Summer Footware

Summer Footwear Pains

Let's face it there are many people who can wear whatever type of shoes they want without any consequence. You know the women who can wear high heel dress shoes and walk 15 blocks in the city or dance all night at a wedding and not have so much as a blister.  If this is you and you can wear all types of shoes without pain, stop reading.   However, for many people trying to wear sandals, flip flops or water shoes in the warm weather leads to foot pain.

 In my office, summer brings  a wave of patients with problems that are triggered by the type of shoes that they choose to wear in the summer.  The majority of the time the shoes we choose to wear in summer are significantly different than what patients typically wear in cooler weather. This leads to shoes/sandals that have inadequate support, poor cushioning, and decreased heel heights. To make matters worse with the warm weather patients are usually walking and standing in these types of shoes for longer periods of time.

 Shoes with very thin soles provide no cushioning or support under the foot.  With minimal shock absorption there is increased pressure on the bottom of the foot.  This can lead to heel pain (plantar fasciitis), pain in the joints of the ball of the foot, pain or arthritis of the big toe joint, callouses, and arch stain. Heel pain complaints skyrocket in the summer.  This is due to change in the type of shoes people are wearing and their increased activity. The results-- Heel pain, strains, sprains and tendinitis!!!

I'm not naive.  I realize that patients (and myself for that matter) are  not going to change the types shoes that are worn in summer and on vacation.  I would never recommend that everyone stop wearing sandals and flip flops. But some of us are going to pay the price and you need to be aware why these shoes cause problems,  what type of problems they cause, as well as how to avoid them.  There are some sandal and flip flops that provide better support than others.  If you insist on wearing sandal/flip flops using styles with contoured foot-beds, arch support and good cushioning are the way to go. ( see image below)

Click on this link for a variety of sandals that are better for your feet

http://www.ourdoctorstore.com/catanese/store/index.asp?DEPARTMENT_ID=258

 

If you are having foot problems, evaluating what you are wearing on your feet is essential.  The majority of patients that come in with foot pain caused by the wrong type of shoes/sandals have never considered it could be the shoes.... or don't want to admit it to themselves.

The Most Common Complaints

Heel pain(Plantar Fasciitis):  #1 on the list!!! Pain at the bottom of the heel.   Flat, poorly cushioned shoes, with little to no arch support, and low heels, lead to an amazing number of people who develop heel pain.  The pain is typically worse in the morning and after rest. (For a detailed explanation of heel pain and its treatment see my blog post "The Most Common Foot Problem: Heel Pain"  Click on this link   http://doctorsfootnotes.blogspot.com/2010/09/most-common-foot-problem-heel-pain-heel.html )

Achilles Tendinitis:  This pain is located in the back of the heel. Either on the heel bone or on the tendon at the back of the ankle before it attaches to the heel bone.  We see this more often in summer due to patients switching from sneaker or shoes with a thick heel to flat heeled shoes or sandals. This puts increased stretch on the Achilles tendon and leads to tendinitis

Strains:  The aforementioned lack of support and cushioning put abnormal strain on the ligaments and tendons of the foot.  Weather it be arch strain or pain in the central/mid-foot area, the extra work the tendons and ligaments have to do leads to inflammation and pain.

Ball of foot pain / Metatarsalgia:  Pain he ball of the foot is also common with summer footwear. This pain is most commonly experienced in the ball of the foot behind the second toe but can occur anywhere in the ball of the foot.  The lack of cushioning under the ball of the foot is the obvious cause. and sandals with low heels, or worse, high heels increase the pressure on the ball of the foot.  If this excessive pressure on the ball of the foot continues, it can lead to permanent injury to the soft tissue in the ball of the foot and toe joint.

Check out my interview on NY WABC 7 about how to get your feet ready for summer:

"Caring for your feet during the summer"

http://abclocal.go.com/wabc/video?id=9114818

 

 

What not to wear...

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Nearly all shoes that have thin soles also have inadequate support. That is especially the case with  sandals and flip flops.  That lack of structural support in the shoe means that all of the tendons, ligaments and joints need to work harder during walking and standing.  These types of shoes also provided virtually no shock absorption.

Flip flops

The number one culprit!!!  Inexpensive, comfortable, cool, easy to put on and off, and seemingly always in style.  The problem with them is obvious yet most patients are in denial that they could be the cause of problems.  If you are going to wear flip flops choose styles that have cushioning and support.

Ballet Slippers

Worse than Flip flops!  less cushioning, less support!!!  Very popular but very bad for your feet.

Dress Sandals

    Here comes the broken record....No support thin leather soles, no cushioning....Foot problems waiting to happen.   Add low heel, to this type of sandal and you shift all of your weight to the ball of the foot without any cushioning to protect you. The result is pain in the ball of the foot (metatarsalgia) and the possibility of permanent injury.    

Water Shoes

     Good for water, Good for the beach!  Bad for prolonged walking and standing.

Ganglion cysts of the foot and Ankle

Ganglion Cyst of the Foot and Ankle

Ganglion Cysts are a type of benign tumor or soft tissue mass that causes a bump, lump or enlargement on the foot. A cyst is an abnormal closed sac that is filled with either a fluid, gaseous, or semi-solid substance.  The Ganglion Cyst structure can best be described as being shaped like a water balloon.  They have a stalk type base (stem of balloon) which leads to the body of the cyst (balloon), which has a well demarcated membranous wall.  Ganglions are also known as "Bible Cysts".  This name comes from an old time treatment of the cyst by hitting it with the biggest book in the house, a bible.  Hitting the cyst causes the wall to rupture (popping of balloon) and the contents of the cyst can leak out.  Patients typically notice that the size of the mass/lump will change, getting larger and smaller.  This happens when the ganglion cyst wall spontaneously beaks or tears allowing the contents to leak out and the cyst/lump becomes smaller.  The defect in the cyst wall heals and refills with ganglionic fluid and then enlarges again.

Ganglion Appearance:

 A ganglion appears as a enlargement or bump, and may appear anywhere on the body but are commonly found on the hands, or feet (fig 1).  Ganglions are filled with a thick fluid whose consistency can vary from honey to a jam type consistency.  The actual size of the cyst can be deceiving.  Frequently a large portion of the cyst can't be visualized because its below the skin surface (similar to an iceberg) where its originating from a tendon or joint.

figure 1

Symptoms:

Typically patients will come to see the doctor out of concern over the a bump or lump which may or may not be painful.  Ganglions are not painful in and of themselves.  Ganglions become painful when they put pressure on vital structures or restrict motion, or become large enough that shoes begin to irritate them.  A common complaint from patients is nerve symptoms i.e. Burning, tingling or electrical sensations.  This occurs when the ganglion puts direct pressure on a sensory nerve.

Causes:

There is no definitive answer as to what causes a Ganglion.  The general consensus is that ganglions are due to trauma or irritation of a joint or tendon.  This can be either direct sudden trauma or more commonly minor repetitive trauma.  The repetitive or micro trauma can be as simple as constant shoe pressure over a tendon or repetitive irritation of a joint.

How do I know its a Ganglion?

Lumps and bumps on the foot can be caused by either a bony prominence or a soft tissue mass.  Prominences caused by bone are not freely movable in the surrounding tissue and have a firm hard consistency.  soft tissue masses that are not ganglion can sometimes be difficult to distinguish from a ganglion.  The location and "feel" of the mass can often give the doctor a diagnosis of ganglion with a high degree of certainty.  MRI's can also be helpful in identify if the enlargement is a ganglion or some other type of mass or bony prominence.  A doctor can also attempt to remove fluid from the a ganglion through a simple procedure called an aspiration.  To accomplish this a needle is inserted into the mass attached to a syringe.  When the plunger of the syringe is pulled back it draws fluid from the cyst into the syringe. (fig. 2)  This fluid can than be analyzed.

Treatment Options for Ganglions:

A Ganglion can be treated in two different ways:  Either by Aspiration(draining of the cyst) or by Surgical Excision. 

Aspiration of Ganglion:

(figure 2)

     As stated earlier aspiration is accomplished by inserting a needle and removing the contents.  This is done after injection of a local anesthetic to numb the area.  The procedure is simple, quick and the only discomfort is from the injection of anesthetic which is minor.  The procedure is typically performed in the office.   The patient can leave the office wearing their shoes and are able to drive or walk afterwards.   Some doctors may choose to inject a steroid (anti-inflammatory medicine) into the cyst after its been drained to help prevent return of the cyst.  Not all ganglions can be drained by aspiration and therefore need to be excised.

     Surgical Excision of Ganglion:

Surgical excision of a ganglion is done in a sterile operating room.  The patent is given a intravenous sedative and then the area where the cyst is located is numbed with a local anesthetic.  an incision made and the cyst is surgically removed.  There are obvious risks associated with surgery.  With excision of the ganglion there is a possibility of damage damage to nerves, blood vessels tendons and any other vital structures that may be encounter in the process of getting to and dissecting out the cyst.  Despite how ominous this may sound the complication rate with surgical excision is quite low.

There are several situations where I would recommend surgery for my patients:
- If the Ganglion is causing numbness, tingling, burning or significant pain.  This is due to pressure the mass on sensory nerves.
- If there is a question as to the mass is a ganglion or some other type of tumor.
- if the mass returns quickly or frequently after aspiration.
- If the Ganglion is causing difficulty wearing shoes

     With either treatment, recurrence of the cyst is possible.  However with aspiration the recurrence rate is much higher.  Aspiration is usually my first choice in treatment of a ganglion.  Its relatively painless, quick, and even if the ganglion returns the cyst can be aspirated again.   If unsuccessful, the mass can always be excised.   

The Most Common Foot Problem : Heel Pain. (Heel Spurs, Plantar Fasciitis)

    The Most Common Foot Problem : Heel Pain. (Heel Spurs, Plantar Fasciitis)

  What's the most common foot problem that walks into my office?  What is the most common problem my friends, neighbors, employees, and yes even strangers as ask me about?  Without question its Heel Pain. It's so common that its seems the question isn't if you'll experience it, but when.  It's so common that my daughters are no longer phased by the sight of  one of my friends sprawled out in my family room getting an injection in their heel.  There are various conditions that can cause heel pain but 90% of the time its due to Plantar Fasciitis commonly called Heel Spur Syndrome, or Heel Spurs.

                                                     HEEL SPUR????????

     First Let's start with the name.  Although Heel Spur is the commonly accepted name for the condition its a misnomer.  The more accurate and correct name is Plantar Fasciitis.   The pain associated with the condition is due to an inflammation or irritation of the Plantar Fascial ligament .  The ligament is a thick band like structure which runs from the bottom of your heel to the ball of of your foot(fig. 1).

(fig.1) The ligament is stretched at its attachment to the heel with walking and standing

     When you stand and walk the ligament is stretched and elongated.  If the ligament is overstretched or irritated it becomes inflamed and painful (fig.1).  This usually occurs where the ligament attaches to the heel bone at the bottom of the heel.  This is also the location where some people will develop a small bony projection off the bottom of their heel called a spur (fig 2).  The spur may develop due to chronic tension of the ligament as it pulls at its attachment to the bottom of the heel bone. The spur does not cause the pain.  Its not a cases of you walking on the spur that's causing the pain. The spur projects forward toward the toes, not downward to the ground. The pain is due to the ligament becoming inflamed where its pulling on the heel bone at its attachment.  Frequently patients with severe pain will have no spur on x-ray and conversely patients will have huge bony spurs projecting off their heel and have no pain.

(fig.2) Heel spur projects forward not down

 
     Pain after resting or sitting is one of the hallmark symptoms of the condition.  This occurs because when you sit or sleep the foot is in a relaxed position and the foot is effectively pointed in a downward position.  This relaxes and takes tension off the Plantar Fascial ligament, the muscle group in the back of you leg and the Achilles tendon.  The ligament and the tendon get used to the relaxed position.  When you stand and put weight on your feet the ligament and the tendon are  put under sudden stretch and there is sudden pressure on the heel.  This is when you may feel severe sharp piercing pain.  Typically the pain beings to improve after you've been on your feet and walking for a period of time.


Hallmark Symptoms of Plantar Fasciitis / Heel Spurs.

1. Pain at the bottom central or bottom inside portion of your heel
2. Pain in the morning with first steps
3. Pain with standing/walking after sitting or rest
4. Pain with prolonged periods of standing walking
5. Increased Pain with walking barefoot or on hard surfaces
6. Burning pain or numbness of the bottom or inside of heel

So...you have heel pain.  Your symptoms mimic some or all of those above.  You have Fasciitis. Right?  Probably.  Chances are about 90% that you have Fasciitis.  However some conditions such as nerve entrapment, bone tumors, soft tissue masses, arthritic conditions, and trauma can cause similar symptoms so if symptoms do not improve, or get worse over several days, a visit to the Podiatrist is in order.

What Causes Plantar Faciitis???
Plantar fasciitis occurs when the plantar fascial ligament becomes inflamed or irritated.  The inflammation of the ligament causes pain.  So the real question is what causes the the ligament to become inflamed?...The list is endless;  Standing on hard surfaces, standing for prolonged periods of time, shoes with poor stability(especially sandals, flip flops), shoes with poor arch support, Weight gain,  increase in activity, decrease in activity, direct pressure to the ligament(i.e. standing on rungs of a ladder), activities that stretch the ligament...and the list go on!  What caused the ligament to become painful is not what's important.  What is important is what we need to do to resolve the pain.
 
The good news is that about 80-90 % of the patients that I see have their pain resolve.    Remember that this is a condition that did not begin suddenly.  Even if you notice the symptoms suddenly it is has been developing over time, so you shouldn't expect it to resolve suddenly. 

This is an extremely treatable condition and many of the measures that are used to treat this can be done at home once you begin to have symptoms.  Follow the suggestion below to begin treating your heel pain immediately, even if you plan on seeing the doctor.  The earlier you begin treatment the better the chances are at resolving the pain.  

There are three main components to treating heel pain: 
1) Reduce inflation of the Plantar Fascial Ligament
2) Support the Plantar Fascial Ligament
3) Stretch the ligament and tendons

 Here is what to do if you have heel pain:

1) REDUCE INFLATION:  

      Over the counter anti-inflammatory medication such as Motrin or Alieve should be started. For people who can tolerate these medicines,Tylenol can be taken.  Tylenol is not an anti-inflammatory medicine and won't be as effective.  Ice and Ice Massage is effective at reducing inflammation, 20 minutes on then 20 minutes off the area of pain.
( Ice massage- Freeze a bottle of water and use it like a rolling pin under the heel to massage and cool the area of pain)  If you don't massage the heel with ice just applying a bag of ice (20 min on 20 min off) is also very effective.

2) SUPPORT THE LIGAMENT:

       Supporting the ligament means supporting the arch of the foot.  A good quality athletic sneaker should be used.  This sneaker should have a removable insole so a better, more supportive arch support can be used in its place. Arch supports provide more substantial support of the Plantar Fascial and are extremely effective at reducing pain and keeping it away.

3) STRETCH THE LIGAMENTS AND TENDONS:

      Stretch the muscles/tendons of the back of the leg.  The Achilles Tendon and the Ham Strings.(fig. 3)  Stretching is Boring and it doesn't seems like its doing anything but it essential and it works!!!  Stretch a minimum of three times a day and before and after any sport activities including walking.  The use of a "night splint" is also an effective way to keep the ligament stretched while your sleeping or sitting. (see product recommendations below)  Stretching is key to treating this so stretch, stretch, and stretch...and when you think you've stretched enough stretch more.  Stretching is boring!  It may not seem like its having any effect and that your wasting time.  But it works!!!  Stretching is the simplest and most effective thing you can do.  So just do it !
   Check out this video for stretching the muscles in the back of you leg if you need to see how to stretch.

Achilles Tendon / Hamstring stretches.  Do 3 sets of 10,  3 times per day.  Click to see video:
http://www.youtube.com/watch?v=xI0tT0dY95E

 This video show how to stretch the Plantar fascial ligament in the bottom of the foot.
if you having pain when you stretch than you stretching too hard.

Platar Fascial Ligament stretch.  Do it 3 sets of 10, 3 times a day.  Click to see video:
http://www.youtube.com/watch?v=rxu433AIb7Y

These measure are extremely effective at treating the condition when done consistently.  So stick with them and if you don't feel better see the doctor for treatments you can't do at home.  The Podiatrist can provide prescription medicine, injections, physical therapy, x-rays/MRI's etc.  
     Most importantly the Podiatrist can make sure that it is Fasciitis and not some other condition that mimics the symptoms and may be more serious.


Let's talk about heel spur injections.  These injections are a mixture of steroids and local  anesthetics which are highly effective at reducing inflammation.  The class of steroids used in the injection are the type that reduce inflammation not the type that build muscle.  They are extremely safe when used sparingly.  Most podiatrist will limit the injections to about three per year.  If multiple steroid injections are given over a short period of time, detrimental effects can be seen.  In the case of multiple injections the steroid can begin to atrophy or shrink the protective fat pad at the bottom of the heel. It can  also effect the skin at the injection site similarly.  Frequent steroid injection can also weaken and possibly rupture the Plantar Fascial ligament.  Don't let this scare you off form getting an injection.  For patients with significant pain its often the best and quickest ways to break the inflammatory cycle and reduce or stop the pain.   

Radiofrequency Ablation
     If my patients' pain doesn't resolve after trying these treatments then I'll switch my treatment plan and focus on blocking the pain they are experiencing since stopping the cause of the pain has not worked.  This is done by stunning the nerves that transmit the pain from the ligament and blocks the pain.  Stopping the nerve from transmitting pain signals is accomplished through a procedure which uses radiofrequency (a form of electricity) to ablate or stun the nerve.  This procedure, Radiofrequency Ablation, is successful  in stopping pain in approximately 70-80% of patients who's pain is not resolved with the above traditional treatments. We'll save a complete discussion of Radiofrequency treatment of Heel Pain and Neuromas for another blog entry. Visit Neurotherm.com by clicking on the following link, for detailed information about radiofrequency treatment of heel pain including my articles and research.  http://www.neurotherm.com/podiatry_education.htm

 The following products are helpful in treatment and prevention of heel pain

SNEAKERS:  If you want to support your ligament and cushion your heel properly invest in a good pair of athletic sneakers.  A cross trainer or walking sneaker is best. Stick with the major athletic brands like New Balance or Nike.  Don't waste money on Easy Spirit, or Curves or designer sneakers.  If you sneakers are over 6 months old get new ones.  Even if they look good the materials begin to loose their  shock absorption properties.  If you have a wide foot stick with New Balance sneakers and get the appropriate width to match the size of your foot. These sneakers have removable insoles.  This allows the insole to be removed and replaced with an  better more supportive Arch Support or Custom Orthotic.

CUSTOM ORTHOTICS aka Custom Arch Support:   Considered the gold standard in treating fasciiitis.   Orhtotics prevent the arch from flattening, reduce the stretch of the ligament, and cushion the heel.  Podiatrist are trained in understanding the relationship between the mechanics of walking and running and how to design a custom arch support (orthotic) to correct any problems with the way the foot is functioning.  Custom Orthotics are made from a cast or impression of the foot.  The Podiatrist will then have the orthotic fabricated based on a mold of the foot and an exam of the foot function.  Orthotics are helpful in addressing many foot and lower extremity problems.  Some insurance plans cover the cost of orhtotics recognizing that the are successful in treating various conditions.  So again check with you Podiatrist. 


ARCH SUPPORTS(non-custom orthotics):  Arch supports or Orthtotics prevent the arch from flattening, reduce the stretch of the ligament, and cushion the heel.  The problem is that the number of choices in non-custom, over the counter orthotics, is daunting.  The vast majority of the arch supports available at your pharmacy are worthless.   The problem is that most arch supports are made in a generic manner with soft materials which are inadequate in the amount of support they provide.   These devices are not optimal for treating Plantar Fasciitis.  Fortunately there are a few very well made Arch supports that provide proper support at a reasonable price.  These supports use better materials and are constructed to provide better support.  

    The arch supports listed below are some of the best non-custom devices you can get.  They can be hard to find since most pharmacies don't carry these brands.  If you can't find them visit my web store by clicking on the link below the picture.

     SUPERFEET GREEN:
 To see item at our online store click link below:

http://www.ourdoctorstore.com/catanese/store/item.asp?ITEM_ID=331&DEPARTMENT_ID=57

 POWERSTEP:
To see item at our online store click link below:


http://www.ourdoctorstore.com/catanese/store/item.asp?ITEM_ID=741&DEPARTMENT_ID=57

 Night Splints:  There have been numerous scientific studies showing the effectiveness of Night Splints in treating Plantar Fasciitis.  I believe that the effectiveness can be increased if the splint is worn in the evenings while watching TV or reading.  Many people spend 3-4 hours or more off their feet each evening before going to bed.  This in addition to the time you're asleep can amount to 12 hours a day that the ligament and tendons are not optimally stretched and in a relaxed position.  Wearing the Night Splint keeps the ligament and tendons stretched during this time. Some insurance companies cover night splints for fasciitis so check with your Podiatrist.

    NIGHT SPLINT:

 To see item at our online store click link below:

http://www.ourdoctorstore.com/catanese/store/item.asp?ITEM_ID=412&DEPARTMENT_ID=57

PROSTRETCH  PS-100:  Pro-Stretch stretches the foot in the proper position to relieve plantar fasciitis, heel spurs and heel pain, calf muscle pain, and Achilles tendinitis.  This is a very effective and easy to use stretching device.

Just three repetitions of 30 seconds each safely and effectively stretches to relieve lower body pain, easy to work into even the busiest schedule.  You may use this type of device if your are sent for physical therapy.  Many therapist have these in their office.

To see item at our online store click link below:

http://www.ourdoctorstore.com/catanese/store/item.asp?ITEM_ID=199&DEPARTMENT_ID=57

FOOT ROLLER: Designed specifically to massage and stretch the Plantar Fascial ligament.  This device provides superior massaging properties compared to a water bottle and is firm enough to stretch the ligament. 

FOOT ROLLER:
To see item at our online store click link below:http://www.ourdoctorstore.com/catanese/store/item.asp?ITEM_ID=776&DEPARTMENT_ID=57

 

 

Something I always tell my patients is that when there are multiple treatments for any condition it means that there is no one good treatment.  We see this with Fasciitis.  Despite the fact that we are very successful at treating this there is no one treatment that works for everyone. So use all of the measures discussed and you should see results.