Maybe it’s the sound of the waves or the feel of the sand beneath your feet.  Perhaps the rich colors from beige to blue, green, red, yellow, and pink or the smell of the ocean breeze.  Whatever it is about the beach, people love to run on the sand.

A recent vacation found me running barefoot on the beach.  After a crisp-paced warm up mile on the packed sand splashing as the waves rolled in, my feet began to ache.  Knowing what I know, I quickly altered my running style, which helped until the way back.  By the time I turned and headed back people were enjoying the surf so I was forced onto the soft sand.  Another mile and my legs and feet were cooked.  I reached a level of fatigue I rarely achieve at home.

What is it about running barefoot?

In the media, people seem to be all for it or completely opposed.  There doesn’t seem to be any middle ground.  At Desert Foot Surgeons, it is my job to educate you so that you can make the choice that best fits your needs.  Maybe you want to run barefoot and maybe not.  Let’s talk about it and see what you decide.

First of all, what are the benefits of running barefoot?  I will warn you that this is all theory!  No scientific evidence exists to date supporting these theories.  Running barefoot is said to increase the muscle strength of small (intrinsic) muscles in your foot.  By doing so it is thought that your foot will become more stable with the added strength thus help prevent injury and possibly even deformities such as bunions, hammertoes, and plantar fasciitis.  A study has shown that collegiate female track athletes who trained barefoot suffered fewer injuries.  Similar high level athletes have shown the same results such as volleyball players.

Here’s the catch with running barefoot…

There is a level of genetics involved in becoming a collegiate level athlete.  Of course there are your 5’6” guys who can dunk a basketball and a 5’9” football player who runs a 4 second 40, but for the rest of us we are not fortunate enough to have the same gifts as these people.  I’m not saying hard work and excellent coaching can’t make someone a collegiate athlete, I’m trying to keep the topic real.  A collegiate level track athlete has been coached for years and puts in significant miles with this coach.  These athletes know how to alter there stride length, change posture, modify their arm swing, go from heel strike to toe strike for different reasons.  Even in the famous book, “Born to Run” by Christopher McDougal, he was coached before he could accumulate any distance running barefoot.  So that leaves one question:  do you have a coach?

I’m not going to tell you that running barefoot is good or bad for you, that’s not my job.  My job at Desert Foot Surgeons is to examine your feet sitting, standing, walking, and even running.  With that information I can help you achieve your goals, but it might take some work.  If you want to run barefoot we are going to have to work on some things. Stretching programs, strengthening, balance and running in shoes with or without orthoses might be the first few steps before you ever step out there barefoot.  You might need help from a coach or trainer.  I can get you to the right people.  I don’t want you to be injured and the number of stress fractures in my practice has tripled this past year solely due to barefoot running.  To review injuries while training review my previous blog about marathon training.

“I’ve been to two other doctors for this pain in the ball of my foot and I have to say doc, if you could…you know…skip the needles…maybe…I sure would be happy.”

This is the first thing a lot of patients say to me.  Pain in the toes or ball of the foot is very common, but making the right diagnosis is harder than you might think.  This part of the foot has only one muscle running from outside (little toe side) to inside (big toe side), but there are 7 tendons surrounding each joint, bones, joint capsule, ligaments, nerves, and fat.  Every step you take transfers weight across the ball of your foot as you move forward.  The 3 bones on the inside of your foot move as a unit and the two on the outside are another unit.  Each bone also has motion of it’s own besides the motion of the toe on the metatarsal bone.

Enough of the anatomy lesson, let’s get to the point.  A neuroma is a pinched nerve.  Plain and simple, there is nothing more to it.  The nerve lies in the space between your metatarsals (those are the bones in the ball of your foot) and divides to send a smaller nerve into each side of the two toes in front of it. The nerve gets pinched against a ligament running sideways from one metatarsal to the other.  Easiest way to think of it, the nerve is constantly irritated by pinching against this ligament.  That causes inflammation and then scar.  The longer this keeps happening the scar gets bigger and bigger until there is a lump.  Sometimes you can feel this lump “click” as it rubs against the  ligament,  ouch!!  If your toes are bent upward the nerve is more likely to rub against the ligament so pain is usually worse in heels, going down stairs (you land straight onto the ball of your foot), or hiking up hill.  Why does the nerve get pinched?  There are two reasons.  First, if you have toes that are buckled, bent, sitting on the top of your foot, the nerve is always pressed up against the ligament.  Second, there is abnormal motion between your metatarsal heads (that means an unstable foot).

Treatment for neuroma is: 1.  Relieve inflammation, 2.  Stabilize your foot so the pinching stops, 3.  If all else fails surgery.

1. Every article on this website talks about relieving inflammation.  Do you remember why?  That’s right, because, at Desert Foot Surgeons, I always say, you can’t heal until the inflammation is gone.  Ibuprofen, Naproxen, Celebrex and other pills can be prescribed to fight the inflammation.  Steroid injections can be given if the lump is really big or your pain is just that bad.  The steroid can shrink the scar a little bit. Note:  Sclerosing injections are different from steroid injections.  These use a chemical to destroy the nerve leaving you numb in that area.  Before considering a sclerosing injection seek a second opinion to make sure the diagnosis is correct.
2. The underlying problem causing the pinched nerve is your unstable foot.  Arch supports are a good place to start, but if your foot is hard to control expect me to suggest custom molded foot orthotics.
3. Surgery for neuroma is something that I find controversial.  I have surgically removed very few neuromas throughout my career, while colleagues of mine seem to remove a few each week.  Why do so many doctors surgically remove neuromas?  In my opinion it’s because the orthotics are not made correctly or the diagnosis is wrong.  Remember I’m the doctor seeing the patients who have failed treatment by other physicians, or were deemed too difficult or too sick to treat.  Be cautious when considering surgery for a neuroma.  With that said, surgery consists of either removing the nerve that is damaged by scar or cutting the ligament that the nerve rubs against.  If you’re the type of person who has toes that are buckled, than the treatment is to straighten the toes and not touch the nerve.

So there you have it.  Morton’s neuroma is a pinched nerve in the ball of your foot as the result of you having an unstable foot.  If you relieve inflammation and stabilize your foot using orthotics the pain goes away.  At Desert Foot Surgeons, I have not needed to surgically remove neuromas.  Before you have surgery I would suggest you get another opinion.  The diagnosis might not be correct.  Think about all of the things in that area of your foot.  I will discuss other problems in the ball of the foot in later articles.

I love when art and science come together to make something beautiful.  Wine, food, boats, and skis are just some of my favorite examples.  Custom molded foot orthotics are an area I deal with everyday where art and science collide, but not everyone sees it my way.  In previous articles I have taught you about unstable feet and the related problems.  I have mentioned that orthotics are used to make your feet more stable and treat problems like plantar fasciitis, heel pain, flat feet, pain in the ball of the foot, and neuromas.  I guess it stems from a general lack of understanding or the desperation of being in pain for so long, but lots of people seem to think that an off the shelf arch support is the same as a custom orthotic.

I’m not saying off the shelf inserts do not have their place.  I prescribe off the shelf arch supports for many of my patients.  These are not made to anyone’s foot in particular, and the materials used in construction are less expensive.  For these reasons off the shelf inserts might not work for you.  For one thing they don’t last very long because the materials are weaker and lose their shape sooner.  It is not made to your foot so might not work for your problem depending what that is.  Do some people get better using off the shelf arch supports?  That depends on what’s wrong.  At Desert Foot Surgeons, I exam your feet sitting, standing and walking.  If your foot is easy to control, than an off the shelf insert might help.

Custom orthotics are an art form.  First, I take a mold of your foot using plaster.  It is very important to hold your foot “just right” to capture the true shape of your foot.  The mold is then sent to a laboratory where it is scanned into a computer.  The lab now has a model of your foot.  The technician has to be an artist as well, which is why I only use one lab to make my patient’s orthotics.

Unfortunately art alone won’t make your foot stable.  The science is called biomechanics and takes many years to learn.  The clerk at a shoe store does not have training in biomechanics.  Remember at Desert Foot Surgeons, I examine you walking, standing, and sitting.  I take what I learned during your exam and write a prescription so the orthotic will control your foot.  Based on my prescription, adjustments in the computer image of your foot are made and the orthotic constructed to make your foot stable.

Not everyone treats you like I do at Desert Foot Surgeons.  For one thing, some molds are taken from pushing your foot into a box, onto an image scanner, or standing on a platform.  The problem with these methods is that any pressure on the sole of your foot causes the muscles to spread out and the foot to change shape.  Hence, the orthotic will not match your foot.  A tracing, thermal print, or pressure map of your foot cannot be used to make a custom orthotic because there is no model of your foot.  Standing won’t help, because I am trying to control the way you stand not accept any deformities or imbalances in your foot.

Don’t be fooled:

Have you seen any infomercials where they are selling arch supports?  They always show you how much more stable the person is in the arch support by pushing their arms down.  Here’s the trick.  You can try it at home:

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You will need a partner and a piece of paper.  Keep your partner barefoot and standing with their arms straight out in front of them.  Push their arms down.  It should be pretty easy to move their arms.  Next put the piece of paper under their heels.  Again standing with their arms straight out in front.  You push their arms down.  Wow!! Like magic it is harder to push their arms down.

Unfortunately this is not because your friend is now stable standing on the piece of paper.  This is a physiologic principle called “muscle memory”.  The first time you push your friends arms down, their muscles don’t know what to expect.  The second time the muscles remember what is going to happen and respond more appropriately making it harder to move the arms down.  Notice in the infomercials how they never test their product first, because there is no muscle memory.

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So don’t be fooled!  If the arch support is cheap, it’s not custom made.  If no 3-dimensional model of your foot was made, it’s not custom.  If you were standing while the mold was made the orthotic is custom, it just won’t fit your foot the way I need it to in order to help you.  If no exam was done with you sitting, standing, and walking, then there is no way to write the prescription.  You are paying for custom orthotics.  At Desert Foot Surgeons, that is exactly what you will get.

I love when art and science come together to make something beautiful.  Custom foot orthotics might not look beautiful to you, but being able to create a piece of plastic that can stabilize your foot and relieve pain is pretty beautiful to me.  Let me show you how I combine art and science to fix your feet at Desert Foot Surgeons.

I love when patients come to me with advertisements, especially about shoes.  The latest trend is “toning shoes”.  I’m sure you’ve seen adds with Joe Montana or beautiful models in exercise clothes walking with these thick-soled shoes that are supposed to tone you calves, thighs, and buttocks.

I’m drawn to these advertisements as much as you, but I have a responsibility to my patients when it comes to shoes so I dug a little deeper into the toning shoe topic.

At Desert Foot Surgeons, we want our patients to be well informed so below is a link to an article about these shoes.  If you have thought about purchasing a “toning shoe”, please read this article.

http://www.acefitness.org/getfit/studies/toningshoes072010.pdf

Dr. Geller

That unsightly lump or bump on the inside of your foot behind your big toe is known as a bunion.  This is the hallmark of having an unstable foot.  When your foot won’t work in a stable position the bone behind your big toe (1st metatarsal) drifts toward the inside of your foot.  As the bump on the inside of your foot gets bigger, the big toe gradually slips off of the metatarsal and drifts toward the 2nd toe.  Think of it this way:  a table has a broken leg.  That table is no longer stable in that area.  If you begin to stack objects on the table, eventually the weight over the missing leg will build up and the table will tilt.  The bones along the inside of your arch are very important to maintaining a stable foot when you walk.  Having a bunion makes other areas of the foot unstable leading to hammertoes, arthritis in the back part of your foot, heel pain, inflamed tendons, on and on.

Because your bunion involves an unstable foot, surgery to correct the bunion has to take into consideration this issue of stability.  There are many different surgeries for correcting a bunion ranging from simply removing the lump, correcting the bone in various places, or fusing the joint at the base of the metatarsal.  Planning bunion surgery requires a thorough evaluation of your foot at rest, standing, and walking.  At Desert Foot Surgeons, I perform video gait analysis on all patients with bunions.  I am currently involved in a research project that will show other foot surgeons how to determine exactly where to correct a bunion for the most stable result.

Bunion surgery is very complicated because of the stability issue.  Other surgeons promoting aesthetic bunion surgery state that their surgery will work to, “maintain or enhance the mechanics of the foot”.  Many of these aesthetic foot surgeons also tell patients they can walk immediately after surgery.  That means that they are either just removing the bump or correcting the bone near the lump.  Medical research has shown that this approach to bunion surgery makes the big toe less stable leading to further loss of a stable 2nd toe causing a hammertoe and those other problems we talked about above.

My approach to bunion surgery is to use science and apply to your problem.  You and I will talk about the best surgery to correct your problem.  If you cannot cooperate with the recovery I will work with you to get to the point that you can manage the rehabilitation or suggest alternatives.  It is these alternatives that you  need to understand.  When alternatives are chosen you are making sacrifices.  In the case of a bunion you are usually sacrificing stability.  Think of the table with one broken leg.  If you repair the table leg with duct tape the table is still unstable and will eventually tilt and possibly break completely when objects are placed on the table.

As far as cosmetic bunion surgery, the placement of the scar has to allow the surgeon to clearly see the bone being worked on.  I don’t want you to have an ugly scar, so whenever possible I will hide the scar.  But fair warning, the bigger the bunion the less likely it will be to hide your scar.

When considering cosmetic surgery, remember the goal is to make your lump or bump look better and relieve pain.  If the scar can be hidden it will, but the key to correcting your problem is choosing the correct surgical procedure based on a thorough exam including gait analysis.  Performing an alternative surgery requires sacrifices be made on your part and the part of your surgeon.  When all is said and done, a scar, time off your foot, having to perform physical therapy are reasonable things in order to make pain go away and prevent the problem from returning.

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!!

A note from Dr. Geller I know what you’re thinking;  Hey doc, you don’t say much about what you do during this recovery.  That’s because recovering from a marathon is all about you.  I’m very happy and proud that you were able to complete a marathon especially if I could help in the beginning.  I hope you don’t need me for this, but if you do, I’ll be there. You did great! Sincerely, Dr. Geller

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