Sometimes doctors speak a different language.  I am flying home after taking part in a lecture series at the podiatry school in Oakland, CA.  There were 4 speakers from prestigious teaching hospitals lecturing to an audience of 2nd year medical students.  I enjoy listening to my friends lecture, but as I looked at the audience it was a sea of blank expressions.  It was like the lecture was in a foreign language and the interpreter had taken a break.  I suddenly realized that the lectures and slides were complicated surgeries and doctor talk. These students have been in a classroom for 2 years working in the science of medicine.  No one in that audience had seen a patient yet, so the lecture was in a foreign language.

When I talk to you about the causes of your foot pain I have to remember that we speak different languages.  For example, your big toe in podiatry talk is your hallux (hal-ux).  I’ve been calling the big toe a hallux since the beginning of medical school.  I have to speak your language, but sometimes I can slip so let’s go over some common causes of foot pain in both for comparison.

First of all the foot is divided into three areas.  The front part containing your toes and the ball of your foot is called the forefoot.  Your arch is in the middle of your foot and is called the midfoot.  The back part of your foot has the heel, but of course that’s too easy for doctor talk so we refer to the back of the foot as the rearfoot.  Each area has a unique set of problems that can cause foot pain.  Since this is like learning a foreign language I will cover the front of the foot in this article and then the middle and heel next time.

It doesn’t matter if your 2nd toe is longer or shorter than your big toe.  Any toe that is buckled or bent is called a hammertoe.  When a toe is crooked like it can press harder on your shoe causing hard skin to form.  An area of hard skin that develops on a toe from pressure is called a corn or heloma durum.  Your toe can curl so much that it almost sits on the top of your foot.  This causes increased pressure on the bone in the ball of your foot and hard skin can form at this point.  Hard skin forming on the ball of the foot is called a callus or IPK, which stands for intractable plantar keratoma.  Not all hard skin is a corn or callus.  Warts are areas of hard skin with tiny black spots in the center.  This is a virus infection of the skin called verruca.

What about lumps and bumps on the toes and ball of the foot?  A bump at the base of your big toe, remember that’s called the hallux, is a bunion.  In podiatry talk we say the big toe has drifted toward the 2nd toe or hallux valgus.  On the opposite side of your foot at the base of the little toe you can get a bump.  At some point in time this was common in jobs where people sat with their legs criss-crossed or Indian style.  Tailors used to sew sitting in this position so they call this a tailor’s bunion or little bunion, bunionette.  In the center could be due to a broken bone.  Stress fractures are a common cause of swelling, bruising, and pain in the forefoot.

Another cause of pain in the forefoot is a pinched nerve called a neuroma.  You might have a neuroma if the pain is in the ball of your foot and shoots out your toes.  Unfortunately not all foot pain in the ball of your foot is a pinched nerve.  There are tendons and joint capsules in the same area that can become irritated.  When tendon or joint capsule becomes inflamed this is called tendonitis or capsulitis.

That’s a lot of new words so I’ll let you study this for a while then come back with the common terms used in the middle and back of the foot, the midfoot and rearfoot.

Paul trained for his first marathon.  He was smart about it going first to his doctor for a physical then having his feet and shoes checked in my office.  His training program included strength training, flexibility, and running.  Paul said the race was hard on his body, but he was happy to have finished.  About 3 weeks later I saw Paul again.  This time he was a wreck.  He was in pain from his low back to his toes.  Paul hadn’t been sleeping well and was just not as happy as he expected to be after completing his first marathon.

I asked about his recovery from the race.  I heard about the celebration that night soaking in a hot tub with friends drinking and eating whatever was there.  His wife had scheduled him for a massage the day after the race.  Paul said it hurt more than it felt good and had no lasting effect.  Stretching was impossible because of the pain and stiffness.  The tight muscles made it nearly impossible to run the few times he had tried.  When I asked if he was following any schedule or program he reminded me of his pre-race training program, but had nothing to follow for recovery.  Do you know what Paul did wrong?

What you do immediately after the race is as important as what you did to get there.  You know that running 26 miles is serious business, that’s why you were so careful in your training program.  After the race you will be exhausted mentally and physically.  Your recovery plan has to be set before you race so you won’t have to think about it.  Your muscles have worked hard for 26 miles and all nutrients in your body have been used.  When your body works hard for a long time you get inflammation.  Treat your body right and this will go away quickly so you’ll be running again in no time.  Ignore the inflammation and you’ll suffer.  I’m sure you’ve heard stories about people who ran a marathon and were never able to run again.  If you ask them about their post-race recovery I bet you’ll get a blank stare.

As soon as you finish the race:

You’re exhausted and legs feel weak, but this is the time you need to keep walking.  Don’t stop and get a chair massage, don’t chat at the booths.  Get your packet, medal, snack pack, and drink water as you walk around.  Make a mental note of what hurts.  I don’t mean big areas like your entire leg.  I mean specific areas like your calf muscle, front of your thigh, back of the thigh, front of your leg, arch, heel, toe.  Pay attention to any pains so that you can address these after a thorough cool down.

Your kidneys have been fighting to balance your hydration and electrolytes.  All the waist products coming from all that muscle action of running 26 miles is filtered by your kidneys.  They have worked overtime and need to recover.  Anti-inflammatory medications stress your kidney more.  This is not the time to take anti-inflammatory medications like Ibuprofen or Naproxen.  Refuel by drinking water, electrolyte drinks are OK, but water has to continue even if you’re drinking electrolytes.  Eat like you did while you were training.  Protein helps repair muscles and carbohydrates help with fuel. 

I don’t know how to describe it, but there’s an excited feeling in your legs, some people tell me a throbbing, others say it’s like their legs are just revved up.  Don’t stretch until that feeling in your legs goes away.  You can ice the sore spots and gently stretch.  When you get home take a cool bath.  Use a foam roller or gently massage sore muscles.  If possible schedule a massage in the evening, at least 4 hours after the race.

Things to avoid:

1. Sitting for more than 10-20 minutes
2. Soaking in warm water or hot tub
3. Sauna
4. Anti-inflammatory medications

The first week:

Inflammation can last 24-72 hours.  You will have to pay close attention to your body. If you treat the inflammation right you’ll be running again after a few days.  Ignore the inflammation and it can become a repeating cycle that is difficult to break even with my treatment.  Have more massages, practice yoga, swim or bike.  Don’t be aggressive, your goal is to stay loose.

If you have no aches and pains by day 3 you can begin gentle-paced, low mileage runs.  Do not exceed the mileage you did the week before the marathon.  Begin every three days with light resistance training on off days.  Any aches and pains need to be addressed.  Don’t wait to see me for any pains that remain.  The sooner these are addressed the easier they are to treat.

The 2nd week and forward:

If you’ve made it this far without needing me you’re doing well.  Gradually increase run frequency and distance back to your training levels as tolerated.  You might find that you are more easily fatigued, but that is normal for the first month.  Anything more than that and you should seek medical attention.  Don’t forget to have your running shoes checked.  During this return to training period you will need to have new shoes.  At Desert Foot Surgeons we offer video gait analysis to see what the naked eye cannot.  Come have your gait analyzed in or out of shoes.

Congratulations, you did it!!

Eli Manning Gets Good Advice For Heel Pain

On October 5th Eli Manning, the quarterback for the New york Giants, was diagnosed with plantar fasciitis after limping off the field in the 4th quarter the day before.  In the NFL pregame show October 18th the treatment for Eli’s condition was discussed.  On the advice of an old football coach he is wearing cowboy boots during the day, using plantar fascia night splints, and wearing custom foot orthotics in his cleats.

Think about this, Eli Manning, a world champion quarterback, franchise quarterback for the New York Giants, brother of Peyton Manning and son of Archie Manning, has possibly the best medical care available second only to the president of the United States, but he is taking the advice of a former coach. Why? One simple reason, the advice is good!

Plantar fasciitis is an overuse injury resulting in heel and arch pain. Wearing cowboy boots takes the strain off of the plantar fascia. Dr. Geller always says, “You can’t begin to heal until the inflammation has gone away”. Taking the stress off the Achilles tendon by wearing cowboy boots plus the physical therapy the Giants training staff is providing for Eli is doing just that.

At Desert Foot Surgeons we often use splints at night. The plantar fascia night splint keeps the Achilles tendon and plantar fascia stretched while you sleep. If you get the severe sharp pains when you get out of bed in the morning this is what night splints are used for. If you can get rid of that morning “zinger” your day will be better.

The overuse part of Eli’s injury and anyone’s plantar fasciitis involves pronation or lowering of the arch. To review pronation is the normal shock absorbing motion of the foot. The foot rolls to the inside, the arch lowers and the heel turns out. This is good, we want to be able to absorb shock when we walk and run. Of course too much of a good thing is bad. When your arch is still lowering at a time when it should be stable is bad and leads to injury. Custom molded foot orthotics prevent abnormal flattening of the arch and heal the plantar fasciitis. Dr. Geller uses video gait analysis and a detailed examination to make the perfect custom molded foot orthotic that will keep your foot stable when walking.

Below are stretching and icing instructions Desert Foot Surgeons has available for patients with plantar fasciitis. Hopefully Eli won’t find this website before the Giants play the Cardinals.

When I was in college I ran 12 miles a day. This was Boulder, Colorado so summer days always had about an hour of rain at 4pm and then everything would cool off. I enjoy running in the rain so scheduled my runs during this little drizzle. After a month of wonderful, calming runs I developed itching between my toes and a red rash with cracking skin in the crease under my little toes. The burning from the cracked skin was intense at times and the itching nearly drove me insane. Have you ever seen this before?

Athlete’s foot is an infection of the skin caused by fungus. Besides redness, itching, burning, and cracking skin, as I experienced, there can be blisters and oozing. If left untreated the infection worsens. The toenails can become infected causing thick and discolored toenails, but that’s a topic for another day. The fungus can decrease your skin’s defenses leading to infection with bacteria noticed by swelling, redness, and more severe pain.

Treatment of fungus begins by removing the source of the infection. Fungus grows in dark, moist places. Can you figure out what I was doing wrong? In my case I was wearing wet shoes everyday to run. Shoes take 24 hours to dry so alternate your shoes everyday. That means don’t wear the same pair of shoes two days in a row. Always wear clean and dry socks, wash your feet thoroughly and make sure you dry between your toes.

Other treatments for fungus are readily available at your store. Medications are usually creams, powders, sprays, gels, or solutions. The antifungal medicine needs to be applied twice each day for about one week. Beware of using creams. If the infection is mostly between your toes creams might keep the area too moist and fail to kill the fungus. Try powders, sprays, or solution between the toes. If you don’t improve after a week you need to see a physician.

Do you have young boys with stinky feet? Look more closely at their feet. Many times a parent brings in a young teen with redness, blisters, scaling and cracking skin, and the overall complaint of “stinky feet”. Dr. Geller has treated many children with pills to kill the fungus infection besides using creams or powders, clean dry socks, and changing shoes. Some people think treating fungus with oral medicine causes liver damage. They are referring to older medicines not used today. The newer pills to treat fungus are safe if prescribed by an experienced physician. Dr. Geller used pills to treat a fungus infection in his son.

Do not delay treatment of athlete’s foot. Bacterial infections are much more painful and challenging to treat. The earlier you are seen the easier the treatment.

Dr. Stephen Geller, AZ Podiatrist

Of adults over 40 years of age in the United States, about 4.5% have peripheral arterial disease (PAD). This is a lack of circulation to your legs and feet.  Healing an ulceration where there is a lack of circulation is very challenging for you and your doctor.  The most important part of healing these open sores is bringing blood into the foot.  Dr. Geller works with vascular surgeons, interventional cardiologists and radiologists who can help with this part of your care.  The actual care of the open wound is determined by Dr. Geller.  This will involve something to keep pressure off the sore and medication applied to the wound.  At Desert Foot Surgeons you will find a physician with the expertise and experience needed to develop a program that best suits your needs.

Those of you who have healed an arterial ulceration have suffered a great deal of pain and possibly even undergone surgical correction of the poor artery circulation.  If this is not enough reason to quit smoking I don’t know what is. Part of your recovery will be walking for exercise to increase circulation even if you had surgery. Since most arterial ulcerations are on the feet you will need protection of the scar by shoes and possibly inserts. Your heels may need to be protected while lying in bed. Moisturizing dry skin using specific foot creams is also recommended to help prevent new or recurrent ulcerations.

Dr. Stephen Geller, AZ Podiatrist