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Common Podiatry Questions
Q: What is a balance test?
A: In the context of foot pain, normal balance is essential to effortless walking. Balance is governed by the autonomic (aka unconscious or “sympathetic”) nervous system – the same system that governs digestion, sweating, heart rate and flight-or-fight (survival) reflexes, to name a few. There is a test called postural reflex testing that examines this part of the nervous system. It is based on pediatric reflexes, because babies have only these types of reflexes. As our nervous system becomes more complex as we mature, these primitive reflexes are buried by more sophisticated brain function, but they’re not gone. They arise again when an autonomic portion of a nerve becomes inflamed. When this happens to a nerve in the feet, it can alter your balance. If a nerve malfunctions, then what it governs malfunctions. When the nerves that govern balance don’t work we develop muscle and joint pain from trying to balance. Balance is automatic – we should not have to work hard to achieve it.
Q: How can you have an injury in one part of your body and feel it in another?
A: Compensation. We automatically shift our weight when our body perceives an injury. If you twist your right ankle, you’ll hop on your left. Well, more subtle compensations exist as well – early arthritic changes in the big toe will often cause patients to roll their foot to the outside, which hurts the side and heel the of the foot. Unless a full exam of the both feet is done, treatment of the heel may not resolve heel pain.
Q: Why don’t Dr. Scholl arch supports relieve my arch pain?
A: Sometimes over-the-counter (OTC) arch supports do relieve arch pain – when they don’t, it is often because the support is insufficient or is not specific enough. If you buy a pair of inserts from the pharmacy, the left and right are symmetrical. Your feet are not necessarily so. You may need a pair of inserts professionally made that are specific to your foot structure and function. Also, arch pain has SO many potential origins. You could have a nerve impingement in your low back, the beginnings of diabetic nerve damage, or arthritis in the ball of your foot. All of these could cause arch pain without causing similar levels of pain at the source.
Q: Are x-rays enough to tell the source of a foot problem?
A: NO. An examination of the foot and ankle is functional, not just structural. A full exam includes, but is not limited to, having a patient stand, walk and perform simple muscle strength tests. Asymmetrical function can tell a great deal about how pain developed and therefore how to eliminate it. X-rays are only part of the overall exam.
Q: When would I need a cortisone shot?
A: When it would be part of an overall treatment plan to quickly reduce pain and inflammation. These injections can provide wonderful, welcome relief for severe heel pain or a swollen joint. However, they are little more than a “quick fix” if you are not also prescribed a long-term resolution. Plantar fascitis is a common example – “heel spurs”. Cortisone helps, but the pain will come back soon if the foot is not also supported by an orthotic, taped or splinted, or even immobilized in a walking cast boot. One or all of these may be implemented to rid you of the pain and keep it from coming back.
Q: How many shots can I have?
A: You can have up to three cortisone injections into an anatomical space in one year. These are usually spread out over two week intervals, and not repeated for a year. Sometimes, depending on the period of relief from the first shot, they can be spread out over several months. If you have too many, the cortisone may damage normal adjacent structures.
Q: Regarding “heel spurs”, when is surgery needed?
A: When several weeks to months of treatment have failed to relieve the symptoms adequately for you to function without pain or disability. If the pain adversely affects you life, your job, your exercise it may be time to release the fascia from its attachment at the heel. Spurs are not generally removed since they are not what is causing the pain. The pain is from the constant tension and thickening of the fascia. Once it is released, the pain can resolve.
Q: What is a bunion?
A: When the first metatarsal shifts medially (toward your other foot) and the big toe shifts laterally (away from your other foot). The head of the metatarsal forms the large visible bump, and sometimes gets even larger from swelling and overgrowth of the bone, The joint’s normal position is altered by too-tight shoes, a genetic tendency for the deformity, a flat flexible foot type or in older patients, a laxity in the ligaments surrounding the joint. It is usually a combination of two or more of these forces, especially if there is a family history of the problem.
Q: How does one treat a painful bunion?
A: Sometimes the pain can be relieved by stretching your shoes over the painful bump and wearing supportive orthotics. This accommodates the bunion and can prevent it from getting worse. However, this often is not enough relief, nor does it permit a wide variety of shoes. To truly correct a bunion requires surgery. The first metatarsal is cut and moved back to its original position, then held in place by screws. The ligaments at the base of the toe are also cut to allow the toe to straighten. There are several variations on this concept, depending on the severity of the deformity and the age of the patient. It requires approximately four weeks in a walking, removable boot, perhaps physical therapy to make the joint flexible again, and prescription orthotics afterward to prevent a recurrence of the problem.
I will say here that having had both my bunions operated on years ago (age 24 and the other one at age 34), I strongly advise all my patients to wear orthotics afterward. My flat, flexible feet could very well sustain the same forces that created the bunion in the first place if I were not preventing that with prescription arch supports. They control the pull on the joint to prevent it drifting again. Patients with flexible feet have more of a tendency for recurrence than those with a high, less-flexible arch. Bunions can recur and orthotics help prevent it.
Q: What is a hammertoe and how do you treat it?
A: It, too, is a joint deformity that results from unequal pull on the joint. Too-short or too-narrow shoes contribute to the problem, as well as extremes of arch height. A very flat arch can cause them because the flexor (bottom) tendons to the toes have to stabilize the foot when the arch can’t. This buckles the toes, making them curl down. A high-arch foot develops them as a result of the extensor (top) tendons firing more than the flexors during the swing phase of gait, so your toes clear the ground. All are repaired by cutting the bone and decreasing tension on the tendons. Sometimes, the flexor tendon is transferred to the top of the toe to eliminate the too-tight pull that contracts the toe. Usually a pin or screw is used to hold the toe in place while it heals, and a protective walking boot is worn for several weeks. Again, prescription orthotics afterward help prevent recurrence.
Q: What is the difference between a wart and a corn?
A: A wart is caused by a virus that enters your skin and creates a small hard lesion. It can develop on any part of your foot. If left untreated, some warts multiply until you have several all over your feet. Some remain solitary for years, never changing. They require diligence to cure – not only does the wart have to be burned, frozen or cut out, but you need to practice prevention to avoid getting them again. And even if you get rid of one, it could easily and quickly recur because some of the virus may remain.
Corns develop only on weight-bearing areas of your foot, or on the tops of toes where shoes create pressure. They can be shaved down for comfort, but they will recur if the source of pressure persists. Corns on hammertoes require a change in shoes, gel pads for corns, or surgery to remove the source of pressure. “Corns” on the bottom of the foot are calluses with a deep hard central “kernel” to them. They, too, require removal of the pressure by modifying shoes, using pads or having surgery to relieve the pressure. Orthotics can also help with these.
Q: How is an orthotic different than an arch support I can buy at a sporting goods store?
A: An orthotic is a prescription device, measured for and designed by a podiatrist or pedorthist. The left is designed just for the structure and function of the left foot, the right just for the right. They can be made of soft or firm materials, for sports and for dress shoes, and should last 2-5 years depending on your activity level. They can so accurately balance the weight-bearing of each foot that often a good orthotic can cure an injury or chronic pain without surgery. Old ones can be modified for new problems. Old worn-out ones can be “refurbished” so that the shell remains and the soft pad or liner is replaced only. These modifications can extend the life of an orthotic another 2 years if the shell has not broken down.
Q: I’ve had orthotics before, and they were never comfortable. I have friends, however, who swear by them. Why didn’t mine work?
A: There are two main reasons – first, the prescription was off. You may have been prescribed a device for a specific complaint, but it created pain in another area that before was not painful (i.e., back pain or knee pain caused by orthotics). Sometimes the wrong prescription will simply fail to relieve the original complaint.
The second reason is that you could not tolerate the material used. If the shell was too hard or too flimsy, you may get no relief, or your original pain may worsen, even if the prescription was just right. It sometimes requires a little fine tuning. I will often give patients a temporary device to try in their shoe, see if the prescription helps. If so, I can make a permanent one based on the trial with the temporary.
One of the things I focus on is a COMPLETE exam, so I won’t make an orthotic that compromises some other body part. Not only do I x-ray the feet and do a gait exam, I do a postural test as well. I examine all three components of normal gait – musculoskeletal, neurovascular and balance functions. You can’t walk without all of these working normally. Sometimes we order labs to rule out gout, rheumatoid arthritis, diabetes – all potential factors in causing foot pain. Orthotics won’t do any good if the source of the pain is diabetic “neuropathy” (Literally translated as “nerve disease”).
Q “What is giving me that burning sensation in my feet?”
A: There are several potential causes –
1. Athlete’s foot - a fungal infection of the skin
2. Diabetic neuropathy - diabetes causes nerve damage, the nerves create a burning sensation. Eventually, a diabetic’s foot can go numb
3. Nerve compression in the low back – this can cause sciatica, with a burning pain all the way down the leg, but it can also “hopscotch” directly to the nerve endings in the feet, causing a burning sensation
4. Nerve damage from chemotherapy or radiation therapy for cancer
5. Medication side effect – Aciphex, for example, for reflux/gastritis
6. Dermatitis of the feet
Other causes may be environmental, like intolerance for synthetic shoe material and reaction to dyes in shoe leather.
Q: I understand that Lamisil can cure nail fungus but has potentially dangerous side effects on the liver and kidneys. Is there an alternative?
A: Thanks to the successful growth of compounding pharmacies, there are now several excellent alternatives to oral anti-fungal medications. The three most common oral medications are now routinely made into topical solutions – Lamisil, Nizoral and Diflucan. This is not yet possible for the other popular one, Sporanox. The solution is applied twice a day at the periphery of the affected nail with an applicator brush. It takes a LONG time for fungus to grow off – 6-9 months. If you do not diligently apply the medication until the nail slowly clears, you will not get rid of it. It helps to have your podiatrist culture the nails as well, so you know which organism is growing and therefore which drug to use. ALSO, you need to treat your environment so you won’t catch it again from your own shower, bath mat, towels, etc. Once your nails or skin is infected, you spread it all over your own house. You have to clean bathroom and shower surfaces with bleach, your socks have to be bleached, and you have to spray your shoes with an anti-fungal spray such as Tineacide spray, Tinactin or Micatin. Believe me, the prevention instructions are just as important as the treatment.
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