This was a goal I had set intending it to take 8 weeks to achieve, but completed it in only 6.

What’s special about this?   I did it without injuring myself!

There was a day when I would get up early and hit the road running 26 or more miles a week.  I suffered through heel pain, stress fractures, back and hip pain, but kept on going making the same mistakes day in and day out.  When I became a podiatrist and started treating athletes at Geller Podiatry I started to see a lot of the mistakes I had made.

It may be due to the fact that I am a runner, but I like to think it is my attention to detail that allows me to work well with athletes.  At Geller Podiatry I examine your back down to your feet, sitting, standing, and walking.  I find a lot of patients complaining of foot problems when the real cause of their pain is coming from an alignment problem in the hip or knee, tight muscles around their low back, or that ever annoying iliotibial band (IT band).  You can’t get better if the problem is not identified and watching patients walk is when I find most of the problems others have missed.

I can’t fix problems above your ankle, but I have a team who I work with.  I will get you to a trusted orthopedic surgeon, chiropractor, physical therapist, or massage therapist to make your problem go away.  As more and more people take to running I am getting more involved in their training.  I can draw upon my personal experience as well as my medical knowledge to help you reach your goals.

Good luck in the upcoming race season and let me help you train.  At Geller Podiatry we offer video gait analysis, shoe analysis, custom foot orthoses, bracing, and even surgery if it is needed.

With great care your surgeon has explained the details of the surgical procedures, discussed with you the things that could go wrong since this is not a perfect world, and developed a game plan for recovering from surgery to achieve the best possible outcome.  At least at Geller Podiatry, this is how it is done.

A great deal of information gets exchanged, but ultimately the days or weeks leading up to your surgery are busy planning for the big day.  You need to schedule time off from work, someone to help with household chores, care for the kids and their needs.  I’ve already written about planning before surgery, but there are little things that can make a huge difference.

What is the biggest obstacle to healing your hammertoe surgery?  After thousands of hammertoes treated at Geller Podiatry the one thing that differs between easy and difficult recovery from surgery is swelling.  Remember what I always say, “You can’t start to heal until inflammation is gone”.  Well one of the key signs of inflammation is swelling.

Toes are small.  There isn’t much room for them to swell.  Increased pressure on nerves causes more pain.  Increased pressure on your circulation to the toe makes healing take longer.   Patients who control swelling from day 1 always have a faster recovery.

The key to controlling swelling:  “RICE”

Rest, Ice, Compression, Elevation

Rest:

The way I discuss surgery with my patients always involves this statement: “No matter how minor you think this surgery is going to be, you need to treat it like it is major surgery”.  If you think you are going to pick up where you left off one or two days after surgery, think again!  Your daily routine will have to wait for your recovery, that’s why we plan before your operation.  First of all rest involves lying down, not just sitting.  you will be prescribed a boot to wear on your foot.  This boot is also part of rest.  The area of surgery will be protected or rested while wearing the boot.  Do not remove the boot until you are told that this is OK.

Ice:

In all of my years of experience I would have to say that ice is possibly the most under-rated anti-inflammatory in the world.  There are some simple rules you need to follow when using ice: 1.  do not put ice directly on your skin; 2. ice is applied for 20 minutes and then left completely off for 40 minutes.  Ice is usually applied to the ankle or behind your knee.  My patients tell me that behind the knee is the easiest and if it’s easy you are more likely to do it.  Put a washcloth over the ice pack and then rest your knee on the ice.  If you leave the ice on for more than 20 minutes or without protecting your skin you could develop a cold injury or frostbite.

Compression:

Keeping snug bandages on your foot help to prevent swelling.  There is a difference between snug and tight.  The appropriate amount of compression is still comfortable.  If your compression is applied too tight you will notice things like the toe changing color, usually blue, but white can also occur.  Numbness and tingling can occur when the bandages are too tight.  If these are noticed call your surgeon and loosen the bandage.  The layer of bandage that supplies the compression is always the outer most layer.  If you need to loosen compression only touch this outermost layer, nothing beneath it without your doctor’s permission.

Elevation:

This is the easiest part, but the one most people fail to do.  Elevation of a foot means getting your foot above your heart.  Remember that the heart is in your chest, so you have to lie down and get your foot up on pillows or the arm of a couch.  A helpful hint is to keep your knee bent slightly for comfort.

A Geller Podiatry, our team spends a tremendous amount of time with you planning for your surgery.  These simple steps are what we see as making the biggest difference between what patients consider an easy recovery vs. a difficult recovery.  Rest, ice, compression, and elevation (RICE) is an old standard because it works.  Don’t underestimate the power of RICE.  I hope you have a wonderful surgical experience when you decide to have your hammertoe surgically corrected.

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.

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’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:

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.

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’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

In the foot people can have unsightly problems and what’s worse pain.  A bunion is a lump on the inside of the foot behind the big toe.  The size can vary and the toe can begin to move closer to and even under the 2nd toe.  When the smaller toes are buckled that is a hammertoe.  Here’s the key:  because we wear shoes, bunions and hammertoes hurt much sooner than if we went barefoot all the time.  Let me make this perfectly clear, wearing shoes does not cause the deformity, but wearing shoes does make a deformity hurt sooner than it otherwise would.

Bunion and hammertoe surgery can be cosmetic, which in my opinion means the deformity will look better after corrected so that you feel better since pain will be gone.  That’s a little bit different from other forms of cosmetic surgery.  When I perform bunion surgery or hammertoe surgery I always keep in mind the fact that you will be walking on the end result for years to come.  Because the bunion and hammertoe develop in an unstable foot I have to make sure the problem does not return.  Face lifts, tummy tucks, or breast augmentation have their long term considerations, but honestly you will not be walking, hiking, or running on these parts of your body.

There are people who want to fit into those 4” spiked heels at any cost.  They want their wide foot narrowed and long toe shortened.  I’m not talking about business executives who have to maintain a specific style of dress in order to advance their career and suffer horrible pain in these shoes.  I’m talking about people who would otherwise have no pain, but insist on wearing these heels for social purposes.  I caution those people who do not have pain!  Foot surgery can result in scar within the joint leading to stiffness and arthritis.  There is no true preventive surgery for arthritis.

One final word.  Recently a Beverly Hills Podiatrist coined the term “Cinderella Surgery” for correcting a bunion, long 2nd toe, and bunionette (on the outside of the foot) so that women can wear their high heels.  He did a very nice piece on the television show, The Doctors.  My problem is this:  I always say, feet are like snowflakes no two are alike, well here is a podiatrist telling women he can perform the same procedures on their feet in every case so they can walk immediately after surgery and their feet will fit into their stilettos.  That is just not possible without making some sacrifices.  To read about these sacrifices that might be made check back every few days for my new articles on cosmetic bunion surgery and cosmetic hammertoe surgery.  

A hammertoe is when your toe buckles or bends as a result of an unstable foot.  This can range from a mild twisting of the toe to such a severe buckling that the toe sits on the top of your foot.  Dress shoes for women and men are not made with ample room for the toes.  When a toe is buckled there is pressure and rubbing of the toe against the shoe leading to pain, redness, and formation of hard skin known as corns and calluses.

Hammertoe surgery has been described in a previous article where I talked about the difference between correcting the 2nd and 3rd toes vs. the 4th and 5th.  To review the 2nd and 3rd toes usually involve toe fusion surgery, while the 4th and 5th involve toe joint surgery where the joint is removed.  Muscles and tendons are often rebalanced around the base of the toe and sometimes work further back in the metatarsal is needed.  Cosmetic surgery on a hammertoe can mean hiding the scar or just the fact that I will make your toe look better.

Many people have one toe longer than the others and consider this unsightly.  Mind you this toe is not buckled and not painful, but some people want this toe shortened.  A doctor might decide to remove some bone from the toe shortening this long toe and performing toe fusion surgery thinking he is making the toe stable.  Unfortunately there are tendons in each and every toe that are not shortened with the toe because tendons don’t heal well.  Tendons rely on being a specific length, for geeks like me that would be 125% of the muscle/tendon resting length, in order to work.  So yes I can shorten your toe and in turn I have just made your toe unstable.  I might have performed toe fusion surgery to make that toe joint stable, but the other joints are not, so your toe buckles and now you have a toe sticking straight up in the air.  Would that be worth it to you?  As the podiatrist who spends a great deal of time fixing poor surgical outcomes, I can tell you it is much more difficult for me to correct this problem.

What exactly do I mean by hiding your scar?  Most hammertoe surgery is done through the top of the toe.  This is beneficial if I have to address the tendons, ligaments, joint capsule, and even bone at the base of the toe or metatarsal.  If your toe can be treated just by toe joint surgery alone than I can make the incision on the side of your toe so that no one will ever see your scar.  The sacrifice I am making to use this incision is that I cannot rebalance the joint in the ball of your foot.  If your toe is buckled and you have pain in the ball of your foot do not expect a scar any where other than the top of your toe.

Cosmetic hammertoe surgery means making your toe look better and relieving pain.  I have talked about some of the risks and sacrifices that are involved in making this decision.  Remember what I always say, feet are like snowflakes, no two are alike.  Your surgery will be different from your friends and it should be.  Don’t forget to read the articles on toe surgery without the pin and recovery from hammertoe surgery.

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.

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

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

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

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

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

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