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Dr. Leonora Fihman attended undergraduate school at the University of California at Davis where she completed her Bachelor of Science degree in psychobiology. She volunteered at the UC Davis Medical Center where she learned about various medical specialties. It was there that she was exposed to podiatric medicine and decided to make it a career. She went on to graduate and received her medical degree (DPM) from the New York College of Podiatric Medicine. Her postgraduate training was completed at Kindred Rancho Hospital in Rancho Cucamonga and at Camp Pendleton Marine Corps Base. She received extensive 3 year training in both podiatric medicine and surgery. During her final year of residency, Dr. Fihman held the position of chief surgical resident. Following residency, she underwent additional training in aesthetic foot surgery with Dr. Vladimir Zeetser and after working together, she was asked to join the practice.
Dr. Fihman is extensively trained in all aspects of the foot and ankle with a focus on adult and pediatric flatfoot reconstruction, trauma, sports medicine, deformities and wound care. She likes to complete all her surgeries with an aesthetic twist. She is currently on staff at Northridge Hospital, Mission Community Hospital and various surgical centers in the San Fernando Valley.
Dr. Fihman is a member of several societies and organizations including the American Podiatric Medical Association and the Los Angeles County Podiatric Medical Society. She is board certified by the American Board of Podiatric Medicine (ABPM).
Dr. Fihman maintains ongoing training and education to remain up to date on the newest innovations in technology and the latest trends in podiatric medicine and surgery.
Dr. Leonora Fihman is a podiatric physician and surgeon specializing in foot and ankle surgery. She combines state of the art implants and fixation devices with the latest and most innovative procedures available today to obtain the best possible aesthetic and functional result with little to no pain.
The main focus of her practice is the complete satisfaction of all of her patients. Every effort is made to ensure that her patients make well-informed choices and achieve the best results possible, all within a comfortable and confidential setting.
One of the goals of this website is to provide you with an extension of care. As you navigate through the site, you will find a wealth of information and services available. Dr. Fihman treats all aspects of foot and ankle structural disorders, including lower extremity muscular, neurological, vascular and skin conditions.
During your consultation, Dr. Fihman always performs a thorough evaluation, explains her findings in detail and creates a treatment plan tailored to your specific needs. You will find her warm and direct approach for treatment very comforting. She involves her patients in their care and is easily approachable for questions and concerns.
Dr. Fihman has received extensive training in lower extremity wound care and diabetic limb salvage. She uses a variety of the most advanced topical wound treatments available including specialized collagen and silver impregnated dressings and topical medications. She has had great wound healing results with a dehydrated Human Amnion/Chorion membrane allograft called Epifix. Dr. Fihman treats complicated wounds, which are difficult to heal.
It is estimated that approximately 17 million Americans have diabetes mellitus with almost 1 million new cases diagnosed each year. Diabetes is a multisystem disease that effects the cardiovascular, renal, retinal, nervous and immune systems, which all contribute to diabetic foot complications. Foot ulcers contribute to lower extremity amputations and 85% of diabetes related lower extremity amputations are preceded by a foot ulcer. Routine exams with a foot and ankle specialist is extremely important to prevent ulcerations, infections and amputations.
Ten percent of all diabetic patients have some form of sensory, motor, or autonomic dysfunction at the time diabetes mellitus is diagnosed. Sensory neuropathy is the most prevalent nerve dysfunction in diabetic patients and is the major factor precipitating foot ulceration. Pain may be superficial and patients feel a burning, tingling, shooting or cramping/aching type sensation. Motor neuropathy is clinically evident by the presence of claw toes caused my muscle weakness and Achilles tendon contracture. The combination of these factors causes transfers stress leading to high pressures and skin breakdown. Pressure is placed on top of the toes as they come in contact with the toe box of the shoe as well as on the ball of the foot causing a risk of skin breakdown. Autonomic neuropathy occurs when the autonomic nervous system is not able to control the sweat and lubricating glands in the foot causing dryness and cracks in the skin. This allows for a pathway of bacteria to enter the skin.
Treatment for peripheral neuropathy is medications, infra-red light therapy such as Anodyne which Dr. Fihman offers in her office and surgical nerve decompression.
Vascular disease resulting from diabetes mellitus may be the underlying cause of most diabetes-related complications. Atherosclerosis which is a disease in which plaque builds up inside your arteries, which in time limits the flow of blood to your organs and other parts of your body. Decreased blood flow to the lower extremities causes poor healing and wounds become easily infected leading to gangrene and amputations. Peripheral arterial disease in diabetic patients occurs at a much younger age and with more rapid involvement than in nondiabetic patients. If ischemia is present the patient will be referred to a vascular surgeon who will perform an arterial bypass or an angioplasty. Dr. Fihman works closely with vascular surgeons in her area who strongly believe in limb salvage to help her have good results with these complicated cases.
Ulcers occur in diabetic patients as a result of peripheral neuropathy, peripheral arterial disease, or a combination of both. With chronic open wounds, the risk of osteomyelitis and amputation increases. Local wound factors such as infection, recurring trauma to a wound combined with a patient’s limited ability to sense pressure applied to it, continued pressure from a bony prominence, ischemia or a foreign body can cause wound healing to fail. Risk factors for ulceration include: poor glucose control, malnutrition, immunosuppressive drugs, steroids, tobacco, peripheral vascular disease and extremity swelling from venous insufficiency or congestive heart failure. Treatment for diabetic foot ulcers includes sharp debridement of all unhealthy tissue, off-loading the pressure that is causing the ulcer and applying various wound dressings. Sometimes surgery is required to remove pressure on the affected area by shaving, excising bone or correcting deformities such as bunions or hammertoes.
Diabetic foot infections are often polymicrobial meaning they have multiple types of bacteria. Diabetic foot infections that do not threaten the limb can be treated with either oral or IV antibiotics. Limb-threatening and life-threatening infections are treated with IV antibiotics. Antibiotics used to treat osteomyelitis, which is a bone infection may be taken for 4 to 6 weeks depending on the bacterial agent and the extent of the bony debridement. Osteomyelitis develops due to a non-healing or neglected ulcer. Due to diabetic neuropathy a patient with a foot infection such as osteomyelitis may not have any symptoms except an ulcer that is becoming worse or not healing. Foot infections are diagnosed by blood tests, x-rays, MRI, bone biopsy and cultures that will determine the correct antibiotic treatment.
To prevent the above mentioned foot problems affecting diabetics follow simple guidelines and you can prevent infections and other problems from developing. Also by routinely seeing your podiatrist. Call the office immediately if your foot becomes red, hot or swollen. If you develop foot or leg pain. If you develop a blister, sore, abrasion, burn or ingrown toenail.
Leonora Fihman, DPM
5400 Balboa Blvd #325
Encino, CA 91316
Aetna, United Health Care, Cigna, BlueShield, Anthem Blue Cross, Health Net
We accept major credit cards including VISA, MC, AE and Discover
We have state of the art digital X-ray equipment in the office for your convenience.
An ingrown toenail is when the nail plate has grown into the sides of the nail with or without an infection. The skin becomes irritated when the nail digs into the nail borders and can cause pain, redness, swelling and warmth to the toe (paronychia). An infection occurs in the area because an ingrown causes a break in the skin allowing bacteria to enter. At times a pus pocket can be present under the skin. With chronic ingrown toenails, overgrown tissue develops along the nail fold causing repetitive wound irritation and bleeding.
What causes an ingrown nail?
Ingrown toenails are caused by multiple factors. The most common cause of ingrown toenails is improperly cutting the nails. When the nails are cut too short or at an angle the skin next to the nail is likely to fold over the nail. In many people ingrown nails are a result of genetics. Trauma such as stubbing a toe, having an object fall on your toe, physical activities that cause constant pressure on the toes and improperly sized footwear also can cause ingrown nails. Patients with fungal infections are also prone to ingrown toenails.
Ingrown nail treatment
Treatment involves education on proper nail trimming techniques such as cutting the nails straight across and not cutting them too short. If the case is mild and just beginning and the patient does not have any signs of infection or any at risk medical conditions than initial treatment can be safely performed at home with warm water Epsom salt soaks. It is not recommended to repeatedly cut the nail as the problem may worsen. If your symptoms do not improve, it is time to see a specialist. If an ingrown toenail is infected no amount of antibiotic will cure it until the offending nail border is satisfactorily removed.
Temporary removal of the offending border is generally recommended in a first-time case of ingrown toenail, while chronic ingrown toenails are best treated with either a chemical or surgical matrixectomy.
Dr. Fihman treats many sports related injuries ranging from trauma to wear and tear to chronic injuries. The most common sports injuries in the field of podiatry are ankle sprains, chronic ankle instability, tendonitis, fractures and stress fractures.
A neuroma is a benign thickening of nerve tissue and the most common in the foot is a Morton’s neuroma, which occurs between the third and fourth toes. With chronic irritation, the nerve thickens and enlarges. The mechanism of injury of the nerve is due to entrapment and repetitive injury of the nerve.
The incidence of interdigital neuromas is much greater in females than males because they typically wear shoes with a high heel and narrow toe box, which is a major cause of the disease process. Anything that causes compression or irritation of the nerve can lead to developing a neuroma. Activities that involve irritation to the bottom of the foot such as walking or running can contribute to the development of a neuroma as well as any trauma to the foot. Patients with foot deformities such as bunions, hammertoes and flatfeet are at a higher risk of developing a neuroma.
Patients commonly report pain at the ball of the foot. The pain is usually accompanied by a burning and tingling sensation that shoots into the involved toes. As the injury progresses patients may feel numbness. Patients may describe the feeling of something moving around or a wrinkle in the sock on the bottom of the foot. Symptoms are often relieved by stopping the aggravating activity, removing the shoe and massaging the foot. The symptoms become more intense and last longer as the neuroma enlarges and causes permanent damage to the nerve.
Diagnosis is best made by a thorough history and physical examination. A helpful test is to squeeze the foot from side to side while touching the web space, which may result in a click or grinding feeling. Weight-bearing x-rays may be helpful to rule out a bone related problem such as a stress fracture. An MRI can also be ordered to diagnose a neuroma.
Non-surgical treatment is often successful. Neuroma symptoms can be relieved by wearing wider shoes, shoes with stiffer soles and lower heels. A metatarsal pad can alleviate excessive pressure under the metatarsal heads. Ice therapy and anti-inflammatory medications (NSAID’s) can be used to decrease pain and inflammation. Custom molded orthotics is important and help provide the support needed to reduce the pressure and compression that is placed on the nerve. Dr. Fihman will also recommend corticosteroid injections to reduce any inflammation and break down scar tissue around the nerve. Sometimes multiple injections are needed. In more severe and chronic cases in which conservative treatment has failed, another treatment option is alcohol sclerosis injections. This injection deadens the nerve causing less pain because the nerve is no longer signaling.
Surgical treatment is indicated when nonsurgical treatment failed. The most common surgical treatment is excision of the nerve. The procedure removes the nerve from the area of the metatarsal heads. Surgery will decrease or completely remove the pain.
What is toenail fungus?
Toenail fungus is a very common condition in which the fungus invades the root of the nail. Fungus is everywhere in the environment and only becomes harmful when it invades through minor cuts or after injury. Fungus likes to live in dark, moist surroundings like the inside of shoes and stockings, which make feet susceptible to a fungal infection.
Symptoms of toenail fungus
Signs of a fungal infection are thickening and discoloration of a nail. The nail may become darkened, yellow or brittle. The nails often become brittle with pieces breaking off from the toe. The nail may appear raised or detached from the nail bed. There may be an unpleasant smell. The nails may be painful in a shoe due to the thickness.
What cause toenail fungus?
Nail fungal infections are typically caused by a dermatophyte fungus that invades the nail root and bed. Yeasts and molds can also cause nail fungus infections. Also as we age blood circulation is diminished and the nails begin to grow slower and thicker. Risk factors for fungal infections include diabetes, athletes foot, wearing closed toes shoes for excessive periods of time, sweating, humid environment, going barefoot in public areas such as pools, gyms and shower rooms, wearing socks and shoes that do not have good ventilation and having a weakened immune system.
Diagnosis of toenail fungus
Diagnosis is made by a clinical examination and any history of nail damage. A sample of nail may be taken from the infected nail and sent to a lab to determine if a fungal infection is present and the type.
Treatment of toenail fungus
Patients have to understand that it may take a year for a new nail to grow and replace the old infected nail. Toenail fungus is not an easy condition to treat. The first go to treatment is typically a topical medication which is typically a gel or nail polish. A prescription will be given or a topical anti-fungal can be purchased over the counter. The patient has to know that this medication must be applied every day for at least a year for optimal results. For more severe forms of fungal infection an oral anti-fungal medication named Lamisil is recommended and has a higher success rate as compared to a topical alone. A liver function test must be done to make sure there are no current liver problems prior to starting the oral medication. Dr. Fihman also uses the CoolTouch Laser to treat fungal infections with excellent results. As the laser treats the nail patients feel a warming sensation. The treatment takes 3 treatments and a touch up if needed. Laser is a very effective and safe method of toenail fungus treatment.
Orthotics are shoe inserts that correct an abnormal, or irregular, walking pattern. Generally called arch supports, orthotics allow people to stand, walk, and run more efficiently and comfortably. Podiatrists sometimes prescribe orthotic devices to correct an abnormal walk, or gait, and often for patients following surgery. Orthotic devices come in many shapes and sizes, and materials and fall into three main categories: those designed to change foot function, are primarily protective in nature, and those that combine functional control and protection.
What is it?
The most common cause for heel pain is plantar fasciitis. There are many other causes for heel pain such as stress fracture, fat pad atrophy, arthritis, compressed nerve, tendonitis or cyst. Heel pain must be properly diagnosed to begin the right treatment course. The plantar fascia is a tough, fibrous band composed of both collagen and elastin fibers that extend from the heel to the toes. The plantar fascia is the major support of the arch during gait. When there is prolonged, excessive tension in the plantar fascia usually secondary to excessive pronation (rolling in), inflammation of the plantar fascia results at its attachment in the heel causing heel pain. A heel spur may or may not be present and is rarely the source of the pain.
What causes Plantar Fasciitis?
This is a unilateral condition occurring in both men and women who remain active by walking and performing standing activities. Causes include poor foot mechanics such as patients with flatfeet or high-arched feet, as well as a tight Achilles tendon. Repetitive microtrauma to the ligament can begin to cause pain and inflammation at the heel because the micro tears have increased. At night when the patient sleeps, the foot relaxes in a downward position allowing the inflamed fascia to shorten and tighten. On the first step in the morning, the contracted fascia is stretched too quickly and therefore very painful. Inappropriate footwear such as flats can cause a strain on the plantar fascia. Being overweight can also contribute.
Symptoms of Plantar Fasciitis
Patients usually describe a gradual onset of deep aching pain at the bottom of the heel that is not associated with any specific injury. The pain is well localized to the bottom inner aspect of the heel. The patient’s history usually describes a recent increase in ambulatory activities prior to the onset of pain. Patients often report pain that is most severe when they take their first few steps when arising from bed in the morning or standing up from a chair. They also report that pain is aggravated by weight-bearing activities and relieved by rest.
Diagnosing plantar fasciitis
Plantar heel pain syndromes are primarily defined by a detailed history and physical examination; however ancillary tests may be appropriate to confirm the diagnosis, since there are many causes for heel pain. Digital x-rays of the feet will be obtained. Sometimes heel spurs are found in patients, but these are rarely a source of pain. If a heel spur is present, the condition is called “Heel Spur Syndrome.” If the problem becomes chronic or the ligament is ruptured, an MRI must be ordered.
Treatment for Plantar Fasciitis
90% of cases improve with nonsurgical treatment. Treatment of plantar fasciitis begins with a protocol that can be done at home. Exercises that stretch out the calf muscles as well as the plantar fascia effectively treat plantar heel pain. Since plantar fasciitis is an overuse inflammatory condition, avoiding high-impact activities and maintaining aerobic fitness by swimming, biking, or using an elliptical walker is recommended. You can reduce inflammation and pain by applying ice and taking anti-inflammatory medications (NSAIDs). Avoid going barefoot because when without shoes you put strain and stress on the plantar fascia. Also wear supportive shoes with an arch support and avoid wearing flats. In the office, Dr. Fihman will recommend custom molded orthotics that slip into your existing shoe. The purpose of orthotics is to hold the foot in its proper position and alignment. The orthotics supports the plantar fascia when it is torn or inflamed. A night splint is also recommended to assist the patient with stretching. A night splint has been shown to help alleviate pain on the first step in the morning by maintaining the fascia stretching during sleep. A corticosteroid injection can also be administered to help alleviate pain. Wearing supportive shoes, stretching and using custom orthotic devices are long term care for plantar fasciitis.
Most patients with plantar fasciitis respond to non-surgical treatment and a small percentage of patients require surgery. Surgery may be considered if there has been at least 6 months of failed non-surgical treatment. Dr. Fihman has found that the best surgical results are with a complete release of the plantar fascia from its attachment at the heel. The ligament can no longer tear and cause inflammation. The patient will be in a cast to control the stress on the plantar fascia post-operatively. This is an outpatient procedure.
It is appropriate to treat a bunion non-surgically. The patient must be educated about appropriate shoe wear, including wearing low-heeled shoes with a wide toe box and soft leather uppers to relieve pressure over the medial bunion. Various padding devices or cushions placed over the bunion may be helpful as well as toe spacers between the big toe and 2nd toe. Strapping or splinting the big toe may partially reduce the deformity, but does not provide long-term benefit. Calluses can be shaved in the office periodically. Custom orthotics are recommended in alleviating symptoms in patients with flatfoot and associated pain along the metatarsals. Corticosteroid injections can be useful in treating the inflamed bursa that is sometimes seen with bunions.
Surgical treatment is chosen for hallux valgus deformity when non-surgical measures have failed. Surgery may be the first method of treatment for a patient with a severe deformity with pain. The goals of surgery are a pain free joint, intermetatarsal angle less than 10 degrees, congruent joint, good range of motion, sesamoids in good position, a beautiful aesthetic result and have the least chance of recurrence. There are a lot of myths about the recovery after bunion surgery. Most of our patients experience minimum to no pain after surgery. Based upon radiological and clinical assessment the surgeon must decide the right choice of procedure.
The FastForward Bunion Correction Procedure is a revolutionary approach to bunion surgery. An FDA-approved medical grade titanium alloy plate is used to anchor the first metatarsal to the second metatarsal with very strong suture material and reduces the deformity while sparing the bone. The unique design of this medical device, achieved through 3D printing technology, comes in multiple sizes to closely match the anatomy of the second metatarsal. Traditional surgical approaches as stated above involve cutting, realigning and fusing the first metatarsal or the metatarsal-cuneiform joint. These procedures however require long recovery periods and complications including delayed union, malunion, nonunion, avascular necrosis (death of bone tissue due to a lack of blood supply), excessive shortening of the 1st metatarsal, hardware failure and prolonged non-weightbearing. The FastForward Bone Tether plate eliminates the need for bone screws in the second metatarsal. The plate allows the podiatric surgeon to safely wrap the metatarsals with suture tape and pull the bones and big toe into proper alignment. There is a quicker recovery and less pain for the patient with less drilling and bone cutting.
A bunion deformity is a misaligned big toe joint that can become swollen and tender, causing the big toe to deviate towards the second toe and a bump or bunion to form on inside (medial aspect) of the big toe joint. As time progresses, the angle between the first and second metatarsal bones increases and the bunion becomes larger. Initially, it may be without symptoms, however because of the deviation at the joint, arthritis may develop and destroy the joint and cause pain. Bunions are generally thought to be hereditary, but their development can be exacerbated and hastened by tight fitting or narrow shoes, flat foot and hypermobility deformity. It becomes very difficult to wear shoes comfortably and depending on the patient’s age, can lead to skin breakdown and wounds. Conservative therapy is typically only temporary and thus surgery is frequently performed to correct the problem.
A painful bunion leads to restrictions of daily and recreational activities, difficulty in wearing shoes and overall decreased quality of life. A Bunion (hallux abducto valgus) occurs in both adults and adolescents. A bunion is not simply a bump, it is actually a dislocation of the 1st metatarsophalangeal joint. There is a medial deviation of the first metatarsal meaning the 1st metatarsal shifts away from the other long bones causing an increase in the angle between the 1st and 2nd metatarsal. At the same time this deviation leads to increased laterally directed pressure on the big toe. As a result of this the head of the 1st metatarsal becomes very prominent making it difficult to wear shoes due to pressure and becomes painful. As the deformity worsens as it does over time, the 1st metatarsal becomes unstable causing arthritis in the big toe joint, transfer stress to the 2nd metatarsal head as well as causing a hammertoe to the second digit due to the hallux pushing against the 2nd digit.
Bunions are primarily genetic in nature; however there are numerous factors that have been proposed as contributors to the development of one. Inappropriate shoe wear, particularly high heels allow limited space for the forefoot pushing the big toe to the second toe. An underlying flatfoot deformity or hypermobility of the medial aspect of the foot can cause changes in the mechanics and muscle direction of the joint causing the shift of the 1st metatarsal. Inflammatory arthropathies, including rheumatoid arthritis and psoriatic arthritis are also predisposing factors.
Bunions are not always painful, however when they are the location may mean different things. Pain medially may indicate bursal irritation, which is a fluid filled sac that provides cushion between bones and tendons that becomes inflamed from friction. Plantar pain may be indicative of sesamoid involvement because hallux valgus causes sesamoids to be in an abnormal position, therefore causing improper pressure. Pain on top of the joint implies arthritic involvement of the joint. Patients can notice painful thickening of the skin (calluses) as well as swelling and redness along the medial bump. Other symptoms include numbness and a burning sensation along the prominence when rubbed in a shoe.
Bunions are diagnosed by physical examination and x-rays. The overall alignment of the foot is visually inspected, including the arch height, lesser toe deformities, and any plantar calluses under the second or third metatarsal heads, which may indicate hypermobility of the medial column. Appropriate radiographic evaluation requires weightbearing views to determine the true extent of the deformity.
Certain angular measurements are determined to aid in defining the type and severity of the deformity, which Dr. Fihman will explain to the patient in great detail.
Hammertoe is a bending of one or both joints of the lesser digits (digits 2-5). Hammertoes become a problem when wearing shoes because the abnormal bending can put pressure on the toe and cause painful corns and calluses. Digital deformities are classed according to their flexibility, which changes over time becoming more rigid. Once the deformity becomes rigid surgery may be the only option as far as treatment. Hammertoes should be addressed early as they are progressive and never get better without intervention.
Although neuromuscular and congenital pathologies may contribute to lesser toe deformities, ill-fitting shoes along with the aging process are the leading cause. The lesser toes contribute to balance and pressure distribution on the foot and when this delicate imbalance between muscles and tendons occurs, deformities such as hammertoes or claw toes can result. A hammertoe may result if a toe is too long and becomes cramped when a tight shoe is worn. With a severe bunion deformity the big toe shifts toward the 2nd digit causing the ligament on the bottom of the joint (plantar plate) to stretch out and exacerbate the hammertoe deformity.
These deformities are typically painful when the patient is wearing shoes. The flexed tips of the toes can develop corns as well as on the top of the toe caused by constant friction against the shoe. Inflammation and redness can also occur. In patients with neuropathy like a lot of our diabetic patients, this can result in infection of soft tissues and bone.
During physical examination, the physician evaluates the flexibility of the deformity to determine a treatment plan because the surgical options vary based on whether the deformity is rigid or flexible (able to be reduced). Digital x-rays will be obtained in the office and will show the extent of the contracture.
Roomy, well fitted shoes with a high toebox and a soft sole are the primary treatment. Shoes with high heels or pointed toes should be avoided. Protective pads or sleeves over the dorsal aspect of the toe can be applied to diminish pressure from the toebox of the shoe. Over-the- counter medicated pads are not recommended because they may contain a small amount of acid that can be harmful. Hammertoe slings attached to a metatarsal pad and taping of the MTP joint toward a neutral position also can be beneficial. Corticosteroid injections as well as oral nonsteroidal anti-inflammatory medication are sometimes used to help with pain and inflammation. Custom orthotics can also be made to help control the muscle/tendon imbalance; however there is no way to reverse the deformity. This is a progressive deformity that will only become worse with time.
Surgery is typically needed when the hammertoe has become more rigid and painful. The goal of surgery is to bring the toe into a corrected position, increase its function, and create a pain-free aesthetic result. When a flexible deformity becomes painful and assessed early enough early correction can be as simple as a soft tissue release. The best results occur when the deformed and contracted digit is fused along with a tendon transfer. The digit is fused with wires or implants that are hidden within the digit and do not require later removal. Following the surgery, the patient is weightbearing in a boot.