In a message dated 16/05/98 03:19:16 GMT, you write:

<< 1.  In debriding a diabetic ulcer, is it best to debride down to bleeding
 tissue?  How often is the optimal frequency of debridement?>>

Not if it's ischaemic. Neuropathic ulcers need thorough debridement and this
often causes bleeding. If there is no overt sepsis, use a tcc and need for
debridement will be reduced.
 
 >>2.  What is the best method of performing partial or total nail removal on
 hallux and lesser digit nails?>>

Not sure how to answer this one other than release the eponychium, free the
nail plate from the bed, cut the nail if partial and remove in a twisting
motion with Spencer Wells or artery forceps.
 
 >>3.  What are the various pros and cons of different types of foot soaking
 protocols?>>

For what ?
 
 >>4.  What is the best method to eliminate painful heel fissures caused by
 overly dry skin?>>

Rule out mycoses as this is a common cause. If positive treat topically or
with one week of Lamisil. If not, use CCS emollient from Pure Swedish, the
best on the market.
 
 >>5.  Which stretching technique is best to increase ankle joint
dorsiflexion?>>

Have the patient use the ADEAS, a stretching board available from Pilgrim
Technologies. Not only is this the most effective method I have used but it
can also be used for assessment. Alternatively, have the patient stand on a
bread board that is angled on books.
 
 >>6.  Does stretching of the plantar fascia work, and which methods work
best?>>

I do not know for sure. I have my patients do a traditional calf stretch with
the foot in an uncorrected position.
 
 >>7.  Do night splints work for plantar fasciitis, how well?>>

I know Tim Kilmartin has rejoined the mailbase although he may not pick this
up. He has recently performed a study looking at this issue. I believe he
found this to be a useful adjunct to other treatments with a positive benefit
in 70% of patients (correct me if I am wrong Tim).
 
 >>8.  How often do cortisone injections cause cortisone flare?  Which of the
 cortisone injectables cause less tendency toward flare?>>

I have only had two in the last 7 years although I do not administer loads of
injections but always advise my patients of the possibility. I wonder if it is
the longer acting ones eg Depo-medrone ?
 
 >>9.  What is the best way to conservatively treat painful hallux limitus
with
 orthoses and shoes?>>

If there is some motion (eg 45 deg plus) I usually mobilise the joint and 1st
ray and get my patients to repeat the exercise. I then provide orthoses
(simple to start with) that have a medial wedge 2-5 (to allow the first ray to
plantarflex) but situated beneath the mtpjs, not behind. If this does not work
and/or the limitation is worse, I use a shaft beneath the 1st mtpj which
extends to just proximal to the ipj of the 1st toe (used to be called a Dudley
Morton shaft). A rocker sole shoe is also useful in severe cases as are heel
raises if equinus is present, depending on the degree of limitation. Cortisone
has a role as an adjunct to treatment. I have one patient who has been helped
by a homeopathic remedy but I cannot remember the name.
 
 >>10.  How long and how frequently should overuse injuries of the foot and
lower
 extremity be treated with icing (or heat therapy)? >>

As long as the patient feels it is of benefit.

Short answers I know, but that's what I do.

Trevor Prior


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