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second opinionepisode #903 foot pain announcer: major fundingfor "second opinion" is provided by the bluecrossand blueshield association, an association of independent, locally operated,and community-based blue cross and blue shield companies.for more than 80 years, blue cross and blue shield companieshave offered health care coverage in every zip codeacross the country

and supported programsthat improve the health and wellnessof individual members and their communities.the bluecross and blueshield association's mission isto make affordable health care available to all americans.news about our innovations is online at bcbs.com and on twitter@bcbsassociation. "second opinion" is producedin association with the university of rochester medical center,rochester, new york. salgo:

welcome to "second opinion,"where you get to see, firsthand, how some of thecountry's leading health care professionals tackle health issues that are importantto you. i'm your host, dr. peter salgo,and today we're happy to welcome physical, occupational, andmassage therapist boyd bender. our "second opinion" primarycare physician, dr. lisa harris. dr. judy baumhauer from theuniversity of rochester medical center.dr. douglas hale from the

foot and ankle center ofwashington. and dave heller, who's here toshare his case with us. by the way, this is a case thatour panelists, along with you at home, will be hearingfor the first time. so let's get right to work.dave, several years ago, you were training to go -- and i'mnot making this up -- an extreme elk hunt? heller correct, yes.and you had to hike in

60 miles. correct.you want to tell me about this? well, actually, a friend ofmine who lives in colorado, in the northwestern part, doesan annual elk hunt, where they go into federal lands and hikeall the way in and spend about ten days to two weeks.and in preparation, i decided to start working out -- probablyabout six months before the hunt.so, doing regular physical activity -- i am a plumbingcontractor -- i'm in pretty good

shape and decided that i neededto work on strength of my legs, as well as increasing mylung capacity, wind, because we'll be at 11,000 feet.so i started working out, and one of the workouts wason a treadmill, and i became quite proficient on thetreadmill and decided that i would put it on an inclineand then start to run on an incline on the treadmill.but the thing is that, with working out on this treadmill,after probably about 2â½ months or so, i suddenly got atremendous pain

in my right footand decided i should go to our local podiatrist and see what'sgoing on with the foot. now, had you -- well, first of all, what did the podiatrist tell you? well, he told me that i hadpinched a nerve in the front part of my foot,just below my toes. salgo all right, and had you everhad any foot problems

prior to that? actually, no.i was born flat-footed. i've worked in constructionsince i'm 14 years old, which includes jumping into deepexcavations and jumping off of scaffolding and ladders andtrucks and things like that. so i want to stop for aminute, because everybody i know has heard the phrase,"flat feet." we have a picture of a flatfoot. that's what a flat footlooks like.

what are we looking at?anybody want to help me out here? baumhauer well, it's a foot that issort of sagging in. we call it "pronating."and essentially, the structure of the foot is quite flat, so ifyou walked along the sand, instead of having a little archin your footprint in the sand, you'd notice your whole"flintstone" foot would be sitting there.so i want to talk about the

treadmill for one second.so, the treadmill, the repetitive, continued walking atthe exact same speed, with the exact same step,makes anybody who has any near foot problem vulnerable.it would be better to walk outside.change your terrain, change things around so that you're notdoing the exact same thing. harris: you actually havean abnormal gait on the treadmill because of thestructures in the front.

you change your natural gait,and we see a lot of problems that occur with people -- bender: well, also, peter,you've mentioned that he changed two variables at the same time.you increased the incline of the treadmill and then startedrunning, which can oftentimes cause a problem. hale: yeah, on a treadmillwith the elevation, your heel

cord gets tighter, your foot'sgoing to flatten out more, you're going to put a lot moreforce through your foot, also through the front of your ankleand your forefoot, with going on an incline on a treadmill. and now you've gotfoot pain. and somebody's told you you'vegot a pinched nerve. now, you're on your feet allday, and your feet are hurting. heller: correct.

what happened? i went to, again, a localfoot doctor, podiatrist, determined it was a pinchednerve in the front of the foot, which he gave me a shot ofcortisone, i believe, something like that, and said, "by theway, you have really flat feet." and i said, "yeah, i've beentold. i notice how my work boots wearout, you know, on an angle, and so forth, like that."and he said, "i'd really like to fit you with orthotics."

all right, so, let'sstop again. because you've seen yourpodiatrist. did your podiatrist get anyx rays, any studies? just looked at your foot? actually, he did x rays. i would ask, where were youhurting at, what location was your pain? the front part of my foot,just below my toes, was where most of the pain was.just in one foot at that

particular time. and was it continuous, orjust occurred when you were exercising? no, that was continuous --after i had done whatever damage i did, then that was it, thatwas start of. salgo: even at rest? yes. even sitting or lying inbed, it would hurt? it actually -- i guesssitting or laying in bed, it

wasn't bad, except when yougot up. then it was bad. okay, so, if someonecame into your office with foot pain, how would you work it up? well, the first thingis to get some of the history that we've already asked -- whatwere the activities? one other question would be,did you buy new shoes? or were you using older shoes?i'd want to examine the shoes that you brought inthat you were wearing during

your exerciseand the ones that you wear during the day.and then a good examination of the foot, including a sensoryexamination, so we would check to see if there was any loss ofsensation anywhere in the foot. i would do exactly that.i think every patient, you have to start with a good history.you can't do tunnel vision. you have to find out, do theyhave any arthritis themselves or in their family, any othermedical issues

you may be dealing with?and then every patient needs an excellent physical.so you need to look at their skin, you need to look at theirblood supply, you need to look at their nerve status.and then you need to do a good musculoskeletal examinationto find out exactly what structure is hurting, wherethey're hurting at, to make that diagnosis.so a diagnosis needs the proper exam to get that done. i would take it even furtherwith the physical examination.

with the complaint of just --the problem on the one side -- is, people always have a historyof old injuries, not just at the foot or ankle, butat the low back. and there could have beenan old disk injury that healed a long time ago, but now it'smanifesting itself in a way where there's a lot of weakenedmuscles in the lower leg, that may cause that foot toflatten more than it normally would. what i'm hearing is veryinteresting.

you've looked at the foot.but you've thought beyond the foot. you have to.to think of other things which might be impin-- that'svery interesting. impinging on the foot.would you do anything else? baumhauer: think what's interestingabout the story is, he says, "when i'm at rest, i'm doingbetter, and when i get up and use it, it hurts more."so i always think that's

mechanical foot pain.and not -- it takes me a little bit away from nerve pain. nerve, that's right. so i'm thinking more, it'sbones, joints, than the nerves, that are primarily the problem. all right.but dave gets cortisone and gets an orthotic.what's an orthotic? when do you prescribe it?what's it supposed to do? and, actually, i justwant to jump in with my

non-ortho expertise.starting an orthotic when he has acute foot painthat's unrelated to, you know, his flat feet.i'd want to take care of the current problem before i startedprescribing orthotics for a chronic problem. what is an orthotic? an orthotic is something thatyou apply to the bottom of the foot -- it can be dispensed overthe counter or custom-molded. it's an insert.

goes in the shoe.and it's supposed to straighten your gait and make everythingbetter. it's supposed to support thefoot in areas that require it, to try and decrease painor improve function. in his particular case,i'm not clear exactly what the ongoing diagnosis was, but i'msuspicious that they thought it was a neuromaor something like that, with that cortisone injectiondiscussion. and sometimes, anover-the-counter orthotic

with a little pad can help splaythe forefoot open a little bit and allow the nerves to be alittle less squished, if you will. but that's depending on thediagnosis of the nerve impingement.so the $64 trillion question in today's health care economy,how did those orthotics work out for you, dave? well, not well at all.i think the original, first set of orthotics -- by the way, theywere --

oh, i know we're going tohear about more. okay, made the pain better,worse? the pain got worse? what? well, the initial pain seemedlike it was improving. i mean, becoming less.but i don't think it had anything to do with theorthotics, because the orthotics weren't dealing with the initialreason why i went there. did your injectiontemporarily relieve your symptoms?

i had three differentinjections. but for, like, an hour afteryour injection, did your pain go away? it numbed it for a while.or it felt a little better. so, if you look at, if we doa diagnostic injection, whether it's on a joint or on a nerve,if your pain goes away 100% for an hour, there's a good chanceyou're at the right spot. if you inject a nerve and yousay, "my pain doesn't go away," it may be the joint that's atanother area of your forefoot.

so the big question is, doesthat diagnostic injection relieve your pain?'cause if it doesn't, maybe it's not the nerve, maybe it'syour joint. forefoot pain is commonlyjoint issues also. i'll back up on the orthoticissue -- so, a lot of people come in, they're not coming inbecause they feel fine. they're coming in because theyhave a foot-pain issue. so you're trying to help themresolve that problem. so the first thing to look at isshoes -- a lot of times, they're

wearing an unstable shoe.they're wearing a shoe that's not properly fitting for them.so it's giving them pain in a certain area because of theirshoe gear. so a lot of times, we can changethe shoe and make them much better.the other thing is an over-the-counter insert, and alot of times, we are rebalancing the forces in the foot.so we're using an over-the-counter insoleinitially to rebalance those forces, to move force to an areathat doesn't bother them.

now, i was listeningto you, dave -- i caught a whiff of, you went to the first one,you tried the orthotic, it really didn't work very well,time went by, i heard there was at least one other orthotic.was that with a second podiatrist? okay, and that didn't workvery well? that didn't work very well. salgo:so let me guess. you went to a third podiatrist.

went to a third.this particular foot specialist also did sports medicine, and heworked with a lot of people who ran marathons and thingslike that. so he agreed that yes, i haveflat feet, and yes, i could use orthotics.and of course the other ones were not properly administered.but in the meantime, he decided that i also had heel spurs. a bone spuron your heel? both feet.

in the interests ofeducating america, we've got a bone spur.can we put that up and have a look?there it is. what are we seeing here?somebody want to -- we're seeing a spur atthe bottom where you typically see plantar fasciitis. plantar fasciitis iswhere that fascia, some of the connective tissue in the foot,hooks on. so the connective tissue onthe bottom of the foot hooks on

and pulls, and you get thatspur. so we know heel spurs are commonwith aging, from studies. people who have heel pain have ahigher chance of having a heel spur.but you don't have to take the heel spur offto get them better. let's pause for a minute,because that's a heel. and if you follow the bottom,there's that little hook-y thing on the bottom.that's the bone spur. hale:correct.

salgo:and that hurts. harris:well...sometimes. it may or may not.may or may not. right, so gettingan x ray and seeing a bone spur does not translate intofoot pain. and the other thing is,patients should realize that you don't have to haveyour bone spur out. so 35% of people have an x rayjust like that and no pain whatsoever.so don't treat the x ray.

so bone spurs don'tnecessarily need treatment. bone spurs don't necessarilycause pain. just finding a bone spur on anx ray, dave, doesn't necessarily mean that's what's causing yourtrouble, correct? correct. however, i believethat, with wearing the orthotics, now both feet hurt.okay, remember, i started off with one foot with what ithought was a pinched nerve. now both feet hurt. so no good deedgoes unpunished.

by the time i got to thethird foot doctor, okay, he is now saying, "yes, they'reflat, yes, you need this, but you're also --" and i wasexperiencing pain in my heel. both heels.so this is when he determined that i had heel spurs. but there's no guarantee thatthat pain is from the spurs, is what i'm hearing from my panel. the spur is a secondary\thing, not a primary thing. what treatment did youget from your third doctor?

well, actually, i wenttwice a week for, i would say, five or six months, but therewas all types of, you know, certainly the whirlpool thing.you know, there was different types of stimulation. this is your area ofexpertise, isn't it? does this stuff work?there's massage and electric stimulation... it can work in the acutephase, but it's certainly not something that's going to healthe problem.

again, you have to get back towhat is causing the problem. okay, and all of these otherthings may be ways of treating it, initially. okay, so the acutephase means it can make you feel better, but it doesn'tnecessarily fix the problem. it does not fix the problem. when he'sfirst hurting. when you'refirst hurting. he's now intochronic pain.

you're now into –years into this. where did you go next? well, that particularspecialist finally decided that he could go no further with meand then recommended a rheumatoid guy.maybe i had some r.a. in my foot. "r.a." meaning"rheumatoid arthritis." meantime, you know,the foot -- both feet are now to the point where i'm kind ofhobbling a little bit.

i thinkwhere he's falling short -- so applying something to thebottom of his foot, sending him off to physical therapy,you know, we're all sort of questioning, where's thediagnosis, and where is it going?you know, there are a lot of options here.if in fact you had heel spurs, plantar fasciitis, if in factthat was the case, you know, the mainstay of treatment isstretching exercises that you do at home.so that costs you nothing but

your time, but important for youto get better. and, you know, i also want tointerject, because the care givers that you'retalking about are all different people, so there's podiatristsand there are orthopedic surgeons that are foot and anklespecialists, and the rheumatologists are internalmedicine specialists. so you have actually sort ofmixed and matched, i believe, to many different people. which is notnecessarily a bad thing,

if they were getting somewhere. i think the mostimportant thing in any medical case -- we see a lot of this,where people are getting treated, but you really need toget an accurate diagnosis. so you have to do whatever ittakes to get the diagnosis, whether it's further diagnosticstudies, but the most important thing is listening to thepatient, hear what they're telling you, where they hurt,doing the physical exam, doing the appropriate studies andworkup to get them a diagnosis.

once you get them a cleardiagnosis, now you can set a treatment plan in place, versustreating but not really having a diagnosis. had you had any otherstudies done? i heard the one x ray, but didyou have an mri or anything else done? yes, somewhere in between thethird podiatrist/foot doctor and the rheumatoid guy, i did go into mention the hospital of special surgery in new york,which is extremely precise

when it comes to any type oforthotic surgery and things like that.and i saw one of their top fellows, and we did the --starting off with the regular x rays, cat scans, mris,so forth and so on. and now we were starting to get,you know, what the real situation and the realproblem was. so what i'm hearingis that now, for the first time, you're getting a battery ofstudies on this foot, other than just a plain x ray.

and you're doing whateverybody else here has asked you to do -- or asked them todo -- get the right diagnosis. if you're treating the wrongdiagnosis, you're not going to get better.so what did they tell you at the hospital for special surgery? heller; well, basically, because of,i assume, being born flat-footed, that the tendons onboth feet were torn, and it would require a surgery thatsounded quite extensive, where

they actually cut the bone atthe bottom of the foot, and then they take a bone frommy hip, put it into the bottom of my foot, and then i guess thetendon would reattach itself or whatever.well, the procedure for each foot is about eight months. well, the procedure isn't,right, it's the recovery? well, the recovery is abouteight months, so we're talking, you know, over a year and a halfof my life to be, you know, dedicated to these feet.so, at that point, i said,

"uh, maybe not."he recommended to wear these small braces and try them out tosee if they would ease pain. they're not going to correct theproblem, but they may make it more bearable for you tofunction, to walk around. i want to stop youright here, because now we've described an operativeprocedure. this is the first timesomebody's saying, "i've done all the studies, i've got adiagnosis, and i'm going to fix you with surgery."does this surgery sound

rational? well, i have totell you, you have me, like, off balance here,because you started out with forefoot pain.okay, forefoot pain, pain in the ball of your foot.then you said, "now i have heel pain."i don't know if it was first few steps in the morning pain, thatkilled you when you got out of bed, like plantar fasciitis is,but now you're moving into, "i got posterior tibialtendinitis," which is the tendon

on the inside aspect of yourfoot, that allows you to -- when it ruptures or elongates,falls in. so then you got three differentthings going on. i cheated -- i read a littlebit of your story. i know you got a second opinionfrom another orthopedic surgeon, who also recommended surgery. and then, on the verge ofdoing the surgery, somebody said, "don't."someone said to you, "you know, maybe at your age, eight monthsper foot, not such a great

idea."and you decided to forgo the surgery, and you wound up --you're wearing braces now. can you show us the bracesthat you're wearing? yeah, they're a strap-on.they go under the foot. i basically have to wearthese -- actually, i wear them all the time.they're doing nothing to correct the problem, they're just makingit less pain. they're supporting you. so, to me, it's giving mesome support down there, and

therefore taking awaydiscomfort. so let me summarizewhere we are, if i may. you had an injury.then you went to -- i'm counting here -- three podiatrists,two orthopedic surgeons. you've had a lot of orthotics,massage, electrotherapy, acupuncture, cortisone,lots of other treatments, and you're still in pain.this has been quite a story. so i want to be sure we'vesort of summed up where we are. a thorough evaluation todetermine the cause of foot pain

is necessary if you're going toget successful treatment. when it comes to the treatmentof foot pain, one size does not fit all.and the cause is everything. if you're treating the wrongcause, it's not going to get better.fair enough? correct.all right, so we need to move on.of course, dave is here with us today.you've had foot pain now for many years.no treatment so far has beenable

to make your pain really goaway. is it fair to say that somepeople simply have to put up with foot pain?is dave going to have to put up with foot pain for the restof his life, is that it? well, i think you've nowtrialed him. you've put him in braces, and hesays, "i'm better in the braces." right? so he is better.so now he's better in the braces, so you've -- yourhypothesis is that it was

a tendon problem.and he seems to be supported with that tendon problem.and that's -- and now he has to decide, "am i going to live inthese braces? is there another type of braceoption or orthotic option for me to sort of step down into?or should i have surgery for this problem?"that's really where he is in the decision mode. right. i want to come backto your problem. now, lisa, shoes.can you show us the shoes you're

wearing today, please? i guess so. thank you.they have heels. very high heels.are these good shoes to wear all day, every day? i would tell you that nomatter what you say, it's like, "could you stop wearing those?"well, some people feel good in those.and it's about how you feel. so i believe that we're going tohave people wear high heels.

so we're going to have todeal with it. what you want to do is have themwear them occasionally, not their everyday shoes,just to events, just when they look goodon sitting on a chair. because she's not weight-bearingon her foot with those high heels.she just looks great. i'll ask theprovocative question -- you wear these all day, don't you? all day, every day.

i'll add to that -- alot of foot symptoms are caused by a tight achilles tendon,or the tendon on the back of your leg, so a lot of peopleget foot pain because of that. so a little bit of heel liftwill take force off your foot, such as your plantar fascia,your midfoot. so a little bit of a heelhelps a lot of people. now, let me just rattle offvery quickly, now, a couple of things.crocs -- you like them? baumhauer;

i think if they feel good onyour foot, it's fine with me. earth shoes? birkenstocks? earth shoes have a negativeheel on them, which means the heel is lower than the forefoot,so for most patients, that's not a good shoe for them.for some patients who have a lot of motion in their ankle,that shoe works for them. pedicures -- good or bad? i think pedicures, you've gotto make sure you have a place that is clean and sterilizes --or at least cleans -- their

equipment.so you have to be a little careful with that. and i just want todovetail on something that judy said about crocs, or even if youtalk about flip-flops or other shoes like that.it's important that you don't have pain, because what a lot ofpeople do is grip with their toes to keep the shoeon their foot, and then they start developing foot pain. i want to get onerecommendation, maybe, one

sentence from this whole group,the best thing you can do to keep your feet healthy. i think the one thing isa good shoe. and everybody's footstructures differently. different people like differenttypes of shoes. but a good, supportive shoe,a shoe that doesn't cause you pain, is the best shoe for you. a good shoe, don't smoke,watch your weight, i mean, all these things loadonto your foot.

i just want to commenton that -- that's really important.we hear this on almost every broadcast.don't smoke -- bad vascular disease causes bad foot disease.don't get too heavy -- not only does it put pressure on yourfeet, but it can lead to uncontrollable diabeticproblems, foot ulcers, sepsis, losing your foot.bad. okay. and even if you walk 20 to 30minutes a day, that's good activity for your feet.

excellent. let's stop for a moment andwe'll sum up where we've been, then we will go forward a littlebit after that, but this is a complicated subject.that being said, there is a lot you can do to keep your feethealthy and pain-free, such as wearinggood shoes appropriate for the season, lisa.not sharing the pedicure tools -- they've got to beclean. finally, listen to your feet.they do talk to you.

you should consult aprofessional when unresolved pain or other problems impactyour ability to walk and to perform your everydayactivities. you know, dave, i understandthat people who know you say that you're always up.your spirits are high, and they would never know that you havefoot pain. how do you get through the daylike that? well, one of the things i'verealized about pain is that your body and your mind work verywell together when it comes to

something thatdoesn't feel good. i had just had rotator-cuffsurgery, i had fallen off an extension ladder, i have anindirect hernia, i have an enlarged prostate, ihave about five or six things going on.so, you know, the feet are important, 'cause they get mefrom point "a" to point "b," but they're not my whole life. all right, well, iwant to thank you very much for being here, braces and all.

braces and all. unfortunately, we're out oftime, and i hope that you'll continue the conversationon our web site. there, you will find the entirevideo of this show, as well as the transcript and linksto the resources that we can provide.the address is secondopinion-tv.org.again, thank you for watching. thank all of you for being here.i'm dr. peter salgo. i'll see you next timefor another "second opinion."

"second opinion" is producedin association with the university of rochester medical center, rochester, new york.