Why Pain is Good

Really?  How can this be?  To talk to most people, they will do just about anything to avoid pain.  Indeed, I spend a lot of my time treating patients who have pain that keeps them from doing the things they enjoy in life.  Just ask a person with heel pain, or a painful ingrown toenail, and they will tell you how much pain is, well, a pain!  But pain is there for a reason.  Pain lets us know that there is something wrong and needs attention.  Imagine if you were to break a bone in your arm and have no pain.  You would likely not think there was anything wrong.  You would not protect the arm or seek treatment.  And it is likely that the fracture would not heal properly.  This is why pain is good, even though no one likes it.

For my diabetic patients, pain is not only good, but vital.  Problem is, many patients with diabetes develop a condition called peripheral neuropathy.  With peripheral neuropathy, the sensory nerves (primarily in the feet and lower legs) do not function as they should.  The pain signal is not transmitted to the brain.  This leads to some severe consequences.

A patient I saw recently was a perfect example the consequences of peripheral neuropathy.  He was working and stated that at the end of his work shift, his foot felt uncomfortable.  When he took off his shoe, he found that he had stepped on a nail that had gone through his shoe and into one of the bones in his foot.  Now, if I had stepped on a nail, you can bet that I would know right away that something was very much wrong.  I suspect that everyone around me would be aware as well, as they would likely cover their ears from my screaming.  However, this patient likely walked around for at least a few hours with a nail in his foot!  This of course made a bad situation worse.

Most of the time, the problems I see are not as dramatic in their presentation, but have the potential to be equally as devastating.  Quite often, it is not the nail in the foot that causes the ulcer or sore to form, but the constant light pressure from a callus or ill-fitting shoes that causes damage to the skin.  For this reason, I strongly urge all my diabetic patients to inspect their feet daily looking for signs of an ulcer developing.  These signs can include redness, swelling, bleeding.  If calluses are present, darkening of the callus can be a sign of bleeding and skin breakdown.  A best case scenario is to have a spouse, partner or friend inspect the feet, as it can be difficult to fully examine your own feet.  And by all means, if anything is seen that raises a concern, DO NOT DELAY calling your podiatrist to have your feet looked at!  It may save you from a long, difficult healing process.  It may avoid the need to amputate your leg.

To learn more about diabetes and its effects on the feet, please visit my website at http://www.concordfootdr.com/diabetic-foot-care.html

A Success Story!

About 2 weeks ago in my last blog posting, I talked about one of the treatment options for painful morton's neuromas - a cortisone injection.  Those who may remember, the "patient" was myself.  I had been having moderate pain in my right foot from the neuroma, and it was getting worse.  I decided to inject my foot with Kenalog, a type of cortisone.  The purpose of the injection was to help to relieve pain, and hopefully cause some shrinking of the neuroma itself. 

After my injection, I noticed an immediate decrease in pain.  This was expected, since I also had included a local anesthetic in the injection.  After several hours, the local anesthetic wore off, and the pain came back just as bad as before.  This was to be expected, and I was not surprised.  I can see how this can be discouraging to patients though, which is why I warn them that he effects of the cortisone can take a few days to become evident.  When I woke up the next morning, I was pleased to find that my pain level was decreased by about 50%.  The next day, the pain was 100% resolved!  That was a welcome relief!  Since that time, I have not had any pain in my foot whatsoever!

The real question now is this:  How long will this pain relief last?  The honest answer to that question is that I really don't know.  In most cases from patients I have injected for this condition through the years I have been in practice, pain relief will last for several months.  I do have some patients who never have symptoms again, others will come back 6 months later stating the pain has returned.  I have no problem with giving injections a couple times per year on an ongoing basis to control symptoms.  However, if the symptoms come back more quickly, it's time to get more aggressive.  I, like my patients, am hoping for the best!  Look for further updates on this subject in the coming months!

Treating a Morton's Neuroma via a Cortisone Injection

As a podiatrist, I have treated the condition called morton's neuroma many, many times over the course of my 22 years in practice.  However, my latest patient hit much closer to home.  Me!  Turns out I have developed a neuroma in my right foot recently, and have had the opportunity to experience first hand what my patients have been experiencing all these years. 

A morton's neuroma occurs in the forefoot and consists of inflammation and swelling of the nerve.  This will frequently cause pain that will radiate out to the 3rd and 4th toes.  Often there is a tingling, burning or shooting sensation reported.  It is unclear the precise cause of this deformity, but damage to the nerve is suspected.

There are numerous treatment options available to treat this condition.  In my office, I like to start with simpler options first.  In my case, I decided to administer a cortisone (steroid) injection to the nerve.  This can be helpful in decreasing the inflammation and pain in the nerve, although the relief from an injection is often not permanent.  Other treatment options include the use of orthotics, anti-inflammatory medications, icing, decreasing activity levels, and surgery.  Like most patients, I would like to avoid surgery!

For your viewing pleasure, I had my assistant record myself administering the injection.  My experience was like that of many of my patients over the years - the injection for a neuroma is not that painful.  The fact that I was able to give it to myself while standing is a good indication that this was not a traumatic experience.  As I continued with the injection, I could feel the area become numb, since I also injected a local anesthetic with the cortisone.  You may notice that the injection took over a minute.  I have found over the years that injecting slower decreases the pain, since the local anesthetic will numb the area as the injection proceeds.  Typically though, the cortisone will take a few days before patients notice relief following a cortisone injection.

http://www.youtube.com/watch?v=DTMJ4KOqcr8

I will update this blog in the coming weeks to let you know if my injection helped to relieve my symptoms.

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.