Dr. Evan Loewy, Foot and Ankle Presentation

Alright, well good morning everyone. Thanks for having me. Like I said my name is Evan Loewy, new with Florida Orthopaedic Institute about four months now. But as she mentioned I am a local guy. I was born and raised in Winter Haven, Florida, not too far away. Did my undergraduate at the University of Florida in Gainesville, medical school down in Miami at the University of Miami, and then up in Tampa with University of South Florida did my orthopedic residency, and then was up in Charlotte for a year focusing on foot and ankle orthopedics at OrthoCarolina, a similar practice to FOI, a little bit bigger but generally the same kind of deal in terms of their practice.

So today I just want to go over a couple of main common causes a foot and ankle pain issues. Talk about them kind of go over a little bit, give a little insight into what when I see a patient like that in my office what I do, what I’m looking at, and kind of what I like to talk about and explain. And then also if you have this or know someone that has this maybe offer you a little bit of a bonus to kind of initial treatments of things that you can get started on and hopefully get rid of that pain or make it a lot more tolerable for you.

Okay, So going to do a little bit about heel pain. Mostly plantar heel pain and then also about flatfoot. So don’t want to get too academic today but

I’ll like to mention I kinda like to go over some basics in terms of education with my patients and about what their condition is and the specifics of that thing that makes us able to get on the same page with some terminology and just kind of why I’m saying we should do what I’m saying and not just that oh you should do this and I’ll get better. But why is that the case. So this is a response for starting with the heel pain on your left. It’s just the bottom of the foot. Basically just showing the plantar fascia. So the important thing with that is it’s a fibrous tissue it’s not very stretchy and doesn’t have great blood flow. It goes in the bottom of your foot, starts at the bottom of your heel bone kind of in the middle and then goes out all the way to your toes.

And so again a fun party trick or if you want to feel it yourself if you bend your toes back, that makes the tissue tight on the bottom your foot and that kind of band that pops out, that’s the plantar fascia. That helps hold up your arch. And that’s part of the components of it. And then on the other side, that’s just kind of looking at your heel pad or the fat pad underneath your heel bone. Normally it’s that spongy. It’s a fatty tissue but it’s spongy, elastic. Kind of gives you a good cushion. And then as it becomes less useful and we’ll talk about that later but not so much that the volume is gone or it doesn’t sort of go away, but it’s just not as spongy or is not as cushiony as it should be.

Briefly on heel pain imaging so this is a lateral extra and something I like to talk about. It’s a common misconception that a heel spur is the reason for the pain. So there’s no evidence that we have in medical research that that is actually the case and so estimated about 10 percent of people, in general, have a heel spur. Only about 50 percent of people that have a heel spur actually ever have pain. It’s just it’s not actually attached to the plantar fascia. It’s near it. But there’s no reason to believe that we’ve seen that actually removing that will get rid of any pain. Sometimes it could actually make things worse.

Hopefully, that’s showing up a little bit but basically that’s just showing the bottom your foot. So in terms of an exam is where does it hurt kind of keys us into what’s going on. And so basically you may not be able to see well but in the front part of your heel pad or the round part where your heel is on the bottom kind of on the front of that on the inside of your foot on the instep that’s where the plantar fascia is, that’s where it hurts. And that’s where if you come in and I think that’s what you have a push right there and then you’re gonna say how did you know that’s where it hurts. That’s why I say we probably go to school for so long so we’re efficient and we know how to hurt you.

Then if it’s central heel pain or something else that we’ll talk about in a minute that’s more just right in the middle and the center on the bottom, dead center underneath your heel that’s where that hurts typically. And so plantar fasciitis similar to it’s actually similar from a disease process to a tennis elbow which is pretty common or lateral epicondylitis. So it’s not really an inflammatory condition even though the name kind of infers that. It’s really more of a degenerative process. And so what happens is in these tissues that don’t have great blood flow what we think happens is that you get a small tear or very small injury that’s really not you know anything major but it’s since it doesn’t have good blood flow it doesn’t really heal. So it kind of heals with scar tissue and then that can tear a little bit and so it kind of smolders and has this kind of circular effect that can happen and kind of smolder for a little while. It’s hard to rest it because you’ve got to walk and somewhere like with tennis elbow you’ve got to use your hands and so that’s why it kind of can smolder like that and kind of continue.

Like I said it’s more of a degenerative process than an inflammatory process which is important because anti-inflammatory uses aren’t always helpful with this condition because there’s not inflammation for it to treat always. Classically with plantar fasciitis, we say it’s the worst step. The first, excuse me, the first step in the morning is the worst step of the day. So a lot of times what happens is you get tight overnight. Kind of everything in your calf muscles and your feet, everything kind of tightens up while you’re sleeping and you step down and it retears. And then you walk for a little bit and say OK, it loosens up I feel a little bit better it doesn’t hurt quite as much but you know what the more I’m on it all day then it starts hurting again and gets worse and worse again.

And that’s more because as I said when you bend your toes back so when you walk every time you step over the top your toes get pulled and that pulls on that tissue and just kind of aggravates it throughout the day. And so that’s why that happens.

So with treatment I would say that one of the most important treatment regimens is education. So that’s kind of why good talk about all the background things so that I can explain kind of why we’re doing what we’re doing. Tell patients that the good news is that 90 to 95 percent of the time this will get better without any surgery or without any big major treatments. The less good news is that it can take up to a year to do that. Not always and doesn’t typically take that long but it can’t take that long. The most important thing of all the million-dollar market if you google it or search for it or talk with people you hear about all kinds of inventions, gadgets, treatments you can buy. Really the best thing that we have that’s been shown with research over and over again is the specific stretching program.

And I’ll show you that can the specifics of that here in a minute but basically stretching your calf and then also trying to stretch that tissue on the bottom or actually stretch the plantar fascia. Like anything with stretching it doesn’t happen overnight. It takes typically about six weeks till you really start feeling some difference and then you know to continue to improve with time but it does take time and typically does work. Night splints basically show a picture that’s basically like a boot or something that you wear on your heel that keeps your ankle at 90 degrees or keeps you from kind of crumpling down or kind of tightening down overnight. I don’t think I could sleep with that on my foot so I usually don’t necessarily recommend it. We talk about it in case you think you could and usually, it’s really just shown to be helpful as an adjunct

In addition to stretching so you’re not taking the place of stretching. And I also tell people that if you don’t think you can sleep with that, don’t worry if you just stretch and do these stretches before you put your foot down it’s probably pretty similar effect that way. There’s no evidence that custom orthotics are gonna change this at all. Some people if you have a significant flat foot or other problem that may help it but I wouldn’t feel like you have to spend money on a custom orthotics for this problem specifically. And there are some over-the-counter ones just like a cushion or you know a Dr. Schultz type of thing that’s just soft or padding into that area. It’s probably just as beneficial. Sometimes anti-inflammatory will help. Like I said sometimes not. And basically gauge that kind of on how your exam is and how bad it is and associated conditions.

So the left there, that’s a picture of a night splint. That’s one version, there are tons of versions of them that actually have one. It’s called a Strassburg sock. It’s kind of like a big tube sock that comes off and then you wrap around your legs. Pretty crazy looking but then basically just trying to keep your ankle from getting pointing your toes down overnight and then that’s just kind of a cushion there on the floor a heel cushion for your shoes that you could get something like that. This is the stretches that we talk about and have a hand out that I can give patients. But the key is having your knees straight and so if it’s up on something on a chair or Ottoman or on the couch with you and then using something that’s non-elastic so like a belt or a rope, luggage strap something like that, towel, and then put that around the ball your foot and pulling back and stretching. You should feel it stretch all the way behind your knee.

And so that’s the important part there and so that’s one of the major stretches. I use it, we do that with a non-weight bearing rather than putting your foot up again. You know kind of up against the wall and pushing your foot back that kind of a classic stretch because that is actually pulling on those toes and so it’s kind of aggravating the plantar fascia. And then the other picture there on the left with just the foot, so that’s just the plantar fascia specific stretch and so I kind of try to, hopefully, I don’t fall over here, I would say it’s your right foot so if you cross your legs like so kind of just figure four and then if it’s your right foot, use your right hand then you come over the top. Grab your toes and you’re pulling back stretching that tissue on the bottom. So holding that 10,15 seconds and then release and doing that you know multiple times like 10 times and doing that a few times a day it just really can’t stretch it too much and just trying to loosen things up with time lessen the pressure and that can help this kind of let it burn out and let it progress through the stages.

So from we call more interventional or kind of more involved treatment options if that doesn’t work. And so typically with these we wait till at least six months of symptoms despite appropriate conservative treatment. So meaning that you’ve been doing the stretches, you’ve tried the other inserts and all this kind of stuff and you say Hey man I’ve done all that you talked about. It still is driving me crazy. What are the other options?

So there’s, a lot of people do steroid injections so I personally am not a huge fan of it for this condition unless you know if someone crawls in and can’t put their foot down and then we talk about it but it’s not steroids aren’t really good for tissue healing. They’re good for inflammation. But as I mentioned it’s not really an inflammatory process. And so sometimes it helps a little bit. The research that we have shows that it can change the symptoms if versus placebo or just kind of water injection. It’s about a month that it may help symptoms but it doesn’t change the overall course of the disease. Some people will say Hey I got an injection before and it went away. I kind of like not to taking antibiotics for a viral infection. You know if you get a cold is probably going to get better sometimes take an antibiotic that may help too.

But a lot of times it doesn’t. But the problem with it is, more importantly, is that it weakens the tissue and so you can rupture the plantar fascia. Problem with that is there’s no surgery to repair it. It’s a bigger problem that kind of changes the way you walk and the way your foot works and then we talk more about custom orthotics and things like that. So I don’t like to really recommend it unless there’s a serious problem but not to say if you’ve had one before someone did something wrong to you but that’s just my personal belief and my training. There is shockwave is an option and so it’s actually like what you get for kidney stones. That’s an option. Unfortunately insurance doesn’t cover it. Hopefully there are no insurance people here. But I usually kind of say that that’s. Purely conjecture and no one’s told me this but it’s probably too easy for you to get

And that’s why they don’t want to cover it because then everyone will be like Sure why not do it. Hey why not. So you kind of, it’s out of pocket unfortunately but that is something that has been shown to help stem cell type injections. Again all this is really to try and stimulate blood flow to that area and to try to get it to heal. So there are different types of stem cell injections that are out there. The one that probably has the most research behind it is actually amniotic tissue but nevertheless this type of stem cell, reasonable evidence behind it. Again insurance doesn’t cover it because it’s expensive and some people would argue that the research is biased because the companies that own that product sponsored the research, but nevertheless it’s an option potentially. And then there’s surgery which either percutaneous made through a small incision or open meaning a bigger incision insurance will typically cover those but it’s a lot more of a recovery standpoint. It’s more involved from a treat from more that you got to put into it and go through and so that’s probably why they cover it because it’s more of a commitment.

All of them in general from shockwave stem cells percutaneous open surgery generally speaking around 85 percent success rate in the literature in our research. So all generally is similar but just varying levels of recovery and limitations afterwards. But again the good news is most of the time don’t have to worry about that.

A far as central heel pain, just to briefly touch on that, you know risk factors say repetitive story injections, inflammatory conditions, repetitive trauma, just degenerative issues, I mean basically just for some reason that tissue gets worn out or if it gets weakened from steroids or inflammatory conditions those types of things essentially just it’s a lack of cushion on your heel for all intensive purposes. Shows a blow soft flat surface on the heel there sometimes you can have some bursitis or some redness swelling associated with that. Unfortunately, there’s not a lot of great options for this. This is we talk about more specifics in terms of just cushioning with shoe modification or inserts.

You know our famous orthopedic famous if it hurts don’t do it try to avoid things that make it worse. Basically what can happen is your bone gets has less cushion and so your heel bone kind of gets a bruise and it’s really hard to get that to resolve because you’ve got to be up and moving around and so hopefully the cushions and changing your activities a little bit will let that cool down and not be as bad for you. There’s not really any safe consistently shown injectable replacement cushion or anything like that or tissue. I always tell patients that if by chance you figure something out let me know we’ll have a lot of time on the beach together.

Moving on to flat foot, touch a little bit on that. Two general causes of flatfoot I’m going to touch on. So, in general, the normal arch of your foot is maintained by a combination of the bones ligaments tendons all those things together acquire or acquire flat foot just meaning you weren’t necessarily born with it you can get that from different causes.

The most common cause you may have heard of posterior tibial tendon dysfunction or posterior tibial tendonitis basically has to do with the tendons and ligaments. That’s the most common cause. Also you could have something that we call atypical flat foot which is usually more related to the bones or joints rather than the tendons. I’m going to touch a little bit on both. It’s important to know and for the provider to understand because there’s a treatment’s a little bit different in terms of these.

And so it’s important to be able to distinguish those when that happens. Well sorry. We go back. Thanks.

So briefly again the anatomy such as the drawing of the inside part of your ankle. So the poster tibial tendon is one of the main components that helps with your walking and it’s important to use for the arch. It’s a start. The muscle starts in the back your leg and then the tendon runs right around the inside bone and your ankle runs right behind that bone. It’s a pretty narrow shallow groove that this tendon runs in. Unfortunately, there’s not good blood flow in that area. So it’s kind of set up to fail in a sense but that’s that’s the tendon that can get injured and get stretched out. The interesting thing about it, at least it’s interesting to me, I think is that this is a really important tendon for your normal gait and walking in your foot posture.

The whole tendon in the works. It all does as it pulls and it’s two centimeters. That’s all it does it pulls two centimeters so basically the width of your finger. And so if you imagine if you have even a minor injury to it that maybe lengthens it by five millimeters, that’s 25 percent of its function is gone. Just like that and so that’s why it’s just very susceptible to injury into dysfunction. The other pictures just showing it basically comes around attaches almost the entire bottom of your foot. Which shows you how important it is that it’s set up to do that.

So there’s just a couple x rays shown I’ll get a bit more into that detail with these are just the bones of the foot from a side view and the top view. We’ll explain the importance of that here in a minute.

Pathophysiology which is basically what’s going on why is this happening. So like I said it’s a sharp turn in a narrow groove, kind of has a lot of little injuries to it. There’s not good blood flow. And so with time that kind of stretches out. Usually, it doesn’t rupture so to speak in terms of if you imagine like a rope completely breaking. Usually what it is more is it’s with time it kind of frays and get stretched out and beat up and raggedy and then that it’s just once it stretches out too much it’s not working the same like if a rubber band is stretched out it’s still there and it’s intact but it’s not doing its job.

So patients come in typically a lot of time will say I have fallen arches. And so it’s important for us to understand and to ask you to say OK well is that how you always have been. Is that your foots always been like that or does it have a little bit. And then recently it changed or was it always looked normal and looked like everyone, you know, a normal with the arch and then recently that changed. Typically in the course of this condition, you have pain on the inside part of your ankle or we call medial based on the inside part. It starts there and then as the condition progresses through later stages you have pain more on the outside part.

This is what we look at basically kind of just to show you what’s going on and so the picture on the left looking at the back of somebody and they’re healing so you can kind of see the one on the left that line is straight. And so that’s typically generally where your heels should be in relation to your leg and then in the right part of that picture you can see that angle there. We call it valgus. So basically that’s someone that’s knock-kneed is we call that valgus. If you’re bow-legged that’s various. But basically there’s valgus. So the angle is pointing towards the inside of your body. And so that’s the abnormal side and then we like to call that too many toes sign is basically when I can look from behind, and you see in the picture on the right, his right foot you can see more of his toes on the other side and that means that he’s kind of splayed out under his arches flattened.

Just this we look at too. I”ll have you stand up and look from behind. Have you go up on your toes and if you’re heels out to the side but then when you stand up it comes in, that’s normal and that shows me that it’s flexible and that your tendons still works. If that doesn’t happen or you can’t do it, that means that that tendon is not working.

So basically this is an abnormal actually. There’s one that I have it’s a normal one to show the difference it’s not working. I apologize for that, but that one I showed before the important thing to see is that these lines Should be basically it should be one line. So basically the whole part of your foot should be continuous pointing down towards the same and you can see that it’s not. It’s broken there. And so this is a, It should be, these should be, this bone should be pointing right down that bone.

And then this is a normal one from the top. And so this top of the same two bones that we’re looking at on this view. It doesn’t necessarily have to be one line but we want them to be parallel. And then we’re looking at this joint here to make sure that it’s lined up and that’s basically a ball and socket that everything’s that the sockets covering the ball. And then this is a flat foot. So you see these lines are no longer parallel. And then this socket is no longer covering the ball. So the scoops, the cones kind of fallen away from the ice cream.

A lot of times I like to show you that so you don’t think I’m making stuff up. I can be like look something’s wrong here. So going through the stages, briefly the stage one is just when you have tendonitis or inflammation in that tendon. There’s no deformity to it or your foot still looks normal. Just that pain that you can have swelling there. You’re able to do that straight leg or single like standing on one foot going up on your heel.

You can do that. The tendon works is just angry. Stage two is when that tendon no longer works. And so that’s when you start having the flat foot or actually looks different. It’s still flexible meaning that when you sit down and I examine your foot I can move it around and make it look like I want it to in terms of where it should be but then it goes back away from that on its own. And then that you cannot go up on your heel. Stage three is when

That kind of continues and I would say is that your foot’s not working right. The tires are out of alignment and then they wear out faster should you get arthritis and then it gets stuck there. And so that’s got a rigid deformity meaning it’s flat. I sit you down, I can’t move it. It stays there no matter what I want to do. It stays out flat like that. And then also you have sinus, STS, sinus tarsi, basically, you having pain more in the joints rather than just in the tendons and this is kind of when you start having pain on the outside part of the foot like I mentioned.

Then then the final one is somewhat controversial I guess when we have our meetings everyone gets excited about argues about what this means and why this is stage four and what that actually is. But nevertheless the important point is when eventually it puts stress on your ankle joint and then your ankle joint becomes abnormal too. Not just the foot part. That complicates things as you’d imagine. So the reason I went over that is just to talk about different treatment strategies. OK. So if it’s flexible we do what’s called a corrective bracing meaning something that’s going to move you where it should be and hold you there. If we have to do surgery if conservative treatment doesn’t work, which we always try first, we do surgery. It’s called extra-articular surgery. I’ll show you what that means. If it’s rigid then we you accommodative bracing meaning that we’re just trying to hold you there and limit the motion and try to make it more comfortable because we’re not trying to put you back because your foot won’t go anywhere else.

And then we do intra-articular surgery. Explain that briefly. So first stage 1 and 2 when you come in, first what we do is we want that tendon to rest. Sorry the arrows are a little messed up there and the words I apologize for that. But essentially want that tendon to rest so we can start with what’s a like a lace-up brace. That’s the picture down on the left, Goes in a regular shoe. If you still have pain with that then we go to a boot. If you have pain even in the boot then I tell you that you should try to stay off of it. And so we’ve got to get that tendon to cool off one way or the other. We usually have if you’re able to take anti-inflammatory is like aleve or Motrin and have you do that for a couple of weeks trying to get that help calm things down and physical therapy can be helpful.

You know I don’t want you to get too aggressive in terms of strengthening it until that tendon stops hurting. Then you can focus more on that tendon but generally stretching, Iontophoresis and basically different modalities that they have in terms of like ultrasound and medications and ice and stretching that can help kind of get the tendon cooled down and then start on strengthening afterward. So the stuff that’s jumbled up there it’s basically just saying that you know oral or injectable steroids again are not a great option here because it weakens that tendon and we’re trying to get it to heal and keep it as healthy and intact as possible. So I typically don’t recommend steroids either injections or like a medical dose pack.

And then hopefully we get that calm down and you feeling better and so then what do we do to keep it, we use something more. Then we talk more about orthotics, either off the shelf arch support or custom depending on the situation in exactly the best and the specifics of your foot or you can do some specialty shoe stores have shoes that are kind of with built-in arch supports now that are very helpful in that situation as well. If that stuff doesn’t work we can do surgery. If it’s stage one tenosynovectomy it just means we’re cleaning up the tendon because still intact. It’s just angry.

Sorry guys. And then stage two is then we start doing we called joint sparing reconstruction so. Well basically the first one would show just the flat foot like that other X-ray I showed you. I apologize again it’s not working. This is after surgery. This uh Alicia’s 55, had the flexible flat foot. So this is surgery, we keep the joints intact but we have to cut bones and move around and reshape things move tendons around and basically everything still moves the same but we’re just reshaping things. That’s the type of surgery we do for stage two.

It’s common with stage three or four more of the rigid deformity that’s kind of treat that almost more like arthritis because that’s really what’s going on. Really what’s causing the pain the tendon typically doesn’t hurt anymore. It’s the arthritis that you’re left with what’s hurting you. So you do more bracing and sense of accomodative bracing as your foot is stuck in that position but we’re trying to limit the motion there at that joint that’s arthritic and so different types of braces that we can do both custom or off the shelf that can help limit that. And then anti-inflammatory sometimes we can do cortisone injections for this problem because we’re doing it for the joint for arthritis much like you may have had for a knee or possibly hip.

This type of surgery is little more involved. It’s more intra-articular surgery. So again this is the afterwards x-ray. This when we have to go into those joints and then realign them and then fuse them together and so there’s no motion at those joints. But typically when we get to this part you don’t have motion there anyway and so we’re not losing motion with surgery but we’re getting it lined up and stable.

And so your footwork’s a little bit better and gets rid of the pain. This patient was 74 had some persistent flat foot deformity and pain. It wasn’t working with bracing and so had this surgery. This x-ray is four months after surgery. She’s been walking in a regular shoe for about six weeks at that point and I’m feeling good. And again briefly stage four just to show some specifics or you know go over it again. This is where it gets even more involved and at times we have two surgeries. We have to stage it occasionally where we do one to address the foot, get that lined up and then go back. And then sometimes have to address the ankle with different ways. This is a 73 old male who had persistent flat foot despite bracing. That was the first surgery did realign the foot. And then this is a total ankle replacement we did afterwards to address this ankle pathology.

Briefly, the atypical flat foot that’s more arthritis in the midfoot causes instability and flattening there. Even though the tendons can be working OK. And so again that’s why it’s a little bit different treatment. Conservative. First we use a stiff-soled shoe with a rocker bottom and so again those joints in the middle of the foot aren’t really supposed to move much. They don’t move much in normal action but when they get arthritic they move enough to hurt which is kind of annoying. But what you can do is a stiffer soled shoe is going to limit how much motion happens and flex through those joints. And so that limits pain if there’s less motion through the arthritic joint that times have a little bit of a rocker bottom not necessarily like a beach ball or anything like that but just a little bit of a curve so allows you to still walk normally with a stiff sole. Anti-inflammatory is possibly a cortisone injection and then surgery is similar to the second parts of the other one. If we need to do surgeries more fusing those joints just getting them lined up and then doing surgery to stick, to keep them there. Sorry guys for the problem with that but surgery keep them there lined up and again doesn’t really affect your motion and sounds like it does with a fusion, but those joints aren’t supposed to move anyway so. Thank you guys, sorry for the A.V. issues but I appreciate your time and I’m happy to answer any questions.

So associated with them. I don’t have a clinic in that building. My closest clinic here actually is the Brandon office. At this point in time but I am the same group but just different practice different locations. Several years ago I would say I Volunteered and I’d been doing a lot of standing. My wife and I were standing and I all of a sudden I felt a pop in my right foot. And subsequently, to that I developed my arch in my foot. had to go out but I developed a large callus on my arch which has been there ever since. But I step on that callus sometimes in person. What can be done.

It’s a good question. So what I tell patients a lot of times to start is that I’m a surgeon. I love doing surgery. That’s why I did all that training and everything and I love doing it. But if it doesn’t hurt that much then don’t let anyone do surgery on it.

You know I can sure I can make it lined up probably but the calluses is kind of the secondary problem from the shape of it. And so then that’s just from extra pressure on an area that’s not supposed to see pressure. And that certainly can be painful when you get that callus there. So initially with that, you know things to start with or depending exactly where it is and how much mobility you have in your foot.

Different types of bracing orthotics can help limit that. But you know if it’s able to get lined up you know or just kind of pad that area and offload the pressure and that’s where I would start with. Depends a little bit on the specifics but what kind of brace and that type of thing. But if it’s mostly just a callus and you know you’re kind of are able to deal with it and maybe with braces a bit better I would do that. Surgery may help get it lined up and minimize the callus. But just depends on how much it really bothers you. And I would definitely start with the brace or something probably.

So it was that tendon. And so sometimes it can kind of stret