• 4502 Riverstone Blvd, Texas 77459 , US
  • Mon - Fri 8.00 - 18.00. Saturday & Sunday CLOSED

Fully Equipped Clinic

State-Of-The-Art Facilities and Utilises

Get Fast Result

Satisfied Patients

Personalised HealthCare Service

Quality Diagnostic Treatment

Category Archives: Insights

Early signs and symptom of Diabetes : Foo

Spotting Diabetes (Mellitus) Early: Signs and Symptoms

There are signs that let you know if you have diabetes mellitus and give you a chance to start treatment early before things get too detrimental. These signs depend on what kind of diabetes mellitus you might have. Diabetes means “excessive urination” and mellitus means “honey”, these two words together means “sweetness in urine” or in other words “sugar/glucose appearing in urine”. There are many forms of diabetes mellitus that are due to different causes.

Diabetes may be primarily—caused by another disease, or secondary—caused by damage of the pancreas by another disease. Approximately 98% of diabetes patients have primary diabetes mellitus, the idea behind this article is to help learn about the two kinds of primary diabetes: Type 1 and Type 2 diabetes.

Insight and self-consciousness, makes it mainstream to ponder the wholeness of our health. There is an abundance of social media influencers advertising “eating plan” and “exercise regimen”. Lifestyle apps that keep you healthy by reminding you to drink water, recommending what best to eat and at what time and ensuring you have enough breaks during the day.

Considering all these general mindfulness being the “in thing” in our society, it is alarming to see that so many people don’t understand the inner workings of their own bodies. So many people go through everyday life,  experiencing the symptoms of diabetes but take it as a normal occurrence because a large number of the symptoms do not present as dangerous on their own, and that in itself is its danger. Understanding and recognising some early symptoms of diabetes can help us understand when we need to seek some form of medical consultation.

Early Symptoms Of Diabetes

The most common signs of diabetes mellitus (both type 1 and type 2) are frequent thirst, excessive urination and increased hunger. The excess glucose (sugar) in your blood that isn’t absorbed into your body due to diabetes is diluted by water and gotten rid of by the kidneys. This is the reason for frequent urination.

Because a lot of water is accompanying the glucose on the way out, the body gets dehydrated. You become thirsty and drink a lot of water to replace what was lost. Basically, glucose and other nutrients and food groups necessary for daily life from your everyday meals. Because there is now less glucose in your body (it has been flushed out), you start to feel hungry and crave food to compensate for the lack.

This leads to a cycle of always eating and drinking without actually getting any of the benefits. Controlling your blood glucose levels and keeping them optimal makes it possible to live life normally, eating and drinking whenever you wish without a condition forcing you to.

It is sad to see that these symptoms are so often written off as ‘normal’, but it is understandable. A busy person will not think thirst or a little nausea is a big deal, and even the more severe symptoms closely resemble the symptoms of a common cold or flu that goes away on its own after some days of rest and many bowls of chicken soup.

Not enough people realise that all these signs are hinting at the body’s inability to absorb glucose, which is caused by a lack of or resistance to insulin—the hormone that transports glucose to where it’s needed. To be on the safe side, if after being sick your thirst still lingers, a visit to the doctor should be the next thing on the list. One single blood test can clear years’ worth of doubt.

The human body extracts glucose from food to use it as fuel. Every process in the body requires it, like how a car needs gas to run. The cells, tissues and organs get the glucose that’s digested in the stomach after it has been transported out by insulin. Therefore, without insulin, there would be no energy for you to do work. The body would stop functioning properly.

The unique combo of continuous thirst, frequent urination, and sudden weight loss are key signs of an increased amount of glucose in the blood. These three symptoms are common in both type 1 and type 2 diabetes. Type 1 and Type 2 diabetes are different branches of the same disease. They are both caused by problems regarding insulin.This difference between the two types is the reason why the rest of the symptoms begin to vary after the early stages.

In Type 1 diabetes, the pancreas does not produce enough insulin to transport all the glucose you eat to where it is needed, so the rest remains in the blood.

In Type 2 diabetes, the pancreas produces enough insulin but the body does not recognise it so it cannot use it, and that causes the glucose to remain in the blood.

Symptoms Of Type 1 Diabetes

Type 1 diabetes happens suddenly and at any age in life—but usually it occurs before the age of 40. It happens when the pancreas stops secreting insulin. It is caused by degeneration of the cells of the pancreas, damage to the pancreas due to autoimmune diseases, congenital disorder of pancreas cells or destruction of those cells by viral infection.

what is dka (diabetic ketoacidosis)?
Diabetic Ketoacidosis)?

When it occurs in infancy or childhood, it is called ‘juvenile diabetes’. It can take weeks or months for the pancreas to completely stop secreting insulin, but eventually a normal, healthy person will become insulin-deprived and their glucose levels will shoot up to dangerous levels. A patient with Type 1 diabetes will become dependent on insulin injections for treatment so Type 1 diabetes is also called Insulin-dependent diabetes mellitus (IDDM).

Since the body can’t access the glucose in blood, it begins to find alternate sources of energy and starts breaking down fat and muscle. The end products of this are ketones (ketoacids).

The abundance of these acids makes the blood more acidic and leads to acidosis. This will cause fatigue, lack of appetite and confusion.  

When the ketone level in your blood is very high, your heart will begin to beat faster and your breathing rate increases. Your breath will have a sweet, fruity smell because of the many ketones present in the bloodstream—and at this stage the amount would have reached a life-threatening level that can cause unconsciousness.


Symptoms Of Type 2 Diabetes

Type 2 diabetes is caused by a partial deficiency of insulin caused by the body’s cells not being able to receive the hormone even after it has been produced. It is the more common type of diabetes and usually occurs after the age of 40. Only a few forms of it actually required insulin as treatment. It can be controlled by taking oral hypoglycemics (drugs that make the body more receptive to insulin/increase insulin production). Because of this, this type of diabetes is also called noninsulin-dependent diabetes mellitus (NIDDM).

Insulin Resistance can be caused by genetic factors, stress or lifestyle changes. Examples of these lifestyle changes are bad eating habits and lack of physical activity that leads to obesity. Physical activity helps a person burn glucose and makes their body more sensitive to insulin while being overweight increases insulin resistance (scientists aren’t completely sure why).

A patient with Type 2 diabetes does not need insulin in the beginning because the pancreas overproduces to compensate for the unreceptive cells—this is the reason why Type 2 diabetes often goes unnoticed for years. But eventually, the pancreas isn’t able to keep up and the glucose builds up in the blood even with insulin being constantly produced. Eating healthy, cutting back on sweets and losing excess weight helps control the glucose levels in a person with type 2 diabetes. Early treatment positively impacts and maintains a good quality of life.


Complications Of Diabetes Mellitus

Diabetes Foot

Prolonged hyperglycemia (high blood glucose levels) damages the retinas of your eyes (which spoils your vision). When caught early, this condition is manageable, but if left untreated, Diabetic Retinopathy will cause permanent damage to the retina of the eyes. Not only this, high glucose levels can damage the kidneys (Diabetic Nephropathy) and nerves (Diabetic Neuropathy) of the body as well as hypertension and heart attack.

A person with diabetes is more prone to getting fungal infections, and when they are infected it is quite hard to treat. Yeast grows from sugar and is naturally occurring in the body but when too much yeast accumulates it causes pain and itching. It grows in moist and warm places like the mouth, the folds of the skin, the genitals, the eyes and the foot (especially the toenails).

Without treatment, such infections can lead to blindness or become life-threatening when the yeast manages to get into the bloodstream of a patient who has a depressed immune system and spreads to other parts of the body.

The high blood glucose also causes slow wound healing due to lack of energy and the neuropathy of the nerves will prevent you from feeling pain sensations, so a lot of tiny wounds become ulcers and if left untreated can cause problems later on.

For this reason, it is always good to pay close attention to the state of your body and catch these signs and symptoms before they progress too far and become deadly. Early intervention and correction of elevated blood glucose can promote proper circulation and healing while preventing the onset of all these complications.


Juvenile Diabetes:

Young children aren’t able to properly convey the changes that occur in their bodies due a lack of understanding or communication skills. Because of this, it’s hard for parents to tell whether their children are suffering from Type 1 diabetes, especially since the symptoms are so easy to miss—being very hungry and very thirst are easily noticeable signs but these are also just the normal behaviours of growing children and shouldn’t be a cause for alarm. 

The following are some behaviours observed in children with Type 1 diabetes:

  • Getting yeast infections (thrush).  
  • Acting out of character. Being moody or restless. Having mood swings. 
  • Losing weight despite having frequent meals.
  • Feeling tired, dull and lacking strength to play.
  • Peeing more, or even wetting themselves despite having been toilet trained.
  • Having a sweet smelling breath

If while watching their children grow, parents notice any of these symptoms of elevated blood glucose levels in their infants, toddlers or young children they should immediately seek their pediatrician’s guidance.

Type 1 diabetes can strike at any age. The sudden pause in Insulin production leads to a rapid rise in glucose levels which can quickly become Diabetic Ketoacidosis (DKA). Catching these signs early can ensure that insulin is given promptly and the quality of life is preserved. 


When to See a Doctor

The symptoms of diabetes in the early stages can easily be confused as a minor illness, so it can be hard to pinpoint exactly whether you, or someone you care about, has it. But that’s okay.

If you are want to confirm whether what you have been experiencing could have been diabetes, you can ask yourself these questions:

  • After getting a cold or the flu. Do you recover quickly? Do you still feel sick?
  • Have you noticed any cuts and grazes that seem to be taking longer than usual to heal?  
  • Do you experience numbness and tingling in your hands or feet? Is this a recent development or a long term condition?
  • Have you always wrestled with yeast infections, or are recurring infections a new struggle?
  • Have you noticed weight loss you can’t explain? Are you overweight?
  • Have you felt thirstier, or found yourself drinking more than usual in recent weeks or months?
  • Have you noticed any changes in your vision?


Catching It Early Makes All The Difference

If you are concerned about your health, visit your physician and tell them your concerns. A simple test strip or lab draw, can supply you both with a wealth of information about if necessary, treatment can be started. Early diagnosis and treatment by a professional makes all the difference between managing your condition and having to suffer unknowingly.

Since 2012, our goal at mySugr has always been to make diabetes suck less for people within the diabetes community.  We have long endeavored to educate, advocate, and elevate the global working knowledge of living life with both type 1 and type 2 diabetes to the fullest. Utilizing our combination approach of sound coaching and advancing tech, we’ve made huge strides at creating an environment that lets all people with diabetes maintain optimum health while living their best life!


Diabetetic And Unaware

According to the World Health Organization (WHO), the number of people with diabetes rose from 108 million in 1980 to 422 million in 2014—”About 422 million people worldwide have diabetes, the majority living in low-and middle-income countries, and 1.6 million deaths are directly attributed to diabetes each year.”

According to the American Diabetes Association, in 2018, 10.5% (34.2 million American adults) of the American population had diabetes. 24.8 million were diagnosed and 7.3 million were undiagnosed. And 1.5 million Americans are diagnosed with diabetes every year.

This means that right now millions of people walking around with a dangerously high amount of glucose in your blood, experiencing complications and receiving no treatment for them. We hope that everyone reading this gains an understanding of diabetes, whether they have it or not.

We know that it is improbable to reach everyone, but if you can help spread awareness and educate those around you on the symptoms of early stage diabetes, that means an increased awareness in your community, which can reduce the number of undiagnosed diabetic patients in your direct environment.

If you have a family member or relative who has been diagnosed as being diabetic, to be on the safer side, you should visit your doctor to discuss the possibility of being at risk. A bi-annual blood test can provide a constant baseline for your doctor to monitor for any unusual increase in blood sugar levels. 


Dr. Babajide Ogunlana

If you or your child struggle to maintain a healthy weight, ask your doctor and/or your child’s pediatrician for pre-screening and lab work to look out for early signs of diabetes. By working hand in hand to achieve optimum health, you and your medical team can be proactive partners in warding off any symptoms of diabetes before they begin to damage peripheral systems.

If you or your child have other genetic factors (such as other auto-immune conditions), you should ask your doctor for pre-screening lab work to rule out any signs of diabetes. Auto-immune conditions tend to breed additional auto-immune conditions. Still, by creating a team-work approach to full-body care, you can provide a protective screening system that stands sentry against the early warning signs of diabetes. In this way, you can begin any treatment at the earliest possible opportunity and set the stage for successful long-term health.




African Women’s Health Project International #AWHPI – Fight Cancer Global.

Join Dr. Babajide Ogunlana this month of October, on the African Women’s Health Project International #AWHPI in collaboration with Fight Cancer Global. AWHPI 2020 Learn Pink Breast Cancer Awareness campaign initiative for the entire month of October. Throughout the month of October on each Monday, we will be disseminating vital information via all our Social Media platforms, and will be making and sharing videos relating to the fight against Breast Cancer. Additionally, we are showcasing our AWHPI Learn Pink Breast Cancer Awareness campaign Champions.
We are delighted to have the partnership collaboration of Fight Cancer Global – the leading global corporation on the fight against Cancer with operations in over Sixty Countries worldwide!

We are delighted to showcase our AWHPI Learn Pink Breast Cancer Awareness Champions FOUNDERS here…

foot odour

Foot Odour and Smelly Feet

The feet actively supporting the rest of the body, tend to be covered up all day. Thereby restricting the follow of air that helps reduce sweat and decrease bacteria activity on the feet.  Which can cause the feet to smell worse than other parts of the body. Smelly feet and foot odour can become problematic and if not treated accordingly leads to not only embarrassing moment, but affect your self confidence and freedom to wiggle those feet of yours

At one point in time we all tend to sweat and perspire on the feet  due to several reasons like those listed below. When these sweat itself can not evaporate then it leads to smell or stinking feet. This is usually caused by skin bacteria breakdown and secretes. Fungal infection, such as Athletes’ feet and other factors listed below can cause foot odour. 

To help prevent this condition of smelly feet or foot odour at the office, during sport practice, at your loved ones home or just simply stretching your feet out at garden or when having a picnic at the park. Dr. Babajide Ogunlana has a few tips: 

  • Avoid  the use of shoes that are tight to the feet as this can help reduce heat that makes the feet sweat and feed the growth of bacteria. Doing this also helps to avoid you developing conditions such as  bunions, toes fungus and corns and callus.
  • Clean your feet regularly with soap and water at least once a day and more if you do rigorous activities such as exercising, running , sport and walking. Take your time to dry your feet thoroughly afterwards, especially between your toes.
  • Have an extra pair of shoes so that you can rotate your shoes daily. This will give them a chance to air and dry at least 24 hours before the next wear. You can use Clean Sweep an antimicrobial Shoe Protection Shield, clinically proven to inhibit the growth of odor-causing bacteria, fungus, and mold. In your shoes at the end of the day after wearing them. Antiperspirant spray  or deodorant can help your feet stay dry or the use of foot powder to absorb sweat from your feet.
  • Use wool or cotton socks  preferably  and not nylon,  as they help to  absorb moisture better. Change your sock at least once a day, use sports socks and medicated insoles that are made to keep feet dry, and special antibacterial socks, which have a deodorising effect for your feet and shoes.
  • Avoid going barefoot in public space and communal facilities like gyms, bathing places and swimming pools. It is very easy to pick up germs, such as bacteria, fungus, and warts
  • Wear flip flops and when practicing yoga, clean your feet with antiseptic wipes or hygienic baby wipes in case you don’t have access to a shower right after class.
  • Good foot hygiene is essential , keep toenails trim and clean and remove callused skin with a foot file. Get a foot soak like using a salt bath, tea soaks or apple cider vinegar will help with callused skin and bacteria.


  • Reduce and if possible avoid the consumption of refined carbohydrates. Instead, take a balanced diet, with enough fruits & veggies and plenty of water.  

Condition that can lead to such foot odour and smelly foot are; 

  • Fungal Infection
  • Standing All Day 
  • Overactive Sweat Glands
  • Genetics
  • Injury Due To Structural Tissue
  • Bacterial  Breakdown On Skin
  • Hormonal Changes
  • Daily Stress
  • Poor Personal Hygiene 
  • Wearing Same Shoe Everyday Without Airing Them

Does Psoriasis Or Fungal Infection Make Patients More Vulnerable To COVID-19?

The authors of a recent study suggest that patients with some dermatologic diseases, such as superficial fungal infections and psoriasis, may be at higher risk for the COVID-19 virus, due to a possible similarity between cutaneous and mucosal immunity.

In the study, published by Dermatologic Therapy, researchers assessed dermatological comorbidities of 93 patients with the COVID-19 virus. They found that the most common skin conditions in this patient cohort in the past three years were superficial fungal infections (25.8 percent), seborrheic dermatitis (11.8 percent), actinic keratosis (10.8 percent), psoriasis (6.5 percent) and eczema (6.5 percent).

In addition, 17 of the patients in the study also presented to the dermatology clinic in the last three months. Among this subcohort, the most common dermatological conditions included superficial fungal infections (25 percent), psoriasis (20 percent) and viral skin diseases (15 percent).

Tracey Vlahovic, DPM, FFPM, RCPS (Glasg), says the study authors have made broad assumptions and do not mention other comorbidities or contributing factors. She adds that the study is also problematic since it combines groups receiving topical and systemic/biologic therapy, and suggests that both groups are at risk. Dr. Vlahovic, who is board-certified by the American Board of Foot and Ankle Surgery, recommends monitoring the National Psoriasis Foundation and the International Psoriasis Council websites for guidance.

“The National Psoriasis Foundation recommends those who are on systemic and/or biologic therapy should remain on therapy unless they develop a COVID-19 infection. Patients who have other comorbidities should speak with their physicians regarding staying on their current treatment or changing it,” maintains Dr. Vlahovic, an Associate Professor in the Department of Podiatric Medicine at the Temple University School of Podiatric Medicine.

“The National Psoriasis Foundation recommends those who are on systemic and/or biologic therapy should remain on therapy unless they develop a COVID-19 infection,” says Tracey C. Vlahovic, DPM, FFPM, RCPS (Glasg). (photo courtesy of Tracey C. Vlahovic, DPM)Joel Morse, DPM agrees that the premise that those with fungal infections or inflammatory skin disease are more likely to contract COVID-19 is suspect.

He wonders if major comorbid conditions such as diabetes could be contributing to an increased risk of developing the COVID-19 virus. Can the virus move through the skin if the stratum corneum is compromised? These are important questions to consider, says Dr. Morse, a Past President of the American Society for Foot and Ankle Dermatology.

Annette Joyce, DPM concurs that this study has limitations including: a small sample size; lack of specificity as to the location and type of fungal infections involved; and failure to link immunosuppression specifically to these superficial fungal infections.

“Fungal infections of the nails and skin are harder to treat in some patients due to immune system phenotype,” says Dr. Joyce, the Medical Conference Chair for the DERMfoot conference.

Dr. Joyce also notes that organ-specific immune response in the evolving knowledge of antifungal immunity could play a role in future immune-based COVID-19 therapies, but there are still so many unknowns.

Dr. Morse advocates for investigation of other viruses in patients with skin disease, and whether this heightens the risk for infection.

“When someone is in the hospital with COVID-19 life- and limb-threatening issues, we are probably not looking for tinea pedis or scaling on the elbow … but maybe we should,” suggests Dr. Morse, who is board-certified by the American Board of Foot and Ankle Surgery.

Can Adding Plantar Plate Repair To A Metatarsal Osteotomy Yield Better Results For Forefoot Metatarsalgia?

Regardless of the degree of plantar plate injury, adding a plantar plate repair to a shortening second metatarsal osteotomy may improve outcomes, according to a recent study published in the Journal of Foot and Ankle Surgery. 

In a prospective study, the authors evaluated 86 adult patients who had second metatarsal Weil osteotomies with and without concomitant plantar plate repair for sub-second metatarsal head pain over a 3.5-year period, and followed them for one year. Patients in the group who had a plantar plate repair with their second metatarsal osteotomy showed better foot-specific quality of life and pain scores at one year despite this group having more severe baseline injuries to the plantar plate. Researchers noted no difference in pre- or postoperative radiographic parabolas, second toe alignment or complication rates between the two groups.

Adam Fleischer, DPM, MPH, FACFAS, the lead author on the study, shares that after successful plantar plate repair from a dorsal approach, he observes patients are less “aware” of their previous foot ailment, which correlates with a higher level of confidence and higher quality of life scores.

Erin Klein, DPM, MS, AACFAS, a co-author of the study, finds in her practice that repairing the plantar plate helps with stability of the MPJ as well as pain.

Dr. Fleischer notes that in his experience, magnetic resonance imaging (MRI) and ultrasound both correlate closely with intraoperative evaluation of the extent of plantar plate injury, which he finds helpful during operative repair.

Dr. Klein agrees. She elaborates that a special MRI protocol with 0.2 to 0.3 mm slices through the metatarsal head/plantar plate region will help the surgeon understand the pathology much better.

“Correcting instability by repairing the plantar plate and then addressing the deforming osseous force (metatarsal length) provides pain relief and improved function postoperatively,” explains Dr. Klein.

Lowell Weil, Jr., DPM, MBA, FACFAS, a co-author of the study, emphasizes the clear necessity to address and correct metatarsal length.

“The plantar plate is a truly important structure that one should repair appropriately when pathology is present,” notes Dr. Weil, CEO of the Weil Foot and Ankle Institute. “Doing this combined procedure yields the highest level results in our research.”

“If patients demonstrate clinical instability of the lesser metatarsophalangeal joint and require a Weil osteotomy, (I recommend) a low threshold for anatomic repair of the plantar plate,” says Dr. Fleischer, who likens it to mechanical instability of the lateral ankle, which benefits from imbrication and advancement of the native tissues.

Are There Identifiable Trends In The Organisms Involved In Osteomyelitis?

What organisms might one expect to see upon bone biopsy in cases of osteomyelitis? A new study in the Journal of Foot and Ankle Surgery takes a closer look at patterns that may help in prescribing effective antibiotics.

Reviewing two random cohorts of 151 patients each in 2005 and 2010, the authors examined demographics, comorbidities, microorganisms found on bone biopsy and culture, location and pre-biopsy antibiotic use. Gram-positive bacteria, specifically methicillin-sensitive Staphyloccus aureus (MSSA), was most common in both groups. However, methicillin-resistant Staphyloccus aureus (MRSA) decreased from a prevalence of 28.3 percent to 10.6 percent from 2005 to 2010.  The most common gram-negative bacteria was the Pseudomonas species and patients with peripheral vascular disease exhibited a higher incidence.

Mitzi Williams, DPM, FACFAS, one of the authors on the study, was not surprised by the results as they align with her clinical experience.

Regarding the reduction in MRSA between 2005 and 2010, Dr. Williams personally feels the reason is multifactorial and could include antibiotic stewardship and striving to minimize admissions and returns to the operating room.

Windy Cole, DPM agrees that the findings correlate with her clinical practice. She adds that S. aureus is readily found in the environment as well as the normal skin flora of healthy individuals.

“It is when the bacteria enter into the deep tissues or bloodstream that potentially serious infections can occur,” explains Dr. Cole, the Director of Wound Care Research at Kent State University College of Podiatric Medicine.

MRSA infection reduction could also be attributed to better hygiene, sterilization and cleaning techniques in the hospital setting and the community, adds Dr. Cole.

Dr. Williams also feels podiatrists approach amputations in a way that prevents future infection.

“We recognize that removal of a central ray will likely result in a transfer lesion and may subsequently become infected,” notes Dr. Williams. “Hence, we do not simply remove what is infected. We perform a functional amputation, which carries lower long-term risks.”

Dr. Cole adds that bone biopsies and deep tissue cultures are the foremost way to isolate pathogenic bacteria and form the best treatment plan.

Currently, empiric antibiotic use should cover MSSA, says Dr. Williams, a Diplomate of the American Board of Foot and Ankle Surgery. Careful analysis for a history of MRSA, chronic ulcerations or a finding of liquefactive necrosis may lead one to redirect empiric therapy. She adds that one should choose empiric antibiotics based on the most likely organism(s) involved.

May 27, 2020
Volume 33 – Number 6 – June 2020
Pages: 10 – 11
By Jennifer Spector, DPM, FACFAS, Associate Editor
Resource Center
Podiatric Dermatology
plantar plate tear repair

Current Best Practices In The Treatment Of Plantar Plate Tears

After 20 years in practice, I have found that one of the more complicated issues is the treatment of lesser metatarsophalangeal joint (MPJ) instability. The MPJ is a very complicated joint, which is connected by collateral ligaments and pulled on by multiple external and internal foot tendons. All of these can cause strain on the joint and be sources of deformity and pain.

A common problem causing instability of the lesser MPJ is a plantar plate injury. Overall, there have been significant advances over the years in repairing the plantar plate but correcting hammertoes with complicated MPJ instability continues to be challenging.

Key Diagnostic Considerations Plantar Plate Tears

It is essential to listen closely to patients in order to understand their concerns and needs. Not every patient needs surgery or has pain that requires extensive repair. Most patients are more concerned initially with the new and worsening pain under the metatarsal head. They will sometimes note their toe is starting to shift. Patients with more long-standing pain will often have a more severe shift of the toe and even a crossover toe syndrome (most commonly the second toe crossing over the great toe). Overall, it is vital to understand what the patient expects. A stiff but straight toe after an arthrodesis may not be what the patient needs.

Most commonly, the patient wants to be pain-free and perform his or her normal activities. However, in addition to concerns about pain and toe position, one needs to ask more subtle, specific questions of the patient. Does the patient have difficulty in all shoes or just a certain type? What activities does the patient prefer and does a stiff toe preclude that activity? These questions will ultimately help with treatment selection.

The physical examination also needs to be fairly detailed. When a dorsal drawer test reveals instability of the toe, this is a sign that the plantar plate is lax or partially torn. However, we need to ascertain more information to inform our treatment plan. Is there a tendon imbalance? Is there more weakness on one side of the toe versus the other, suggesting only a partial plantar plate tear? What is the level and rigidity of the digital contracture? Is the metatarsal head very prominent? Finally, is there a bunion deformity, causing overloading of the second MPJ?

Diagnostically, standard radiographs are a good start. The goal is to see the general position of the foot and bone architecture. Furthermore, metatarsus adductus and the level of toe deviation are also important factors along with the size and extent of any present bunion deformity.

If surgical intervention is a consideration, obtaining a magnetic resonance imaging (MRI) study of the foot can help the surgeon assess the level of plantar plate tear, check for a neuroma and also ensure the articular surfaces are not badly damaged. Plantar plate damage can be subtle. The surgeon should interpret the MRI as well, not just the radiologist. Get to know your radiologist and explain what you are looking for as the radiologist may not know what you suspect or be as familiar with the intricacies of the plantar plate.

Evaluating Non-Surgical Approaches To Plantar Plate Tears 

Unless the patient has significant deformity, one should first attempt non-surgical care. For acute pain less than three months in duration, patients may respond to plantarflexory strapping of the toe and the use of a stiff shoe or boot to prevent strain. Physical therapy and oral steroids are also options. I do not recommend using a steroid injection as this can cause further damage and rupture to the plantar plate.

When it comes to more chronic and non-inflammatory pain that is greater than three months in duration, I prefer to add a platelet-rich plasma (PRP) or amniotic injection to the region to increase healing potential. Anecdotally, I have found this to be successful in early cases. Clinicians must convey to patients that strapping, the use of a boot or injection treatments will not correct the toe position. Again, this is why it is critical to understand the patient’s needs and expectations.

For many older or sedentary patients, fitting into shoes is impossible due to severe toe contracture. Strapping alone may improve this. For patients in this population who have a severe bunion and medially deviated third toe with a dislocated second toe, one might consider a second toe amputation.

Assessing Current Surgical Options For Plantar Plate And Hammertoe Repair plantar plate tear repair

As I noted above, there have been significant advances in surgical repair of the plantar plate. The question is what works and what does not. I have experience with many systems, plantar and dorsal approaches, all with or without osteotomy or hammertoe correction.

The hammertoe contracture is an important deforming force. Correction of the hammertoe increases the plantar strength of the flexor tendons and helps with relocation of the toe. If there is a severe dorsal contracture, an extensor lengthening can help relax the dorsal strain. It is important to remember that if the toe is medially deviated as well, one must not neglect this during hammertoe correction. During my procedures, I prefer to preserve the length of the proximal interphalangeal joint (PIPJ) length and not use a saw. I primarily employ a cup and cone technique with a rongeur, and do subsequent rounding with a burr. I also try to keep the joint fairly tight but still maintain reducibility at the PIPJ so there is less gapping at final reduction.

My preferred implant is the Hammertoe Fixation System (Ossio), which is made out of a natural fiber material that incorporates easily into bone. There is no absorption and the material has a sticky quality, which keeps the bones from separating. It is also trimmable, allowing one to reduce length if the intermediate phalanx is smaller. Surgeons can also cut through this implant in case of revision or conversion to an arthroplasty. The implant can also go through an MRI without signal. I no longer use metal in my hammertoes as it is mainly intramedullary and is very difficult to remove without severe damage to the toe.

Salient Pearls For Assessing And Addressing MPJ Deformity And Dislocation 

When correcting the MPJ, one must consider the stability of the joint, the amount of medial deviation, partial versus complete plantar plate tears and the amount of time that has passed since complete dislocation. The MRI and exam should help with decision making.

I divide my cases into mild, moderate and severe dislocations. A mild dislocation is a somewhat unstable joint with a very mild medial shift of the toe and very little dorsal contraction. A moderate case is one with a fairly lax joint on a dorsal drawer test and enough medial deviation that the great toe and second toe are touching or mildly overlapping. A severe case has significant medial deviation with crossover of the second toe or a complete plantar plate tear and dislocation at the MPJ. Each of these categories has some overlap so be prepared to treat and classify in a fluid fashion.

A metatarsal osteotomy and a possible extensor lengthening are often applicable in mild cases. I try to avoid a tenotomy because transfer of strain to the other digits may cause them to contract over time. I find extensor lengthening to be far better. The biggest pearl for my metatarsal osteotomies is to shift the metatarsal medially and shift the toe laterally, much like a bunion correction. I will, at times, imbricate the lateral capsule and collateral ligament for mild cases. In these instances, there is very minimal plantar plate tear and therefore, I find no need to repair it. It will heal during the post-surgical period and there is less stiffness of the joint without repair.

Moderate cases require plantar plate repair. Performing a metatarsal osteotomy shifts the metatarsal medially to help with repositioning the toe. One should examine and repair the plantar plate prior to repair of the metatarsal. A majority of plantar plate tears are lateral or central-lateral. I do not free up the entire plantar plate as I find this causes a great deal of scar tissue. I prefer to release the lateral plantar plate in the region of the tear, remove a triangular wedge and then utilize one of the plantar plate repair systems.

My system of choice currently is the Hat-Trick Lesser Toe Repair System (Smith & Nephew). I utilize the full repair system and pass two sutures, one on the medial side of the repair site and one on the lateral edge. I pass these two sutures through one or two holes, and hold them in place with PEEK interference fixation. More often than not, I use a single hole from lateral to medial and pass the sutures through that hole with one interference pin to stabilize the joint. The Hat-Trick system provides me with better correction of the medial deviation and less scarring. It is very rare for me to perform a flexor tendon transfer for a moderate case but I suggest being comfortable with it in case of poor plantar plate quality or if damage is apparent during repair.

A severe case either has a great deal of medial deviation or dislocation. In such cases, I find the plantar plate is either very poor quality or non-existent. For these patients, I now perform a flexor tendon transfer as I find it far more reproducible and successful in stabilizing a severe joint shift. I harvest the flexor tendon at the PIPJ prior to performing my hammertoe fusion. One then splits the tendon and pulls it medially and laterally along the proximal phalanx to the base of the toe on either side. The surgeon should place the tendon directly against the bone in order to avoid neurovascular damage before tensioning it and placing a single temporary stitch to hold it.

One subsequently positions and stabilizes the metatarsal in the osteotomy region. Holding the toe in position, the surgeon crosses the tendon ends over each other and adjusts tension on each side until the toe is stable and well-positioned at the MPJ. I use a 3-0 taper needle to place three double-pass stitches through the tendon to stabilize it. Then I tie the end sitting on the lateral side of the toe to the MPJ lateral capsule for additional stability and fine-tuning of the crossover toe correction. I do not use a K-wire across the MPJ and prefer to strap the toe with dressings for stability. You may have the patient begin MPJ range of motion at week two or three to prevent scar formation and joint stiffness.

A metatarsal osteotomy is usually, if not always, necessary as are hammertoe correction and extensor tendon lengthening. One may employ strapping and dressings to facilitate stabilization until suture removal. After removing the sutures, a toe strap should suffice. I like the Darco TAS Toe Alignment Splint (Darco) as it is very solid, can also incorporate a bunion splint and has an elastic band around the midfoot that decreases edema. However, any splint that prevents toe dorsiflexion is okay.

What You Should Know About Avoiding Post-Op Stiffness And Floating Toe 

About 20 percent of patients will still have a floating toe at three to six months postoperatively and will require an in-office tenotomy and capsulotomy of the MPJ to reduce dorsal scarring and contracture. These procedures have proven to be very good adjuncts in my patients.

I find flexor tendon transfers rarely result in a floating toe but there is a bit more stiffness. As I noted above, one can have patients initiate gentle and stabilized range of motion of the MPJ with practicing of grip strength of the MPJ. Range of motion can be more aggressive in weekly increments with physical therapy highly recommended. Wrapping the toe with a Coban wrap for two to three months is essential to avoid swelling. A Coban wrap for the midfoot is helpful but far less important than it is for the toe.

In Conclusion 

Proper planning and a solid understanding of different surgical options will make plantar plate and hammertoe repairs gratifying and fairly reproducible treatments for patients. Although plantar plate repair can be difficult, it is important for the surgeon to have a comprehensive mastery of options as one procedure does not fit every patient case.

Dr. Baravarian is an Assistant Clinical Professor at the UCLA School of Medicine. He is the Director and Fellowship Director at the University Foot and Ankle Institute in Los Angeles ( 

Dr. Baravarian has disclosed that he is a consultant for CrossRoads Extremity Systems and OSSIO. 

May 11, 2020
Pages:30 – 32
By Bob Baravarian, DPM, FACFAS
Hi, How Can We Help You?