Charcot‐Marie‐Tooth
The Role of Podiatric Medicine and Surgery in Treatment of theCharcot‐Marie‐Tooth Patient
September 14, 2011San Francisco, CA
Hal Ornstein, DPM, FASPSHowell, New Jersey
Reviewed and accepted by the 2011-2012 Neuromuscular Committee ofthe American Association of Neuromuscular & Electrodiagnostic Medicine Certified for
CME credit 10/2011 – 05/2020Reviewed 10/2017 by the 2017-2018 Neuromuscular Committee
What is Podiatric Medicine?
• Medical and surgical care and treatment of the foot and ankle
• Sub‐specialties include sports medicine, wound care, podopediatrics, podogeriatrics, reconstructive foot and ankle surgery, trauma, and the diabetic foot
Education of a Podiatrist
• Four year undergraduate degree required• Four years of podiatric medical school
(nine schools in the US)*** two‐part National Board while in podiatric medical school and another part upon completion of the podiatric medical school program.
• Two to four year residency (most are three years)
• Additional fellowship training
What is the licensing and certification process for D.P.M.s?
Two Major Certifying Boards in Podiatry
The American Board of Podiatric Orthopedicsand Primary Podiatric Medicine
The American Board of Podiatric Surgery
What is a D.P.M. (Doctor of Podiatric Medicine)?
Comprehensive health practitioner of the lower extremity that specializes
in the diagnosis and treatment of conditions effecting the foot, ankle and lower leg in all age groups
• Conducts examinations• Prescribes medications• Performs surgery• Academic appointments at university hospitals• Conducts translational research • Approximately 15,000 podiatrists in the US
Orthopaedic Conditions
• Plantar Fasciitis• Hammertoe• Bunion and bunionette• Osteoarthritis and Bone spurs
• Sports medicine related injuries
Onychomycosis
• Dermatophyte• Often seen with skin
manifestations• Usually acquired but may
be inherited• More treatable than in
the past• Differentiate from
Melanoma
Onychomycosis Treatment
• Debridement• Topical• Oral• Matrixectomy• Nail Biopsy for dermatopathology
Paronychia
• Erythema and edema of the ungual labia
• Wide or incurvated nail plate
• May drain serous to purulent exudate
• Hallux most effected
Paronychia Treatment
• Incision and Drainage• Oral antibiotics usually not
necessary• Longstanding infection may
require X‐ray• Chemical matrixectomy,
partial or total
Verruca Treatment
• Debridement is diagnostic and therapeutic• Chemocautery• Various topical treatments available• Oral Cimetidine for pediatric usage (30‐40Mg/Kg in 3 divided doses)
• Curretage
Plantar Fasciitis• Inflammation and pain of
the plantar fascia, usually at its insertion at the plantar medial tubercle of the calcaneus
• Becomes chronic in 5‐10% of all patients
• Is not necessarily associated with a heel spur
• Over 90% resolve with conservative treatment
Plantar Fasciitis Symptoms
• Weight‐bearing pain on arising• Pain subsides, returns with activity• Footwear related to pain?
Plantar Fasciitis Treatment
• Nocturnal Anti‐contracture Devices
• Orthotics• NSAIDS• Cortisone shot(s)• Rarely surgery
Hammertoe
• Digital Contracture• Usually PIPJ• May have MPJ dorsiflexion
• May have clavus• Pre‐ulcerative in patients with diabetes
Hallux Valgus
• Painful bump secondary to increase IM angle
• Poor biomechanics• Hurts in shoes• Usually bump pain vs. joint
pain• Wider shoes help• Orthotics slow or stop
progression and pain
Ankle ‐ Foot Orthosis
• Articulated hinge device• Used when functional orthotic fails or will fail
• For active patient that can tolerate motion
• Excellent for sports
Ankle – Foot Orthosis
• Gauntlet style for total control
• For patients that cannot tolerate motion
• Good for severe DJD and Charcot foot
Ankle Sprains and Fractures• Tear or stretching of the
ligaments of the ankle. Usually the ligaments on the outside of the ankle are involved.
• Caused by and twisting injury of the foot / ankle .
• Instability of the ankle can develop due to the ligament injury.
• Most often treated conservatively. Surgical repair can be performed to treat chronic ankle sprains.
Morton’s Neuroma
• Painful swelling of the interdigital nerve
• Most commonly seen in third web space
• Patients can feel numbness of adjacent digits and plantar pain
• Etiology is abnormal stretching of the nerve
Morton’s Neuroma Treatment
• Change shoe gear• Padding• Orthotic• Cortisone injection• 4% dehydrated alcohol injection for neurolysis
• Surgical excision
Diabetic ulcer
• Etiology is usually traumatic caused by shoes
• Bony prominence is usually involved (hammertoe, bunion, plantarflexed metatarsal, bone spur)
• Often start as a blister, corn or callous
Diabetic ulcer treatment• Always obtain serial X‐rays to rule
out osteomyelitis• Debride the wound to granular
bed• Remove hyperkeratosis• Gently probe wound for deep
sinus• Dress initially with Silvadene
cream• Consider other wound products• Consider offloading
Charcot Joint• Diabetic Neuroarthropathy• Often involves both
pathologic dislocation and fracture
• Usually effects midfoot, but all lower extremity joints are susceptible
• Foot is acutely edematous and warm
• Deformity is common
Charcot Joint Treatment
• Non‐weight bearing for 12 weeks
• Patient education is critical to outcome
• Serial X‐rays to document deformity
• Molded shoe often needed after coalescence
• Surgical Treatment
Therapeutic Shoes
• Newly diagnosed + 33% 1990’s
• Amputations + 28% 2000 ‐2001
• Medicare has stated that 50% of amputations were preventable
Therapeutic Shoes
• Focal pressure keratosis with accompanying risk factors are the major cause of ulcer.
• Patients who have regular, frequent foot clinic visits that include risk evaluation, debridement of lesions, prescription of appropriate shoes and patient education are less likely to ulcerate. 1
• 1 Sage RA, Webster JK, Fisher SG: Outpatient Care and Morbidity Reduction in Diabetic Foot Ulcers Associated with Chronic Pressure Callus. JAPMA 91:275, 2001.
The Role of the Podiatric Physician in CMT
• Palliative Care for callus/corn/keratoderma
• Professional shoe fitting/ education and modification
• AFO/bracing fabrication• Physical therapy• Surgical intervention for
recalcitrant deformity• Orthotics• Education for prevention
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Hal Ornstein, DPM, FACFASAffiliated Foot and Ankle Center, LLP
4645 Highway 9 NorthHowell, New Jersey 07731
732‐905‐1110 [email protected]