 Hello and welcome to this edition of Quality of Life. Today we're going to talk about podiatry. And helping us do that is Dr. Susan Evans from Prevea Foot & Ankle Center. Dr. Evans, welcome to the show. Thank you for having me. It's a pleasure to be here. Wonderful. Just to start off with, what is the medical discipline of podiatry? Podiatry is basically everything that involves the foot and ankle. Whether it be something with your bones or your skin or tendons and muscles, the foot is a very complex part of our body. It has 28 bones, over three dozen tendons and over 120 ligaments. A quarter of the bones in your body are found in your feet. So with such a complicated structure, it's easy to see how a lot of things could go wrong with it. Sure. For our viewers at home, could you give us some background on your education and your study and how much you've been involved with podiatry? Well, I've been a podiatrist here with Prevea for about two years now. Prior to that, my training was a total of 11 years. We first have to graduate from undergrad and then have four years of medical school and then a three-year residency. Okay, so you're quite specialized in the area. Yeah. Well, one thing I've been reading on the Internet is, you know, there's treating the foot like you're doing or being consulted and then there's a surgery part of it. Are you involved with both? Yes, I am. That's one thing that drew me to podiatry was I wanted to have something that had a good balance between the clinic as well as surgery. And I wanted something where I could see patients, you know, and develop relationships with them and see them down the road as well. Okay. What are the qualifications to be a podiatrist? Obviously, you just said medical school and undergraduate and residency. Is there anything else? Like, do you have to be board certified or anything like that? Yes, there's a process with becoming board certified. It involves about taking seven or eight different tests starting after our second year of med school. Typically, the average podiatrist is board certified after about five years of being in practice because we have to generate enough different type of surgeries to submit to the board. But after residency, we take a test and are considered board qualified. So that's what I am right now. Okay. Just on average, you know, rough guess, how many surgeries would you say a do a year? That's a good question. If I were just to guess, I would say maybe 50 to 75. Wow. Wow. That's a lot. Well, that's more than one a week. There's 52 weeks. So you're quite busy with that plus seeing your patients and everything else. Wow. That keeps you busy. Okay. With the foot, I mean, you said you gave us, you know, indication before that there's a lot going on in the foot. There's lots to it. What does the body depend upon the foot to do for us other than walking, obviously, or running? Well, that's one thing I was going to start with was getting around without our feet. We can't get to where we're going unless then we're, you know, confined to some people like in a wheelchair or a different device. The average person in the course of their lifetime walks to circumferences of the earth. So obviously it's important that we have a good set of wheels to get us around. Other things that are important for the feet, sometimes it's the first sign of someone becoming diabetic because one of the signs of that is numbness in their feet. And that will prompt someone to go to their doctor and get that looked into. Other problems with your blood flow can be first seen in the feet because you can actually get pain from not having enough blood since that's what carries our nutrients. Sure. I know when I see my doctor for regular checkups, he tests my feet and it's a very scientific approach he takes. He takes a paper clip and unwinds it and then he touches my feet and then he tells me to close my eyes and identify where I'm touching it. Once while I give him the wrong answer just to keep him on his toes as well as far as that goes. And definitely I can see that plus I also have type 2 diabetes which probably how many other Americans or people do in this world. Yes. And so being a diabetic you probably already know that the three things most affected with diabetes are your eyes, your kidneys and your feet. And that's why one of the most important parts of my job is preventing foot amputations. Okay. So you've already explained why it's so important to take care of your feet because of the functions it does for your body. What are some of the other health issues that can arise that affect your feet? Most definitely the by far the most common thing I see is plantar fasciitis. A study showed that approximately 40% of people have that at some point in their life. The lay term is called heel spurs. Some people in the general population refer to that. What the plantar fascia is is a ligament which means a band of tissue. I have a model right here. Perfect. And it starts here on your heel and then it goes up to the ball of your foot. And if you think of it like a rubber band and it's constantly stretching and relaxing stretching and relaxing during the course of our day. Very frequently especially where it starts it gets inflamed where this red is showing right here. And people are very affected by it because especially that first step out of bed in the morning you have that sharp pain in the bottom of your heel. Okay. The main reason actually why people get this is because of having tight calves. That's something I test every new patient that I have that comes in the office as part of my general foot examination. And unless someone is already going to yoga regularly or already has a stretching exercise pretty much everyone has tight calves. What that creates is a tight achilles tendon because the achilles tendon comes down and inserts right here on the back of your heel. Okay. And then you can see kind of how it's a lever with the plantar fascia down here and the achilles tendon really is tendon. And how if you don't have enough flexibility that's really going to pull up especially during our gait cycle when we're walking. Then your foot compensates which is a fancy term for saying kind of changes what it's doing. Sure. It's so small that we don't notice that we're doing it when we're doing it but over time it can really stress this plantar fascia area. Okay. Since you have your model I know one thing that I know when I'm growing up I was told I have that feet. No arches. So why is having a good arch so important? If you think of it like an arch in a doorway and there's a lot of different stones making up that arch. If it's a little bit flat and actually I can show you better on this model. So here's looking at the foot and like we already talked about it's a complex structure. Here's an average arch. If you have too high of an arch you can see how that would really stress out the foot and then also too low of an arch. And obviously I'm exaggerating this. But you're going to put extra tension on everything below. People who have a flat foot structure and again it's something that you're born with so it is very hereditary. Typically everything is really kind of loosey-goosey in their foot whereas people who have a higher than normal arch everything's really tight and rigid. That's why I typically recommend people with flat feet have more of a rigid shoe. That's more solid whereas higher arch have more of a cushioned shoe. Sure, sure. I know when I was younger I had the lift supports and everything that I had to get and always use that to help me with it. Because it doesn't you know good foot structure also then contribute to good posture you know as far as you know strain on your back and everything else. That is true just like that old song when we were children you know the hip bones connected to the knee bone. And if you think about how buildings are built and you need a strong foundation when you're building up a building it's very the same with your feet. For example growing up I had a lot of knee pain and one of the treatments my orthopedic surgeon did was send me to a podiatrist for custom shoe inserts or orthotics. And even though I didn't have any foot pain it really helped stabilize my knees. So when you see on TV Dr. Scholes or something like that do things like that really help? Dr. Scholes has a great marketing campaign so I think they do a really good job of reaching out to people who have foot pain. It's like taking daily vitamins you know you can take them but I think there are better things that you can get over the counter than Dr. Scholes. What you want to have is something that has more support on the bottom so if you take that insole that you're the orthotic you know they're kind of interchangeable that you see on the shelf and you can bend it with your fingers the weight of your body when you're walking is one and a half to two times your actual weight. So if you can do this with your fingers you know it's obviously not going to be that supportive. But there are some good ones out there. The brands I typically recommend are Power Step and Super Feet. Those tend to have a little bit more stabilization in them. A couple other things I like to touch on and I'm kind of at living so forgive me but I know one common ailment which I've had too is gout. Totally I think it's the most painful thing I've ever had. So can you go into that as far as you know how it relates to the foot? Yes well you probably already know this from experience because it's very painful so most people go into the doctor right away when they have that. What gout is is you have an increase of uric acid in your blood and what can happen is that crystal can then precipitate out of the blood. So a lot of times I explain it to patients like if you dissolve salt into water that's what it's like having high concentrations of uric acid in your blood and then you know back in high school when we did that chemistry experiment you boiled it out and then you saw the salt crystals. That's what happens when you have a gout attack is the crystals actually come out of your blood and then if you think of having these sharp crystals in your joints. The big toe is one of the most common areas for that to happen. It can happen any part of the body but the big toe the pH level is a little bit different than the rest of your body just because of how far it is away and so that environment excuse me makes it a great place for those crystals to precipitate out. Sure. And as far as treatment for that so there's two forms of treatment. One is to control the we call it hyperureosemia where you're either not excreting enough of the uric acid or your body produces too much. So that would be something where you'd be on a long term medication that you take every day to prevent that from building up. I don't treat the long term I treat the acute phase and basically help with the inflammation. I can do things in the office you can come in that day and I can do things to that joint to make the swelling go down right away and make the pain better. Nice. I know I'm on for the maintenance I'm on to say how the perinol I take. Which is your long term thing but yeah they have to blast it or whatever there's different procedures I've been through. I've had gallic pretty much in every joint in my body except the big toe believe it or not. I've had it the whole side of my foot the top of my foot, the ankle, the knee and it's just terrible. Yeah and sometimes when you have it over and over you can get these gouty deposits and it actually kind of looks like cottage cheese that's stuck in your underneath your skin. So sometimes those can become just painful enough themselves. Are planner sports still a common? They are common. So planner sports that comes from a virus a lot of times I see people after they've already tried something on their own because some planner warts you can do home therapy and get rid of them but some of them are just kind of like super power warts and especially the ones that there's a few of them clustered together we call those mosaic warts if you think of like a mosaic and those often require a lot heavier treatment than I do in the office I have a special agent that I use that blisters the virus off. I know they can be quite painful and I know one time my sister had one in the treatment was as you put a shot right into it and kind of froze it or got it out that way which I mean there's tender the way it is. Yeah there's a lot of different treatment options the one that I found that works the best and is the least painful compared to a lot of the other ones is the blistering agent because it gets underneath the virus and then blisters it off. Nice. At what point in our lives or should say do we run into possible foot you know problems or arch problems I mean young on we have that if we're born with it but as we get older what are some of the types of disorders we may see? So one thing that I love about my job is I have a variety of different types of patients you know little babies who start out with foot problems to you know the geriatric population as far as kids you're right to say that you can be born with flat feet and that can cause problems other things are a lot of kids get ingrown toenails and then that happens I have patients who are all ages with that a lot of kids are especially active and tend to break things and so I treat everything broken from the ankle down it doesn't always necessarily need surgery but it needs to be treated so it can heal properly other things that can happen you know we have problems with our skin sometimes people get athlete's foot you already talked about warts fungal toenails are more common as we get older one thing I usually tell patients is it has nothing to do with cleanliness because that's a big misconception and unfortunately a lot of people are very self-conscious about that in our environment I have fungal spores in my shoes you have them in your shoes they're floating around the air it's just when they get an opportunity to get underneath the nail and make a home it's like prime real estate and things that make that happen more frequently are things that lower your immune system such as when we age our immune system doesn't work quite as well as when we were younger other things would be trauma like some people drop something on their foot it breaks the toenails slightly to give that fungus an opportunity I see it frequently in long distance runners just because of the micro trauma that over and over adding up all that little trauma against the end of their shoes other things that I can see a lot of men especially in their middle age even younger than that 30s to 40s to get Achilles tendonitis I touched on that briefly before that pretty much everyone has tight calves the calf comes down and makes the Achilles tendon and there's a lot of men who like to be active and we call that a weekend warrior so you don't play sports for a living but you like to be out there and active and that puts people at risk for having a rupture so that's something I treat that unfortunately it has to be typically surgically I have to put that back together but if you come in early enough fortunately we can catch it and then treat it before that happens a lot of women in their middle age get what's called adult onset flat foot which is posterior tibial tendon dysfunction also called PTTD there's a tendon that comes on the medial side of your ankle or the inner side called your posterior tibial it starts as a muscle in your leg comes down behind your medial malleolus here part of it inserts right here and then another part of it goes underneath your foot and splits and its main job is to hold up your arch very frequently I'll have active women in their 40s and 50s say they feel like their ankles are falling in or they're getting flat feet and that's because that's getting stretched out so that's another thing that's common in that population so and then but a lot of things it doesn't matter your age you can be affected by it what about some of the diseases that are around like muscular dystrophy or polio I mean pretty much there's vaccinations and they've eliminated them but it can still happen well not muscular dystrophy but do they affect the feet as well yes they do the neurological system is very interesting you know it innervates all the different parts of your body and frequently I actually just had a patient who had polio as a child he's obviously older because it was before the vaccine but he had a lot of issues with his toes and becoming curling and making problems so I helped straighten those out a lot of people with other neurological problems tend to have a higher arch and then really contracted toes and tend to have something called drop foot because they can't pull their foot up and then that causes a lot of problems with getting around and tripping and so that's something I do evaluate for and there's special things I can prescribe to help with that okay another question I had is what is hammer toe that's a very good question what a hammer toe is if you look here on the anatomy of your foot you have this is called your MPJ which is right kind of like right here for the knuckle and what happens is it starts to this bone here called the proximal phalanx start to kind of move upwards and then his second toe kind of moves downwards and then like this so if you look to compare on a finger it would be like this a big reason why that happens is tendon and balances in our foot frequently the big tendons that come from the big muscles in our legs overpower the tiny little muscles that start and end in our foot that stabilize the toes so as far as treatment for that and then just to touch on that a lot of it's hereditary also so unfortunately a lot of foot problems are hereditary so as far as treatment there's different kind of like little splints I can do to help pull the toe down or recommend different shoes or things to put in your shoes and then if that doesn't work surgery is always an option what's nice about the new technology that they have out there is you know years ago you used to have to have a why you're sticking out of your toe for several weeks now they've come up with new technology where I can use something that you have the foot and so you don't have anything sticking outside your toe okay nice are athletes more prone to foot problems other than injuries you see like Jordy Nelson twisted his ankle and the turf and all of that but some athletes you see they have turf toe I've always wondered what turf toe is so turf toe is basically you have your big toe joint and it's you can see here again on the foot model you have these your toe and then your metatarsal these are your sesamoid bones which are kind of embedded in a tendon that come up here and then you have a capsule that is kind of like a blanket that holds everything together and frequently that area can get kind of jammed that's why they call it turf toe because it gets jammed on the turf but you don't have to be playing sports to have that happen and then it's kind of inflammation of everything almost as bad as going no I trust me it's not as bad as going oh it's not as bad as going that's one of the worst pains I hear you I've been through it okay how does physical therapy play into helping alleviate some of the foot problems I mean like you know if you have tendonitis they give you exercises and things other exercises as well that you prescribe that people can do for their feet yes one of the main things I tell pretty much every patient to do is to stretch out their calf because as we've talked about that causes a lot of foot problems a big thing that people do when they do their stretches first off they start for a few days doing it and then they you know get kind of lazy doing it so the big thing is to continue doing it but then also to do it for long enough I recommend people hold their stretches for 30 seconds and not one two three four five six seven it's one two three and do 10 repetitions of that preferably three times a day I know with busy lives not everyone is able to do that so for example sometimes if I'm waiting for the microwave or waiting for the elevator I'll put my foot up against the wall and kind of lean in because you get a nice calf stretch there because I know I'm like most people and have tight calves so do as I say not as I do but other things as far as physical therapy for hammer toes or people who have problems with the tiny little muscles in their foot getting fatigued I'll have them pick up a towel with their toes and let go or a marble and do that 20 times 3 times a day I love referring people to physical therapy because I think physical therapy is doing an amazing job and fortunately at Prevea we have one of the best physical therapy departments that I've ever worked for or worked with a lot of people have the misconception that physical therapy they're just teaching you how to stretch and they think I can do that at home they have different modalities such as ultrasound that they put over to help with inflammation there's different kind of steroid patches it's called iontophoresis and it helps deliver steroids to an area and then there's also something called fluid therapy which is a special machine that not all physical therapy departments have and it helps with painful neuropathy which is also another thing I treat where the nerves are kind of over firing kind of switching gears a little bit the workplace how important is the footwear that you wear can contribute so let's say if I'm in a workplace where I'm standing on concrete all day I mean or if I'm standing there's times where my back just gets totally sorted I can't take it or if I'm in another environment let's say an office environment feet fall asleep or whatever how important is it to like you said do the stretching keep moving around being active like during the day at work or the workplace or the footwear that you wear it is very important and I recently toured one of our local factories and it was very fascinating and after having the tour for an hour and a half my feet were aching on that concrete and I had good shoes on so I can only imagine doing an eight hour shift how hard that is a lot of the employers in the Sheboygan county that Prevea's partnered with has programs where they have you can get custom orthotics at a much reduced price they can when I prescribe orthotics I can put special things on there like to offload high pressure points or what's really good for people who are on concrete all day is to put like extra foam so that they can have extra padding people who stand in the same place all day long they have a lot of achiness with their legs because they're not moving around and so the blood in their veins is kind of stagnant and they get a little bit swollen so I usually recommend people with that if they are not walking around and contracting that calf muscle to move the veins every hour that you can pump your ankles ten times that'll get things moving and also a mild compression sock can really help with that for example on days when I'm doing surgery I'll wear a mild compression sock a lot of people think that it's one of those that you need a special device to put on and they do have those for people who've had surgeries on their veins and arteries but they also have some over the counter that can really it's kind of like wearing I know you men won't understand this as much but wearing spanks a lot of women spanks kind of hold everything in it's kind of like that for socks and it really helps with pain and swelling I know my wife through her stroke and lymphoma when she had cancer and everything she wears those socks as well they'll keep the fluids up and it probably sounds like the same type of thing likely she if she went through that has a prescription strength which as you probably know is a lot harder to get on but they do make lighter compression that's easier if I wanted to learn more about podiatry or do some research what's a good resource to go to a great organization is the American Podiatric Medical Association and you can go to apma.org and there's lots of different patient education materials there and then you can also go there to find your local podiatrist okay what thoughts you may have on podiatry and what we had talked about today or advice to people I think there's a big misconception in our society that you just have to live with foot pain or people say you know I'm a little overweight and I know that's why my feet hurt I just have to live with it or I'm getting older and I have to live with it and that is completely not true there are things out there and if you go to a specialist and they evaluate you and you get back and moving and so that you can enjoy life without experiencing pain every day okay one last question I have you know some girls women you see around and they've got high heels that are about that high of a spike tell me is that good for your footwear or is that just for looks or what I just was dying to know about that well it is very in fashion so you are right a lot of women have that I have seen women break their ankles wearing that when I have patients who aren't going to listen to whatever I tell them I know special events people are going to wear these high heels so I try to tell them everything in moderation and especially don't get something so high like if you look at my shoe you know I don't wear these shoes every day they have their little got dressed up for you they're pointy and they have a little bit of a heel it's just about an inch heel the more heel you have the tighter calf is going to be the more stress you're going to put right here and another thing with the pointy toes is that increases your chance of having an ingrowed toenail which is something I meant to touch on before because that's very common and that can lead to infection and if that does happen I meant to mention earlier that you can come into the office and we can do a procedure right there to get rid of that okay well Dr. Evans I'd like to thank you for being on the show that was quite informative well thank you so much for having me and it sounds like you're a great example for podiatry patients with all the problems you've had thanks a lot that's really great appreciate that if any of our viewers that have any questions about podiatry you can contact us at the station on our website at www.wsgboygan.com for Quality of Life and Dr. Evans I'm Dave Augustine thank you for watching