When Should I Call My Podiatrist?

Over the years, I have noticed that many of my patients hesitate to call my office for an appointment, wondering if the problem they have will just get better by itself.  Sometimes, that is the correct thing to do – wait a few days to see if it gets better.  If it does get better, then you’ve saved yourself from having to come in to see the doctor.  However, there are some instances when waiting a few days (or weeks) can be dangerous, and you can end up with a very serious problem that could have been treated without too much difficulty had it been addressed sooner.  I would like to discuss a few instances where waiting to see the doctor is a poor choice.

If you have diabetes, and notice any redness, blistering, warmth or open sores on your feet, I personally want to see you ASAP.  We will make room for you on the schedule.  We will stay late.  If for some reason, we can’t see you, we may even recommend you go to the emergency room at the hospital.  It is shocking how fast a little blister on the foot can progress to a large, infected ulcer (sore), leading to possibly loss of the leg itself.  If you have had a past history of a foot ulcer, or have poor circulation, you are at even greater risk.  Please don’t wait to call!

Any injury that causes significant pain, you really should have it looked at.  Often, patients will say that they didn’t think they needed to be seen after an injury because they could still walk.  The ability to walk or move the injured part of the foot, they reason, means it is not broken.  While this may sound reasonable, it is in many cases not so.  I have seen many fractures over the years that were dismissed as a simple sprain just because they could still walk.  Your suspicion for a fracture should be higher if you see significant swelling, pain that persists beyond a few days, or see bruising around the injured site.  And, when you come to my office, I may believe there is a fracture based on my exam of you, but even I won’t know for sure in most cases until an x-ray is taken.  Fractures that are not addressed can lead to poor healing, or in some cases, lack of healing at all.

Ingrown toenails are something that patients will put up with for weeks, and in some cases, months before coming in to see me.  And it is true that mildly ingrown toenails will sometimes work themselves out.  However, I have found that a lot of patients delay coming in to have the ingrown toenail treated because of fear of the minor surgery to remove the ingrown nail.  Let me put that fear to rest.  The vast majority of patients who have ingrown toenails removed say to me afterwards that the procedure was not anywhere near as painful as they had feared, and they express relief at how much better the toe feels afterwards.  Contrast that to the patient I am currently treating.  He has a severely ingrown, infected toenail that has been literally festering for years.  In his case, the infection has gone into the bone, and he now is scheduled to have his toe amputated to remove the infected bone.  This is not something that happens frequently, but had I been able to address his ingrown toenail when it first became an issue, he would have been relieved of years of pain, and he would not be losing his toe.

Finally, heel pain is a problem that patients tend to procrastinate treating.  If a patient were to begin to feel the symptoms of heel pain (also known as plantar fasciitis), I would recommend first using over the counter arch supports.  If the symptoms are not improving in a week or so, I would recommend having the patient into the office to see me to verify the diagnosis, and begin more aggressive treatment of the condition.  Plantar fasciitis is a condition that can almost always be treated successfully using conservative measures.  I have found that those patients who do go on to require surgery, their symptoms have been present for longer periods of time, often without any treatment being received at all.

The list I have provided in this blog is certainly not conclusive.  In short, if a patient feels any concern at all about their feet, I recommend having them come in for an evaluation.  It may be that nothing is wrong.  If that’s the case, you’ll have peace of mind.  However, if something more serious is amiss, we can get you on the road to a full recovery.

How Long is "Too Long" When You Are Waiting to See Your Doctor?

Few things about seeing a doctor are more frustrating than having to wait for long periods of time before you’re seen. In my mind, having to wait for 10 to 20 minutes is acceptable. If you find yourself waiting for more than 30 minutes, that’s too long. Several years ago, I myself waited over an hour and a half before I saw the doctor! Why is it that doctors make their patients wait so long? Does it have to be this way? What can you do to help?

After more than twenty years of running my own office, I have some thoughts as to why we as doctors run behind schedule at times. Let me say that running on time is something we take very seriously at Concord Foot and Ankle Clinic. I don’t like having to make people wait on me any more than they like waiting. And most days, I can proudly say, we see patients on time. But there are “those days…”

First and foremost, seeing a doctor is not like getting the oil changed in your car. We can’t always know ahead of time how long each patient will take to be treated adequately. So, reason #1 for falling behind is because a patient who we expected to have a simple visit turns out to be much more involved and takes more time than expected. An example of this would be a diabetic patient, seen for toenail care, and during the course of examination and treatment, I discover an ulceration, or a sore on the foot. Suddenly the 10 to 15 minute visit ends up taking me 45 minutes! And sadly, patients scheduled after the one needing the extra attention, end up paying the price by having to wait longer to be seen. I have found most patients are very understanding when I explain that an earlier patient during the day required extra care, causing me to run behind schedule. They seem to understand that it could just as easily be them needing the extra care the next time around.

Reason #2: We sometimes fall behind schedule in our office because one or more patients do not show up on time for their appointments. When they do show up, they invariably show up the same time as the next patient. In that case, no matter which patient I see first, the two will take longer than the allotted time for the one patient, putting me behind schedule.

Reason #3: This has to do with patients coming to the office unprepared. For new patients, we send out forms to be filled out ahead of time to streamline the process of checking them in. If they forget the forms, or bring them in not filled out, it affects how long others have to wait.

Reason #4: There are days when I perform surgery, that for a variety of reasons, my case starts late, or perhaps ends up taking longer than I had anticipated. Normally, my office schedules in a “fudge factor” following surgery to account for any delays before patients are scheduled in the office, but sometimes, the delay is more than we had planned.

Reason #5 has to do with overbooking the schedule. This is sometimes the fault of the doctor’s office, and sometimes is unavoidable due to urgent conditions that can’t wait to be treated. In the example I gave above, I was being seen for a fracture in my arm. I was being squeezed into an already full schedule. However, I had to have the fracture treated that day, not next week. And although I did not like waiting, I understood the reason for the long wait.

So what can you do to help? First, show up to your appointment on time and prepared. When you make the appointment, communicate with the scheduler all the reasons you need to be seen so that adequate time can be allotted for your visit. If it appears that the doctor is behind schedule, ask for an estimate of how long the wait will be, and if necessary, reschedule the appointment. Another great idea is to schedule your appointments for the first thing in the morning, or the first patient after lunch. If you find that a particular office is ALWAYS behind schedule, ask to speak to the office manager. Explain your displeasure in having to wait so long to be seen, and if the problem cannot be resolved, it may be time to start shopping for a new doctor.

Tobacco and Your.... Feet?

Everyone is aware of the dangers of smoking to your lungs and heart. But the effects of smoking go far beyond your heart and lungs. Are you aware of what smoking can do to your feet? When I tell patients that smoking cigarettes can affect their feet, many are surprised. But the fact is that smoking can lead to serious problems with your feet.

First, when you smoke, levels of carbon monoxide become elevated in the bloodstream. Carbon monoxide displaces oxygen in red blood cells, and the result is that the blood is not able to carry as much oxygen. Since the tissues in your body (and feet) need oxygen, this is serious. Once oxygen is displaced from the blood cell by carbon monoxide, that blood cell can no longer carry oxygen for the rest of its lifespan (about 3 months).
Secondly, nicotine, which is found in cigarettes, causes the blood vessels to constrict and become narrower. This decreases the amount of blood (that’s the blood that already is carrying less oxygen) that can get to the tissues. The effects of nicotine diminish after two weeks, so quitting can improve circulation in a relatively short period of time.

Thirdly, smoking greatly increases the risk of PAD (peripheral arterial disease). This occurs when the arteries become clogged with plaques, further decreasing blood flow. Of the three main effects of tobacco smoking on circulation, this is the slowest to reverse itself after smoking is stopped (see www.padcoalition.org).

Why should you care if your feet are receiving adequate blood flow? Patients with poor circulation often will develop a condition called claudication, which manifests itself by causing severe pain in the legs when a person walks for short distances. In essense, the pain is a result of the muscles being starved of oxygen. When blood flow is poor, your body’s ability to heal itself (such as if you have an ulcer) is greatly diminished. Bones are also slower and more difficult to heal with a smoker who has poor circulation. In fact, when the circulation is bad enough, healing will not occur at all. This leads to tissue death (gangrene), and ultimately, amputation of a portion of the foot, or even the leg. This is very serious, because studies have shown that the 5-year mortality rate following a major amputation was 68%! This is higher than those diagnosed with colorectal cancer (39%), breast cancer (23%), Hodgkin’s disease (18%), and prostate cancer (8%). Losing a leg is not something to be taken lightly. Lung cancer, as it turns out, has a higher mortality rate (86%), but then again, tobacco is the major cause of that cancer too.

So what can be done? First, if you don’t smoke, please don’t start. I know very few people who are happy about the fact that they’re addicted to cigarettes. Secondly, if you do smoke, talk to your doctor about ways to quit. It probably will not be easy, but will most definitely be worth not only saving a foot, but saving your life!

Your choice of shoes really matters!

On the average, I see more women patients than I do men. There are potentially many reasons for this, which can include men’s reluctance to see a doctor, and the type of shoes worn. Certainly, I would encourage men if they have a problem with their feet to seek treatment – it’s always easier to fix a problem early on before it gets out of hand. Quite often though, the shoes I see my patient’s wearing both in the office and out in public, lead me to believe that the choice of shoes some women make can be extremely detrimental to the health of their feet.

Perhaps few would argue the fact that wearing high heeled dress shoes alters the appearance of not only the foot, but the leg, hips and back as well. Wearing a shoe with a high heel lengthens the leg, and makes the foot appear smaller. Obviously, it also will make a women appear taller. But at what cost?

It should come as no surprise that wearing high heels places more pressure on the forefoot. To add to this, often the shoes worn have insufficient space for the toes. This leads to increasing pain and symptoms from hammertoes, bunions and neuromas. Corns and calluses are also more frequent and symptomatic. But the problems don’t stop there. Because the foot is plantarflexed when high heels are worn, chronic wearing of high heels can and does tighten the achilles tendon. This can make it difficult for women to wear flats as they get older. To accommodate for the plantarflexed position of the ankle, the knees are slightly bent. This causes the muscles surrounding the knee to work harder, leading to pain. Traveling up the leg, high heels alter the position of the hips and lower back, leading to pain there as well.

The pictures attached illustrate what high heels do to a foot. The body’s center of gravity is therefore moved forward over the forefoot. Normally, a body’s weight is distrubuted roughly equally between the heel and the forefoot. The structures of the forefoot are simply not up to the task of taking on the additional burden. You’ll also notice in the picture that shows the foot next to the shoe that the forefoot is actually wider than the shoe itself!

What can be done? Well, just between you and me, I have tried and have decided that my crusade against high heels is a losing battle. Some women will never give them up, regardless of the symptoms they cause. Here’s my compromise then…. If you feel you must wear high heels, limit the amount of time your feet are in the shoes, and equally as important, limit the amount of time you are standing and walking in the shoes. If you feel the urge to take your shoes off because your feet are hurting, don’t ignore it – take the shoes off! Perhaps you could have another pair handy to put in in their place that are more comfortable. Remember, your podiatrist can do some pretty amazing things. But what he/she can’t do very well is fix a foot and expect it to stay symptom-free when the very thing that is causing your symptoms is continued to be worn.

Why Are My Prescriptions So Expensive?

Soaring prescription prices… Why is this?

No one likes spending a lot of money on prescriptions. It seems like when something is really neededto treat a condition you have, you should not be prevented from taking thatmedication due to inability to afford it. At the same time, quite often it is the lure of those very same highprofits that encourage pharmaceutical companies to produce many of the amazing,and quite often, life-saving drugs that we all depend on. Eliminating the reward would, in my opinion,lead us to where fewer and fewer new drugs would be developed.

There is one drug, however, that has been around for years…indeed thousands of years. It is called colchicine. It is a powerful anti-inflammatory medication that is most often used in the treatment of gout. Gout is a condition related to anincrease in uric acid in the body. This can lead to severe pain and inflammation in the joints. Quite often, the joints of the foot are involved. A patient with gout will typically come to my office stating that the pain, redness, and swelling in their foot came on quite suddenly and is excruciating. Colchicine treats acute gout very effectively, relieving symptoms quite often in a matter of hours. So, you can imagine the surprise of patients(and doctors) when it was discovered that generic colchicine was no longer available! Instead, the drug wasavailable only in the form of a non-generic called Colcrys. Same drug. Same benefits. Not the same price. How much has the price gone up? According to as CBS Evening Newsreport, a 23 day supply has gone from $6.72 up to $185.53! Why is this happening? Watch this news report from CBS Evening newsthat aired last night:

http://www.cbsnews.com/stories/2011/10/10/eveningnews/main20118283.shtml#comments

To make a long story short, there are many drugs which pre-date the FDA – one of which is colchicine. The FDA was concerned because there was a lack of modern research on the medication. Now, no drug company will ever do research on inexpensive generic drugs. To get around this, the FDA has taken the generic version of the medication off the market to allow URL Pharma, the company that makes Colcrys, to help recoup money it had spent to study the drug. Now, my patients spend A LOT more on their prescription for colchicine. Is this right? It may not be as clear cut as it would seem. As a result of the studies done by URLPharma, it was determined that a lower dosing of colchicine would be just aseffective as the traditional dosing, making it safer to use. So, you tell me: If it were you paying out of your pocket for this medication, would that information be worth the extra $$$ knowing know that the medication was safer for you to take? As is the case with many medical questions, the answers can be hard to come by.

What Toning Shoes Can't Do For You

In the last few years, many manufacturers of shoes have developed and marketed “toning shoes”. The claims that the manufacturers make are very appealing – that by walking in these special shoes, the muscles in your feet and legs will be forced to work harder, and thereby allow you to achieve better outcomes with less effort on your part. In one advertisement, fit woman was used to describe how the shoes worked – and that by walking in the shoes you would strengthen your hamstring and calf muscles up to 11% more than with normal shoes, and that the buttocks would be toned an up to 28% more! Magic! Well, not so fast…

This past week, one manufacturer, Reebock, was forced to pay $25 million in a settlement for deceptive advertising. It turns out that their claims had no substance, and there was no real proof that the benefits they were touting would be seen by the public who were using the shoes. The link here goes into more detail regarding this settlement: http://www.ftc.gov/opa/2011/09/reebok.shtm
From my perspective, I have a few thoughts to share. First, I am always amazed at how easily people will fall for such claims. As the saying goes, if it seems too good to be true, it likely is. If you want to tone your calves, hamstrings and buttocks 11 – 28% more, there is a real simple, tried and true method to do so. Work 11 – 28% harder!

I have patients come into my office with these shoes from time to time. Some love them, some do not. Most will put more pressure on your forefoot and midfoot, which in the case that I tried, was painful. I could not tolerate the pair I was given by one manufacturer to try. However, if you like them, I feel that there is no problem with the shoes. Just don’t buy them with the expectation that in a matter of weeks you’ll look like the woman selling them on tv

Seven Questions To Ask Your Podiatrist BEFORE Foot Surgery

You’ve made the big decision to have surgery on your foot. You will likely have an appointment with your podiatrist shortly before surgery to discuss the surgery, and you will also in most cases be asked to sign a consent form. Instead of just listening to your podiatrist tell you about the upcoming surgery, here are some questions you can him/her to make sure you understand all aspects of what will be happening before, during and after surgery.

Question #1: Is this surgery necessary? The follow up question to that is what would happen if the surgery was not performed. In most cases, foot surgery is elective. What I mean by elective is that while there may be good reasons to do the surgery, such as relieving pain, it is not mandatory that the surgery be performed. An example of a surgery that is not elective would be surgery to remove a ruptured appendix. So in the case of your bunion, for example, it may be important to perform the surgery to allow walking and wearing shoes without pain, but people can and do live with bunions. In the bunion example, perhaps your podiatrist will say that not performing the surgery will likely lead to progression of the bunion which will lead to more pain, and a more complicated surgery down the road to correct.

Question #2: What type of anesthesia will be used? For anesthesia, there are a few choices which you may want to discuss so that the experience of foot surgery is as comfortable as possible.

The first choice is local anesthesia, which means the area to have surgery is made numb by given an injection of a local anesthetic. This works very well for simple procedures, and in some instances, may be the preferred method for even more involved cases. It is very safe, and although the injection is uncomfortable, once the area is numb, you will feel no pain the remainder of the surgery. You will be able to hear what is going on, which can be disconcerting to some patients.

The second choice is called monitored anesthesia care. This is the type of anesthesia I usually use for most of my surgeries performed in a hospital or surgery center setting. Medication is given through an IV by an anesthesiologist to put the patient in a light sleep. Once the patient is asleep, the part of the foot that will be operated on is numbed by a local anesthetic. Then, during the procedure, the patient usually remains in a very light sleep. No breathing tube is used – the patient is able to breathe by him/herself. Typically, the patient is unaware of what is going on, hears no sounds, and when the procedure is done, wakes up to a numb foot feeling well-rested.

The third choice of anesthesia is general anesthesia. In this case, the patient is put totally asleep by the anesthesiologist. A breathing tube is put down the throat, and the procedure is done with no chance of the patient ever being aware of what is going on. Recovery following general anesthesia is a little longer, but this too is usually very well tolerated by patients. A sore throat afterwards is not uncommon. If I perform a surgery using general anesthesia, I will generally numb the foot at the end of the surgery so that the patient will have no pain for several hours afterwards.

What anesthesia is best for you? Talk over the choices with your doctor, and the two of you will come up with a plan for what will be best for your particular surgery.

Question #3: What restrictions will there be after surgery? Will you be able to walk on your foot? How much? Will you be able to get the foot wet? Will you have to wear any special shoes or perhaps a cast? If you cannot walk on your foot, what method of keeping weight off your foot will be used? (crutches, wheelchair, etc?)
If you will be using crutches, ask your doctor or his assistant to show you how to use them, particularly going up and down stairs.

Question #4: How long will I be off of work? This question will depend in large part on both the type of surgery performed, and the type of work you do. Someone who sits a desk for work all day will be able to return to work much sooner than someone who does extensive standing or walking as a part of their job. When your doctor gives you an estimate on when you’ll be able to return to work, please understand that it is just an estimate. Perhaps things will go very well, and you’ll be back to work sooner, or perhaps you will take a little longer. The period of time given will usually be an estimate on what most patients experience.

Question #5: How long will it be before I can return to my regular shoes and my normal activities? Again the answer to this question will depend on the surgery performed, the shoes you would like to wear, and the activities you plan on participating in.

Question #6: How will post-operative pain be managed? With any surgery, there will be discomfort in the period afterwards. Pain medication will help to decrease the pain, but will rarely make it go away completely. Ask what you can do to help control pain. This might include icing your foot, keeping it elevated, etc.

Question #7: Under what circumstances should you contact the doctor after surgery? From my perspective, I want patients to call me if there is bleeding that is excessive (coming through the bandage), the level of pain is unbearable, they injure the surgery site, or they get dressings wet that were supposed to be kept dry. However, you should feel free to contact your doctor whenever you have a serious concern.

Surgery is a partnership between the patient and the doctor, and best results are obtained when the patient fully understands the process and is committed to doing his or her part.