed he was leaving for his trip “no matter what.” 

“I utilized phrases with him such as ‘You have a limb- and potential life-threatening situation if you take a long flight out of the country,’ and ‘It is essential you stay in the hospital where you will have the support and care necessary,’” emphasizes Dr. Fassman. While it took repeated efforts, Dr. Fassman notes the patient did eventually cancel his trip.

A frequent concern she hears from past students, residents and fellows, says Dr. Marmolejo, is how to discuss the situation with a patient when an amputation is required. Taking the potential negative aftermath out of this conversation is a talent honed with time, according to Dr. Marmolejo. 

“This conversation can be traumatic for the patient, causing a multitude of emotions, including aggressive and negative ones that may be provider-directed,” notes Dr. Marmolejo. “The provider must learn to give the patient grace, understanding and honesty, and not take the expressed emotions personally. Additionally, one must strive to understand the patient’s perspective and concerns in order to address him or her appropriately, building a relationship with the patient that facilitates the best functional outcome and quality of life.”  

Dr. Fassman is a Fellow of the American College of Foot and Ankle Surgeons, and a Certified Wound Care Specialist (CWS). A Diplomate of the American Board of Foot and Ankle Surgery, Dr. Fassman is in private practice in Colorado Springs, Colo.

Dr. Marmolejo is a clinical wound specialist with LifeNet Health and is a medical writer with Scriptum Medica. 

Dr. Suzuki is the Medical Director of the Apex Wound Care Clinic in Los Angeles, CA. He is also a member of the attending staff of Cedars-Sinai Medical Center in Los Angeles, CA. He can be reached at [email protected]


1. Beattie AM, Campbell R, Vedhara K. ‘Whatever I do it’s a lost cause.’ The emotional and behavioural experiences of individuals who are ulcer free living with the threat of developing further diabetic foot ulcers: a qualitative interview study. Health Expect. 2014;17(3):429-439.

2. Fejfarová V, Jirkovská A, Dragomirecká E, et al. Does the diabetic foot have a significant impact on selected psychological or social characteristics of patients with diabetes mellitus? J Diabetes Res. 2014:371938. DOI: 10.1155/2014/371938. Available at: Published March 25, 2014. Accessed April 13, 2020.

3. Vileikyte L, Rubin RR, Leventhal H. Psychological aspects of diabetic neuropathic foot complications: an overview. Diabetes Metab Res Rev. 2004;20 Suppl 1:S13-8.

4. Vileikyte L. Psychosocial and behavioral aspects of diabetic foot lesions. Curr Diab Rep. 2008;8(2):119-125.

5. Roukis TS, Stapleton JJ, Zgonis T. Addressing psychosocial aspects of care for patients with diabetes undergoing limb salvage surgery. Clin Podiatr Med Surg. 2007 Jul;24(3):601-610.

6. Kinmond K, McGee P, Gough S, Ashford R. ‘Loss of self’: a psychosocial study of the quality of life of adults with diabetic foot ulceration. J Tissue Viability. 2003;13(1):6-8, 10, 12 passim. Erratum in: J Tissue Viability. 2003;13(2):80. 

7. Iversen MM, Midthjell K, Tell GS, et al. The association between history of diabetic foot ulcer, perceived health and psychological distress: the Nord-Trøndelag Health Study. BMC Endocr Disord. 2009 Aug 25;9:18.