Dr Ricciardi is a specialist in caring for foot and ankle issues, especially those stemming from diabetes.
We treat all aspects of podiatric medicine including reconstructive foot and ankle surgery, sports medicine, trauma, diabetic foot care, limb salvage, and primary podiatric medicine.
At our office, you will receive the personal care and attention you would expect from a caring professional. You can expect an accurate diagnosis and successful treatment by our board certified Podiatrist. Below you will find a list of some of the different conditions we treat and treatments we provide:
Neuropathy is a term used to describe any problem related to the nerves. Most problems in the legs are considered peripheral nerve problems meaning the CNS is not involved but in the legs themselves. Sometimes the lower back can contribute to the pain or neurologic symptoms in the leg and acts as a “double” crush. Think of nerves as a garden hose and the spigot is the spine and at the end of the hose are the toes. Any kink or “crush” of that hose/nerve will cause some damage and there can be multiple crushes, which can make things more difficult to achieve a successful treatment outcome. Diabetics are more prone to neuropathy and should be monitored regularly because if there is loss of sensation this can lead to ulcer, infection and even loss of limb. Many cases of neuropathy are often called idiopathic. This term means that there is no known cause. In most cases, this is NOT the case. Usually, there is an entrapment or compression of the nerve(s). A nerve entrapment can be easily identified by a peripheral nerve surgeon, when present in the leg. Dr. Bregman and Dr. Ricciardi have been specially trained to diagnose and treat these problems. Many times other doctors will not be able to diagnose these nerve entrapments and often, special studies such as MRI or nerve conduction studies will not identify the problems. Also, if there is a history of carpal tunnel or arm nerve problems then it is more likely to be present in the legs.
Common sites of nerve entrapments in the legs:
Tarsal Tunnel – this is like carpal tunnel in the wrist. The nerves on the inside of the ankle become stretch and compressed. This can be aggravated by flat, or hyper-pronated feet. The medial calcaneal nerve is also present here and can be a problem.
Common Fibular Nerve – this is a nerve behind the head of the fibula near the knee. It is prone to entrapment and can also cause lower back pain and restless leg syndrome symptoms. Cramping in legs can also be present.
Superficial Fibular Nerve – this is a branch of the common fibular nerve that is in the anterior-lateral leg and extends over the ankle into the foot. It is often injured in sports or ankle fractures but can also be a problem in athletes.
Tibial Nerve – this nerve starts in the back of the knee and continues behind the calf muscles and eventually turns into the tarsal tunnel. Cramping is often present in the calf area.
Deep Peroneal Nerve – this nerve is present on the top of the foot just below the ankle and can often be a problem with shoes or if there is a spur present near it.
Saphenous and Sural Nerves – these are purely sensory and run on the inside and outside or the leg respectively. They can be injured during any surgery or injury.
Treatment if neuropathy/entrapments:
First, the proper diagnosis of the problem is made by a combination of the history, exam, and diagnostic testing. Many times there can be hormonal imbalances or other medical issues. Blood tests will often be ordered, and also a 3mm biopsy of the skin on the leg is often needed to rule out small fiber neuropathy, which is another kind of neuropathy. Diagnostic local anesthetic blocks are used to help isolate the involved nerves. In 70% of entrapment cases, surgical decompression is the treatment of choice in the other 30% they can respond to specialized physical therapy known as nerve gliding or nerve flossing. Topical prescription creams are also used to help with pain. In some cases, prescription vitamins are also prescribed as well as other medication to help deal with the pain of neuropathy. Most of the nerve surgeries are fairly quick surgeries and the patient is back to regular activity in a few weeks. Dr. Bregman is the only physician performing endoscopic tarsal tunnel surgery and teaches other doctors on the technique.
What Is a Bunion?
Bunions are very common foot deformities that affect the side of the foot and the largest toe. A large, bony bump begins to form along the foot at the joint at the base of the great toe—where it meets the long midfoot bone known as the first metatarsal. At the same time, your large toe begins drifting in the opposite direction, pressing into (or even crossing over or under) the second toe.
Do You Need Surgery for Bunion Treatment?
Not everyone with a bunion necessarily requires a surgical procedure. The main goal of bunion treatment is to eliminate pain and allow you to function normally. In some cases, this can be accomplished with conservative treatments designed to reduce pressure on the bunion and improve alignment. Topical and oral medications, changes in your footwear, and orthotics are all potentially effective options.
That said, conservative treatments will not cure your bunion. If you find that you are still experiencing pain, discomfort, or mobility limitations, it is probably best to get your bunion fixed via surgery.
There are many different types of bunion surgeries. The specific procedure or procedures used will be selected based on the severity of the condition itself, as well as any other considerations about your general health, personal goals, or activity level.
This procedure may be selected for simple bunions with relatively minor alignment issues. We make a small incision at the bump, then remove the prominence using a special saw or burr.
The surrounding capsule is cut and tightened in order to help maintain the correction. Because the surgery is less invasive, recovery is much quicker—most people are back in regular shoes within a month.
This is the most common procedure we perform. In it, the surgeon cuts through the first metatarsal bone in the shape of a sideways Z. This allows the bone to be realigned and repositioned in a more natural state. Any remaining “bump” will be removed and the repaired joint held in place with two to three screws.
The initial recovery period for this procedure usually lasts about 48 hours. After that, you will be in a walking boot for up to four weeks before you can return to wearing normal shoes.
Full recovery generally takes about 3 months. During that time, we may recommend physical therapy, laser therapy, splints, topical creams, or pain medications if they are necessary.
A fusion may be selected in the case of more severe bunions, or those caused by hypermobility at the joint between the first metatarsal and medial cuneiform bones (the TMT joint) in the middle of the foot. Here, the affected joint is fused to provide stability.
During the procedure, cartilage lining the TMT joint is removed. Bones are then straightened, and held together using appropriate hardware (such as screws, plates, and/or staples). Part of the bunion bump may also be removed, and the capsule surrounding the joint is cut to help maintain the corrected alignment.
Lapidus fusion requires a somewhat longer recovery, with up to 4 weeks of total non-weight bearing after the procedure using a knee roller or cam walker boot. Return to regular shoes may require 3 to 4 months, depending on swelling.
Additional Surgical Procedures
Sometimes, the surgeon may need to perform a secondary procedure alongside the main bunion surgery in order to provide the best outcome. The decision may need to be made at the time of surgery. These might include:
Akin Osteotomy—a small wedge of bone is removed from the big toe in order to allow it to lie straight. This may be done with a minimally invasive approach, or using traditional staple fixation.
Sesamoid Removal—the two tiny sesamoid bones act as “pulleys” underneath the big toe joint to help generate power. However, they often become dislocated as a result of a bunion. One of both may need to be removed.
Second Toe Surgery—sometimes, the surgeon will also need to correct a dislocated second toe or perform other surgical procedures as needed. The need for a second toe surgery may not be apparent until the actual surgery is in progress. Any such decisions are made with your best interests in mind.
Our doctors offer extensive experience, specialized training, and board certifications in complex foot reconstruction and fixation techniques. We are proud to report a 95% success rate with our bunion surgeries. Among those who get bunion surgery, fewer than 1 in 20 suffer a recurrence.
Why is it important and even life-saving?
Diabetes is a serious disease that can develop from lack of insulin production in the body or due to the inability of the body’s insulin to perform its normal everyday functions. Insulin is a substance produced by the pancreas gland that helps process the food we eat and turn it into energy. Diabetes affects approximately 23 million Americans and is classified into 2 different types: Type 1 and Type 2. Type 1 is usually associated with juvenile diabetes and is often linked to heredity. Type 2, commonly referred to as adult onset diabetes, is characterized by elevated blood sugars, often in people who are overweight or have not attended to their diet properly. Many complications can be associated with diabetes. Diabetes disrupts the vascular system, affecting many areas of the body such as the eyes, kidneys, legs, and feet. People with diabetes should pay special attention to their feet.
Of the 23 million Americans with diabetes, 30% will develop foot problems related to the disease. Diabetic foot conditions develop from a combination of causes including poor circulation and neuropathy. Diabetic Neuropathy can cause insensitivity or a loss of ability to feel pain, heat, and cold. Diabetics suffering from neuropathy can develop minor cuts, scrapes, blisters, or pressure sores that they may not be aware of due to the insensitivity. If these minor injuries are left untreated, complications may result and lead to ulceration and possibly even amputation. Neuropathy can also cause deformities such as Bunions, Hammer Toes, and Charcot Feet. It is very important for diabetics to take the necessary precautions to prevent all foot related injuries. Due to the consequences of neuropathy, daily observation of the feet is critical. When a diabetic patient takes the necessary preventative foot care measures, he or she reduces the risks of serious foot conditions. We at The Foot & Ankle Lower Leg Center have the latest treatment options for neuropathy. Dr. Bregman is the only Foot and Ankle trained peripheral nerve surgeon in Nevada.
Diabetes often leads to peripheral vascular disease that inhibits a person’s blood circulation. With this condition, there is a narrowing of the arteries that frequently leads to significantly decreased circulation in the lower part of the legs and the feet. Poor circulation contributes to diabetic foot problems by reducing the amount of oxygen and nutrition supplied to the skin and other tissue, causing injuries to heal poorly. Poor circulation can also lead to swelling and dryness of the foot. Preventing foot complications is more critical for the diabetic patient because poor circulation impairs the healing process and can lead to ulcers, infection, and other serious foot conditions.
Treatment and Prevention
Footwear and orthotics play an important role in diabetic foot care. Orthotics designed with Plastazote foam, the #1 material for protecting the insensitive diabetic foot, are usually recommended. Plastazote is a material designed to accommodate pressure “hot spots” by conforming to heat and pressure. By customizing to the foot, Plastazote provides the comfort and protection needed in diabetic footcare. Footwear constructed with Plastazote is also recommended frequently for the diabetic patient. Diabetic footwear should also provide the following protective benefits:
High, wide toe box (high and wide space in the toe area).
Removable insoles for fitting flexibility and the option to insert orthotics if necessary.
Rocker Soles designed to reduce pressure in the areas of the foot most susceptible to pain, most notably the ball-of-the-foot.
Firm Heel Counters for support and stability. If you are a diabetic, you should be particularly alert to any problems you may be having with your feet. It is very important for diabetics with neuropathy to take necessary precautions to prevent injury and keep their feet healthy. If you have diabetes and are experiencing a foot problem, immediately consult your foot doctor.
Foot Care & Diabetes
Proper foot care is especially critical for diabetics because they are prone to foot problems such as:
Loss of feeling in their feet.
Changes in the shape of their feet.
Foot ulcers or sores that do not heal.
Simple daily foot care can prevent serious problems. According to the National Institute of Health, the following simple everyday steps will help prevent serious complications from diabetes:
Take Care of Your Diabetes Make healthy lifestyle choices to keep your blood sugar close to normal. Work with your healthcare team to create a diabetes plan that fits your lifestyle characteristics.
Check Your Feet Every Day You may have foot problems that you may not be aware of. Check your feet for cuts, sores, red spots, swelling, or infected toenails. Checking your feet should become part of your daily routine. If you have trouble bending over to see your feet, use a plastic mirror to help. You can also ask a family member to help you. Important Reminder: Be sure to call your doctor immediately if a cut, sore, blister, or bruise on your foot does not heal after one day.
Wash Your Feet Every Day Wash your feet in warm, NOT HOT, water. Do not soak your feet because your skin will get dry. Before bathing or showering, test the water to make sure it is not too hot. You should use a thermometer or your elbow. Dry your feet well. Be sure to dry between your toes. Use talcum powder to keep the skin dry between the toes.
Keep the Skin Soft and Smooth Rub a thin coat of skin lotion or cream on the tops and bottoms of the feet. Do not put lotion between your toes, because this might cause infection.
Wear Shoes and Socks At All Times Wear shoes and socks at all times. Do not walk barefoot, not even indoors. It is extremely easy to step on something and hurt your feet. Always wear seamless socks, stockings, and nylons with your shoes to help avoid the possibility of blisters and sores developing. Be sure to choose seamless socks that are made of materials that wick moisture away from your feet and absorb shock and shear. Socks made of these materials help keep your feet dry. Always check the insides of your shoes before putting them on. Make sure the lining is smooth and there are no foreign objects in the shoe, such as pebbles. Wear shoes that fit well and protect your feet.
Protect Your Feet From Hot and Cold Always wear shoes at the beach or on hot pavement. Put sunscreen on the tops of your feet for protection from the sun. Keep your feet away from radiators or open fires. DO NOT use hot water bottle or heating pads on your feet. If your feet are cold, wear seamless socks at night. Lined boots are good to keep your feet warm in the winter. Choose socks carefully. DO NOT wear socks with seams or bumpy areas. Choose padded socks to protect your feet and make walking more comfortable. In cold weather, check your feet often to keep your feet warm avoid frostbite.
Keep the Blood Flowing to Your Feet Put your feet up when you are sitting. Wiggle your toes for 5 minutes, 2 or 3 times a day. Move your ankles up and down and in and out to improve blood flow in your feet and legs. DO NOT cross your legs for long periods of time. DO NOT wear tight socks, elastic, or rubber bands, or garters around your legs. DO NOT wear restrictive footwear or foot products. Foot products that can cut off circulation to the feet, such as products with elastic, should not be worn by diabetics. DO NOT smoke. Smoking reduces blood flow to your feet. If you have high blood pressure or high cholesterol, work with your healthcare team to lower it.
Be More Active Ask your doctor to plan an exercise program that is right for you. Walking, dancing, swimming, and bicycling are good forms of exercise that are easy on the feet. Avoid all activities that are hard on the feet, such as running and jumping. Always include a short warm-up or cool-down period. Wear protective walking or athletic shoes that fit well and offer good support.
Communicate With Your Doctor Ask your doctor to check the sense of feeling and pulses in your feet at least once a year. Ask your doctor to tell you immediately if you have serious foot problems. Ask your doctor for proper foot care tips and for the name of your local podiatrist.
This is a symptom of a problem with one of the metatarsal-phalangeal joints of the foot usually the 2nd but can be others or more. The joint will have more pressure on it for a variety of reasons but most commonly from an elongated metatarsal with or without a hammer toe. In many cases a bunion can be present which may or may not be painful but often needs to be addressed as well. This condition must be differentiated from a nerve entrapment or both can be present.
Conservative Treatment – this is focused on reducing the inflammation and pain with ice, Rx topical cream, laser and sometimes injections. Strappings can also provide temporary relief and can be done in the office at time of visit. Orthotics also can be effective at removing the load to the affected joint. Sometimes oral steroids can be given for 5 days or so. Shockwave treatment is also another option. In rare cases, a walker boot can be given. Avoid any high heels at all. You must apply ice 4x/day for 15 minutes at a time or it will not help. NO exercise till your pain is gone by at least 90%. Can swim anytime though.
Surgical Options – this will depend on what deformities are present on the foot when reviewing x-rays. The goal is to remove the forces on the joint. Commonly a shortening osteotomy of the affected bone(s) is carried out and fixated with a screw. In some cases, if a bunion is present, this will have to be addressed as well because the first ray must be functional to take the load from walking or running. If a hammertoe is present this must also be addressed and this can be done via minimal incision technique (MIS) or standard technique. Also very often one of the main contributors of this problem is a tight heel cord or Achilles. If significant enough this will need to be lengthened by endoscopic technique. Post Op recovery is typically 48 hours of elevation, ice, and no weight bearing. Then into a cam boot for 4 weeks followed by graduated weight bearing in a stiff shoe or sneaker. Full activity in 3 months.
When you think of arthritis you don’t always think of the feet or ankles. Most of us are aware of arthritis in the hands and knees. Well, arthritis does not stop at the knees.
What exactly is arthritis? By definition, it is an inflammatory process of a joint. Initially, the joint or joints can become swollen and the surrounding capsule can become inflamed. Over time the joint will start to break down because of the inflammatory process and the cartilage will deteriorate and eventually the joint can be bone on bone which can be very painful. There are really 2 types of arthritis:
1) Osteoarthritis – which is a breakdown of the joint due to injury or just wear and tear. It affects 10% of the population. In the foot or ankle, this is quite common and you see this in the older population or in athletes. Osteoarthritis is most common in joints that bear weight — such as the knees, hips, feet, and spine. It often comes on gradually over months or even years. Except for the pain in the affected joint, you usually do not feel sick, and there is no unusual fatigue or tiredness as there is with some other types of arthritis. Cartilage is a slippery material that covers the ends of bones and serves as the body’s shock absorber. As more damage occurs, the cartilage starts to wear away, or it doesn’t work as well as it once did to cushion the joint. As an example, the extra stress on knees from being overweight can cause damage to knee cartilage. That, in turn, causes the cartilage to wear out faster than normal. This also happens in the ankle and the big toe joints.
2) Rheumatoid arthritis and all other genetic types are the rest – This is more of an immune or inflammatory diagnosis and has many different types with RA being the most common. There are many more that can affect the body. Blood work is often needed to make the diagnosis and sometimes this does not even work. Gout also falls into this category as well and is an inflammatory arthritis that affects the joints due to a problem with protein synthesis in the body. Medication is often needed to treat the symptoms of Gout as there is no cure. Patients with Gout are more difficult to operate on because of the crystals that form in and around the joints.
Patients with severe deformity of their feet due to rheumatoid arthritis can achieve a pain-free foot and be able to wear regular sensible shoes with a forefoot reconstruction procedure. Often times the toes are mangled and the ball of the foot are prominent due to the deformities and breakdown of joints. We can reconstruct the foot and provide full relief of pain and provide you with a much better foot to walk on and wear shoes. Orthotics can also be a great adjunct or a standalone option for some patients.
We are experts in dealing with joint problems of the ankle and the foot. We use state of the art medical and surgical treatment to try and repair or salvage your joints.
In cases where the joints are too far gone, our physicians have been trained on all of the latest implants available in the foot and ankle. Not everyone is a candidate for an implant and careful biomechanical evaluation is needed in order to assess and make sure you are a candidate. The success rate of implants will vary from patient to patient but there is no guarantee that the implants will last forever and sometimes further surgery is needed.
This is arthritis of the big toe joint (metatarsal phalangeal joint) which is graded by it’s severity: Stage 1 – Mild arthritis with inflammation, swelling and some pain which is usually not constant. Stage 2 – Moderate arthritis with a limitation in the range of motion of the big toe joint and aggravated with activity and high heels. X-rays will show spurring and some loss of joint space. Sesamoids can be affected. Stage 3 – Severe arthritis with almost complete loss of joint space on x-ray and constant pain. Sesamoids are almost always involved. Stage 4 – No joint space.
Stage 1 – NSAIDS, Rx Topical Medication, Laser, ICE and Orthotics management. Stage 2 – Same as Stage 1 but if fails may consider injection of Amniotic fluid (insurance usually won’t cover this) Surgery in the form of a cheilectomy, which is a removal of the arthritis/spurs by removing it with surgical equipment. Not always definitive. Also may consider an osteotomy of the metatarsal or phalanx depending upon the structure of the foot. Stage 3 – Can try amniotic fluid injection but this will not cure it, may last for 6 months to a year. Can inject over and over if you like this treatment. Surgical-osteotomy of bone to shorten or lower with or without implant. Implant into one side of the joint or both. This is surgeon preference based on patient activity level and x-rays. Fusion is an option as well but this will cause permanent loss of motion to the joint but will relieve all pain in 95% of patients. Stage 4 – Fusion or Implant.
Post Operative Courses for Above Surgical Options:
Cheilectomy – 48 hours stay off foot and elevate and ice. PT. Dynasplint (medical device to wear at home covered by insurance) Then wear boot for 2-3 weeks, then back in sneakers till 6 weeks or so then regular shoes to tolerance. We recommend post op cold laser treatment to speed recovery. Topical pain meds. Osteotomy With or Without Implant – Stay off for 48 hours completely, elevate and ice. Wear cam walker boot for 4-6 weeks. PT and Dynasplint. Topical pain medication, cold laser therapy. Back in regular shoes around 8-10 weeks. Return to full activity around 3-4 months depending on activity level. Can swim or do stationary bike after 4-6 weeks. Implant – 48 hours ice and elevate, start walking in cam walker boot for 1-2 weeks then wear sneaker at 3-4 weeks will depend on swelling. Return to full activity in 6-8 weeks. Laser, topical cream and PT and Dynasplint post op.
A hammertoe is commonly mistaken as any type of toe deformity. The terms claw toe, or mallet toe, although technically different than a hammer toe, are commonly referred as such. The toe may be flexible with movement at the joints, or it may be rigid, especially if it has been present for a long time. With a true hammertoe, the deformity exists at the proximal interphalangeal joint only. The true mallet toe has its deformity at the distal interphalangeal joint only and more commonly causes a callous on the tip of the toe as pressure is placed there. The true claw toe is a combination of the hammer and mallet toe deformities and involves both joints of the toe. If the big toe (hallux) has a hammertoe, it is more commonly called a Hallux Hammertoe and may be treated somewhat differently than described here. Symptoms of a hammertoe are usually first noticed as a corn on the top of the toe or at the tip which produces pain with walking or wearing tight shoes. Most people feel a corn is due to a skin problem on their toes, which in fact, it is protecting the underlying bone deformity. A corn on the toe is sometimes referred to as a heloma dura or heloma durum, meaning hard corn. This is most common at the level of the affected joint due to continuous friction of the deformity against your shoes. A soft corn, or heloma molle, may also exist in the web space between toes. This is more commonly caused by an exostosis, which is basically an extra growth of bone possibly due to your foot structure. As this outgrowth of excessive bone rubs against other toes, there is friction between the toes and a corn forms for your protection.
Causes of hammertoes are usually structural in nature. Many times this is the foot structure you were born with and other factors have now made it so that symptoms appear. The muscles in your foot may become unbalanced over time, allowing for a deformity of the small bones in each toe. With longstanding deformity, the toe may become rigid. Sometimes one toe is longer than another and this causes a buckling of the digit. A hammertoe may also be caused by other foot deformities such as a bunion. Trauma or other surgery of your foot may predispose you to having the condition if your foot structure is altered. Prevention of a hammertoe can be difficult as symptoms do not arise until the problem exists. Wearing shoes that have extra room in the toes may eliminate the problem or slow down the deformity from getting worse. Sometimes surgery is recommended for the condition. If the area is irritated with redness, swelling, and pain some ice and anti-inflammatory medications may be helpful. The best prevention may be to get advice from your podiatrist. Podiatric care may include using anti-inflammatory oral medications or an injection of medication and a local anesthetic to reduce this swelling. When you go to your doctor, x-rays are usually required to evaluate the structure of your foot, check for fractures and determine the cause. The podiatrist may see you to take care of any corns that develop due to the bone deformities. They may advise you on different shoewear or prescribe a custom made orthotic to try and control the foot structure. Padding techniques may be used to straighten the toe if the deformity is flexible, or pads may be used to lessen the pressure on the area of the corn or ulcer. Your podiatric physician may also recommend a surgical procedure to actually fix the structural problem of your foot.
Surgery to correct for a hammertoe may be performed as an outpatient procedure at a hospital, surgery center, or in the office of your podiatrist. There are multiple procedures that can be used depending on your individual foot structure and whether the deformity is flexible or rigid. There may be a surgical cut in the bone to get rid of an exostosis, or a joint may be completely removed to allow the toe to lay straight. Sometimes when the joints are removed the two bones become one as they are fused in a straightened position. Many times one toe will be longer than another and a piece of bone is removed to bring the toes in a more normal length in relation to each other. Sometimes tendons will be lengthened, or soft tissue around the joints will be cut or rebalanced to fix the deformity. Angular corrections may also be needed. The surgeon may place fixation in your foot as it heals which may include a pin or wires. MIS Surgery for fixing of hammertoes: Dr. Bregman is the only surgeon who is performing this specialized surgery that does not use big incisions and has a much quicker recovery with almost no pain after surgery! (see before and after pics) He uses a special drill to do all of the surgery through a small incision near the toe and can do all the work needed underneath the skin.
Every day, millions of Americans are greeting in the morning by intense heel pain. As a matter of fact, more than half of the population will suffer from significant heel pain at least once in their lives. We’re not talking about ordinary aches and pains here, but shooting, stabbing, even knife-like sensations that linger and persist for days and weeks.
Although heel pain is extremely common, it is not a normal part of life. Your feet are designed to provide a lifetime of locomotion, and when heel pain gets in the way of daily living, you need to see an expert who can help you heal.
Causes of Heel Pain
Heel pain is not caused by a single condition, and usually can’t be traced to a single incident or injury. More likely, your heel pain is the result of multiple small traumas over time. Each step can place a force on heels equal to anywhere from one and a half to three times your own body weight. Days, weeks, even years of wear and tear from physically demanding occupations, athletic participation, and other activities will slowly build the pain and pressure.
This is the most common form of heel pain in adults. The most notable symptom is heel pain that feels worst with the first few steps of the morning, but gradually recedes over the next 10-15 minutes.
It is caused by stretching, tearing, and inflammation of the plantar fascia, a long ligament on the bottom of the foot that runs from the back of the heel to the ball of the foot. When the fascia is inflamed, it tightens and shrinks, pulling uncomfortably on the heel. (This may further cause a hook-shaped bony deformity known as a spur to form on the heel bone, though heel spurs are usually painless.)
Tarsal Tunnel Syndrome
You’ve probably heard of carpal tunnel syndrome of the hands and wrists. Tarsal tunnel syndrome is a similar condition involving the feet and ankles. There is a narrow, constricted space called the tarsal tunnel that must pass though the ankle, and this tunnel surrounds a major nerve. If the nerve becomes compressed, it can cause pain and tingling throughout the foot, but especially so in the heel. Unfortunately, it is often misdiagnosed as plantar fasciitis, which delays successful treatment.
Our own Dr. Bregman is one of the few podiatrists in the country fortunate to study with Dr. A. Lee Dellon of Johns Hopkins University, a nerve expert who developed groundbreaking techniques for surgical decompression of the tarsal tunnel (along with other nerves of the feet and legs). We can treat the condition endoscopically, which means a quicker recovery than through other means.
Other Heel Pain Conditions
Some other conditions we treat frequently include:
Adolescent Heel Pain
Heel Pain Treatment Options
The good news is that, 9 out of 10 times, conservative treatments like icing, stretching, and custom orthotics will help you ease the pain of plantar fasciitis, along with most other forms of heel pain. For tougher pain, we may prescribe more aggressive treatments, including:
Cortisone injections, which provide stronger pain relief to the aching tissues than over-the-counter medications.
Shockwave therapy. This advanced technology uses high-intensity pressure waves to stimulate injured tissues, which reduces pain felt by nerve fibers, increases circulation, and triggers stem cells to accelerate the healing process.
Cold laser therapy. The laser emits a beam of light tuned to a highly precise wavelength and intensity. At this frequency, the laser is able to penetrate deep into soft tissues to fight inflammation, improve blood flow, remove waste products, reduce pain, and stimulate tissue repair.
For most heel pain conditions, surgery is a last resort that is only rarely required, for the most severe cases. The exception is tarsal tunnel syndrome, which is usually best treated with a decompression surgery.
It is critical to understand that not all heel pain is created equal. Even if the symptoms seem the same, the causes may be very different. Each case needs to be fully evaluated by an expert in order to ensure you get the most effective treatment.
We pride ourselves on offering the most advanced technology and techniques for our patients. Medicine is constantly evolving, and we work hard to stay on the leading edge of the latest research, so we can help you get back on your feet as quickly and painlessly as possible.
Here are just a few of the state-of-the-art tools and procedures we’re putting to use for our patients every day:
LunulaLaser® Treatment for Fungal Nails
Electrical Nerve Stimulation for Neuropathy
Endoscopic Tarsal Tunnel Decompression
Weight-Bearing CT Scanner
Minimally Invasive Surgery
In many ways, kids’ feet are very different from those of their parents. Softer bones, growing bodies, congenital deformities, and other factors mean they face very different challenges (and often require very different treatments) from adults.
There are advantages to this situation—kids generally recover quickly from injury, and some conditions may spontaneously improve without much treatment at all. However, since kids have their whole life ahead of them, it is extremely important that any foot conditions that could cause developmental issues or complications later in life are addressed immediately.
Do your child’s feet look strange or out of place? Are they experiencing any pain? Are they exhibiting strange walking gaits or behaviors? If so, make sure you bring them to the pediatric foot care experts at Foot & Ankle Specialists of Nevada.
Common Child Foot Pain Conditions
Although far from a comprehensive list, some of the most common pediatric conditions we treat include:
Intoeing / Pigeon Toes. Your child walks with toes that appear pointed inward, and may also sit in the “reverse W” position. This condition may be caused by an inward rotation in the foot bones (metatarsus adductus), shin bones (tibial torsion), or hip bones (femoral anteversion). Some cases of intoeing may correct spontaneously without treatment, while others may require treatments such as physical therapy and orthotics.
Flat Feet. Due to soft and flexible bones, children commonly have a flexible flat foot in which the arch “collapses” under body weight but returns in other circumstances. Most of the time, this corrects itself eventually. However, there are other congenital flat foot conditions (both flexible and rigid) that will not self-correct and will require treatments such as orthotics, stretching, physical therapy, or surgery.
Toe Walking. An overly tight Achilles tendon or other developmental issue may cause your child to do most of their walking on tiptoes. If this continues to happen beyond age 2, your child should be evaluated. More serious treatment remedies (including physical therapy and potentially surgery) may be indicated if the problem persists until age 5 or 6.
Heel Pain. Young adolescents, usually from about age 9 to 14, are especially susceptible to a heel pain condition known as Sever’s disease, or calcaneal apophysitis. At this age, the relatively soft growth plate of the heel bone is exposed and growing rapidly. This combined with a high level of physical activity may lead to swelling and irritation in the growth plate. Most of the time, this can be treated conservatively.
Ingrown Toenails. In this condition, the corner or edge of a nail grows in rather than out, digging into soft flesh. This may produce pain or even an infection. Recurring ingrown toenails in kids is generally evidence of a genetic predisposition. We will remove the ingrown edge and then perform a chemical destruction of that part of the nail root. This keeps the problem from returning, and the procedure both has a high success rate and is usually not painful.
Warts. Kids often develop warts on hands and feet, due to underdeveloped immune systems. Sometimes warts go away on their own, but if your child’s warts are causing pain, embarrassment, or have lasted for at least 6 months, they should be treated. We offer a range of options, including topical acid therapy, laser treatment, or sometimes oral medications. Deep, painful warts may need to be excised surgically.
Every physical activity carries with it a certain degree of risk. Because they’re not only responsible for supporting your entire weight but also powerfully propelling running strides, jumps, and cuts, feet and ankles are especially endangered.
Whenever your experience an injury in your lower extremity, make a point to see the team at the Foot & Ankle Specialists of Nevada. These incidents take away your ability to play, work, and move the way you want to, and ignoring them almost always makes the problem worse in the long run.
Injuring Your Feet and Ankles
Broadly speaking, there are two main types of foot and ankle injuries: traumatic (or acute) injuries, and overuse injuries.
Acute injuries happen in an instant—a big hit, a sudden stumble, an unfortunate hyperextension—and result in immediate (and often severe) pain and damage. On the other side, overuse injuries slowly build up over time, and dozens or hundreds of tiny impacts, stresses, and wear and tear weaken muscles, soft tissues, and bones.
Common causes of foot and ankle injuries include wearing improper shoes or equipment, rapidly changing your workout routine or increasing mileage/difficult too quickly, and not taking enough rest time between workouts.
Some of the most common injuries in this category include:
Ankle sprains. The most common sports injury, sprains occur when ligaments supporting the ankle joint are stretched or torn. Prompt medical attention is required, as a sprain that heals improperly may result in chronic pain and weakness.
Achilles tendon ruptures. A partial or full tear of the Achilles tendon may be accompanied by a popping sound, along with immediate (and usually severe) pain. The tear usually occurs a few inches above the tendon’s insertion into the ankle, which is the weakest point. Healing and rehabilitation, unfortunately, may require some time.
Bone fractures. Partial, complete, or complex breaks in bone may occur after a severe sprain, high-impact injury, or auto accident. Sometimes, you may not even realize a bone is broken if the fracture is relatively stable. Common symptoms include swelling, blisters, bruises, and an inability to bear weight.
The following are among the most common “wear and tear” injuries of the feet and ankles:
Heel pain. Many different conditions can cause heel pain, including plantar fasciitis, Achilles tendinitis, and others.
Ball of foot pain / metatarsalgia. Although the heel is more common, stress and pain may be located more toward the middle or front of your feet instead.
Stress fractures. When soft tissues in the feet wear down, more and more impact forces get transferred directly to the bones, especially the metatarsal bones in the middle of the foot. This can lead to the formation of thin cracks in the surface of the bones called stress fractures.
Sports Injury Treatments that Work
Regardless of the type, location, or severity of your foot or ankle injury, our doctors are exceptionally qualified to diagnose and treat it. With a wide range of treatment options, spanning traditional conservative remedies to advanced technologies and state-of-the-art surgical techniques, our team will help you get back on your feet fast.
Tried-and-true treatments like rest, icing, compression wraps, elevation, stretching, and others still have their place in sports injury recovery, and are often part of a comprehensive treatment plan. In fact, they may even be sufficient on their own for minor injuries.
For tougher pain or more serious damage, we can provide a range of more aggressive (but still conservative!) treatments, including custom orthotics and technologies like laser and shockwave therapy. These cutting-edge options are often a great alternative to surgery, which is reserved only for the most serious cases.
Learn about LunulaLaser® Treatment
Toenail fungus infections can be extremely unsettling and embarrassing, but they’re a lot more common than you might think. In fact, the American Academy of Dermatology estimates that about 12% of Americans are affected, with older adults especially likely to carry the pathogen.
Traditional treatments for fungal nails are spotty at best, and carry a risk of potentially serious side effects. However, cold laser therapy has dramatically improved the situation, and treatment is now much safer and boasts much higher success rates.
Do I Have Fungal Nails?
At the earliest stages of a fungal nail infection, you might notice a single whitish or yellowish mark under the tip of your toenail, or small ridges forming on the nail plate. As the condition worsens, symptoms include:
Discoloration (typically anywhere from off-white and gray to yellowish or brownish)
Thickening of the nail
Ends of the nail becoming crumbly, ragged, or flakey
Severe warping or distortion of the nail shape
What Causes Fungal Nails?
Toenail fungus is caused by dermatophyte fungi—the same microorganisms responsible for athlete’s foot, ringworm, jock itch, and other common skin conditions. If you have athlete’s foot, the fungi can sometimes get underneath the nail through tiny cracks or cuts. It’s also possible to spread the fungi from person to person through indirect contact with infected surfaces—gym or pool floors, towels, even salon tools.
Zap Your Fungus with Laser Therapy
At Foot and Ankle Specialists of Nevada, advanced cold laser therapy is the treatment of choice for fungal nails, although we still offer older methods like oral and topical antifungal medications. It offers many advantages over previous procedures.
How It Works
The beams of light generated by the laser are tuned at a precise wavelength, power, and frequency that allows them to pass through the nail plate and attack the fungus underneath—all without harming your own cells. This makes it both highly safe and highly effective as a method of treatment.
One laser session requires about 30-45 minutes, though times can vary depending on how many toes are being treated and how severe the condition is. No anesthetic is required and you should not feel any pain or discomfort. Once the session is over, you can go right back home or to work—no down time. Some patients may only need a single treatment; however, as many as four treatments might be necessary to fully eradicate the fungus.
Once the fungus has been eliminated, a new, healthy, clear nail will grow out it its place. Although you will likely see some level of aesthetic improvement very quickly, it may take several months for the portion of the nail that has already been damaged to grow out and away.
Advantages Over Traditional Treatments
Compared to antifungal medications, laser treatment is:
More effective. Cure rates for oral antifungals hover around 50-70 percent, and may be less effective in older patients or those with low circulation. Topicals are even less effective, since the medicine can’t really penetrate the nail plate. Laser treatment has provided much better results.
Safer. Oral medications in particular carry a risk of side effects, including liver damage and failure. Some people tolerate them well; others do not. There are no known side effects or health risks with laser therapy.
More convenient. A typical oral antifungal treatment regime requires 6-12 weeks of daily pills. Topicals may require up to a year of daily application, alongside thinning of the nail on a weekly basis. Laser requires just 1-4 sessions of 30-45 minutes.
Podiatric surgery involves procedures both simple and complex: hammertoe to tendon repair, skin biopsy to ankle arthroscopy, bunion correction to flat foot reconstruction. Surgery is often necessary treatment for relief of many painful foot deformities and traumatic injuries. Our surgeons educate you to make an informed decision. Minor procedures may be performed in the office mini-surgical suites depending on the complexity of the procedure.
Digital X-rays are the most advanced way to assess injuries. Our in-house digital X-rays provide thousands of details from a single image, allowing for accurate diagnosis and detect changes of existing complications. This advanced digital technology allows us to measure a patient’s progress and post-surgical follow-up evaluations as well as secure prompt transfer of the images in real time. This means reducing the chance for misdiagnosis, quicker treatment and eliminating the need to go elsewhere.
Diabetic Management, Transitional Surgical Care, Preventive Foot Care, Physical and Occupational Therapy Support. We customize programs to meet each patient’s unique circumstances by matching the patient with the right specialty professionals, such as physical therapist, when necessary. Patients in our prevention and rehabilitation care are continuously screened to identify their level of risk, need for education, specialized footwear as well as skin and wound care. All patients receive instruction regarding skin care, warning signs, and daily foot care.
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