Back to School - Prevent Foot Pain

Kids are heading back to school, with backpacks packed, lunches filled with nutritious food and heads waiting to be filled with information. However, one thing that they kids should not have as they start the school year is foot pain. Foot pain is not normal in kids or adults. Most kids have been wearing flip flops all summer long and now as they head back to school it is not uncommon for foot pain to have developed. What problems may your kids complain about?

First, flip flops do not offer support or cushion. Kids can develop arch pain from the lack of support from flip flops. This develops from the Posterior Tibial Tendon, the major supporter of the arch, can develop a tendonitis, or inflammation around the tendon. As the tendon works hard to hold up the arch the bones continue to allow the foot to roll in and cause the tendon to become inflamed and over used. Pain can be sharp or achy in the instep or around the inside of the ankle.

Another problem that can develop from long term flip flop usage is heel pain. Adults heel pain is a result of a strain or pulling of a long ligament on the bottom of the foot called the plantar fascia. However, children with heel pain is normally the result of an irritation of a growth plate. Achilles tendon, is tight and pulls on the growth plate of the heel bone or from a lack of cushion at the growth plate.  According to ACFAS, American College of Foot and Ankle Surgeons, " People often don't realize that even into your mid-teens, there's new bone growing in your heel. Flip-flops don't cushion the heel, so repetitive stress from walking can inflame that heel bone growth area and cause pain and tenderness".

Bones grow in length at a growth plate. This is an area of soft tissue between two bones where new bone is produced. If there is a tension across this area, inflammation and pain can result. Normally, tension can result if the heel cord,

Now that they are back to school and out of flip flops, make sure they are rotating their shoes. Fungus lives in everyone's shoes including children.  The fungus likes the dark moist environment. If shoes are worn daily, especially when the feet perspire, this could lead to an overgrowth of fungus in the shoes. Fungus is the cause of athlete's feet infections, a fungal skin infection, and onychomycosis, fungal toenails. By rotating the shoes and treating the shoes with an anti fungal spray you can reduce the fungus within the shoes and reduce the chance of developing fungal issues.

To make sure the kids are starting with their best foot forward this school year make sure they are starting the school year without foot pain.
Have a safe and happy school year!

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

For years we have been trying to educate patients on the damages improper shoewear can cause. Now, thanks to a newly developed 3-D scanner from the UK called the PedCAT, the detrimental affects of poor shoes can be clearly visualized. The PedCAT machine, the first of its kind from the UK, does a 360-degree scan of the patient's feet in just 60 seconds. Podiatrists can then view the resultant 3D image from every angle, spinning it around to view the foot from above, below and the side. It also takes 600 2D views of the foot.

The image allows the podiatrist to see 3-D scans of the foot in the position the foot normal functions.  These 3-D images allows the Podiatrist to make accurate diagnosis. X-rays can often be confusing because the image is one dimensional and there is a lot of superimposition of the bones. However, the price has made this machine a  luxury that most doctor's office cannot afford, with a price tag well over $300,000. With the advances in technology it may not be long until this becomes a cost effective reality.

Dr. Alexandra "Sandie" Grulke
Dr. Brad Jacobs

http://www.podiatrycarespecialists.com/

And the Oscar goes to....

Millions of people were glued to the TV on Sunday night to watch all the glitz and glamour of the "Red Carpet", like myself. I enjoy seeing what everyone is wearing and who they are with. I was surprised to see crutches make an appearance on the red carpet. Kristen Stewart, of Twilight fame, ambulated down the red carpet on crutches Sunday because she stepped and cut her foot on glass. Ouch! Just a good reminder of how careful you have to be with your feet, especially if you have diabetes.  If a healthy young women can cut her foot so badly on glass that she requires crutches on Oscar night reinforces what podiatrists preach, that people with health and foot issues need to be careful. The biggest health issue affecting the feet is Diabetes.

There are three things that can be affected in regards to your feet and diabetes.  Diabetes is the inability of your body to produce enough insulin or utilizing the insulin our body produces. The hormone insulin allows the sugar that is produced by the breakdown of food to be moved into organs to be used as energy. However in diabetes, the sugar remains in the blood and cannot be used as energy. Eventually the blood sugar can get absorbed into the lining of the small blood vessels such as the small arteries in your toes, fingers, eyes, etc. This causes the arteries to become calcified and limits the blood flow to the affected area, commonly called Peripheral Artery Disease or PAD.

Secondly, the blood sugar can get absorbed into nerves causing chemical nerve damage, called neuropathy. This results in numbness, burning, tingling, and pain. Often the first symptoms can be felt at night only and can be painful. Eventually, this can progress to complete numbness. This is when people are at most risk for developing problems. Because they cannot feel, they often wear shoes that are too tight, step on something, cut their feet, etc and do not realize it. Often the first sign of a problem for them  is when they see drainage or blood on their sock or on the floor, and unfortunately it may be days afterwards that this is initially noticed. For this reason it is extremely important if you are suffering from neuropathy, daily inspections of your feet must occur.

The third major complication of diabetes related to your feet is the higher your blood sugar is, the less able your body is to fight off infection. The white blood cells (that are the body's major defensive cells against bacteria) and viruses are inactive when the sugar levels in your blood is high. This can make it difficult to try and heal a problem once this process has started.

Prevention is the key with people with diabetes or other foot health issues. Don't forget to see your podiatrist at the first sign of trouble. Now we can focus on the best and worst dressed at the Oscar's. I loved Anne Hathaway's dress and did you see Jennifer Lawrence fall on the way to receiving her Oscar (another potential podiatric patient).

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

Your Health and the Internet

The internet has a wealth of information on every topic. So it is not surprising that between 79-89% of internet users spend time looking up medical information, according to an article Sharing Internet Health Information With Your Doctor. So how do you determine what sites are reliable? How do you know that the information is up to date and not a self serving promotional ad?

First, look at who is sponsoring an ad.
Often drug companies will have information regarding a disease that their medication can treat. If you find only one treatment option for a particular disease then most likely this is disguised as an advertisement. You should look for websites run by respected academic, governmental, medical, and nonprofit organizations and institutions or specific websites directed to you by your doctor. A study conducted by the Pew Internet & American Life Project in 2007  found that while eight in 10 American adults have consulted the Web for health care information, 75% failed to check a source's validity or relevance. The source of the information is just as important as the content of the site.

Second, be careful.
Recent research into peoples search engine habits suggests that people are more likely to progress from benign to more serious medical inquiries, the longer they search for information. Your simple heel pain search can quickly lead to concerns of bone cancer or compartment syndrome, which are very rare causes of heel pain. Also, be specific when searching for your symptoms but also realize some conditions can only be diagnosed by your physician after a full understanding of your medical issue.

Third, consult a physician.
Seek out a physicians expertise to discuss your findings on the internet. A visit with your physician will be to address all of your questions regarding your medical issues.  Also, make a list of your questions or concerns when you see your physician so you can get as many of them answered from your appointment.

The internet can be a fantastic tool in conjunction with a visit to your healthcare provider. However, always consider your sources. Be specific with your symptoms. The internet can be a good starting point in looking up and treating your medical condition but do not hesitate to consult a physician also.

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

APMA Seal of Acceptance

A sure sign of Spring is the Summer children's shoe catalogs are out. Yesterday in the mail I received a catalog for a local shoe store with all the summer sandals and sneakers in bright happy colors. I noticed some of the shoes brands in the catalog had a symbol located near the name.

So what does this mean. Are these shoes better than other shoes listed in the catalog? What advantage do these shoes have for your children's feet that other shoes do not have?
I went to the APMA website to see what this symbol meant and what these shoes companies had to do to get this seal of acceptance. The Seal of Acceptance is given to footwear, insoles, hosiery or equipment. The Seal is given to the companies that have proven the footwear or equipment allows normal foot function or promotes foot health. The companies must provide the Podiatric Seals Committee with research documentation of the benefits of the products, as well as, composition and quality control procedures. It is important to note that the Seals Committee does not evaluate footwear companies that have not applied for the seal, nor does it evaluate one footwear brand versus another. The companies that have been approved with a Seal of Acceptance are required to re-qualify every 3 years .

The Seal of Acceptance should be used as a guide when shopping for shoes. However, everyone's foot is different and therefore this should not be the only reason to buy a shoe.

For more shoe buying tips see an earlier blog we posted http://howtotreatfootproblems.blogspot.com/2012/01/first-question-out-of-most-peoples.html.

Dr. Alexandra "Sandie" Grulke

http://www.podiatrycarespecialists.com/

How far would you go to wear Stilettos?

As young girls we have heard the phrase "Beauty hurts." This definitely includes the trend of wearing stilettos. As a result of wearing these high heels, women are developing a host of foot problems including corns, calluses, hammertoes, bunions and ball of foot pain. Some have even gone as far as to surgically alter their feet to allow them to wear stilettos. Procedures such as toe shortening or even removal of the 5th toe to allow a more comfortable fit of these high heel shoes have been performed. When is it appropriate for these surgical procedures and what else other than surgery can you do to wear shoes comfortably?

Stiletto

According to Fox News Garrett Tenney, Eighty-seven percent of women have had foot problems from wearing uncomfortable or ill-fitting shoes such as high heels, according to the American Podiatric Medical Association. So to avoid surgery, a more practical solution is sensible shoes. Nowadays, a sensible shoe does not necessarily mean an ugly one, so here are some tips as to what to look for in a sensible shoe.  Firstoff, a squared toe box in the front of shoes allows much more room  than a pointed toe box. The toes will not rub in the shoes or be cramped and therefore, will reduce pain and pressure. The pressure from the toes rubbing on the shoes can cause the corns and calluses to develop. Then shopping for a lower heel causes less pressure on the forefoot  and lessens potential ball of foot pain. A stiletto heel can be anywhere from 1 inch heel to believe it or not, a 10 inch heel! When you are walking, the entire body weight is supported by your foot. When you are wearing a shoe with a high heel, 8 times your body weight is being supported by your forefoot, according to a study from Indiana University. So it is not too surprising that you instantly can develop pain under the ball of the foot after wearing stiletto heels.



More sensible Aetrex shoe

The thought of doing surgical procedures for purely aesthetic reasons reminds me of the handouts that come with your prescription medications. This states your doctor has decided the benefits of the medication out weigh the risks. In terms of anesthetic surgery, the risks seem to out weigh the benefits. Typically we recommend surgery when the pain is preventing a patient from doing their normal daily activities and maintain their quality of life. In these cases the surgical benefits far out weigh the risks. But to perform surgery when pain is associated only to accomodate a certain style of shoes is not in their best interests. In fact both the APMA and American College of Foot and Ankle Surgeons do not recommend cosmetic foot surgery. According to Fox News Garret Tenney's article, "surgical procedures of the foot and ankle are generally performed for relief of pain, restoration of function, and reconstruction of deformities". Patients considering surgery of the foot or ankle, whether for medical or aesthetic reasons, are advised to consult a member of the American Podiatric Medical Association. "Surgery performed solely for the purpose of improving the appearance or size of the foot or ankle carries risks without a medical benefit, and therefore should not be undertaken,” according to the American College of Foot and Ankle Surgeons.

Is this what we are heading to?

 

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

Scott Hartnell Fractured Foot

Scott Hartnell from the Philadelphia Flyers has suffered a fracture of his first metatarsal. While he was playing, he took a puck shot to the foot that broke the bone.  He had successful surgery the other day to have this repaired and will be out for up to 6-8 weeks. If you have suffered from a foot or ankle injury it is always important to have this evaluated.

http://www.podiatrycarespecialists.com/

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/