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.