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All right. Welcome to Doc Talk Live from the Matthews Art Center here in Spearfish. Thank you to everyone joining us in person and those listening online. Today we're going to talk about something that affects people of all ages, bunions, flat feet, and ankle pain. So whether you're on your feet all day, active in sports, hiking in the Black Hills, or just noticing changes as you age, foot and ankle pain can significantly impact your quality of life. With us today is Dr. Colin Zdenek, a fellowship-trained foot and ankle specialist at Spearfish Clinic on North Tenth Street, who specializes in diagnosing and treating conditions of the foot and ankle, from common issues like bunions to complex injuries and total ankle replacements. Dr. Zdenek, thank you for being here with us live at the Matthews Art Center.
Yeah. Can you hear me okay? All right. Thanks, everybody, for coming out. I'm just going to talk about a few things, a few different topics that I routinely see in my clinic. Since you guys came here, if you guys have anything you'd like to talk about first, if you've had any previous surgeries or know somebody or have specific questions, keep it completely informal. So please feel free to interrupt and ask questions. Is there anything specific that anyone would like to talk about? I can talk forever on any topic that deals with foot and ankle, unfortunately. So do you guys have any things you would like to discuss? Any deformities or anything that you currently have or would like to talk about? Don't be shy.
Arthritis, particularly in a certain spot of the foot or the ankle, or just in general. How do you treat that?
Yeah. You know, when you say surgery, steroid injections. Yeah. So I think probably what I'll do with that one, since that kind of fits into a lot of topics that we'll talk about, I can kind of speak on that because that's a tough one. Treating arthritis is a tough one. There's a lot of other modalities you can do to help treat it. So I'll probably just start off with that. I think the first thing we'll talk about is bunions and kind of talk about the arthritis with that too. So anybody got a bunion? Yeah, I'm getting older and I can see mine kind of turning in a little bit too. So I think the first thing we can talk about is just the etiologies and how bunions happen and who they occur in. In my practice, I've seen bunions in kids and older patients. And so a lot of people ask, do shoes cause bony deformities? But typically what I found is that a lot of people, you can blame it on an aunt or uncle or grandma or grandpa. They didn't like it and you can blame it on them. That's how you got the bunion. A lot of kids can have bunion deformities and adults too. And so the etiology and how bunions develop is that if you look at the big toe, and I do have foot models here, basically what we're looking at is this bone right here will kind of start sticking out. And a lot of people think they grow extra bone on the side of that joint. But really what happens is that metatarsal, this long bone right here, when that happens, that bone will actually kick out and it will rotate as well. So you're not growing bone, it's just that the joint is being exposed. And so the toe will come back in. A lot of the times with that, I actually see a lot of patients with just mild bunions where it's not a large bunion, but it hurts them a lot because as that toe rotates, there's actually a nerve right there that gets pushed upon and causes a lot of nerve pain. And with that too, a lot of people can get swelling with certain activities. So I tell all of my patients with any kind of deformity, even everything that we're going to be talking about with flat feet and ankle pain, a lot of people can get flare-ups with these types of deformities. Most flare-ups will go away. I even have a tailor's bunion, which is basically a bunion on the fifth metatarsal. You can get flare-ups where it's red, hot, swollen. A lot of times it can happen with activity like hiking or playing pickleball, which is pretty common. A lot of those you just need to slow down, ice it, decrease your activity. And I think the hardest part with foot problems, particularly bunions, is that it hurts every step that you take. And it's hard to stay off of it. So people try to cut back their activity. Icing will help, anti-inflammatories. But the hardest part is finding the right shoe. And I think that's a hard thing to tell people, what type of shoe gear to get. Because a lot of times I stopped giving advice on buying a certain brand, because shoes nowadays are two hundred and fifty dollars and I tell a patient to buy a two hundred fifty dollar pair of shoes and it doesn't help. And I get yelled at. So I try to avoid that. But the biggest thing for bunions is finding a comfortable shoe. Whether it's a really supportive shoe or a kind of a flimsier shoe, a lot of people like Hey Dudes or Crocs. As long as your pain is going away, I would keep wearing that. And don't underestimate the icing with it. Topical pain relievers can help a lot of times too. A lot of people will try to wear splints and that can actually help with the pain and the soft tissue. The problem is the splints won't correct the deformity. So once you take that splint off, the goal is to get rid of the pain. A lot of people want to wear the splints to correct it, but typically right when you get the splint off, your bunion deformity is still there. Going on from there, there are more invasive things that you can do. There are steroid injections you can try. The injection takes a few days to kind of kick in and sometimes it doesn't work at all. And then these flare-ups that continue throughout your life, sometimes you have a bad month, pain completely goes away. I tell my patients, if you do get that pain to go away and you have the deformity, you don't have to fix it. You don't have to address it. You just kind of keep living with your life. And then if it ever does reoccur, you can readdress it the same way. So the time to come in is when the pain continues and it doesn't improve. That's when we'll get some X-rays. Sometimes we'll get MRIs. And then there is a time for surgery with it. There are newer techniques that you can do with bunion surgeries. Typically the protocol for that, and I always tell people the time to get surgery, because I try to talk people out of surgery because I don't want it either, is when you stop doing the things you enjoy doing that you should be able to do for someone your age. So if you want to go for a walk with your spouse and walk for a mile a day, you should be able to do that for as long as you live. But if you're out running a hundred miles a day and you have pain, I would say probably cut that in half and see if you get better. Any questions about surgery or any aspect of that, or any other conservative treatment options for bunions, or another question?
So can you touch on why it happens? Like, is there a way to avoid it? Like, do you need to put yoga toes between your toes every night? I mean, is it just a natural aging process?
Yeah. A lot of people will say, are the shoes I wear causing the bunion deformities? But a lot of times the biggest issue with it is hypermobility. So when those joints kind of give out, the bone takes the weight of your body and it splays out. That's how it develops. So a lot of it isn't wearing a certain shoe that causes a bunion, unfortunately. Wearing high heels and stuff like that, that's why it's a little bit more common in women. Shoe gear can actually make it worse, but it doesn't give you the bunion deformity. Typically it's inherited. A lot of it is genetic. And then the other one too is just hypermobility, where those joints really want to kick out.
Okay. Yeah. So like when we talked about the veins with Dr. Czosnyka, he said it was becoming more common because of our lifestyle and being overweight. Does that contribute to these as well?
Yeah, I think some of that too. And especially in older populations, they're so active nowadays. I think pickleball is a big one. People are going out a lot more and being more active with it. The problem is, you know, I'm almost forty-two and I'm getting some foot pain. You can feel it. I think a lot of people have issues with their feet and it's a big deal because it slows you down from your job and doing activities that you want to enjoy. With increasing activity, you've got to be more cognizant of taking care of your feet. Playing pickleball and doing those things definitely adds to it. And people are a little bit more physically active running long distances later in life too. And so all of that kind of plays a role in it.
Have the surgeries changed?
Yep. So there's over a hundred different types of surgeries for bunions. And so it's actually changed quite a bit. We have newer techniques that I've been doing. They're minimally invasive, so they're smaller incisions. A lot of times we can fix it with these small incisions on the side of the bump. So you do shave off the bunion on the side, and we can do small incisions where we can actually put plates and screws inside of the bone so it's not so prominent on the skin. And the benefit of it is that a lot of these surgeries back in the day, we used to keep people off their feet to recover from surgery. Now I get all my patients walking the first day in a boot. Yeah. So there are different types, and that's the problem. There's not, you know, you can talk to a family member or a friend and they said, oh, I had bunion surgery. But the problem with it is there are different types of deformities. Some people have just a bunion and some people have a bunion with arthritis. And so you have to address both of those at the same time. So everyone's a little bit different. But the techniques are changing in terms of fixation, because I'm sure you've heard rumors like, oh, my bunion came back. And unfortunately that does happen. But the newer techniques are kind of helping to prevent that a little bit more.
My brother-in-law had his toe taken off and that solved his bunion. Is that anything? He had a sore on that toe. Oh, like the toe next to it? And the top half removed. And he said it was great.
A lot of times that would be more suited for like my older patients, you know, in their early nineties, where if they do get a wound, again, there are so many different ways to address it. And so if you're ninety years old and you have a wound on your toe, the last thing you want to do is a big reconstructive surgery. So it sounds barbaric, but sometimes that is an option, just amputating, removing it. I try not to do that, obviously. But the biggest thing is you don't want somebody to get an infection and get sick from that. But yeah, in younger populations I try to avoid that. That's more so for people who aren't good surgical candidates.
So in terms of conservative treatment for the bunions, finding the right shoe, make sure that it's wide enough for you. A lot of the shoes now, with tying the shoes and bending over, mesh shoes are really good. You've got to pay attention to the seams. Sometimes the seams of the shoe can push on the bunion and cause pain. So experiment with different types of shoes. Having a mesh on the side actually helps relieve some of the pain. And some of those silicone spacers and braces, they do temporarily relieve the pain. So if you can get just that acute pain to go away, then kind of go on from there. So yeah. Any other questions about bunions?
No.
Okay. Well, we can probably talk about the ankle arthritis a little bit too. That's a big one. With ankle arthritis, there are so many things that can cause arthritis. A big one is trauma. So a lot of ankle fractures can happen. And with ankle fractures, a lot of times we tell our patients there's a risk of post-traumatic arthritis. And so anytime you break your ankle, you can damage some of the cartilage. And it's really tough to regrow that cartilage. And so you get scar tissue there. So ankle fractures are a big cause. There are a lot of reasons for ankle arthritis, but ankle fractures is a big one. The other one I tell people too is ankle instability, which I see quite a bit in my practice, even with young kids and older patients. With ankle instability, a lot of people, if you've sprained your ankle in the past, back in high school, pretty common. So with ankle instability and sprained ankles, physical therapy obviously helps. And most people that have ankle sprains, we don't have to do a whole lot. We kind of monitor them. We can put them in a boot, icing, and the classic RICE, where you rest, ice, and elevate. Most ankle sprains actually do really well. It's the repetitive ankle sprains that cause issues. I have some patients that have really bad arthritis, and if you ask them if they sprained their ankle a lot back in high school, they're like, oh, I'd step on a pebble and sprain my ankle. It's very common. So the problem with instability of the ankle joint, or if your ankle always wants to give out, it's kind of like when your alignment is off on your vehicle, the steering wheel starts shaking. When the alignment is off, that causes the bone in your ankle joint to kind of tilt back and forth. And so that wear and tear is your cartilage. And the problem with the cartilage in your ankle joint, once the cartilage that you're born with is gone, you'll never get that back. So it can develop some scar tissue and arthritis. And there are a lot of preventative things you can do about it. The most important thing is if you do have ankle instability and you're concerned about ongoing pain or down the road, a lot of people kind of wait till the pain comes. You can always come in, have a visit, take some X-rays, because there are a lot of preventative things we can do. Physical therapy by far has been really beneficial for my patients. Exercising and doing ankle stability work can help control the ankle joint to avoid that rolling. I have some patients where they don't have pain, but their ankle just constantly gives out. And so leading up to the ankle arthritis, a lot of the times when patients come to see me, we'll try a lot of bracing. Icing, anti-inflammatories can help. And physical therapy is a must for everybody. On top of that, if people continue to not improve and they're getting worse, a lot of these patients are tough and they can deal with the ankle pain for a while. So it can lead to what's called an ankle replacement. When I was in residency, we did a lot of ankle fusions. If you imagine your ankle joint, you're taking your bones together and putting plates in and actually fusing the joint together. Trying to walk like that is rather difficult. But at that time, that was what we typically did. We used to fuse ankles quite often. But coming up with ankle replacements, the technology is really advanced lately. It's a tough joint to fix because it's kind of like a knee replacement, but the joint in the ankle is a lot smaller and there's more added weight with the leg. So we want to try to avoid ankle replacements in patients. And we always have a saying that the older you are, the better you'll do, because ankle replacements can fail, just like knee replacements and hip replacements. I just wanted to kind of talk about one thing that I did my fellowship in, which was joint replacements. We'll actually have patients come in, and what we do for these ankle replacements is we do CT scans for these patients from the knee all the way down to the foot. With that, the CT scan will actually show the axis of where your knee and your ankle are, and we know where the best spot for that ankle is to be. This technology is really advanced. We order a specialized CT scan, and there are actually physicians and engineers that will design a specific ankle implant for the patient themselves. I kind of have these little implants, kind of neat to show patients, because I like to have something you can see. These are kind of like Styrofoam sterilized implants. So this is actually one of my patients that I did. So the ankle joint, this is like the front of the leg on the tibia, right down here. And so what these scans do, it's actually really neat because you can have a deformity of the ankle. Some people's ankle joint is tilting, and this is why it's important to come in and get X-rays if you've had chronic ankle sprains or chronic pain. Because if that ankle joint starts tilting, it kind of keeps going. It's like a teeter-totter effect. Once it kind of tilts, it keeps going, and it makes you a different candidate where you may have to do a fusion because the ankle joint tilts too much. So with these devices, when we get the CT scan, they actually have this in the operating room. These come sterilized. So this is actually a patient's tibia, the front of the ankle joint. And what they do, I'll hand these around so you guys can kind of get an idea of it. So this is basically the cut guide for doing the joint replacement. This guide right here is actually really reproducible when you put it on the ankle joint. I'll have it in the operating room, I'll take this out, it's sterilized, and I put it right in front of this tibia. I can actually outline where this should fit. And if you actually take this and I'll hand this around, you can move it around and it almost clicks into place. And so then what you can do is I take this guide, make my marks on the bone here. Then I go to the patient right in front of the ankle. The ankle is all open. I put this device and it has the same press fit on the patient's bone in the operating room. So this actually implant goes on the bone. And you'll see these four holes in this device. So you put wires down here, and then once that's secure, we take X-rays. And basically with that CT scan that we had done before, we can make sure all the lines and everything is perfectly matched. So it takes the guessing game out of a joint replacement. It's very reproducible. It's actually made my job a lot easier. When I first started, we had to free-hand cut these and it's kind of nerve-racking because if you make a wrong cut, you've got to shave some more off and you keep chasing it. So this actually takes the guessing game out of it. And so I'll hand this around. When that guide goes on there, we can put basically now a metal guide that goes on top of it, that fits in those wires sticking out of the tibia. And then we can make our cut in the bone that's perfectly matched. And the neat thing about it is I've seen some really deformed ankles where the ankles are really tilted or there's a lot of arthritis. And so this can actually correct if you have an ankle joint that's tilting in one direction or the other. We can actually use this cut guide to fix that deformity by taking a wedge off the opposite side. It just completely takes the guessing game out of the whole thing. And here's another piece. So this would be the bottom half of the ankle joint, the talus, sitting right here. This one's a little bit more difficult to put on. When you put this on you can kind of feel it, it's a nice press fit. Again we do the same thing with this. We put the wires in here and then we can make a perfect cut on the talus based off the patient's deformity or the level of the arthritis that needs to be removed. So once we have all the bone out, we can put the implant in the ankle joint. And I think if you put yourself in this perspective or any family members with it, an ankle fusion is a very difficult thing to get through. I'm actually very surprised by some of my patients that can be non-weight-bearing for six to eight weeks. It's pretty difficult. A lot of these ankle fusions, you're not walking on the ankle for about two months. It's really difficult. Imagine just being laid up for two months. It kind of takes a toll on the body. And so with these ankle implants now, this has been probably one of my most satisfying things that I do in the operating room, because people almost instantly feel like their pain is completely gone the next day. It's one thing that always happens. I get complications with other surgeries and people have some pain post-operatively. But these ankle implants are really nice. And the good thing about that implant, once it's in, we can actually put what are called poly spacers in the ankle joint to make sure it feels nice and tight. If it feels a little bit loose, we can go up in size and make sure it fits the patient. So the benefit of this one is I do keep patients off their foot for a little while just to allow the sutures to heal up. So it's the incision right in front of the ankle joint, and we sew it up and give them about two to three weeks of staying off it. And then we can get them walking. So basically going from ten to twelve weeks of not walking to getting people to walk in about three weeks. Any questions about total ankles? I know it's kind of a lot thrown at you, but the technology has changed quite a bit.
Can we go way back to what causes arthritis?
Yeah. So I think a big one would be ankle sprains, probably the most common that causes arthritis. A lot of the issues too with foot deformity. Some people have really flat feet or they have a high-arched foot. The flat foot is the next topic that we could talk about as well. But every person has a different kind of foot deformity. It's pretty rare to see what a normal foot looks like. And so when you get X-rays, the neat thing is we can actually measure certain angles and degrees of what normal should look like. And then with certain deformities like a high-arched foot or a really flat foot, you can kind of predict where patients are going to have pain. I can walk into a clinic room and see a patient with a flat foot who has a hard time explaining where their pain is. And I can take my thumb and push right where I think they're going to hurt. And it's usually pretty reproducible. With arthritis, if you do have a deformity where it's flattening, it just puts abnormal pressure on different joints. And so that abnormal pressure kind of shears those joints and slowly wears and tears some of that cartilage. But a lot of times too with arthritis, I've seen bone-on-bone arthritis in patients who have no pain. So that's why I always tell patients, I don't treat X-rays. You can have bone-on-bone arthritis and you can see the arthritis on the patient's big toe joint, and you can ask them if they have any pain. If they don't, it's just one of those things where if it doesn't hurt, you don't have to address it. You don't have to fix it, you don't have to do surgery with it. Just kind of monitor the pain. If you do get a flare-up, that's why I always tell patients, just kind of slow down your steps in the day. It's hard to be non-weight-bearing. If you can cut half your steps down in a day, that's kind of what you should do for that. Ice it, rest it. But the hard thing with arthritis is it's hard to reverse it. There's not a whole lot to do with that. But if you can capture things early and say, hey, you've got a flat foot deformity, we can try some custom orthotics and kind of re-support the arch and help prevent or slow down the rate of arthritis.
How do you know if you just have an injury or pain, or if you have arthritis that needs to be treated?
Um, I think a lot of the times, if you have a deformity it's pretty straightforward to figure out if you had an injury, like you went for a long hike or anything like that. But I think a lot of times people don't know what's going on with their pain. I had a patient today who went on a long hike and their ankle was swollen on the inside. And so they thought it was from the hike, but the patient had a flat foot deformity. And so the deformity is kind of like why some people get a knee replacement at sixty-five on one side and then at seventy-five it hurts on the other side. If you catch these deformities, you can't really reverse them without surgery, but you can support it with inserts or bracing or casting, just to kind of help support the part of the foot where it's actually deforming and collapsing. With the arthritis, most of the time with end-stage, bone-on-bone arthritis, it's pretty easy to see on the X-ray. But there are other things that you can catch where it's not just the bone-on-bone arthritis causing pain. You can actually get cracks in the cartilage where some of the lubrication in the joint gets into the bone and can cause a lot of pain. If you do have pain, it's better to come in and be assessed rather than waiting for it to get worse because a lot of things are easily treatable.
What are the various nerve disturbances? I'm assuming that some of the issues with our feet are nerve changes, pinches, growths that cause foot pain.
Oh, so if this were my foot and I pushed there behind that toe, yeah, there's pain there. Not always goes away. Between your third and fourth toes.
Yeah, yeah. Which toe is that?
Yeah, that's a very common one. So that's called a Morton's neuroma. It's interesting about that one. It's the only spot on the bottom of the foot where there are two nerves that actually join together. It's the only spot in the foot where that happens. And those two nerves join together, and it's kind of like a bottleneck going on the interstate, everyone merging getting off the exit. So all the traffic is coming in and it joins together. That nerve inherently is a little bit bigger on everybody. And so that nerve is supposed to be there. But again, certain activities, shoe gear, trauma, you can step on a rock and irritate that nerve. And then with all the anatomy in the front of the foot, that nerve gets irritated and rubbed on between the bones. So that's just one of them. Those kinds of issues, are they fixable by surgery? Just paying attention to your shoe gear? Are there exercises? I think most of the stuff that I take care of, besides trauma, there are a lot of things you can do conservatively. I think the hardest part for me is that treating certain patients, I can do one thing for one patient and say, hey, you should try this shoe, and they come back like everything is great. And I can say the same thing to the next patient and it didn't help at all. So I think the majority of things that I do for my practice is I try to find as many things as I can that will help the patient, but it only works about sixty percent of the time. Again, it doesn't matter which one it is, as long as we get you feeling better, that's the key. A lot of things you can do, shoe gear is very important. I usually don't tell brand names because there are so many different new brands I can't even keep up with them. But what you can do is take a shoe, and if you can bend it in the middle of the shoe, it's probably not the most supportive shoe. You want the one that's a little bit more rigid right in the middle. So if you can take Hey Dudes and actually fold them in half, put them in your pocket, probably not the best shoe. But then the problem is I have people where Hey Dudes are the only thing that helps them. And that's why I say majority of the time I offer that for patients. Again, with conservative treatment, I go through quite a bit of things with patients. And again, it's not so much like icing always works or anti-inflammatories always work. Some patients with steroid injections, I mean, I look like a hero sometimes, I give an injection, they come back with zero pain. And then the next patient, a steroid injection didn't help at all. I usually offer as many conservative treatment options as possible. You talk to other friends or family members that may have had something done, or like a neuroma that we were talking about with that nerve. Some people had a steroid injection, didn't work for me at all. Or I tried this insert, didn't work for me at all. But the thing is, there are so many other patients where it does work for them. So I usually offer as many things that I have found in my practice that help those patients and hopefully a number of those help out.
Any other questions on that? I appreciate the question. Another one too is in terms of flat feet, I do see a lot of pediatric flat feet. I think that's an important one for parents. My nephew actually had flat feet and had surgery too. It's one of those things that's near and dear to my heart. During my residency program when I was in Pittsburgh, we did a lot of flat foot surgery in pediatrics and older patients. And so I think a good topic to talk about is pediatric flat feet. It's pretty normal to see. We've got a three-year-old and he's got some flat feet right now. It's pretty normal. So between the ages of zero and seven, the feet will actually rotate, go from a flat foot to a neutral foot to kind of tipping over on the outside, and the foot will rotate because as the bones grow in a kid, the bones will actually rotate. So it changes the foot and the foot has to catch up with it. Especially if there are grandkids that have flat feet, a lot of times a three-year-old is not going to come up to you and say, my feet hurt because they're flat. I always educate, usually when I first see the patient. But I think the most important thing with the appointments I have with parents and young kids is education. A lot of kids that have flat feet don't know how to tell their parents that they hurt. And so a lot of times it's monitoring the kids. Are they not participating in sports? Do they prefer to play video games and not go for a run, or hate gym class because of it? Because they associate all activities with pain. Imagine being born with that flat foot and it always causes pain with physical activity. So they may like basketball, but they don't do it because it's associated with pain. I always educate the parents on that, to keep an eye on the kids. A lot of times most parents will say, every time we go for a hike or a long walk, they're always last, always way behind us. And so I kind of tell them I'm defending the kids too. It's not that they're lazy or want to be the last one in line. It's just because it's extremely painful for them. In my practice, custom orthotics are a big part of treatment for this. I recommend all pediatric patients with flat feet just come in and have it evaluated. Most of the time they have no pain, it's asymptomatic. But with flat feet, I always recommend that after the age of seven, if it becomes painful, that's when you start considering orthotics for the kid, because you don't want to interrupt the way the foot and the leg are growing. We just want to let it do its own course. But when kids become symptomatic, it's quite painful. I've seen a few kids come in crying, just walking to school, walking to classes. So on the first visit with the patient and the parents, if they're older than the age of seven, we get X-rays and we see how bad and how severe the flat foot deformity is. And the first thing we always do is custom orthotics or over-the-counter inserts, because custom orthotics can get expensive, up to four hundred dollars, and they're very expensive. And unfortunately, insurance companies are getting good at not paying for things, so it's out of pocket a lot of times. But again, it's the same concept with basically any deformity, any bunion or hammer toe or flat foot that people can have. You'll get these flare-ups where it's very painful. It doesn't mean you have to go and fix it. You can just go through the whole process again, decrease activity, physical therapy, icing, anti-inflammatories, the typical conservative treatment. And then kind of slowly get people going. It's just the chronic patients where no matter what they do, it's chronically painful. So there are two different types of ways, if people have tried and failed all conservative treatment with flat feet. With pediatrics, there's a joint-sparing and a joint-destructive type of surgery that we do. For pediatrics, the goal is to save the joints as long as possible because we want kids to have full functionality with their foot. There are a few options that we can do for it. And even with surgery, there's not like a flat foot surgery that we do. Every foot is completely different. You have to analyze the foot. Some people have a deformity in the back or the front or the midfoot. So it really changes the whole process. Every patient is unique and their foot is unique. There are twenty-six bones in the foot. Every bone has at least one joint, some have up to four. So it's a very complex foot. Everyone has different deformities and different spots. Kind of talking about the arthritis as well, with the flat feet, again, if they're asymptomatic, we don't typically treat them. But when people get into adulthood, if you have flat feet, I highly recommend custom orthotics. The custom orthotics won't correct your flat feet, but they'll definitely maintain its position and slow the progression down. So with bunions, with flat feet, typically it progresses and worsens more and more with time.
I have a question. My grandson is five and he has a friend who walks around on his tiptoes. What is the cause of that?
Yeah. So that's a good one. I think some kids just like walking on their tiptoes. The first thing I do is ask the kid to stand on their tiptoes and then get their heels down. If they can get their heels down, I'm not too worried about it. A lot of kids do grow out of that and they stop doing it. But some kids will do that because it's the least painful position to be in. So when I do flat foot consults with parents, the number one thing I always see with flat feet is they have a tight Achilles tendon. Their calf muscle is really tight. And so when kids walk on their tiptoes, if they can keep that calf from being stretched out, it provides a lot of pain relief for them. So it's actually a comfort thing because it avoids the pain. That can be a surgical issue. We try to avoid doing surgery in kids that young. The youngest I've ever done was nine, because of flat foot deformity and tight calf muscles. It's pretty common that kids with flat feet always have tight calf muscles, in my opinion. A lot of times you'll see those kids compensate one of two ways. One is to walk on their tiptoes and the other is to kick their feet way out. So they're kind of walking like this. That kind of gets rid of the tight calf muscle. If they don't compensate that way, the tight calf muscle, when they start standing, causes the arch of the foot to collapse and the foot wants to splay out. And so that's where the flat foot deformity comes from. Physical therapy for that works really well. We've even done Botox with that to help stretch out the calf muscle, just to relax the muscles. But some of those kids, when they're that severe, if it is painful when they're walking on their tiptoes, it can be a surgical problem. You can actually lengthen out the calf muscle pretty easily. And then you can cast them for a little bit just to maintain that correction where you stretched out that calf muscle.
As far as pronation, yeah, is there something other than orthotics that you can do to help prevent that?
That's a tough one. She said, with pronation, is there anything else you can do besides orthotics? Pronation, as a flat foot, is a very tough one. In my opinion, there's not a whole lot you can do to prevent it. Once the body has a flat foot deformity, you usually always have it. And so the goal is to treat the symptoms. Again, if you have a flat foot and you have zero pain, I don't really recommend doing a whole lot with it besides the custom orthotics just to help maintain it. And again, it's the same, this is the only thing I see all the time. If you have a really bad deformity or a really bad flat foot, and it's very painful the first few days, you kind of repeat the process. All right, let's get this acute pain to go away to see if when you're walking in the future, you're fine. Because I ask a lot of people, did you have pain six months ago? And a lot of times they say no, it's only been like four weeks. Well, you had a flat foot six months ago and you were pain-free. So if you can get rid of that pain, keep on going. But the orthotics definitely are probably the best thing you can do for it. Physical therapy, I don't really do a whole lot of physical therapy with flat foot because it's never going to really re-correct the arch. It's kind of like once you have it, you have it.
Any other questions?
What causes nodules, or feeling like there are little stones in your foot? Like in the arch.
Yeah. So there are a lot of soft tissue masses that we come across. Most commonly right in the bottom of the foot. The plantar fascia, we've all heard of plantar fasciitis. Plantar fasciitis is a very common thing that we see. So the plantar fascia goes from the heel all the way to the front of the foot. And it really supports the bottom of the foot. The problem is you can get some scar tissue down there that can cause some of those little nodules. A lot of times they're called fibromas. They're actually extremely painful. And basically, when you get tearing of the tissue down there, you can get a lot of scar tissue. And again, a lot of my patients that I see actually don't have a lot of pain with it. They just want to know what the lump on the bottom of their foot is. And so nine times out of ten it's a plantar fibroma. But any soft tissue mass in the foot, bottom or top, I usually always get an MRI for that, just because it's a soft tissue mass. I'd be concerned, patients are concerned about masses because, you know, there's always the cancer thing. But cancer is pretty rare in the foot. I still always get the MRI though because I think it gives patients a sense of relief. If it doesn't hurt, we don't have to do anything about it. With any kind of soft tissue masses in the foot, if it doesn't hurt, I tell people keep doing what you want to do. The moment you start feeling pain, find the right shoes or orthotics to offload the area. And then if it still hurts, there are other modalities you can do. Steroid injections can decrease the mass depending on what it is. A lot of the time you can just remove them too.
Keep these questions coming. This is great. Okay, so bottom line, most people aren't going to go to the podiatrist. What are the best ways to keep our feet healthy so we don't have to come see you? Tell me what kind of foot care I need to do. Yoga? Massage? Pedicure?
Whatever. Yeah. Bottom line, I mean, I see the extremes of everything. Some people just want to be pain-free, but then there are people that want to be very proactive with their feet. When I was in Pittsburgh a while ago, barefoot running was a big thing. Do you guys remember that? The problem with barefoot running in the middle of downtown Pittsburgh is probably not the safest thing for your feet. So there were a lot of foreign bodies removed that year. But I do believe in that, particularly with kids too. A lot of parents have questions about whether they should keep their kids in shoes. My thing is, keep them out of shoes as long as you can. Let them run around, gain foot strength. I think the reason why a lot of people have foot pain is the moment you go into shoes, your feet inherently weaken because now you're not relying on supporting the arch of your foot, you're relying on the shoe to support it. And so again, if you took an X-ray with your tennis shoes on, high heels push it in. On the X-ray, when you take the shoe off, the toe will straighten out. But a lot of shoes can actually promote a lot of that. So a lot of people do the barefoot stuff or the minimalistic shoes. My advice on that is to be very careful with it, because we've been walking in shoes our entire lives mainly, and then people just one hundred percent go all into barefoot walking or barefoot minimalistic shoes. You want to do it nice and slow, because stress fractures are the most common thing with that. Doing something too much too soon causes a lot of pain. I think it's pretty rare to see people doing workouts with their feet. But you definitely can. There are exercises you can do, stability exercises. I work out at home with my feet. Yeah. My wife sees me doing that all the time. But yeah, I think just wearing the right shoes is the most important thing. And if you do have a concern about anything, I would say most people have something wrong with their foot. I can take an X-ray and I can always find something wrong. Again, if it doesn't hurt, don't do anything about it. But it's good to have an idea of what could progress and things you can do to help offload it and prevent the pain. Strengthening is a big one. Yeah, absolutely. I think the biggest thing is stability. That's where a lot of people have problems, rolling their ankles. We live up in the mountains here, so going on trail hikes and stuff like that. There are a lot of things you can do to support the ankle and the stability. It's just pretty rare to find people wanting to do that, though.
Okay. So there is this, I've heard of a doctor of some sort saying we should be jumping like twenty times a day. So not only should we be taking protein and creatine and lifting heavy, but we should also jump up and down twenty times a day because it promotes bone health. Are these the exercises you're talking about for your ankles? Is that helpful? Is this real?
I think jumping is a good thing. I do trampoline stuff. No, again, I think having force, especially as we age, and particularly in females, doing resistance training, I think jumping is a good thing. But you just don't want to jump into it too much too soon. That's where most of the problems I see with patients come from. They do something way too fast and then they have the problem. People come in January with a New Year's resolution and flood in February with new pain because they did something too much too soon. I like the jumping stuff. I think the impact forces bone to grow because now it's bearing more weight than it typically does, so you can strengthen your foot that way. I would just maybe start with a couple bunny hops and work your way up. Yeah, again, I think there's a lot of benefit to that with lymphatic pumping and keeping those joints moving and putting them in stress like that is a good thing. So it's real. Yes, I have seen it.
Nice. I don't promote it in my clinic. I was like hopping around the house thinking, this better be real, right?
Yeah. Yeah. My doctor told me. Just do some bunny hops for a while.
Any questions about anything else? Anything random?
I spent a lot of time looking backwards.
That's great.
I've been doing that for probably fifty some years. Jogging backwards. Yeah, all the time. Not all the time though, because I'll pivot around. But I just keep going backwards. I just can't see what's behind me.
Yeah, I'll just do a little hub. Yeah. I actually completely agree with that. I'm not an orthopedic surgeon, so I don't do knees, but I did have some knee issues. I think a lot of times, you know, we were taught in school when you do squats to not let your knees go past your toes. And again, this is not my area of expertise, but a lot of the stuff that I've been doing now, I've actually been letting my knee go past my toes to strengthen it. And one I have done is walking, don't make fun of me, walking backwards on a treadmill when it's turned off. It actually will strengthen the quads and stabilize the knee. I agree with it.
Yeah. Yep. Yeah. Absolutely. Yeah. Just add some hops into there now.
I have a question. When you go to the rheumatologist and your choices are, oh, we're going to fuse it, or cortisone shots. And if you don't tolerate those, oh, we'll just fuse it. But aren't you going to lose a bunch of mobility? What is the purpose of that? What does it really fix? Or is it just one more surgery?
Yeah. I think rheumatology patients are tough. The autoimmune disease really affects the joint. Basically with that, it attacks the sides of the joint that destabilizes it. So it causes a lot of hammer toes, causes bunion deformities. But whenever you lose that stability with rheumatoid arthritis, it really affects the smaller joints. It really destabilizes them. And the destabilization is what causes arthritis. Kind of like the analogy I was using, when your alignment is off and your steering wheel is shaking, those tires are going to wear a lot faster as opposed to having your alignment perfect, steering wheel not shaking, tires rotating well. So it's the instability of that autoimmune disease that really affects those joints. And again, especially in the foot, there's not a whole lot to do with that. The biggest thing is just to help prevent the pain. Orthotics are a great idea for that too. All my rheumatoid patients, I always recommend custom orthotics, even if they don't hurt, because with that they kind of get fat pad atrophy on the bottom of their foot, their joints are a little bit more unstable. And when they get hammer toes, it really causes the bones to be pushed down on the bottom. A lot of my rheumatoid patients, I mean, it's skin and bone on the bottom and it's extremely painful. A fusion is one of those things that gets rid of the arthritis and gets rid of the pain. Unfortunately you do lose motion with that. But the problem with rheumatoid arthritis, if that joint is so bad, it's the movement that hurts. So that's kind of why there's no arthritis right here because there's no joint. If you fuse those two bones together, then there's no joint. That's what relieves some of the pain.
Okay. Awesome. Well, thank you all for coming out and listening. If you guys have any other questions, feel free to talk to me after, or feel free to stop by. But I think the biggest thing I can tell you is don't wait on things. There are a lot of things we can do preventatively. We have a lot of conservative treatment options available. And the biggest thing too is just because one thing didn't work for your friend for the same diagnosis you may have, it might actually work for you. So getting some advice, coming in and seeing where you're at, I think it's a good thing to be proactive, because step-wise, sometimes the longer you wait the worse it can get and the harder it is to address it. So don't be shy to see us.
Well, thank you all for all of your thoughtful questions tonight. Thanks.