Podiatry Associates of Belleville John Cozzarelli Joseph Cione Gregory Rivera

ELLMAN RADIOWAVE SURGERY
This is a very common complaint that we see in our office on a daily basis. The most likely diagnosis from your history seems to be a recurrent Ingrown toenail. This is a condition in which a portion of the nail presses into the flesh, causing pain, redness and sometimes infection. If this

condition is left untreated, the flesh along side the nail can become enlarged and painful as well.
An ingrown nail occurs for many different reasons. One can be the way the nail was cut to having a fungal infection to having a bone spur under the tip of the nail or trauma. The toe is composed of the nail plate, nail bed and nail matrix. The nail matrix or nail root is where the nail grows from. You can not see this and it is covered by the cuticle. As the nail grows forward it may cut into the skin fold and then bacteria gets seated in the skin forming an abscess. The skin becomes infected and pain then occurs. Most times the nail has to be removed before the infection will resolve. Oral antibiotics will not work unless the nail is removed.
There have been many different types of procedures to remove ingrown nails permanently. The earliest removal of an ingrown was reported by a French surgeon named Dr. Quenu in 1887. Since then different techniques have come and gone. The chemical that was utilized to destroy the nail root is called Phenol. This was most likely what was utilized to create the chemical matrixectomy. It is 88% pure and creates a chemical burn. The procedure has a relatively high success rate. The pitfalls are if the phenol is old it becomes inactivated or if it is sparingly applied. If so there will be a recurrence of the ingrown. In 1955 Dr.. Polokoff described the use of galvanic current to create an electrical burn of the nail matrix. There was some success with this method but pain was high after the procedure was performed. In 1976 Carbon Dioxide laser was utilized with better results. The downside to this procedure was the recurrence rate was high.
The most recent advance in the permanent removal of ingrown nails comes from a unit called the Ellman Surgitron. It utilizes Radio Waves to permanently remove an ingrown nail. Electric current is converted into controlled energy in the form of Radio Wave Frequency of the electromagnetic spectrum. It uses a frequency of 3.8MHz. It is applied for 4 seconds to the nail matrix. The advantage to this procedure is that it sterilizes the area while it is being used and this results in less post operative pain and swelling. Infection rate is also decreased via this method offering a 98% success rate.

NEUROMETER TESTING
A complete and thorough neurological examination is of extreme importance in patients suffering from lower extremity nerve disorders. The Podiatrist must be able to monitor the course of the neuropathy and stratify patients according to their risk factors. Those patients found to be at high risk can be treated prohylactically with accommodative orthoses, custo

m molded shoes, braces and/or surgery. Traditional methods of assessing the sensory nervous system includes semm weinstien filaments, tuning fork and use of a pinwheel are highly subjective, variable and prone to the examiner bias, making their use for assessment over time very difficult. Current Perception Threshold evaluations that can be performed in the office and aid in the diagnosis and treatment of neuropathy and nerve entrapment/compression syndromes.
The current perception threshold evaluation is a quantitative test which provides a reproducible functional assessment of the peripheral sensory nervous system.1 The current perception threshold is the minimum amount of a transcutaneously applied current that an individual consistently perceives as evoking a sensation. The evaluation is painless, non-invasive and easy to perform. The current perception threshold evaluation is performed using the Neurometer CPT/C Device. This is a neuroselective diagnostic stimulator which uses a microprocessor-controlled stimulus to obtain current perception threshold measures. The electrical stimulus selectively excites distinct subpopulations of nerve fibers as a function of the sinusoid frequency.2 The 2000-Hz stimulus evokes responses from the A beta, the 250-Hz stimulus evokes responses from the A delta, and the 5-Hz evokes responses from the C fibers. As compared to Nerve Conduction Velocity, tests solely large fiber function and thermal perception threshold, test solely small fiber function. These different nerve-fiber populations have shown varying susceptibilities in radiculopathies and compressive neuropathies.3 Patients with neuropathy have been shown to anesthetic to the maximum stimulus at one frequency of the current perception threshold evaluation but within normal threshold range for the other 2 frequencies.4 Therefore, the testing of all three nerve fibers is of the utmost importance.
The procedure for CPT evaluations is quite simple. The patient is made comfortable in a location with minimal distractions. A pair of 1cm diameter electrodes is coated with conductive gel and then taped to the body site that is being tested. The device controls are shielded from the patients view and the sinusoidal electrical stimulus is slowly increased, from 0.00 up to 9.99mA, until the patient reports feeling it. The stimulus is then turned off, the intensity level lowered, change the frequency level and then the stimulus is turned back on.
The Neurometer CPT devices are prescription devices and U.S. Federal Law requires that they be limited to use only by or under the order of a physician or other appropriate medical personnel. The Neurometer was approved by the F. D. A. in 1986.
Quantitative sensory nerve testing with the current perception threshold evaluation provides an objective, reproducible, reliable and painless measure of both Hyperesthesia and Hypoesthesia in the 3 different nerve fibers; A beta, A delta and C fibers. This is extremely helpful in the initial evaluation and workup of patients with painful neurological conditions, as well as a valuable tool in the serial evaluation of patients to assess the outcome of any therapeutic and/or surgical intervention.

NON-INVASIVE DOPPLER FLOW TESTING FOR CIRCULATION
Arterial disease or other wise known as poor circulation can have a devastating impact on a patients quality of life. Chronic, progressive arterial disease can lead to complications such as pain in the calf upon ambulation. Ischemic rest pain, which is pain due to a lack of oxygen to the extremities, can be a common result of poor circulation. Ulcerations and infections can develop and the healing potential is very poor if the arterial disease progresses.
A thorough vascular examination should be performed by your physician. There are various physical tests that can be performed by your doctor during a typical office visit to assess circulation. A very highly conservative, non-invasive, sensitive examination performed in office to assess a patient's circulation includes an Arterial Doppler Flow Study. This a non-invasive examination that can test

for the circulation in the lower extremity including the Arteries and the Veins. A probe (transducer) is placed against the skin on a slight angle. The probe then uses then reflects the sound of blood flow going by. This sound is then amplified on an external speaker. The sound is audible and sounds like a heart beat. A tracing is then made on the analyzer and certain characteristics should be present. There are no side effects or risks to the patient.
The microcirculation is tested via photoplyethsmography (ppg) non invasively. A small probe is placed on the tip of the toes and the microcirculation can be assessed. The greatest offenders to microcirculation are caffeine and nicotine which may be responsible for cold hands and feet. This non-invasive test is performed in office rapidly and results are available on the completion of the test.

ENDOSCOPIC SURGERY (Plantar Fasciitis Surgery and Ankle Arthroscopy)
An Endoscope is a tiny fiber optic camera. It allows the surgeon to make a tiny stab incision in the body and to visualize the anatomy without dissecting the surrounding anatomy. The camera is 4.0mm in diameter and has a light source which sound light down a fiber optic cable to illuminate

the surgical site. It is visualized by the surgeon on an external monitor and is recorded on a VCR tape. Images are printed as color pictures during the surgery. It the endoscope is inserted in a joint it is then called an arthroscope.
Endoscopic Plantar Fasciotomy (EPF) is one of the surgeries used to treat severe strain of the plantar fascia. Plantar fasciitis is a common complaint of many heel spur syndrome patients. The plantar fascia is a dense fibrous band that is attached to the heel bone andd can form a spur from the constant pulling and pressure. When the patient first steps out of bed it is the most painful step to take.
The surgeon make a small stab incision on each side of the heel. The endoscope is inserted in the small opening via a cannula (tube). The inflamed plantar fascia is visualized. The fascia is then released from the heel bone. The surgical release immediately eliminates the inflammation area of the spur and normal foot function can resume.
The procedure was developed by Dr. Stephen Barret and Dr. Stephen Day of Texas. Dr. Cozzarelli was trained by Dr. Barret in Hershey, Pennsylvania in November 1995.
An ankle arthroscopy is a procedure where a tiny puncture is made on each side of the ankle. The fiber optic camera is inserted in the ankle. The most common complaint of patient's with ankle pain is a diagnosis called Synovitis which is an inflammation of the synovial tissue. The ankle joint is lavaged with 3 liters of Sterile Saline. If any fibrous attachments or adhesions are visualized these are removed arthroscopically. There is usually a small stitch on each side of the ankle. Patients may resume normal activity in about 5 days.

This procedure is reserved for only severe and resistant cases of heel pain that will not respond to all conservative treatment. The procedure can be performed on resistant cases of Plantar Fascitiis, Achilles Tendonitis, Neuroma/Neuritis and Tarsal Tunnel Syndrome.

RadioFrequency Lesioning is a minimally invasive procedure. RadioFrequency does not require stitches, skin incisions or bandages. RadioFrequency doesn't disable you and it does not involve an extensive period of healing. It is not associated with the many complications and risks that are associated with surgery. The procedure is done an out patient basis and you can return to shoe gear and work the next day.

Prior to the procedure, the heel is examined and we locate all the very sensitive areas of pain around the heel. There are usually 5-6 areas that are very tender and we call them the "hot spots". We treat only those painful areas with RadioFrequency. The RadioFrequency probe, approximately the size of a needle, is placed through the skin into your heel in the area of pain. Wile under IV sedation, the tip of the probe heats up to 87 degrees Celsius. It is kept in the area for 90 seconds. This in essence decrease the deep pain sensation in that area, the size of the probe's tip. The nerve endings are desensitized in these specific locations, thus eliminating the pain. This procedure is then performed on all the painful areas that were identified. Following the procedure, local anesthesia is injected into the treatment sites. Band-Aids are placed over the multiple puncture sites and you are able to return to shoe gear immediately following the procedure.

In most instances, complete resolution of your pain is achieved within 2 weeks following the procedure. In the Journal of Foot and Ankle Surgery, Vol. 86, No. 3 in 1997, a 92% success rate was demonstrated, treating heel pain with RadioFrequency.

ESWT stands for Extra-corporeal Shock Wave Therapy. It is a very simple non-surgical procedure.

Lithotripsy, a similar procedure, is used regularly for breaking up and dispersing kidney stones. When Urologists reported that patients who had their kidney stones treated with Lithotripsy were presenting increased bone density and new tissue growth, the possibilities of Shock Wave therapy were revisited. As a result, ESWT was studied for chronic heel pain management resulting from plantar fasciitis and heel spurs. An amazing 92% of patients were reported to be healed or dramatically improved following ESWT. (This data reflects the results of all patients in the study one year after only one treatment.)

First and most important is to find the root of your pain and determine the best course of action. Your doctor will complete a thorough examination and will inform you of a diagnosis and what treatment is recommended. If ESWT is right for you, here's what you can expect:

You lie back in a comfortable chair with your foot resting on a large fluid-filled rubber dome. The Mobile Center's staff will make sure you are comfortable throughout the entire procedure. Though not necessary, a local anesthesia is used for the procedure to ensure patient comfort. The procedure does not hurt. The equipment has a wide range of settings and penetration depths. This allows our doctors to fine tune the procedure to your individual diagnosis. Ultrasound will be used to view and target the damaged location. During the treatment all you will be aware of is a repetitive clicking sound as the pulses penetrate the center of your pain site at a rapid rate. What's most important is what's going on inside of your foot. The shock waves stimulate the diseased tissue, activating your body's natural healing process. Blood and oxygen rush to the site, activating a metabolic response that:

It's literally an amazing advance in medical science. All you do is lie back and relax, your doctor and the staff of Excellence Shock Wave Therapy will do the rest! The procedure only takes about a half hour to complete!

This bears repeating because we know it's important to you. ESWT does not hurt. This is not a painful or invasive procedure. There is no cutting of skin.

Since the procedure encourages blood flow to the area, you may experience some mild bruising or soreness. You may walk out with no pain at all, or you may feel pretty much the same. Never does your current condition get worse. That is why this procedure is so wonderful. If you have any concerns of a long drawn-out recovery cramping your style, you can forget that. From the first day, improvement is expected. The only thing that is individualized is how much, how soon. In some, the majority of the pain relief is immediate. In others, it gradually gets better from day one through the first six weeks. In others still, it gradually gets better from day one up to 12 weeks. But never is there any reason to put it off. With successful ESWT Therapy the pain and the causal condition will begin getting better immediately after the treatment. You do not need to plan time off from work or your life!

Sport Laser

The Sport Laser is a handheld, battery operated, noninvasive, light-emitting medical device. Recently cleared by the FDA for sale and use in the treatment of Carpal Tunnel Syndrome, Relief of muscle and joint pain, arthritis, muscle spasm, relief of stiffness, and the promotion of muscle relaxation, this device is a low energy laser also known as a "cold laser." In contrast to general surgical or cosmetic lasers that produce heat and thermo-destructive laser energy, Low Level Laser Therapy (LLLT) produces no harm to human tissue in normal use and thus is classified by the FDA as a Class IIIB medical device. Cold lasers used in LLLT have been in medical use for over 30 years and have a long record of successful clinical studies demonstrating medical efficacy and safety. The Sport Laser produces infrared (invisible) laser light at the 830 nm wavelength via three LASER diodes. A fourth visible LED (Light-Emitting Diode) is used to provide a visible red target light field for the clinician to target the desired tissue area. As a noninvasive contact medical device, the SportLaser is completely portable, very easy to operate and provides reliable and effective treatment options to the clinician and patient.

Through the action of photo-stimulation of light reactive biological receptors (chromophores) in the body, Low Level Laser Therapy (LLLT) has demonstrated the ability to significantly accelerate and enhance the body's natural defense and repair components in the presence of injury, inflammation and certain disease processes. By modifying the effects and limiting the duration of inflammation as well as enhancing specific repair and healing processes, LLLT is consistent in providing pain relief, reducing injury damage and loss of function, in addition to facilitating more rapid repair and stronger healed tissue structures. Multiple clinical studies have noted the following results of LLLT:

1. Increased collagen production
2. Increased cell membrane potential
3. Enhanced nerve regeneration
4. Reduced edema magnitude
5. Increased vasodilation
6. Increased microcirculation
7. Reduced inflammatory duration
8. Increased tissue and bone repair
9. Increased cell metabolism
10. Increased lymphatic response
11. Increased pain threshold
12. Increased enzyme response

Light receptive chromophores, both in cellular and sub-cellular locations, become stimulated to more active levels of function and increased interaction by being exposed to coherent laser light, which penetrates much deeper than other light wave forms. Laser therapy stimulates increased endorphin release and increased prostaglandin synthesis. Due to the powerful effect exerted by photo-stimulated enzymes, both localized and systemic cascade reactions occur that result in immunomodulation and inflammatory mitigation. In summary, Low Level Laser Therapy stimulates improved vascular, lymphatic and enzymatic activity, which increases collagen synthesis and production, satellite cell presence and cellular metabolism, resulting in the enhanced healing of damaged skeletal, connective and neurological tissues and structures.

Patients treated with the portable SportLaser will experience significantly faster healing, increased range of motion, significantly decreased pain, and more complete tissue regeneration.

Biophotonic Scanner

Scientists believe free radicals contribute to the aging process. It’s a fact of life … we age, every second, of everyday. And although we can’t stop the aging process, we can take steps to improve our health as we age. Certain known causes of free radical damage such as smoking or sun exposure can have negative impacts on how we look and feel. Pollution, exposure to toxic chemicals – even the air we breathe creates free radicals within our bodies.

There are many different kinds of antioxidants and they work together to help fight the harmful effects of free radicals. Our bodies produce some antioxidants and other important antioxidants are consumed in our diets. All of these antioxidants work together to form a powerful defense system to support good health.

Antioxidants can actually capture or neutralize free radicals and therefore stop the chain reaction. One of the most powerful classes of antioxidants is carotenoids. Carotenoid antioxidants break the chain reactions of free radical damage.

That’s why it’s important to get tested and know your Pharmanex® Antioxidant Score. You can take steps to raise it by eating properly and by taking supplements. By supplementing your diet with LifePak® and being scanned every 60 days, you will now be able to track your body’s antioxidant score.

Most people do not consume an optimal amount of all vitamins by diet alone. Pending strong evidence of effectiveness from randomized trials, it appears prudent for all adults to take vitamin supplements.” Journal of the American Medical Association, June, 2002.

Scientists from around the world are talking about a brand new invention that is on the verge of changing the way people think about health – the Pharmanex® BioPhotonic Scanner. This revolutionary tool enables us, for the first time, to measure our level of carotenoid antioxidant protection quickly.

Antioxidants are our front-line defense against the free radicals that constantly affect our cells. Over 30,000 scientific papers have been written about free radicals and antioxidants in the last 20 years. With the Pharmanex® BioPhotonic Scanner we can now obtain an accurate reading of your personal antioxidant score.

Sir C. V. Raman discovered the technology on which the scanner is based in the 1920’s. Sir Raman was awarded the Nobel Prize for the discovery of the Raman Spectroscopy in 1930.

That was in the 1920's, but until the onset of the computer, optical and laser technology reached its current sophistication, the concept was not really practical.

Raman’s discovery proved that there are certain molecules, like carotenoids, that can be excited with a certain wavelength of laser light. The molecules then begin to resonate in very particular ways, releasing a very specific light signal of an altered wavelength that then can be measured. This discovery was revolutionary at the time, but computer and laser technologies could not fully apply it until recently. In just the last ten years, researchers at a major university, led by Dr. Werner Gellerman, actually started putting all these pieces of technology together.

The scanner technology is a tremendous scientific breakthrough. Scientists realized that the concentration of carotenoids in the eye is related to eye health. Because carotenoids are found throughout the body as part of the body’s antioxidant network, scientists believed this same technology could be used to measure carotenoid levels in human tissue. That’s when the scientists at Pharmanex® collaborated with Dr. Gellerman to develop the Pharmanex® BioPhotonic Scanner.

By simply placing the palm of your hand in front of a safe, low-energy blue light laser, you obtain an immediate reading of your carotenoid antioxidant activity—your antioxidant Score.

Please feel free to call the office to schedule an appointment to have you antioxidant levels measured and evaluated.

Acupuncture

Acupuncture literally means "needle piercing." Very fine needles are inserted into the skin to stimulate specific points called acupoints. It has traditionally been taught as a preventive form of health care, but it has also been found useful in the treatment of a variety of acute and chronic conditions. Acupuncture has been used for over 3,000 years in China as a major part of their primary health care system. In modern times, it is used for the prevention of and treatment of diseases, for the relief of pain, and as an anesthetic for surgery.

Acupuncture stimulates the nerves in skin and muscle, and can produce a variety of effects. We know that it increases the body's release of natural painkillers - endorphin and seratonin - in the pain pathways of both the spinal cord and the brain. This modifies the way pain signals are received.

We at Podiatry Associates of Belleville use acupuncture to treat muscloskeletal pain, in combination with podiatric and physiotherapy interventions in order that your problem can be tackled as quickly as possible. Each patient's case will be assessed by Dr. Cozzarelli or Dr. Cione and treatment will be tailored to the individual. Typically, fine needles are inserted through the skin and left in position briefly, sometimes with manual or electrical stimulation. The number of needles varies but may be only five to six.

Treatment might be once a week to begin with, then at longer intervals as the condition responds. A typical course of treatment lasts 5 to 8 sessions.

Dr. Cozzarelli and Dr. Cione are Board Certified in Podiatric Acupuncture for the treatment of any lower extremity pathologies. If you are interested in undergoing a regimen of Acupuncture feel free to call the office and schedule an appointment for an evaluation.

Magnetic Resonance Imaging (MRI)

Magnetic Resonance (MR) Imaging (MRI) is a state of the art imaging technology which allows cross sectional viewing of the body. The past 15 years have witnessed an explosion of information regarding the role of

magnetic resonance imaging in assessing pathologic conditions of the ankle and foot.

It does not use any ionizing radiation and has rapidly evolved into an accepted modality for medical imaging of disease processes in the musculoskeletal system, especially the foot.

MR imaging is increasingly being recognized as the modality of choice for assessment of pathologic conditions of the ankle and foot. Magnetic resonance images provide a digital representation of tissue characteristics that can be obtained in any tissue plane. MRI is based on the principles of nuclear magnetic resonance (NMR), a spectroscopic technique used by scientists to obtain microscopic chemical and physical information about molecules.

Magnetic resonance imaging has opened new horizons in the diagnosis and treatment of many musculoskeletal diseases of the ankle and foot. It demonstrates abnormalities in the bones and soft tissues before they become evident at other imaging modalities.

The exquisite soft-tissue contrast resolution, noninvasive nature, and multiplanar capabilities of MR imaging make it especially valuable for the detection and assessment of a variety of soft-tissue disorders of the ligaments (e.g., sprain), tendons (tendinosis, peritendinosis, tenosynovitis, entrapment, rupture, dislocation), and other soft-tissue structures (e.g., anterolateral impingement syndrome, sinus tarsi syndrome, compressive neuropathies [e.g., tarsal tunnel syndrome, Morton neuroma], synovial disorders).

MR imaging has also been shown to be highly sensitive in the detection and staging of a number of musculoskeletal infections including cellulitis, soft-tissue abscesses, and osteomyelitis.

In addition, MR imaging is excellent for the early detection and assessment of a number of osseous abnormalities such as bone contusions, stress and insufficiency fractures, osteochondral fractures, osteonecrosis, and transient bone marrow edema.