NEW! Ultrasound Imaging of the Foot & Ankle now at Palm Beach Orthopaedic Institute
Ultrasound imaging is a fabulous office based technology for rapid diagnosis of your orthopaedic injury. Ultrasound uses high-frequency sound waves to produce immediate live images of the foot & ankle. Ultrasound exams are non-invasive and do not use harmful lionizing radiation(as used in x-rays).

Ultrasound images of the musculoskeletal system provide live, real time images of muscles, tendons, ligaments and joints.
Musculoskeletal ultrasound exams are painless and performed in our office . Ultrasound is used to image the fetus in expecting moms so you know it’s safe. You can watch as we image your lower extremity and identify the problem area in real time.
Dr. Schilero uses orthopaedic ultrasound to diagnose tendon injuries, masses, ankle sprains and most soft tissue problems that do not show well on traditional x-ray.

Call Palm Beach Orthopaedic Institute now for a consultation.

Orthotic Therapy is the science of employing in shoe devices to support your feet and legs. Dr. Schilero prescribes Custom digital orthotics to help support, align and correct deformity. Custom orthotics are the way to conservatively stabilize your feet, relieve pressure and restore the sound biomechanical alignment of your lower extremity.

Unlike, over the counter products prescription orthotics compensate for factors that Dr. Schilero diagnosed and improves the ability for your feet to function normally.

Feet are our foundation and feet that are not properly aligned can aggravate problems such as bunions,calluses and corns. The foot bone is connected to the leg bone and misaligned feet can affect the chain and contribute to pain in the knee,hip and lower back.

SUPERIOR ORTHOTICS BY DIGITAL TECHNOLOGY!

The foot is a complicated machine. Each foot contains 26 bones and 33 joints held together by 107 ligaments, 19 muscles and even more tendons. That’s a lot of moving parts ! Sports activities cause these structures to battle against gravity and the ground to control the force and weight of your body. Digital scanning is a high-technology solution that Dr. Schilero uses to create superior orthotics for patients with foot problems. The scanners capture the scientific data on your feet in seconds and coupled with our prescription for your best foot function the information is electronically submitted to a custom laboratory.

TAKE CARE OF YOUR FEET AND THEY WILL TAKE CARE OF YOU !

Description of Condition:

The plantar fascia is a thick fibrous tissue on the bottom of the foot which protects sensitive structures such as nerves, vessels, muscles and tendons and is also responsible for maintaining the arch of the foot. When the plantar fascia becomes aggravated or inflamed, plantar fasciitis develops. In many cases, plantar fasciitis is called “heel spur syndrome.” Many people think that heel spurs are the cause of their foot pain, but the pain is actually caused by the inflammation or irritation of the plantar fascia. If untreated, plantar fasciitis can lead to a heel spur.

Symptoms:

The symptoms of plantar fasciitis may vary among different patients. Its onset is insidious and it is not associated with a specific incident or trauma. In many cases, the patient suffers from a dull intermittent pain that eventually progresses into a sharp persistent pain. The pain usually is the worst in the morning with the first steps out of bed or after long periods of sitting. The pain is aggravated by continuous weight bearing and becomes progressively more severe over time.

Incidence and Causes:

Plantar fasciitis affects over two million Americans each year and as much as 10% of the population over the course of a lifetime. Plantar fasciitis is caused by a number of factors and is a common sports injury among runners, walkers, and athletes. In fact, it is the most common diagnosis for pain in the inferior aspect of the heel and accounts for 10% of running injuries. Studies have shown a direct relationship between plantar fasciitis and obesity, occupations requiring prolonged standing or walking on hard surfaces and athletic related overuse injuries. In addition, pes planus (flat foot), pes cavus (high arched foot), and inadequate dorsiflexion (tight Achilles tendon) have been recognized as predisposing factors to developing plantar fasciitis.

Anatomy:

The band of tissue that stretches along the bottom of the foot is known as the plantar fascia. The plantar fascia runs from the front of the heel bone (calcaneus) to the ball of the foot. During normal gait progression, the fascia alternately goes through states of relaxation and tension. The above mentioned factors cause an overstress on the insertion of the plantar fascia, which in some cases radiates toward the midfoot and toes. Irritation and microtears of the plantar fascia are considered to be the beginning of the pathological process. The tissue then becomes inflamed. Once started, the symptoms often progress rapidly because it is difficult to rest the foot. A bony heel spur may be observed on X-ray; however, it often does not correlate with the symptoms. In contrast, corresponding symptoms may occur without the bony heel spur being observed.

Patient Selection:

The Dornier Epos Ultra is a non-surgical alternative for the treatment of chronic plantar fasciitis for patients with symptoms of plantar fasciitis for six months or more and a history of unsuccessful conservative therapy.

Examination:

On examination, the patient typically has a point of maximal plantar tenderness on the medial calcaneal tuberosity. Ultrasonography of the heel can confirm the diagnosis and can help exclude other entities, especially fascia rupture. Ultrasonographic diagnostic criteria include thickening, hypoechogenicity, and alterations in the normal fibrillary pattern of the plantar fascia

Treatment Description:

The Epos Ultra delivers high-energy shock waves to the area of pain to increase blood flow and stimulate healing of the affected foot. The therapy head of the Epos Ultra uses a magnetic current impulse to generate shock waves. Shock waves are a type of sound wave. A pulse of electrical energy causes strong magnetic fields, which produce forces that vibrate and create a pressure wave or shock wave. The shock waves travel through the water in the shock wave source (coupling cushion) mounted to the therapy head, where they are precisely focused by a lens to the target tissue without any energy loss or damage to the body tissue. Before treatment begins, the patient will be given a local anesthetic. Using ultrasound guidance, the source of the pain will be located. Ultrasound gel will be applied to the foot and the therapy head. Treatment then begins and lasts approximately 20-25 minutes. The ultrasound is used throughout the treatment to assist with the targeting of the shock waves.

Post-Procedure Protocol:

After the shock wave treatment is complete, the foot is assessed for any side effects or complications. Side effects that may be related to the ESWT treatment may include:

Pain or swelling for a brief period following treatment:

• Localized numbness, tingling or decreased sensation in the foot or at the site of shock wave delivery; and/or
  Minor bruising or small purplish spots on the skin on the foot or at the treatment site.

Instruction on what steps should be taken to ensure the best possible results should be given to the patient. He or she may need to limit athletic activities for several weeks after the treatment to ensure that there is no further injury to the foot. Questionnaires (e.g. VAS and Roles & Maudsley) may be used to assess pain levels before and after treatment.

Alternative Treatment Options:

During the early stages of plantar fasciitis, one or more of the following alternative measures may be utilized to relieve symptoms:

• Rest
• Physical therapy
• Heel cushions
• Nonsteroidal anti-inflammatory drugs (NSAIDs)
• Corticosteroid injections
• Taping
• Orthotics
• Shoe modifications
• Nightsplinting
• Casting

If these treatment options are not effective (and other specific criteria is met), shock wave therapy or surgery may be recommended. One benefit of shock wave therapy over surgery is that it is conducted in an out-patient setting. This means that the treatment is performed at a doctor’s office or clinic and an overnight stay in the hospital is not required. Another significant benefit of shock wave therapy versus surgery is the recovery time is significantly lower, as are the side effects.

A Case Study by John Schilero, DPM, Palm Beach Orthopaedic Institute, Jupiter, FL

CASE STUDY: EASYCLIP SUPERELASTICSTAPLE FIXATION FOR THE CLASSIC CHEVRON BUNIONECTOMY ABSTRACT

The Chevron bunionectomy has proven to be a safe and effective repair for moderate hallux valgus. Fixation was modified by using the EasyClip staple as an alternative to commonly performed screw fixation. The EasyClip staple afforded the surgeon a very low profile, constant compression across a more distally placed osteotomy in faster healing cancellous bone, easy insertion and faster surgical time.

Patient History
A 37 year old female presented for elective repair of her painful hallux valgus deformity. Preoperative history and physical and a complete surgical discussion with the patient was performed.

PROCEDURE
The Chevron bunionectomy was performed under intravenous sedation and local anesthesia. A pneumatic tourniquet was applied to the right ankle and elevated to 250mm of mercury. The foot was prepped and draped in the usual sterile manner.
A 6.0cm dorsolinear incision was made over the first metatarsal phalangeal joint of the right foot medial to extensor hallucis longus. A linear capsulotomy was performed exposing the dorsomedial eminence of the first metatarsal. The prominent portions of bone were resected and all rough bone edges were smoothed. A classic lateral release was performed so as to neutralize the deforming soft tissue forces on the great toe. A 60 degree V-shaped osteotomy was performed from medial to lateral in the capital fragment of the first metatarsal with a power sagittal saw. The capital fragment was transposed laterally and temporarily fixated with a 0.062 K wire.

The 18mm wide double-holed EasyClip template/drill guide was centered over the dorsal first metatarsal osteotomy site and a 2.0mm drill was used to prepare the canals for the 18mm EasyClip staple. After each drill hole was completed the 2mm post provided was used to maintain and identify each drill hole. After measurement with a depth gauge an 18mm wide by 14mm long staple was loaded on the provided forceps. The forceps is used to preload and diverge the legs of the staple. The staple is then inserted into the predrilled holes in the first metatarsal with one leg anterior and one leg posterior to the osteotomy site. When the forceps is released the legs of the staple converge and afford compression across the osteotomy. This procedure was then repeated to insert a similarly sized second staple just medial to the first. The staples were seated flush with the first metatarsal dorsal surface with a tamp. C-arm imaging was used to confirm adequate alignment and fixation. The medial overhang of first metatarsal was removed. Deep and superficial closure was followed with a sterile dressing and the tourniquet was deflated.

RESULTS
The patient followed a typical post-operative course for Chevron bunionectomy. She was ambulatory in a surgical shoe and progressed to normal foot gear over the next 8 weeks. There were no complications

DISCUSSION
The EasyClip SuperElastic staple offers a fast and easy alternative to other forms of fixation of the Chevron bunionectomy. The EasyClip staple offers compression due to its spring-loaded shape and elastic memory. The EasyClip staple is a titanium nickel alloy (Nitinol) that is stored at room temperature. This device offers several advantages over screw fixation. It is low profile, offers faster and simpler instrumentation and is easy to retrieve and reposition if the first placement is unsatisfactory. The origninal chevron bunionectomy has been modified in recent years with a long dorsal arm that extends into more proximal diaphyseal bone to accommodate screw design and fixation. The shape and low relief of the EasyClip staple allows the surgeon to perform the osteotomy in more distal, faster healing cancellous bone under compression.

Case study by John Schilero, DPM

John Schilero, D.P.M.
Diplomate, American Board of Podiatric Surgery
Fellow, American College of Foot and Ankle Surgeons
Palm Beach Orthopaedic Institute, Jupiter, FL

(commonly referred to as a “heel spur”) is a common cause of heel pain and affects about 2.5 million people each year in the U.S.
The ligament that stretches along the bottom of the foot (the plantar fascia) is responsible for maintaining the arch of your foot. When the plantar fascia pulls away from the bone, your heel becomes painful. Your body may react by filling this space with new bone – a heel spur. Most people think that heel spurs are the cause of their foot pain – but the pain is actually caused by the inflammation or irritation of your plantar fascia muscle.

Plantar fasciitis is caused by a number of factors and is a common sports injury among runners, walkers and athletes. Overweight people and those whose jobs require a lot of standing or walking are also at higher risk. Other factors leading to plantar fasciitis include flat- or high-arched feet, worn out or improper shoes, jogging on sand – and increasing age.

Call today for a consultation with Dr. Schilero and find out the best way to care for your bunion.

The modern bunion correction can be completed in usually less than one hour in time for breakfast.The newest correction and technologies afford a pain free breakfast bunionectomy where most patients can walk the day of the procedure. We offer the latest techniques, plastic surgery type skin closures with no sutures to remove in a state of the art, safe surgical center. Because of our many years of experience , Dr Schilero has access to the latest technologies to insure as safe and rapid recovery as possible. For instance, the new Mini Tightrope technique where extensive bone cutting has been replaced with a sling technique to realign the crooked big toe.

Bunion Section Paper

ESWT- Procedure

Description of Condition:

The plantar fascia is a thick fibrous tissue on the bottom of the foot which protects sensitive structures such as nerves, vessels, muscles and tendons and is also responsible for maintaining the arch of the foot. When the plantar fascia becomes aggravated or inflamed, plantar fasciitis develops. In many cases, plantar fasciitis is called “heel spur syndrome.” Many people think that heel spurs are the cause of their foot pain, but the pain is actually caused by the inflammation or irritation of the plantar fascia. If untreated, plantar fasciitis can lead to a heel spur.

Symptoms:

The symptoms of plantar fasciitis may vary among different patients. Its onset is insidious and it is not associated with a specific incident or trauma. In many cases, the patient suffers from a dull intermittent pain that eventually progresses into a sharp persistent pain. The pain usually is the worst in the morning with the first steps out of bed or after long periods of sitting. The pain is aggravated by continuous weight bearing and becomes progressively more severe over time.

Incidence and Causes:

Plantar fasciitis affects over two million Americans each year and as much as 10% of the population over the course of a lifetime. Plantar fasciitis is caused by a number of factors and is a common sports injury among runners, walkers, and athletes. In fact, it is the most common diagnosis for pain in the inferior aspect of the heel and accounts for 10% of running injuries. Studies have shown a direct relationship between plantar fasciitis and obesity, occupations requiring prolonged standing or walking on hard surfaces and athletic related overuse injuries. In addition, pes planus (flat foot), pes cavus (high arched foot), and inadequate dorsiflexion (tight Achilles tendon) have been recognized as predisposing factors to developing plantar fasciitis.

Anatomy:

The band of tissue that stretches along the bottom of the foot is known as the plantar fascia. The plantar fascia runs from the front of the heel bone (calcaneus) to the ball of the foot. During normal gait progression, the fascia alternately goes through states of relaxation and tension. The above mentioned factors cause an overstress on the insertion of the plantar fascia, which in some cases radiates toward the midfoot and toes. Irritation and microtears of the plantar fascia are considered to be the beginning of the pathological process. The tissue then becomes inflamed. Once started, the symptoms often progress rapidly because it is difficult to rest the foot. A bony heel spur may be observed on X-ray; however, it often does not correlate with the symptoms. In contrast, corresponding symptoms may occur without the bony heel spur being observed.

Patient Selection:

The Dornier Epos Ultra is a non-surgical alternative for the treatment of chronic plantar fasciitis for patients with symptoms of plantar fasciitis for six months or more and a history of unsuccessful conservative therapy.

Examination:

On examination, the patient typically has a point of maximal plantar tenderness on the medial calcaneal tuberosity. Ultrasonography of the heel can confirm the diagnosis and can help exclude other entities, especially fascia rupture. Ultrasonographic diagnostic criteria include thickening, hypoechogenicity, and alterations in the normal fibrillary pattern of the plantar fascia

Treatment Description:

The Epos Ultra delivers high-energy shock waves to the area of pain to increase blood flow and stimulate healing of the affected foot. The therapy head of the Epos Ultra uses a magnetic current impulse to generate shock waves. Shock waves are a type of sound wave. A pulse of electrical energy causes strong magnetic fields, which produce forces that vibrate and create a pressure wave or shock wave. The shock waves travel through the water in the shock wave source (coupling cushion) mounted to the therapy head, where they are precisely focused by a lens to the target tissue without any energy loss or damage to the body tissue. Before treatment begins, the patient will be given a local anesthetic. Using ultrasound guidance, the source of the pain will be located. Ultrasound gel will be applied to the foot and the therapy head. Treatment then begins and lasts approximately 20-25 minutes. The ultrasound is used throughout the treatment to assist with the targeting of the shock waves.

Post-Procedure Protocol:

After the shock wave treatment is complete, the foot is assessed for any side effects or complications. Side effects that may be related to the ESWT treatment may include:

Pain or swelling for a brief period following treatment
Localized numbness, tingling or decreased sensation in the foot or at the site of shock wave delivery; and/or
Minor bruising or small purplish spots on the skin on the foot or at the treatment site

Instruction on what steps should be taken to ensure the best possible results should be given to the patient. He or she may need to limit athletic activities for several weeks after the treatment to ensure that there is no further injury to the foot. Questionnaires (e.g. VAS and Roles & Maudsley) may be used to assess pain levels before and after treatment.

Alternative Treatment Options:

During the early stages of plantar fasciitis, one or more of the following alternative measures may be utilized to relieve symptoms:

• Rest
• Physical therapy
• Heel cushions
• Nonsteroidal anti-inflammatory drugs (NSAIDs)
• Corticosteroid injections
• Taping
• Orthotics
• Shoe modifications
• Nightsplinting
• Casting

If these treatment options are not effective (and other specific criteria is met), shock wave therapy or surgery may be recommended. One benefit of shock wave therapy over surgery is that it is conducted in an out-patient setting. This means that the treatment is performed at a doctor’s office or clinic and an overnight stay in the hospital is not required. Another significant benefit of shock wave therapy versus surgery is the recovery time is significantly lower, as are the side effects.