599 Sir Francis Drake Blvd #207

Greenbrae, CA 94904


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Hello Marin...

Tune in to hear from our doctors, Dr. Anthony Fedrigo and Dr. Oendrila Kamal about the latest and most up-to-date information about all things related to foot and ankle and sometimes life in general.  


By Foot and Ankle Specialists of Marin, Oct 12 2016 10:11PM

Heel pain is the most common problem that foot and ankle specialists treat. Many things can cause heel pain including calcaneal stress fracture, calcaneal fat pad atrophy, tendinitis and neuritis. However, plantar fasciitisis the cause of heel pain the majority of the time. In Marin and Sonoma County, we see plantar fasciitis in all ages, men, women, athletes and non-athletes.

The plantar fascia is a soft tissue structure on the bottom (or “plantar” aspect) of the foot that originates from the heel and extends towards the toes. When the fascia becomes inflamed around its insertion in the heel, that inflammation causes pain. Therefore, therapy is directed at decreasing inflammation. Initial anti-inflammatory therapies include:

• Decreasing weight-bearing activities

• Modifying shoe gear

• Icing

• Oral anti-inflammatories

When these initial anti-inflammatory therapies do not provide relief, the doctors at Foot and Ankle Specialists of Marin can evaluate the cause of your plantar fasciitis, rule-out other causes of heel pain and make further treatment recommendations, including:

• Specialized stretching exercises

• Pre-made and custom orthotics

• Anti-inflammatory injections

The vast majority of patients with plantar fasciitis find relief with the above non-surgical therapies. However, when pain persists despite these efforts and affects your daily activities, surgical options are available.

By Foot and Ankle Specialists of Marin, Mar 3 2016 12:57AM

What is a bunion?

A bunion forms when the great toe (or hallux) begins to drift towards the lesser toes and the the bone behind it (called the 1st metatarsal) begins to drift in the opposite direction, creating a boney “bump”. This bump rubs in shoes and makes narrower shoes very uncomfortable.

Why do bunions form?

Bunions can occur for many reasons. Typically, shoe gear, biomechanics and foot structure are the cause of bunions. At Foot and Ankle Specialists of Marin, we are often asked if bunions are “genetic”. While there is not a gene specific to bunions, it is common to see bunions “run in the family”. That is to say, since we are all more or less shaped like our parents, our feet are no exception.

How do I avoid bunion surgery?

Wearing wider shoes, custom or over-the-counter pads and orthoses can provide temporary relief of bunion pain. Some patients find pain relief with these measures for an extended period of time, while others do not. Unfortunately, even with specialized padding and bracing, bunions worsen with time. We do not recommend surgery until discomfort begins to affect your daily activities and decision-making.

What does bunion surgery involve?

Surgical correction of a bunion involves removing the boney “bump” and redirecting the bone and soft tissue of the hallux and 1st metatarsal. There are many ways to do this and your surgeon will select a bunion procedure based on your bunion type.

What is recovery like?

In Marin and Southern Sonoma County, where so many of our patients are active and do not want to be away from activities for an extended period of time, the recovery period is often a concern. Post-operative activity level depends on the bunion procedure appropriate for your bunion type. Most patients are what we call “partial weight bearing” immediately after surgery. This means you can put weight on the heel, but cannot “push off” of the front of the foot. This usually lasts for 2-3 weeks. Some bunion procedures require a longer period of partial weight bearing or even non weight bearing and this depends on the severity of your bunion.

To schedule an appointment to discuss bunion surgery click here.

Follow this link for more information about bunions.

By Foot and Ankle Specialists of Marin, Feb 19 2016 08:52PM

The third condition we see in the winter is something I like to classify as cold induced tissue trauma. This can be from extreme frostbite, which is uncommon in Marin County, to chilblains (pernio), to Raynauds Syndrome. Frostbite and Chilblains is from overexposure to cold for a prolonged period of time and can lead to very serious tissue loss.

Raynaud's Syndrome is a cold induced vasospasm of the small arteries that go to our fingers and toes. Several patients a year come to our office with the complaint of color changes or wounds on the tips of their toes. Unlike overexposure to cold, Raynaud’s happens when the temperatures drop, but the patient is wearing shoes, socks and warm clothing. Patients often notice color changes first in their fingers. The fingertips around the nail, or up to the first or second knuckle will turn white. This can last for several minutes. Then the fingers turn bright red followed by a bluish/purple color. The physiology behind this is what is called a vasospasm. As the blood leaves our core, it cools as it moves into our arms and legs. The cold blood and cold temperatures can cause the arteries to spasm in some people. As this happens the blood vessels clamp down, and less blood flows to the skin and the skin blanches and turns white. As metabolites build up in your tissues, mainly nitric oxide, the blood vessels dilate. Sometimes they dilate so much that you get a rush of blood back into the body part and the skin turns bright red. As the blood rushes in, the venous system gets overloaded and venous congestion develops causing the tissues to turn blue. The problems arise during the blanching phase of Raynaud's. As the tissues are “starved of blood,” inside of that harsh shoe and sock environment, tissue damage begins to occur from rubbing and friction. The longer the vasospasm, the higher the risk of worsening tissue damage. Patients often come in with wounds on the plantar fat pads of their toes with no known cause of trauma. The surrounding skin will have a mottled red, purple appearance. With a careful history, the patient will describe color changes they have noticed in their fingers, which goes unnoticed in their feet in closed shoes.

Treatment for Raynaud’s Syndrome is tailored first to prevention. Keeping your extremities warm is the key. Not only hands and feet, but arms and legs. I tell my patients you need to wear long underwear, long Johns or leggings to keep the blood warm as it moves from your trunk to your feet. The same goes for the upper extremity. You need to insulate those arms and legs and protect from the cold. Patients with severe Raynaud’s often have vasospasms even in warm weather. Patients that have severe Raynaud’s are often treated with oral nifedipine, a vasodilator used to treat high blood pressure. The effect of nifedipine, helps prevent the arteries from spasming. It is very important to treat any wounds that form from the tissue trauma. This can be as simple as covering the wound with a topical antibiotic and a large sterile dressing, to more advanced wound care techniques which we perform at Foot and Ankle Specialist of Marin.

So to recap. Keep your feet clean and warm, but dry, all Winter long, and remember… Spring is coming.

Dr. Anthony Fedrigo

By Foot and Ankle Specialists of Marin, Feb 17 2016 08:45PM

The second condition we see in winter is Onychomycosis, aka: Toe nail Fungus. While treating skin is relatively easy, treating toenails is much more difficult. When the skin is wet, fungal infections spread from the skin to the nails. Do you see a theme here? Fungal infections are moisture driven. The main reason we develop toenail fungus is trauma. Inside a shoe and sock all day is a very harsh environment. The trauma to our skin and toenails makes us susceptible to fungal infections. The toenails are particularly prone to fungal infections because of this. Shoe trauma to the nails causes the toenail plate to move and shift on top of the nail bed. What I mean by trauma, is just daily shoe wearing. Not acute trauma like dropping a frozen Thanksgiving turkey on your toe. As the trauma occurs the toenails lifts off the nail bed, and those pesky dermatophytes find their way under your toenail. At first you may just notice some thin white or yellow streaks at the tips of your toenails. Sometimes the streaks will be along the nail groove where the skin meets the side of the toenail. As it progresses, you start to see yellowing, thickening, and sub-ungual build up under the toenail. As you build up more dissolved skin, nail and fungal elements under the nail plate, the nail can start to change shape and the nail may take on a more curved appearance. I often have patients ask if they should try and clean this out from under their toenails. The answer is no. As you use an instrument to clean under your toenails, you not only lift the nail plate more, helping the fungus get further underneath, you also push these microscopic organisms further and further under the toenail plate. This is a common problem with patients that get regular pedicures. Watch for our summer time blog on how to avoid these common problems from pedicures.

The difficulty in treating toenails, unlike skin, is the slow growing nature of toenails. A toenails takes 9-12 months to grow from start to finish. Typically the fungus grows faster. So even though you produce perfectly sterile healthy toenails, as they grow out, the fungus in the toenail continues to reinfect the healthy toenail. As a result, there are very few topical treatments to clear your toenails of a fungal infection. All of the products over the counter may help, especially if treatment begins very early in the course of the infection, but for the most part, I tell my patients we are hoping for controlling the spread, not curing the condition when using an over the counter topical treatment. And I have heard of just about every topical home remedy from Clorox to Vics Vapor rub, to oregano oil, to grapefruit seed extract oil, and white vinegar to listerine to being applied on the nails. You name it, someone has tried it. That goes to show you how common onychomycosis is in the population.

Now this takes us to medical treatments. In my opinion there are only two options for cure. The first is a prescriptions topical that is relatively new on the market called Jublia (efinaconazole). The other is a prescription oral antifungal called Lamisil (terbinafine). Jublia is applied daily for 11 months. Remember how slow toenails grow. When applied daily, Jublia acts as an external barrier to prevent further fungal infections of the nail plate. Once a week I recommend patients cut and file away any loosely attached nail. The goal of Jublia is to apply it to the remaining healthy nail by removing the infected damaged toenail.

Lamisil is an oral antifungal medication available only by prescription. Lamisil is taken once daily for 90 days. Before you start the medication you need to get a blood test to check your liver enzymes. Even though the risk of liver involvement is very low, a baseline liver function test (LFT) is recommended. At the end of your 90 day course of Lamisil your toenails will not look any better =( . It takes another 6 to 9 months for your nails to clear up. Again the reason, slow growing toenails. On the other hand, fingernails grow almost twice as fast as toenails. So if you want to have great looking toenails by summer, Winter is the time to start treating your toenails

Dr. Fedrigo

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