Talking Foot Health and Shoes with Dr. Nicole Nicolosi

Podcast Transcript

Speaker 1: There's so much health advice out there, lots of different voices and opinions, but who can you trust? Trust the experts, the world's brightest medical minds, our very own Cleveland Clinic experts. We ask them tough intimate health questions, so you get the answers you need. This is the Health Essentials Podcast brought to you by Cleveland Clinic and Cleveland Clinic Children's. This podcast is for informational purposes only and is not intended to replace the advice of your own physician.

John Horton: Welcome, and thank you for joining us for this episode of the Health Essentials Podcast. My name is John Horton, and I'm your host. Today, we're talking to a podiatrist, Nicole Nicolosi, about how shoes affect your feet. Odds are, you've got a closet filled with all sorts of shoes, ranging from dress shoes to gym shoes, to flip-flops, to boots. Here's the question, though: Is your choice of footwear causing you aches and pains? That's what Dr. Nicolosi is here to chat about, while also offering us some tips to keep you and your feet feeling great. Thanks so much for being with us here, Dr. Nicolosi.

Dr. Nicolosi: I'm glad to be here. Thank you.

John Horton: Great, great. Hey, let's start by having you tell us a little bit about your work here at Cleveland Clinic and how podiatry serves as a gateway to address so many different health issues.

Dr. Nicolosi: Well, thanks. So I've been a staff podiatrist here at the Clinic since 2015 and the podiatrist, as well as surgeon. I'm a foot and ankle surgeon as well. And so I do see both ends of things, the clinical aspect, as well as when patients need to go that extra step into surgery. OK. And so podiatry is a gateway to other health concerns, being proper alignment from the ground up helps out your back, can affect different conditions. If you can't be active, then you can't exercise. You can't maintain your cardiovascular health. So having good foot health, in general, is important for your overall well-being.

John Horton: Well, definitely, definitely. If your feet aren't doing well, you've got some issues, which we'll talk about. So now, let's move on to our main topic, which, I guess, is shoes and your feet. And let's kind of get started with a real basic question: How important is it to wear a supportive pair of shoes that fits properly?

Dr. Nicolosi: So, very important. So, abnormal shoe fit can result in foot irritation, and that could result in callous, which in the diabetic population can result in an ulceration and lead them down the path of amputation. In a nondiabetic, improper shoe gear can also lead to structural deformities, such as toe contractures and other foot pathology, which can cause chronic pain.

John Horton: Wow. Chronic pain is something I think we all want to avoid. So clearly, I mean, the wrong pair of shoes can make your feet miserable. So what are some of the ... you had mentioned just aches and pains. I mean, what are some of the foot injuries that you could have, real specific sort of stuff?

Dr. Nicolosi: So one condition in particular is plantar fasciitis, and this is a condition which can result from overuse, from a tight ligament on the bottom of your foot, which supports your arch called the plantar fascia. And when your foot arch is not adequately supported and your arch collapses, OK, and this ligament is tight, it causes tearing essentially or ripping of this ligament. And this results in inflammation and the pain that results can be debilitating. So it's very important, in general, to wear good arch supports, good foot supports.

John Horton: Yeah. I'd imagine if you have ... I know I've talked to people … I run, and I know I have talked to people who have plantar fasciitis. You're not just plowing through that.

Dr. Nicolosi: No.

John Horton: So aside from your feet and the issues like plantar fasciitis that you can have, can bad shoes cause aches, pains and injuries in other areas of your body?

Dr. Nicolosi: So absolutely. So we were talking about alignment. If your foot alignment is off, that affects your knees and then, in turn, it affects your hips and then your back. So having a good alignment from the ground up is very important, having your arch supported to prevent your knees from turning inward, to avoid your hips ... So an orthotic or a shoe inlay that fits into your shoe to correct that alignment will, in turn, affect the rest of your body and prevent pathology higher up.

John Horton: Wow. Yeah, I think this is one of those things ... you think of shoes and your feet and everything, and you think of them as so isolated ... they're down there. But it sounds like if something's not right, if you get one little thing off, there's kind of a cascading effect all the way up and down your body where it can cause problems.

Dr. Nicolosi: Absolutely.

John Horton: OK. So when you're buying shoes then, I mean, in general, what should you be looking for to avoid having those sort of issues?

Dr. Nicolosi: So a good quality shoe, for me, has several good components. The shoe has to be decently rigid. And a good test, I tell patients, for this is if you can take your shoe and bend it clear in half, OK, this is not a good shoe for your foot and toe. So the structural support, with somewhat of a rigid shoe ... not to say it's a completely hard board or stiff pole that you're walking on, but something that offers you some structural stability, also, a shoe with a flexible type of material on the top, so especially in the area where your toes are.

This will allow for any high-pressure areas to develop on the toes. Let's say your toes have a slight curve to them, and there's not too much fat cushion on the top of your toes. So any hard leather ... that's going to be a really high-pressure source for the toes rubbing, so a flexible or a soft type of material on the top of the shoe and that toe box area. And lastly, the insole … so if the insole is completely flat, doesn't have any cushion to it, you don't have any arch support. And so fashion flats are example of this, where they are completely flat on the inside and don't have that arch support.

John Horton: OK. All right. Those are all great tips. And I think we're going to get into this a little more later when we talk about real specific shoes. Let's talk a little bit about shoe sizing. Now, I've worn a size 12 for as long as I can remember. I've got big clod-hopper feet. My wife gets tired of tripping over my shoes in the back hall. Should I assume that I'm always going to wear that size, or I mean, should I expect my feet to grow or shrink over time?

Dr. Nicolosi: Oh, good question. So yes, our ligaments and tendons that support our arch can become worn or degenerative. And as a result, there is a lack of support to the arch. And just from visually, if your arch is like this and you don't have that support, the foot lengthens as a result of your arch collapse. So yes, your foot length or your shoe size can, thereby, change.

John Horton: What about width? I mean, can your feet get wider over time, too?

Dr. Nicolosi: Yes. So in pregnancy, there's a hormone called relaxin, and this ligament is normally meant to stretch out the ligaments in your pelvis and widen the cervix. But when you're pregnant, it just affects you body-wide. And so the hormone also relaxes the ligaments in your feet, and that includes those that support your arch but also the widths. And so the ligaments that hold the bones together width-wise are also relaxed. And so females' widths, as well as length of their arch, can decrease and result in a lengthened foot or in a wider foot as a result.

John Horton: All right. This is going to sound like a silly question, too, but I mean, would weight gain just even contribute to your foot being, I mean, wider or narrower?

Dr. Nicolosi: Yes, absolutely. So it's the same kind of respect. If our ligaments aren't doing what they're supposed to, and everything is stretched, then everything widens as a result.

John Horton: OK. All right. All right. Now, let's do a little shoe shopping 101, take advantage of all your knowledge here and get a little more specific about different types of shoes and kind of the pros and cons of each when it comes to your feet. So let's start ... I mean, it's been warm here lately. Let's talk about flip-flops, and I know those have evolved from just wearing them at the beach to wearing them everywhere you go. Is that good for your feet, or are we causing problems?

Dr. Nicolosi: So flats and flip-flops kind of fall in the same category of a very unsupportive shoe. Again, if you could take your flip-flop and move it every which way are possible, then that is not very supportive of your foot. For the most part, athletic shoes are engineered to have that structural support, and so they are the best things for your feet. But any flip-flop that doesn't have an arch support will allow for your toes to kind of compensate for that lack of support and kind of grip the ground as a result. So I don't know if you've noticed, wearing flip-flops, your toes kind of curl, and this is a compensation that can result in hammertoe deformities to develop over time.

John Horton: Ooh. All right. So those 99-cent flip-flops … probably not the best form of footwear, huh?

Dr. Nicolosi: Chuck them in the garbage.

John Horton: All right. Let's change seasons now, and we were talking beach shoes. Let's talk winter. Are there concerns about all those sheepskin boots, kind of those UGGs® and BEARPAWs® and all those things that seem to be on every set of feet that you see in line at the coffee shop?

Dr. Nicolosi: So if you look inside those shoes and notice, it's completely flat on the inside without any structural support. So this structural support, being an arch support, is important for the proper alignment of our foot, like we were talking about, and that results in altered mechanics. So I give the analogy of a car. If your car is out of alignment, you get more wear down in certain tires. OK. And same thing with your foot. If your foot is out of alignment, you get more wear down in certain joints. OK. So in terms of the foot, this is abnormal motion, results in wear and tear of your cartilage, resulting in arthritis long-term. So adequate support, it prevents long-term pathology.

John Horton: And I know one of the things that those sort of boots are known for, too, is they're— I mean, so fuzzy on the inside and obviously very comfortable. But I'm going to go out on a limb and guess that is probably not the best thing as far as bacteria growth and all that too.

Dr. Nicolosi: That's absolutely ... so bacteria likes to grow in that damp environment. And so you'll often smell more as a result because bacteria will let you know when they're there, by an odor.

John Horton: OK. Well, that's another thing to watch out for. So since we're already in the boots section, let's look at a couple other ones. What about cowboy boots, that traditional Western gear?

Dr. Nicolosi: So very often, cowboy boots will have this kind of pointed end to the toe box, and this encroaches and narrows the foot in the toe area. And by compressing the structures in that forefoot, you then press on or impinge different structures, one being the nerves. OK. And long-term impingement of the nerves in the forefoot can result in inflammation or scarring or thickening of these nerves, something called a neuroma. And this will present to you as numbness and tingling and burning. And unfortunately, nerve healing takes a very long time to recover from.

John Horton: It sounds like we do a lot of stuff to our feet that is not very nice, with our choice of shoes. So with boots, too, I mean, does heel height matter? I know you see some boots, and the heels are just ... they're huge. And then some are kind of flat. How does that all fit into things, and what does that do?

Dr. Nicolosi: So by wearing a type of shoe with a large heel or a high heel over time, this can result in shortening of your Achilles tendon. It contracts your ... or tightening of your Achilles tendon over time. As a result of having a tight Achilles tendon, now you have ... when you don't wear those shoes with a heel height, now you're walking on flat ground. Now your Achilles tendon is short, and now it's pulling, pulling as a result of this tightness on where it attaches. And this pulling causes tearing on a micro level. It results in inflammation, predisposing you to Achilles tendonitis. Other pathology is that your Achilles tendon is a very strong tendon, and such a strong deforming force that it's stronger than the other tendons in your body, and your foot in particular, that raises your arch, your posterior tibial tendon. And so because of this overpowering effect of the Achilles tendon, it can lower your arch over time or flatten your arch as a result of the altered mechanics or overpowering of one tendon over another. So it can predispose you to a number of conditions, to being Achilles tendonitis and flatfoot pathology.

John Horton: And I'd imagine that's like ... goes into what we were talking about before, with problems going up and down your body, that if you're Achilles tendon's off, that can cause problems through your … band up into your hips, even in your back, too.

Dr. Nicolosi: Absolutely. For sure.

John Horton: OK. And so with boots, then, if you just go with more of a flat boot, is that, then, the way to go? Or if you go that way, do you have to make sure, then, that you just have arch support? I mean, what should you look for?

Dr. Nicolosi: So a flat shoe, it would be more supportive if it did have an insert in it or an orthotic. So the orthotic, what it does is, it offers our foot more structural stability. As we walk our heel strikes the ground, then the pressure is offloaded to the outside of our foot. Our outside of our foot is what is called a mobile adapter. It accommodates uneven terrain. OK. And so this load then transfers to the forefoot, so across the bottom of the forefoot and then to the big toe for propulsion going forward. And so if you have abnormal mechanics, from the point your heel strikes the ground, so if there's excessive motion in any one of these components, it then transfers down the line. OK. And so the tendons, for example, on the outside of your foot, in the midfoot area called the peroneal tendons, accommodate this excessive terrain or instability to the foot. And as a result of this lack of stability, they're being overworked. They're constantly trying to stabilize the foot as a result. And so they can be overworked as a result, resulting in tendonitis.

John Horton: Wow. From everything you're saying, it sounds like your feet are just ... they're really an engineering marvel with the way everything comes together. Let's move on now into the dressier side of the shoe store and talk about high heels and stilettos. And I think, some of this we've already covered, you said about with heel height and everything, but are high heels ... I mean, are they good for your feet, or are they going to cause some issues if you're in them all the time?

Dr. Nicolosi: So being a female, I wish this wasn't true, but yes, stilettos, high heels, they put all the weight of your body to the forefoot. Thinking of that, so your weight, all your weight, going to the ball, walking on the tippy-toes, it's putting pressure there where it should be more evenly distributed across the entire bottom of your foot. And so this uneven distribution of pressure kind of predisposes you to inflammation of these joints called capsulitis or metatarsalgia, which can take a while for this to calm down and resolve.

John Horton: I know with heels, too, you often see where they get, I mean, so pointy. I can't even imagine trying to stick my piggies in some of the shoes that I've seen. What is that going to do, with those high heels that you see go to that really extreme point?

Dr. Nicolosi: So that very, very narrow toe box, not only will this predispose you to that neuroma condition that we discussed previously, but also kind of exacerbate any bunion or hammertoe deformities. These are, first and foremost, genetic predisposed, but these type of shoes, which kind of bring your toes in that direction can cause this to worsen and develop these deformities over time.

John Horton: OK. All right. We've talked about high heels, just kind of regular old dress shoes, the boring dress shoes, like what I've got, what should you look for in those?

Dr. Nicolosi: A lot of men's shoes do have that narrow point, same as female's. And so you do need to be cautious of shoes that, also, will narrow your forefoot, and then dress shoes for a male do have that flat or unsupportive arch as well. So having a little bit of an arch support in those dress shoes will make that dress shoe more supportive.

John Horton: OK. Great, great. Now, let's get a little sporty. We're going to exercise a little bit because that's part of being healthy, too. If you're doing a sports or a fitness activity, what should you be looking for in a shoe?

Dr. Nicolosi: So I really defer to the arch type here. So if you have a higher arch versus a lower arch, that will determine, at least for me, the type of athletic shoe I will tend towards. So I love Asics® in this respect. I don't know if we're allowed to say shoe brands here. But Asics has a line of shoe geared towards higher arch foot types and then the lower arch foot types. And it really stops that instability or lack of control of your foot motion that will progress forward in your foot when you run or walk. So I, myself, wear the flatfoot line of Asics, and it really prevents my foot from collapsing in. And the same goes for that higher arch foot line, which would prevent your foot from turning out.

John Horton: OK. And I guess, the best thing you should do, to even figure out what you need there ... a good shoe store, or a running-shoe store will be able to kind of help guide you there as far as what you're going to need.

Dr. Nicolosi: Absolutely, for sure. And there is a lot of good shoe stores out there.

John Horton: All right. Now, a lot of ... you've talked a lot about kind of having the support and the arch support and all that. I know there's also an entire movement, sort of away from that, the minimalist shoes. And that's probably most obvious in those little, the five-toed shoes. They look like you're going to put gloves on your feet. Are those worth trying? I mean, do they offer any sort of benefit?

Dr. Nicolosi: So there's controversy on this. So this minimalist-type of shoe are good in certain respects and negative in others. OK. And so why it is the new trend is that it is for this very experienced runner who wants to increase their performance, get them running how their body is naturally meant to do this with their natural mechanics as a result of wearing kind of very minimal on their feet, almost running in their socks, as God intended. The purpose of these shoes is meant to reduce stress injuries that would come from wearing more of a structural or a restricted shoe.

But the controversy exists in the fact that because of this restriction, in lack of support, you're then predisposing the foot into other mechanical conditions. In particular, stress fractures is very common in this minimalist type of shoe and Achilles tendon pathology as a result of not having a little bit of a lift or support to the Achilles tendon when you're running. So personally, I'm in the more of the camp of the support. I think that this minimalist type of shoe is more for kind of the experienced runner that really wants to take it to the next level.

John Horton: OK. All right, great. Now, let's get to maybe the most boring shoe of all. If you are working, and you're on your feet all day, what is a must have for you as far as with a shoe?

Dr. Nicolosi: So work shoes may have certain aesthetic requirements that you need to look a certain way, being in a professional environment. And so the restrictions ... with that being said, it's very important that the work shoe, or the shoe that you wear at work, be very supportive of your feet, and that's because we're wearing our work shoes the majority of our work week. We are wearing them more so than our shoes that we wear on the weekends or in the afterhours. And so these shoes are very important. They should support your feet. I, myself, wear our Dansko®. They have a built in arch support to them. They also have that structural rigidity that I was talking about. First and foremost, the athletic shoes should be an automatic go-to because of their engineering. But Vionic® actually is a very good brand of shoe that makes a dress shoe that is also very supportive of your foot.

John Horton: OK. All right. And this is always a problem when you go shoe shopping. I mean, you’ll look at a shoe and go, “This looks incredible. I love this.” And then you put it on, and it doesn’t feel good. Style or comfort, which way should you go?

Dr. Nicolosi: Comfort. Your body's telling you it's painful for a reason. And so it's going to rub in the shoe store. It's going to rub even worse at the end of the night. And your feet are not going to be liking you at that point. So I would always go comfort over style. But females, you do have to have these exceptions to the rule. And not to say to always wear something that is comfortable and not aesthetically pleasing, but let it be the exception and not the rule to what you daily wear. Diabetics, though, do need to be more strict in terms of that comfort. They cannot wear anything that will rub on their foot because, again, they are predisposed to ulcerations and amputations as a result.

John Horton: All right. So sometimes, you're just going to have to put ... if that pair doesn't feel right, just put it back and know you'll find a cute pair that does feel good. Be optimistic.

Dr. Nicolosi: Be optimistic.

John Horton: All right. One last thing, and before we kind of leave the whole notion of shoes, what about just absolutely going barefoot? And we touched on this a little bit with the running and what you might want there. But just padding around in your house or outside or anything like that ... I mean, if you're barefoot, are there issues that you're causing for your feet or extra stress you're putting on it that you're just not thinking of?

Dr. Nicolosi: I tell most of my patients to wear shoes indoors as well as outdoors. Have an indoor pair of shoe, have an outdoor pair of shoe. We talked about the structural support, that it comes with wearing a shoe and the orthotic. Diabetics, especially, you cannot go barefoot. Walking barefoot with something called neuropathy ... that occurs with diabetes, is where you don't feel as you should. And so walking barefoot, you can get something stuck in your foot, not realize it, end up with an infection that then you can't fight off, and end up with an amputation as a result. And I see it all the time, unfortunately.

John Horton: Wow. OK. All right. Well, it's something to … to think about as you're making your choices and deciding whether to even wear shoes at all. Now, you had touched on ... if you make the bad choice with your shoes, and your feet are killing you at the end of the night, what are some things you can do? I mean, I know there's some TikTok trends out there that talk about using a numbing spray, lidocaine to ease the pain. Is that a good idea?

Dr. Nicolosi: So I think, when you're sitting, and you want to ease the pain, having a lidocaine or a topical anesthetic cream is good. I wouldn't recommend maybe using that same cream with activity. That would then lead you to potentially developing rubbing when you don't feel it, and kind of causing worse problems where you should be feeling pain and you don't. So having these topical pain relieving creams, like lidocaine ... Voltaren® is another one ... which aim to kind of temporarily relieve that pain ... yeah, I think that's great. Soaking your foot, Epsom salts for 10 to 15 minutes, as long as the temperature of the water isn't too hot, also, kind of relieves any muscle soreness or aches that your feet might be experiencing as well.

John Horton: OK. So to do it afterward, it sounds like it would be a decent thing to do. Doing it ahead of time, maybe not the best thing because you want to know if you're having issues.

Dr. Nicolosi: Correct.

John Horton: OK. All right. You have other issues. Say, if you have bunions or hammertoes, are there at-home treatments that people can try to kind of make their feet feel a little better?

Dr. Nicolosi: So there is something you can purchase when your toe is in a flexible state. So hammertoes come in different forms. There is a flexible state and a rigid state. Flexible, meaning you can take that contracture and unbend it. OK. So it's still flexible. You can de-contract that toe. OK. Rigid, being you can't unbend that toe anymore. It's stuck in that rigid position. And so unfortunately, once you're in that rigid position, it's more just kind of padding or comforting that area of increased prominence with over-the-counter supplies at the drug store but also that soft shoe mesh or toe box cover, like we talked about.

But what you can purchase when you're in that flexible stage, is something called a YogaToe®. OK. And so what this YogaToe does is essentially stretches out the tightness to that toe. And so the toe mechanics ... what's causing that toe to contract is an overpowering or over tightening of the intrinsics versus the extrinsics of your tendons in your toe. And so by stretching out what's tight will allow for that toe to eventually get back into a normal position. So you no longer have that tight or contracted or curled toe any longer. So YogaToes is something that I advocate.

John Horton: What about with bunions? I know that's something ... I'm starting to see a little bump out on the side. I believe it's a gift handed down from my grandmother, and I know there's ... I've looked online, and there's a little miracle worker things you can find that kind of go up against it and bring your big toe over. I mean, do those do anything, or is it just a ... I just wasted 20 bucks?

Dr. Nicolosi: Unfortunately, you just wasted 20 bucks.

John Horton: Oh, it happens.

Dr. Nicolosi: So here, just looking at your foot ... what a bunion is, is when the bone in the actual foot goes outward. And so as a result of this first metatarsal swinging in, your big toe swings out. And so these devices that kind of strap on the big toe, to aim, to bring it in this direction, unfortunately, don't do a thing for the actual driving force behind the bunion, which is the bone just behind it. So unfortunately, nothing that you can strap on your big toe that's going to correct that bunion other than surgery.

John Horton: Well, if my purchase helped somebody else avoid that purchase, I suppose it's a good thing. So I'll look at it that way.

Dr. Nicolosi: There you go.

John Horton: We've covered a lot of ground here today, Dr. Nicolosi, is there anything else? Is there anything we haven't discussed that's important for people to know or understand about shoes and their feet?

Dr. Nicolosi: I think that the proper measurement of your foot is so important. And so please go to your local shoe store and have your foot measured on something called a Brannock Device®. I'm sure you've seen that as a child growing up, those metal kind of devices that will measure the width as well as the length of your foot. And so what we want to look for is one to two centimeters, so about a thumb's width from the longest point of your toe, edge of your toe, to the shoe. OK. And so you can incorrectly go up on a shoe size thinking that, "Oh, this doesn't fit. I'm just going to go up on the size of your shoe." And that may not be correct. You may need to go in the width to adequately fit your foot. And so having your foot measured is important for your foot. It fits in your shoes as well as foot health in general.

John Horton: Well, that's good to know with the thumb up there because I know whenever I went to go get shoes when I was a kid, my mom tested it all the time. And it was always about a thumb width, is what she was looking for. No. Mom always knows.

Dr. Nicolosi: Mom knows. Yeah.

John Horton: Dr. Nicolosi, thank you so much for being with us here today and talking with us on this really important topic.

Dr. Nicolosi: Thanks for having me.

John Horton: If you have questions about your feet, talk to your doctor or call 216.444.4998 for an appointment at Cleveland Clinic. You can also find more information on foot health online at clevelandclinic.org. Thank you so much for being with us today.

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