Online Health Chat with James Sferra, MD

April 9, 2013


Proper foot care is not something most of us think about until problems literally put us out of step. Yet, foot and ankle problems are among the most common health ailments. It is likely that the majority of people will experience some degree of foot and ankle problems during their lifetime.

A normal foot and ankle has 26 bones, 33 joints, and more than 100 muscles, tendons and ligaments. The average person will walk the equivalent of four times around the world in his or her lifetime. So it’s hardly surprising that nearly three-quarters of Americans will eventually experience some type of foot problem. In athletes, these problems are even more common.

Some of the more common foot problems involve ingrown toenails, bunions or warts. Medical conditions such as diabetes and arthritis typically affect the foot and ankle. More complex problems of the foot and ankle may involve diabetic ulcers, infections and conditions such as tendinitis or flat feet, which require surgery. Inherited foot and ankle problems include club foot and hammer toe among others. Add to this the numerous injuries that occur regularly, including sprains and fractures, and it is clear that we rely heavily on the health of our two feet and ankles.

Although some problems are inherited, many stem from a lifetime of accumulated abuse and neglect, such as wearing improper footwear or not seeking early medical attention. Proper assessment and treatment of problems are critical to foot and ankle health.

About the Speaker

James Sferra, MD, is a foot and ankle orthopaedic surgeon specializing in foot and ankle reconstructive surgery, fractures and sports injuries of the foot and ankle. He is board certified in orthopaedic surgery. Dr. Sferra completed a foot and ankle surgery fellowship at Medical College of Wisconsin in Milwaukee after an orthopaedic residency at Cleveland Clinic. He graduated from Medical College of Ohio at Toledo.

Dr. Sferra’s interests include sports medicine, fractures, bunion and lesser toe deformities and occupational injuries.

Let’s Chat About What You Need to Know About Foot and Ankle Health

Foot Health and Diabetes

Realtom: Please talk about foot health and preventative measures for people with type 2 diabetes. For example, how careful should we be about preventing cuts, and what about foot dryness?

James_Sferra,_MD: Foot problems are very common in patients with diabetes and prevention certainly seems to be the best way to avoid problems. It is important to inspect your feet everyday to look for signs of potential problems, such as very dry skin or small nicks or calluses. Using a mirror to check the bottom of your feet is helpful. Also, be generous with the application of lotion to stop your skin from drying or cracking.

Ann862: My mother has significant toenail fungus and she also has diabetes. She hasn't tried to treat the fungus. Does this present as any particular concern?

James_Sferra,_MD: Toenail fungus is a very frustrating entity to treat. It is difficult to get rid of completely, and often recurs. Therefore, unless it is particularly bothersome, it is often ignored. There are over-the-counter creams, nail polish lacquers and even oral medications that can be used. However, these rarely cure the fungus. Diabetes does make one slightly more susceptible to toenail fungus, but routine diabetic foot care is recommended. Our diabetic foot clinic in Cleveland Clinic’s Foot & Ankle Center is a good place to start.

Athlete’s Foot Fungal Infection Treatment

johnnnita: Last November I developed what I thought initially was a foot boil. After applying over-the-counter topical medication for several weeks, it didn't go away and developed a ‘head’ with redness. I then saw a dermatologist who immediately diagnosed it as a foot and toenail fungus (athlete's foot). He also observed that my toenails seemed to be discolored, but I thought this was normal. He prescribed terbinafine (Lamisil®) 250 mg once daily for 90 days, which I've been taking for about one month. I saw my dermatologist around April 1, and he looked at the foot and said it was healing along better than normal. I've never had such an incident before and will be thankful when this process is completed. It does seem to be healing, although it has taken longer than I would think.

Does this process seem to make sense? Is this normal? Assuming everything goes accordingly to plan with healing, what else should I be doing with regard to taking care of my feet in the future? I will soon be 64 years old and have been quite active with daily exercise at the gym. There's some thought that this athlete's foot fungus was caused by sweating of foot.

James_Sferra,_MD: This does sound like a fungus infection. It is not uncommon for these to take an inordinate amount of time to heal, so this does seem to be normal. Good hygiene, such as changing your socks frequently and using antifungal powder in your athletic shoes, will help. It is not uncommon for this to recur to a lesser extent in the future if you are not attentive to your feet.

Morton’s Neuroma Treatment

Adam: What is a neuroma and how is it treated?

James_Sferra,_MD: A Morton's neuroma is an irritation of the nerve in the front part of the foot. It typically cause intermittent sharp pain with weight bearing, and is relieved by removing one's shoes. Classically it is between the second and third or third and fourth toes in the pad of your foot. Treatment includes wearing thick, soft-soled shoes, avoiding barefoot walking, using over-the-counter gel-type inserts, and occasionally using custom inserts. If pain persists despite this treatment, then an injection can be helpful. If only temporary relief is obtained from the injection, then surgical excision of the neuroma is indicated.

Plantar Fibroma Treatment

filler989: What is your best advice on treatment for a plantar fibroma? My doctor mentioned surgery, but from what I have heard, surgery is not usually necessary.

James_Sferra,_MD: The most common treatment for plantar fibroma is merely observation. Meaning it is extremely rare to perform surgical excision of a plantar fibroma because the lesions tend to multiply after surgery. Also, custom inserts to accommodate the fibroma is usually all that is required to make them relatively pain free.

Plantar Fasciitis Treatment

lebby: Is there a cure for plantar fasciitis? Or do you use a multiple disciplinary approach of night splints, orthotics, physical therapy, cortisone injections, etc.?

James_Sferra,_MD: Plantar fasciitis typically resolves with appropriate treatment. However, it usually takes significant compliance from the patient to cure it. Our routine treatment for plantar fasciitis consists of Achilles tendon stretching exercises throughout the day, avoidance of walking barefoot, use of heel cushions, ice application at the end of the day, and use of nonsteroidal anti-inflammatory drugs (NSAIDs), and a night split while sleeping. It is not uncommon for it to take up to six to nine months to resolve.

glbfranck: I am having a lot of problems with plantar fasciitis. I have had it for a long time and need advice.

James_Sferra,_MD: I outlined what I believe is typical appropriate conservative treatment for plantar fasciitis in a previous answer. Most patients need to adhere to this plan for at least nine to 12 months before considering further intervention. Further treatment can consist of: referral to physical therapy, cortisone injections, cast or boot placement, shockwave therapy, or possibly even surgical release of the plantar fascia. I view surgery as the last resort since 95 percent of the time plantar fasciitis resolves with no surgical intervention.

glbfranck: What kind of night splints do you recommend?

James_Sferra,_MD: Dorsiflexion night splint or a Strassburg Sock™.

Ankle Arthritis Treatment

sinaihospital: I have right ankle arthritis for over five years. I have tried injections, medications and therapy boots. None of these helped me. I have seen three bone and joint surgeons and they have said to hold off having surgery on my right ankle. Can surgery help to fix my arthritis in right ankle? Must I see a foot and ankle doctor or a bone and joint surgeon for this?

James_Sferra,_MD: There are several surgical options for ankle arthritis. Either an ankle fusion or a total ankle replacement is performed for this condition. Both have advantages and disadvantages, and should be tailored to the individual patient. Both surgeries are very good at relieving pain. The ankle fusion does restrict some up and down movement of the ankle, but rarely require more surgery in the future. An ankle replacement lasts only 10 years on average. Therefore, it is best for patients older than 60 years old. An ankle fusion is the gold standard while ankle replacements are becoming more popular. However, if complications arise after an ankle replacement, they can be difficult to address.

Bunion Surgery

Whet_Head: Can you talk a bit about bunions? What do you base surgical criteria on—appearance (yes, they are ugly) or pain?

James_Sferra,_MD: There are over 150 different operations which have been performed for bunions. The best reason to undergo bunion surgery is for pain relief. Other reasons include difficulty finding comfortable shoes and limiting your activities because of your foot pain. Things that we consider when deciding which surgical procedure to perform include: deformity, age, activity level, presence of arthritis, and goals of the patient. Most surgeons have 10 procedures that they perform on a routine basis to address bunions. It’s rare to surgically address a painless bunion.

Foot and Ankle Trauma

Leisa: I am prone to ankle sprains and have sprained my ankle severely several times just stepping awkwardly and turning it in or slipping on stairs. I have thin ankles. Are there strengthening exercises that could help?

James_Sferra,_MD: There are definitely ankle exercises that will help strengthen your ankles and potentially decrease the amount of ankle sprains that may occur in the future. A referral to physical therapy for instruction in these exercises is recommended.

jdavidof: If you have a sprained ankle how long after the swelling and pain goes away should your wait until having a pedicure? Are pedicures good for your feet? What are the best kind of shoes and sneakers are good for your feet? Are flat sandals good to wear?

James_Sferra,_MD: There is no time frame between an ankle sprain and a pedicure. My only concern to avoid a pedicure is when you have an open lesion on your foot such as a surgical incision. There are no health benefits to pedicures, but they are a treat that doesn't have a significant down side. We discussed proper footwear and sandals in a previous question.

JmattTX4: I teach ballet and I have several students who complain of pain in the back of the ankle just above the heel when pointing one or both feet, or when working on relevé (rising up onto the balls of the feet or onto the toes when wearing pointe shoes). Is there any exercise I can have them do that will relieve this problem? Should I advise them to see a foot specialist?

James_Sferra,_MD: Relevé requires maximal plantar flexion of the ankle (pointing the toes downward) which can cause pain in the posterior aspect of the ankle secondary to posterior ankle impingement. The best way to decrease this pain is to try to minimize the time spent in maximal plantar flexion or to make sure your students gradually increase the amount of time they spend in this position. Your students can ice and take anti-inflammatories (NSAIDs) afterward to minimize discomfort, but avoiding exacerbation of (increasing) the pain is the best way to address it. It is a good idea to see a specialist if pain persists. Cleveland Clinic has a sports medicine/physical medicine and rehabilitation specialist who treats dancers, Kim Gladden, MD.

jontt: I'm debating whether or not I should see a doctor about a potentially broken foot. I believe it might be the fifth metatarsal.) I have full mobility of the foot, and there is no swelling or visible bruising. However, it hurts very badly in the fifth metatarsal region when I put any weight on the foot. The more I try to walk or stand— the worse it gets. That said, it doesn't hurt at all when I'm sitting. After resting all night I can walk normally for about 10 minutes before the pain suddenly returns. I massaged the area and a couple of spots were mildly tender, but there were no shooting pains to the touch. Could it be a stress fracture?

James_Sferra,_MD: You are describing what sounds like a classic fifth metatarsal fracture. Typically, these only hurt when performing weight-bearing activities. The best way to diagnose it is an x-ray of the foot.

yes sir: My son fractured the growth plates in both ankles at different times (one ankle twice). The first time it happened, he was five years old. How will this affect him throughout his life? He is 20 years old now.

James_Sferra,_MD: It is very difficult to predict whether or not these fractures will affect him in the long run. X-rays to assess his ankles along with whether or not he has any pain would be the best predictors of any future problems.


Carie: One of my feet is in pronation due to an old knee surgery that left that knee in a valgus position. I wear shoes with a wide and deep toe box plus good orthotics that also have a medial wedge in the heel. They help a lot with everything except my big toe. The big toe continues to be uncomfortable on the bottom medial side—I assume from continued pressure when I walk. Do you have any suggestions for me to offload the medial big toe in some way?

James_Sferra,_MD: It sounds like you are quite knowledgeable about your problem. Orthotics are definitely the best way to address the big toe. Rarely, surgery may be necessary to decrease the pronation in order to unweight the big toe further.

Proper Footwear

Bea: I am concerned about the type of women's shoes that are considered fashionable these days—either very high heels or flat sandals and flip-flops without any arch support. Do you have any thoughts about this dilemma?

James_Sferra,_MD: Women's shoes have been very good for my business! I think that your concerns are valid concerning very high heels and flip flops. I fixed an ankle fracture last week in a young woman who tripped while wearing her four-inch heels at a wedding. In addition, flip-flop sandals provide no stability to the foot. Therefore, they should only be used when you are relatively inactive. The dilemma is always between fashion and function. You have to try to find a happy medium where she shoes are aesthetically pleasing to you, but also provide comfort and support to your feet.

lebby: What causes clicking/popping sounds in an ankle? Is it anything to be concerned about?

James_Sferra,_MD: Clicking and popping from the ankle can come from a variety of causes such as tendons snapping over one another, tendons snapping over bone spurs, or from irregularity in the joint itself. Painless clicking and popping is never a concern. Most clicking and popping from the ankle is not related to a significant problem. Occasionally it can cause pain, which then should be assessed by a physician. Rarely clicking and popping can be from arthritis in the ankle.


Moderator: I'm sorry to say that our time with Cleveland Clinic expert Dr. James Sferra is now over. Thank you Dr. Sferra for taking your time to answer our questions today about foot and ankle health.

James_Sferra,_MD: Great questions! I enjoyed chatting with you today.

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On Cleveland Clinic

Cleveland Clinic's Foot & Ankle Center located in the Orthopaedic & Rheumatologic Institute provides comprehensive diagnostic, treatment, and rehabilitation services for all adult foot and ankle problems. Our staff of orthopaedic surgeons, podiatrists, nurse clinicians, certified pedorthists and technicians deliver state-of-the-art care exclusively for problems of the foot and ankle. All specialists and surgeons at the Foot & Ankle Center have extensive training in the diagnosis and surgical and nonsurgical care of a wide range of foot and ankle problems. Cleveland Clinic’s orthopaedics is ranked best in Ohio and third in the nation by U.S.News and World Report.

For more information, please visit Cleveland Clinic’s Foot & Ankle Center.

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Reviewed: 04/13