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.
