Kicking Foot Problems

Common foot problems -- from the itch of fungus to the pain of a strain -- can stop us in our tracks.  Some foot issues may even point toward more serious conditions that shouldn’t be ignored. What might your aching feet be telling you? And how can you keep putting your best foot forward?
Thomas San Giovanni, M.D., an orthopedic surgeon with Miami Orthopedics and Sports Medicine Institute shares his expertise with host, Jonathan Fialkow, M.D. on this episode of Baptist HealthTalk.

Transcript

Announcer:

At Baptist Health South Florida, it's our mission to care for you when you're injured or sick and help you stay healthy and fit. Welcome to the Baptist Health Talk podcast, where our respected experts bring you timely practical health and wellness information to improve your family's quality of life.

Dr. Jonathan Fialkow:

Hello, Baptist Health Talk podcast listeners. I'm your host, Dr. Jonathan Fialkow. I'm a practicing preventative cardiologist and lipidologist at the Miami Cardiac and Vascular Institute at Baptist Health South Florida, as well as the chief population health officer at Baptist Health. We started this podcast to answer the kinds of general health questions my colleagues and I are often asked by family and friends. For instance, there are many people out there who have questions about foot pain. That's not surprising when you learn that 75% of Americans will experience foot problems at one time or another in their lives. We'll find out why foot pain's so common and learn what we can do to take better care of our feet on this episode. I've invited Thomas San Giovanni, MD and orthopedic surgeon with a subspecialty in foot, ankle and sports at the Miami Orthopedic and Sports Medicine Institute to share his expertise with us today. Welcome to the podcast, Tom.

Dr. Thomas San Giovanni:

Great, Jonathan. It's a privilege to be here. Happy to speak with you all.

Dr. Jonathan Fialkow:

Great. So let's start with some basics as we get into this conversation. People think of the foot as just a single entity, but what makes it so complex? Why does it seem to be more susceptible to pain and maybe even injury than we might think compared to other parts of the body?

Dr. Thomas San Giovanni:

In contrast to what many people think, the foot can actually be one of the more complex areas of the body in orthopedics to evaluate and treat. It has to do a lot of times with the amount of bones that are in the foot. There's 28 bones, and these all have interconnecting joints which function somewhat independently at times, but then in conjunction with each other as we walk. So there are many different things that can occur and combinations of things. So it's a bit of a challenge. It's not just a hinge joint, it's all these complex joints rolling together.

Dr. Jonathan Fialkow:

So again, some people think of it as something, "A simple part of my body," but obviously there's complexity that warrants high levels of assessment and treatments such as by doctors such as you. In that vein, what are the more common foot problems we see in our society? And then let's take it to your practice in specific. What are the kind of problems that you see?

Dr. Thomas San Giovanni:

Certainly, I think very commonly... I'll break it up in regions, let's say. Let's say the heel. We see many issues with heel pain, heel pain along the back of the heel or what we call the posterior aspect. Oftentimes it's related to Achilles issues. So insertional, it's where the Achilles tendon inserts, and we commonly see problems with either overuse or degeneration, ruptured Achilles tendons. So those are the things that we see often in the back of the heel.

Dr. Jonathan Fialkow:

Before you go on, do you see something, and maybe as you address each part, is this more in common, the lay people, or is it more in athletes, or it can be in anyone?

Dr. Thomas San Giovanni:

It can be in anyone. The tendon is common to everyone, let's say. And they're an issue. So 20 to 50 year old range are more susceptible, let's say, to an Achilles tendon rupture. Whereas the older, wiser patients that we have, or some that also have other medical issues can have degenerative issues with the tendon at it's insertion site. We also see it in women, in terms of there are certain problems with heels, even in men with a bony prominence in the back of the heel.

Dr. Jonathan Fialkow:

So the heel problem you described can happen to anyone, usually a little bit as you get older. And when people feel that heel problem, and again, I do want to go through other parts of the foot, when should someone seek help and what kind of help should someone seek?

Dr. Thomas San Giovanni:

Well certainly for something that persists and lasts, let's say greater than 24 to 48 hours, we're talking about something that may not be an obvious acute injury, like a rupture. It's something where pain is experienced in the back of the heel. They have swelling, redness that seems to persist, and it doesn't respond to the typical anti-inflammatories or ice or rest. Those are times I think that you would be more inclined to see somebody specialist to diagnose you. The other heel pain that we see quite commonly is pain on the bottom of the heel. One of the most common problems we see is a condition called plantar fasciitis.

Dr. Jonathan Fialkow:

Heard of that. Let's go into that a little bit, because it does [inaudible 00:05:01] Can you explain a little bit what that is and what brings it on and what people can do about it?

Dr. Thomas San Giovanni:

Certainly. Plantar fasciitis, once again, the location is in the bottom of the heel. The plantar fascia is a thick band of tissue, very similar to a ligament that attaches from the forefoot, the bottom part but front of the foot, to the very back, and its attachment point is on the bottom of the heel. That structure can get injured if there's overused surface or a strain to it and conform these little micro tears and inflammation. How it presents in a patient, the classic presentation, would be when you wake up and first thing in the morning, you get out of bed and your very first few steps feel like there's a little gremlin stabbing you in the bottom of the heel with a knife.

Dr. Thomas San Giovanni:

A very sharp, sudden pain after prolonged time sitting, if you've been in a car driving for a period of time and then you get out, the first few steps, a sharp, sudden pain. And then gradually, you walk it off and it feels better, but that can be a persistent problem on a daily basis and it can be quite debilitating to people if it lasts for a long time, which a tendency is for it to last a long time.

Dr. Jonathan Fialkow:

So I think that's a great point. And I want to elaborate a little bit. So someone may feel that, and it could be a plantar fasciitis pain, but that doesn't mean it's going to go on to a chronic condition. It may, and that could be more frequent, but if someone getting out of the car feels a sharp pain, goes away in a minute or two, they wouldn't necessarily need to do anything about it? Or there is something that they should do?

Dr. Thomas San Giovanni:

Exactly. A onetime thing like that, or something they felt could just be identifying that it took a little shock to the system. It was like a rubber band that got a sudden jolt, but it doesn't mean that it's going to create the problem that we just spoke of. In fact, 80% to 90% of people that even have this, let's say had it and it's been going on for two or three weeks, that 80%, 90% will get better over the course of several months. The ways you can try to get rid of it faster often tend to be very simple tissue specific stretching. So when you first get up in the morning, a gentle stretch of your Achilles and of the plantar fascia, little toe stretching exercises you can find on online. But in particular, there's a continuum between the Achilles and the plantar fascia.

Dr. Thomas San Giovanni:

The more you're loosened up in the Achilles, the less impact that that region of the heel will see in the bottom. So simple stretching, probably if you can put it into your daily routine three or four times a day for about a minute, it's only three or four minutes out of the day. But if you do it routinely over the course of a couple of weeks, this should go away. Other things would be wearing a soft cushioned heel soled shoe. Let's say a sneaker that's got a good cushion to it, avoiding hard floors, things like that. More advanced would be a night splint, something to keep you stretched out overnight, and ice and anti-inflammatory, those are all kind of common things that we do to try to get rid of this earlier.

Dr. Jonathan Fialkow:

How about some other parts of the foot? What's a bunion. I see it a lot, I hear about it a lot. My wife bugs me a lot about her bunion, which she probably doesn't want the listeners to know, but part of the conversation. What is a bunion and what should people do about a bunion?

Dr. Thomas San Giovanni:

What a bunion actually is, it describes an angulation of the great toe, the big toe, where it starts to drift outward so that there's a prominence, or a bump that you'll notice along the inner aspect of the great toe. Often when it first presents, it oftentimes may not be painful. And many people have a very flexible foot, and they don't have any pain with it. Where at some point in time though, patients can experience symptoms from a bunion. And it really depends on is it aggravating their daily activities from a functional standpoint? And I make that emphasis from a functional standpoint.

Dr. Jonathan Fialkow:

As opposed to cosmetic, you mean?

Dr. Thomas San Giovanni:

As opposed to cosmetic. We all know that a lot of times people, they'll look at the foot and they just want that toe straighter from a cosmetic standpoint. But what they don't realize, I think, is like I said, not all bunions are painful. And if you are flexible and functioning quite well without an issue, what you may find is that the correction of it can often cause some stiffness at the toe because it's been living in that position for so long. So I wouldn't just correct it just for the looks, when you look at the patient satisfaction level from a surgical standpoint, the satisfaction level is certainly not as high as if you did it from a standpoint of doing it for a functional reason or a combination of functional and looks. There's got to be more than just looks, I think, for you to do that.

Dr. Jonathan Fialkow:

Are there things that contribute to a bunion? Is it genetic? Does it have to do with the jobs or the kind of shoes one wears?

Dr. Thomas San Giovanni:

Yes. There's people that are predisposed to it. There are also contributing factors of shoe wear. Shoes that have a very narrow toe box towards the front, or are tapered towards the front, it almost accentuates and pushes the toe in that direction so that it's creating a force against... Especially if somebody is predisposed to it, that can be a factor.

Dr. Jonathan Fialkow:

So again, it brings another point, which I appreciate. So I do want to get the other parts of the foot, but let's talk about footwear a little bit in general. How much of what you see, obviously a specialist in foot, ankle, and sports at the Miami Orthopedic and Sports Medicine, how much of what you see is footwear related? And then would it be maybe a podiatrist to other parts of the medical specialties where you might see more footwear related? So what is the relationship of footwear and footwear choices towards foot pain and foot abnormalities?

Dr. Thomas San Giovanni:

When it becomes a problem with footwear or shoe wear is really a mismatch, meaning a mismatch between the shoe that you're wearing, with the surface that you're wearing it on, with the activity that you're doing. And the final factor would be genetics, hereditary. For instance, if you haven't run for a long time, let's talk about the COVID pandemic, and everybody's at home getting bored and they want to all of a sudden go out and do some running or jogging. So they pull out their old shoes, their old sneakers, running shoes that they haven't worn in about nine months. And all of a sudden they start running every day on asphalt. And they maybe they're choose or worn or they're maybe a super flexible non-supportive shoe, or they lost their support.

Dr. Thomas San Giovanni:

And so we've been seeing a lot of issues with that in terms of metatarsal algia, pinched nerves, what we call them, [inaudible 00:12:32] issues related to mismatching the shoe with the surface and your activity level. So there are a lot of issues that we see that are shoe wear related, but it's usually a combination of the wrong shoe for the wrong activity or the wrong amount of time repetitively doing it. I'd say usually patients will have some signs of it by responding with pain. And oftentimes they'll try to push through it and that may not be the right thing to do. If your body's telling you that it's too much stress or force at this time, or maybe they need to change something in that regimen.

Dr. Jonathan Fialkow:

So what would be recommendations, if it's possible, if it's not too broad, selecting footwear, or would it just be, if you're going to do a physical activity, start slow? Where can we avoid some of these shoe wear related as well as activity related foot injuries?

Dr. Thomas San Giovanni:

I think that in general, if you're going to be doing repetitive walking for extended periods of time or high impact, that you need a shoe that's going to be supportive, have some degree of cushion to it, and that is going to protect that area of the foot, which is usually the arch, the heel and the forefoot that you're going to need.

Dr. Jonathan Fialkow:

And I guess another point would be, if you're starting to feel pain, then don't just continue doing what you've been doing the way you've been doing it?

Dr. Thomas San Giovanni:

Yeah. I think if you start to feel pain, you got to listen to your body. And much like when I take a history in a patient... Do you remember that? I'm sure a lot of these people on the podcast may not remember. Remember that old show Colombo?

Dr. Jonathan Fialkow:

Yeah, of course. Peter Falk.

Dr. Thomas San Giovanni:

I act like that guy Colombo. I end up sitting there asking questions that sound like they're unrelated to what they're doing. And then all of a sudden, the patient tells me the problem themselves in the end, if you ask the right question. So if you start feeling that pain, start thinking to yourself, "What shoe was I wearing? What was I doing?" I'll ask a patient, "When did it start?" And they'll say, "Well it started... I don't know, it started a couple of weeks ago." And I said, "Well, what day did you notice it?" "How am I supposed to remember what day I noticed it." And then I said, "Well, was it a Monday?" And they said, "Yeah, it was a Monday." And then I go back, "Well, what were you doing that weekend?" "Well, I was walking on the beach." "Well, what were you wearing?" You see what I'm saying?

Dr. Jonathan Fialkow:

So basically you got to be a detective.

Dr. Thomas San Giovanni:

Right, you got to pay attention to the details. And if you think hard enough, you can realize, "Well jeez, what was I doing yesterday that caused this?" And then you change that.

Dr. Jonathan Fialkow:

I don't want to denigrate your detective skills, but they did tell you who committed the murder at the beginning of Colombo.

Dr. Thomas San Giovanni:

Yes, that's true.

Dr. Jonathan Fialkow:

All right. So these are great points and great information. So we talked about the heel and the Achilles tendon, plantar fasciitis, bunions, common complaint. A couple of other just general foot concerns people have maybe I could throw at you before we talk about a couple of final points. Toe fungus, I know it's maybe not something you treat, but is it just ugly or is there a danger to it? It's fairly common, obviously bothers a lot of people. So what can you tell us about toe fungus?

Dr. Thomas San Giovanni:

Toe fungus, you'd be surprised. On average, 20% of the population will have toe fungus at some point in their life. When they look at statistic, 75% of people over the age of 60 will have toe fungus. It's often more cosmetic than an issue. But it can be a telltale sign that something's going on, meaning that it can be a clinical sign you may have a bit of a vascular issue, a microvascular issue, or pre-diabetic or nutritional. Maybe worth paying attention to, especially in the older population. The cause of it is typically moist heat. Fungus loves to live it's culture medium, loves to live in an area of humidity. We'll see sometimes more often in summer. Let's say if you're wearing socks and you're sweating, you could also see it in people that frequent the gyms a lot.

Dr. Thomas San Giovanni:

That might be one time that you'd want to bring your flip flops, the gym and the showers and things like that, and gymnasium locker rooms. But it's usually due to some moisty fungus colonize and then it becomes a problem. But to answer your question, it's more cosmetic. At times it can be painful when it becomes really inflamed. And rarely, it can be a serious problem. There's different treatments for it. But I would say that it's more of a... Like I said, it's more of a cosmetic issue, but none of us really want to see it. You want to get rid of it.

Dr. Jonathan Fialkow:

So if someone does have it, it might be a marker of other medical conditions, which is why they may want to get a medical checkup. But more often than not, it's just a cosmetic thing, and again, [crosstalk 00:17:51]

Dr. Thomas San Giovanni:

There's various things like topical treatments, like antifungal cream, various creams that are out there that are antifungals that you could find in the local pharmacy. Shoes, like I said, once again paying attention to the shoes and the socks, that maybe change the socks often enough that if you're sweating in them, that you try to change them to keep things dry. Also old shoes, you want to change your shoes out every once in a while so that they're...

Dr. Jonathan Fialkow:

And would those be kind of the same? So we talked about toe fungus, but for athlete's foot and other relatively common elements would be the same type of recommendations [inaudible 00:18:30]

Dr. Thomas San Giovanni:

Exactly. They tend to be humidity and moisture related type issues with the foot and ankle.

Dr. Jonathan Fialkow:

I would be remiss if we didn't bring up something that I'd just like you to elaborate on, the concept of diabetic neuropathy. And again, it's important for foot health, but can you articulate a little bit why, especially in a diabetic, especially with neuropathy, what they should really pay attention to with their feet and the reason why?

Dr. Thomas San Giovanni:

Yes. Well, with somebody who has neuropathy and diabetes are there...

Dr. Jonathan Fialkow:

I apologize. Neuropathy means is that the diabetes has affected the nerves so they don't have proper sensation, right?

Dr. Thomas San Giovanni:

Exactly. And so they lose the sensation. Some early on might still say, "Oh, I have sensation. When you touch there, I can feel, but the sensation is altered." They lose their protective sensation. So when there's a problem going on, they may not realize it because their body won't sense it. And then they can get into the problems. A problem might be the beginning of a pressure ulcer or pressure phenomenon on the bottom of the foot that they can't see. And it becomes inflamed. In fact, that might be the only thing they see, is they see inflammation, but they may not feel the pain or the degree of pain. And before you know it, that turns into an ulcer, there's a break in skin integrity, and then it's a downward spiral.

Dr. Thomas San Giovanni:

Sometimes you're having to... You know what I mean? You end up having to treat the wound and you have to unload it. So that's extremely important, their shoe wear. They have to have shoes that are not tight fitting, that have enough room in the toe box, which is the front part of the shoe, and the height and the width, more of a cushion feeling to the surface. But also a shoe that's got a lot of support. So it's got to be a combination of the surface against the skin that's cushioned, but the sole of the shoe that can take the brunt of walking. I would recommend that, once again, that they pay attention to their shoe wear, that they check their feet every day. If they can put a mirror, because you can't see them. So they put a mirror and then put their feet out so they can see the mirror and they can see the bottom of the foot because it's one of the most problematic conditions that we probably face in the US and also in the future. I've got to throw some stats at you if this is okay.

Dr. Jonathan Fialkow:

Yeah, sure.

Dr. Thomas San Giovanni:

Close to 23 million patients that have diabetes in the US, close to 8% of our population, in 2030 they're predicting close to 70 million diabetic foot problems or infections represent about 25% of hospital admissions for those that have diabetes. So it's a quarter of the admissions for diabetics.

Dr. Jonathan Fialkow:

And of course the consequence can be infections and infections in the bone, and it can even lead to amputations, which is all the more reason for the diabetic to be hyper vigilant, looking for any kind of foot problems.

Dr. Thomas San Giovanni:

Exactly.

Dr. Jonathan Fialkow:

And I think it speaks to something else. You brought up in every topic, pain, right? The concept was foot pain. Pain is the body's way of saying, "You're doing something, something's wrong here." And if the diabetic doesn't get the pain, they don't have those normal warning signals.

Dr. Thomas San Giovanni:

The most extreme of diabetic neuropathy would be a condition called a charcot foot, which is where they become insensate. They don't have much feeling or pain, and a minor injury or minor thing could lead to dislocation of the joints before you know it because they lose their sensation.

Dr. Jonathan Fialkow:

Well Tom, this is great information. I guess we'll have to bring it back, we didn't get to the fun stuff like ingrown toenails and corns and bone spurs. But I think it just reiterates your original point, the foot is a complex structure of multiple bones, tissue, tendons, blood vessels, and we tend to ignore it as a part of our body that can be injured and cause problems. And thankfully, you're here to help us when we get into trouble. Any final comments or any final thoughts that you'd like to mention to our listeners before we wrap up?

Dr. Thomas San Giovanni:

No, I think as I think that's it. I'd be happy to come back on again if you like, and it was a pleasure speaking to you.

Dr. Jonathan Fialkow:

Well, thanks again. And to our listeners, appreciate your listening. And as usual, if you have any thoughts for future topics or any concerns, any complaints, any recommendations, please email us at baptisthealthtalk@baptisthealth.net. That's one word baptisthealthtalk@baptisthealth.net. Thank you for listening, and stay safe.

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