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Women’s feet hurt more in autumn

Fall season is fast approaching.  

Autumn is a painful time of year for many New York women.

As they transition from open-toed sandals to closed-in boots and shoes, I notice more women seeking relief for painful bunions.
Some of my female bunion patients are in agony. They describe a constant, throbbing pain, even when they take their shoes off.

While the changing weather brings more bunion patients into my office, some women inquire about surgery in the fall because they’re less busy than in summer months. Many are also closer to meeting their insurance deductibles.

I emphasize that surgery is a last-resort treatment for women with painful bunions.

For many women, simple changes like wearing shoes with wider toe boxes can significantly reduce bunion pain. Custom shoe inserts, gel- or foam-filled padding and anti-inflammatory medications may also provide pain relief.

When the pain of a bunion interferes with a woman’s daily activities, it’s time to discuss surgical options.

Glenn J Donovan, DPM

Dr. Donovan is the Chief of Podiatry at Coney Island Hospital.

For more information on  foot problems  please contact Dr. Donovan at 718-616-5509

Surgical GPS

I have a terrible sense of direction. I always take getting lost in stride. I tell my wife that I am late because I am exploring new areas; she knows better and does not believe me. She says my brain is too clogged with knowledge about surgery and anatomy and that there was no room for information about the streets of New York. GPS has changed my life. I now have a device that helps me know where I am, where I am going, and how to connect the dots.

In surgery I do not get lost. I always know where I am, and what my goal is. The art of surgery is how to connect those dots. When doing hip replacement surgery we implant artificial parts to replace a damaged joint. There is a range of positions, a neighborhood of acceptable alignments that you can implant the parts in and expect an excellent result. We have found that with the newer materials we sometimes use the acceptable neighborhood is quite small. So small in fact that is difficult for surgeons to consistently achieve the level of precision needed to ensure an excellent result. In other words mere human surgeons cannot always put the implant in the best possible position. The problem is that it is very difficult to precisely asses the alignment of the body lying on the table. The visible anatomy does not lend itself to the new degree of precision needed.

Enter CAS or computer assisted surgery. This is a GPS system for the OR. Instead of satellites we use a special three dimensional camera and a series of infra-red trackers. The camera sees the trackers and sends their location to the computer. At the beginning of the procedure I place a pin in the pelvis and electronically mark a number of anatomical landmarks. The computer remembers this and during the procedure I input internal positions until the computer can generate an accurate model of the hip. This model is displayed on a screen.  My surgical instruments have trackers on them as well so that while I am working on the hip I see an Avatar of the hip and the instruments I am using. Thankfully we are not blue as in the movie.  As I move the instruments the images move in real time. Along with the images I see a numerical readout of the alignment and position of the implant. When I see the position and alignment numbers I want, I am done. Many scientific studies have validated the accuracy of the system I am now using. The majority of hip replacements are done using materials that do not demand this high degree of precision. However when using these materials CAS is extraordinarily helpful.

I have always enjoyed driving but was sometimes a little nervous when I had to go someplace new. I would have a nagging concern about finding the right place. GPS has alleviated that concern. Similarly, I enjoy performing surgery, but had some minor concern about being able to be accurate enough to do the best for my patients when using newer materials. CAS like GPS has completely alleviated that concern. With this technology I can offer the best to our patients, and find my way home quicker.

Jeffrey Passick, M.D.

Dr. Passick is the Director of Orthopedics at Coney Island Hospital. He can be contacted at 718-616-3440

Be Smart About Back-to-School Shoe Fitting

In previous blogs I talked about general shoe fitting for children.  With kids back in school after a summer of bare feet and sandals, parents are shopping for shoes for feet that seem to have grown longer in just a few months.  To help busy parents with shoe choices, I recommend some simple guidelines to prevent or minimize possible foot problems from inappropriate shoes, such as painful ingrown toenails, blisters, heel pain and flat feet.

When choosing kids’ shoes, size and shock absorption are the key considerations, especially if your child has flat feet that can worsen from improper fitting or worn-out shoes. Also, a child’s foot can grow a size or two within six months, so it’s critical to allow room for growth in the toe box—about a finger’s width from the longest toe.” 

Snug shoes put pressure on the toes, causing ingrown nails. The nail compresses and grows down into the skin. Infection can occur when an ingrown nail breaks through the skin.

If there’s pain, redness and fluid draining from the area, it’s probably infected. The ingrown nail can be removed in a simple, in-office procedure. Don’t try to remove a child’s ingrown nail at home; this can cause the condition to worsen.

Tight-fitting shoes also cause blisters, corns and calluses on the toes and blisters on the back of the heels.

I recommend never buy shoes that feel tight and uncomfortable in the store. Don’t assume they will stretch or break in over time. 

Conversely, that shoes that are too loose can cause problems, too. 

If a shoe is too loose, the foot slides forward and puts excessive pressure on the toes.

I also recommend parents carefully inspect both new and old shoes to check for proper cushioning and arch support. 

Shoes lose their shock absorption over time, and wear and tear around the edges of the sole usually indicate it’s worn out and should be replaced. If a child keeps wearing worn-out or non-supportive dress or athletic shoes, it elevates the risk for developing heel pain, Achilles tendonitis and even ankle sprains and stress fractures.

A good tip for parents when buying new shoes: The toe box should flex easily and the shoe shouldn’t bend in the middle of the sole.

For children with flat feet, parents should buy oxford, lace-up shoes that have enough depth for an orthotic insert, if necessary. 

Unfortunately, there isn’t much choice for kids with flat, wide feet. They need shoes with a wide toe box and maximum arch support and shock absorption. Slip-on loafers aren’t right for them.

Glenn J Donovan, DPM

Dr. Donovan is the Chief of Podiatry at Coney Island Hospital.

For more information on  foot problems  please contact Dr. Donovan at 718-616-5509

Check Kids’ Feet Before School Starts

Simple at-home checks help spot foot problems

Back to school season is getting underway. I have included some advice for area parents.

Take five minutes to inspect your children’s feet for problems that could sideline your son or daughter from sports or other activities.

Parents should look for these warning signs:

Do the bottom of the child’s shoes show uneven wear patterns?

Does the child walk irregularly? Is one leg longer than the other or do feet turn in or out excessively?

Do pre-schoolers walk on their toes?

Does the child often trip or stumble?

Does the child complain of tired legs, night pains and cramping?

Following this checklist can uncover common problems like ingrown toenails to more serious problems like flat feet. If your child’s shoe is worn on the big toe side of their foot, it could be a sign of poor arch support or flat feet.”

I tell the parents of my Pediatric patients that they  can spot several potential foot problems by observing how their kids walk.

If you find out one of your child’s legs is longer than the other, heel lifts may be required to restore proper balance..

Early intervention can prevent scoliosis, a curvature of spine, later in life.

Sometimes younger children toe-walk because of tightness in their Achilles tendon. This  can happen when toddlers spend too much time in walkers.

I recommend stretching exercises that can be fun for small children and help prevent lower back pain as they get older. For older children beginning college, heel pain and shin splints can plague freshmen not used to walking long distances across campus to attend classes.

I see students every autumn complaining about pain from walking so much everyday. For most students, daily stretching and proper walking shoes can solve the problem. If there are foot deformities like hammertoes, surgery may be advised to make walking more comfortable.  “Growing pains” are a myth.

If your kids complain about tired legs, heel pain or leg or foot cramps at night, consider that a warning sign and see a doctor. Leg and foot pain can indicate flat feet or other disorders that are easier to treat the earlier they’re diagnosed.

Children with flat feet are at risk for arthritis later in life if the problem is left untreated.

Glenn J Donovan, DPM

Dr. Donovan is the Chief of Podiatry at Coney Island Hospital.

For more information on  foot problems  please contact Dr. Donovan at 718-616-5509

Going barefoot? Beware!

Shoes are the best way to protect your family’s feet from injuries. But if your summer just wouldn’t be the same without kicking off your shoes or sandals, you can still make it a safe season.

I offer these tips for a safer barefoot summer:

–See a foot and ankle surgeon within 24 hours for a puncture wound.

Why: These injuries can embed unsterile foreign objects deep inside the foot. A puncture wound must be cleaned properly and monitored throughout the healing process. This will help to avoid complications, such as tissue and bone infections or damage to tendons and muscles in the foot. Foot and ankle surgeons are trained to properly care for these injuries.

–Make sure you’ve been vaccinated against tetanus. Experts recommend teens and adults get a booster shot every 10 years.

Why: Cuts and puncture wounds from sharp objects can lead to infections and illnesses such as tetanus.

–Apply sunscreen to the tops and bottoms of your feet.

Why: Feet get sunburn too. Rare but deadly skin cancers can develop on the feet.

–Inspect your feet and your children’s feet on a routine basis for skin problems such as warts, calluses, ingrown toenails and suspicious moles, spots or freckles.

Why: The earlier a skin condition is detected, the easier it is for your foot and ankle surgeon to treat it.

–Wear flip-flops or sandals around swimming pools, locker rooms and beaches.

Why: To avoid cuts and abrasions from rough anti-slip surfaces and sharp objects hidden beneath sandy beaches, and to prevent contact with bacteria and viruses that can cause athlete’s foot, plantar warts, and other problems.

–Use common sense.

Why: Every year, people lose toes while mowing the lawn barefoot. Others suffer serious burns from accidentally stepping on stray campfire coals or fireworks. Murky rivers, lakes and ponds can conceal sharp objects underwater. People with diabetes should never go barefoot, even indoors, because their nervous system may not “feel” an injury and their circulatory system will struggle to heal breaks in the skin.

Glenn J Donovan, DPM

Dr. Donovan is the Chief of Podiatry at Coney Island Hospital.

For more information on  foot problems  please contact Dr. Donovan at 718-616-5509

Don’t let your feet ruin your day at the beach

Coney Island Hospital is surronded by the most popular beaches in Brooklyn.  There are 3 within walking distances:  Coney Island, Brighton and Manhattan Beaches. Hence the Podiatry Department sees many beach related injuries. As millions of Americans hit the beach this summer, I’d like to share these safety tips:

Puncture wounds and cuts: Wear shoes to protect your feet from puncture wounds and cuts caused by sea shells, broken glass and other sharp objects. Don’t go in the water if your skin gets cut – bacteria in oceans and lakes can cause infection. To avoid complications from a puncture wound, see a foot and ankle surgeon for treatment within 24 hours.

Jellyfish stings: Remember that a jellyfish washed up on the beach can still sting if you step on it. If their tentacles stick to the foot or ankle, remove them, but protect your hands from getting stung too. Vinegar, meat tenderizer or baking soda reduce pain and swelling. Most jellyfish stings heal within days, but if they don’t, medical treatment is required.

Sunburns: Feet get sunburn too. Rare but deadly skin cancers can occur on the foot. Don’t forget to apply sunscreen to the tops and bottoms of your feet. 

Burns: Sand, sidewalks and paved surfaces get hot in the summer sun. Wear shoes to protect your soles from getting burned, especially if you have diabetes.

Ankle injuries, arch and heel pain: Walking, jogging and playing sports on soft, uneven surfaces like sand frequently leads to arch pain, heel pain, ankle sprains and other injuries. Athletic shoes provide the heel cushioning and arch support that flip-flops and sandals lack. If injuries occur, use rest, ice, compression and elevation to ease pain and swelling. Any injury that does not resolve within a few days should be examined by a foot and ankle surgeon.

Diabetes risks: The 20 million Americans with diabetes face serious foot safety risks at the beach. The disease causes poor blood circulation and numbness in the feet. A diabetic may not feel pain from a cut, puncture wound or burn. Any type of skin break on a diabetic foot has the potential to get infected and ulcerate if it isn’t noticed right away. Diabetics should always wear shoes to the beach, and remove them regularly to check for foreign objects like sand and shells that can cause sores, ulcers and infections.

Glenn J Donovan, DPM

Dr. Donovan is the Chief of Podiatry at Coney Island Hospital.

For more information on  foot problems  please contact Dr. Donovan at 718-616-5509

Fix feet for weight loss success

Many of the estimated 70 million obese Americans are trapped in a life-threatening vicious cycle:  Obesity aggravates foot problems, like heel pain and flat feet; sore feet make it hard to exercise and lose weight; and without exercise, obesity worsens and exacerbates progression of diabetes, heart disease and other serious health threats. I urge obese adults to seek immediate treatment for chronic, activity-limiting foot and ankle problems to foster compliance with physician-directed exercise programs.

It’s unfortunate obese adults get caught up in the vicious cycle of avoiding physical activity due to foot or ankle pain, thereby permitting cardiovascular disease and other life-threatening conditions to worsen as a result. In many cases, chronic heel pain occurs from carrying too much weight.  Left untreated, it becomes an impediment to physical activity and meaningful weight loss.” 

There’s no reason foot or ankle pain should stop obese patients from exercising. The first step toward breaking that vicious cycle is an evaluation by a foot and ankle surgeon. 

Many causes of foot pain can be relieved without surgery through stretching exercises, orthotics and athletic shoes with good shock absorption and support. If a bunion, heel pain or other condition requires surgery, patients can participate during their recovery in non-weight-bearing activities, such as riding a stationary bike, swimming or weight training. 

For those moderately to severely overweight, thorough physical examination is mandatory before beginning an exercise program. 

Once cleared by your physician to begin exercising, don’t try to do too much too soon.  Follow a gradual routine until your body adjusts to the stress of regular physical activity. For example, I counsel overweight patients to avoid working out on treadmills or elliptical machines to minimize pounding and stress on their joints.”  

Shedding excess pounds helps diabetic patients control their disease, but many who experience foot ulcerations and vascular problems caused by diabetes might think they shouldn’t exercise. 

Every diabetes patient needs regular foot exams to check for possible sore spots and assess nerve sensation. And with proper diabetic foot care and the right footwear, most patients can follow an exercise regimen that is safe and appropriate for them.

Glenn J Donovan, DPM

Dr. Donovan is the Chief of Podiatry at Coney Island Hospital.

For more information on  foot problems  please contact Dr. Donovan at 718-616-5509

SPRING HAS SPRUNG

 As quickly as winter came upon us, it has left. We have been blessed with the first hints of warmth and sun. People are emerging from their winter routines and the streets and parks are beginning to fill with sportsmen and women. As I observe this pleasant scene my mind always returns to the same thought, DID YOU STRETCH?

 Stretching is only one part of the regimen we should undertake when we transition from the relatively sedentary existence of winter to the renewed activeness of spring. Our bodies need to adjust gradually or we can become injured. What parts of our bodies? What injuries you say? I am glad you asked.

 All physical activities make use of the musculoskeletal system. This system is made up of the bones, muscles, ligaments and tendons that help us move. Here are some basic definitions:

 Bone: hard structure made primarily of calcium

• Muscle: tissue that by actively contracting and passively expanding make us move
• Tendon: Tissue that connects muscles to bone
• Ligament: Tissue that connects bone to bone

 What is common to these four tissue types is that they respond to use, or disuse. Muscles atrophy or shrivel when not used; bones get soft and brittle under the same conditions. Tendons and ligaments similarly get weak. This weakening process can be unfortunately rapid. If we go from hibernation to marathons our musculoskeletal system may not be able to tolerate the strain and an injury may occur. Some of these injuries are just annoying, but others can be catastrophic. Blogs in the near future will talk about these injuries and their treatment. For now let’s talk briefly about prevention.

 First, always gradually increase your activity level; especially when starting from a period of relative inactivity. Pain is a protective mechanism; it is there to stop us from doing stupid things. In general if something begins to hurt, STOP. You can rest a day and then come back to the same activity and find you can go a little farther before having discomfort again.

 Stretching if done correctly is also important. There is now some disagreement about the need for continual stretching into the active season. However at the beginning of the season slow gradual stretching can help regain motion we may have lost from disuse. When stretching it is best to use gradual rhythmic motions not one massive pull.

Think of the wisdom in fables of old when it comes to renewing physical activity after a period of hibernation – slow and steady wins the race.

Jeffrey Passick, M.D.

Dr. Passick is the Director of Orthopedics at Coney Island Hospital. He can be contacted at 718-616-3440

Child Obesity and Foot Problems

An estimated 16 percent of U.S. children ages six to 19 are overweight, according to the Centers for Disease Control and Prevention. Poor  diet, lack of exercise and genetics can play a role.  A “vicious cycle’ of foot pain and obesity traps some children.

 You want overweight children to exercise and lose weight, but because of their weight, their feet hurt and they can’t exercise.

 The foot is a complex structure consisting of 26 bones, 33 joints and more than 100 muscles, tendons and ligaments. Recently researchers in Britain reported “alarming new evidence that childhood obesity changes foot structure and results in instability when walking.” Being overweight flattens the foot, straining the plantar fascia, a band of tissue which runs from the heel to the base of the toes, causing heel pain.

 Because the heel bone is not fully developed until age 14 or older, overweight children are more prone to Sever’s disease. Although not an actual disease, it involves an inflammation of the heel’s growth plate due to muscle strain and repetitive stress. Walking makes the pain worse. Being overweight may also cause stress fractures, or hairline fractures (breaks) in a child’s heel bone.

 Some overweight children suffer foot pain from congenital or inherited foot conditions, such as bunions, hammertoes, pediatric flatfoot and tarsal coalition, an abnormal connection between two or more bones in the back of the foot. Children with these deformities may be less active because of pain.  Sometimes a child will complain of calf or arch pain. This results from a flatfoot that is flexible. The collapsing of the arch can require more energy, making it more difficult for a child to walk and run.

 Foot and ankle surgeons treat many overweight children with custom orthotic devices (shoe inserts), physical therapy and other conservative measures to reduce or eliminate pain. But treating painful feet and ankles is only part of the childhood weight loss equation.

 As foot and ankle surgeons, we can reduce the aches and pains so these children can run around and play like all the other kids, but parents need to take responsibility for watching their children’s’ lifestyles and diets.

Glen  J. Donovan, D.P.M.

Dr. Donovan is the Chief of Podiatry at Coney Island Hospital.

For more information on  foot problems  please contact Dr. Donovan at 718-616-5509.

Mentor- A wise and trusted counselor or teacher

I have been on vacation this week visiting family and friends in Los Angeles.  We have family here with whom we remain close with despite the distance.  We have friends here as well because 20 years ago we lived here for over a year while I did a fellowship in Joint Replacement.  To become an Orthopedic Surgeon you spend 4 years in college, 4 years in medical school, 1 year of internship and 4 years of residency.  Many of us go on to study an additional year in an area of specialization; this year is called a Fellowship.  I spent mine in Los Angeles with Dr. Larry Dorr.

The teaching of medicine has changed somewhat over the years.  In medical school the first two years are still spent learning the basic medical sciences in books and labs.  Anatomy, physiology, biochemistry are the building blocks upon which further education is layered.  In the later clinical years, learning and teaching have become “evidence based”, rather than experience based, that is you have to be able to support your decisions and treatments with literature evidence.  In my educational days the ward attendings, the senior doctors who supervise the residents and students, would almost always start a discussion with the phrase “In my experience…” Now that statement can be “The Cochrane guidelines state…”.   This works well in Internal Medicine and to a degree in clinical surgery, however when it comes to the OR there is no substitute for hands on experience.  This where Larry Dorr made me the surgeon I am today.

Different people think in different ways.  In chess, some players analyze their moves by trying to figure all the possible outcomes of each possible move, and then choose the best alternative.  Others use pattern recognition.  That is they look at the board and think “I have seen this before” and base their decision on the known outcome of that previous similar situation.  The best players use a combination of both.  As novices play more games and study other games they recognize more patterns.  In speed chess there is a clock as well; you cannot spend forever pondering one move.  You must move on. Surgery is similar.  You start with basic book knowledge and memorized techniques. You then spend years assisting and observing and then you perform surgeries while being observed.,. Ultimately you need to be able to assess a situation and react quickly on your own.

That year in Los Angeles I assisted Dr Dorr with over 700 surgeries.  In the beginning I watched.  Then I began to do more and Dr. Dorr watched. When I got in trouble he would take over and bail us out. I would be lying to say that when he did take over Dr. Dorr was gracious or supportive.  Usually there was a look and a comment that made me feel two feet tall.  At the end of the day I was expecting to be told I should look for another profession, instead Dr. Dorr would invite my wife and I out to dinner on the spur of the moment.  We would talk with his wife about children and politics, but never surgery.  It was not until years later that I realized his annoyance was not entirely with me but with himself as well, for not preparing me better. Though he was probably at least a little annoyed with me too.

Dr Dorr also taught me about people. Surgery is a team sport. You cannot do it alone and if your think you can you are bound for failure. Just as he nurtured me and boosted my spirits when I was most dejected, he knew how to take care of his team. He expected nothing less than complete dedication and perfection from everyone he worked with, and led by his own example. In exchange for their dedication, those who worked with him were treated as family. Dr. Dorr hosted several events a year to thank his team for their hard work. When working for Larry Dorr you never felt unappreciated.

This is beginning to sound a bit like and obituary and it most certainly is not. The day I spent with Dr Dorr he did 5 surgeries. I saw that he did some things differently, some the same. He is developing a computer navigation system, not unlike a GPS for surgery. This system offers great promise in increasing the precision of joint replacement surgery.  I will incorporate some of the changes I saw into my technique, and hope to utilize the computer system here at Coney Island in the near future. I also saw the complete dedication of Dr Dorr to his patients,and the staff to Dr. Dorr.  Some things do not change.  

            Luckily I will have the chance to see Larry Dorr soon at a national meeting next month. We have an alumni group of former fellows that will be gathering a day prior to the meeting to teach and learn from each other and Dr. Dorr. We had our first such meeting 19 years ago. It was a much smaller group then, and some us got together and purchased a bottle of fine wine to give to Dr. Dorr in appreciation.  As I left him this week he mentioned that he has kept that bottle all this time and will bring it to the meeting for us to drink and enjoy.  He thinks it may have gotten better with age, I know it has.

Jeffrey Passick, M.D.

Dr. Passick is the Director of Orthopedics at Coney Island Hospital. He can be contacted at 718-616-3440