Happy Holidays, A Time to Reflect

Sometimes with the holidays we get caught up in the hustle and bustle of cooking, cleaning, entertaining and shopping. However, with last weeks horrific tragedy it reminds me to take a step back and realize how much I have. I have my wonderful family with four beautiful healthy children and I am surrounded by my loving family. I am lucky enough to work with some wonderful people in a job I love and find rewarding. With the holidays upon us I hope you can take a few minutes to reflect on what is really special about these holidays, our health and families.
From all of us at Podiatry Care Specialists

Dr. "Sandie" Grulke
http://www.podiatrycarespecialists.com/

Todd Herremans Foot Injury

It has been a long football season for the Philadelphia Eagles and its about to get even longer for them. The latest an injury news for them is Todd Herremans. Herremans has a rare injury where he dislocated the cuboid bone and dislocated the peroneal tendons while doing this. The foot has many different bones, ligaments, and joints.

The cuboid bone as seen in the picture is located on the outside part of the foot. The peroneal tendons run along the side of this bone and help to control the outward movement of the foot. 

Team Doctors are still deciding on what to do for him. Whether to perform surgery to fix the dislocation or place him in a CamWalker. 

It is always important to know when to call a Podiatrist for any injuries that you may suffer. Pain is not normal, and if you are experiencing it, dont delay!

Dr Chad Friedman

http://www.podiatrycarespecialists.com/

A Marathon in Flip Flops?

Last week I read an article of a man attempting to break into the Guiness Book of World Records by running a marathon in flip flops. Unfortunately, he was unable to break the world record but he did develop pain in the balls of his feet, sore quadriceps and blisters.  In fact the article from Runner's World By Scott Douglas stated "By the following day, Levasseur said, the balls of his feet were "quite sore," in part because "with the minimal padding and inability to place my foot like I normally do, I had to slap the front of my foot quite a bit, especially on the downhills." Levasseur said his ankles and quadriceps were also more sore than usual because of his altered gait."  This reminds me how important having the right shoes for the particular activity is. Now maybe we do not go to the extremes as far as attempting to wear flip flops while running a marathon, but we have trouble wearing the appropriate shoes. For example, for the day "out shopping" in shoe boots look great but an hour into shopping, our feet may not think so. What can wearing the wrong shoes do to your feet?

First, blisters on feet are a common problem caused by friction from shoes or socks which rubs repeatedly on the skin. If the shoe fits improperly, the resulting friction can cause blisters on prominent areas of the foot such as the back of the heel or on the toes. By wearing roomier shoes, with wider toe boxes, and proper fitting shoes can prevent these problems. If you wear hiking boots ensure all seams are flat inside the boot. Take care of the boots, do not leave them on radiators or near heaters. This may cause the leather to shrink and cause the seams to protrude.  Keep feet as dry as possible. Wet shoes, boots and socks will cause blisters far quicker than dry ones. 

Ball of foot pain can develop with shoes without proper padding into the forefoot of the shoe. If you are a runner on a hard surface you need a shoe with a sufficient padding. Also, footwear with a narrow toe box forces the ball of foot area to be forced into a minimal amount of space. This can cause pain when walking. Another factor that can cause excessive pressure in the foot include shoes with heels that are too high. By purchasing shoes with a wider toe box and sufficient forefoot cushioning should eliminate ball of foot pain related to improper shoes.

Lastly, if you wear shoes without sufficient arch support you can develop ankle pain. The tendon that is the major supporter of the arch crosses the inside portion of the ankle as it attaches to the midfoot. This is the tibialis posterior tendon. If there is not enough support, the tendon can become irritated and inflamed as it works harder to support the arch. Behind the ankle the blood supply to the tendon is the poorest so this is the area most susceptible area to injury. By wearing shoes with good arch supports with an orthotic that will externally support the arch and take away the need for this tendon to work so hard.

I don't believe many people would wear flip flops to run a marathon but I don't believe we consider how appropriate our shoes are for our daily activities.

Dr. "Sandie" Grulke
http://www.podiatrycarespecialists.com/

Comprehending a Doctor Visit

As the face of healthcare is changing, doctors are no longer going to be paid on productivity but on successful outcomes. However, a recent article in Forbes magazine recognizes that patients only understand or remember less than 20% of what their doctor tells them during their appointment. If a patient cannot understand or remember what was discussed with them, we have a very poor chance of a successful outcomes. Obviously, as a doctor we need to become better communicators. In our practice, we have used our own website as an adjunct teaching tool. By placing patient education and instructions on our website, we can easily refer patients there to answer questions they may have or re-explain something that they may have forgotten. However, here are a few tips to help you get the most information out of your visits with your doctor.

First, write down any questions or concerns you have. Often, I get phone calls several hours after an appointment about a concern a patient forgot to ask. Unfortunately, with a busy schedule it can take awhile to get back to the patient. It is much better to get these questions or concerns answered during your appointment.

Second, take notes. even if you are only able to put down a few key words, this can stimulate your memory. For example, when I am discussing heel pain I say there are 3 important tenets of treatment; reducing inflammation, stretching, and arch support.  If you are able to jot these down then when you get home you will remember that stretching is an integral part of the treatment plan for heel pain. Even if you don't remember the stretches demonstrated, you will remember that you need to stretch and can simply look on our website for the necessary stretches.

If it is an important visit that is going to be extended and detailed, for example, a pre-operative visit, where you expect the surgeon to discuss the surgery and post operative course, then bring someone else with you. 4 ears are better than 2.  As an example my mother went alone to her pre-op visit for her upcoming knee surgery. Afterwards I asked several basic questions such as: would she stay the night, would she go home, or go to a rehab hospital after the surgery. My mom stated she didn't think he went over these questions. Not to doubt my mom, but more than likely he did explain everything and she was just overwhelmed with so much information that she did not remember. It would have have helped to someone else with her to increase the chance of information retained.

As patients and doctors we need to become a better communicators. Doctors must work on conversing in 2 languages; the medical one, and most importantly being able to translate medical terms into layman's terms for our patients. Patients need to make sure the information is comprehended to ensure a cohesive relationship.

Dr "Sandie" Grulke
http://www.podiatrycarespecialists.com/

I never heard of a Lis Franc injury

 To add to the New York Jet's woes, wide receiver Santonio Holmes may have suffered a dreaded Lis Franc's injury. He crumpled after catching the ball and seemed to loose his footing. So far x-rays are negative. A copy of his MRI is being sent to a leading foot surgeon to read. What is this and why is this such a devastating injury? When might he be able to return? To answer these questions it is important to understand the complex anatomy in this area of the foot.

The Lis franc's area is made up of five long bones called the metatarsal bones and 4 smaller bones( the cuboid and 3 cuneiforms). In addition, there are several soft tissue structures that hold these joints together, the biggest one is between the bones closest to the inside of the midfoot called the Lis Franc ligament (named after a French surgeon who preformed amputations in the midfoot during war times). Injury can occur causing fractures of the bone, dislocations of the mid-foot joints, or injury to the soft tissues surrounding these areas. Injury can occur through direct injury, such as dropping a heavy object on the foot, or indirectly through a twisting injury when the foot is fixed to the ground, i.e.- a cleat stuck in the turf. With these injuries, the joints can be damaged along with the cartiledge. With fractures or a tear of the Lis Franc ligament, surgery may be needed to achieve a more stable foot. The recovery time is 6-8 weeks non-weight bearing following the surgery and progressing over the next 2 months from non- to partial- to finally full-weight bearing. The concern with this injury is whether there is a return of the mobility of the midfoot. Often, professional athletes' ability to return to professional sports is questionable.

The x-rays for Santonio Holmes are negative but let's hope the MRI does not show a Lis Franc's ligament tear. "Gang Green" has enough issues for this season.

Dr. "Sandie" Grulke
http://www.podiatrycarespecialists.com/

Ryan Howard Fractured Toe

Ryan Howard can not catch a break!!! Literally. The latest injury he has suffered was a broken big toe. And how did he do it?? Dropping a lead pipe on it. He suffered a chip (or avulsion) fracture off the big toe. Hopefully it just missed the joint. If it didn't, there is a chance he may develop arthritis in the joint. The good news is that they said he does not need to wear a camwalker like he did when he ruptured his Achilles tendon last year. He also has a wedding coming up in December and they said should be fine by then.

Chip or avulsion fractures can occur at any bone. It usually involoves ligaments or tendons that can cause a sudden contraction that "avulses" or "chips" off a potion of the bone. The X-rays show an example of this.
 So how does one treat this? It depends on how big the fracture is, if it is located in the joint, and if there is displacement. Some may require a screw or a pin to help fixate the fracture.


One should always seek their Podiatrist for treatment for any toe fracture. If a toe is broken, there is something that can be done with them besides just splinting it.

Please visit our website for more information.
http://www.podiatrycarespecialists.com/

What are those Nike green shoes that I see on the Olympic athletes?

If you have been watching this years Olympics, you might have seen those bright green sneakers that the Olympic runners have been wearing. What are those you might ask? Those are the Nike Flyknit shoes. These shoes are trying to be as close as the minimalist shoes that are our their now. They have a special stitching that will knit the sneakers upper part with individual threads that will make them very lightweight.

These sneakers were unveiled back in February and sparked a lot of interest in the running community. Now with millions of people watching the Olympics it is starting to spark the trend all over again. The release date was July 27, 2012. It appears the only place at the current time to get these are online at Nike.com

When looking for athletic shoes it is important to look for quality characteristics that makes the shoe comfortable and well constructed. Running shoes must be lightweight, yet well supported. For most recreational runners, walkers, and athletes; a good cross trainer is sufficient.

Foot type is also important as athletic shoes are now manufactured more specific for a flat foot, a high instep, and you have a propensity to pronate (arch flattens) or supinate (foot rolls to the outside).

For more information please visit our webpage
http://www.podiatrycarespecialists.com/

Are There Healthy Flip Flops ?

The summer is coming and the weather is definitely getting warmer. We have traded our sweaters and pants for shorts and tanks. We also have kicked off our sensible cold winter shoes and now need to

look for sensible summer sandals. But are there summer sandals that are good for you feet? YES.

In general,  the concern with flip flops is the lack of support. The flimsy rubber flip flops offer no arch support and result in overworking  of the muscles in the legs and feet. As a result the toes curl, the arch ligaments can be strained, or you can develop tendinitis around the ankle. In addition, the plantar fascia can be put under strain which can result in heel pain. Also, flip flops tend to be a flat rubber mat which can cause ankle sprains. The lack of a heel cup in a flip flop also allows the heel to move excessively and can allow the ankle to roll and  be more susceptible to a sprain. 

Newer sandals have been engineered to have built in arch support or custom orthotics, such as Sandalistas by Aetrex or Dr. Comfort flip flops. In general cork soles are better than most rubber soles. Look for solid straps or Velcro straps to hold your foot securely in the sandal.

For more information regarding healthy flip flops please watch this informative video from APMA.

Dr. "Sandie" Grulke
http://www.podiatrycarespecialists.com/

Hakeem Nicks Foot Fracture

Giants WR Hakeem Nicks fractured his foot during OTAs today. He’ll undergo surgery on Friday to have a screw inserted into the broken bone. The team expects Nicks to be out 12 weeks. That timetable would have him back by mid-August. He’ll miss virtually all of training camp, but barring a setback, he should be able to get in some action in the preseason and be ready to roll for Week 1. There are 5 different types of 5th metatarsal fractures. The first type is called a Jones Fracture. Athletes will usually get these fixed because of the poor blood supply to the bone as it heals. 

These still can take a long time to heal and requires one to be in a cast  and non weight bearing.

http://www.podiatrycarespecialists.com/

Podiatrists can help lower back pain

Recently on the show "The Doctors" TM  a patient suffering from lower back pain was followed. She had attempted massages, strength training but her back pain persisted. She was examined on the show by a chiropractor who determined that in part her lower back pain was caused by her feet. He used a scanner showing areas of high pressure and weight distribution across both feet. Often, the feet are overlooked at the cause of ankle, knee, hip and lower back. However, your feet are your foundation of your body.

 In our office, we use a scanner similar to what is shown in the chiropractor's office. It allows us to visulaize both feet while standing naturally. You can determine with the scan where there are areas of high pressure, where the center of gravity is, the arch height, and size of your feet. We use the scanner with on a large number of patients from patients with sport injuries to diabetic patients. With the results from the scanner you can prescribe insoles or orthotics that will try to restore the arch, regain a normal center of gravity or redistrubute pressure through the foot.

In scans with a decreased arch height often means a flatfoot. With the foot collapsing the ankle rolls inward with the knee and hip follow the ankle. This results in more pressure being in the inside portion of the knee and hip and can result in knee, hip and lower back pain. High arched feet are associated with high insteps. In extreme cases these feet are rigid, limit shock absorption from having reduced ground contact area and can result in foot pain. On a scan that shows an area of high pressure can be as a result of corns, calluses, hammertoes, bunions, etc. The concern especially in the diabetic population is these high pressure areas can result in ulcerations.

The scanner has become an effective tool in our efforts to treat lower extremity pain. Often the feet are overlooked as a cause of back, hip and knee pain. Your feet are the foundation for the rest of your body. If there is some problem with the foundation other problems can result. If you are suffering from lower back pain, knee and hip pain consider that your feet may be the problem.

Dr. "Sandie" Grulke
http://www.podiatrycarespecialists.com/

Michael Martinez fractures his 4th metatarsal

The last thing the Phillies needed was another injury but unfortunately on Tuesday in the game against the Orioles, Michael Martinez suffered a foot fracture after being hit by a pitch. Like Chase Utley, Martinez will start the season on the disabled list.

Martinez suffered a 4th metatarsal fracture after a pitch hit him directly in the foot. The metatarsal is a long bone that is located behind the digits. With a direct hit it seems that bone fractured but has remained in good position. If the bone had fractured into several pieces or moved away from each other surgery would be necessary. Instead, he will be forced to immobilize the area until healing occurs. The fracture fragments will knit together in 4-6 weeks. This process can be sped up with the use of a bone stimulator. A bone stimulator uses ultrasound or electric current (which does not hurt) to increase bone healing.

Hopefully he will heal uneventfully and be back on the playing field soon, the Phillies could use a break.

Dr. "Sandie"Grulke
http://www.podiatrycarespecialists.com/

Ingrown Toenail West Chester and Newtown Square Update

A few weeks ago we talked about ingrown toenails. An ingrown toenail can occur on any of the toes (as well as fingernails). They can occur from improper trimming of the nails, trauma to the nail, family history of ingrown toenails, style of shoe/sneakers, and toe deformities (such as a bunion or hammertoe). Treatment options vary depending on how severe the toenail is. The pain can actually come from a callous that has formed in the corner of the nail. As the toenail grows into the skin, a callous may form in the corner of the nail. This also may cause some pain more so than the ingrown nail. Both usually will get removed when they are present.

One may also develop referred pain of the ingrown nail where it will happen at the base of the nail or even around the joint of the nail. Its always important to get these checked out if you are dealing with pain to prevent them from getting infected. Most of the over the counter products do NOT work and can make it worse.

If you keep getting ingrown nails, there is a minor in-office procedure that can be done to help prevent the ingrown nail from coming back.

Please visit our website for more information and a video on ingrown toenails!

Chad Friedman, DPM

http://www.podiatrycarespecialists.com/videos.html

Ingrown Toenails in Newtown Square or Audubon PA?

Is your toe hurting at the nail corner? Is it red or inflamed? Then you may have an ingrown toenail. If so, this can be fixed with going to see your Podiatrist. It is important to see someone when it begins to hurt. This can help to prevent it before it gets infected. If you continue to keep getting them, there is a an office procedure that can be done to help prevent them from growing into the corner. If you live in the West Chester, PA, Newtown Square, or Audubon area, please make an appointment to be seen.



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