Foot & Ankle

Plantar Fibroma What You Need to Know

Plantar Fibroma What You Need to KnowA plantar fibroma is a benign, noncancerous nodule that grows in the arch of your foot. It develops in the plantar fascia, the thick, fibrous tissue at the bottom of your foot. This tissue covers the area from your heel to your toes and stabilizes your foot arch. The exact cause of plantar fibromas is unknown but many experts believe that they begin with small tears in your plantar fascia from a trauma. The nodules develop as a result of scar tissue that forms from healing the tears. Recent studies suggest that plantar fibromas may also be genetically inherited.

Common symptoms of fibromas are pain and discomfort, especially when wearing shoes. Unfortunately, fibromas will not go away without treatment. If your podiatrist determines that a plantar fibroma is the source of your problem there are several non-surgical treatments available. Options can include topical gels, corticosteroid injections to help reduce pain and decrease the size of the nodule and custom orthotics for comfort and cushioning. In severe cases surgery may be needed to remove the nodule. Plantar fibromas are diagnosed through examination and imaging such as MRIs and X-rays. It is important to be examined by a podiatrist if you notice any new growths or masses to rule out more serious conditions.

Reviewed by Daniel Perez, D.P.M., AACFAS

Dr. Perez is a fellowship trained foot & ankle surgeon specializing in ankle arthroscopy, total ankle replacement, advanced trauma and complex reconstructive surgery of the foot and ankle. He has additional focus in charcot reconstruction, general podiatry, wound care and sports medicine.

Exercises for Increased Bone Strength

An estimated 10 million people in the United States have developed osteoporosis. Osteoporosis is characterized by chronic bone loss that leads to weak bones that fracture easily. Fractures of the spine, hip, and wrist are the most common. With the right steps and effective care, it’s possible to boost your bone health and lower your fracture risk.
The Best Exercises for Bay Area Orthopaedic Specialists


Exercise increases your muscle mass which in turn can enhances your strength, muscle control, bal­ance and coordination. Good balance and coordination can mean the difference between falling, suffering a fracture or staying on your feet. Medical studies have proven that regular physical activity can reduce falls by nearly a third in older adults at high risk of falling.



This form of exer­cise challenges your muscles by working against resistance such as dumbbells and elastic bands. Resistance exercises including classic strength training or even using your own body weight to rely on muscle contractions that stimulate muscles to build up.



Weight bearing exer­cise are activities such as running, walking, dancing, hiking, climbing stairs, playing tennis, golf, or bas­ketball in which you carry your body weight and work against gravity. The force you exert to counteract gravity when you do weight bearing activities stimulates your bones to become stronger.  This is in contrast to non-weightbearing activities such as swimming or cycling where the water or bicycle supports your body weight.



When you run, jog or power walk you mul­tiply the weight bearing effect of gravity. Higher impact activities have a more pro­nounced effect on your bones than lower impact exercises. Impact can be increased even more if your speed increases.



Changing direction benefits your bones. When researchers reviewed bone strength in the hips of athletes, they found that those who played sports such as soccer which involve rapid turns, start-and-stop actions had bone strength similar to those who did high impact sports like high jumpers, they all had greater bone density than long distance runners.



Balance exercises involves doing exercises that strengthen the muscles that help keep you upright, including legs and core. These types of exercises serve as a bone-protecting function that improves health, stability and helps to prevent falls.

Consult your specialist before starting any exercise program if you have been diagnosed with osteoporosis. In the meantime, think about what kind of activities you enjoy most. If you choose an exercise you enjoy, you’re more likely to stick with it over time. Regardless of age or gender it’s never too late to start exercising!

Reviewed by David T, Braun.  MD

A Challenging Case of Limb Preservation for A Patient with Neuropathic Pedal Dislocation

Ronald D. Troxell, DPM and Mohammad Abuamaish, DPM December 2021
Podiatry Today – December, 2021 – Full Article


In the summer of 2020, an 82-year-old male presented to the emergency department to evaluate right foot pain and swelling over the past week. He saw his primary care physician earlier in the morning, who referred him for more emergent evaluation. He states he fell at home one week ago, injuring his right foot. This initially resulted in minimal pain, but over one week, the pain and swelling continued to worsen. He notes that he had no open wounds or active bleeding at the time of the initial injury. However, over that week, in addition to the escalating pain and swelling, he developed a bleeding ulcer on the dorsal aspect of the right foot. He could stand and ambulate, albeit with discomfort. He states that weight-bearing and ambulating for prolonged periods exacerbate his symptoms. He notes that the pain today is moderate and that he has not tried any therapy to relieve his pain besides rest, which only marginally helped. The worsening pain, swelling and bleeding prompted his visit to his primary physician.

The patient’s past medical history was significant for benign essential hypertension, hypothyroidism, benign prostatic hypertrophy without obstructive symptoms, and idiopathic neuropathy. His past surgical, family and social histories, along with his allergies were all unremarkable. The patient’s medications included doxazosin 2 mg by mouth twice a day, lisinopril 20 mg by mouth once a day, and levothyroxine 50 mcg (0.05 mg) by mouth once a day. The patient had no other associated symptoms or findings upon review of symptoms, aside from those from the past medical history. Wound cultures revealed colonization by Pseudomonas spp. susceptible to ciprofloxacin. Laboratory examination was normal, and in fact, the ED physician initially had concerns for possible compartment syndrome. Examination revealed a foot that was cool to the touch, with non-blanchable erythema, crepitus and a fully mobile LisFranc joint.

Pertinent Points in The Treatment Course
The patient has no prior incident of Charcot neuroarthropathy, and it is important to note that the patient does not have diabetes, but has idiopathic neuropathy. We discussed multiple points with the patient, including the neurovascular insult as well as the neuropathic dislocation. We also discussed the active soft tissue necrosis and the likelihood that the dislocation itself was present for greater than just that week with soft tissue contracture. We felt it necessary to explain to the patient that at this point, in our opinion, it was unlikely that his foot would reduce in a manner that would lend itself to normal anatomy. The goal, ultimately, would be to establish a plantigrade foot. We discussed the high probability of a below-knee amputation due to multiple factors, including the current state of the foot. The patient voiced understanding of the situation, and expressed that he wanted to try all possible options to save his foot. He explained the importance of performing his normal daily activities, including transferring around his home. Two recurring themes we note when considering treatment of Charcot neuroarthropathy are setting appropriate patient expectations and understanding the patient’s needs. These two concerns are very intertwined and in our experience, can dictate the treatment plan going forward. In this case, the patient did not have diabetes, had low metabolic demands, and we felt saving his foot would likely increase his quality of life.

The patient underwent Charcot foot reconstruction on the right foot with application of a Stryker triplanar external fixator. There was a significant component of laxity noted with attempts at closed reduction. However, due to the significant dislocation and length of time of presence of the deformity, it was immediately apparent that reduction would not be simple.

Despite the compromise of the soft tissue envelope structural integrity, it was necessary to make multiple incisions to achieve relative reduction. There were three incisions in total: the first incision along the medial column; the second lateral to the second metatarsal base; and the third between the fourth and fifth metatarsal bases. Even with this adequate exposure, the foot could not adequately reduce in the sagittal plane. Multiple osteotomies across the tarsometatarsal joint with overall shortening achieved the desired reduction. Temporary pinning-maintained position.

We then assembled and affixed a Stryker butt frame to the right lower extremity. Utilizing the concept of the butt frame along with the dynamic struts, we achieved stability to the rearfoot and further dialed in the correction of the forefoot utilizing the forefoot ring and struts. The patient remained pain-free and was discharged home with home health and oral antibiotics per infectious disease recommendations. The goal was to have him remain in the external fixator for three months for consolidation and further soft tissue healing. Discoloration to the distal toes improved exponentially after surgical reduction, and the toes returned to a more normal appearance. The patient followed up routinely every week with further necrosis and soft tissue demarcation, especially at the dorsal aspect of the foot and the medial column. He underwent gradual, weekly debridement with further soft tissue demarcation and evidence of viability of the underlying tissue noted to the dorsum of the foot. However, the medial column gradually worsened, and at the five-week mark, there was exposure of the medial cuneiform bone. We decided to take him back to the operating room. Though the patient had been very adherent with his care, surgical debridement of the bone and potential hardware removal would be necessary.

Six weeks after Charcot foot reconstruction, the patient returned to the operating room. We removed the external fixator and debrided the nonviable tissue. Debridement of the medial cuneiform revealed it to be soft. The overall architecture of the foot was such that the medial cuneiform was very prominent in an area of extensive soft tissue necrosis. We decided to remove the cuneiform and send it for pathology. He underwent pinning of the tarsometatarsal joint, and remained non-weight-bearing. Additionally, we debrided the remaining wound and applied a Stryker ProLayer® acellular dermal matrix. The pathology report was positive for osteomyelitis to the medial cuneiform. The patient had a PICC line placed for six weeks of IV antibiotics, per infectious disease recommendations. Postoperatively, the patient continued to improve. The graft and the pins remained in place for one month; then, we decided to take him back to the operating room for additional debridement with a second graft application. We removed the second graft five weeks after its application. The patient had been weight-bearing as tolerated in a CAM boot during that time.

Weekly local wound care continued with no further grafting. He transitioned back into a standard shoe for transfers around his home. His wound healed 10 weeks later.

In Summary
The total time to heal for the patient was eight months. He underwent a total of three surgeries. The patient has a brace and a boot but admits he just wears a slipper in his home and is fully ambulatory for transferring with an overall low activity level. Ultimately, the patient is very happy to have his foot. The osseous anatomy remains flexible, and he has no pre-ulcerative areas of concern.

Dr. Troxell is a podiatrist with Bay Area Orthopaedic Specialists in St. Petersburg, FL. He is a staff physician with the St. Petersburg Innovative Foot and Ankle Surgery Fellowship program

Dr. Mohammad Abuamaish is a first-year podiatry resident with the James A. Haley VA in Tampa, FL

Ronald D. Troxell, DPM Performs the First 4-D Minimal-Incision DynaBunion™ Surgery in Tampa Bay

DynaBunion 4D Minimal Incision Bunion CorrectionBay Area Orthopaedic Specialists is proud to announce that Ronald D. Troxell, DPM has performed the first 4-D minimal-incision DynaBunion™ Surgery in the Tampa Bay Area.

The 4-D minimal-incision Lapidus System for surgical bunion repair enables surgeons to restore normal foot anatomy by realigning the bones in four different dimensions through smaller incisions. “Patients can look forward to less pain and scarring thanks to a smaller incision. Due to the enhanced stability, patients are able to begin walking in nearly half the time of typical bunion surgery.” said Dr. Troxell.

For more information or to schedule an appointment with Dr. Troxell please call 727-209-6677.

What is a Podiatrist?

Podiatrist“But that’s what podiatrists do. They deal in fungus. They’re knee-deep in fungus. This guy knows fungus.” This quote may sound familiar if you are a fan of Seinfeld…

And yes, it is true. A podiatrist is your go-to doctor for fungal toenails and athlete’s foot. But today’s podiatrist can offer so much more.

A podiatrist specializes in all aspects of the lower extremity below the knee. This classically includes toenails, heel pain, bunions, hammertoes, flat feet, arthritis, and fractures. Additionally, podiatrists deal with aspects of dermatology, neurology, plastic surgery, and complex reconstructive surgery of the lower extremity. This may include diagnosing and treating a melanoma, treating peripheral neuropathy, performing a skin or muscle flap to cover a wound, or even addressing a residual clubfoot deformity. Podiatrists play a crucial role in the management of diabetes and peripheral vascular disease as well. In fact, it is recommended that these patients see a podiatrist every 3 months for routine care.

Podiatrists employ many cutting edge techniques including stem cell injections, laser therapy, shockwave, minimally invasive surgery and 3D scanning of orthotics.

Whether a painful ingrown toenail or a complex deformity correction, a podiatrist can handle any problem that involves your foot or ankle. Let us help you at Bay Area Orthopaedic Specialists. Call to schedule your same day appointment with Dr. Troxell.

Strategies For Beating Heel Pain: Guide To Overcoming Plantar Fasciitis

Heel pain is one of the most common chief complaints seen in a foot and ankle specialists’ office daily. Its most widespread cause is plantar fasciitis.

Plantar FasciitisPlantar fasciitis is inflammation of the wide band of tissue called the plantar fascia located deep in the sole of your foot. This band runs from your heel bone towards the ball of the foot. It is a ligament that attaches your heel bone to the bones of the metatarsals.  It serves as a supporting structure for the arch of your foot.

The plantar fascia has a huge job supporting the arch of the foot and can commonly become fatigued or injured. This creates inflammation and pain especially with the first step out of bed in the morning or standing after extended periods of rest.

Over time if left untreated it can lead to damage to the architecture of the ligament itself with tearing and chronic inflammation. The tightness of the ligament can also lead to the development of heel spurs. It is important to see a specialist when these symptoms first arise as effective treatment becomes more difficult the longer it has gone neglected.

Treatment for plantar fasciitis is most successful when done in a multimodal approach. This includes a regimen of rest, icing, oral anti-inflammatories, injection therapy, stretching, proper shoe wear, and orthotics.

If you are suffering from heel pain, call to schedule your appointment with Dr. Troxell and get back to being pain free. 727-209-6677.

Save Your Feet and Do the Sting Ray Shuffle

Stingrays can be found swimming in the warm shallow water at every beach in Florida, they are very shy and not aggressive. Injuries from stingrays occur when the stingray gets frightened from a person unexpectedly stepping on them.  When stepped on, they will whip their long thin barbed tail into your foot or ankle leaving behind traces of venomous toxins. The sting is powerful and incredibly painful.

You can lower your chances of being stung by a stingray by learning a little about them, and what you can do to avoid them.

Florida stingray season is April through October. They are often found very close to the beach, burying themselves in the sand to hide from predators.  Stingrays have extremely poor eyesight; they use electro-sensors/vibrations to know what’s going on around them. To avoid stingrays, do not run and jump into the gulf water with large steps, shuffle your feet in the sand lightly as you move out into water, this will help push vibrations out in your surrounding area. This shuffling will let the stingrays know you’re in the area and they will most likely move away from you.

What to do if you’re stung by a Stingray

If you are stung by a stingray, immediately get out of the water. If you have trouble walking, which is normal, sit down and ask someone nearby to get help. Because stingray injuries hurt so much, medical attention is usually warranted. Pain management, wound care, a tetanus vaccine update and antibiotics are the most likely treatments. If the barb has punctured and broken off into your foot or ankle don’t attempt to remove it. Seek emergency medical attention immediately.

If pain is tolerable and no broken barb is embedded in your foot or ankle, clean and disinfect the puncture wound with soap and water and immediately start soaking your foot in hot water, this will neutralize the venom and eventually reduce the pain. The hotter the water, the better. Oral pain medication such as acetaminophen (Tylenol) or ibuprofen (Advil) can be taken, Follow up with medical care is advised.

Reviewed by Ronald D. Troxell, D.P.M.

Dr. Troxell offers both conservative and surgical management to the lower extremity. Ronald treats all aspects of the foot and ankle, from ingrown toenails and skin lesions to complex fractures and nerve pain. He specializes in arthroscopy, trauma, bunions, Charcot, total ankle arthroplasty, complex reconstructive surgery of the foot and ankle, and sports medicine.