How to Manage and Treat Foot Pain with Dr. Georgeanne Botek

Podcast Transcript

Nada Youssef:   Hi, thank you for joining us. I'm your host Nada Youssef. And you're listening to Health Essentials podcast by Cleveland Clinic. Today, we're broadcasting from Cleveland Clinic main campus here in Cleveland, Ohio. And we're here with Dr. Georgeanne Botek. Dr. Botek is the Head of Podiatric Medicine and Surgery here at Cleveland Clinic as well as a founding member of FLIP, which stands for Functional Limb Preservation Council. Correct?

Dr. Botek:  Correct.

Nada Youssef:   Thank you so much for being here today.

Dr. Botek:  You're welcome.

Nada Youssef:   Could you tell me a little bit about FLIP?

Dr. Botek:  Sure. So FLIP is a term we designed about two years ago to represent a collaboration of a lot of specialists to prevent diabetic foot complications and ultimately amputation, so functionally preserving limb... Preservation is trying to restore mobility to patients who have foot problems and leg problems, whether it's poor circulation or poor sensation, infections. So between vascular surgery, podiatry, orthopedics and plastic surgery, we meet regularly and try to come up with good pathways and try to help treat our patients comprehensively.

Nada Youssef:   So like a multidisciplinary approach, everybody that...

Dr. Botek:  Exactly, yes.

Nada Youssef:   That's perfect. Great. And so today, we are talking about foot problems. And, please remember, this is for informational purposes only and it's not intended to replace your own physician's advice. So before we jump into topic, I'm going to ask you three questions completely off-topic just to get to know you better. So did you always want to be in medicine?

Dr. Botek:  I probably wanted to be in medicine starting in eighth, ninth grade.

Nada Youssef:   Wow.

Dr. Botek:  Of course, before then it was a flight attendant and an actress. But starting in about eighth, ninth grade, really trying to think about life, I thought, "I really want to help people." And medicine was a good platform. We have direct patient contact. You can really change people's lives. So I wasn't sure at that point what kind of medicine I wanted to practice, but no regrets at this point with treating foot and ankles.

Nada Youssef:   That's amazing. That's great. My daughter's eight and she's talking about being a doctor. I'm like, "Wow, that's early."

Dr. Botek:  It is.

Nada Youssef:   Now, if you had an extra hour of free time a day, how would you use it?

Dr. Botek:  Oh, exercise.

Nada Youssef:   Exercise? Perfect.

Dr. Botek:  Yeah. Never enough time to exercise. Just physically and mentally feel much better to move.

Nada Youssef:   Sure.

Dr. Botek:  So much of our life, and especially work related, we're sitting at a computer or standing at a computer. So just to be able to get and move, whether that's yoga, spin or whatever.

Nada Youssef:   Yeah, yeah. That's a great answer.

Dr. Botek:  Yeah, exercise.

Nada Youssef:   And then what is your favorite thing to do on a sunny, Cleveland weekend?

Dr. Botek:  Sunny. Well, it depends on the time of the year. This time of the year, definitely hit an Indians game, okay?

Nada Youssef:   Yes.

Dr. Botek:  In the fall that would be the Browns. And in the winter probably a Cavs game on the weekend. But, otherwise, if I can get out there and bike or walk my dogs myself, that's also a great day.

Nada Youssef:   Excellent. Great. All right, well back to discussion. So our feet take a lot of abuse, walking, running hiking, all kinds of stuff.

Dr. Botek:  They do.

Nada Youssef:   So naturally they are subject to many different types of problems from improper footwear, diabetes, aging, they all contribute to foot problems.

Dr. Botek:  Right.

Nada Youssef:   So before we get into that, I want to first talk to you or have you talk about the anatomy and the design of a foot. Because I don't think we think about it much. But what is...

Dr. Botek:  The feet are pretty intricate with 26 bones and 33 joints. And many people have more than 26 bones too. We have a lot of accessory little bones in our feet that we can have, which you don't really know unless you have an X-ray. But they're meant for shock absorption and cushion. And we really do get a lot of use on our feet. The average person probably walks about 150,000 miles, so that's like six times around the world in a lifetime.

Nada Youssef:   Wow.

Dr. Botek:  So it's natural that as we get older that we kind of have, just like you put wear and tear on your tires of your car, you're going to be wearing down your feet too.

Nada Youssef:   Yes, yes. So can you talk about some of the common problems that you see from the patients that come to see you here at Cleveland Clinic?

Dr. Botek:  Sure, sure. There are a lot of common problems that patients don't necessarily come to see us with, whether it's warts and toenail fungus and athlete's foot that can affect, but I would say on an average day probably the most common symptoms that we'll see will be heel pain or arch pain, just generally getting out of bed in the morning and have heel pain. Pain across the ball of the foot that occurs after age 50, that's on the forefoot. Lifting your heel from the ground, feeling that pain across the bottom of the foot. Arthritis in the feet can affect ankles, midfoot, forefoot. Hammertoes, bunions.

Nada Youssef:   Wow.

Dr. Botek:  So those are the more common reasons people come to actually see us with pain, and pain that's usually prolonged.

Nada Youssef:   So does that sound like it's more age related?

Dr. Botek:  It can be. Definitely, if you go to our waiting room, you're going to see more people over the age of 50 and 60 than you are 20 and 30.

Nada Youssef:   I see.

Dr. Botek:  But we do see, as a foot and ankle doctor and podiatrist, we see patients of all ages.

Nada Youssef:   Sure. And now something like diabetes, they could have a lot of foot problems with diabetes.

Dr. Botek:  Right.

Nada Youssef:   Can you talk about the issues that come with that?

Dr. Botek:  Right. Yeah, diabetics, in specific, do have a fair number of foot problems. And it really originates from two issues, either poor circulation or poor sensation, okay? So poor circulation would be a lack of blood flow getting to the feet. And that can cause subsequent problems whether they realize it or not. Not healing a corn or a callus, developing a blister or sore that won't heal, or having pain in the foot and leg and even swelling in a foot and leg can be circulation related. Neuropathy, which is a general term that can affect up to 40% or more of diabetics, is a loss of feeling. So it's really our job when we do a diabetic foot exam, which are typically done annually, to determine is that person with diabetes at low risk of developing a foot problem or at higher risk? So if someone has a lack of feeling or poor sensation, that puts them in a little bit of higher risk. Imagine putting your shoe on and not realizing you had a key in your shoe.

Nada Youssef:   Right.

Dr. Botek:  A Lego in your shoe.

Nada Youssef:   Wow.

Dr. Botek:  So as time wears on, you can wear a hole in your skin like you can wear a hole in a sock.

Nada Youssef:   Wow.

Dr. Botek:  Not realizing it.

Nada Youssef:   So neuropathy is not feeling the whole foot or the whole bottom of the feet?

Dr. Botek:  It starts in a stocking and glove distribution. We say gloves, fingers of our gloves and the tips of our toes. And as it progresses, it can move further up the foot and leg.

Nada Youssef:   Sure, sure. And then how about arthritis, do you see a lot of patients?

Dr. Botek:  I see a lot of arthritis, absolutely. Especially with aging population and people are living more longer, healthier, active lives.

Nada Youssef:   Right, right, right.

Dr. Botek:  So we used to see a lot of arthritis 20 years ago in the 40 and 50 year old population. Now we're seeing it in the 70 and 80 year old population, even 90s, never being treated for arthritis before, coming in with severe arthritis. But, because they are active on these aging feet, have pain.

Nada Youssef:   I see. I see. From wear and tear. So are there any other symptoms or signs that accompany foot pain that is usually related with foot pain?

Dr. Botek:  A lot of people come in with swelling, swelling of unknown origin. Just, "My feet are edematous," or "It's hard to fit on shoes," or "Something's rubbing with the sock and shoe," and not really knowing the source of the swelling. So swelling can be just a sign of poor circulation or it can be a sign of arthritis. It can be a sign of other more systemic conditions.

Nada Youssef:   Okay. And the swelling usually starts in the feet?

Dr. Botek:  It can. It often does. Just imagine sitting and gravity pulling that blood down to your feet. Obesity is a huge issue as well. A lot of our foot problems that we see occur more commonly in people who are above their ideal body weight, and swelling is one of those too.

Nada Youssef:   Sure, sure. So when is it time to seek medical treatment for foot pain? Because, just like you said, sometimes you wore the wrong shoes or you walked too much. When is it time, like this kind of pain is different?

Dr. Botek:  Yeah. There are definitely some people I'll see that their pain just started yesterday. So it really becomes a subjective or elective treatment when you decide that you need to be seen. But in general, if you can't walk on your foot comfortably or you're limping, it's probably time to have an evaluation. If you feel like you have a problem that's worsening over the last few weeks. I kind of use that four-week mark. I mean typically if you have pain for a day or two, it can resolve. Our bodies are amazing. They can heal themselves or you can kind of nurture and just listen to your body. But if your problem has been prolonged, it's getting worse or it's not relieved with things that you do, whether it's modifying your activity or modifying your shoes or taking a Tylenol or icing your foot, then it's probably time.

Nada Youssef:   Okay, great. So how do you diagnose foot pain? What do you do when a patient comes to you and tells you, if it's not a wart or ingrown nail, if it's just pain? How do you diagnosis it? How do you evaluate it?

Dr. Botek:  So much of an exam is just by touch, a physical exam, looking, touching, listening to the symptoms. So if it's in the soft tissues of the feet, there are times that we don't need to go further than an exam, okay? We're checking circulation, checking the sensation, looking at the skin, putting a foot through a range of motion, detecting strength and comparing both sides. You should always take your shoes and socks off both feet when you go in for an exam just to compare. But if it needs to go beyond that skin or physical examination, then the first thing we'll order is a plain X-ray. So a plain X-ray just to look at an overview of the foot. You're looking at the bones of your feet, looking at the joints, looking at the bone density even. You can detect systemic illness sometimes just by getting a foot exam and having an X-ray of a foot and noticing things.

Nada Youssef:   Interesting.

Dr. Botek:  So a plain X-ray is done in the majority of patients. If we're looking for a little bit more detailed information, another go-to test would be an ultrasound. So an ultrasound of the foot or ankle can detect things that are happening mainly in the soft tissues, the tendons, the ligaments, even some of the nerve structures. And actually an ultrasound can detect some boney problems too. It's a low-tech and an inexpensive way to get more information of the foot beyond a plain X-ray that just looks at the bones and joints. An MRI is often done in more recalcitrant pain or more acute injuries where we really need to see the anatomy with more detail. A CT scan is another radiographic test that can be done to look at the bones of the feet. So if there's any congenital, from birth type issues or traumatic issues, a CT scan. Or even a foreign body, this time of the year we see a lot of foreign bodies, glass and splinters and...

Nada Youssef:   Ouch.

Dr. Botek:  ... that sort of thing can be gotten quite a bit of information with a CT scan.

Nada Youssef:   Sure. How about any blood tests for diabetes or arthritis?

Dr. Botek:  Diabetes is such a multidisciplinary condition that, for the most part, most blood tests are being done by the primary care doctor or the endocrinologist. But there are times that we may need to step in if someone hasn't had that type of care, preventive care, that will get those types of studies. Or if someone has an infection, we may be monitoring an infection through laboratory work.

Nada Youssef:   Sure.

Dr. Botek:  Another, probably most common, test that we'll get in the diabetic is checking the circulation. So we can get what we call an ankle brachial index. So we do this in my office where we'll get a pressure exam of the ankle and the arm, and compare blood pressure, just assessing the circulation to the feet. But a more extensive or more I guess accurate way would be to go to a vascular lab and have Dopplers done and be able to detect the blood flow from the heel and hip to the tip of the toe.

Nada Youssef:   Sure.

Dr. Botek:  So a Doppler exam is very sensitive.

Nada Youssef:   So what would usually be the reason that something like blood circulation not getting to your feet? Besides diabetes, is there anything else that...

Dr. Botek:  Yeah, there are other conditions that can affect circulation most certainly, in combination with diabetes. One of those is cigarette smoking. So tobacco abuse, if you've smoked, even if it's been in the remote past and you smoked about 20 years or more, that can definitely impact the arterial blood flow, the blood that gets from your heart to your toes. Just like it can affect the blood that gets to your carotid arteries, that go to your brain or your kidneys, okay?

Nada Youssef:   Sure.

Dr. Botek:  So smoking is definitely a co-existing condition or a past medical condition that can impact the circulation. Others, coronary artery disease. So we see a lot of diabetic patients who have heart disease or kidney disease. That, too, can impact the circulation getting to the feet.

Nada Youssef:   Wow.

Dr. Botek:  So if I have someone who comes in who has a history of diabetes, they have coronary artery disease, they had a 30-pack year history, they smoked from the time they were 15 to 45, 50.

Nada Youssef:   Right.

Dr. Botek:  We're going to get an ABI, PVR. If we can't detect pulses and we can't hear the pulse, we're going to get that more sensitive Doppler exam.

Nada Youssef:   Sure. Can we talk a little bit about something like gout?

Dr. Botek:  Sure.

Nada Youssef:   How do you check for gout? And if you can explain also to the audience what it is and how you get it.

Dr. Botek:  Yeah. So gout is a crystal type disease where you can develop this crystallization around the joints. Often it is the foot because urate or the monosodium crystals can deposit in the foot. It's a cooler place, okay? Your foot's cooler than your core temperature. So typically we have a condition called podagra, which is a red, hot, swollen big toe joint. So gout affects mainly men before the age of 60. But, once we get to the age of 60, it kind of evens out, affecting both men and women pretty fairly equally. Gout, you're more prone to gout if you have a history of high blood pressure, you've been on diuretics. Men typically have more urate in their blood system. So we have this uric acid, or urate, in our blood system normally. But when we get an over-deposition or an under-excretion of those crystals, they can deposit into just about any joint in the extremities.

Nada Youssef:   Wow.

Dr. Botek:  So it's a very painful condition, okay?

Nada Youssef:   Yes. And that is tested? Could that be tested through blood tests as well?

Dr. Botek:  So it can be tested through blood. A high uric acid level can be diagnostic. But we can also get those crystals out of a joint. So if we numb up the foot and aspirate a joint, we might be able to see those crystals under a microscope.

Nada Youssef:   Wow. That's very, very interesting. So then that's when something like your foundation, FLIP, something like gout or something with diabetes, this is when you would have the multidisciplinary approach of talking about one patient? Is this how that works?

Dr. Botek:  Yeah. That's kind of another discipline.

Nada Youssef:   It's a different one.

Dr. Botek:  That's rheumatology. Yeah, rheumatology, endocrinology, primary care with our profession. So that's another group.

Nada Youssef:   Sure, sure. Okay, great. So I want to talk about treatment for foot pain, ice or heat? Because you always here, "Oh, I did something to my ankle. Should I heat it? Should I..." I know earlier you said cool it, right?

Dr. Botek:  So ice in general is something that I usually recommend for most foot and ankle problems and pain because it's just a natural antiinflammatory, okay? Nobody makes any money off of ice so it's the most undersold item, but it really can give you a lot of bang for your buck, okay? But then, when we think about our population of patients or the person who has diabetes or potentially some decreased circulation to their feet, it's like the very branches at the tops of the tree where the focus, or that stem or root, comes from the heart and your blood vessels have the most blood circulating. By the time you get to the extremities, the tips of the toes, those branches are more brittle.

So to put ice on the tips of the toes is really not a smart thing to do most of the time to cause more decreased circulation to that part. But if we put ice more on the backs of the knees or at the ankle area, it can give you a lot of good foot relief. The most common application of ice probably, in our practice, would be a fracture, someone who breaks a bone. We're going to put ice on that area. Someone who's just had foot surgery, we're going to ice it down. That's a great antiinflammatory.

Nada Youssef:   Sure.

Dr. Botek:  Or an acute injury like an ankle sprain. Other more chronic conditions, we don't have a lot of beefy muscles or a lot of cushion in the foot so that's why heat isn't generally recommended unless you're soaking your feet, trying to maybe draw out something.

Nada Youssef:   Sure.

Dr. Botek:  Whether that's a foreign body or an infected ingrown toenail.

Nada Youssef:   Oh yeah, toenail. So let's talk about ingrown toenails. Because I feel that's like an everybody kind of problem. And a lot of people go just get that done at the nail salon.

Dr. Botek:  Absolutely, every day, all day long.

Nada Youssef:   Yes. Can we talk about how to prevent them and why they happen and why some happen to more people than the others?

Dr. Botek:  Sure, yeah. So it used to be that ingrown toenails were really the most common in teenagers, okay? Teenagers would just kind of get aggressive or their toenails would grow really fast all of a sudden, have a growth spurt and be wearing their soccer shoes that are two sizes too small. So teenagers still are more the at-risk group for ingrown toenails. But, at the same time, I feel like over the last 20 years of my practice I see more people in their 50s and 60s and 70s coming in with painful ingrown toenails. For one, the nail can become a little thicker as we get older. Whether that's a fungus or just normal wear and tear, the nails become a little thicker and the shape can change.

Basically our toenails can kind of change shape like our shoes do, all right? Your shoes are rounded, it's hitting the outside of that big toe and the nail, over time, kind of adapts and starts to grow down into the flesh. Some people just don't cut their toenails really well either or really go digging doing that bathroom surgery and creating this chronic, recurrent ingrown toenail. And then also we think about the lifestyles. So if you're running and jumping and playing volleyball or other sports, the nails get the brunt of some microtrauma and the nails start to grow ingrown. It can be very painful.

Nada Youssef:   Sure, sure. So I kind of wanted to go back to the surgery thing that we talked about with foot surgery and ankle surgery. I wanted to talk about recovery, what is expected and things like that if someone does have to have ankle or foot surgery.

Dr. Botek:  Yeah. That's probably the main drawback to surgery. We've got good ways to control pain. We've got better equipment and internal fixation now to fix problems. But it's that postoperative recovery. Some conditions, you're off your foot for eight to 12 weeks after surgery, some of the major reconstructive surgery that can be done to the foot. You just need time to heal. And, again, gravity pulls and you're carrying two to two and a half times your body weight through your feet with every step you take at times. So elevation and compression and being immobilized in a boot or a shoe can really lay you out for a while, decreasing your work time and your activity time and being active, or even driving. So, depending on what kind of procedure, that time can really change, okay?

Nada Youssef:   Sure.

Dr. Botek:  I know that I try to get patients walking as soon as possible but that would be for the more minor surgeries. So we're getting patients walking in modified shoes or padded surgical shoes. There's different styles and different heels on surgical shoes now. We're typically using more removable devices rather than casts which are quite heavy and cumbersome. So there is a period of immobility where you're not 100%. Not every surgery requires crutches or a walker, but there are those that do.

Nada Youssef:   Some do, yeah. Yeah, on your feet, that's the hardest one to...

Dr. Botek:  That is the hardest part.

Nada Youssef:   Yeah, to not work with.

Dr. Botek:  And imagine not driving.

Nada Youssef:   Right. Especially if it's your right foot or right ankle.

Dr. Botek:  If it's your right foot, yeah.

Nada Youssef:   Don't know what to do with that.

Dr. Botek:  That's rough, real rough.

Nada Youssef:   That is very rough. So, finally, I'd like to talk about preventable measures that we can take, if we are healthy, we don't have diabetes or arthritis, anything like that, to prevent warts, to prevent ingrown toenails and things like that. What preventable measures do you suggest?

Dr. Botek:  Yeah. Well, first of all, barefoot is for babies, okay? As we get older, we should wear shoes, all right?

Nada Youssef:   Yes.

Dr. Botek:  So the shoes are protective. Just today, I had a patient come in, diabetic. I've seen him for over 10 years, maybe 20 years now. And I look and his shoes have the holes in them and he's got no socks. I'm like, "Where are your socks?" You feel like you're talking to your kids. But socks with the shoes are important. Your shoes can be your treatment though. So when you look at certain conditions that you have, I mean your shoes shouldn't be more narrow than your foot. It should be round. It should be the same shape as your foot. Maybe because I'm a woman too, I'm not opposed to flip flops all the time or a little bit of a wedge or heel or sandals. But we have to be selective too.

Nada Youssef:   Yes.

Dr. Botek:  Your shoe is a good investment. A good shoe is a good investment. So not every flip flop, sandal or high heel is the same. You look for more platform or more gradual change to the heel, a chunkier heel. For sandals, we can have good arch support. Some of the foot beds of many sandals are kind of like built-in foot inserts or foot orthotics. Some of the flip flops now have deeper heel sets, have more arch support. In general, I say take that shoe and just kind of put it on one side of your hand, cup it on each side of the palms of your hand and try to squeeze the shoe, okay?

Nada Youssef:   Mm-hmm (affirmative).

Dr. Botek:  If that shoe squeezes, you can stick in your pocket, that's probably not the right shoe for you.

Dr. Botek:  It's going to lead to potential plantar fascitis, potential hammer toes, potential ingrown toenails, metatarsalgia, pain across the ball of the foot. So having a solid sole to the shoe and I think even going and getting your foot sized. So many people wear shoes that maybe they wore five or 10 years ago. And our feet do change over time. Since 1980, the average shoe size in an American has gone up two sizes.

Nada Youssef:   Wow.

Dr. Botek:  So is it the shoe? Is it our feet? Is it our food? I don't know. But it is worth getting fitted because the width of you shoe that you're wearing might be different than what you really, truly should be in.

Nada Youssef:   Yeah, yeah. And my foot size completely changed when I got pregnant.

Dr. Botek:  After pregnancy.

Nada Youssef:   After pregnant, yeah.

Dr. Botek:  There you go.

Nada Youssef:   Absolutely. And sometimes you feel like it doesn't even go back. And how about like heels? Heels really hurt when you have an uncomfortable... And a lot of women like to wear pretty shoes. And these heels, you talked about the ball of the foot and all that good stuff.

Dr. Botek:  Right, yeah.

Nada Youssef:   I mean that could really damage it. Or is that...

Dr. Botek:  There are so many shoes out there, and some are better than others. But once you get beyond two inches, you're putting so much more weight on the ball of the foot. Also, high heels can hurt your back and your knees. So the general rule is try not to wear a shoe that's greater than two inches more than three days a week. Try not to use them, wear them back to back. Pick your days so that you're not wearing those higher heels on the days where you're going to be on your feet for more than four hours of walking and standing. So kind of using them wisely. Or maybe you walk into the job in your comfortable tennis and then you put on your higher heels limitedly throughout the day.

Nada Youssef:   Sure. And maybe get some foot massages on the weekends here and there.

Dr. Botek:  Can't hurt. Can't hurt.

Nada Youssef:   Thank you so much for your time today. Thank you.

Dr. Botek:  Yeah, you're welcome.

Nada Youssef:   And to schedule an appointment with a foot and ankle specialist, you can call 866-275-7496. Thanks again to everybody listening. Hope you enjoyed this podcast. To listen to more of our Health Essentials podcasts from Cleveland Clinic experts, make sure you go to clevelandclinic.org/hepodcast, or you can subscribe on iTunes. And for more health tips, news and information from Cleveland Clinic, make sure you're following us on Facebook, Twitter, SnapChat and Instagram at ClevelandClinic, just one word. Thank you, we'll see you again next time.