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Scientific News in Foot Pain (Part 2):
Non-Insertional Achilles Tendinopathy Treated with Gastrocnemius Lengthening
Tendinitis of the Achilles tendon is one of the most frequent problems that I see. It can be located either directly above the back of the heel or behind the ankle. When it is behind the ankle, it is often a bulbous lump. Sometimes people are concerned that it may be cancer, but tumors in this area are very rare. When it is near the heel (insertional Achilles tendinitis), it can rub on the counter of the shoe.
Prolonged nonoperative treatment including physical therapy, immobilization, weight relief, and strengthening exercises for two months or more are generally recommended prior to any consideration of surgery. Surgical treatment involves removing the scarred and degenerated tendon and repairing it. The recuperation can be painful and prolonged. The success rate is generally quoted at between 70 and 90%.
Dr. Duthon and her associates (Duthon VB et al. Noninsertional Achilles tendinopathy treated with gastrocnemius lengthening. Foot Ankle Int. 2011 Apr;32(4):375-9) have reviewed the success of gastrocnemius tendon lengthening in treatment of non-insertional Achilles tendinitis after two years. This surgery involves cutting a portion of the tendon/muscle area in the midcalf. Lengthening of the tendon in this area is easier to recover from and is usually less painful. It relieves some of the tension around the inflamed area. Of the 14 patients (three whom had both of the tendons done in this manner), all but one was satisfied with the results, and 11 of the 14 were able to resume their previous sporting activities. MRIs taken of the area showed a decrease in the signal hyper intensity, suggesting that some healing had occurred.
I find this study interesting not only because it demonstrates a easier, more effective, less direct surgical treatment for Achilles tendinitis, but also because it seems to suggest that loosening the gastrocnemius muscle complex aids in the healing of Achilles tendinitis. Because of this, I am more convinced that stretching exercises along with eccentric muscle/tendon conditioning directed at loosening the gastrocnemius muscle nonoperatively can be effective if treatment is continued over a long period of time.
–Brett Fink, MD. Co-author of The Whole Foot Book: A Comprehensive Guide to Taking Care of your Feet
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Scientific News in Foot Pain (Part 3):
Association between Plantar Fasciitis and Isolated Contracture of the Gastrocnemius
My book, The Whole Foot Book, is focused on the nonoperative treatment of foot pain. One of my main tenets is that many common chronic foot pains are caused and can be treated by correcting overloading of the forefoot. Many studies have shown an association of limited ankle dorsal flexion or gastrocnemius contracture and plantar fasciitis and other foot problems. In fact, they have shown that surgical loosening of a portion of the gastrocnemius is effective at relieving the pain. This is mentioned not so much to advocate it as a panacea for the treatment of foot problems, as there are many serious consequences to gastrocnemius lengthening, but to illustrate that directing treatment towards the underlying stiffness in the Achilles and hamstring muscles is a powerful tool in curing plantar fasciitis.
Dr. Patel and Dr. DiGiovanni (Patel A, DiGiovanni B. Association between plantar fasciitis and isolated contracture of the gastrocnemius. Foot Ankle Int. 2011 Jan;32(1):5-8.) examined people with plantar fasciitis. They found that 83% of people with plantar fasciitis had some form of limited ankle dorsal flexion or stiffness. Many of these were felt to be due to contracture of the gastrocnemius/Achilles muscles and tendons.
Other researchers have noted this in the past. One researcher, Dr. Labovitz et al. (Foot Ankle Spec, Jun 2011, 4(3), p 141-144), commented that, in addition to gastrocnemius tightness, patients with hamstring tightness were about 8.7 times as likely to experience plantar fasciitis. This helps doctors design rehabilitative treatments that are likely to help people with plantar fasciitis.
–Brett Fink, MD. Co-author of The Whole Foot Book: A Comprehensive Guide to Taking Care of your Feet
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I’ve written several times previously regarding the use of platelet rich plasma in the treatment of musculoskeletal problems, primarily commenting on its uses in the foot and ankle (See also my recent article in J Musculoskeletal Medicine on Plantar Fasciitis, and upcoming comment on PRP in Achilles Tendinitis). A recent new article appeared in the AAOS (American Academy of Orthopedic Surgeons) newsmagazine AAOS Now. It describes a presentation done by Dr. Raymond Monto, M.D. at the 2012 AAOS annual meeting entitled “PRP is more effective than cortisone for chronic severe plantar fasciitis”. Unfortunately, while I was at the meeting, I did not get the opportunity to see this presentation.
According to the article, Dr. Monto reported on 40 patients randomized into treatment with cortisone injection or PRP. He followed these patients for a year. Initial function scores were approximately 44 initially. At three months, those in the PRP group were at 95 while those in the cortisone group had function scores of 81. At the conclusion of the trial, the PRP group continued to have scores that were 94, while those in the cortisone group had scores around 58. It should be noted that Dr. Monto disclosed an association to Exactech, Inc., a company that, among other products, does sell equipment that makes PRP. No mention in this article was made regarding whether the patients were blinded to their treatment.
While this study is encouraging, it should be noted once again that several other studies have failed to definitely show an improvement in other forms of connective tissue damage, such as recently Achilles tendinitis. This study has many limitations and caution should be used until it is confirmed by other larger studies. PRP continues to be poorly covered by most insurances.
The need for the slow incorporation of this new product into general treatment is highlighted by another article in the same issue of AAOS Now which discussed the disappointing results of BMP (bone morphogenic protein) in operations used to make bones fuse. The large industry-sponsored trials used to evaluate the substance showed it to have no bad effects, but this did not prove true with further study. They stated that “shortfalls, including poor design and reporting bias in peer review/publications, ‘may have promoted widespread, poorly considered on-and off-label use, eventual life-threatening complications, and deaths.’” The history of medicine is littered with these stories.
In medicine, what seems a logical, safe, easy, and common-sense approach to a problem may in the end be ineffective and possibly even dangerous. Safe, non-operative methods of treating plantar fasciitis exist. Stay persistent and consistent and often it will pay off. Avoid the temptation to resort to unproven methods such as platelet-rich plasma (PRP).
–Brett Fink, MD. Co-author of The Whole Foot Book: A Comprehensive Guide to Taking Care of your Feet
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Scientific News in Foot Pain (Part 1):
Alcohol Sclerosing Therapy Is Not an Effective Treatment
for Interdigital Neuroma
Morton’s neuroma is a commonly diagnosed pain in the front of the foot. This pain is characteristically between the third and fourth toe in the ball of the foot. It is usually worse with walking and with tighter shoes. Often, a click is noted in this area and numbness or tingling is in the toes. It can be quite painful.
Injections with alcohol are commonly prescribed. As you can imagine if you have ever put alcohol on an open wound, injections of alcohol into your tissue are quite painful. A recent study done by Dr. Espinosa in Zürich, Switzerland (Espinosa N et al. Alcohol sclerosing therapy is not an effective treatment for interdigital neuroma. Foot Ankle Int. 2011 Jun;32(6):576-80.)
recently reported on 32 patients who had been treated with alcohol injections around the painful neuroma. The patients had been injected with alcohol several times over a year treatment period in the irritated area in their forefoot. Of the 32 patients, 25 showed no significant reduction of symptoms or underwent surgery for the Morton’s neuroma. Three of these patients developed transient intolerable pain from the injection, but no major complications or otherwise noted.
While there are several other reasonable nonoperative and operative treatments for Morton’s neuroma, sclerosing injections with alcohol are of questionable benefit. Phenol is also sometimes used. This substance is even more toxic than alcohol. While it is also questionable whether it gives any long-term benefit, I have found injection with steroid or cortisone to give often remarkable symptomatic relief over the short term. This along with a stretching program focusing on hamstring and Achilles tendon contractures and the use of shoe pads is a reasonable initial nonoperative step.
–Brett Fink, MD. Co-author of The Whole Foot Book: A Comprehensive Guide to Taking Care of your Feet
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An article of mine outlining exploring the causes of plantar fasciitis and traditional and new treatments has been published in the Jounal of Musculoskeletal Medicine and is available on-line. If you have plantar fasciitis or treat people with plantar fasciitis, it may help you put these treatments in perspective.
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This interview was conducted by Gary Pozsik, host of Health, Wealth, And Happiness, WGCV, Columbia, SC on February 24, 2012 at 12 o’clock.
Gary Pozsik : Good afternoon everyone, welcome to Health, Wealth, and Happiness. My first guest joins us via the phone. He is Dr. Brett Fink, author of the Whole Foot Book: A Complete Guide To Taking Care of Your Feet. And today we’re going to talk about how to take better care of your feet.
Welcome, making his first appearance on Health, Wealth, and Happiness, Dr. Brett Fink. Good to have you here.
Dr. Fink: Thank you Gary. It’s a pleasure being with you.
Gary Pozsik : There’s no doubt about it, one thing that makes your business the business that it is, is footwear, especially women’s footwear. It ain’t good for the foot.
Dr. Fink: Well, certainly some of it isn’t good for the foot. The high-heeled shoes that women wear can certainly make the women’s foot painful. And sometimes the flexibility of the shoe that is common in women’s high heels can overload the front of the foot and can keep you from being comfortable.
Gary Pozsik : And I would guess with the numbers of young people that wear flip-flops on a continuing basis, 30 years from now you’re going to see a heck of a spike in people coming to see podiatrists saying, “my God, something is the matter with my feet.”
Dr. Fink: Well, I’m not sure that I agree with that completely. The feet adapt to the conditions that they’re in. To be honest with you, I feel that people see would be much more healthy if they were kept in the foot wear that our bodies have evolved into, and that is nothing at all. Until the last hundred years, people really didn’t wear shoe wear. I think that a lot of the problems that we have now occur because the foot is not allowed to develop normally, seeing the stresses that naturally help it develop. Flip-flop shoes in people that are not used to them can be difficult, but they don’t really cause problems in my mind. Because the shoes are not well attached to the foot, they can become unstable. So for something like soccer, they might be inappropriate, but flip-flop shoes in healthy feet are actually okay.
Gary Pozsik : Boy, when you talk about footwear designed for the foot, there’s no doubt about the fact that in the last 25 years, shoe manufacturers when they come to the area of foot had designed every kind of footwear known to man. For your favorite sport, there is a shoe that is made for you.
Dr. Fink: That’s certainly true.
Gary Pozsik : Is that a sham or is that really necessary.
Dr. Fink: Again, I mentioned before that for the last hundred years, we didn’t wear shoes for much of the time. But now our feet are accustomed to shoe wear. They have developed softer footpads, the muscles are less strong. So, a lot of times the shoes are necessary to protect our deconditioned feet.
Besides, the stresses during the sports that we subject our feet to, are not really natural stresses. So, having a shoe with a cleat, or making the shoe more rigid or more flexible for the sport that you are practicing is entirely appropriate. I’m just saying, there’s not anything wrong with minimalizing the amount of support within the shoe, and I believe it makes the foot stronger over the long run.
Gary Pozsik : Obviously, you and your co-author wrote a book because you thought it was necessary that people have information on how to take better care their feet.
Dr. Fink: Yes, the book that I wrote is geared toward people who already have a foot problem and are looking for ways to make it better. The reason that I wrote the book is because people who go to a primary care physician, even a specialist, do not get a complete picture or enough information to really make it easy for them to manage the foot. And, really, while the doctor is able to make suggestions, if the person having the foot problem does not understand the suggestions, then it is difficult for them to be enthusiastic or effective at implementing them well.
Gary Pozsik : Well, Brett, do you think that part of the problem is that when you go to any pharmacy, pick the one you want whether it is a big-box pharmacy or a compounding pharmacy, you see Dr. Scholl’s and a blue million products for the foot, so you can be your own Dr. Fix-it? How much do you want to spend? Step right up here and we will show you what product you should buy for your foot in some of these products are not $3.99 some of them are $80.
Dr. Fink: A custom orthotic generally runs $300 or $400. And the stores, the big-box stores, have convinced the public that orthotics and other devices are healthy and necessary for their foot. That their foot is a little bit more fragile than it really is. I agreed that it is more fragile than it should be, but if people used their feet in a more natural way, it would be less fragile and would have less problems. While arch supports are very helpful for certain problems, not everyone needs support and not every foot problem requires support.
Gary Pozsik : I keep waiting to go back to footwear, but is part of the problem vanity? Should a woman wear a size 8 when trying on a size 6. My God a size 8, all make it fit.
Dr. Fink: I think that there is something to be said for that. If you wear a shoe that does not conform to the shape of your foot, obviously it’s going to push on the foot in ways that could cause you to develop deformities. If you look at the Japanese or the Oriental society a hundred years ago, they would actually bind their foot in order to make it conform to a certain desired shape. So it is possible to mold the foot in ways that are not healthy for it. But a lot of the things that are blamed on the shoes are probably a part of natural aging and genetics, an aging process that has probably been made worse by overprotecting the foot in modern shoes.
Gary Pozsik : The reason why I ask it is in my next question is are corns and calluses in bunions natural phenomenon or are they something that are doing wrong?
Dr. Fink: That’s interesting. There are actually a couple of studies that have looked at populations of people who live close to one another that either wear or do not wear shoes. What they have found is that people who do not grow up wearing shoes have a much lower incidence of bunions and flat feet. And you may say that this is because the shoes mold the feet, but I believe that it is because the muscles have not been allowed to develop properly inside of the shoes.
Gary Pozsik : You see people that are 60+ years old that are literally hobbled many times because of their feet and the condition of the feet.
Dr. Fink: Oh yes, I see that frequently. Once a person has developed this problems, the horse is out of the barn. There is not much you can do to reverse it, to make an arthritic foot less arthritic or to make a foot with a ligament irritation such as heel spurs or plantar fasciitis less problematic. What you have to do is to protect the foot until those problems heal, once they had healed in a gradually reintroduce exercise stress to make the foot more resilient.
It’s a little like when you have a fracture. A cast is often used to treat this. But once the fracture has healed, it is no longer necessary to use the cast indefinitely. In fact, it can be unhealthy for the arm to be placed in a cast for long periods of time. The muscles begin to atrophy and waste and the joints become stiff.
The same is true for foot problem. If it is an issue that can be reversed like tendinitis, then what you wanted to do is to protect the foot until the tendinitis resolves. And then, after it is resolved, expose the foot more and more stress and tell it obtains the resiliency that you want. Tendinitis, a tendon is a simple structure and can heal back to its normal architecture and shape. However joint cartilage is more complex and once it has been damaged really can never return to its normal status, so that arthritis really never completely resolves once it has begun. But people with arthritis can be made better with an exercise and conditioning program that decreases the damaging loads that a poorly conditioned foot is exposed to and perhaps can avoid surgery or prolonged use of overly restrictive shoes.
Gary Pozsik : Speaking of pain, one of the reasons why people don’t seek podiatry is just that they are under the impression that if they going to have the corn removed, by God, that’s going to hurt. Well, let me use myself as an example, I had a corn and I thought a corn, how much can that hurt. The answer is a lot. And I suffered with it for about, I’m going to admit it, four months, and I had just about all the fun I could stand. I, like everybody else, tried several different Dr. Scholl’s products, but, I’ll have you know, finally I went to a podiatrist. And he looked at it and said that you have to get the core out. He did that it didn’t hurt, and so I was setting myself up and I wish I would’ve seen a professional sooner, but I was afraid that this was going to hurt like sin because, man, it hurt. I thought, me, I don’t want somebody cutting on me, this is really going to be painful, but it wasn’t. It wasn’t painful at all. So there you go.
Dr. Fink: Well, fortunately, corns are more or less a problem of the skin. They are callouses that develop under an area where the bone is pressing against the skin too hard and so if you remove the corn, it generally doesn’t involve any of the parts of the tissue that are that bleed or have sensory nerves. So, it should be fairly painless. It should not hurt a great deal to have a corn removed.
But getting back to my point, as far as corns are concerned, a corn does not generally developing young people. It is usually that affects us as we get in our 30s, 40s, and 50s. And what happens sometimes is that the skin on the bottom of your foot acts like the skin and the rest of our body, it becomes thinner. And if the skin on the bottom layer foot becomes thinner, the bones put much more pressure on a direct point in the skin. And just like it does on your hands, stress stimulates the skin to become thicker. The pressure from walking the callous pushes the callous into your skin. Essentially at that point, what you are doing is walking on a BB ofhard skin tissue. You have to remove that BB in order to relieve the pressure and the pain. So, the podiatrist, or in my case an orthopedic surgeon, shaves the BB down so that it is much less painful. The tissue gradually fills behind the callous until it becomes normal again. If you keep up the shaving or if the pressure is relieved, then the callous will no longer form and the corn will not redevelop.
Gary Pozsik : And that’s exactly what happened. It went away and hasn’t reoccurred. But, it’s like the old adage, there is no greater fear, then fear the unknown. And it was fear the unknown. If I ever have this recur, at the first sign, I will make a beeline for the podiatrist and get it taken care of. When we come back after the break, I’d like to get a reaction from you, of the people that have read your book, and I bet there are a lot what had they had to say about your book and if they had shared for with you why they have bought your book and if it is help them.
(break)
Gary Pozsik : We’re back, and my guest is Dr. Brett Fink, co-author of The Whole Foot Book: A Comprehensive Program for Taking Care of Your Feet. Coming to us from Indianapolis. I have a Masters degree from Indiana University so I’m somewhat familiar with where you are. We were talking before the break about different problems with regard to the foot and obviously you and Dr. Mizel wrote a book about the foot and it’s a complete program for taking care of your feet. How long has the book that out?
Dr. Fink: It came out in the very beginning of January.
Gary Pozsik : What kind of reaction have you had from the readers?
Dr. Fink: Well, so far it’s been very positive. My book is been out on Amazon and I recently got my first review on Amazon. And she was very happy with the book. The physicians and podiatrist that I had review it have also been very positive. Of coarse, I looked too many of them for suggestions about what to include in it even before it was published.
Gary Pozsik : Over the years in your practice, what is the biggest mistake that people make in regards to their foot care?
Dr. Fink: Well, I think that some of the biggest things that I see are the misconceptions that people have about foot care. One of the biggest is that there is any ideal shoe for a foot. A lot of times I have mothers and fathers come in with their children worried that they need to buy a certain very expensive shoe in order for the child’s foot to develop properly. As I stressed before, I really think that no shoe in all is probably the most healthy way to allow a child’s foot to develop properly. After that, it’s also the feeling that a particular orthotic is going to solve a problem. In general, I look at the whole foot, the posture, and the flexibility of all the joints in the legs and back that my lead and overload certain parts of their body. I think that that is the key to giving someone a long fasting result.
If you look again to a problem like heel spurs or plantar fasciitis, the surgical treatment for that disease treats the symptom and not the underlying problem. A person who has an operation for plantar fasciitis may develop relief from the plantar fasciitis only to develop another problem that is caused by the same mechanical overload that caused the plantar fasciitis. In my practice, I like to emphasize maintaining proper foot health as a way to keep it healthy over the long term and avoid unnecessary surgery.
Gary Pozsik : I’m sure that people do not realize the wear and tear that they put on their feet over the years and so they really have a problem. And you explain to them, it’s in little or no wonder. They don’t understand the importance of keeping healthy feet. They make their money on their feet.
Dr. Fink: Sure, we all make our living on our feet. No one could function properly without walking on the feet. I agree with you, when we are younger, in our teens and in our 20s, it’s very easy for our feet to adapt to our mechanical problems. As we got older, they become less and less resilient. Perhaps, they become less and less resilient because we protect them more and perhaps as a natural part of the process of aging.
Gary Pozsik : Are there any exercises to the feet that you recommend?
Dr. Fink: Absolutely, I think that most common foot problems result from overloading the front of the foot. I find commonly that the Achilles tendon and hamstring muscles are contracted and lack proper flexibility. This causes them to put too much pressure on the front of the foot and to leave that pressure on the front of the foot too long at the end of the step. That causes the foot to overload. So addressing that by having a consistent stretching program, it I think is very helpful. I also think it’s helpful for people to watch their posture. If you walked slumped over or have abdominal conditioning problems, such as the typical beer belly, it shifts all the weight forward and the only way that you can control that weight is by placing pressure on the front of the feet. So I recommend working on abdominal conditioning and lumbar conditioning, ensuring that the shoulders are centered over the pelvis. I think all of these are important and often overlooked problems they can really be key to the success of treating many chronic foot problems such as forefoot pain or metatarsalgia, or heel pain, known as plantar fasciitis.
Gary Pozsik : It’s interesting to hear you talk about the importance of stretching, because certainly you see before you professional athletes prior to football games, before basketball games, you see it in professional dancers, they all really go through a regimen of stretching, not only of their feet but their legs as well.
Dr. Fink: Right, I think it is also important that stretching me done other times than right before an athletic event. It should be a part of a daily routine, as a matter of fact, several times a day. What stretching does is stimulate the muscle fibers to become longer. If the muscle fibers are not stimulated on a regular basis, you really are not caught accomplishing much.
Gary Pozsik : I’m sure that people come to see you for things, I know that as a surgeon, that people have to go under the knife. But I’m sure they complain of, like leg cramps, my God, I can wake up in the middle of the night with a Charlie horse in my leg, and people have restless leg syndrome. These are things that are very common in the general population.
Dr. Fink: Sure, as far as leg cramps, usually leg cramps are caused by fatigue. The muscles have been asked to do more than they are accustomed to or conditioned for, or more than they are capable of, then they become very irritable and spasm frequently. And then there are the occasional people with leg cramp that have an electrolyte problem such as the calcium being too low or their potassium being too low, and those people should be worked up for metabolic problem by a physician. As far as of restless leg syndrome, that’s a degenerative neurological condition. Often, it is very treatable with medication, but of course those medications have any side effects.
Gary Pozsik : What kind of side effects?
Dr. Fink: I would have to say that that is kind of outside of my practice, but usually sleepiness, difficulty getting up in the morning, nausea, those kind of side effects.
Gary Pozsik : I got you. What is the normal thing that people come to see you with, that you see on a regular basis?
Dr. Fink: The foot has an infinite number of ways that it can break. Some of the most common things that I see are Achilles tendinitis, pain in the back of the heel, plantar fasciitis, pain on the bottom of the heel, I would say that those make up about 60% of what I see. And then, hammer toes and bunions, and foot arthritis of various joints. And then there are the more difficult cases where it takes a little bit more work to figure out what is going on. And in those patients, their diagnosis may be unique to them.
Gary Pozsik : And there again, I’m sure a lot of people put up with a great deal of pain and suffering before they ever come to see you, I’m just surmising, but I’m sure you’re thinking that, gee, it would’ve been great if you had come here six months ago?
Dr. Fink: Well, I would have to say that I try not to bash people over the head with that too much. Generally, there are an awful lot of pains that you just live with. People that run to a doctor immediately when they develop a pain may spend all of their time in a doctor’s office. There our problems that I think are okay to watch and often they will go away on their own. I, myself, have had several forms of tendinitis that seem to just come and go, but when they become persistent or when the foot changes in alignment, it probably is a good idea to see a physician to be diagnosed and at least to have the peace of mind that you are not doing any harm to your foot. So, while I’ve written a book to give people an idea of what kind of things they can do beyond the advice given to them by their doctor, or what their doctor may not have been able to go over with them during the course of a fairly short appointment in a medical clinic, which unfortunately is 15 or 20 min. at most. It is a good idea to see a doctor and be diagnosed and to at least be given some advice on what a good treatment plan is. So, while I hope my book is informative, it is not a substitute for proper medical care.
Gary Pozsik : Brett, for those people that are interested in getting a copy of your book, The Whole Foot Book, how can they do that?
Dr. Fink: Well, it’s available at Barnes & Noble online as well as on Amazon.com. I hope that it will soon be available in bookstores, you know local bookstores, but that will depend upon the initial sales.
Gary Pozsik : I thank you so much for sharing on Health, Wealth, and Happiness.
Dr. Fink: It’s been a pleasure, Gary.
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This is an interview with Matt Nie of 89.1 WBSD, Community Focus in southwestern Wisconsin, February 16, 2012.
Matt Nie:
Good morning, welcome to Community Focus. A show dedicated to exploring the personalities, issues, and events of southeastern Wisconsin. I'm your host Matt Nie. Today we have Dr. Brett Fink, co-author of the book, The Whole Foot Book, A Complete Program for Caring for Your Feet. Dr. Fink, I know a lot of us don't put in the amount of time thinking about feet as you do, yet in paging through your book it is amazing that this is what holds us up every single day. Can you explain your fascination that led you to create The Whole Foot Book?
Dr. Fink:
Thank you very much, Matt. Just like you, I've always been fascinated with mechanics of the foot. Of course, the foot contains many, many tendons, joints, ligaments, and bones and they all work together in such an intricate way that, I agree with you, it is quite amazing that it does what it does for us. This was my inspiration for becoming a specialist in foot and ankle problems and I’d like to share with my readers.
Matt Nie:
Now, though foot book is very comprehensive. And I just mentioned the co-author, Dr. Mizel, put a lot of work into outlining every potential aspect of the foot, problems as well as foot care. Some things are very specific. But, in general, what do you think are some of the basic foot maintenance things that we should do throughout the course of our lives?
Dr. Fink:
The main premise of the book is that many of our problems are caused from overload of the forefoot and this happens for a lot of different reasons. Because, we live in a society where footwear is important, the foot does not develop quite the way should. The foot is protected from a lot of the forces that it naturally would encounter and because of this we develop problems in our ligaments. Unfortunately it's hard to tell a patient this after they've already developed foot problems. Once a foot problem has developed foot injuries, it is important to protected it for a time, but is important to regain the strength of the foot after the foot has begun to heal.
It is my feeling that a lot of foot problems, even foot problems with lots of different manifestations, with lots of different places that you may hurt, should be approached in the same fashion. Ensuring that all the ligaments of the entire leg are stretched out properly, ensuring that you use proper posture, and use proper shoes that address the needs of the foot at the time that I see it. Protecting the foot during the initial healing phase, and exposing it to greater and greater stresses during the recuperation.
Matt Nie:
I know that there is a trend, and I don't know whether it's here to stay, of the glove shoe or minimalist shoe, where does that fit in in terms of your thinking of the foot?
Dr. Fink:
I agree with the concept of the minimalist shoe. In fact, I think it would be best, if you're on a safe surface, to wear no shoe at all. If your yard is quite safe and free of objects that might hurt the foot and the foot is properly conditioned, I think it is quite reasonable to go barefoot. Now, short of that, we live in a world where there are objects on the ground that might hurt the foot, especially as the skin on the foot has become protected and quite fragile because of the protection. Now, in a healthy foot, I see no reason that people cannot enjoy using minimalist running shoes. However, it is important to realize that the foot needs to be conditioned to that stress. If your foot is used to a standard running shoe or you have never run before, it is important that you approach the stresses incrementally, because otherwise you could overuse the foot and develop an injury that could take some time to recover from.
Matt Nie:
I am absolutely fascinated by the chapter on rehabilitation, the suggestions, a lot of the different stretches do not seem to even address the foot at all. I'm looking at chapter 10, the rehabilitation of the foot, and the first things that I see are neck twists, crossover shoulder stretches, shoulder rolls, how does this all factor into foot rehabilitation?
Dr. Fink:
For the person that is not a high level athlete, who just does the normal everyday activities, it is absolutely critical that, if they have a foot problem, that they use good posture. And that involves ensuring that the head is centered over the shoulders, that the shoulders are centered over the pelvis, and that we are not leaning forward and shifting weight onto the front of our foot. And so these exercises are directed towards increasing back flexibility, hip flexibility, to ensure that we carry ourselves in the proper fashion, so that our forefoot is loaded as appropriately as possible. I believe that foot problems should be looked at as a total body posture problem rather than treating it in isolation.
Matt Nie:
If you're just joining us, we are talking to Dr. Brett Ryan Fink, the co-author of The Whole Foot Book, a Complete Program for Taking Care of Your Feet. Lots of mention of shoes, even orthotics, we see so many inserts on the market as well as substantial prescription based orthotics. What are your feelings on orthotics?
Dr. Fink:
Shoe prescriptions and orthotics are just a method of approaching deficits that people have in their feet. They are not a cure-all. In fact, for normal healthy feet, I do not feel that they are helpful. Certainly, it is difficult to approach the subject scientifically because it's hard to take a group of people and use them essentially as lab rats to find out if they are going to respond favorably to posture changes. But it makes sense to me to put the foot in the most natural environment possible, but if you have certain problems, orthotics can be helpful. But for someone that does not have foot problems, I think that they are harmful. Anything that you put in your shoe to protect the foot is going to deconditioning the muscles, it's going to deconditioning the skin in your foot which is a very important natural protector of the bones and muscles and it helps to diffuse and redistribute the stresses with her foot.
If you can imagine, as a doctor, I often have the opportunity to shake people's hands, if I shake the hand of someone who is a manual laborer, I will feel the palm and it will be very thick. It won't move and it will not be very flexible. However, if I shake the hand of, I hate to pick on lawyers, an attorney, their hands will be much softer, I will feel the bones and tendons easily through their skin. The same thing happens in the foot. If the foot is overly protected when it's healthy, then it will be less resistant to injury. However, if it has already been injured, it is important to protected it until it is healed. Once it is healed, stresses can be incrementally reintroduced until it becomes resilient to the stresses that it sees every day
Matt Nie:
It's interesting. Many of us have had the experience of being at a wedding all day in those hard soled shoes and were very sore at the end of the day. How can we tell the difference between what is normal wear and tear and what is a sign of a problem?
Dr. Fink:
I think that the larger problems and the smaller problems that you mentioned are part of a spectrum. If you have been at a wedding and had been on your feet for several hours, what your feet are telling you is that they are not use to those kinds of stresses. Therefore, parts of your foot are being overused and your muscles are becoming fatigued. When your muscles are becoming fatigued, then the ligaments take over as part of the non-fatiguable part of your foot, but they're going to become irritated. If you continue to expose your feet to stresses that are intermittent and strong, then it's quite possible for you to develop a chronic irritation of these structures. That's when you develop the common overuse problems such as plantar fasciitis or heel spurs, hammertoes, and midfoot irritation. All of that stuff comes with chronic overuse or chronic variable amounts of stress that we expose our foot structures to.
Matt Nie:
Let's take a condition like plantar fasciitis, what is some of the self-care, the small changes that we can do to prevent problems?
Dr. Fink:
I think that plantar fasciitis is almost a prototypical injury. There is some scientific suggestion of this, but in terms of scientific fact, it is not yet proven. My belief is that people develop plantar fasciitis because they overload the plantar fascia, they expose the plantar fascia to more stress than it can repair by overloading the ball of the foot. If you overload the plantar fascia, and the plantar fascia is an important part of the way that the body redistribute stress through the midfoot, then you will get inflammation, small tears, and then it will become chronically painful or the pain will not go away for some time. Most people with plantar fasciitis will heal up eventually, but in some it will become very difficult to treat.
Matt Nie:
It seems logical to the layperson that I'm putting too much stress on the foot and therefore why don't I treat this stress with a cushion or wear an arch support.
Dr. Fink:
And I would agree with that for the most part, but there is so much more that you should do. The rocker soled shoe, a shoe with a rounded stiff sole that helps to offload the front of the foot and reduce the stress on the ball of the foot, will make the foot feel better and is much in my opinion a good “healing” shoe. It protects the plantar fascia and perhaps will help it heal, but you need to improve your Achilles and hamstring flexibility. Once again, you have a healing phase, followed by phase where you gradually expose the foot to more stress. Perhaps, however, if we stayed away from overly protective shoes and kept the muscles in the skin of our foot from atrophying, we might see a lot less plantar fasciitis than we see nowadays.
Matt Nie:
It's very interesting, in terms of exercise, weight loss, you mentioned many things. Do you have a short list, not necessarily rehabilitation, of daily maintenance, things that we should all be aware of to keep our feet healthy?
Dr. Fink:
Perhaps the most important thing is to use proper posture, to be aware of centering your shoulders over your pelvis, and leaning backwards slightly on your pelvis so that your hips open up slightly. Any weight that is forward of your sacrum, or tailbone, is going to have to be counterbalanced. And usually you counterbalanced this weight by placing more weight on the front of your foot. It is been shown that people with plantar fasciitis had a tendency to have less flexibility in their Achilles and less flexibility in their hamstrings, these are important things to correct. You need to work on weight loss, if that's a problem, but that doesn't come quickly. It is important to stress that a diet is not a weight-loss plan. True weight loss involves changes in dietary habits which do not come quickly and should be permanent.
Matt Nie:
Time for two more questions. Where can we go to find out more information about you and the whole foot book?
Dr. Fink:
Well, I have a website, www.wholefoot.com, and I write a blog on that website to keep people informed on my own thoughts and ideas about foot pain. I have several worksheets that review the causes, the symptoms, and initial treatment of the most common foot problems. But I always encourage people that, if their foot problem is more than a mild problem, that they should see a physician for evaluation. A website or a book is not proper medical treatment and is not a proper way of treating a definite medical condition.
Matt Nie:
It's interesting when we watch little kids move and play, and they do it with such ease, and over time, I don't know if we forget how to move or if we just reinforce bad habits. How can we be aware of what we need to know about our foot as we age and is there some wisdom that can be gained from watching how children move?
Dr. Fink:
I think that part of the reason that we age, in a lot of ways, is that we spend our life thinking of how to protect ourselves and our feet. As if our bodies are something that needs protection from the environment that it evolved in. Again, if you have any children, children hate shoes, and it is best for them to be and be in as natural a condition as possible. Let them spend time out of their shoes. If we did this throughout our lifetime, I feel that we would have a lot fewer foot problems.
Matt Nie:
All right. I really want to thank you for your time. We've been talking Dr. Fink, of The Whole Foot Book, a Complete Program For Taking Care of Your Feet. We really want to thank you for coming out today.
Dr. Fink:
Thank you very much, Matt. I enjoyed it.
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Interview with Dr. Brickey, podcast, February 7, 2011 at 4 PM
This is an interview that I did with Dr. Michael Brickey, a psychologist who runs an educational institute Called Ageless Lifestyles at www.agelesslifestyles.com. He also does a periodic podcasts where he talks about health and longevity issues. I had a great conversation with him and will put a link to it here. The transcript is below and is quite long. If you don't want to read the whole thing, I will summarize the key points below.
- There are many effective ways to nonoperative we treat most chronic problems.
- Therapeutic shoes and orthotics are helpful for specific problems, but are not recommended for healthy pain-free feet.
- Even healthy feet need to be gradually transitioned into new activity or radically different shoes to avoid stress injuries.
- Ideally, we would subject our feet to natural stresses. However, because of societal requirements, we must wear shoes for at least a part of the time.
- Given this requirement, I recommend that you were the most comfortable, least restrictive shoe possible.
- For most problems and most feet, custom and non-custom inserts are equivalent in patient satisfaction.
Dr Brickey: This is Dr. Michael Brickey with Ageless Lifestyles, cutting-edge thinking to keep you useful at every age. In this program I bring in experts to tell you what it takes to live longer healthier and happier. Our feet take a pounding day after day, year after year. Most of us take our feet for granted until problems develop, and then we seek someone like Dr. Brett Ryan Fink who is co-author of a definitive book on foot care, The Whole Foot Book. Dr. Fink, welcome.
Dr. Fink: Thank you, Dr. Brickey. I'm glad to be on the program.
Dr. Brickey: Dr. Fink, I didn't want to introduce you as an orthopedic surgeon, because people might think that the show is about surgery. And one of the things that you write about is that the surgery is not usually the solution for foot.
Dr. Fink: that's right, my book is centered around the nonoperative treatment of foot problems which I believe get short shrift in medical care, mainly because it is difficult for doctors to do it. A lot of them are uncomfortable with it. It takes a lot of engaging your patient in buying into the solution and, sometimes, nonoperative care takes some time to see results. And that takes a lot of patience, both from the patient and the doctor.
Dr. Brickey: What type of surgery tends to have the best results?
Dr. Fink: Well, surgeries that are done for straightforward problems. I find that the best results are for problems that are traumatic like ankle fractures, sometimes for arthritis if there's no other way. Sometimes surgery is the best option because it treats the symptom and not the underlying cause of foot problems.
Dr. Brickey: Now, are bone spurs one thing that tends to have reasonably good surgery results?
Dr. Fink: Actually, not very well. Let's kind of define what a bone spur is. A bone spur is something that you see on an x-ray; it is not necessarily a diagnosis. Actually, bone spurring is a common part of aging. If you look at someone's x-rays, often they have bone spurs present in places where ligaments and tendons attached to bones in they really have no symptoms, you may have taken the x-ray for another problem. And sometimes, bone spurs are completely asymptomatic. When people normally talk about bone spurs, they are normally talking about plantar fasciitis. And the plantar fascia is a ligament on the bottom of the foot that spans the entire foot, from the toes to the heel. It attaches to the bottom side of the heel bone or calcaneus. Calcification is a part of the inflammation and the inflammation is what causes the pain. It is actually the inflammation and the deterioration of the ligament itself, which causes the pain, and not a bone spur.
Dr. Brickey: Interesting. You mention in your book that you can help people with their foot pain by improving posture. How do you make them improve their posture?
Dr. Fink: That's a very good question. The biggest key to that is practice. Whenever you're going down a hallway or something like that you have to really concentrate on your posture. And posture involves shifting your center of gravity backwards, away from the front of the body. It takes strength to develop good posture and exercise is a very important part of that, especially exercises that involve the abdomen and back. A physical therapist can be very helpful in helping people to learn about good posture, especially a physical therapist that is interested and enthusiastic about posture. And certainly physical therapists vary in their training in how much they feel that posture is a problem. Personally, I feel that posture plays a key role in the development of foot pain including plantar fasciitis, Achilles tendinitis, midfoot arthritis, and various types of pain that develop around the toes. In fact, I think it contributes to the development of the flatfoot deformity or “fallen arch”. A lifetime of poor posture is key to the development of the problem and a key to the solution.
Dr. Brickey: So you talked about help for abdominal muscle tone is a part of the problem. I gather that another part of the problem is that if we lean forward so much with computers and driving that were pumping our head and shoulders forward.
Dr. Fink: Yeah, I think that it probably is more of a problem when someone standing or walking so much as when people are car. It's with standing or walking the people are putting majority of the weight on her foot. If you shift your weight forward, then your money to counteract that in some way and usually that is by shifting your weight from the heel to the front of foot.
Dr. Brickey: I was thinking more that he used a slumped forward posture and muscles get kind of tight, after a while he gets hard even keep shoulders back.
Dr. Fink: Sure, poor conditioning is a part of that. If he is allowed to be placed in a position where the muscles are really not active, the muscles begin to lose their condition and are really not able to maintain proper posture.
Dr. Brickey: Another problem besides posture that can help enormously with foot problems is getting the right shoes. I gather from the whole foot book that the best place to start is to be clear about what your foot problems are and what their special needs are because of this the problems.
Dr. Fink: Right, I think that what you have to differentiate between is what the requirements of a healthy foot are and what requirements of an unhealthy foot are. It's my belief that healthy feet don't require shoes at all. Our feet, more or less, have adapted and evolved to being barefoot. Until the last couple of hundred years, the majority of us with their foot for most of our lives. I think that that is one of the healthiest ways foot to be. Unfortunately, in Western society, there are things on the ground that might hurt our feet. And culturally it is accepted to wear footwear even when the weather is nice outside. So the healthiest type of footwear for a foot that is not having problems is probably no shoes at all. If you ever noticed a laborer, of course as a Dr. I shake a lot of hands every day, there is a wide variation in how tough it can feel. If you have a laborer or someone that does construction work or something, you'll notice health their palms are. However, someone like myself, a doctor or lawyer or something, you'll notice their palmar skin is very foot. Well, your feet are the same way. If you wear shoes all day, skin and fat in the soles of her feet becoming conditioned to being protected all of the time. And this actually damages the foot's ability to distribute weight across its surface area. This on the bottom of the foot gets thin, the bones begin to press on the skin, you develop calluses, the pressure across her foot is not diffused over its area and you develop concentrations of stress within your bones and joints and ligaments. And in that way the foot becomes less capable of resisting stress. In the same way, the muscles of our feet are constantly adapting to the irregularities of the surface that we are walking on, and so in a shoe your muscles don't do nearly as much of that and therefore they atrophy. This puts much more stress on the ligaments such as the plantar fascia and therefore you develop foot problems. So a healthy foot, I believe, should be stressed so that it develops proper conditioning. On the other hand, a sick foot, someone who is already developed a foot problem, has to be protected. Just like, if you have fracture, you might be placed in a cast, but after the fractures healed you go back to your normal protection and activity. A sick foot, such as a foot that has plantar fasciitis, has to be protected until it becomes less symptomatic and then, you can reintroduce its activities so that the foot becomes more conditioned again.
Dr. Brickey: So with a healthy foot it would be a good idea to go barefoot when you're at home and even to do some exercise barefoot.
Dr. Fink: Sure, if your foot is strong, if your foot is used to that kind of activity, then I think that would be the ideal circumstance. But unfortunately a lot of our feet are used to that kind of thing. If you're kind of getting into middle-age, if you're obese, if you had foot problems in the past, you want to eat into that kind of shoe wear or that kind of activity or exposing your feet to those kinds of stresses.
Dr. Brickey: Would the same kind of thing apply to people with high arches or are they better off wearing shoes?
Dr. Fink: I think that any shape of foot can be strong. A person with a high arch has a little less flexibility so is prone to certain problems. A person with a high arch can have a normal strong foot that is just as resilient as a foot with a low arch or abnormal arch.
Dr. Brickey: So some of the things that most of us don't think about when we are going shoes. One of the things that you say is that you can have stiff sole or flexible sole. When do we want this and when do we want flexible?
Dr. Fink: Well, to some extent it depends on what you're treating. I would have to say for a healthy foot a flexible sole is good. For foot that is having any of a number of problems such as metatarsal pain, pain in the ball of the foot, were plantar fasciitis, then a stiffer soled shoe would probably be better. If you have ankle arthritis or Achilles tendinitis, pain in the back of the heel, a shoe with a little bit of the heel would probably accommodate this pain and motion restrictions that are by avoiding the pain that you normally have with these conditions when you bring your foot back at the end of your step.
Dr. Brickey: And there would be some cases where it would be an advantage not to have a heel at all?
Dr. Fink: I think for the most part that someone with normal foot should not require a heel. I guess I have to differentiate between a shoe with a heel and a high-heeled shoe such as the fashionable shoes that women sometimes wear. I think that to some extent that wearing high heels is a dangerous thing and I would not recommend. But wearing a shoe with a little bit of it elevation, of 1/2 to 1 inch heel, can be helpful for certain foot problems. But for normal healthy foot, for someone that doesn't have this foot problems, I don't think it's necessary to add an elevated heel unless that is something that they desire. They might be self-conscious about their height I found that a lot of women are self-conscious of their height. They want their head to be roughly level with everyone else's. They would don't want to feel like they are beneath everyone else.
Dr. Brickey: What are the obvious considerations is it the shoe rubs in the toe area, part of that is fine the issue with a large toe box, part of that is defined shoe with a removable insert. And you say that shoes can also be stretched. How do you stretch a shoe?
Dr. Fink: Let's go back to your first question, how do you accommodate foot deformities in the front of the foot, deformities like bunions and hammer toes? There are a couple of different ways. One is to buy a shoe that closely parallels the shape of your foot. If you have a very long second toe, a pointier toed shoe might accommodate that better. If you have a wider front of the foot, many wider boxier toed front might be better. You really need to find a shoe whose shape fits your foot. Other things that you need to look at is the compliance of the material that the shoe is made of. Certainly some leathers such as a patent leather are very noncompliant and so you want to stay away from that if you have a foot deformity or numb feet. Someone with a numb foot such as a person with diabetes may have to be very careful because the shoe could irritate the skin enough to cause an ulcer. As far as other ways of accommodating that… I'm sorry, I forgot your question.
Dr. Brickey: About stretching shoes?
Dr. Fink: Oh, it's quite easy to get a hold of a shoe stretcher. Some of the better shoe stores have them. There is also a website which I have absolutely nothing to do with, but the gentleman who runs it is very nice, www.heelingtouch.com. He has an assortment of stretchers that are very reasonably priced, $30, which I think is a very appropriate price for shoe stretcher. So you place the stretcher in the shoe the night before you wear it so that your foot does not need to stretch the shoe to its normal comfortable volume or shape. The stretchers a lot of times will have little knobs that you can attach them so that if your problem is a bunion the shoe can be stretched in that area. Certainly, a more natural material like leather will stretch better then a more artificial material like plastic.
Dr. Brickey: One of the things that I was amazed and amused by was that you have shoelace tricks to help accommodate problem feet.
Dr. Fink: Yeah, there are couple of things that you can do in that line. It's a little easier to illustrate that it is to describe on the podcast, but if there are certain tender spots on your foot, you can alter the lacing pattern so that they don't crisscross over that area, by skipping a loop or by not releasing it all away to the bottom to loosen the bonds of the shoe. You can avoid lacing it all away up to the top if there is a particularly painful spot near the ankle. And if some people are having a difficult time with grip strength, you might not choose a shoe with laces. You could go with one with Velcro and the straps can be allowed to be much looser. While there are a couple of commercially available shoes with Velcro, a lot of times you can go to a shoe repair shop and have them alter a pair shoes so that they have Velcro closures. They can also do many other things that can make a shoe considerably more comfortable. A professional like it prosthetist or a pedorthist, a guy who actually professionally changes shoes for people, can alter it, but they will be a little bit more expensive than someone who runs a shoe repair shop.
Dr. Brickey: Another consideration that you mentioned was if you have a problem with turning your ankle too much, sometimes a high top shoe will help.
Dr. Fink: Yeah, there are a couple ways to approach an unstable foot. One is to basically build up the shoe so that it does not allow the foot to turn. The other is to go the other way and to make the shoe more flexible. The reason that can be helpful is because, like I said before, the foot is naturally able to accommodate to surfaces. Unfortunately, a rigid soled shoe actually hurt you in that if you step on a rock or uneven place it will tend to tilt the entire foot. And that can start a cascade of the foot rolling over the side that is almost like a slinky going over the step. Once it starts is hard to stop, it just seems to keep going. So I guess there are two ways of approaching that, one is to build the shoe up to prevent you from spraining it and the other is to allow the foot to accommodate the ground. I think that either way is fine you just have to find out what works for you. There is a shoe company called Ektio that makes a very good basketball shoe. It is built to attach more solidly to the foot. A lot of times what happens to the foot are that if it's not closely and firmly attached to the shoe, it can roll within the shoe causing the foot to be unstable inside of the shoe. And they approach it that way. They do a very good job of stabilizing the shoe to the foot. In the more flexible direction, you can go with a barefoot running shoe such as the Vibrium Five Fingers. I think that almost every shoe company has a minimalist running shoe that is more compliant. And I think can help people with ankle instability.
Dr. Brickey: What's your take on the rocker soled shoe like the MBT?
Dr. Fink: Well, a rocker-soled shoe is another way of protecting the foot. Unfortunately, many of the rocker soled shoe companies have made some marketing claims, which most doctors found to be preposterous. They, more or less, claimed that you could lose weight as a result of wearing these shoes and that it would firm and tone your rear end, which, of course, is a true. It does however change the way that you walk so that you could get some pain in your buttocks. I guess that's why they made these claims, because you would get sharp pains in the back of your rear end. I think that rocker soled shoes can be very helpful for treating a number of foot problems including metatarsalgia, forefoot pain, midfoot arthritis, and plantar fasciitis, or heel spur pain. Rocker soled shoes are actually the shoe that I recommend for those problems, especially when the patient's do not have a foot which you can condition to the point that they can wear a normal shoe.
Dr. Brickey: One of your pieces of advice is that when you're having your shoe fit that you should go in the evening.
Dr. Fink: Oh yeah, there is a certain way that you should buy shoes. First of all, if you have a foot that is hard to fit with the shoe, it is probably best to go to a shoe store where the people that work there are better at fitting shoes, where they are more professional. Many shoe stores cater to that type of thing; they have people who are certified shoe fitters. Now, becoming a certified shoe fitter is not an extensive process, but it does show that the person sitting your shoes takes their job seriously, which you don't get in some shoe stores. In some shoe stores, the person sitting your shoes may have been pulled from another department to fill that position and they may no very little about fitting shoes.
If you go in the evening, your feet will be a swollen as they really ever are. Therefore, you will buy shoes that are too small for you. If you measure the foot, it will be his biggest possibly can be. It is always better to fill a shoe that may be slightly large then to force your foot into a smaller shoe. That can be painful or even dangerous in someone with nerve problems.
Dr. Brickey: And you also said don't assume that your feet are the same size.
Dr. Fink: Oh no, as many as 20 or 30% of people will have feet that differ in size by as much as a whole shoe size. You always have to fit to the larger sized foot. So that if your left foot is a size 9 and your right foot is a size 8, then you should get a shoe that is a size 9.
Dr. Brickey: So when you go to shop for shoes, you ask the clerk whether they are a certified shoe fitter? Or would you account for that by going to better stores? How does one know?
Dr. Fink: I guess I would go to the shoe stores that, more or less, cater to people with foot problems. Every city has them. In our city, The Walking Company does a very good job of helping people with hard to fit feet. In other cities, it may be quite different. Most of those stores will have people that are certified shoe fitters. You'll know the stores, because their prices are going to be a little higher, but the salespeople should approach you in a more professional way. I think that is pretty easy to find stores like that. If you go to one of the chains, and I don't want to name names, but one of the athletic shoe places, and you're met by a 17-year-old kid then they are probably not a certified shoe fitter. But if you'd like to quiz them, I'm sure they'd tell you. Being a certified shoe fitter is just a way of indicating that your sales person takes their job seriously and is a professional. And usually you can tell just by the demeanor of the clerk, whether they take their job seriously, whether they're professionals, or whether they're a casual shoe salesman.
Dr. Brickey: I would take it even a step further; I think that having the correct shoes is so important, that if your feet are hard to fit, you should go directly to a certified pedorthist, podiatrist, or orthopedic surgeon, and get the best possible advice. I think you said in your book the certified shoe fitter has a couple of days training, whereas the pedorthist has several courses.
Dr. Fink: Yeah, but I think you have to be realistic about this. Some people, perhaps even the majority of your listeners, have only a limited amount of money to spend on their foot problem. They simply do not have unlimited funds to spend on issues. People, unfortunately, do not have an unlimited amount of resources to devote to these problems. Certainly, if you go to an orthopedics surgeon, you're going to get very little help in less the doctor is a specialist in feet. Or to a pedorthotist or to a podiatrist, I think they'll all be able to help you. We all have our idiosyncrasies as far as what we think works. I would say a lot of it is trial and error, you got a find out what works for you. I think that the care that you take in selecting shoes really depends upon the problems that you have with your feet. Certainly, in my practice, I had people that have really horrible problems with finding shoes that fit comfortably. And a lot of times, it takes a lot of counseling, a lot of discussion, and a lot of trial and error.
Dr. Brickey: My experience with certified pedorthotist is that most of the time is spent with diabetics or very serious problems, and they're selling shoes to people that had extreme needs in the $100-$200 range. They are able to do any modifications that you need on the shoes.
Dr. Fink: Yeah, but even in that situation there is some trial and error that is involved. A person that has special foot wear needs, the nice thing about going to a pedorthist is that they have equipment and machines that are necessary to modify and adjust shoes, and customize things if you need it.
Dr. Brickey: I don't want to sell the podiatrist and orthopedic short. You still need to go to them to get a good diagnosis. A lot of times, that's where you're going to get prescription inserts or supports.
Dr. Fink: Exactly right.
Dr. Brickey: And certainly if you need braces.
Dr. Fink: Exactly right. And if you need to run it through insurance, if it's something that is covered by insurance, you will need a doctor, an orthopedist or podiatrist, to write a prescription for it. Otherwise you may not get compensated for that.
Dr. Brickey: And speaking of insurance, a lot of people with insurance, Medicare, can get their shoes covered if the diabetic.
Dr. Fink: Yes, as a part of a congressional act, people with diabetes under certain very specific circumstances can get their shoes paid for. They've got to have circulatory problems, nerve problems, or foot deformities, or history of ulceration, and the prescription needs to be a part of an overall diabetes management plan. They're qualified to have the expense of their shoes covered under Medicare to the extent that Medicare will pay for anything. For traditional Medicare, it pays about 80% of the cost. That brings the total price of the diabetic shoe paid by the patient to about what it costs to buy normal shoes commercially in a department store.
Dr. Brickey: We’re talking with Dr. Brett Fink, who is a private orthopedic surgeon in Indianapolis. He along with Dr. Mark Mizel have written a book, The Whole Foot Book, which is a very comprehensive, everything you want to know about foot care, that discusses shoe wear and foot problems. It's very nicely done. As a matter of fact, Dr. Fink, I used your book last night with my daughter. My 12-year-old daughter was complaining of vague foot pain. I looked at her feet and I didn't see anything wrong or acute. I literally had her read the page that you had on growth pains and how they're very common in children from age 5 to 14. (Laughter). And it allayed some of her fears.
Dr. Fink: That's so wonderful. That is why I wrote the book. I hope that it helps.
Dr. Brickey: So, you do a day-to-day foot practice, and Dr. Mizel has a strong academic background.
Dr. Fink: Yes, Dr. Mizel was my preceptor, when I was at the end of my training and sub specialized in to become a foot ankle specialist. He taught me a great deal about feet in the theory behind some foot problems. And I owe a great deal to him. He's currently retired from medical practice. As far as my own practice, I work at Community Hospital in Indianapolis. I see patients on a regular basis. I'm a full-time practicing orthopedist. I am not a university professor. I just take care of people's feet in a very personal way.
Dr. Brickey: So, you cover everything from the very practical to the very technical.
Dr. Fink: More or less, when I began writing this, I took the questions that my patients were asking me every day and I put the answers to them in each chapter. These questions are asked of me time and time again, and over the years I believe that I have come up with some good answers to them. That's what I put in the book.
Dr. Brickey: And, just out of interest, I noticed that both you and Dr. Mizel are veterans.
Dr. Fink: Oh yeah, Dr. Mizel was in the Vietnam War. He was a helicopter pilot and was actually was injured as a helicopter pilot. And I was a doctor in the Navy, and served during the Persian Gulf War.
Dr. Brickey: Well, thank you for your service. We greatly appreciate it.
Dr. Fink: Thank you very much, Dr. Brickey.
Dr. Brickey: Tell me about orthotics. When are they helpful?
Dr. Fink: Again, for healthy feet, I try to keep people out of arch supports. Even, and I see a fair number of children who are brought in for various concerns including flat feet, in telling and out towing, knock knees and bow legs, I really avoid putting them in arch supports. Like constrictive shoe wear, arch supports can decondition the muscles in the foot. This exposes the ligaments to more stress. In order to wear an insert you have to wear a fairly heavy shoe and a larger shoe, because they are the only shoes that can accommodate insert, and it really over protects the foot. Usually children with flat feet will grow up into adults that perhaps have flat feet but are completely without pain. And besides, most children do not want to wear the shoes that an orthotic will fit into and they don't want to be unlike any of their peers.
For adults, orthotics can be helpful for certain problems. Orthotics are very helpful for someone with plantar fasciitis or heel spur syndrome. Orthotics are very helpful for someone with midfoot arthritis, arthritis in the joints above the arch. They can also be helpful with some modification for pain in the ball of the foot, the forefront. I do not think that orthotics are necessary or desirable at all for someone with healthy feet.
My other belief, and this it has been suggested in several scientific studies, is that non-custom or over-the-counter orthotics are just as effective as custom orthotics. The satisfaction rate in most studies is the same. And so, unless there are fairly good reasons that they may not get the same result with a non-custom orthotics; I recommend the off-the-shelf orthotic as opposed to the custom orthotic. If you look at them mechanically, there is a really very little difference and a custom orthotic can cost $300 or $400 as opposed to a good quality, non-custom orthotic that you can get at a drugstore, which generally runs between $20 and $50.
So there are fairly specific reasons why I would recommend an orthotic and usually it is the less expensive non-custom orthotics, because people can afford them and a lot of times they are not covered by insurance. And they seem to work just as well.
Dr. Brickey: I found it interesting, the way that you describe certain interventions such as shoe wear and orthotics, that you're trading off reducing stress in one part of the foot at the expense of another. It's not like there's a magic cure for this.
Dr. Fink: No, you're exactly right. And you may not realize this. This occurs in many parts and treatments of musculoskeletal problems. There's almost always a disadvantage to treatment. If you protect an area, you're also protecting it from the stresses that make it more resilient. If you decrease the motion in one part of your foot, you usually increase motion in another part of the foot or leg. So that someone who is being treated for plantar fasciitis and gets placed in a stiff soled shoe, their Achilles tendinitis may get worse because their ankle has to move more. Their ankle arthritis may get worse or their knee arthritis may become more symptomatic. All of these regions are interconnected so you're treating one at the expense of potentially more symptoms and another.
Dr. Brickey: Of course you realize, in the sound bite world, what the headline would read is “Dr. Fink says ‘man up, go barefoot’.”
(Laughter)
Dr. Fink: Well, I don't disagree with that. I wish our world was more conducive to that. I wish that the weather would allow us to go barefoot more frequently. We would probably all be better. Unfortunately, the world is the way it is. In Western society, I go to wear shoes. I think that just about everyone does. I think it's helpful today could break from this; to expose our feet to more natural stresses so that they can function the way that they were meant to function.
Dr. Brickey: Are Crocs getting closer to being barefoot?
Dr. Fink: I think that Crocs are useful shoes. There are certain circumstances where I have tried everything that I felt mechanically made sense, but my patient felt more comfortable in Crocs. People just say my crocs feel good. The problem with crocs is that they can be kind of loose and they can slip on your foot. They can cause you to misstep. It's kind of that shoe instability problem that we were talking about before. If the shoe does not stay firmly attached to the foot and slips a little bit, it can actually be a dangerous situation. We get into that sometimes with flip-flops; they can twist on your foot and cause you to trip.
Dr. Brickey: So with flip-flops or minimalist sandals your biggest concern is the instability on your feet, not so much what they do to the bottoms?
Dr. Fink: Yeah, it can be a problem the ankle twisting, but if your feet aren't used to that kind of freedom, you can get overuse injuries too. There have been a couple of papers published on runners developing stress fractures after switching to minimalist shoes. I think that's something to be concerned about. It just goes to show you that whatever you do, whatever shoewear you transition into; it's got to be gradual and incremental. Gradual increases in the stresses that you exposure feet to can toughen them up, but in the short run, you can open yourself up to stress injuries or some other problem.
Dr. Brickey: It's like someone that is unused activity that suddenly decides that they're going to get fit and decides to lift 100 pound weights, they'll pay for it the next day.
Dr. Fink: Exactly, if your body isn't ready for it, you can develop an injury because of that.
Dr. Brickey: And, for the record, the gadgets like bunion splints, very few of them do any good.
Dr. Fink: Yeah, for the most part, I have not found it very helpful.
Dr. Brickey: What should we know about bunions?
Dr. Fink: Well, there's a lot to say about bunions. I would have to say that after 15 years of treating foot problems, there are still many questions that I have about them. I believe that they begin as an instability of the foot, and instability of a joint in the middle of the foot near the arch called the tarsometatarsal joint. It is also a simultaneous instability of the metatarsal phalangeal joint, which is closer to where the bunion is actually at. As one bone tilts towards the inside of the foot, the other tilts towards the outside of the foot and you get this large prominence that people associate with the bunion. The prominence can rub and put pressure on the shoe and be quite painful. What you may not notice is that the skin underneath the bunion becomes smooth and soft. This is because the instability of the joints around the big toe makes the total unstable and therefore less pressure is placed on the big toe and the big toe begins to rise away from the floor. A lot of times that stress is transferred to the second toe, which is right next to it. And that's why you develop problems with the second toe. In fact, many people develop ligament injuries to the second toe that result in the second toe crossing over the big toe or they can develop hammertoes. Or even pain in the other bones of the foot because of the bunion. Many people come to me complaining of a bunion when really the pain is underneath the other bones of the foot because of the stress that is transferred there.
Dr. Brickey: So once you have someone who is wearing appropriate shoes and is using good posture, what are the next things that you do for a bunion?
Dr. Fink: A lot of times it depends upon the bunion, because there are so many things about a bunion that can vary from person to person that may affect the appropriate treatment. Someone that has developed a lot of instability in their big toe can begin to roll the foot and ankle and appear to even have a flatfoot deformity or “fallen arch”. In a person like that I think that orthotics can be helpful to reestablish the stability in that side of the foot.
And someone that is having pain because the shoe is pushing on the prominence of the bunion, things need to be done in order to reduce that prominence. This may include using a shoe with a soft flexible upper such as Spandex or Gore-Tex or soft pliable leather. If they're barefoot all the time, that a lot of times the bunion will not hurt because the she was not pushing on it. Avoiding placing the shoe all of the way to the bottom will loosen the toe box and decrease the pressure on the bunion. Ensuring that the shoe fits the shape of the foot.
Sometimes, when all else fails, you have to go to a surgical treatment or bunionectomy, but I try to encourage my patients to try all other forms of treatment prior to considering this. I have my own bunion. I would not let anyone touch it, unless it was bothering me a lot. The fortunate thing is that it's never bothered me and so I don't plan on having it operated on any time soon. If it did begin to bother me, then I would go through all of the things that I've recommended. Fortunately, it doesn't and so I am able to wear all the shoes that I would like.
Dr. Brickey: Well, Benjamin Franklin said that the secret to a long life was to have some medical problem that you had to take care of. A bunion is one of the more modest ways of doing that, I guess.
Dr. Fink: Yeah, certainly, my own foot problems have helped me to understand the problems that my patients go through. And it has helped me think more about ways in which I could help them.
Dr. Brickey: With arthritis, you have all sorts of trade-offs. Can you talk about some of the trade-offs that you have with treating arthritis?
Dr. Fink: There are lots of different types of arthritis. There are many many joints in the foot and each of them can be arthritic. As far as arthritis in the big toe, which is a very common symptom, usually what is happening is that the top of the joint is wearing out and it limits the ability of the toe to come up. So someone with this type of problem may be successfully treated by a more rigid shoe such as a rocker sole shoe. It can keep them from forcing the toe up into a position that is very uncomfortable. Sometimes stretching the Achilles can help with that as well as stretching the hamstring muscles. I think that drills that are directed towards helping people to improve their posture can help a great deal with toe arthritis.
It's the same with midfoot arthritis. The joints on the top of the foot, what people call the instep or along the arch, can become arthritic and painful. That is extremely uncommon especially as you get into your 50s, 60s, and 70s. It rarely requires surgery. And things such as arch supports, rigid rocker soled shoes, and stretching exercises can be quite helpful in controlling the symptoms, in addition to ensuring that you are using proper posture.
As you get into the ankle, which is probably the next most common place that people develop arthritis, stretching exercises for ankle arthritis are probably not a good idea. You're going to end up probably aggravating the ankle by trying to increase its range of motion. Once you have fairly advanced arthritis, you probably aren't going to be able to increase the motion with exercises. You'll end up making the ankle sore and inflamed. Usually the problem is that you cannot bring the ankle up and off and as you transfer your weight onto the ball of the foot at the very end of the step, the ankle is forced into this uncomfortable position. Someone that wears a heel pad to elevate the heel up or chooses a shoe with a little bit of an elevation in the heel when compared to the forefront may position the ankle so that it opens up slightly and this may make walking more comfortable. As far as injections into the ankle with steroid medications, I believe they can reduce the pain when it flares, but it probably has very little effect on the eventual deterioration of the joint. It generally doesn't do anything long-term to the problem.
Dr. Brickey: If I were looking for a podiatrist to treat a foot problem, I would look for someone that discusses the trade-offs of treatment like you do. You mention in your book two other criteria. One should be cautious if the doctor is ordering a lot of tests without explaining why. And secondly, someone who is quick to recommend surgery.
Dr. Fink: Yes, someone that offers surgery as an initial treatment for a chronic problem should really explain why other less invasive initial treatments should not be tried. Sometimes when I see a patient who is been through multiple treatments and has failed, we will begin to discuss surgery as the initial treatment as I see them because I have very little else to offer them. But if you come in with a problem that has never been evaluated or treated before, and your surgeon recommends surgery as the initial step, I think that you have to decide whether that really makes sense to you. There are affective nonoperative treatments for almost any problem. They're not 100% successful, but you never know who's going to benefit from them until you've tried them. And you have to be really conscious of whether this person is really paying attention to what you're saying to them, that there really willing to take the time to take you through and educate you on a nonoperative treatment program.
Nonoperative treatment is not easy. For the doctor it means that you have to do a lot of patient education. Patient education takes a lot of time for your doctor. And time is money. That's the nuts and bolts of medical practice. We'd all love to have an unlimited amount of time to spend with their patients, but we don't. In order to stay viable, your doctor needs to see a certain number of patients. Now hopefully, he spends the amount of time that each patient needs, but I don't think that's the case with every doctor.
Dr. Brickey: That's another trade-off.
Dr. Fink: Exactly.
Dr. Brickey: Well, the good news is that most people don't need surgery. The Whole Foot Book is just a wonderful resource. The website is really complicated, www.wholefoot.com, hard to miss on that, wholefoot.com. And we've been talking with Dr. Brett Ryan Fink who along with Dr. Mark Stuart Mizel is co-author of The Whole Foot Book. And Dr. Fink, excellent advice. We appreciate it.
Dr. Fink: Oh, thank you very much. I enjoyed it.
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Ankle fractures:
When the surgery necessary?
- The ankle's resilience and weakness lies in its stability.
- When this is impaired, the ankle can progress into rapidly progressive arthritis.
- The goal of ankle fracture surgery is to reestablish the stability and congruence of the ankle joint.
So you're taking your dog out for a walk, enjoying the night air, when suddenly the dog lunges for the bushes. Your shoulder is snapped into tension, and your ankle rolls over the edge of the sidewalk. You hear a sickening “SNAP!” Suddenly, your ankle will no longer carry your weight. It didn't seem like such a hard roll. How in the heck could you have broken your ankle?
At the ER, an x-ray is taken. Sure enough, you have a crack in a bone on the outside of your ankle, the fibula. Are you going to need an operation or not? How is that decision made?
In order to figure out why ankle fractures sometimes require surgery and other times do well without surgery, an understanding of the anatomy of the ankle is necessary. The ankle is made of three bones, the tibia, the fibula, and the talus. Together, the fibula and the tibia create the roof of the ankle joint. They surround the talus on three sides, creating an extremely stable hinge joint. The stability is both the strength and the weakness of this joint.
These three bones are held together and their motion is guided by their ligaments. On the inside of the ankle, the deltoid ligament spans the gap between the medial malleolus of the tibia and the talus. On the outside, the lateral ligament complex stabilizes the fibula to the talus, and keeps the ankle from rolling over or spraining. Perhaps most important are the ligaments that bind the tibia and the fibula, stabilizing the roof of the ankle, the syndesmotic ligaments.
The stability of this joint makes it extremely resistant to arthritis. While arthritis without underlying injury is extremely common in the hip and knee, it is very rare in the ankle. However, after injury, any loss of stability or congruence in the ankle joint is often followed by rapidly progressive arthritis. Why? The pressure distribution between the tibia and the talus is distorted by even small degrees of malalignment. This distortion leads to an even wear in the damaged ankle.
So the goal of fracture treatment is to strictly restore the alignment and the stability of the ankle joint. This is the most reliable way of ensuring that the ankle will function in as normal a manner as possible. It is therefore critical that the intra-articular portions of the fracture are exactly opposed. It is also extremely important that the ligaments, especially the syndesmotic ligaments, are stabilized completely, so they can heal at proper length. This includes ensuring that the fibula’s length is precisely reestablished.
To illustrate this, we will look at two very similar fractures, both of them potentially unstable. In case A (these are x-rays looking at the ankle from front to back), the fibula is broken at the level of the ankle joint (blue bracket) and a small portion of the medial malleolus (green arrow) is torn off along with the deltoid ligament. However, the ankle joint itself is in its normal position (red lines). Although this injury has the potential to fall out of alignment, scientific investigations have shown that this rarely happens. It is safe to treat this injury in a cast with close observation.
In case B, the fibula is also broken at the level of the ankle joint (blue bracket) and a small portion of the medial malleolus is torn off along with the deltoid ligament (green arrow). However, in this example, the ankle joint has been very slightly thrown out of proper alignment (incongruent red lines). It is likely that if this injury were allowed to heal in this position, the result would be a painful joint which would rapidly progress to arthritis. It was my judgment therefore that this patient would do better with surgical stabilization or placement of metallic plates and screws to realign and stabilize the joint.
This is only one common fracture pattern. Many patterns of ankle fracture exist and each requires its own approach.
As in many parts of medicine, there is still a great deal of controversy regarding the fine points of decision-making in treating ankle fractures and many surgeons will disagree on the best way to treat a specific fracture. Hopefully, this article will give you some idea of how these decisions are made. If you have further questions, please enter them in the forum section of www.wholefoot.com and we will answer them.
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Lois: We'll be talking about metatarsalgia, disorders of the forefoot, with Dr. Brett Fink. Dr. Brett Fink is an orthopedic surgeon at the Indian Orthopedic Center and author of the book, The Whole Foot Book, a general reference on foot care which will be published in December of this year. I am Lois Wingerson. Welcome, Dr. Fink.
Dr. Fink: Thank you, Lois.
Lois: Dr. Fink, what are the biggest challenges in diagnosing and treating metatarsalgia?
Dr. Fink: Well, let's start by defining what metatarsalgia is. Metatarsalgia simply means forefoot pain. And so metatarsalgia by itself is a description rather than a diagnosis. And so the biggest challenge in diagnosing and managing this problem is really to make the correct diagnosis. Traditional medical training, the type of training that a medical student generally has, is not very complete in describing musculoskeletal problems. It's more something that people generally pick up as they go along during training. It's even more weak in foot and ankle problems, because for the most part these problems have been relegated to the podiatric community. A significant portion of the people saying a primary care doctor will have foot problems even though this may not be the primary complaint. The forefoot is not a very big structure, but it's packed with a lot of stuff, ligaments, tendons, arteries, bones, and nerves. And all of these things can be a part of the problem. Being familiar with the anatomy is very important in understanding what can go wrong with it. That is probably the biggest thing that a physician needs to know. You need to be aware of the diagnoses metatarsalgia is commonly caused by, because you can diagnose what you don't know. After this, many effective nonoperative treatments can be instituted even by the primary care physician. This is one of the reasons that I wrote The Whole Foot, to help patients and their physicians learn about nonoperative care, because often it is passed over. People often go straight to an operation, which is really a unnecessary shame in my opinion.
Lois: What are the keys to determining the cause of metatarsalgia pain?
Dr. Fink: I think the key is a careful physical exam. And that involves really meticulously going over issues such as skin, nerves, and circulation as a part of the general exam and then being very careful to define exactly where it hurts. One diagnosis, Morton's neuroma, is really very over-diagnosed. The reason is because Morton's neuroma may be the only diagnosis that the physician may be familiar with that causes forefoot pain. If someone has pain which is really across the entire forefoot or is where Morton's neuroma pain is usually not present, then this is probably not the cause of the problem. Also, I think it's important to understand how deformities may interact with the causes of forefoot pain.
Lois: Please explain how other structures may be involved in the development of forefoot pain.
Dr. Fink: It is very important to understand that the foot does not exist in isolation. The simple act of walking is really a function of the back, the hip, knee, and the entire leg. And all the joints, ligaments, and muscles of each one of these areas are involved in the act of walking. Any dysfunction of any one of them will affect the way that the foot experiences pressure, and this pressure is what overloads the foot and causes many common foot problems including metatarsalgia. One of the results of this dysfunction is to shift the pressure in the foot from the entire foot and concentrated on the forefoot itself. This will eventually wear out a structure in the foot. If the weak part of the foot chain is the forefoot, then you will get metatarsalgia. One common illustration that I can think of off the top of my head is that all of someone that has a restriction of knee motion because of osteoarthritis or hamstring contractures, this will subtly change the way that they walk. It will shift the weight to the forefoot. This is something that we can look at on a forefoot pressure scan, a computerized device that measures the pressure on different parts of the foot as we step. Hamstring contractures, according to one article, were the factor most associated with common foot complaints.
Lois: Thank you very much, Dr. Fink.
Dr. Fink: Thank you very much, Lois. I've enjoyed it.
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Forefoot pain is one of the most common problems that I see in my clinic. There is rarely a day that goes by that I do not see someone with pain and swelling in the front portion of the foot. When I speak of forefoot pain, I'm speaking of pain in the ball of the foot, excluding the big toe.
Usually this pain occurs without trauma or other accident. The most common history is swelling and discomfort that occurs at the base of the toe gradually. This may occur with or without deformity. It is usually worse with activity and with certain shoes.
While several things can cause this including stress fractures, Morton's neuroma, several usually benign tumors, the most common cause is injury to ligament that is found on the bottom of the joint at the base of the toe, the metatarsophalangeal joint. This condition is not familiar to most nonmedical patients, and is commonly not familiar to many physicians who do not regularly see patients with foot complaints.
The major ligaments of the metatarsophalangeal joint are located on the bottom and sides of the joint. It is these ligaments that determine the resting position of the joint. The ligaments can weaken and tear. These tears are usually caused by gradual wear due to age, overuse, the shape of the foot, and many other factors. On occasion, the tear can be suddenly caused from a “jamming” type of injury, but often the ligament is abnormal before this injury.
 A hammertoe can develop after these ligament tears. The exact deformity that occurs depends upon the way in which the ligament is torn. A tear, which occurs on the outside portion of the ligament, will allow the toe to tilt toward the inside (figure 1). When the ligament tears in this way, the second toe commonly begins to overlap the big toe; this is called a “crossover” second toe and is often associated with a bunion deformity of the big toe. In the same way, a tear on the inside of the ligament will cause the toe to deviate toward the outside of the foot.
 When the tear involves the central portion of the ligament, a typical hammertoe deformity develops. This type of deformity occurs at both the metatarsophalangeal joint at the ball of the foot and the proximal interphalangeal joint, the joint in the toe closest to the foot. This deformity often causes a painful prominence over this joint from the acute flexion.
Unfortunately, once these deformities have developed, there is little short of surgery that can be done to correct the deformity. Often however the pain associated with the deformity can resolve without correction of the deformity. There is also no proven way to prevent the deformity from occurring even while in its early stages.
Reasonable treatment of this problem involves various methods of reducing pressure at this joint. These include stretching exercises focusing on the Achilles and hamstring tendons, maintaining proper posture, using stiff soled or rocker soled shoes, and using orthotic pads to offload the painful joints. Injections of steroid or cortisone medication into the joint can be very helpful in the short run to help relieve pain, however its safety and effect on the natural resolution of this problem has not been established. Overall more than half of the people that developed this problem do not require surgery although many will be left with toe deformities that usually are minimally symptomatic.
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Mike Buchanan: Thank you very much. And good morning everyone. Well you know most people take a tremendous fuss in their overall health. That's why orthopedic surgeon, Brett Fink, has written a book about the importance of maintaining proper foot care. The foot is an amazing complex organ that provides a variety of activities during a person's lifetime. Dr. Fink will reveal the foot problems that are often misunderstood by the very physicians that we turn to for help. Furthermore, foot problems can affect every aspect of a person's life from work to parenting. These problems can be avoided and even reversed. Dr. Brett Fink is the author of the book, The Whole Foot Book: A Complete Program For Taking Care of Those Feet. And he joins us this morning. Good morning, Doctor, and thank you for joining us this morning!
Dr. Fink: Good morning, Mike, and thank you for allowing me to be on your show.
Mike Buchanan: Always nice to have you on the show. What are some ways to find the best foot care possible?
Dr. Fink: Well, I think that one of the ways to find the best foot care possible is to buy a reasonable pair shoes. I think that, despite what a lot of people think, orthotics are not necessary for a lot of things. For specific foot problems, they can be very important. And then to find a foot doctor who is knowledgeable and can help you with any problems that come up.
Mike Buchanan: For a person that has a foot problem is it best for that person to go to a podiatrist as opposed to a family doctor?
Dr. Fink: I suppose it depends upon what you're looking for. Certainly most people have exposure to a family practitioner on a regular basis, and for fairly minor problems I think that a family practitioner can help them with a lot of those problems. Certainly for a problem that is more persistent, is causing more problems, may be causing swelling, or foot deformity, then seen either a podiatrist or an orthopedist that is knowledgeable in foot problems could get them a little farther than it could with seeing a family practitioner.
Mike Buchanan: I was thinking, Dr., you go to a shoe store, and there are literally hundreds and hundreds of shoes to choose from. Do we sometimes make a mistake by purchasing the wrong shoes for a specific lifestyle or activity that we have?
Dr. Fink: Well, I think , Mike, that's an interesting question. First of all, I think we should take a step back, and look at the way the foot has developed. I mean, before hundred years ago, people didn't wear shoes very often and therefore the foot has evolved to do a fairly good job throughout our lifetime of performing without pain for our lifespan. So often shoes are not necessary or not therapeutic for most healthy feet. I think it is important to find shoes that fit properly and that, if you have foot problems, specific foot problems, then you should look for shoes that are designed, then mechanically counteract those problems.
Mike Buchanan: What are some of the most common foot problems that you find associated with the foot?
Dr. Fink: Well, the most significant problem I think is plantar fasciitis, or heel pain, also known as heel Spurs. That probably accounts for 30% of the people that I see in my office. Ten percent of people will have this sometime throughout their life. And usually it goes away without much problem. After that, various forms of tendinitis. All of these occur because of the way that we use our feet over a long period of time. Again, shoes are part of the problem, because in Western society we have begun to wear shoes that are fairly constrictive. A lot of times the muscles do not develop properly or become deconditioned and I think that this makes us prone to develop problems like plantar fasciitis, like Achilles tendinitis, like hammer toe deformities. That's what I go through in my book, I have developed a program to counteract those problems through exercise, therapeutic shoe wear when necessary, and overall good foot health.
Mike Buchanan: What are some other foot problems that, you know, you come across in your practice?
Dr. Fink: Well, again, hammer toe deformities are perhaps one of the biggest problems. And they often begin as simple swellings in the front of the foot and a lot of times people don't know what they are. You know, unfortunately, a lot of times if you go to a primary care doctor, who may not be quite as sophisticated about the number of diagnoses that he knows well, he may misdiagnose this as a Morton’s neuroma, a stress fracture, or something like that. And usually these problems begin as swellings that eventually become foot deformities. A lot of times the pain will go away but the deformity will persist. Other problems that you might run into are bunions, and various types of arthritis of the midfoot or forefoot. Arch pains, flattening of the arch, there are hundreds of potential diagnoses.
Mike Buchanan: I'm sure you've seen, like I have, these commercials on television and they're usually in like a Walmart store, where you stand on this, kind of like a pad or something, and this machine will tell you that you need this specific type of shoe. Are these machines pretty reliable, accurate, what you think?
Dr. Fink: Well, I don't think that a healthy foot requires an orthotic. The foot that is having problems may require an orthotic and surprisingly there's not much of a difference between orthotics. Studies have even looked at custom orthotics versus the type that you get over-the-counter at one of those kiosks and there is only very subtle differences between them. And foremost normal feet, feet that don't have significant deformities but are painful, just a simple over-the-counter orthotic can help many problems. But those machines, unfortunately, only look at a very small part of the foot, and therefore, I think it's difficult for machine to tell you what to do for any foot problem. And again orthotics are only a very small part of foot treatment.
Mike Buchanan: And you know these machines, Doctor, they are stepped on by hundreds of people don't they malfunction after a while?
Dr. Fink: Well, again, you have to look at the type of information that these machines are trying to get from your foot and it is, it's very limited. And they more or less determine how you distribute the weight on the foot while you are standing. And that isn't necessarily the same as when you're walking or you're doing any of the millions of things that we do during the course of the day. And so those machines, I think they only look at a very limited part of the foot and I think it's difficult for that machine to even judge whether orthotics are the proper way to go as they frequently aren't.
Mike Buchanan: Well, Doctor, let me ask you, we only have a couple minutes to go, are feet sometimes misunderstood?
Dr. Fink: Well, I think that, I still after 19 years of being a doctor, there are many things that I don't understand about the foot. I think that after years of considering some of these foot problems, you do eventually get some insight as to what is going on in them. But I think that, yes, the foot has many, many bones and joints and they all interact with the leg, so it's a very complex situation. But, in a lot of ways, the principles behind them are very simple to understand, but very difficult to convey to the patient during the course of a fairly short office visit.
Mike Buchanan: Doctor, how can someone obtain a copy of your book, The Whole Foot Book?
Dr. Fink: It's available through Barnes & Noble and Amazon and I think it's very reasonably priced. Really for the price that you can go to a physical therapist for one visit, it's much less than the copayment for physical therapist for one visit. And I think that people can learn a great deal if they just take the time to look into this stuff on their own rather than just expecting a doctor or physical therapist to teach them all of these things that I think are very important for them to learn during the course of their foot problem.
Mike Buchanan: As far as surgery goes, use surgery only as a last resort?
Dr. Fink: For most common problems, I think, surgery is almost always a last resort. It's very simple for a doctor to prescribe surgery for problem. They don't have to get a lot of help from the patient. It's time-consuming for doctors to go through with the patient, nonoperative treatment. And I think that it's overlooked and often not paid the attention that it should be. And I think that a lot of times people get in trouble because of that.
Mike Buchanan: Doctor, we have run completely out of time, Thank you very much for joining us this morning on Good Morning Magazine.
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•January 22, 2012 •
Let’s assume that because you have come to this website that you are interested in foot problems. Maybe you have foot pain yourself or maybe you are looking for information for someone else. You must realize that different sources will vary in their portrayal of medical topics. It is up to you to use your own intelligence to decide whether the things that these sources say ring true to you.
The first type is the scientist. This is what you get when you open a textbook of medicine. The Mayo Clinics have a very nice website that interprets their information like this. The information will sound very dry and unfortunately the recommendations will be very non-specific and difficult to follow. This is because science offers us very few clear answers when it comes to the treatment of foot and ankle problems in specific circumstances. Scientific study can speak to the results of treatment within populations, but for individual conditions and all of the myriad of complications that arise, it says much less.
Here is the Mayo Clinic Treatment for plantar fasciitis (http://www.mayoclinic.com/health/plantar-fasciitis/DS00508/DSECTION=treatments-and-drugs):
- “Physical therapy. A physical therapist can instruct you in a series of exercises to stretch the plantar fascia and Achilles tendon and to strengthen lower leg muscles, which stabilize your ankle and heel. A therapist may also teach you to apply athletic taping to support the bottom of your foot.
- Night splints. Your physical therapist or doctor may recommend wearing a splint that stretches your calf and the arch of your foot while you sleep. This holds the plantar fascia and Achilles tendon in a lengthened position overnight and facilitates stretching.
- Orthotics. Your doctor may prescribe off-the-shelf or custom-fitted arch supports (orthotics) to help distribute pressure to your feet more evenly.”
When you read this, what are you left with—really, nothing. Overall, these websites may be useful for general information, but do not help with self treatment or give the reader a clear idea of where to go or what to do. The good news is that they will not lead you wrong. The bad news is that they often will not lead you anywhere.
Scientists are responsible for the great advancements of medicine, but, as doctors, they are not particularly effective. Many are unwilling to take the risks necessary to give the specific instructions required to institute a treatment plan.
The second are the zealots. They are usually on the crest of the latest medical fad. When approaching medical treatment, these sources begin with a premise–that their procedure, medicine or whatever is the answer to whatever is bothering you. The scientific information is spun so that their treatment is supported and all other information is ignored or discounted, sometimes with an angry religious fervor. Perhaps, they believe that one single way of treating things works for a wide assortment of problems. This is the case with Prolotherapy, and a number of other treatments. Don’t get me wrong. These treatments and techniques may be very useful. Before widespread usage of these techniques is recommended, some proof is necessary.
Here is an excerpt from the prolotherapy.com website (http://prolotherapy.com/prolodefine.htm):
“The treatment is useful for many different types of musculoskeletal pain, including arthritis, back pain, neck pain, fibromyalgia, sports injuries, unresolved whiplash injuries, carpal tunnel syndrome, chronic tendonitis, partially torn tendons, ligaments and cartilage, degenerated or herniated discs, TMJ and sciatica.
Prolotherapy uses a dextrose (sugar water) solution, which is injected into the ligament or tendon where it attaches to the bone. This causes a localized inflammation in these weak areas which then increases the blood supply and flow of nutrients and stimulates the tissue to repair itself.”
First, notice the claim. What doesn’t it work for? Second statement, this is full of many factual inaccuracies. Dextrose injection does not cause inflammation. For the most part, it diffuses into the tissue rapidly. Even if it did hang around a bit, increased levels of sugars like dextrose essentially simulates the diabetic state, which has been shown in past experience to be unhelpful in healing soft tissue (as anyone with diabetic foot problems can attest). The other claims such as “increases in blood supply” are unsubstantiated by any research. Prolotherapy may be helpful. No one knows because all the claims are anecdotal. This means that the therapy was tried, it worked on someone, but no one says whether it did or didn’t work on many others.
Some zealots sincerely believe in their product or procedure. Others may have a financial stake in whether the product sells or not. If a clinic or doctor offers only one form of treatment, run away!! No one treatment fits all problems or situations. Be especially suspicious if the treatment’s indications are very broad or the claims are too good to be true. My advice is to carefully assess any claims and do your homework on any form of treatment. If the evidence isn’t there, then weigh the claim and the risks and decide for yourself. Realize however that faith in an unproven medical treatment comes with substantial risk. Many times, the risk is the wasted money and mild pain, but there are some very real complications for unproven treatments.
People with an engineer-mentality make the best doctors. Engineering is applied science as is medicine. An engineer takes the science (all the facts) and uses it in the real world. Unfortunately, everything that an engineer does is not proven either, because the facts have not been completely established for every problem, every circumstance, every person, but an engineer considers all of the facts and tries to objectively come to the best solution for a real world problem. He weighs all treatment options and objectively decides which has the best risk/benefit ratio. In the best circumstance, an engineer has no stake in the outcome of his assessment and is willing to change his view on problems as new information arises. All of us come to the problems with which we are presented with some bias, however. Many times this means that the assessment will be subjective in some sense. Errors will happen, because the outcome has not been proven.
In the end, it is you, the patient, who makes the final decision. All of the sources to which you turn may inform you well or poorly, but you have to weigh them all and decide what is best for you.
–Brett Fink, MD. Co-author of The Whole Foot Book: A Comprehensive Guide to Taking Care of your Feet
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Doctors get foot pain too
One of my biggest reasons for writing The Whole Foot Book was to share the experiences and answer the questions that my patients have had over the years during the course of treatment. It may surprise some readers, but many of the conditions I have discussed, I have had personally. There are many conditions that I have identified that cause me to have a high chance of getting these problems. I have had lifelong problems with controlling my weight; I am not overly flexible; People have remarked on the bouncy step that I had as a child/adolescent as a result of my tight Achilles tendon. My activity has varied widely during my life from extremely athletic to “couch potato”-ish. And now, at age 48, my ligaments, muscles, tendons, skin, and bones do not have the resiliency that they once had. All of these problems lead to overloading the front of my foot.
As a result, I have had Achilles tendon problems repeatedly. I have developed and recovered from plantar fasciitis/heel spurs in each of my feet and I have developed a hammertoe after irritation of the second toe joint in the ball of my right foot.
While some conditions may require surgery for the best result, in most, especially non-traumatic, problems, surgery is neither the fastest nor the best method of recuperation. And while the scars that remain after many conditions (such as a hammertoe), may be objectionable and make me prone to re-injury, in my opinion, it is preferable to the problems (stiffness, numbness, and scars) that follow surgery. In some instances, the deformities and occasional persistent pain may make surgical reconstruction the practical option, but you must understand that there are alternatives to surgery. My foot problems have never come to this point, but those of a minority of my patients have and surgery was the logical choice for them.
These alternatives include exercise therapy (either by yourself or with the assistance of a therapist), temporary or permanent limitations to activity, weight-loss, and therapeutic shoe wear, braces and orthotics/inserts. There are also pain-relieving methods that include massage, anti-inflammatory and other pain medications, and heat and cold application.
Which is right for you? Most of the time it is a matter of trial and error. Usually you should try several methods that will fit in with your life and then modify, and adapt your regimen until you figure out what works for you. Find a doctor that understands your preferred approach to treatment and has the patience to work with this. Communicate your goals to him and often the best course of treatment becomes clear.
As for me and my feet, I have a lot of better things to do than recover from surgery or to take the chance of becoming my doctor’s next surgical disaster (and all sugeon’s have them). All surgeries have a chance of failure and it may surprise you that for most foot surgeries that chance is somewhere between 5% and 30%. In a few, it may be as much as 50%. But my case of plantar fasciitis, Achilles tendinitis, or hammertoe may not be your case and surgery is sometimes necessary. My advice is to give non-operative treatment a chance and this involves patience, persistence, and thought on the part of both you and your doctor.
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How to Care for a Cast
•August 2, 2011 •
Casts are used for many purposes in the orthopedic or podiatric clinic including various forms of tendonitis, sprains and other soft tissue injuries as well as fractures. Proper care of your cast is important for the successful treatment of your problem and for your safety.
While casts can be uncomfortable and the conditions that they treat can be painful, the cast itself should not be painful. If your pain increases or if the cast feels too tight, you should elevate the cast above the level of your heart. If this does not quickly alleviate the problem, contact your orthopedist or podiatrist’s office or the on-call physician immediately.
Itching is also quite common. Over-the-counter anti-histamines such as Benedryl (diphenhydramine) and non-drowsy anti-histamine, Claritin (loratadine) can help stop this. Never stick anything into the cast to scratch your skin, because it can damage your skin and cause potentially serious infections and wounds. The Cast Cooler (www.castcooler.com) is a suction device that uses a vacuum to suck air through the cast. It seems to improve itching and smell associated with cast wear.
Protect your cast when in the rain or in damp places. If the cast gets slightly damp, it can be dried with a blow dryer on low heat. If it gets wet, the cast should be changed because it can damage the skin.
If a cast rubs on your skin, wounds and blisters can occur. This should be immediately reported to your doctor. Any drainage from the cast not related to a surgical wound or ulcer should also be immediately reported to your doctor. These areas are most common at the ends of the cast, especially the top of the foot, the front of the shin, and around the inside or outside of the foot. They are easily and quickly treated with replacement of the cast and simple wound care if they are caught early.
Fiberglass cast surfaces can be abrasive. It is advisable to wrap the cast with an ace wrap at night to avoid damaging your sheets, other leg, or partner.
Smell can also be a common problem and can be helped by regular cast changes usually every three or four weeks. Avoiding heavy physical activity and exercising also will help. Do not pour powder down the cast as it can cake and damage the skin.
Showering/bathing with your cast
It is impossible to guarantee that your cast will remain completely dry during a shower or bath, but most people are unwilling to forgo showering or take a “sponge-bath” for the entire time that they will be wearing a cast. While showering, avoid directing the showerhead at the cast or leg. Never submerge the cast no matter how well it is protected.
Ideally, you should wet your body for a short period. Turn the shower off and soap and lather appropriately. Turn the shower back on for rinsing. This minimizes the chance of moistening the cast. An excellent way of controlling the water is to use a spray attachment to the faucet. These are available at most hardware and discount stores for $10-15.
Prepare the cast by taking a washcloth or hand towel and rolling or fold it into a tube. Tape or ace wrap this above the cast. Place the cast and towel completely within a heavy plastic bag and secure with a rubber band. If there are significant circulatory problems, then the rubber band should be very loose. If the cast is a lower extremity cast, then an ace wrap should be wrapped around the weight-bearing portion of the cast to avoid abrasion and tearing of the plastic bag by the cast.
Commercially-available cast protectors can be substituted for the plastic bag and can be obtained at most medical supply stores or online. The cost is about $30. Manypeople find them more convenient than plastic bags, but they also can leak. Placing the hand towel above the cast and below the cast protector is still advisable. The Drypro cast protector is slightly more expensive, but is the only cast protector on the market that I would feel secure enough with to skip the above preparation.
-Brett Fink, MD, Indiana Orthopedic Center, Indianapolis, IN, (317) 588-2663
Posted in Medical Tips and Pearls, Uncategorized
Tags: cast, feet, foot, foot injury, foot pain, fracture
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•August 6, 2011 •
Although it has been around for over 15 years and has been used with some success in treating difficult-to-heal wounds, platelet-rich plasma (PRP) has come into the literature recently for the treatment of many musculoskeletal conditions including tennis elbow, patellar and Achilles tendonitis. In addition, the successful use of PRP in the treatment of the injuries of many sports figures has been widely publicized. Some physicians that treat these problems are beginning to offer these treatments to their patients, sometimes as a last resort before surgery, sometimes, unfortunately, as an initial treatment. Most insurances have not yet begun to cover this treatment, citing its experimental nature. It can be very expensive to pay for out-of-pocket ($500-1000 or more).
Platelet-rich plasma is a preparation created from blood. The blood is taken from a vein and spun by a centrifuge. This separates the blood into blood cells, serum, and platelet-rich plasma. Platelet-rich plasma, as suggested by the name, contains a lot of platelets. These small fragments of cells when activated release a soup of proteins called growth factors that start the clotting and healing cascade after an injury. The preparation is then injected into the irritated area. Are they the right proteins to help a painful heel heal? Nobody knows.
According to Orthopedics Today, a widely distributed periodical for orthopedic surgeons, a study looking at the effect of PRP on plantar fasciitis was recently presented by Dr Raymond Monto at 12th EFORT Congress in Copenhagen in June 2011. In it, he found that the 40 patients that he studied did significantly better with the PRP injection than the cortisone injection. Dr. Monto is also a speaker for Exactech, a company that markets devices for the production of PRP.
Plantar fasciitis is a sometimes excruciatingly painful and frustrating irritation of the heel. It is the most common cause of heel pain and seems to be the result of chronic scarring of the plantar fascia, an important ligament that connects the heel to the toes and supports the arch. Plantar fasciitis commonly resolves on its own. More than eighty percent of people with plantar fasciitis get better within 6-12 months, sometimes without any treatment. Unfortunately, a portion of them do not. They can be a very unhappy group.
Over the last two decades, many treatments have come in and out of fashion for plantar fasciitis. In the early nineties, night splints, plastic splints that you strap on at night, were the solution. Subsequently, further scrutiny showed the results to be inconsistent and usually fairly marginal. In the early 2000s, Orthotripsy, the application of a high strength shock wave machine to the heel, promised to be the answer. Many orthopedists and podiatrists bought these machines. The manufacturer of one, the Ossatron, has since settled a class action suit over misrepresenting the results of this treatment. Coblation, the use of a probe to burn small holes into the plantar fascia, came out about the same time. Although I have heard little to state that it isn’t effective, the only paper on it over the ensuing years studied 14 patients. It was overall positive, but the evidence is still not sufficient to recommend it to my patients. No published literature is available from a center inside the US. Botulinum toxin, a chemical that paralyzes muscle for months where it is injected, best known for cosmetic treatments of the face, has been suggested beginning in 2005, but the studies to date involve less than thirty patients.
According to a systematic review of blood products including PRP by Van Vos et al in the British Medical Bulletin (2010):
“All studies showed that injections of autologous growth factors (whole blood and PRP) in patients with chronic tendinopathy had a significant impact on improving pain and/or function over time. However, only three studies using autologous whole blood had a high methodological quality assessment, and none of them showed any benefit of an autologous growth factor injection when compared with a control group. At present, there is strong evidence that the use of injections with autologous whole blood should not be recommended. There were no high-quality studies found on PRP treatment.”
Many PRP systems come with the FDA required warning, “The platelet rich plasma prepared by this device has not been evaluated for any clinical indications.” In other words, the evidence to recommend PRP for anything is just not there yet.
While PRP is a promising treatment and evidence may eventually justify its cost, it should not be used as anything short of a last resort prior to surgery. Considerable out of pocket expense should be anticipated. It is my opinion that it should not be used outside of clinical trials until further evidence demonstrates clearly its effectiveness.
-Brett Fink, MD, Indiana Orthopedic Center, Indianapolis, IN, (317) 588-2663, co-author of The Whole Foot Book, A Complete Program for Taking Care of Your Feet.
Posted in New Treatments, Plantar fasciitis
Tags: feet, foot, foot pain, heel pain, heel spur, Plantar fasciitis, plasma, platelet, platelet rich plasma, PRP, tendon
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 What You Need to Know about Narcotics
•August 12, 2011 •
Narcotic analgesics (medications that treat pain) are commonly used to treat pain after surgical and traumatic injuries. They work by mimicking endorphins that help with pain naturally in the body. However, there are many things that you should know about this class of medications.
Normal side effects of these medications include nausea and vomiting, itching, sleepiness, wakefulness, vivid or bizarre dreams, and constipation. Sometimes these side effects are tolerable. Occasionally, they require treatment with other medications. Often, the medication must be stopped or changed because of the side effects. Nausea can often be treated by medications such as phenergan that can be taken by mouth, rectally using a suppository, or by injection at a medical facility. Itching can be sometimes controlled through the use of over-the-counter antihistamines such as Benadyl, Zyrtec, or Claritin. Constipation nearly always occurs to some degree and can be lessened by ensuring that you drink plenty of water. Over-the-counter laxatives such as Metamucil or Colace should be started at the first indication of problems. Your doctor if necessary can prescribe stronger laxatives. True allergic reactions are rare.
All narcotics carry with them a risk of dependence or addiction if taken for a long time. Withdrawal symptoms such as agitation, nervousness and tremors sometimes are felt after discontinuation of narcotics. Some forms of discomfort do not seem to respond very well to narcotics regardless of the dosage and should be managed using other methods.
Narcotic analgesics are controlled substances and it is against the law to alter or forge prescriptions for narcotics or to give them to anyone else but the person for whom they were prescribed. No person should receive narcotic prescriptions from more than one doctor at a time.
If it is discovered that you are obtaining narcotics from more than one doctor, you will be denied further narcotic prescriptions from this office.
Most narcotics that are prescribed for moderate pain last about four to six hours. Some newer long-acting narcotics last longer, but also take longer to get into your system. If pain medication is necessary on a round-the-clock basis, these narcotic preparations may be prescribed according to your doctor’s recommendations.
Narcotics are effective medications for the relief of pain. However, they should not be used longer than they are required and are not a particularly effective way of managing pain over a long term.
-Brett Fink, MD, Indiana Orthopedic Center, Indianapolis, IN, (317) 588-2663, co-author of The Whole Foot Book, A Complete Program for Taking Care of Your Feet.
Posted in Uncategorized
Tags: foot injury, foot pain, foot surgery, medication, narcotics, opiates
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•August 12, 2011 •
Bone density loss is a normal part of aging. Density is basically the amount of bone that is in your bone. The spongy struts that make up the bone tissue at the end of the bones near the joints thin, making them more fragile. It begins at the age of about thirty and continues at a low rate until menopause, but it accelerates for a few years after menopause. Bone density loss is not usually painful and is not associated with arthritis, but, if it becomes excessive, it can predispose you to painful fractures commonly in the hip or back, but also in the wrist, ankle, shoulder, and knees. It is also treatable and preventable.
Bone density can be measured using a test called a DEXA scan. DEXA stands for dual emission x-ray absortimetry. Essentially a special x-ray is taken that allows doctors to measure the amount of the x-rays that is absorbed by the bone. This relates to the density of the bone. The test is painless, quick, and covered by Medicare and most insurances. It can be scheduled at the hospital by our office. It measures the density of the bone using a T- or Z-score, which compares your bone density with that of 20 year-old females (T-score) or people your age (Z-score). A score of -2.0 means that you have less bone density than 90% of people.
Treatment of mild bone density loss involves proper nutrition. Adult should get at least 1200 mg of calcium daily through diet and supplementation. They should also get at least 1000 IU of Vitamin D daily. While taking less than this can accelerate bone loss, taking more than this will not increase it and excess intake (several times the recommended amount) can lead to health problems.
People with a T-score of less than -2.5 or less than -1.5 with additional risk factors should be treated with medication. There are several medications that are FDA approved for osteoporosis. These are listed below.
Miacalcin nasal spray (calcitonin) 200 IU administered as a nasal spray daily
Problems: Nasal irritation
Evista (raloxifene) 60 mg tablet daily
Problems: Possible increases in risk of blood clots, heart attack and stroke. Hot flashes and leg cramps are the most common side effects.
Biphosphonates:
Fosamax (alendronate) 700 mg tablet weekly
Actonel (risedronate) 5 mg daily, 35mg weekly, or150mg monthly
Boniva (ibandronate) 150 mg monthly
Reclast (zoledronic acid) 5 mg given intravenously yearly
Problems: Should be taken on an empty stomach, Irritation of the esophagus/heartburn, osteonecrosis of the jaw, musculoskeletal pain, do not use with kidney failure, hypocalcaemia.
Forteo (teriparitide) 20 mcg injected daily for no longer than 2 years.
Problems: Possible increase in bone cancer (evidence in rats only), avoid with Paget’s disease, hyperparathyroidism, and hypercalcemia, hypotension.
-Brett Fink, MD, Indiana Orthopedic Center, Indianapolis, IN, (317) 588-2663, co-author of The Whole Foot Book, A Complete Program for Taking Care of Your Feet.
Posted in Medical Tips and Pearls
Tags: osteoporosis
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Diabetes and the Foot
•August 12, 2011 •
People who have diabetes mellitus should be very concerned about their feet. The most common complications of diabetes are from damage to the eyes, kidney and the feet. Almost everyone knows someone who has had a disastrous complication of the foot because of diabetes. While diabetes is the most common disease resulting in amputation, amputation is actually fairly rare when considering the number of people with diabetes. Careful foot care, aggressive treatment of blood sugar levels, and smoking cessation will usually help prevent this.
The increased sugar concentration in the blood of people with diabetes damages nerves. The longest nerves are damaged first and these happen to be the ones to the foot. The result is numbness, changes in circulation, muscle weakness, skin rashes and stiffness of the toes.
There are two reasons that the nerves are damaged. First, glucose can actually attach to the all proteins in the body including those that are in nerves. Most proteins in the body have a limited lifespan. They are continually produced and broken down. The proteins that do not turn over rapidly or are made of certain reactive amino acids can have enough glucose attached to them to impair their function. Proteins in the nerve membranes that control the electrical impulses of the nerves seem to be prone to this damage. Second, the increased glucose concentration promotes the production of certain toxins within the nerve cells that hamper their ability to generate energy.
Diabetes can also accelerate hardening of the arteries or arteriosclerosis. This causes the arterial circulation of the foot to decrease, eventually starving the foot of food and oxygen. When the loss of circulation is combined with the numbness, the foot becomes prone to injury and these injuries are much more difficult to coax into healing. Problems that occur in people with diabetes include painful neuropathy, stress injuries, ulceration, and infection.
Painful neuropathy or pain from the sick nerves is generally perceived as burning, aching, or a tight feeling in the feet. It is often more intense at night and can be severe enough to require medication. Initially, anti-inflammatory medications such as naproxen (Aleve) and ibuprofen (Advil, Motrin) and other over-the-counter pain medications such as acetaminophen (Tylenol) can help these symptoms. Lotions such as capsaicin (Zostrix) can also be applied and give relief. When beginning treatment with this lotion, burning is often noted, but generally resolves with the first few days of application. Other prescription medication such as gabapentin (Neurontin), duloxetine (Cymbalta), pregabalin (Lyrica) and topiramate (Topamax) are also effective in more severe cases, but have more side effects. Perhaps the most effective method of addressing these symptoms is careful control of the diabetes through effective medication and monitoring serum glucose level at home with the help of your primary care physician.
Stress injuries, otherwise known as diabetic arthropathy or Charcot arthropathy, are sometimes sustained by people with diabetic nerve damage. The initial symptoms are unusual swelling, redness, and pain. It is often confused with infection. A simple “sprain” is not simple in someone with diabetes. If you experience any of these symptoms, an orthopedist, podiatrist, or other physician should evaluate you immediately. This injury can lead to foot deformities so severe that they require surgery, because the deformity may make wearing normal shoes impossible without injuring the foot. The treatment is protection, immobilization, and/or prolonged restriction of weight bearing using cast, crutches or a walker for as long as six months. Surgery is occasionally necessary.
Ulceration is caused by repetitive or prolonged pressure on a portion of the skin. The pressure can impair the circulation until it the skin dies. Often pressure from a bone underneath the skin combined with age-related thinning of the protective skin causes it, but prolonged pressure to the back of the heel can also cause pressure this great just by resting the foot on a hard surface. A person with diabetic nerve damage should never elevate their leg on a table or other hard surface for a prolonged period of time or use heating pads on their feet. The break in the skin can lead to infection of the deep structures if left untreated. Early signs of a possible ulceration are a heavy callus, blue, black or purple patch (caused by bleeding underneath the skin), or a blister. If you have an ulceration or any of these other warning signs, you should be under a doctor’s supervision until the ulcer is completely healed.
-Brett Fink, MD, Indiana Orthopedic Center, Indianapolis, IN, (317) 588-2663, co-author of The Whole Foot Book, A Complete Program for Taking Care of Your Feet.
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•August 16, 2011 •
The decision to undergo surgery can be associated with many feelings. While you may be excited to be on the road to recovery, the unfamiliarity that most of us have with surgery can instill much fear: fear of the anesthetic, postoperative discomfort, and potential complications. It would be unusual if you did not feel this. This document should answer many of the questions that you may have about your surgery.
Prior to the surgery, you must discontinue most blood thinners. For aspirin and plavix, this should be six days prior to surgery. For coumadin, it should be three to four days. For other anti-inflammatories such as ibuprofen (Motrin/Advil), and naproxen (Naprosyn, Aleve), it should be one day. Other analgesics such as acetominophen (Tylenol) and celecoxib (Celebrex) can be taken right up to the time of your surgery.
For general anesthesia, you must be without food and water for at least six hours. Medications can be taken with sip of water. For most surgeries, this means that you cannot eat anything after midnight the night prior to your surgery. Please report any scratches or wound around the operative site to your surgeon as soon as possible. Tell your anesthesiologist and nurse about any changes in your medical condition or new cold, flu or other respiratory problems. Ensure that your doctor and anesthesiologist is aware of all of your medications including diet pill and herbal and nutritional supplements.
Many surgeries are under general anesthesia (going to sleep). Most patients feel more emotionally comfortable this way. However, many surgeries can be under a local anesthetic or spinal. If you are interested in this, bring it up to your surgeon or anesthesiologist who will let you know if it is possible and compare the risks of this to general anesthesia. During the operation, often local anesthetic is used. Do not be alarmed therefore if there are patches of numbness around the operative area.
Often narcotic pain medications are necessary to help with the pain. These medications help to decrease pain, but most people continue to be aware that they are experiencing pain. Narcotic pain medications can make you nauseous, constipated, and itchy as well as make you feel funny and, occasionally, give you strange dreams and make you disoriented. These problems to some extent are to be expected and are not really allergies. Some can be avoided by changing the narcotic, lessening the dosage or by giving other medications to treat these symptoms. Most narcotic preparations contain acetominophen (Tylenol) and so taking additional Tylenol should be avoided, but you can sometimes take other over-the-counter analgesics such as Motrin and Aleve while taking narcotics. However, if you have undergone a procedure where bone healing is necessary such as fracture fixation, osteotomies, fusions, and joint replacement, it is currently recommended that these medications should also be avoided.
You may notice some changes for some time after the procedure. The leg or arm may become purple, blue or red when it is allowed to be dependent (hanging down such as when you are sitting). This is common and is caused by sluggish emptying of the veins when the leg is swollen. Swelling is often prolonged. Even in minor surgery, some degree of swelling is common for months. In major reconstructions, swelling can last for six months or more. It is lessened by limb elevation. Ice is not especially effective. Compression stockings can be used to control it, but are only effective while they are being worn and some find the tight stocking to be uncomfortable or difficult to put on.
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