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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