5 common things medical professionals can overlook with treating the foot and ankle

To continue my "5 things" thoughts from earlier in the year, I want to focus on some of the things I see that medical professionals can commonly overlook when treating foot and ankle issues.  This list includes some things that I, myself, might not always have noticed at first glance as a podiatrist.

1) Poor circulation:  There is a common misconception, especially with general medical practitioners, that if one can feel a pulse and the foot is warm then the circulation is OK.  I have seen many patients that I have diagnosed with peripheral vascular disease in the lower extremity that has been overlooked by some pretty well-trained and respected clinicians.  Often times, these patients are told it is just their neuropathy or arthritis.  I always become suspicious when a patient admits cramping at night, when they have been or are a smoker, and when they have a history of cardiac bypass and stenting.  A simple doppler test that is abnormal can give an indication to me that can be followed up by other studies.

2) Stress fractures:  A stress fracture in the foot (usually a metatarsal) is often overlooked.  These can be "hairline" fractures caused from injury or non-traumatic simply from a change in activity.  Problem is, normal everyday x-rays usually do not show an early stress fracture.  These are read as negative by radiologists who do not have an opportunity to examine the patient.  (These studies are, in fact, negative most of the time).  I have treated true painful stress fractures for several weeks diagnosed clearly by MRI that not once showed up on regular x-rays.  If a patient comes in with a swollen foot more painful after activity, I tell my patients, "if it looks like a duck, and quacks like a duck, it's probably a duck."  In other words, if I think it is a stress fracture due to what I see, I can do little wrong by treating it as such with immobilization.  Usually, if a stress fracture is caught earlier it resolves more quickly.

3) Not giving an injection when appropriate:  With a lot of conditions we treat, injections are very helpful.  I often see, and was guilty of this earlier in my career, doctors with-hold injections in favor of conservative treatment.  This is fine, if after discussion with the patient, that is what is desired.  However, I have seen people who do not mind injections come in with severe heel or acute arthritis inflammation that have went to other doctors and were given very little treatment.  If appropriate, an injection of a corticosteroid can quickly and safely give a patient great relief.  There is nothing wrong with giving an injection on an initial visit if indicated.

4) Giving an injection when inappropriate:  On the other hand, I have seen injections given when they likely maybe should not have.  Fortunately, it is rare to cause significant harm from giving an injection, but doing so may delay resolution of the condition or frustrate a patient because other treatment is often not given and only temporary relief is gained.  A stress fracture is a perfect example.  A quality practitioner will often get a negative x-ray and inject a painful foot.  If a stress fracture is present, the corticosteriod can delay healing if injected in the area of the fracture.  Also, I have seen injections in areas that are debatable for injecting.  A good example is a tendon.  Corticosteroids can increase the risk of tendon damage and rupture.  Thankfully it is not common, but, in my opinion, conservative immobilization can often heal these patients without taking this risk.

5) Not advising a patient on footwear:  Especially here in Florida, flip-flops and flimsy shoes are common all year.  I have seen patients treated by more than one other doctor when no one talked to the patient about his or her shoes at all.  Many foot and ankle problems will not resolve if people do not at least change their shoes or shoe wearing habits a little.  Sometimes a change in shoes to something more supportive will be all it takes to alleviate foot pain.

So there is my list of "5 common things medical professionals can overlook with treating the foot and ankle."  Please keep in mind that good practitioners disagree on how to appropriately treat many conditions.  I do not make this list to criticize, but instead just highlight some things I have learned throughout my over 10 years of experience as a podiatrist.

My Weekend in San Antonio

This past weekend, I traveled to San Antonio, Texas for a wound care course.  Though I have visited Texas while in middle school, I have never been to San Antonio.  I enjoyed seeing the city including staying on the Riverwalk and visiting the Alamo.  However, my primary purpose for the trip was a 12 hour wound care course.

As a podiatrist, part of what we do is caring for diabetic foot ulcerations.  So, I have been doing wound care for over 10 years.  The 3 years I spent in Pittsburgh was heavy on surgical limb salvage of diabetic feet.  During my time in Winter Haven, I also was on staff at the wound center in Lake Wales, Florida.

I really think I could make a difference in this community of Hernando County in regards to wound care.  Therefore, I have been working closely with the Spring Hill Wound Care Center and the experts at this facility recommended this course.

Though I am experienced, I still learned quite a bit at the course and am eager to begin using these new ideas to help people here in this area.

Two Years in Florida!

Those that know me, know that I like milestones.  I have been blessed to have the chance to experience many wonderful things in my life.  So, today is meaningful to me as I started practicing in Florida 2 years ago today.  Though it has taken some unexpected turns, I have enjoyed my time here and look forward to many more years as a northerner living in the sunshine state.

I think it is a good time to blog about my life and education.  This can be "my bio" as I have not really posted it on my blog yet.

The majority of my life was spend in Northeastern Ohio.  I was born in Akron and spent my entire childhood in Uniontown, Ohio.  A small town between Akron and Canton.  Growing up I always wanted to be a "surgeon."  I enjoyed activities at church, with scouting (I am an Eagle Scout), and playing the saxophone in band.

I graduated from Lake High School in Uniontown and my undergraduate degree is from the University of Akron.  My podiatry degree is from the Ohio College of Podiatric Medicine which is now the Kent State University College of Podiatric Medicine.  (This is interesting for an Akron grad).

I completed 3 years of training in podiatric medicine and surgery in the greater Cleveland area.  My training was affiliated with satellite hospitals of University Hospitals and The Cleveland Clinic as well as the podiatry school.  It was a well rounded program with lots of "hands on training."  On a personal level I married my wife, Heidi, during my second year of residency.

Upon graduation of residency, Heidi and I moved to Indianapolis where I started my career in private practice.  We enjoyed living there.  It had a smaller town feel with a lot to do.  I think some of the best restaurants are in Indy.  Living there over 3 years, we enjoyed all the city had to offer with the sports and auto racing to the culture.

In the fall of 2008 I decided to advance my career and Heidi and I also wanted to move closer to our hometowns and families.  Therefore, we moved to Pittsburgh.  This was 100 miles from my hometown and 100 miles from Heidi's hometown of DuBois, PA.  This was weird for a Browns fan from Ohio to live 6 miles south of downtown, but I fell in love with the Penguins as many know and also enjoyed following the Pirates.  However, sorry Steeler fans, never quite got into them.

The most significant event of our 3 years in Pittsburgh was the birth of our son.  Soon after that a job opportunity came up in Winter Haven and our family moved south.  We enjoyed our time in Winter Haven but transitioned to Spring Hill last April.

As one can see, I have lived in several places.  Great experiences for sure.  However, I certainly wouldn't mind settling here in Spring Hill, Florida and I am very excited as we continue to grow both professionally and as a family as we are expecting a baby girl next month!

MRSA from an Ingrown Toenail

A local football player is battling MRSA for the 2nd time.  The Tampa Bay Buccaneers have confirmed that their guard, Carl Nicks is again being treated for MRSA.  Media sources indicate that the initial cause was an ingrown toenail.

MRSA is an infection of Staph aureus that is found to be resistant to the antibiotic Methicillin.  The media makes the population fearful of MRSA but we do have antibiotics that can fight it.

Additionally, ingrown toenails can become bacterially infected and MRSA can be the cause.  It is important to point out, however, that most ingrown toenails can be treated in the office through excision and oral antibiotics.

As is true with most foot problems, any pain or problems are easier to address earlier rather than later.  I do not know what happened with Carl Nicks but I suspect his ingrown toenail became so infected that the bone in the toe got infected necessitating IV antibiotics.

The moral of the story: If you think you have an ingrown nail, see a podiatrist as soon as you are able for treatment.

Tom Hanks Makes an Announcement

Earlier this week, on late night TV, Tom Hanks announced that he has been diagnosed with diabetes.  He talked about lifestyle changes he needed to make and also a little about how the disease effects the body.  I have had a few patients over the years that presented with foot problems that lead me to suspect that he or she could be a diabetic.  The patient usually knew something wasn't quite right but was completely unaware that this disease was present.

One of the earliest signs of diabetes in terms of the foot would be numbness or tingling.  Diabetes is a disease of high blood sugar and this high blood sugar can cause several problems with the body.  Diabetic neuropathy is caused when nerve fibers are damaged by the high blood sugar.  This can be uncomfortable as a bothersome numbness in the feet but also can lead to pain.  Besides the discomfort, this loss of feeling can but a patient at risk for injury.  For example, a stone in the shoe can cause a sore.  A person without diabetic neuropathy would remove his or her shoe and remove the stone, but a diabetic patient may not even know that there is a stone in his or her shoe.  Left in the shoe the stone can lead to a sore or ulceration.

If you think you have diabetes you should see a physician for testing.  Symptoms are not just tingling in the feet but also weight loss, increased thirst, and increased urination.

5 things people do wrong for their feet

I was recently talking to a close colleague who is an internal medicine physician.  As people who read my blog know, I like to blog about sports injuries and celebrity foot problems.  However, this doctor was interested to know what I believe are the most common things people do wrong with regards to caring (or often times, not caring) for their feet.  I thought about it, and in my 10+ years of experience I had an answer, I thanked my colleague for the question and immediately answered it.  I think this information is worth sharing.

5 THINGS PEOPLE DO WRONG FOR THEIR FEET:

1) Ignore foot pain:  Many patients think that pain in their feet will just go away.  It could, but odds are it will get worse if not treated.  For example, heel pain can affect how you walk as a patient can often compensate by walking differently due to the pain.  Walking differently can lead to tendon pain in the other ankle or in a different part of the painful foot.  Additionally, pain in the foot or ankle is often inflammatory in nature.  Inflammation that is allowed to worsen can often be much more difficult to resolve than when treated earlier.

2) Going barefoot:  Especially down south, many people do not like to wear shoes.  However, this can have significant consequences.  Of course, there is always a chance of injury without the protection of footwear.  Cuts and scrapes can be especially harmful to a patient with poor circulation or feeling in his or her feet.  Additionally, when one goes barefoot there is no support.  This can lead to tendonitis as tendons work to support a foot that a shoe should be supporting.  I often hear, "going barefoot is natural."  I counter this argument by replying "what is natural about concrete?"  You do best in a man-made supportive shoe when walking on this man-made surface.

3) Wearing flip-flops:  In Florida, these shoes are a year round favorite.  In other parts of the country, they come out when the snow thaws.  However, these shoes, especially the really flat flimsy ones, are just as bad as going barefoot.  They offer little support or protection for the foot.  It is hard, as people love these shoes, but at least try to get one with a rigid sole and even an arch.  A small heeled wedge sandal is much better than a flimsy flip-flop.  However, a trip to Disney World is probably best enjoyed in a sneaker.

4) Using medicated pads or callus remover:  I am fine with padding that can be bought in the drug store, as this can be a good conservative treatment for some foot problems.  However, any padding that says "medicated" can be very harmful.  Medicated pads usually contain salicylic acid.  Yes, real acid that damages skin.  The acid can not select the "good" tissue from the "bad" callused tissue and I have seen infections from using these products.  Unfortunately, in a few diabetic patients, I have seen the use of these pads lead to bone infection and toe amputation.  A callus is more than just something that can be removed easily as there is often an underlying deformity leading to this hardened uncomfortable skin.

5) Doing "bathroom surgery":  We likely have all done this.  A toe can be a little sore and we "dig out" a toenail in our bathroom using a dirty pair of toenail clippers or whatever object available.  This can lead to a bacterial infection needing antibiotics.  Again, as with medicated padding, I have seen bathroom surgery lead to amputation.

This is my list of 5 things people do wrong for their feet.  Podiatrists are trained to treat almost all foot or ankle problems.  I welcome new patients who are experiencing any foot or ankle pain.

Kobe Bryant's Scar

There has been a lot of talk recently regarding Kobe Bryant's quick recovery from his achilles tendon surgical repair.  Not to down-play this recovery, but being a physician who has performed several achilles tendon repairs, I noticed something about this scar.  When looking at it, I notice that it is obviously healed well, but I also notice that the scar stops further up on the ankle.  To me, this means that he likely didn't require a more complex repair that often involves some detachment of the tendon from the heel bone.  In this case, the repair, though still very successful, has a much longer recovery time.  This is because hardware is often used to reattach the achilles tendon to the heel.  In this case, the patient must partake in a much more gradual return to activity, especially to perform at the high level needed to play in the NBA.

If you have any achilles tendon problems, keep in mind that it is important to address them and not wait.  Patients who wait have a much higher chance of needing surgical correction.

A Stress Fracture from Golf?

Yes, it is true.  The best swimmer in the world injured his foot, not by kicking a pool deck, but from golfing.  I read the article and found that it wasn't actually from golf itself but from walking the golf course.  Apparently, Phelps walked something like 20 miles over the course of the tournament.  This lead to the injury, a stress fracture of his foot.

There is a lesson in this for all of us.  A stress fracture can occur over time.  It does not have to be a single instance.  In fact, in my experience, Phelps is a perfect example of what can lead to a stress fracture.  It is usually when we walk too much or wear a new or ill-fitting pair of shoes and are too active that leads to stress on the bone.

A stress fracture can lead to a swollen foot that is very painful to walk on.  It does not always even show up on x-ray but left unchecked can lead to a complete break in the bone (usually a metatarsal).  This can be much more difficult to treat and may even require surgery to repair.  Therefore, it is important to see your podiatrist right away with any foot pain.

Something to Celebrate

As a podiatrist, I read with interest a recent study that shows a drastic increase in lower extremity diabetic amputations.  The study was published in this month's Foot and Ankle International.  The study pointed out when looking at Medicare claims from 2000-2010, lower extremity amputations decreased 28.8%.  I am wondering if this is related to the 143.3% increase in the treatment of foot ulcers in the same time period.  Also interesting is that amputations at the upper and lower leg level are down 47% while partial toe amputations increased 24%.  (Sometimes a toe amputation is needed to be done by a physician like myself to prevent the infection from getting worse).  To me this means podiatrists are saving feet and legs.

This is a big deal on many levels.  First, it saves money.  Lower extremity amputations cost our health care system a lot of money.  Second, it improves patients quality of life.  Obviously, having a limb amputation is a big deal and can lead to other problems.  Earlier studies have found that a lower extremity amputation has a mortality rate of 50% within 5 years.  So one can argue that saving some one's limb, saves some one's life.

I am proud to have a hand in all of this and excited to continue to help bring down the level of amputations in my community.

Alex Ovechkin's Broken Foot

As I have said before, I am a Penguins fan so I am biased to say Sidney Crosby is the best player in the world.  However, last evening, the Washington Capital's captain beat Sidney Crosby out by winning the Hart Trophy as the NHL's MVP.

As a podiatrist, I was also interested to learn that Ovechkin played a few playoff games and for Team Russia with a broken left foot.  Surprisingly he admitted not telling doctors about it until after the season.  It is thought that he sustained a "hairline fracture" blocking a shot in the Capitals / Rangers playoff series.

This, in my opinion, is unwise as a hairline fracture or "stress fracture" can become a "full fracture" and lead to a break in the bone that can heal in a poor position or not well.  Sometimes surgery, especially in a pro athlere, is then needed.

Usually stress fractures cause swelling in the foot and pain especially after being on the foot for awhile.  I have seen countless stress fractures that are not visible on x-ray but very evident on MRI.  Therefore, just because one recieves a normal x-ray reading does not mean nothing is wrong.  Any foot pain, especially with severe swelling, should not be overlooked.

Blame your parents for your bunions?

As a podiatrist, one of the procedures I perform most is correction of bunion deformities.  This is a deformity in which the great toe turns out and creates a bump on the inside of the foot just below the great toe.  If conservative treatment fails, surgery is an option for many patients.

A study came out last month that suggested this deformity is inherited.  In my opinion, however, it is more complex than this.  I believe your foot type can be inherited (ie, flat or high arch) and this foot type can lead to deformities.  For example, a young lady can have a foot type that she "inherited" from her father but she gets bunions unlike her father because she wears tight high heels that can lead to easy development of a deformity based on her inherited foot type.

I believe, the environment does come into play.  Another example would be a flat flimsy foot.  An individual with this foot type who wears flip flops all the time may develop a much more severe bunion than someone who wears a supportive shoe and insert most of the time.

Just like other medical risks such as heart disease it is likely that most bunions can be prevented with the proper decisions and care.  You should see a podiatrist if there are any concerns you have a bunion or believe you are developing one.

NBA Playoffs: Full of Foot & Ankle Problems

I have admitted before that I am not a huge NBA fan but could not avoid the news recently as several players have made the news with foot and ankle problems.

First off, Tiago Splitter of the Spurs sprained his left ankle earlier this week in game 3 against the Lakers.  Radiographs were reported as negative, but to me that doesn't mean much as a bad ankle sprain can be very painful and needs treated appropriately.

To a Chicago news station this week, Joakim Noah stated that "plantar fasciitis sucks."  This is a very common condition I see, and I am sure many of my patients will relate.  However, with the right treatment we can help most people significantly.

Chicago's first round opponent, the Nets, also apparently has a player suffering from plantar fasciitis as well.  Joe Johnson received a "cortisone injection" for plantar fasciitis earlier this week and Johnson admitted that this was very helpful.  When appropriate I can also give injections as part of my treatment.

As I often say you do not have to be an athlete to suffer from these conditions.  Come see us at Spring Hill Podiatry with any foot or ankle problems.

Exciting Annoucement

I am very excited to announce that effective April 24, 2013 I will be joining a new practice.  I will be the first podiatrist in a multi-specialty practice in Spring Hill, Florida.  I think my 8 years of experience will allow me to incorporate great podiatric care into this new practice.  I am thankful for the opportunity and am thrilled to continue to practice in the State of Florida.  Here is the information on the location with contact information:

ABSOLUTE HEALTHCARE LLC
3378 MARINER BLVD
SPRING HILL, FL 34608
352-678-3033

Kobe Bryant's "Bone Spur"

Thursday night after the Lakers game against the Bucks, the Lakers revealed that Bryant has a "bone spur" in his left foot.  This could mean many things as there are several places that an individual could have a bone spur in the foot.  However, there are really only two places where a bone spur is common.  The most common is at the bottom of the heel bone.  This is also called the "plantar" part of the heel and a band of tissue that attaches there called the plantar fascia can often get inflamed.  Not always, but usually heel spur syndrome and plantar fasciitis are the same thing and treated the same way.

The other common area for spurring is at the back of the heel where the largest tendon, the achilles, attaches.  This can be more difficult to treat and when conservative measures fail surgery to remove the spur and reattach the achilles tendon is often necessary.

It is difficult to say exactly were Bryant's spur is, but Laker fans should hope it is at the bottom of the heel instead of the back.  Either way, however, both conditions can be very painful.  Fortunately, though, both conditions can be treated and in most instances successfully resolved.

Kris Letang's Broken Toe

I have been enjoying my NHL Center Ice subscription down here in Florida as of late.  It allows me to watch every Pittsburgh Penguins game that I can.  (I am happy as a fan that most of them have been wins).  Along with all the great trades the team has made, there is news that Kris Letang, the Pens all-star defenseman, suffered a "lower body injury."  Hockey does not have to say much about a player's injury but most sources said he is suffering from a broken toe.

It is not just athletes who suffer from broken toes.  Anyone can injure his or her toe to lead to fracture.   The most common way I see it happen is from bumping the toe against a piece of furniture.

Many people don't seek treatment because they believe there is "nothing that can be done."  Often times not much treatment is required but the condition can be painful.  Compensation can occur from trying to walk on a painful foot and this can lead to other problems.  Additionally, if an injury is significant enough to cause a broken toe it is not uncommon for another part of the foot to be injured as well.  Therefore, if you do injure your toe (or foot) a trip to the podiatrist is always a good idea.

Kristen Stewart at The Oscars

I am a little late blogging this but I wanted to chime in.  The details are not know but Kristen Stewart walked the red carpet last week on crutches after apparently cutting her foot on a piece of glass while "partying."  Certainly, this can be a serious issue.  A laceration on the bottom of the foot can lead to painful scarring.  Also infection is a very real concern and often antibiotics are needed.

Of course, the best course of action is to prevent injury in the first place.  Protective shoes are important, especially in a diabetic patient that may not have full feeling in his or her feet.  Going barefoot can be dangerous anywhere, even inside the home.  I have had a few patients require surgery to remove a sewing needle that they stepped on at home.

If you step on a piece of glass or any foreign body, you should not wait but should see a podiatrist right away.

Erik Karlsson's Achilles Laceration

Erik Karlsson suffered a 70 percent laceration of his Achilles' tendon on Wednesday night.  The Senators were playing my favorite hockey team, The Pittsburgh Penguins.  Hockey skates are razor sharp and Matt Cooke's skate caused the laceration.  Matt Cooke has been a subject on controversy but has cleaned up his act recently.  The NHL has determined that the injury was accidental (unlike some of Cooke's actions of the past).  As a podiatrist, I deal with achilles injuries on a regular basis.  Karlsson will likely require surgery or at a bare minimum immobilization and extensive therapy.  Hockey players are not the only ones to suffer injury to the achilles tendon which is the largest tendon (muscle to bone connection) in the body.  However, the Ottawa Senators certainly will miss the services of last year's Norris Trophy winner who was voted the best defenseman in the league.

Pau Gasol's Plantar Fascia Tear

Last week, a doctor confirmed that Pau Gasol tore his plantar fascia and will be out for 6-8 weeks from playing with the Lakers.  Apparently it is also unknown if surgery will be required.  As a podiatrist, this is of course interesting to me.  I see plantar fascia problems several times a day.  What confuses me is the issue of surgery as I have never seen a torn fascia repaired.  Usually, the opposite is true as I have seen chronic inflamed fascia "released" surgically.  In fact, I often perform this procedure myself.

Anyone can suffer from problems with plantar fascia but usually a tear or rupture on a traumatic level is much less common.  The plantar fascia is a band of tissue (or fascia) on the bottom (or plantar) surface of the foot.  It attaches at the bottom of the heel and extends out towards the toes widening before attaching in the ball of the foot.

We commonly see inflammation of the fascia or plantar fasciitis.  This is when the fascia tears on a very small scale repeatedly.  This can be caused by wearing the wrong shoes for two long, going barefoot for to long, or sometimes, but not as common, from trauma (as in Pau Gasol's case).  It is important that if you experience chronic or severe heel pain you are seen by a podiatrist.  We will work to 1) reduce the inflammation and 2) try to prevent the fascia from becoming inflamed again.

Ice Hockey is Back!

I was excited to hear that my favorite sport will be returning to the ice in just a matter of weeks.  Here in Florida, ice hockey is often an overlooked sport.  However, we do have some of the best players in the world over in Tampa Bay.  As I have blogged before, ice hockey players can have many injuries to the foot and ankle.  Despite having a supportive skate, ankle injuries are common.  Obviously when a hard piece of rubber hits a bone, it can cause a bone "bruise" or contusion accompanied by swelling and pain.  Lacerations can also occur when the bottom of a skate, which is razor sharp, makes contact with another player.

You don't have to play ice hockey to have these foot and ankle injuries.  Though we will probably not get hit by a puck, we can still bump our toe, foot, or shin into the bed in the middle of the night.  Just because we will likely not slam feet first into "the boards," doesn't mean we can't sprain our ankle awkwardly stepping off of a curb.  Of course, lacerations can occur in a variety of ways other than from a hockey skate.

I strive to provide great care for everyone; hockey players and non-hockey players alike.