All About Feet: Ask the Doctor

All About Feet

What is a podiatrist?
A podiatrist, or Doctor of Podiatric Medicine, is a doctor who specializes in the medical and surgical treatment of the foot and ankle. DPMs have completed four years of undergraduate education typically in a premed program, followed by four years in a very specialized school of podiatric medicine. Over the years, the training has become more and more rigorous and current graduates spend three years in a surgical residency program. Fellowships allow a podiatric surgeon to specialize even further with an additional year of training in a particular area of interest.

Why should I see a podiatrist?
Podiatric surgeons are the foot and ankle experts. We are experienced in treating everything related to the feet and ankles from minor problems like warts and ingrown toenails to injuries such as ankle sprains and fractures. The most common problems that we see in adults are heel/arch pain (aka plantar fasciitis), toenail fungus, and bunions. Children are often referred to my practice for warts, custom orthotics, and concerns about flat feet or in-toeing. Most podiatrists have privileges at their local hospital and surgery centers.

What are the best shoes for my child?
Footwear like flip-flops and Crocs are great for beaches and pools, but they are not recommended for walking, running, or playing. The best shoes are a good pair of running shoes. Here are a couple of tests that I teach my patients:

  • Hold the shoe in two hands and try to bend it. It should bend where the foot bends, at the ball of the foot. If it bends at the halfway point, in the middle the arch, it will not provide enough arch support.
  • When you pinch the area of the heel just above the sole, it should not compress all the way but should feel firm.
  • Again, holding the shoe with two hands, try twisting the shoe… it should not twist up like you are wringing out a washcloth. It should feel more structured and less flimsy.

What is the proper way to cut my child’s toenails?
Most people know that the best way is to cut them straight across. The part that people leave out is that you should cut ALL of the way across. Ripping the nail or cutting into the corners can cause ingrown toenails.

What do I do about my child’s flat feet?
Possibly nothing! Some children have asymptomatic flat feet and never have foot problems. Others may suffer from pain, tenderness, or cramping, problems with shoes, and even reduced energy when participating in physical activities. If your child makes any of these complaints, an appointment with a podiatrist should be made to examine his or her feet.

What should I do if my child develops an ingrown toenail?
Soak the foot in warm water for about 10 minutes to soften the skin, then gently manipulate the skin edges away from the nail with your fingers. Pat the toe dry with a clean towel, apply antibiotic ointment, and a bandage. Do this twice a day.

If there is any redness, pus, odor, or pain, do not delay in bringing your child to a podiatrist. Primary care physicians generally refer patients with ingrown toenails to podiatrists, so you can prevent further delay and skip that step—no referral necessary. Most importantly, do not try to dig it out yourself as this can lead to infection.

How should athlete’s foot be treated?
Athlete’s foot is essentially a skin fungus, and it can spread easily amongst family members, especially in moist areas of the house like bathrooms. If left untreated or inadequately treated, athlete’s foot can lead to toenail fungus so do not delay in initiating treatment.

I think I have toenail fungus? How do I get rid of it?
Toenail fungus is a very common and often embarrassing problem in adults. I see many patients with toenail fungus and the typical story is that they think they caught it from a pedicure at a nail salon. There are a few different treatment options including the use of anti-fungal liquids and creams however these tend to work less than 10% of the time. Another treatment option is a pill that is taken once a day for at least three months. While this can work well, the potential for serious side effects makes it unpopular with many patients.

In my practice, I treat toenail fungus with the PinPointe FootLaser, the only FDA-approved laser for toenail fungus. It has a high success rate for killing the fungus without any risks or side effects, and no downtime. I thoroughly educate my patients on proper foot care so they can prevent themselves from catching the fungus again. The STRIDE Medical Foot Spa performs medical pedicures called “Foot Revivals” using stainless steel instruments that are autoclaved in the same machines that are used to sterilize surgical instruments so patients never have to feel nervous about getting an infection or a fungus.

I have bunions on both feet and I cannot run for exercise or hike any serious distance without pain. I would love to run and even train for a second marathon. Any advice?
A bunion is a foot deformity that appears as a bump on the inside of the foot at the base of the big toe. Contrary to popular belief, bunions are not caused by wearing tight, high-heeled shoes. Bunions are usually hereditary and they do get worse over time. Bunions may become painful with certain shoes and with certain activities, and can even lead to deformities of the other toes. Oftentimes, the pain associated with bunions can be decreased using ice, anti-inflammatory medications, or comfort devices such as pads, bunion splints, and toe separators. Custom foot orthotics are often prescribed to minimize the abnormal biomechanics that caused the bunion to develop in the first place.

At some point, however, the pain may interfere with a person’s quality of life, exercise routine, and overall happiness. Once a patient has reached this point, a conversation about surgical treatment is appropriate. Radiographs would be obtained and measurements would be made to determine what type of surgery would be most appropriate. Then, an in-depth discussion of the surgery and the recovery process would occur prior to making the decision to have surgery. There are dozens of different surgical procedures and they all have slightly different indications and recovery periods. The recovery for a mild-to-moderate bunion is usually six weeks in a walking boot (no crutches), a transition back to athletic shoes, and finally, a transition back to regular shoes a couple of weeks later. Bunions are structural deformities, and as a result, the only way to truly fix a bunion is with surgery. However, there is rarely a rush to have surgery; it can and should be carefully planned out and fit into your family’s schedule.

I’ve had pain in the ball of my left foot for about three months. The pain is sometimes sharp when I walk on it, especially on hard floors or when the toes are bent back. Sometimes the pain is almost like a numbing tingling feeling instead of sharp. For the last two months, I’ve worn only my most comfortable running shoes. This helps somewhat because my other, more narrow shoes can aggravate the pain. Any thoughts?
The pain and tingling you feel could be one of several different diagnoses; however, the most likely one is that of a neuroma.  A neuroma is an irritation of the nerve that runs between the metatarsal bones of the feet. Some of the causes of neuromas include abnormal foot mechanics, such as excessive pronation or flattening of the arch when you walk, wearing shoes that are too narrow, and repetitive/high-impact activities like aerobics or running. Neuromas tend to respond well to conservative treatment, which can include the use of ice and anti-inflammatory medications, wearing proper-fitting shoes, and treating the abnormal foot mechanics with custom foot orthotics. If the pain is significant, an injection of a steroid mixed with local anesthetic may be recommended to reduce inflammation and pain. Many patients report relief after these measures are taken and as with most podiatric problems, surgery is reserved as a last resort.

My son was recently diagnosed with Severs Disease. What is it? How long does it take to heal? What are steps we can take to help?
Sever’s Disease is the name used to describe the pain caused by inflammation of the growth plate in the heel bone. It is also called calcaneal apophysitis. Sometimes active kids will start to develop pain in the back of the heel at about the time that the heel bone growth plate starts to close. For boys, this is typically around age 10 to 12 and age 9 to 11 for girls.

An increase in activity or simply too much activity can put stress on the growth plate leading to inflammation and pain. The culprits are usually running, jumping, squatting, and gymnastics; however, too much of any activity can cause Sever’s disease as these activities pull repeatedly on the Achilles tendon where it attaches to the heel bone. In addition, muscle tightness, flat feet, and pronation can all potentially increase your child’s risk for this type of heel pain.

The good news is that Sever’s disease is typically “self-limiting,” meaning that it will often eventually go away without any treatment at all and in most cases, this is within a few weeks. The treatments for heel pain in kids typically target the inflammation and reduce the stress on the growth plate from the Achilles tendon. The use of an ice pack for 20 minutes after activity is often recommended and anti-inflammatory medications may also be prescribed to help reduce the inflammation. There is rarely a need to stop sports altogether but your child should cut back on sporting activities until symptoms improve. He or she should also avoid going barefoot and should wear a cushioned heel lift to increase shock absorption and reduce the pull from the calf muscle on the growth plate. Custom foot orthotics may also be prescribed if there are abnormal foot mechanics. In some cases it may be necessary to temporarily discontinue the activity that is causing the problem. Once the pain has resolved, calf stretches, cushioned and supportive shoes, and arch supports are helpful in preventing recurrence.

Dr. Brynn H. Ewen, DPM is a podiatrist and the founder of STRIDE in downtown Palo Alto. STRIDE is an innovative medical practice that combines podiatric medicine and surgery with the only medical spa entirely dedicated to your feet. Following medical school and residency program in San Francisco, Dr. Ewen completed a Sports Medicine Fellowship program at the Palo Alto Medical Foundation (PAMF). Dr. Ewen, her husband Mark, and their two boys, Ryland and Sam, live near downtown Palo Alto. She is a runner and completed her first marathon in June 2010, but also enjoys cycling, golf, skiing, hiking and all of the activities that Palo Alto and the Bay Area have to offer.

“Ask the Doctor” will return again next month. If you have a question you would like to ask anonymously, or if you are a specialist interested in participating in a future “Ask the Doctor” column, please email newsletter@pampclub.org with the subject “Ask the Doctor.”

 

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