If you suffer from paint in your foot, you know it can be extremely debilitating and severely limit your daily activities.
Geoffrey Habershaw, DPM, discusses the most common causes of foot pain, when to see a specialist and the treatment options available at Boston Medical Center.
Geoffrey Habershaw, DPM
Dr. Geoffrey Habershaw, DPM is a podiatric surgery specialist at Boston Medical Center.
Melanie Cole (Host): If you suffer from foot pain, you know it can be extremely debilitating and severely limit your daily activities. My guest today, is Dr. Geoffrey Habershaw. He's the Chief in the Division of Podiatric Surgery at Boston Medical Center. Welcome to the show, Dr. Habershaw. What are some of the most common causes of foot pain that you see everyday?
Dr. Geoffrey Habershaw (Guest): Well, it’s nice to be talking to you, Melanie. It’s a pleasure for me to talk about this. Foot pain, in the working population – people that are very active – usually has to do with overuse activities. That is accentuated by mechanical deficiencies and deformities that might occur during the course of the lifetime. There are some people that you know that never have foot pain. They get through their whole life, and they do well. Well, they’ve had a balance of everything. They’ve had a balance of good mechanics, good habits, good nutrition, weight control; all of these things that eventually are pinpointed down to our foot. If you are lucky enough to be born with good genes and you take care of yourself very well, you can keep foot pain to a minimum.
Melanie: So, what do you see? Do you mostly see people with arch problems, plantar fasciitis, bunions, all of the above – and overuse obviously? What are some of the most common causes of these things? If it’s shoes or you mentioned biomechanics, what are we doing to ourselves?
Dr. Habershaw: Sure, sure. Well, you know, it’s interesting that you say shoes. If foot pain was caused by shoes, how do we explain no pain in patients that have worn shoes their whole lives? We have patients that come in for other problems, and they’ve never had any foot pain. The most common cause of foot pain is an imbalance. Now, the easy way to understand this is the foot as a seesaw – everybody knows what a seesaw is. If you were a kid like me you loved to play on them – one kid on one end, another kid on the other end – and it goes back and forth. It goes down one end and then it goes back down again to the other end. A foot that is imbalanced is either hanging to one side or the other side. It’s either flat or it’s got a high arch on the other side.
The best foot is the one that hangs right in the middle during the most active and forceful motions of gait when you’re walking. If you’re walking and your foot hangs into pronation or flattening of the foot, it puts tremendous strain on the mid-foot, the tendons, and the forepart of the foot, and that’s what can develop deformities, such as bunions and hammertoes. If your foot hangs on the other side of the see-saw and you have a very high-arched foot, you don’t absorb friction. Friction is constantly taken by the foot and transmitted up the body into other structures, such as the knee, the hip, and the back. It’s this balance that’s important to maintain.
Melanie: Well, that’s something you really learn looking at people and the way that their gait is and the way that they walk that based on that base of support, which is their feet, they can come up with all kinds of other issues in the knee, in the hips, in their low back – it works its way up the body.
Dr. Habershaw: Sure.
Melanie: Let’s start with some of the more common, like plantar fasciitis – pretty common, very painful, what do people do about it?
Dr. Habershaw: It’s not just common, it’s an epidemic. I mean, if I see four or five new patients a day, two of them will have plantar fasciitis. It’s really, quite common. The reason it’s a problem is it’s a slow detachment of a very powerful structure, the plantar fascia. The plantar fascia is like the string on a bow. Everybody knows the foot has an arch in it. Well, that’s the bow, and the plantar fascia is the string on this bow, and the weakest attachment point of the plantar fascia is into the inferior surface of the heel bone. When it begins to pull away from the heel bone slowly, it causes chronic inflammation of the soft tissues in this area. Sometimes, a bone spur develops – you can see it on X-ray. All that does is confirm the diagnosis. Bone spurs themselves don’t hurt. It’s the soft tissue attachments around this attachment into the heel that causes all of the pain.
Melanie: So, what do we do about it? People see these orthotics. They see things at Walgreens, and you go into a running shoe store, and they’ve got all kinds of off-the-shelf orthotics, what can help? Whether it’s a cushion or something to lift up and support your arch, what do you do for it?
Dr. Habershaw: Exactly. The treatment for plantar fasciitis is multifactorial. There are lots of things to do. The first thing to do is to put ice on it. Whenever you have an opportunity and sit down at the end of the day, put a sock on your foot and put an icepack on it. You know you need ice when it hurts like crazy when you first get up in the morning. It hurts that bad in the morning because as you’re off your foot, that whole area swells and when you step on it, it stretches those nerves that have been free from weight bearing all night and people can go through the roof. They can limp the way to the bathroom; the limp while they’re getting dressed, and then after they’ve been on it for a little while, they feel a little better. If that’s the case, then even sitting down to have lunch, you get up, you might feel pain in the heel. You know you still need ice.
The second thing to do is to stretch the Achilles tendon. If you look at the tendons and how they attach to the foot, the Achilles tendon surrounds the back of the heel, and then those fibers – a lot of those fibers take off as the plantar fascia. It’s like a contiguous structure, the plantar fascia, and the heel cord, so stretching the Achilles tendon is important. I like to have patients do it passively while they’re sitting. If they put a towel over their toes and pull the towel until it hurts, hold it for a minute, relax 30 seconds, and do that five times.
The next thing to do is to get a good, supportive orthotic. The best ones to get are in sporting goods stores. There are many different types available; you just have to go into a sporting goods store that caters to runners and walkers and say, “What’s a nice, firm orthotic that I can get in my shoe?” They have multiple different types. I don’t have any particular favorite type. You can’t get them in the drug store. They’re too soft, and they’re not supportive. So that’s the next thing to do.
The next thing to do is to wear a shoe that has an elevated heel. With girls, it’s easy. I mean, they just rummage around in their closet, and they can find some kind of a wedge heel that they’ve had in the past. I have them wear it for two or three hours in the morning, maybe two or three hours in the afternoon. By elevating the heel, it takes the strain off the plantar fascia. Men, it’s a little trickier. You can’t tell a man to go wear high heels, but you can tell him to get a cowboy boot, which has an elevated heel, or you can tell him to get a logger’s boot – these are the guys that are working – which have an elevated heel. You see the guys on motorcycles wearing those logger’s boots, so their feet don’t slip off the pedals on their motorcycle. And even a clog – a men’s clog that has an elevated heel can be very useful, especially for people who are in confined areas where they’re standing in one place – like surgeons and cooks. You know, you’re in the kitchen you can wear these elevated heel shoes. Those are the most effective things right up front.
Melanie: When do some of these foot problems become surgical, Dr. Habershaw? We could talk for a very long time – there are so many foot issues, and that was a great, little description that you just gave of ways to deal with plantar fasciitis – but when does it become something that you say, “I’ve got to go see a podiatrist. I may need surgery.” When does that happen?
Dr. Habershaw: Right, so as long as we’re on plantar fasciitis, plantar fasciitis becomes surgical when all of the treatments have been exhausted. If the non-surgical treatments, some of which I just described to you, are not effective, then sometimes, we put cortisone shots in these. We may do up to three shots. After that, if it’s not effective, I might send the patient for radiology for an orthopedic ultrasound of the site because with their ultrasound machine, they have a color doppler and they can determine exactly where the inflammation is. Sometimes they can put a more directed, exact cortisone shot into that area.
And then, when the problem becomes intractable where you have to say, “I’m thinking of quitting my job. I can’t stand the pain in the heel anymore,” or it’s just causing you to limp so much that you’re starting to have knee pain, hip pain, low back pain, then surgical intervention becomes an option. You could argue that this might be true for things like deformities in the foot – bunions and hammertoes. Bunions and hammertoes can be lived with appropriate shoeing for your life. I have numerous patients in their 90s that have had bunions and hammertoes their whole life, and they do fine because they were sensible about the shoes they wore. The bunions and hammertoes that begin to affect the ability to function the way you need to in work and play determine whether you should have surgery or not.
Melanie: And when do you think – you mentioned orthotics, and you don’t have a favorite. What is the difference between going to a podiatrist and getting a made orthotic that’s a prescription versus one of these ones that you get at the store? Do you have a reason that you should do one over the other?
Dr. Habershaw: Yes. Well, I tell people to start with a good over-the-counter one like you get in a sporting goods store because about 30, 40% of these people will have a great result and that will be all that they need. And then if that doesn’t work, maybe 50 to 60% of them will not do well, and then we can go on to a custom device. A custom device is more effective, but it can be several times more expensive. It can be up to $300 for a pair of devices like that. We don’t make them at Boston Medical Center, but we send you to a Pedorthist, in one of the labs around the city where these are made. I like to start – I never know when people are going to do good with the ones over the counter, so I like to start there. If they don’t do well, we send them to get a custom one made.
Melanie: Wrap it up for us, Dr. Habershaw, with your best advice – and I would certainly love to have you on again because we could go over so many of these topics --
Dr. Habershaw: Oh, yeah.
Melanie: But your best advice about the feet, and taking good care of our feet, and when we should see somebody if they’re really causing disability.
Dr. Habershaw: Well, I think just – and when people are not having foot pain, we really forget about our feet because they’re doing what they’re supposed to do. They’re supposed to get you from point A to point B comfortably, without limping. Once you start limping, then you have to start paying attention to them. I’m not – if someone has some arch pain, I have no problem with people going to the drug store and getting a pair of arch supports. I think that’s a reasonable thing to do, but when the pain is getting to the point of where it’s chronic, and it’s slowly biting into the ability to get through your day without thinking about your feet comfortably, then you should get some professional advice. I think that’s the best time to do it.
And then what we try to do is we try to do everything as conservatively as possible to get you the quickest recovery. Sometimes that requires physical therapy, sometimes that requires different shoes that you can wear, and sometimes it’s just a matter of changing your shoes and socks once during the day because what we all forget is shoes begin to lose their cushioning and support about half the day and then you’re more comfortable in your shoes for the rest of the day.
Melanie: Thank you so much. Really, really great advice, Dr. Habershaw. Thanks for being with us. This is Boston Med Talks with Boston Medical Center. For more information, you can go to BMC.org, that’s BMC.org. This is Melanie Cole. Thanks so much, for listening.