How to treat Diabetic Foot Ulcerations

Diabetic Foot Ulcer Treatment Options - Orange County Southern California

Pressure accounts for 99% of why a diabetic foot ulcer occurs. 

Get rid of the pressure and the ulcer will heal.

(if there is an infection present or poor circulation the healing time will be compromised)

OPTION 1

Offloading

Diabetic Shoes
Felt pads
Total Contact Casting
Offloading Walking Boots
CAM Walker
CROW Walker
Wheel Chair

Topical medication - There are so many things that can go on, this is not the main treatment factor. Keep the wound clean. You can spend thousands of dollars on topical medication, if pressure remains then the ulcer will not close.


OPTION 2

Surgery

The goal of surgery is to change the forces around the ulcer and allow faster healing.

Some patients are not able to comply with the offloading treatment (Option 1). Be honest with yourself.

Walking from the bed to the bathroom without protection on your feet negates an entire day of offloading.

Just because you have diabetes does NOT mean you can not have surgery. Surgery is very safe in diabetics. Glucose needs to be closely monitored. Poor glucose control can increase chance of post operative infection.

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An ulceration should be getting smaller every week, every month.

If the size of the ulcer has not changed then the treatment protocol needs to be re-evaluated.

I hate to see open ulcerations for a prolonged period of time because it will increase a chance of bone infection, soft tissue infection, or even becoming septic.

For more information on treatment options please contact Dr. Gennady Kolodenker, DPM, AACFAS
Specializing in Limb Preservation in Orange County.

Pediatric Foot and Ankle Surgeon Orange County

Finding the right surgeon to treat the child's foot or ankle problems can be a daunting task.

Dr. Gennady Kolodenker specializes in foot and ankle surgery, trauma for children.

Does my child need foot or ankle surgery for a fractured bone? 

Children tend to heal fractures much faster than adults. Depending on the level of fracture displacement or angulation will determine the need for surgery. Some injuries can be treated with a simple cast.


I was told my child has a flatfoot. Do they need surgery?

Pes planus, or flatfoot deformity should first be treated by conservative means. Orthotics (over the counter or custom). Better shoes. Physical therapy.  If feet remain symptomatic, painful, then surgery is an option.

There are various surgical options to treat the painful flatfoot deformity that has failed conservative treatment.

Surgery should not be done on the asymptomatic flatfoot. There is no proof that surgery can be done to prophylactically treat future arthritis.


My child has clubfoot, do they need surgery? 

The best treatment for clubfoot is early casting. Sometimes the achilles tendon remains tight and will need to be released surgically. There are some kids that have a very rigid clubfoot and casting is not enough to correct the deformity. Surgery is a good option to release the tight ligaments and have correct foot alignment.


My child has an extra toe, what can I do? 

Polydactyly or extra toe syndrome is a common malformation. The extra toe can be easily removed in the operating room. I would advise to wait for the child to be at least 6 months of age.


My child has toes that are stuck together, webbed toes. What can I do? 

Syndactyly of the toes is treated by a plastic surgery technique to separate the toes. I would advise to wait till the child is at least 6 months of age. It is very difficult to do surgery on very tiny anatomy (before 6 months).

This surgery has very good success rate. Scarring in children is minimal, especially by the time they get older.


My child has an injury to the growth plate. What should I do?

There are various growth plate injuries. It is important to monitor the growth plate (via X-ray) and try to prevent early closure and angulation deformity.

Early treatment is important. Non weight bearing for a period of time might be needed. Periodic radiographs are advised. Sometimes a growth plate injury is not seen on a X-ray and an MRI might be needed for confirmation.  With ankle fractures a CT scan is useful to see all the broken pieces and surgical planning.


My child broke their toe. Should I tape it?

If the toe is not displaced then the typical treatment will be to buddy tape it to the toe next to it. An X-ray is the only way to know for sure if there is displacement or fracture of the toe.


As a child I had a clubfoot, my foot is now deformed. What can I do?

Typically an untreated clubfoot will result in significant deformity and arthritis. There are surgical techniques to fix to foot and make walking more comfortable.

For a surgical consult contact Dr. Gennady Kolodenker, DPM, AACFAS. Pediatric Foot and Ankle Surgeon

In Toeing - Femoral anteversion - Metatarus Adductus

A metatarsus adductus deformity is one that is isolated to the foot and has no other factors to alter the position of the foot.

When parents present their kids with in toeing or walking funny with their feet in it is important to evaluate the  entire lower extremity to rule out other causes of InToeing. Most kids are in fact very NORMAL.

 The position of the foot is based on Version of bones, capsular stretch/motion, muscle balance.

Torsion: Position of the foot relative to the body line. This can be external, internal or neutral

Version: Change in the bone structure, relationship of the proximal end to the distal end (Femoral head or neck in relation to the shaft)

Degree of rotation at the hip plays a large role in a toed-in gait vs a toed-out gait.

Increased Internal rotation at the hip (more InToed Gait) is called Femoral Anteversion.

There are no studies that show any nonsurgical intervention will speed up or change the gait pattern.

No treatment is needed in most kids.

Orthotics are INEFFECTIVE for Femoral Anteversion

If deformity is severe surgery is an option. Surgery does come with its own risks.

www.OCPodiatry.com

For more questions on in toeing or metadductus contact Dr. Kolodenker in Orange County. 

Hammer toe vs. Claw Toe vs. Mallet Toe

Picture is obtained from McGlamry's Comprehensive Textbook of Foot and Ankle Surgery.

Many people are confused about the difference of a hammer toe vs. a claw toe vs. a mallet toe.

Picture A is a Hammer toe.
- Flexion contracture at the Proximal Interphalangeal Joint. 
- Extension contracture at the Distal Interphalangeal Joint ( closest to the toe nail).

(Flexion - point to bottom of foot)
(Extension - point to the top of the foot)
   

Picture B is a Claw toe.
- Flexion contracture at the Proximal Interphalangeal Joint. 
- Flexion contracture at the Distal Interphalangeal Joint ( closest to the toe nail). 

Picture C is a Mallet toe.
- Flexion contracture at the Distal Interphalangeal Joint Only. 

OCPodiatry.com

 

Developmental Milestones in an Infant - Toddler, 3 months to over 2 years.

The information provided will be of education purpose for the parent. This is a rough guide to see when your child should hit their milestones. Do not be alarmed if they do it a little early or a little late. Please talk to your Pediatrician if you have concerns. 

Developmental Milestones 3-6 months

•       Rolling

–      Rolling supine to sidelying - 3 months (range 2-4 months)

–      Prone to supine -  5 months

–      Supine to prone -  6 months

•       Prone

–      Prone on elbows - 4 months (range 3-5 months)

–      Prone on extended arms – 5 months (4-6 months)

•       Crawling (commando) and pivoting in prone – 5 months

•       Supine hands to knees and feet 5 months (4-6 months)

•       Sitting

–      Propped sitting 5 months (range 5-6 months)

–      Ring sitting with full trunk extension and arms in high guard – 6 months (5-7 months)

Developmental milestones 7-12 months

•       Independent sitting – 8 months (7-9 months)

•       Quadruped and pull to stand – 8 months (range 7-9 months)

•       Creeping – 10 months (9-11 months)

–      Creeping versus crawling

•       Pull to stand and lowering self  - 10-12 months – average is 10 months

•       Cruising – 10 months (9-11 months)

•       Pull to stand through half kneel  - 12 months (11-13 months)

Developmental Milestones 12-18 months

•       Walking independently – 12 months (10-15 months)

•       Squatting to retrieve object from floor -  10-15 months

•       Creeping up stairs – 15 months (range 14-18 months)

•       Walking up stairs – 18 months (16-20 months)

•       Attempts to kick a ball – 18 months

•       Climbing 12-24 months

Developmental Milestones 2 years and up

•       Jumping from bottom step – 2 years old

•       Jumps two feet off of floor – 28 months

•       Kicks a ball 2-3 years old

•       Running 2-3 years old

•       Hopping on one foot – 3 years old

•       Galloping – 4 years old

•       Skipping – 6 years old 

Written by Lynda Kolodenker, PT, DPT

Hammer Toe Surgical Treatment

A hammer toe is a deformity of the toes. The toes can curl under or to the side.

To treat a hammer toe contracture surgically will have the most successful results if performed by an experienced surgeon.

Dr. Gennady Kolodenker performs hammer toe surgery in orange county california. 

There are different surgical options when it comes to hammer toes.

Do you want pins sticking out of your toes vs internal metal that stays in forever vs. no hardware at all.

The advantage of hardware is that it keeps the toe from drifting over during the healing process.

Pins are taken out in the office and as much as you think this hurts, It does not. A little uncomfortable, but tolerable.

Internal hardware for hammer toe surgery will stay in unless for some reason it bothers the patient. This hardware is very difficult to remove once the bones have fused together.

Hammer toe surgery is usually very successful and majority of patients are very pleased with the outcome.

Cosmetic hammer toe surgery is not advised. I would recommend considering surgery on the hammer toe only if there is pain.

My plastic surgical technique for hammer toe surgery places the incision to heal naturally and make it look like it is part of normal skin lines.

For more questions contact Dr. Kolodenker in Southern California.

Subtalar Joint Coalition Treatment in Orange County

Dr. Gennady Kolodenker explains the different types of Subtalar Joint (STJ) Coalition.

Sometimes also referred to as talo-calcaneal joint coalition.

Dr. Gennady Kolodenker is a Foot and Ankle Podiatry Surgical Specialist in Orange County.

The Subtalar joint is made up of 3 different parts. Anterior, Posterior and Middle.

The joint parts are called facets.

The Middle Facet of the STJ is the most common one to form a coalition.

Coalition can be Fibrous or Osseous.

A fibrous coalition means that there is a scar between the two bones where there should normally be normal cartilage.

An osseous coalition means that the two bones are stuck together by in-growth of bone.

Treatment depends on the patient age, pain level, and amount of arthritis.

Diagnosis starts with a physical exam and an X-ray. An MRI or a CT scan might also be needed.

For a consult on treatment of STJ Coalition in Orange County or Southern California please contact 
Dr. Gennady Kolodenker

Home Stretching Program for Clubfoot (Talipes Equinovarus)

Home Program for Clubfoot (Talipes Equinovarus) 

The following is a home exercise program that consists of basic information on club foot and on recommended stretching and strengthening exercises.  The goal is to help regain and maintain the necessary range of motion in your infant’s foot and ankle. Upon discharge from the hospital, it is recommended that you follow-up with a podiatrist or orthopedic surgeon regarding continued treatment who specialize in pediatric clubfoot.   

Range of motion: Recommend completing range of motion exercises at least three times a day.  The goal is to hold each stretch at least 30 seconds however it will depend on the infant’s tolerance.  You may need to slowly move your infant’s foot into these positions in order for increased compliance by your infant.  It also may be easier if you are either holding your infant or someone else can hold them.  

1.) Eversion at the talocalcaneal/subtalar joint  

- Starting position: Lay infant on back. 

 

- Place one hand on the lower leg just above the foot and the other hand around the heel bone. Gently push the heel bone outwards.  You want the foot and lower leg to be in line, do not go past midline with the heel.  Be careful not to overstretch this joint. 

  

          

2.)  Abduction of the talonavicular/calcaneocuboid joints (transverse tarsal joint)

 

- Starting position: Lay infant on back.  

- Place one hand on the heel and the other hand just in front towards the toes.  Gently press the inside of the foot (your hand closest to the toes) outwards.  Do not go past neutral with this stretch.

3.)    Ankle dorsiflexion (Talocrural joint) – only perform if you can achieve neutral alignment of the infant’s foot

- Starting position: Lay child on back.  This should be performed both with the infant’s knee flexed and straightened in order to stretch both the gastroc and soleus muscles. Make sure the foot and ankle are in line. 

- Place one hand on the infant’s lower leg to stabilize and place the other hand on either side of the infant’s foot.  Then gently apply an upward force.  

Alternate handling: Place one hand on your baby's flexed knee.  Grasp your baby's foot with the palm of your other hand placing your index finger above the heel.  Now you can gently flex the ankle up with a gentle downward force on the heel.   

Activation of lateral muscles and dorsiflexors – stroking :

-          Lightly move your finger along the top and outer border of your infant’s foot.  Allow your infant time to activate their muscles between each stroke. 

-          Perform this exercise 10 times.

Weight bearing through the foot and ankle for proprioceptive input :

-          This exercise should only be performed if you can achieve neutral alignment with your infant’s foot.

-          Place your infant either on their side with the foot you want to be weight bearing through on top or on their back.  

-          Provide 10 gentle compressions through your infant’s knee or lower leg. 

        

Please be aware that it is important not to overstretch your infant’s foot and ankle. If you are unsure or have any questions, please ask for assistance.  

Written by: Lynda Kolodenker PT, DPT, CNT

Will my insurance cover custom orthotics?

Custom foot orthotics will be covered by most insurance plans.

There are stipulations for obtaining coverage.

Have you met your deductible?

Some patients have a very high deductible. Let's just say your deductible is $900. Before the insurance will cover one single penny you must first pay out of pocket that $900.

On top of that there are rules about how much they will cover...100%, 80%, 50%?

Some will say you can have orthotics only if you are diabetic.

Some will say you can have orthotics for specific diagnosis. Each diagnosis has a ICD-9 Code
-Plantar Fasciits (728.79)
-Bunion (735.0)
-Hallux Limitus/Rigidus (735.2)
-Metatarsalgia (726.70)
-Norma (355.6)
-Illiotibial Band Syndrome (728.89)
-Knee Pain  (719.46)

How many pairs of orthotics can you have?
Most insurance companies will allow only one pair of orthotic. Sometimes you can get a new pair every year or every 2-3 years.

Best way to find out is call your insurance company. Get the name of the person you talk to along with a reference number. 

Ask them about custom orthotic coverage.

To have custom orthotics made here in Orange County please contact Dr. Gennady Kolodenker.
(949) 651-1202