think forward think research channel well thank you for all coming tonight i hope i can give you guys some tips on the aging foot we can’t really slow down the aging process that’s inevitable but hopefully i can give you some tips to keep your quality of life a little bit better the two things that I’ve noticed when I was researching to do this lecture we’re arthritis and obesity and those are two things that go hand in hand with our Asian foot if you can keep an ideal body weight that really can slow down the destruction of your foot and the and preserve their their joints so being active can really helps you know make sure you have an ideal body weight so they’re really connective and as as we’ve seen obesity seems to be in the in the headlines every day about the health impact on that and I see so many patients daily that that are overweight that it really contributes to their foot pain and our joints need activity to keep them healthy that synovial fluid needs to run through through our joints and it can only do that if we’re active and that brings the nutrients to the joints to keep them healthy so it’s really important that we try to maintain an ideal body weight and to remain active so those are things that are really i’m passionate about exercise and i just think that we can all do that it just to keep her general health better so so here’s some foot facts the foot contains 26 bones 28 actually if you include the sesamoid bones where there are these little too bean shaped bones underneath the ball of your foot 107 ligaments 19 muscles basically there’s a quarter of our bones or in our feet and our feet are our foundation for everything so they’re really important and they’re they’re very much abused and it’s amazing the average person you know can write you know 10,000 steps a day which adds up to you know 115,000 miles that’s actually like I believe four times around the globe in a lot in a lifetime we actually walk so it’s pretty impressive women have four times as many problems as men and I do think that’s definitely related to shoes you know shoes are the demise for a lot of people’s feet i see so many problems related to shoes and i think that it’s really overlooked in my other lecture on the runners foot i talked about how it’s so important to replace your shoes often and most runners know that after you know two to four hundred miles to replace their shoes but i find the the older folks that i see don’t tend to replace your shoes as much and they come into my office and they’re their shoes are just not in the greatest condition and that’s just a such a simple thing to to do to replace or you know alternate your shoes more often than than you think and your feet they definitely marry your whole general health again so many problems initially show up in your feet nerve problems neuromas are basically inflammation of a nerve the nerve actually develops scar tissue around the nerve and it can be a very painful scenario it’s basically foot pain in the ball of your foot can lead to numbness and tingling and Bernie in the foot there’s been some other advances on the treatment of that I typically inject that with an alcohol solution to kill the nerve because once the nerve develops a bunch of scar tissue like that it’s basically a big wad of scar tissue around a

non-functioning nerve and in the surgery what we do is we go in there we remove the nerve but to revise surgery you can inject the series of alcohol injections it’s a sclerosing agent and it kills the nerve or basically puts it to sleep and I’d say it’s about seventy-five percent effective circulation problems like in diabetes I see so many people that come in and have numb feet and or burning feet and I ask them are you diabetic like well I don’t know no I’m not and I’ve seen so many people two years before their actual blood sugar was higher that they had these subtle signs of diabetes and I had a strong family history and so definitely your feet marry your general health so what happens in the feet when we age well like anything you lose elasticity your skin is not as strong it’s not as tense the laxity of the ligaments they stretch out they’re not as tight you get atrophy of the adipose or fat tissue in the sole of your feet so you have more bony prominences you have less padding so you feel the bones when you walk more and it’s it’s really not you’re not losing your mind you do you do have less padding down there and so and as well the cartilage degenerates and all these things lead to foot pain the intrinsic those small muscles of your foot they are really important in preventing the formations of hammer toes and other deformities like hallux valgus or bunions and they they tend to atrophy as well and that leads to buckling of the joints that the toe starts to buckle and becomes bent and then that leads to bony prominences bunions and problems and shoes again osteoporosis that’s a thing that we can’t really prevent all the way we can prevent it by having a good diet and definitely weight-bearing exercise has shown that that can that can slow down the progression of that but it is a part of the aging process and again I get back to this common theme of being active i think if we are active we don’t lose as much muscle we don’t lose as much balance or your sense of proprioception that sense of balance and range of motion and our joints if we are active it’s just so connected being active and keeping our weight down can is just so essential to our general health and in the foot it it’s the same oftentimes people come in and they and they say well I’m a size 10b and I can tell their shoes are not fitting appropriately they have these huge sores on their feet they’re getting black toenails or either getting these huge calluses and you’re trying to shove their feet in these little these little shoes and it’s a fact that your feet your foot size does increase your arch height decreases the the joints start to break down the the ligaments become less tight and that leads to a widening elongated foot doesn’t grow it just it just breaks down and so again it’s really important to get your foot measured I think once a year and when you buy shoes it’s good to buy them in the evening or in the afternoon or even after you exercise because then they’re going to be at their their their biggest size this is a my 8 year olds foot so you can see it’s got a nice arch the nice tone nice skin color so forth this is a 43 year old woman’s foot my wife’s foot again it’s uh you can see she’s got an arch she’s got a little bunion but nothing too bad the skin looks good she’s got good tone not too many problems there and then this is a foot of an 83 year old woman so you can just see the the loss of the arch the arch height is decreased the edema in the ankle the skin you can’t really see the supple tight elastic nasaw the younger defeatist just showed you also the nails or a little bit thicker and if you can look really closely you don’t see a lot of hair growth and so forth and all those things or what happens is the foot ages the the foot becomes dry it loses the elasticity the dryness isn’t just as part of the aging process but oftentimes the dryness is from being dehydrated and I I see a lot of folks that are on a

diuretics and they drink they drink coffee and tea and sodas and so forth and on all those or diuretics that that cause dehydration but I don’t find that the older population drinks enough fluid or water and I think that is such an important thing to keep our tissue hydrated and our tissue healthy one of the things that can happen if you have dry skin is your skin is the first barrier to infection and so it’s the largest organ in our body and if our skin is healthy it prevents other little infections like athlete’s foot fungus if you have athlete’s foot fungus I can lead to Wow warts which are viral infections and it all it all is really connected this is another slide to show the back view of the feet as we age our feet lose the the arch height in ER and our arch height collapses in what I do and I look at somebody’s feet to assess them for appropriate shoe or possibly an insert or an orthotic as I basically bisect the calf muscle and the the bisection of the heel and in the perfect scenario that should be a straight line perpendicular to the weight bearing surface if you can look at visually the heel by section of this patient it would be at an angle as her left foot is significantly more pronated and pronation is basically a word that we use to describe the flattening of an arch and when you have flattered feet or pronated feet there and that’s an unstable foot it’s hyper mobile so it moves around a lot so basically in a nutshell your feet have to work harder than they should so that translates up the change so your leg muscles have to work harder and I see this in a lot of runners that have flattered feet their feet are inefficient and they move around too much and that leads to shin and leg pain and so one of the simplest things to do is to get better supportive shoes so what happens in to our skin dermatological changes onychomycosis is a fancy word for fungal infections now I see a lot of patience for dick toenails and they think that’s just well my nails or thick because I’m getting older well that’s really not the case it’s actually from a fungus infection or trauma so those are the two conditions because basically your your toenails should mirror your fingernails they should be about the same diameter but in the in your feet you know they’re you’re traumatized and shoes and activities and so forth and so that can lead to a fungal infection so say you stubbed your toe your toenail turn black and fell off when was growing back in that could have led to a fungal infection if you had athlete’s foot on your foot you got into your toenail and your toenail became thickened that that toenail fungus isn’t the end of the world it’s going to make your nails thicker harder to cut but they can lead to foot pain so if your nails are an inch thick they’re not going to fit into your you know ferragamo shoes so so so if you have a thinner diameter nail it’s definitely going to be more comfortable the other thing that can happen is you could get calluses calluses happened through bony prominences so if you get hammer toes or bunions or as I was saying earlier as if you’re fat path starts to atrophy your metatarsal bones the balls the bones of the ball of your foot become more prominent and we and so your body tries to protect that so that builds up callous and that callous can lead to really painful lesions under the ball of your foot or even on the top of your toes cirrhosis that’s just a fancy word for dry skin often though dry skin is is related to being dehydrated like I was saying before it also is common in people that have fungal infections or athlete’s foot fungus I see a lot of people that have a very dry scaly foot it doesn’t have but that is definitely tinea pedis or athlete’s foot fungus and that again that is your their skin is our first barrier to infection and so I’ve seen other problems related to just common athlete’s foot fungus people can get a super infection a bacterial infection from that especially between their toes if the toes are really wet and whitish and what we call be macerated that can lead to a bacterial infection and I’ve seen a lot of bad infections over the years for especially in diabetics for

that so it’s really important to keep hydrated and into moisturizer skin ulcers those are local areas of tissue destruction their most common forms or stasis ulcers or diabetic ulcers so stasis ulcers are related to the circulation in our in our extremities commonly in the ankle basically the the veins and lymphatic systems don’t pump the blood back up is well back up the legs and it pools in the in the ankle bones and that leads to break down at the skin and it basically can weep and ulcerate and be very difficult to heal so the common thing in diabetics are these diabetic foot ulcers and in diabetics again we most diabetics if they’ve had the disease a long time they have a certain form of peripheral neuropathy so basically they don’t have the feeling and their feet that they normally would so if they were to step on something or have a rock in their shoe or let’s just say they wore a tight shoe and they didn’t notice a callus forming or a blister forming it can be so simple as a blister that leads to an ulcer and then it can be a big problem I’ve seen so many patients that had a blister on their toe that I’ve had to go on and amputate the toe because it didn’t heal and in diabetics the two biggest problems are their circulation the vessels and the toes and the extremities are are not so great and then there’s their nerve sensation they do not notice a problem until it’s a big problem so fissures are another thing I see a lot of those are cracks in the skin and I see this in young and old people but basically what happens is more commonly around the heel a weight-bearing portion of your foot it develops callous and it’s common in people that wear a lot of sandals and clogs and open or backless shoes I think the the skin really dries out especially in the summer and in the winter too but in the summer if you’re in a pool and you’re in chlorine and you’re wearing a lot of sandals that the callus can build up because this the shoe is in providing enough support so your body builds up callous that subsequently dries out and it cracks and it can lead to it very painful basically a cut so it’s really important to try to keep our skin moisturized and if you do have calluses a common thing you can just use a emery board or a pumice stone and use that on a regular basis and in a moisturizing cream that can solve a lot of problems this is a classic picture of onychomycosis or toenail fungus now this woman has a fairly severe infection all her nails are significantly thickened you can also see on our little toe in between our fourth and fifth toe this red patch macerated red scaly pili skin and it’s a classic scenario athlete’s foot and onychomycosis now these as you can tell would be pretty difficult to manage on your own I mean you’d have to have the industrial-strength Clippers did to get through these things so in my practice I see see patients for this problem it’s it can be treated with an oral Asian but I found in in this population there on so many different medicines it’s not really a very good option for him because the oral antifungal medicine can be hard on the liver and if they have diabetes or other problems and they’re on a lot of medicines it’s it’s just another thing that they have to take and it’s really not going to impact their life to too greatly if it’s maintained so this obviously wasn’t maintained but I have people come in every few months and have have these nails too bright ‘add you have to actually use a dremel tool to file them down because they’re so thick but they can lead to a lot of discomfort you can tell how thick they are and if they’re long people are end up walking on the end of their nails and it can be really uncomfortable now this next slide I want to warn you this lady came in at about two months ago and she was an older woman and her daughter brought her in and it’s it’s a pretty severe case of

onychomycosis so there it is now this woman could not wear shoes she came in my office wearing slippers because those nails would not allow her to wear something like this is an extreme case but this is what can happen I want you to look at the skin look at the skin look at how dry her skin is look at the edema in their toes or like little sausages they’re very Adem it is he hadn’t been to the doctor and you know three or four years she was in generally pretty good health but she just wasn’t maintained she didn’t have very good foot maintenance and this can be a big problem so for fungal infections I do treat that and one of the things I like to do is I pulse it with this terbinafine I like to pulse it because I found that it’s a good way to treat it without a lot of the hepatic side effects and it’s been proven to be fairly effective this way so what I do is I have you take the medicine it’s a 250 milligrams tablet you take it once a day for a week and then off three weeks and then you repeat that three more times the classic way to prescribe for int for onychomycosis would be daily for 90 days it takes about nine to 12 months for your nails to grow out so it’s pretty slow process but with the pulse dosing I’ve had patients that that are on a lot of medicines that can still get the benefit of this and and have better looking toenails the other thing I stress with this is you will not get a very good result unless you do topical antifungal therapy it I tell everybody that I treat for onychomycosis it’s not even worth doing it if you’re not willing to do the topicals now there’s a easy topical that you can use lamisil 80 gel it’s a gel so you can use it between your toes where the fungus hangs out also I tell people to loot to put it around the toenail or even on the toenail because the fungus has to get in on the skin to get into the toenail so if you can keep the fungus off your skin theoretically you should be able to keep it out of your toenail but even with all that I’d say the success rate of treating onychomycosis is probably only in the seventy percent range this because it’s a mixed infection it’s not just dermatophytes or fungus it’s mold it’s yeast and we don’t have medicine to kill all those organisms but they have a symbiotic relationship they cling on to the dermatophyte and so if you can kill the dermatophyte oftentimes you can get a pretty good result with terbinafine so other things debridement 44 calluses pads I do a lot of this you can do this yourself with a pumice stone or emery board but calluses are very painful especially on the ball of the foot as you’re as the tissue atrophy but there’s some simple things that you can do with metatarsal pad I have those and I put those behind the metatarsal heads so it’s basically almost in the arch and that off weights the metatarsals and really can help with the callous pain topical catalytics those are basically creams that break down the stratum corneum which is the outer layer of the epidermis that builds up urea is one of the creams that’s available over the counter that’s a great keratolytic and it’s a great moisturizer there’s a cream that’s over the counter called cara solids ke Ras al and it’s a good keratolytic moisturizing cream that I often recommend sometimes surgery is necessary to remove the ingrown toenail or if they have a bony prominence classically this is on the little toe where they get a really thick callous and are not able to wear shoes comfortably it’s a pretty simple procedure where we make a small incision and remove that bony prominence and it doesn’t take a lot of down time and again as shoes shoes are so important I I know I probably spend too much time on shoes I like to keep things simple but I just see so many problems related to shoes and there the the wrong shoe for the wrong foot musculoskeletal conditions so these again are all pretty common the first one hallux valgus or bunion you don’t really develop a bunion from shoes that’s a misnomer you inherit that condition from your parents

basically you inherit all the good and the bad from your parents diabetes high blood pressure the propensity to develop arthritis all those all those things but hallux valgus it can really become painful if that bunion isn’t accommodated so getting a wide comfortable shoe is the first thing I always tell somebody hammer toes those are buckling of the tow the tow starts to bend it can bend at the you have two joints in your in your toe just like your finger so it can bend at the first joint here or it can bend at this joint you could be a clot oh it could be a hammer toe it could be a mallet toe so it could bend at the end like a ballot so all those conditions can lead to calluses on the top of the toes and that can lead to a pain painful condition again shoes that have a high toebox can accommodate those those problems hallux rigidus this is the most common form of arthritis in the foot it’s in the big toe joint the first metatarsophalangeal joint and it basically it’s a narrowing of the joint the joint starts to narrow it the joint becomes arthritic the cartilage starts to erode and you develop all these osteophytes or bone spurs on the top and on the sides of the joint that can be very painful because this is the main joint we use with propulsion it’s the it’s the joint that we push off with every step if you in you should have about 60 degrees of dorsiflexion in this joint for a normal gait if you don’t have adequate dorsiflexion in your joint you will have pain or you will compensate that gate you will walk on the side of the foot leading to other problems I often see people walking on the side of their foot and they come in well my side of the foot hurts but my big toe joint hurts too and that’s because the compensation they’re using their their supinating their foot they’re walking on the side of their foot and that’s causing the tendons on the side of the foot to get overtaxed and because they don’t have the range of motion in that joint for a normal gait the posterior tibialis dysfunction again this is a real common problem I see in the elderly the tendon starts to weaken the post your table of 10 is the main inverter of the arch it really supports the arch and that tends to atrophy it attenuates it loosens up and when that happens the arch starts to collapse and it in it and it flattens out leading to a flatfoot deformity and this can be a very painful scenario because the foot collapses in it pronates it becomes very unstable and that leads to a lot of foot leg pain up to change so it’s a pretty pretty significant problem achilles tendonitis plantar fasciitis I see this a lot as well as you get older you’re less flexible the tissue doesn’t repair itself as fast when you get injured it takes longer to get better I know this myself I I’ve been having calf polls lately and I used to be able to run without a problem and now I have to do all these exercises to keep things from breaking down and stretching and all that but it’s it’s important I think there’s a lot of emphasis on aerobic walking exercise that’s great but I think that we need to also look at other things to keep us moving our joints really need a lot of flexibility and strength training as well and strength training is really important yoga Pilates Tai Chi all these things are really helpful that you can all do to improve your mobility and and I think if if we were to to really look at that and do more flexibility after we exercise a lot of these overuse injuries like plantar fasciitis and achilles tendonitis wouldn’t be as as common so this is a picture of hammer toes you can see the toes the second and third toes actually all her toes are fairly contracted at that proximal that first joined this is obviously non-weight-bearing she’s not standing but if she were to stand the toe still would not flatten out and what this leads to is that there’s redness and pain on the top of those

joints because they stick so far up in our shoes the other thing that happens is the metatarsal becomes plantar flex so if you bend your your finger back your your metacarpal bone will plantar flex and that that makes the the callous or the ball of your foot more prominent and that can lead to calluses and pain so this is a fairly simple procedure to fix what we do typically for this is we fuse the joint we remove the cartilage on the sides of the bone and classically what I’ll do is what’s called a peg and hole fusion i will make a peg out of one of the bones and a corresponding hole and then i will dry vac a wire or wire through the toe shish kebab in the toe if you will to straighten it and that will the the downside of that is it’s not going to bend at that joint but it doesn’t really Bend now anyway it’s fused basically in that position and if if you were to fuse it straight then it’s going to be a more functional toe this is an example of a bunion you can see the toe moving over and what we call the valgus the big toe is touching or a budding the second toe you can see the second third and fourth toe are all contracting they’re buckling and that especially look at the third toe if you’re walking on that toenail that is not a comfortable scenario and oftentimes I’ll see patients that have a really thick painful callus at the end of their toe and their nail will subsequently be thick and that’s because of the constant trauma to the nail the nail gets irritated that either a fungus develops in that or the nail plate or matrix becomes damaged in the nail gets very thick and it’s it’s it’s painful this is an example of an adult acquired flatfoot look at that arch she’s basically walking on her ankle bone there that is a very classic case of posterior tibialis dysfunction the poster tibialis tendon comes down the the ankle bone and inserts into the arch of the foot it’s the main supporter of the arch and she does not recall an injury or anything like that but she said that it’s just over time her her arch started to collapse in and I saw her initially for this a few years back and it was pretty uncomfortable and I put her in an insert and an a more supportive shoe and it definitely helped but it definitely can lead to a loss of mobility and a lot of discomfort so when this if this does happen and the patient is an active person it’s a fairly involved surgery but what we could do is we could do you can do a tendon transfer where we actually transfer one of the tendons next to the poster tribulus tendon and you you insert it or graft it into that area you in this scenario you’d have to do other work maybe a few some bone work as well but it’s a pretty good procedure for patients that have like a tear in their post your table attendant because it’s a really it can lead to really collapsed arch so what do you do for all these problems well if you tried wider shoes and that didn’t help then well you got to go to the next level I tell people when they come to see me if they’re bunion hurts I say well if it’s impacting your quality of life I think it’s then you need to have that fixed if you’re sacrificing your your your lifestyle if you don’t want to go for a walk or a run or a hike or go out with your grandchildren or whatever because your feet will hurt then that’s that’s not a good way to live your life so I I say if it’s a quality of life issue so because the surgery is a fairly simple non risk surgery so the bunion ectomy basically what we’re doing is we’re trying to realign that joint an osteotomy is basically a fancy word for cutting the bone we’re cutting the bone and we’re moving it over to realign that joint and after we do that we often use some sort of fixation to hold it in place so a screw a plate something because you can’t just cut it move it over and so back up it has to be fixated so it doesn’t move back into that that

malposition a fusion like I talked about for the hammer toe that straightens the toe for a hammer toe an X aust ectomy basically just removing a bony prominence that’s causing pain sometimes people have a bunion but their toe is straight either on the top or the side but there but they’re having a lot of pain in their shoes by this lady that ran she was 74 years old she ran for 25 miles a day and she was getting a painful callus from her bunion her toe is straight but she had a big bump on the side of her toe and that led to a really painful callus all I did was I shaved off the bump and she was back running again so it doesn’t have to be a super involved procedure a common thing I do for hallux rigidus or the arthritis in the first metatarsophalangeal joint is what we call a decompression osteotomy you want to decompress that joint because the joint is jammed so there’s no motion there so what we do is we take a wedge of the bone out of the metatarsal essentially shortening that bone so that joint the two bones can move and when we do that we also shave off the top spurs and the sides and basically remodel that joint if there’s erosion in the cartilage often it’s what we do is we fenna straight or poke holes in the erosion of the cartilage and what that does it brings in fibrocartilage it’s not as good as that as the original hyaline cartilage that we’re born with but it’s it’s better than nothing you can put an implant in the joint basically that acts like a spacer so if you go in there and the joint is really not in good condition what I mean by that is the cartilage is really eroded oftentimes it’s just one side of the joint that’s damaged the other side might be okay and in that scenario you can put a partial implant so basically you put a stem of titanium in that joint to act as a spacer where that cartilage was in it’s similar to what they do in hip replacements if all else fails you confuse the joint fusion is not obviously the first option but I think that it’s a great procedure for people that have a lot of joint pain and they have cartilage that’s gone because the pain they’re having from that joint is from their loss of cartilage its bone rubbing on bone and usually at that point they have pretty poor range of motion anyways so if you fuse that joint you’re eliminating that painful motion and they’re still functional I’ve I’ve fused joints in people even under 60 and they have been very active and lead a pretty active life so it’s obviously not my first first shot I would not want to do that but it’s definitely something that that can be done so this is an example of hallux valgus or bunion this person was older you can kind of look at the x-ray and see that she’s got osteoporosis the bone doesn’t really look super strong it’s got kind of a black appearance to it especially in the distal toes the the two bones underneath the bunion those are assessed my bones everybody has those bones they look like a cloud underneath that first metatarsal head and this is after surgery so what we did is I realigned the joy you can see the toe is straighter now and on this person she was in her 80s she had osteoporosis her bone was pretty soft so I used a plate and I usually just use a screw or two but this actually i used a plate and four screws because the bone was soft and that’s another problem that you see this particular lady had other health issues I think she was on prednisone and so forth so she had had problems with that but you need to be aware of those problems before you go in and operate in somebody so that’s why I a bigger fixation unit the being the plate and the screws but again I think if if you’re active and you can you have a good body weight and you’re in good condition because you’re active you can have surgery at this age and not be high-risk so this is an example of hallux rigidus you can look at the joint compared to the other joints the other joints are nice and round you can see

the joint space there the joint is square almost there’s a squaring of the whole joint you can’t really see a lot of joint space there because of all the Arthritis there this actually was someone in her 50s I’ve seen it in all ages but I definitely after the fourth decade I think you know it’s not like we’re sent out to pasture but that definitely is when a lot of problems begin but this woman had a lot of pain she was a walker she she just did not have the range of motion required for a normal gait and so we went ahead and fixed that this is a lateral view you can see that spur on top there how prominent it is now can you imagine putting your slit like that into little pumps I mean I don’t see how anybody could could do that but even a regular athletic shoe she was having problems with that so this is classic how rigidus there’s osteophytes or bone spurs all over on the top and the sides and a loss of joint space and so this is what i did i did a decompression osteotomy basically i shaved off all the bone spurs and i took a wedge of bone from the metatarsal and that screw goes on a button oblique way I shorten that bone so she could move her toe and there was a lot of cartilage erosion is well in there and so I drilled some holes in her cartilage and I I have them do aggressive physical therapy right afterwards because scar tissue is going to form that’s just that’s just a given after surgery but if you can really try to immobilize the joint and move it and be active she’s done great that she’s she’s about six weeks down this is an example of an implant it’s a titanium cap basically this woman had hallux rigidus again she had osteoarthritis of that joint and again this is the main joint that becomes arthritic in the foot what we did was we put this spacer in because her articular cartilage on her toe the proximal phalanx wasn’t very bad it’s usually the metatarsal head that has a lot of the problem and so we put that in there she was shaved off the Spurs it’s not going to be you know perfect but it basically will give her a better range of motion and less grinding where it was bone on bone before so this is an example of effusion and this woman was under 60 she had a couple of surgeries before she had really bad arthritis in that joint and we did what’s called a colectomy first which is basically removing the bone spurs on that range of motion was better than we actually did another surgery where I took the made the bone cut the decompression osteotomies shorten the bone and it just it just didn’t of her enough range of motion and she continued to have pain as she’s a power walker she walks everyday she’s had both of her joints fused and it’s not obviously the best thing for everybody but it definitely can be done and you can still lead a pretty active life you can see that joints been eliminated with that plate and those screws so shoes really industries I can’t tell you how shoes play such a big role in foot pain so I was talking about shoes with the high toe box that means that they are high in the in the toe height so SAS shoes MBT shoes it’s M as in Mary bees and boy cheese and Taylor these are shoes that are very accommodating for the foot the SAS shoes you probably are familiar with her there again they’re wide with a high toe box and they can accommodate a lot of different problems the MBT shoe is a shoe that has this concave or rocker bottom sole and what does that do well it allows you to walk without having to stress your foot so if you have a lot of arthritis or you just have plantar fasciitis any kind of really painful condition that can be improved by this shoe it’s kind of the concept we use like when we put somebody in a cast if you were to see a cast like a walking boot they have a rocker bottom and that again is to just propel the foot without a lot of energy and and

motion is there an sas type shoot that’s a little bit dressier not so orthopedic looking and yes there are absolutely you want vent you want to have something nice but you don’t want to look like Herman Munster either Hannah so I don’t know if I believe all the things that they claim to do about improving your strength and your tone of your legs they kind of go overboard on their average but i do think for a painful foot it can be it can definitely get help and then running shoes running shoes is my most favorite shoe out of anything I if I can wear running shoes that’s the shoe I’m in because a running shoe can provide stability or cushioning they make it differently for different foot types so if you have a flat foot you need more stability or more motion control if you have a high arch foot you typically need more cushioning that’s why I really like for any reason you don’t have to be a runner to enjoy a running shoes walkers can benefit from the running shoe orthotics and inserts so personally I think they’re overprescribed I think there are definitely there’s a role for them it’s especially like if you saw that you know adult acquired flatfoot person there’s no way they could wear over the counter in Seoul and they they’re great for chronic plantar fasciitis and so forth and other problems I do think they’re the best solution for long-term plantar fasciitis because plantar fascia it gets injured it’s stretched and you get little tears in the faccia that leads to thickening and scar tissue and one of the things that helps heal it is that if it’s supportive and if it’s if you don’t have that and your foot continues to stretch out that fashion kind of read tears itself and it could be a really painful situation but super feet are great i wear up in my shoes they don’t work for everybody but that’s one of the first things i recommend for people for plantar fasciitis or foot pain and it’s just a good thing that you can put in your shoes to supplement the support these are examples of other paths I use the white pad on the left is a metatarsal pad and that’s great if you have a painful problem on the ball of your foot you can put this behind the ball to off weight that weight bearing part of your foot the one on the right is also great if you have pain in that joint life from arthritis or the sesamoid bones are often injured those are those bean shaped bones that are under the the ball of the foot the thing on the right are he lifts I use those a lot for achilles tendonitis because if you have achilles tendonitis you want to elevate the heel because the achilles tendon is the biggest thing on your body your what using it with every step you can’t rest it if you’re going to walk and live your life so you have to do things like heel lifts and appropriate shoes to to calm it down cartilage replacement so we don’t really have artificial cartlidge yet to inject into our joints it doesn’t really work that great yet so there is a procedure called the oats procedure and basically you’re transplanting good cartilage into where the bad cartilage wasn’t there and it works pretty well in the ankle and in the metatarsal heads the average time to heal is three to six months and the initial results are fairly promising this is kind of a schematic of what’s done again in the ankle bone and in the first mpj or the primary places that it’s used this is kind of a schematic what they do the cartilage is eroded in the first slide you take a plug of that eroded cartlidge you remove it you harvest some good cartilage from another part of the foot or ankle and then you insert that plug into the area that was the cartilage was eroded and again initial results are fairly good it takes about three to six months for complete healing they’ve been doing it in the knees well for four years and we’re just kind of transferring that technology into the foot and ankle do supplements help again glucosamine and chondroitin sulfate these are two natural occurring substances that’s found in cartilage and they are recommended a lot for arthritis do they really work well the gate study showed that people that had severe arthritic pain and the knee it did prove that it was effective about eighty percent of people improved wasn’t that effective for people that have had mild arthritic pain now does that translate into the foot we don’t really know but for me if I had to take a supplement and it’s you know it’s fairly safe there’s some GI upset with it but other

than that I would probably recommend it if you had severe arthritis as a preventative thing what kind of exercise you can do for your feet basically you can walk in the sand sand walking is excellent for that it builds up the intrinsic muscles of your foot that those small muscles that that if the atrophy that can lead to all these deformities and I find that like I say I see a lot of foot pain in the summer months when people were a lot of sandals or backless shoes or flip flops those are very popular especially with kids I see so much foot pain from that because the shoe is not supportive enough but I do think that our feet have actually gotten weaker because our shoes are better and I do think that we don’t do enough kind of foot strengthening exercises that we should so I do think those those exercises I recommend it is helpful also yoga which is done barefoot is definitely helpful for that other things that I tell people to do our try to pick up marbles with their toes or pencils or you can grab a towel with your toes other things that you can get are these big rubber bands called thera bands and you can put them around your foot and you can do window washing type exercises left right up down that helps the ankle muscles that’s very common after an ankle sprain those are probably some of the best things I would recommend you