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Plantar warts can be challenging to treat in any patient. However, when factoring in complexities associated with a pediatric patient, the provider must carefully consider the best options for each case. Accordingly, the authors share an evidence- and experience-based plan for treating verruca, including what to do when first, second or even third-line treatments are unsuccessful.
One of the most common reasons for a visit to a podiatrist is the treatment of plantar warts. There are more than 30 different types of verrucae. Plantar warts are usually caused by walking barefoot around a swimming pool, on the beach or outdoors where these microscopic viruses are on the ground. These skin lesions are usually painful with lateral compression, have discontinuous skin lines and punctated bleeding upon debridement.
Treatment in the pediatric patient presents additional challenges to the foot specialist as he or she needs to manage parent expectations and patient fears. Accordingly, let us take a closer look at effective treatment for these persistent skin lesions
There are three primary goals of treatment of warts in the pediatric patient, which include resolving the warts as soon as possible, minimizing pain during treatment and keeping the patient active at school or with recreational sports. Parents typically want to resolve the problem as soon as possible. However, conservative care is recommended prior to surgical excision as, in our experience, topical treatments are often very effective in combination with sharp debridement by a podiatrist. If the wart is severely painful, larger than five mm or has been present for more than six months, parents may be more anxious for a quick solution, and the clinician may need to consider surgical excision initially.
Most children will be nervous on the first visit. Conservative care with debridement and topical medication is ideal to initially relax the child, and help the patient feel more comfortable for the next visit. In our practice, we always advise the parents that if the wart is not significantly smaller after three weeks, we will consider a more aggressive topical medication or surgical excision on the next visit.
Reviewing Common Wart Treatments And Associated Concerns
In the past, we have attempted many other methods of treatment for plantar warts but they have proven to be less effective or caused other complications. Prior use of topical medications including topical salicylic acid patches, fluorouracil ointment and others revealed less than a 50 percent success rate and often required numerous sharp debridements. The use of bleomycin injections has a high success rate but the medication is very expensive, has a short shelf life and the insurance companies often do not reimburse for this fairly. In addition, the medication requires a painful injection and may require a second debridement with injectable anesthesia to resolve the verrucae. This is not recommended for children.
In our clinical experience, the use of a carbon dioxide laser is a very effective treatment but often creates a large wound, which will take over one month to completely heal. The post-op wound is often painful and may limit weightbearing for more than three weeks. It also requires an anesthetic injection for excision and may result in painful scar tissue as the depth of the laser is sometimes difficult to control. In addition, the plume of smoke during debridement may be hazardous to the doctor, even when he or she is using a mask. This method is no longer recommended.
Keys To Treatment
Step 1. Our initial treatment plan for plantar warts includes sharp debridement and the application of topical Salinocaine™ (Premier Medical) ointment. One would apply this combination of concentrated salicyclic acid 55% and ethyl aminobenzoate (Benzocaine) under occlusion with moleskin or adhesive tape. For pediatric patients, we recommend applying the ointment at home before they go to sleep and removing it in the morning. This treatment does not usually cause pain and will keep the child active during the treatment process. It may require two to three debridements to resolve the wart. I usually see the patient every two weeks until the verruca is resolved. This method works well more than 50 percent of the time in our experience and clinicians can employ this treatment concomitantly with oral zinc sulfate if multiple warts are present.
Zinc sulfate is an excellent adjunct to topical medications. We typically recommend 220 mg orally twice daily for most children (10 mg/kg up to a maximum dose of 660 mg/day). We have found zinc sulfate very helpful in patients who have multiple verrucae or warts that are multiplying. This will typically take two to three months of treatment. Unfortunately, not all children can swallow a pill nor do they always remember to take the medication.
In a randomized controlled study of 43 patients, 86.9 percent of those in the zinc-treated group had complete wart clearance in three months in comparison to zero percent in the placebo group. Researchers also determined that most of the patients were deficient in serum zinc levels prior to treatment.1,2 It is important to discuss possible side effects from zinc, which include nausea, vomiting and mild epigastric pain. Explain to patients that they can minimize side effects by taking zinc sulfate with food.
Step 2. Vircin (Pedicis) is a new treatment that has emerged in the past few years. We have experienced significant success with it and the medication is well-tolerated by children. This product has povidone iodine, salicylic acid and an immunomodulant, which has antiviral activity. The immunomodulant triggers an immune response to clear the virus and prevent recurrence. The ointment is applied two times a day and you should ask the patient to wait five minutes before putting on his or her socks, or use a hairdryer to dry it more quickly. The product is dispensed from a doctor’s office. The patient usually needs to apply it for one to two months.
Every two to three weeks, a podiatrist should perform debridement until the warts are resolved to achieve the best results. We typically recommend this if Salinocaine was ineffective after three weeks or if the child is having difficulty with the Salinocaine applications due to skin irritation or placing too much cream on the foot at night. One advantage of the topical Vircin is you do not need to occlude it with tape or moleskin, and it comes with an easy applicator at the tip of the tube.
Step 3. If the wart is persistent after the use of Salinocaine, Vircin and/or zinc sulfate, the use of topical Cantharone® Plus (CPS) (1% cantharidin, 5% podophyllotoxin, 30% salicylic acid, Dormer Labs) is recommended with occlusion. Typically, one debrides the skin growth in the office and applies Cantharone Plus under occlusion with a pressure offloading pad. This topical medication will create a blister and is sometimes very painful for the first two days if the child is walking on it. Patients with multiple warts undergoing treatment or warts in weightbearing areas may benefit from crutches.
We recommend keeping the site dry for two to three days before returning to the clinic for surgical excision under local anesthesia. If the child is extremely anxious, then he or she can undergo surgical excision in the hospital or surgery center under local anesthesia with IV-monitored anesthesia. Upon surgical excision, the medication lifts the epidermal layer of the wart and surgical debridement will determine the depth of the excision. One will clearly see the stalk of the verruca and should sharply debride it down to the base. We recommend applying phenolic acid to the base of the wart after excision to cauterize the blood vessels as well as kill any remaining microscopic cells of the benign skin neoplasm. Dressings should include an antibiotic ointment, a non-adherent dressing and gauze for padding. Typically, the post-op wound will heal in one to two weeks and the patient should be able to return to full activities two weeks after the initial treatment.
Prior studies with Cantharone Plus have showed a 95.8 percent cure rate for plantar warts at six months in 144 adults and children.3 In a study by Lopez and colleagues on 75 patients using Cantharone Plus with occlusion followed by surgical excision, 100 percent of the patients had complete resolution at six months.4 Of the 75 patients, 72 percent required one treatment and the warts of the remaining patients resolved after two treatments. Of these 75 patients, 72 percent of the warts were located in the forefoot and 17.3 percent of the warts were in the rearfoot with the remaining warts in the midfoot. 4
Step 4. In rare cases of recurrence, we recommend surgical excision with local anesthesia or with IV sedation depending upon the maturity and anxiety levels of the patient. Initially, we debride the overlying hyperkeratotic tissue down to pinpoint bleeding and incise the verruca circumferentially through the epidermis down to the basement membrane, not extending into the dermis. One often uses a curette to help completely excise the wart. Subsequent pathologic examination of the specimen can help determine the type of verruca and rule out different benign or malignant soft tissue neoplasms.
We typically apply three, 30-second applications of phenol after excision to cauterize the surgical wound and help kill any remaining microscopic viral particles. We recommend daily dressing applications. The wound may take three to four weeks to heal or more depending upon the size of the lesion as we let the wound heal by secondary intention. If the wound is larger than five mm, we may suture the wound closed.
Reviewing The Rationale For A Unique Stepwise Treatment Algorithm
When a child notices a skin lesion on the bottom of the foot, he or she will often not tell his or her parents until it becomes larger and painful. Parents will often try over-the-counter topical acid creams or patches, duct tape or other home remedies. These lesions were often thought to spontaneously resolve in more than 50 percent of cases according to the literature but we have not seen this in our offices.
Many of these home remedies have been disproven in clinical studies over the years.5,6 Many pediatricians and dermatologists use liquid nitrogen on other parts of the body, but this painful treatment has a very low success rate on the plantar aspect of the foot. Analyzing 16 clinical trials of the use of cryotherapy in the treatment of cutaneous warts, Gibbs and colleagues found no significant difference in cure rates when comparing cryotherapy to placebo. 7
Warts on the bottom of the foot are much more resistant to treatment than warts on other parts of the body.8 One reason for this may be due to the epidermis being thicker on the plantar surface of the foot. These skin lesions invade the epidermal layer of skin but do not penetrate the basement membrane or the dermis. Histological exam reveals blood vessels and nerve endings looping up into the verruca, which make these skin lesions more persistent and more painful.
In our experience, good parent-provider communication is the most important aspect of effective treatment. Prior to starting this stepwise approach, one must address parents’ questions and concerns. If the parents are concerned about limiting the child’s activities, post-treatment pain or prolonged treatment, conservative care is always recommended.
Providers face an overwhelming number of treatment options for plantar warts including injectable medications, light and laser therapy, and other topical medications. However, there are no scientific studies to demonstrate their efficacy. Hopefully, the aforementioned stepwise approach, based on clinical experience as well as published research, will help clinicians resolve plantar warts in the pediatric population as soon as possible.
Dr. Feit is board-certified by the American Board of Podiatric Surgery and is a past president of the American Diabetes Association in Los Angeles. Dr. Feit is in private practice in Torrance and San Pedro, Calif. He and his co-authors can be found online at www.precisionfootandanklecenters.com.
Dr. Kashanian is in private practice in Torrance and South Los Angeles, Calif.
Dr. Argade is in private practice in Torrance and San Pedro, Calif.
Dr. Lashkari is in private practice in Torrance and San Pedro, Calif.
Given the increasing popularity of tennis, more and more players will present with injuries to the heel, Achilles, and ankle. These authors offer expertise on the mechanics of injury as well as exercises you can recommend to players for their rehabilitation to get back on the court.
Tennis has been one of the fastest-growing traditional sports in the United States during the past decade. With an estimated 46 percent increase in the number of participants, tennis has outpaced the growth of other popular sports, including baseball, ice hockey, gymnastics and football.1,2
The sport of tennis has changed significantly in the past 25 years. New equipment, including racquets and polymer strings, has increased the speed of the game even for the recreational player. The physicality of the sport is demanding with rapid changes in direction and frequent stopping and sprinting. Differences in skill level, court surface type, player age and physical conditioning can further influence or complicate injury manifestation.3,4
As a result of these changes, we are seeing an increase in the number of foot, ankle and leg injuries. The treatment and prevention of these injuries continue to change as well. With this in mind, we would like to share our experience with the management of these injuries.
In a prior study on 376 participants, Feit and Berenter determined that common foot and ankle injuries in tennis players included Achilles tendon injuries, plantar fasciitis, ankle sprains, subungual hematomas, muscle cramps and blisters of the feet.5 In recent years, we have seen an increased incidence of hip, hamstring, groin and thigh muscle injuries. We believe the increased speed of the game has contributed to this.
Understanding the most common strokes in tennis will help the coach and practitioner in the prevention and treatment of these injuries.
When hitting a forehand (see above left photo) or a backhand (see below right photo), most players use an open stance, which places a majority of the stress on the rear hip, thigh and calf during the backswing, and the weight transfers to the opposite foot after contact with the ball. The player is more prone to a muscle injury of the hip, thigh or groin. After one hits a wide forehand or backhand shot, the groin and ankle are prone to injury as the player tries to plant the outside foot and recover back into the court.
When hitting a serve, the calf muscle and Achilles tendon are most prone to injury, which is a result of stress on the legs and hips during the ball toss. Then there is a rapid jump to make contact with the ball and a forceful landing on the the back leg during the follow through as the back leg moves forward into the court (see photos below). The gastrocnemius muscle is susceptible to injury when a rapid eccentric contraction occurs as the foot experiences rapid dorsiflexion in the presence of knee extension. Although this is common when serving, it may also occur after an overhead smash or when chasing after a short ball.5
When Tennis Players Develop Muscle Strains
The most common muscle strains in tennis players are to muscles like groin and calf muscles that cross two joints. Injury most often occurs when the efforts of the adductors and hip flexors are opposed by lateral momentum, and contraction results in muscle tearing rather than the anticipated deceleration.6
Predisposing factors to muscle strains include muscle weakness, muscle imbalance and a lack of flexibility of muscles and the associated ligaments.7,8 The hamstrings, another common site for injury, should be at least 60 percent as strong as the quadriceps or injury to these muscles is likely.9,10 In recent years, players have been hitting forehand shots with the majority of the weight on the leg farthest from the net in an open stance position (see above left photo) As a result, players often develop one leg that is stronger than the other, which potentiates injury.
Many young tennis players often have weak lower extremity muscles and therefore do not have sufficient strength to hit the ball the way older players do. They must instead rely on biomechanical efficiency and looser string tension to hit the ball with more pace. If there are deficits anywhere in the kinetic chain, there will be an increased load of other joints and muscles, which leads to increased injury risk.8
Patients with hamstring and groin injuries commonly receive physical therapy including phonophoresis, electrical stimulation, taping and ice. These injuries will often keep a player off the court for two to six weeks, depending on the severity of the strain or tear. Continuing to play on the injury will only make it worse.
The calf muscle is a very common site of injury. The medial head of the gastrocnemius muscle is the site of predilection for calf muscle tears.11,12 The mechanism of injury is the result of a sudden step or jump producing an acutely painful situation that players describe as having been struck hard with a club on the back of the calf.
When it comes to calf muscle strains, patients typically receive physical therapy modalities including phonophoresis, electric stimulation and passive motion exercises. Immobilization is not recommended unless it is a severe tear or there is Achilles tendon involvement. Patients should apply topical anti-inflammatory gel in the form of diclofenac gel three times a day and seek treatment with a physical therapist.
Keys To Addressing And Preventing Achilles Tendonitis
Achilles tendon injuries may be acute or chronic. A sudden significant increase in activity or the effect of long-term repetitive stress on the tendon may lead to the development of microtears with or without calcium deposits, or degenerative changes. The area located 2 to 6 cm above the insertion of the Achilles tendon in the posterior aspect of the heel is the most common site of injury. This region of the tendon has poor vascularity and is more prone to injury. Calcaneal eversion, a plantarflexed first ray, flexible forefoot valgus and abnormal pronation may contribute to this injury as well.13,14Rapid, abnormal pronation in gait results in a whipping action of the Achilles tendon, producing an increase in friction between the tendon and peritenon.
Initial treatment for Achilles tendonitis should include a heel lift, ice, topical diclofenac gel, a night splint and rest. If the patient is limping, controlled ankle motion (CAM) walker immobilization may be needed for two to four weeks prior to physical therapy and rehab exercises.
Once the inflammation resolves, we recommend custom orthotics that would include a semi-rigid material (i.e., polypropylene). This material will have some flex when the patient is playing but still provide adequate support. We do not recommend rigid materials for tennis players. A rearfoot post is needed with Achilles tendon injuries to help prevent overstretching of the tendon and further injury. Top covers with nylene and Poron will provide more shock absorption and minimize stress on the lower extremity.
Pertinent Insights On Ankle Sprains
An ankle sprain is a common injury that will prevent the player from competing for two to six weeks, depending on the severity of the sprain. The most common mechanism involved is a plantar flexion inversion type injury. Etiologic factors that predispose the athlete to ankle sprains include a rigid forefoot valgus or plantarflexed first ray, rigid or high degrees of rearfoot varus, limited ankle joint dorsiflexion, intoeing conditions, limb length discrepancy, muscle imbalance or weakness, fatigue, ligamentous laxity, shoes and playing surface.15
Treat grade 1 ankle sprains with ice, compression and proprioceptive exercises. Grade 2 ankle sprains require CAM walker immobilization for two to four weeks followed by the use of an ankle brace. Physical therapy is very helpful after three weeks to help reduce the pain and inflammation. A popular ankle brace for college and professional players is the ASO ankle brace, which patients wear over a sock and has laces with Velcro straps for support. Taping is not as popular anymore as we have found it often loosens up 50 percent after one hour of use. Patients can tighten ankle braces periodically as needed if they are wearing them while playing.
Grade 3 ankle sprains will require more time off the court as they often require six weeks of immobilization in a CAM walker and ankle brace, and then at least four weeks of physical therapy prior to the patient returning to the court. Even after the ankle heals from a sprain, we recommend using an ASO ankle brace for at least one year after the injury for grade 2 or grade 3 sprains to help prevent recurrence. Despite proprioceptive exercises, the ankle is vulnerable to recurrence with the physical demands of playing tennis.
How Can Tennis Players Recover From Plantar Fasciitis?
Pain in the heel and arch is a common injury in tennis players. This injury is a result of chronic overuse caused by microtearing of the fascia fibers secondary to longitudinal midtarsal joint supination with subtalar joint pronation. The microtearing that occurs initiates an inflammatory response in an attempt to repair the damaged fibers. The pain produced is most often localized to the attachment site of the plantar fascia at the medial tubercle of the os calcis. Pain may be most severe when taking the first few steps out of bed in the morning or when warming up to play tennis. The pain may gradually lessen with exercise only to return after a period of rest.
Treatment for plantar fasciitis should initially include ice, calf stretching, over-the-counter orthotics, oral anti-inflammatories and using more supportive shoes. If the pain persists, treatment often includes a night splint and a corticosteroid injection. For long-term pain relief and prevention of recurrence, we often recommend custom orthotics. We recommend a semi-rigid polypropylene device with a soft top cover. Research has shown that custom orthotics help reduce peak pressures on the feet at specific plantar regions, which will help prevent recurrence of the injury.16
Preventing Injuries Before Athletes Take The Court
Fitness training has evolved in recent years to help prevent injuries and enhance play. Prior to playing, patients often perform dynamic exercises to help warm up the hamstring, groin and hip muscles. This may include straight leg swings, skipping, light jogging and side to side shuffling. After playing, static stretching and yoga exercises are the most important factors in muscle recovery and maintaining elasticity of the muscles. Professional players such as Roger Federer and Novak Djokovic will often spend 30 to 60 minutes stretching and doing yoga-type exercises after a match or long practice.
The top five most important stretches or yoga positions after practice include hamstring stretching with a strap or elastic band. The safest way to do this stretch is while the patient is lying on his or her back, and keeping both legs straight. Then the patient should slowly elevate one leg with the use of the strap until he or she feels resistance. Have the patient hold the stretch for at least 30 seconds. It is vital to also stretch the iliotibial band at the same time. The iliotibial band often contributes to knee and thigh injuries. The patient can also stretch the iliotibial band easily while lying on his or her back by simply moving the leg medially with the strap.
Other vital stretches include the crescent lunge, which will stretch the plantar heel and arch, hip, calf and thigh muscles. The groin and quadriceps stretches are also essential after playing.
Strength training is a vital part of a tennis player’s training not only to help improve his or her game but help prevent injury as well. Some exercises that are very helpful are lunges, rotational exercises with a medicine ball and balance exercises with the feet flat or the heels raised in a semi-seated position known as a chair pose (see below photos). When performing this exercise with a medicine ball, patients will strengthen core muscles as well as the peroneals, calf and quadriceps.
What You Should Know About Knee Injuries On The Tennis Court
The sharp side-to-side movements in tennis predispose the athlete to significant valgus and rotary stresses on the knee. The most common injuries include patellar tendonitis, patellofemoral pain, meniscus injuries and cruciate ligament damage. These side-to-side movements require pushing off with the knee in a flexed, valgus and externally rotated position. This places abnormal lateral forces on the knee extensor mechanism, contributing to injury. Some predisposing factors to knee injuries in tennis players include playing surface, shoe gear, increased femoral anteversion, increased external tibial torsion, increased genu valgum and excessive foot pronation.17,18
Patellar tendonitis is a common knee injury in tennis. This may be caused by the constant bending, jumping and pushing off during the recovery of wide shots. This repetitive action leads to fatigue and tissue microtearing at predisposed areas near the insertion of the patellar tendon. Microtearing often occurs at the lower pole of the patella. A hypermobile patella or tight iliotibial band are often etiologic factors in patellar tendonitis.19,20 Treatment often includes ice, physical therapy and use of a patellar tendon strap/brace.
Dr. Feit is in private practice in Torrance and San Pedro, Calif. He is the President of Precision Foot and Ankle Centers.
Dr. Kashanian is in private practice in Torrance and San Pedro, Calif.
Mr. Feit is a research assistant at Precision Foot and Ankle Centers.
- United States Tennis Association. Tennis fastest growing sport in America. Available at www.usta.com .
- Gaw C, Smith G. Tennis related injuries treated in United States emergency departments, 1990-2011. Clin J Sport Med. 2014; 24(3):226-232.
- Perkins RH, Davis D. Musculoskeletal injuries in tennis. Phys Med Rehabil Clin N Am. 2006; 17(3):609-631.
- Bylak J, Hutchinson MR. Common sports injuries in young tennis players. Sports Med. 1998; 26(2):119-132.
- Feit EM, Berenter R. Lower extremity tennis injuries: prevalence, etiology, and mechanism. J Am Pod Med Assoc. 1993; 83(9):509-514.
- Balduini FC. Abdominal and groin injuries in tennis. Clin Sports Med. 1988; 7(2):349–57.
- Liemohn W. Factors related to hamstring strains. J Sports Med. 1978; 18(1):71–6.
- Hjelm N, Werner S, Renstrom P. Injury risk factors in junior tennis players: a prospective 2-year study. Scand J Med Sci Sports. 2012; 22(1):40-48.
- Burkett LN. Causative factors in hamstring strains. Med Sci Sports. 1970; 2(1):39–42.
- Casperson PC. Groin and hamstring injuries. Athlete Train. 1982; 17(1):43.
- Miller WA. Rupture of the musculotendinous juncture of the medial head of the gastrocnemius muscle. Am J Sports Med. 1977; 5(5):191–3.
- Millar AP. Strains of the posterior calf musculature. Am J Sports Med. 1979; 7(3):172–4.
- Leach RE. Achilles tendinitis. Am J Sports Med. 1981; 9(2):93–8.
- Nelen G. Martens M. Surgical treatment of chronic Achilles tendonitis. Am J Sports Med. 1989; 17(6):754–6.
- Petrov O, Blocher K. Footwear and ankle stability in the basketball player. Clin Pod Med Surg. 1988; 5(2):275–90.
- Hodge MC, Bach TM. Orthotic management of plantar pressures and pain in rheumatoid arthritis. Clin Biomech. 1999; 14(8):567-575.
- Gecha SR, Torg E. Knee injuries in tennis. Clin Sports Med. 1988; 7(2):435–52.
- Milgrom C, Finestone A. Patellofemoral pain caused by overactivity: a prospective study of risk factors in infantry recruits. J Bone Joint Surg. 1991; 73A(7):1041–3.
- Ferretti A, Ippolito E. Jumper’s knee. Am J Sports Med. 1983; 11(2):58–62.
- Martens M. Wouters P. Patellar tendonitis: pathology and results of treatment. Acta Orthop Scand. 1982; 53(3):445–50.
For further reading, see “Key Insights On Treating Tennis Injuries” in the August 2005 issue of Podiatry Today or “Pertinent Insights On Preventing Injuries On Tennis Court Surfaces” at http://tinyurl.com/go7kd34 .
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As we move forward with our blog, we hope to promote podiatric awareness as a vital part of your healthy, active lifestyle. Here you will find a variety of articles and topics including the latest developments in podiatry, podiatric treatments and helpful foot care advice from Dr. Feit and his staff.
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