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ARIZONA VEIN & VASCULAR CENTER New Year, New You January-March 2015 Highlighted Articles: What is this painful bump on the back of my heel? By: Dr. Ronald D. Holgado What is Lymphedema? By: Dr. Baljeet S.

Let the health care providers here at Arizona Vein & Vascular Center support you in reaching your goals and resolutions this year! Feel better. Walk faster. Be stronger. Live longer.

1 ARIZONA VEIN & VASCULAR CENTER New Year, New You January-March 2015 Highlighted Articles: What is this painful bump on the back of my heel? By: Dr. Ronald D. Holgado What is Lymphedema? By: Dr. Baljeet S. Uppal It s a new year and the question that is always asked is What s your New Year s resolution? Many of us focus on improving our health. Let the health care providers here at Arizona Vein & Vascular Center support you in reaching your goals and resolutions this year! Feel better. Walk faster. Be stronger. Live longer. To schedule an appointment call AZ.VEINS A Slow-Growing Fire: The Symptoms of Venous Insufficiency By: Dr. James E. Wiseman Dear Reader, We are delighted to introduce you to third edition of the Arizona Vein & Vascular Center s Newsletter. We intend to make this a regular publication and use it to keep you in touch with news and developments, which relate to our centers and staff. We plan on sharing all our activities with you and are excited to include patient stories, bios, articles, updates, related news from our doctors, and more. In this edition, we've included personally written articles from some of our top specialists. -Arizona Vein & Vascular Team

What is this painful bump on the back of my heel? This bump is called "Haglund's deformity. Haglund s deformity is a bony enlargement on the back of the heel.

This often produces an inflammation of the bursa (a fluid-filled sac between the tendon and bone) called a "bursitis.

As a matter of fact, any shoes with a hard back, such as ice skates, men s dress shoes, or women s pumps, can cause this irritation.

2 What is this painful bump on the back of my heel? This bump is called "Haglund's deformity. Haglund s deformity is a bony enlargement on the back of the heel. When the bony enlargement rubs against shoes, soft tissue near the Achilles tendon becomes irritated. This often produces an inflammation of the bursa (a fluid-filled sac between the tendon and bone) called a "bursitis. This deformity is often called pump bump because the hard backs of pumpstyle shoes can create pressure that rubs the heel bone when walking. As a matter of fact, any shoes with a hard back, such as ice skates, men s dress shoes, or women s pumps, can cause this irritation. Heredity plays a role in Haglund s deformity that can make one prone to developing this condition can include the following: A high-arched foot A tight Achilles tendon A tendency to walk on the outside of the heel Symptoms- Haglund s deformity can occur in one or both feet. The symptoms include: Article Written By: Ronald D. Holgado, DPM A noticeable bump on the back of the heel Pain in the area where the Achilles tendon attaches to the heel Swelling in the back of the heel Redness near the inflamed tissue Diagnosis- The foot and ankle surgeon will examine the foot and evaluate the patient s symptoms. In addition, x-rays will be ordered to help the surgeon evaluate the structure of the heel bone. Non-Surgical Treatment Medication- Oral nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen. Ice- To reduce swelling, apply an ice pack to the inflamed area. Exercises- Stretching exercises help relieve tension from the Achilles tendon. Heel lifts- Heel lifts placed inside the shoe decrease the pressure on the heel. Heel pads- Heel pads placed inside the shoe cushion may help reduce irritation when walking. Shoe modification- Backless or soft backed shoes help avoid or minimize irritation. Physical therapy- Physical therapy modalities, such as ultrasound, can help to reduce inflammation. Orthotic devices- Custom arch supports control in the motion of the foot. Immobilization- Casting may be necessary in some instances. Surgical Treatment If non-surgical treatment fails to provide adequate pain relief, surgery may be necessary to remove the bump. To find out if you may have Haglund deformity, please call to schedule an appointment today AZ.VEINS. 2

What is Lymphedema? What is it? Article Written By: Baljeet S. Uppal, MD Lymphedema occurs when lymph collects in the body, usually the arm or leg.

Lymph vessels collect a fluid that is made up of protein, water, fats, and wastes from the cells of the body. Lymph vessels carry this fluid to your lymph nodes.

If the lymphatics or nodes are damaged or not developed, lymph fluid cannot move freely through the system, causing LYMPHEDEMA.

3 What is Lymphedema? What is it? Article Written By: Baljeet S. Uppal, MD Lymphedema occurs when lymph collects in the body, usually the arm or leg. The lymphatic system consists of microscopic lymph vessels and lymph nodes that run through your body. Lymph vessels collect a fluid that is made up of protein, water, fats, and wastes from the cells of the body. Lymph vessels carry this fluid to your lymph nodes. Lymph nodes filter waste materials and foreign products, and then return the fluid to your blood. If the lymphatics or nodes are damaged or not developed, lymph fluid cannot move freely through the system, causing LYMPHEDEMA. It is of two types: Congenital lymphedema- sometimes called primary lymphedema, in which one is born lacking lymph vessels and nodes. It can be of three types, lymphedema congenital, lymphedema precox and lymphedema tarda. Appearing in early childhood, adolescence, and adulthood respectively. A rare form of primary lymphedema develops in infancy and is called Milroy s disease. Acquired lymphedema, sometimes called secondary lymphedema, in which an injury to your lymphatic system causes lymphedema. The injury may be from any surgery, especially extensive surgeries, radiation, cancers, parasites (filariasis). It is much more common than primary lymphedema. It is a chronic and long-standing issue and is rather difficult to treat. Swollen limbs may become vulnerable to infection. Even a minor injury to the skin, such as a cut, scratch, insect bite, or even athlete s foot between the toes can cause a severe infection, which physicians call lymphangitis. Lymphangitis affects the connective tissue under the skin. Repeated infections can cause scaring that makes the tissue vulnerable to more swelling and infection. This leads to the tissue hardening and that is called fibrosis, which is a characteristic of advanced chronic lymphedema. How to diagnose? One may not develop symptoms immediately. Sometimes symptoms occur 15 or more years following an injury to your lymphatic system. When symptoms eventually occur, they can include: Aching, weakness, redness, heaviness, or tightness in one of your limbs Less flexibility in your wrist or ankle Tight-fitting rings or shoes (page 4 continued) 3

4 What tests to diagnose? A thorough history and physical examination by an expert is a must. To confirm a diagnosis of lymphedema, your physician may order tests, including one or more of the following: Lymphoscintigraphy- which uses a low-dose injected radioactive substance to trace the flow of lymph fluid through your lymphatic vessels Magnetic resonance imaging (MRI)- which uses radiowaves and magnetic fields to detect patterns in your internal tissues that are characteristic of lymphedema Computed tomography (CT)- scanning, which creates images of your internal tissues from a series of crosssectional x-rays Duplex ultrasound- which uses high-frequency sound waves and Doppler technology to show vessels and real-time blood flow on a screen, often necessary to rule out a blood clot in your leg Lymphangiography- which uses contrast (dye) directly injected into the lymphatic vessels, which is now used less frequently How is lymphedema treated? If already developed, to prevent worsening by preventing infections some of these steps may help: Clean your affected limb regularly. Remember to dry it thoroughly and apply lotion Wear gloves while gardening and cooking If you shave the affected area, use an electric razor Do not go barefoot Do not cross your legs when you sit Do not carry a handbag with your affected arm In addition, if you are at risk for lymphedema, avoid having injections and blood pressure readings performed on your affected limb. You can also wear a special bracelet or necklace to notify medical personnel of your risk for lymphedema and the risk for complications, such as infection. Physicians have not agreed about how to best treat chronic lymphedema. Some people have benefited from manual lymphatic drainage. This treatment uses massage to stimulate your weakened lymphatic system. Other treatment methods include special exercises that you can do while wearing compression stockings or bandages, and the use of external pumps to aid the movement of fluid through your body. A solution that combines these treatments with lifestyle changes is called complex decongestive therapy by lymphatic pumps. Medication cannot cure lymphedema. However, your physician may prescribe medications to treat associated conditions. For example, antibiotics play an important role in combating infections that can worsen lymphedema. Your physician may recommend surgery to remove excess tissue if your limb becomes so large and heavy that it interferes with your ability to move it. Treating your lymphedema requires your participation because lymphedema can be very painful, you may benefit from individual counseling. You can also join support groups that provide practical advice as well as social and emotional support. For more questions on lymphedema, please call AZ.VEINS. 4

A Slow-Growing Fire: The Symptoms of Venous Insufficiency Venous insufficiency (reflux) is a chronic medical issue, meaning that the disease can be present for many years before it is detected.

Typically, it isn t until several years after the onset of the insufficiency that any effects of the disease are noticed.

5 A Slow-Growing Fire: The Symptoms of Venous Insufficiency Venous insufficiency (reflux) is a chronic medical issue, meaning that the disease can be present for many years before it is detected. In the early stages of venous insufficiency, most people are asymptomatic, although this is not always the case. Typically, it isn t until several years after the onset of the insufficiency that any effects of the disease are noticed. The purpose of this article is to describe the symptoms of venous insufficiency, with short discussions on how the disease causes these untoward effects. Some individuals may experience only one of these symptoms, while others may experience many, if not all of those described. All of them, individually or collectively, can have a dramatic, negative impact on quality of life, and all warrant medical attention when present. Varicose Veins Article Written By: Strictly speaking, varicose veins are more James E. Wiseman, MD appropriately classified as signs of venous insufficiency rather than symptoms. Regardless of what they are called, varicose veins are among the most distressing effects of untreated venous insufficiency. The skin and soft tissue just underlying the skin carry small veins that serve as the route of venous drainage for this tissue. These are countless, and typically are invisible to the naked eye. With chronic venous reflux, excess blood continuously pools in the legs, and these vessels serve as storage sites for this surplus blood. Over time, they become distended and engorged, sometimes to such a degree that they become visible. These visible variants are what are commonly known as varicose veins. It is important to realize that these come in all sorts of shapes and sizes; from cord-like reticular varicose veins to the complex constellations of spider veins. However, these all share a common underlying disease process, and the treatment is therefore identical. Leg discomfort This symptom is both broad in the descriptors used to describe it, and vague in it s characterization. The discomfort can be either generalized, affecting the entire leg, or focal, in that it may be limited to specific areas of the legs. The symptom itself is frequently described by patients as heaviness, or fatigue. These terms probably describe a similar sensation arising from the same phenomenon; specifically, all of the excess blood that collects over time bears weight. Imagine lifting an empty 1-gallon bucket. Piece-of-cake, right? Now imagine lifting the same bucket, this time full to the brim. Your legs bear a greater resemblance to the full bucket than to the empty one after several years of accumulating refluxing blood. Patients with venous insufficiency also report other varieties of discomfort. These range from generalized cramping sensations, to stinging pains limited to specific collections of varicosities. Still others report a vague, intermittent, achiness. The discomfort can be constant or limited to particular times of day, and occurs on a spectrum from very mild discomfort to severe, life-limiting pain. The mechanisms underlying this discomfort are unknown, although they are probably related to the cumulative effects of increased pressure, stretch on vessel walls, nerves, and skin, and loss of nutritional support. (page 6 continued) 5

Leg swelling/chronic wounds Excess blood collecting in the veins of the legs exerts pressure that forces fluid out of the vessel and into the soft

This is commonly known as edema, or swelling, and represents the greatest medical threat associated with chronic venous insufficiency.

Furthermore, this fluid is nutrient-poor and impedes the delivery of nutrient-rich blood to the area, presenting a significant healing challenge.

In addition to being messy, painful, and unsightly, these wounds bear significant risk of infection.

tissue, the accumulated coloring effects of the presence of a multitude of engorged veins, and the generalized redness associated with widespread

Moreover, the psychological effects of leg discoloration can be as damaging as any of the other symptoms characteristic of this disease.

to quality of life. Treatment of the venous insufficiency will halt the progression of all of these signs and symptoms, and may reverse many of them.

6 Leg swelling/chronic wounds Excess blood collecting in the veins of the legs exerts pressure that forces fluid out of the vessel and into the soft tissue of the legs. This is commonly known as edema, or swelling, and represents the greatest medical threat associated with chronic venous insufficiency. Over time, this swelling thins the skin, predisposing the leg to wound, or ulcer formation. Furthermore, this fluid is nutrient-poor and impedes the delivery of nutrient-rich blood to the area, presenting a significant healing challenge. In fact, an estimated 80% of chronic, non-healing wounds of the legs in the United States are directly related to venous insufficiency. In addition to being messy, painful, and unsightly, these wounds bear significant risk of infection. Fortunately, chronic wounds are typically present only in the late stages of the disease, meaning most people at risk of developing them receive treatment before they develop. Leg discoloration Several elements of venous insufficiency can lead to leg discoloration, including the deposition of minerals in the skin and soft tissue, the accumulated coloring effects of the presence of a multitude of engorged veins, and the generalized redness associated with widespread inflammation. Though not typically dangerous clinically, some of the causes of this discoloration are not reversible. Moreover, the psychological effects of leg discoloration can be as damaging as any of the other symptoms characteristic of this disease. Importantly, the signs and symptoms of chronic venous insufficiency effect different people differently, and all of them can be dramatically limiting to quality of life. Treatment of the venous insufficiency will halt the progression of all of these signs and symptoms, and may reverse many of them. Not surprisingly, the earlier the disease is treated, the better the outcome that might be anticipated. Think you may have symptoms related to venous insufficiency? Talk to your knowledgeable professional at Arizona Vein & Vascular Center today! To schedule an appointment in one of our centers, please call AZ.VEINS Meet Our Team AZVVC Providers from left to right: Dr. L Philipp Wall, MD, Dr. Parag Rami, MD, Dr. Marc Eckhauser, MD, Dr. James E. Wiseman, MD, Dr. Ronald D. Holgado, DPM, Dr. Baljeet S. Uppal, MD, Kimberly Hart, NP, Robert Gervais, PA-C, Catherine Munsterman, PA-C, Melinda Gutierrez, PA-C 6

7 Arizona Vein & Vascular Center Issue 3 1st Quarter

Bursitis. Other joints are found between the different bones of your fingers and toes. You also have joints that allow your vertebrae to move.

Bursitis. Other joints are found between the different bones of your fingers and toes. You also have joints that allow your vertebrae to move. Bursitis Introduction Bursitis is a common condition that causes swelling around muscles and bones. It happens most often in the shoulder, elbow, hip, or knee. Bursitis is usually caused by overusing a