Live Lecture: Dr. Youstina Bolos, “Getting You Back on Your Feet”

Kasey Wishart: Good evening and welcome to Florida Orthopedic Institute’s Physician Lecture Series. Thank you for joining us. My name is Kasey Wishart, and I’m a physician liaison here at FOI. Tonight, I am proud to present our new podiatrist Dr. Youstina Bolos, who will be talking about podiatry basics, evaluation, and treatment options. Dr. Bolos is board certified by the American Board of Podiatric Medicine and American College of Podiatric Medicine. She received her undergraduate degree in biomedical science from the University of South Florida, go Bulls, then went on to Barry University in Miami to achieve her podiatric medical degree.

Before we get started, just a few housekeeping notes. First, we’ll be sending everyone a link to this webinar. Second, you can comment or ask questions directly on Zoom, and I’ll be monitoring those questions. You can also send questions on Instagram @fl_ortho or Twitter @fl_ortho. At the end of the presentation, we’ll get to as many questions as possible. Third, if at any time you don’t see your slides moving or have trouble with the audio, please try refreshing your browser. With that, I’m pleased to turn it over to today’s speaker Dr. Youstina Bolos.

Dr. Youstina Bolos: Thank you, Kasey, for that awesome introduction. I really appreciate it. Today, we’re going to be discussing “Getting You Back on Your Feet.” That will include lots of injury prevention discussions, shoe gear that you should be wearing, things to put on your feet to help prevent injuries. Then should an injury occur, when to seek medical treatment and how to try to remedy some of the situations on your own at home, and again, when it’s appropriate to seek attention. Some fun facts that I’ll be throwing out throughout the presentation. First of which is if you walk approximately 8,000 to 10,000 steps every day, over an average lifespan, you will have walked the earth approximately 4 times.

That’s a lot of miles on your feet. It’s really important to protect them and keep them in good shape because they will take you far. That’s where we’re going to go from here. Our topics of conversation today, as I previously mentioned, are proper shoe gear, muscle conditioning, how to prevent injuries, and how to properly support your feet so they can keep you going. Should any injuries occur, we’re going to discuss wound care and proper treatment of your feet and again, when to seek medical attention should an issue occur. Prevention starts with looking at things that could be causing you injury. One of the very, most common things that could be causing you injury is overuse.

That’s the most common cause of foot and ankle injury. As we just discussed, you put a lot of miles on those feet, so they are overused and that’s how injury can occur. Untreated injuries of the foot and ankle can worsen over time because you’re using your feet so much on a daily basis. Our feet and our ankles are what support our body weight. It’s very common for them to very easily become injured and if not properly treated, it can turn into a chronic condition. We will talk about how to prevent that from occurring. Each of our feet are very intricate and have a lot of components.

That means there’s a lot of things that can go wrong, a lot of things that can become painful, and a lot of things that could cause somebody to be in pain and can be overused. We have 26 bones in each foot, we have 33 joints, we have 19 muscles, 10 tendons, and 107 ligaments. That is incredibly intricate and different components of our foot function differently, and again, very easily to become injured and that’s why it’s very easy to protect them. We’re going to discuss how to do so. The first thing and the easiest thing that you can do to prevent injury is inspect your feet daily. Check the bottom, top, sides of your feet, and certainly don’t forget between your toes.

Check your feet daily and if it’s difficult for you to reach your feet or see the bottom of your feet as you can see this device here, it has a long handle and a mirror attached to the end of it to be able to assist you to see the bottom of your feet more clearly. If you have a family member or a friend, you could ask them to help inspect your feet for you regularly. Things you’ll be looking for our bumps, bruises, cold spots, hot spots, rashes, burns, swelling, cuts, anything that is out of the ordinary that wasn’t there the day prior the last time you inspected your feet. If you do notice any of these, make sure you keep a close eye on them.

If not resolved within a few days, that you seek the appropriate medical attention as they can turn into serious problems. Socks are the first thing that you want to use to help protect your feet. When purchasing socks, especially for diabetics or people who have neuropathy, I recommend white socks. The reason for that is when you put a white sock on, if you’re unable to inspect your feet, you can remove a white sock and look for blood or drainage or a hole that wasn’t there the day prior and that would incline you to further investigate where that came from. If an issue is present, you keep a close eye on it. If not resolved in a timely manner, you would seek attention for that.

For athletes or people who live in warm environments like ourselves here in Florida, I recommend socks with synthetic fibers, such as nylon, polyester, and spandex. The reason for that is because those mixed fiber socks can wick away moisture better. You don’t want to leave any wet socks or things that can harbor moisture on your feet because that can lead to a possible fungal infection which we will discuss a little bit later. Cotton socks should be avoided because they retain moisture, they can bunch up under your feet, cause blisters, and cause friction that can turn into a problem. Avoid seams when possible.

Try to buy socks that will not have too many seams, especially in the front of the foot because seams can create friction and lead to blisters, and again could cause ulceration to occur. Extra padding, as you see this sock here, has a little extra padding in the heel that helps to protect the back of your foot and your heel when it comes into contact with your shoe preventing blister formation. Especially for runners or people who do high-impact activity, blisters are very common due to friction. Next, we’re going to discuss shoe shopping. When shopping for shoes, make sure that you go shopping at the end of the day or in the late afternoon because that’s when your feet are at their largest.

You want to accommodate your feet when they’re at their biggest. The best time to do so is at the end of the day. I know it’s very convenient to go shoe shopping online. A lot of us are accustomed to it, but shopping for shoes should be done in person. It’s really important that you put those shoes on your feet, you try them out, you walk around with them, and you make sure they’re comfortable and you get measured appropriately. Our feet are not the same size, one foot is bigger than the other so make sure you get shoes that accommodate the bigger foot. Also, make sure your shoes are the appropriate length.

The length of your shoe is measured from the back of your heel to the tip of your longest toe. Your longest toe is not commonly your big toe, it most often is your second toe so make sure that that measurement goes to your longest toe. There’s a half-inch space between your longest toe and the front of your shoe. Make sure you have some room in that shoe, but not too much. Make sure that you bring your socks and your orthotics with you when trying on shoes. You want to make sure that they’re comfortable when you have everything in them. Finally, when shoe shopping, look for shoes that don’t bend in the middle.

Make sure your shoes only bend in the front of your foot as that’s the natural architecture of your foot. Your foot doesn’t bend in the middle and your shoes shouldn’t either. Our feet change over time so make sure you keep an eye on any changes to your feet. If your shoe size changes, make sure you get shoes that accommodate that change. It’s very common as we age our feet change, or if we gain weight that our feet can spread out and become wider to accommodate that extra pressure that’s placed on them. It’s very often that pregnant women have changes in their shoe size because of that weight gain. Their shoe size can return back to normal after the weight gain is lost, but sometimes it’s not, so make sure that you accommodate your feet in whatever size they are. When shopping for shoes, I’m going to give you some tips on looking for shoes to accommodate the symptoms that you might be feeling in order to reduce some of those symptoms and provide you some relief.

If you’re having pain in the ball of your foot that could be due to loss of fat pad, which is very common as we age, we lose the cushion in the ball of our foot, which makes the ball of our feet a lot more painful when doing activities such as walking or perhaps running so looking for a shoe with extra padding in the ball of the foot, or perhaps getting socks that have padding in the ball of the foot can help to offset that.

Also looking for a shoe with a rocker bottom that can help to propel you forward so that you’re not putting so much pressure on the ball of your foot is another good thing you could be looking for. If you have painful bunions, looking for a shoe that has increased depth to accommodate the hammering of the toes so your toes don’t rub the top of your shoe, which can cause open sores or blisters and can be very uncomfortable.
Look for that extra depth. If you have bunions, make sure you accommodate the width of your foot. Measure your feet from the widest part, which is from the bunion to the other side of your foot, and make sure you’re getting a width that’s appropriate. Change your shoes regularly. Shoes typically last about 6 months or about 300 miles. If you’re not sure how many miles you’ve put on them, check the bottom of them. If you’re wearing the tread out, then it’s time to replace them and if you notice the inside of your shoes is becoming ripped, especially at the heel and you’re noticing the foam is starting to come out, that’s another sign that your shoes need replacing.

Remember we talked about your feet take you many miles, so make sure that you have good protection for them because they support your body weight. You want to make sure you have good support for your feet. When you take off your shoes, your toenails can tell you a lot about your shoes. For example, if you notice that your nails are bruising, lifting or loosening, that could be an indication that you have the wrong size shoe on. It could mean that your shoe is too small because your feet are hitting the front of your shoe causing damage to your nail, or it could mean your shoes are too big.

Again, your foot is sliding in the shoe causing a high impact to your toenails. Check your shoe size if you’re noticing a change in your toenails when you take your shoes off. If you wear pointed shoes or high heels, you can notice that you’re starting to develop ingrown toenails and that’s from the extra pressure that’s placed on your toenails being squeezed into a shoe.

If the corners of your nails hurt when you take your shoes off, give your feet a rest, and maybe don’t wear those pointed shoes or those high heels for a little bit. Things you can do to care for an ingrown toenail include at the onset of slight pain, you could soak in mild warm water with a little bit of Epsom salt and keep an eye on it for a few days. If it doesn’t resolve, you make an appointment to see your doctor. Do not soak. If you see redness, blood, pus, if they’re swelling or if you’re not feeling well, because those are signs of infection and you don’t want to soak your feet if there’s an infection.

You want to make sure that you go see a doctor as soon as you see those signs and if you have an ingrown toenail. It’s also important to make sure you’re cutting your nails straight across and keeping them short so that they don’t get damaged when you wear your shoes. Avoid barefoot walking. I know it’s very difficult. We live in Florida and we all walk around barefoot, it’s very comfortable, but there are a lot of things that can go wrong when you walk barefoot.

First of all, again, we live in Florida, the surfaces that we encounter are very hot, especially in the summer. A quick trip to the mailbox or a hot pool deck can cause severe burns to the bottom of the feet and can cause ulceration to occur in people that have full sensation and especially in people that have maybe some loss of sensation in their feet.

Another thing that can occur if you walk barefoot is you can contract some bacterial organisms or fungus or can possibly develop a wart. We’re going to discuss that in a minute. Again, we talked about earlier that you lose your fat pad as you get a little bit older, and walking barefoot causes more pain and pressure to the ball of the foot, which can perpetuate forefoot pain or ball of the foot pain.

Having some cushion on your feet definitely helps. It can increase the development and progression of deformities in the foot so having protection and something to take up that extra pressure when you walk really, really helps. Going back to warts which we briefly discussed, they are caused by contracting the human papilloma virus and that occurs when you are in direct contact with that virus.

It can look like you have a callous on the bottom of your foot. You can see tiny little black spots in that callous. Those tiny black spots are actually due to dried blood that occurs because capillaries feed the virus and the blood becomes dry. The virus causes a painful callous to form and it’s really important that if you notice that, that you see a doctor and make sure you’re keeping the insides of your shoes and surfaces that you encounter clean because viruses can be transmitted to other individuals.

Foot odor is another topic that is very common in a population and it’s due to the fact that we have over 250,000 sweat glands in our feet that produce about half a pint of perspiration a day. That’s a lot of sweat. Again, going back to our talk about the socks needing to be moisture-wicking because naturally we perspire and if we live in a hot humid environment, our feet retain moisture that can harbor fungus as fungus likes warm, moist, and dark environments.

It’s important to regularly disinfect your shoes by spraying them with Lysol, letting them dry in the sun if they’re wet. Rotating your shoes out is also really important. Also making sure that if you can’t get rid of a foot odor that you see a doctor because that can be a cause of something that would require treatment and if someone at home or lives with you that has a fungal condition that you make sure you’re disinfecting communal surfaces as again, that can be transmitted.

It’s really important to change your socks every day. As again, slight moisture in the socks can harbor fungus. In the summer, if you’re caught in a rainstorm and your sandals or your shoes become wet, make sure you take them off promptly, dry your feet, try to put dry shoes on so not to keep something wet on your feet and harbor that fungal infection. It’s also really important to keep your feet hydrated and hydrate every part of your leg and your feet, except between your toes.

It’s very easy for moisture to get trapped between the toes, so it’s important to not put any lotion between your toes as to increase that moisture production. Also increased moisture between your toes can lead to skin breakdown and fungal infection which is common again in the summertime don’t forget the sunscreen. Very important that you put sunscreen on your feet as they are most often sun-exposed and skin cancers can arise in the feet. Try to purchase and put on waterproof sunscreen again, because of the perspiration and maybe getting into a pool. It’s a good idea to have waterproof sunscreen protection.

Next, we’re going to discuss some good shoes to be picking when you’re participating in various activities. The activity you participate in or the sport you choose to engage in requires different shoe gear. We’re going to discuss some tips and tricks of shoes you should be looking for to help support the activities you’ll participate in. Runners should look for extra padding in the front of their foot as that excessive propulsive movement they do when running puts a lot of pressure on the front of the foot. Looking for extra padding or cushion there is very important. Looking for extra padding in the heel so that you don’t develop blisters or ulcerations because of the friction that occurs is really important. Bikers should look for a stiff sole so that it can accommodate the use of the pedal.

If you will engage in cycling a stationary bike, make sure you’re clicking in and out of that bike appropriately so you don’t get an ankle sprain or cause damage to your feet or your ankles. If you’re going to participate in weightlifting make sure that your shoes support the weight that you’re going to be lifting. Make sure you take into account that extra weight so you get a rigid sole, a more sturdy sole that can withstand that weight.
If you’re participating in racquet sports such as tennis or perhaps pickleball, make sure you have a shoe that has good stability for side-to-side motion and can help to better support your ankle when you’re doing those movements and help to prevent an ankle sprain from occurring. Stretching is really, really important pre and post-activity to help prevent injury. Stretching includes calf stretches, quadriceps stretches, IT band stretches and hamstring stretches.

Again, taking those extra few minutes before and after your activity can definitely help to prevent injury and can help to keep you going with your activity a little bit longer. Conditioning your muscles is another way to prevent injury and prevent you from developing any overuse injuries. Increasing the time you spend on an activity gradually if you’re starting a new activity make sure you do it gradually and you don’t overdo it. If you are rehabbing from an injury make sure that you return to your normal activities slowly and gradually.

Build up muscle strength over time and perhaps with the guidance of your physician if you’re under the guidance of a physician. Participate in different activities to condition different muscle groups that can assist in helping you do your activities and preventing injury. Ultimately listen to your body, if you feel pain, that’s your body’s way of telling you something is wrong. Pain is our body’s signal that something could be wrong. Make sure if you feel pain you modify your activity or you stop the activity you’re doing as something could be causing you an injury. Go through the proper rehab if you have had an injury again because that can prevent re-injury from occurring.

Custom orthotics are a great way to help protect your feet while you’re doing the activities you love. Custom orthotics are typically made with taking a 3D scan of your foot and ankle and they help to correct any biomechanical imbalances that you could be having. They help to provide you stability and strength when you’re walking, standing, or running. These orthotics are made with a prescription that considers your weight, your shoe gear, the activities you want to engage in, and any foot conditions you may have or complaints that could be troubling you.

Custom bracing is another option for preventing injury or could be a great way to support your feet and ankles if you are not a surgical candidate or don’t want surgery. They can help to treat conditions such as dropfoot, posterior tibial tendinitis or flat feet, deformities of the hindfoot and ankle, lateral ankle instability, or midfoot arthritis. Again this is something that can be done via 3D scanning and a prescription. Next, we’re going to discuss if you end up with an injury or perhaps a break in the skin or a cut, how those are treated, what things you need to look for, when to see a doctor, and how to care for your injuries at home should they arise.

We’re going to talk about some different types of wounds and how each wound is treated differently as well as some underlying medical conditions that can lead to a delay in wound healing. Types of wounds that are typically seen are diabetic foot ulcerations, wounds due to venous insufficiency, arterial disease, traumatic wounds, or delayed healing surgical incisions. Diabetic foot ulcers affect approximately 15% of diabetics over their lifetime. These ulcerations are typically found on the bottom of the foot and they’re due to pressure.

Diabetics oftentimes develop something called peripheral neuropathy which is when a person loses the ability to have full sensation of their feet and have good proprioception. Meaning they can’t feel how hard they’re walking when they’re taking a step, putting increased pressure on their feet and it occurs when there’s a foot deformity that leads to a break in the skin. These deformities and these ulcerations lead to problems in the feet and ankles that require medical intention as it’s important to take the pressure off of the wound site in order for it to heal properly.

Next, we’re going to discuss venous leg ulcers. These are wounds that occur to the outside of the ankle or the medial side. They’re due to venous insufficiency which leads to high pressure in the veins that causes capillary leakage and skin breakdown. These ulcerations are treated with compression because it’s important to get that blood flow back up the leg and prevent that high pressure from occurring and causing that skin breakdown.

Arterial wounds are typically seen on the toes and over bony prominences and they’re due to insufficient blood flow to the toes which leads to a decrease in oxygenation to the toes. That leads to wounds that can perhaps take longer to heal or wounds that don’t heal properly because there’s not enough blood flow. They can have a punched-out appearance to them so it’s really important if you see these types of wounds that you seek medical attention immediately because the underlying condition of why this occurred has to be addressed.

Our wounds whether they’re large or small, any break in the skin heals typically in four stages and the wound healing process starts almost immediately. Wounds heal from the inside out and as they start immediately they can take upwards of 18 months for a scar to fully resolve. In patients that have underlying medical conditions that timeframe can sometimes be lengthened which is why it’s important to address those underlying medical conditions and get that wound healed up quickly as to prevent infection from arising.

If you do notice a wound very important that you take care of it appropriately obviously the best way to prevent a ulceration from occurring is to follow some of the things that we discussed earlier. Avoid barefoot walking, protect your feet and prevent it from occurring in the first place. Should you have a break in your skin, wash that area with clean water and mild soap. If you see any visible debris or dirt make sure you remove it, you keep that area clean and dry. Apply a thin layer of ointment to it, change that dressing daily, and monitor for signs of infection which include redness, swelling, pain, pus or you start to not feel well.

If your wound is just not healing appropriately and after a couple of days you’re not seeing good signs of healing then you want to make sure you make an appointment and see your doctor. Things not to do is do not use hydrogen peroxide or alcohol, as we discussed a wound starts healing almost immediately. When you pour hydrogen peroxide or alcohol to that wound site you’re killing all those good cells that are coming to the area to start the healing process so do not use those two. Also, don’t soak your feet because any break in the skin allows bacteria to immediately enter so soaking your feet can harbor bacteria and cause an infection. to occur so do not soak. If you see a blister, whether it’s due to friction or because of a burn do not deroof it, don’t pop it. Resist that urge because that is actually not a break in the skin, there’s still skin protecting you so you want to keep it there. Just keep an eye on it, keep it clean, and keep that skin intact. Definitely do not wait to seek medical attention.

If you have anything wrong with your feet and you see a break in the skin, it’s lasting more than a couple of days, make sure you make an appointment and seek attention for that. Some underlying conditions that cause a delay in that wound healing process that we’ve been discussing are things like vascular disease, diabetes, peripheral neuropathy, obesity, and malnutrition including insufficient intake of protein.
Those things can definitely delay your wound healing process. That’s why the goals of care when treating a wound are always getting a good comprehensive, diagnostic exam because there’s a lot of components that go into wound healing and it’s important to address those underlying conditions as they play a big role in how quickly a wound is healed.

The goal is to get that skin to heal quickly and that helps to prevent infection from setting in and keep the bacteria out. A big goal is to heal skin quickly and maintaining a good healthy wound bed because as we discussed your wound heals from the inside out, so you want to make sure that you’re keeping a good wound bed that can support that good healing process as it occurs.

As we’ve been saying, managing your underlying medical conditions, whether it’s high blood sugar, smoking, or a diet that doesn’t have enough protein, those things are always addressed and changed if need be to improve the healing process. Healing modalities that are typically utilized include topical ointment, dressings that include silver. Silver dressings act as an antibacterial and they help to prevent bacteria from growing within a wound bed. Foam dressings, if somebody has arterial disease can help to bring good blood flow to a wound site. Wound vacs, that can help to pull that wound from the inside out. If a wound has been present for a long period of time advanced biologics are then utilized.
Don’t forget that on average, our feet absorb a total of approximately 26,000 pounds per day. That’s a lot of pressure and to put it into perspective, that’s the weight of two elephants. Make sure you’re taking care of those feet. If you ladies add a two-and-a-half-inch heel to that, that increases that force and pressure on your feet to about 45,500 pounds.

Again, a lot of pressure, and I hope that this presentation has been helpful and keeps your feet going as we need to get around the earth approximately four times in our lifetime. Thank you.

Kasey: Thank you, Dr. Bolos, that was a great presentation. Very informative and helpful for anyone with podiatry needs. Now we’ve got time for a few questions that have been submitted. Dr. Bolos, should or shouldn’t you rent shoes at the bowling alley?

Dr. Bolos: That’s a great question, Kasey. It’s a good idea to rent those shoes because you need them for bowling, you don’t want to injure yourself when you go bowling, but you want to make sure that perhaps you give those shoes an extra wipe down or spray them with Lysol before you put them on your feet and certainly do not go without socks.

Make sure you bring your socks with you because again, you can contract, viruses or fungus from communal shoes. Give them a good spray. I know those bowling alleys do spray them, but just for good measure, spray them yourself and let them dry for a couple of seconds.

Kasey: What shoes are recommended for plantar fasciitis?

Dr. Bolos: Good shoes for plantar fasciitis are ones that help to give you a little extra cushion in the heel. Plantar fasciitis is an inflammation of a banded tissue that connects from your heel to the front of your foot. Getting good arch support, good cushion to the heel can help with that plantar fascial pain, but ultimately the best way to treat plantar fasciitis is some good stretching and maybe seeing your doctor for some other good modalities if it persists.

Kasey: Do you need to keep using the equipment necessary once you no longer have the issues?

Dr. Bolos: Yes, it’s a good idea for prevention to keep up with the modalities that you’ve been using to prevent any injuries from reoccurring. Maintenance plans such as stretching before and after your activity is definitely indicated to help prevent you from getting further injuries.

Kasey: What are hammer toes?

Dr. Bolos: Hammer toes are when your toes kind of go like that. It’s a good way to explain it. They turn into hammers and they can rub at the top of your shoes and be very uncomfortable.

Kasey: Yes, that doesn’t sound like fun. What is a wound bed?

Dr. Bolos: A wound bed is the red beefy part of your skin as your skin is healing. It turns that reddish color and that’s what a wound bed is. In wound treatment, it’s important to keep it that red beefy color because that’s a healthy wound bed that can promote healing from the inside out.

Kasey: Is wearing high heels bad for my overall foot health?

Dr. Bolos: Oh, that’s a great question and one that pains me deeply because I do love high heels, but yes, it’s not good for your feet. As I mentioned in the last slide, it puts a lot of increased pressure on your feet. It increases that force to your feet by about double.

It can cause pain to the front of your foot. It can cause pain to your toes. It can cause ingrown toenails to occur. There are a lot of things that can be detrimental with high-heel wearing, but occasional high heels are okay as long as it’s not a regular shoe gear choice.

Kasey: All right. That is a wrap for tonight’s live lecture. Thank you everyone for joining us and have a great night.