Wednesday, October 17, 2018

Kids Shouldn't Be Sidelined by Heel Pain

A common complaint among my young, athletic patients is heel pain. Typically, this complaint will come from a boy between the ages of 8 and 12- but girls are affected by this as well. More often than not, these kids have had a recent growth spurt. 

Heel pain among kids is usually encountered in impact sports, such as basketball, soccer and running .Kids usually, but not always, have pain in both heels while they are exercising and for a short time afterwards. In most instances, the pain goes away when they are not playing the sport and rest. 

A lot of times, parents will notice their child limping off of the playing field in absence of any injury will playing.  Usually there are no signs of swelling, bruising or redness, which can be confusing to the parent of a child who is acting as if injured.

Heel pain in kids is becoming much more common as they are becoming increasingly more athletic at younger ages and because more frequently kids are playing sports all four seasons without rest.  Calcaneal apophysitis or "Sever's Disease" is the most common cause of heel pain in kids. I hesitate to call it a "disease" because this can be misleading to many people-it's a very treatable problem with an excellent outcome for the child. 

All bones in the human body have growth plates. As our skeleton matures, and we stop growing, the bones fuse. The calcaneas, or heel bone, is the last of the bones in the feet to completely fuse, and in the developing foot this bone is much softer than mature bone. Fusion of the growth plates occurs around the ages of 12-14 for girls and 14-16 for boys.

Calcaneal apophysitis occurs when there is irritation of the growth plate which in turn causes heel pain. This type of heel pain has been linked to particularly to impact sports because of the repetitive micro-stresses to the open growth plate.. However, I believe that biomechanical aspect to this issue as well. For example, most of my patients with this problem also tend to have flat feet (a foot with an insufficient arch), or a pronated ankle (one that bends towards the midline of the body) and tight calf muscles. If a child with flat feet and already tight calf muscles has a growth spurt, it tends to make their calf muscle even tighter because the muscles have a hard time keeping up with the growth of the bones.

Our calf muscles are comprised of three large muscles; the gastrocnemius, which is made up of two large muscle bellies and the soleus (Figure 1). The two gastrocnemius muscles blend to form the Achilles tendon that inserts into the back of the heel bone. In the case of kids, this tendon inserts into the growth plate that is not yet attached to the rest of the heel. If the Achilles tendon is too tight, it causes increased pull on the growth plate which then causes heel pain (Figures 2 and 3). 


             Fig 2

                     Fig 3  

It used to be that the gold standard for treating calcaneal apophysitis was to take the kids out of their sport for two weeks with rest, ice and elevation. However, in this day in age where kids are very serious about their athletics this is not a solution that's met with enthusiasm. That's where stretching, good shoes and an orthotic or insert will get the child back to their sport quicker.

Because the problem is usually related to tight calf muscles, teaching the child to do some simple lower leg stretches can be very helpful to increase their flexibility. These stretches should be done three times a day and before and after exercise. There are a series of stretches that I teach to all my patients who suffer from this issue. One effective stretch starts by facing a wall, about 2-3 feet away. Place both hands on the wall at shoulder height, keeping your legs straight and feet flat on the ground, gradually lean forward until you feel a stretch in the calf muscles (Figure 4). What I always tell my patients is that the stretch should be a little uncomfortable but never painful!

Fig 4

Again, these children tend to have flat feet. Therefore, I usually recommend an over the counter orthotic device with a heel lift, which takes pressure off of the heel. Or, in more server, cases I will cast them for custom orthotic devices.  The advantage to custom orthotics is that they can be made specifically for the type of athletic footwear that they are wearing.

Athletic footwear is very important to address as well. I frequently find that these children are wearing shoes that are too worn out, poor quality, or not the right size. This needs to be addressed as well, and I ask my patients to bring in their shoe-gear so that I can evaluate it. As soccer cleats are a common form of athletic shoe-gear that I see in my office, I want to make a special note here-never allow your child to use soccer cleats with a three-cleated heel. Cleats should always have four cleats at the heel to evenly distribute the impact at the heel.

With increased stretching, icing, over the counter anti-inflammatories, orthotic devices and a little education, most patients are able to resume their normal activities fairly quickly. 
The good news is that this is one pediatric condition that a child will outgrow. Once the growth plate has ossified (or fused to the rest of the heel bone), the pain will subside. However, until then the problem can usually be conservatively treated. When it comes to kids, it's always best to be conservative. Whenever a child complains of pain or limps and the reason isn't readily clear, it's always a good idea to have it checked out.

Dr. Jennifer Tauber is a podiatrist at New Canaan Podiatry, LLC.  107 Cherry Street New Canaan, CT  06840.


How to prepare your feet for a marathon

If you are planning on running in a marathon expect on average to take between 30,000-40,000 steps during its course. While the impact on each foot coming in contact with the ground can equate to almost three times your weight.  So, if your feet are bothering you - it's going to be a long and painful 26 miles.

Here are a few tips to help keep your feet healthy and happy!

First of all, you need to be running in a proper pair of sneakers.  For avid distance runners, I typically do not change the shoe they are running in.  These runners tend to be running shoe specialists on their own.   However, I do remind them that they need to be changed every 300-500 miles for a new pair.

If this is your first marathon, you also do not want to run in an old sneaker.However, and this applies to long distance aficionados as well - you do not want to run in a brand new pair! They should be broken in for a few months before you set out on race day.  Make sure you have been measured by a reputable running shoe store to ensure that they fit appropriately.  Always stand up when trying on sneakers.  There should be room between your toes and the end of the sneaker.  Your feet will swell over the race, and the shoe size needs to accommodate for that.  Also, not everyone's large toe is their longest.  Some people need to measure by their second toe for sneakers.  If you are unsure if the sneaker you have is appropriate, then bring it to a Podiatrist (preferably my office) to check it out!

Socks are important as well.  The best socks for running are light weight, but also made of materials that wick away moisture.  Regular cotton socks are not going to cut it and will more than likely lead to increased blister causing friction, because they do no wick away the moisture.  The good news is that socks are cheaper than shoes, so I recommend buying a few brands and experimenting before race day.  I like the brands, Wright Socks and Feetures.

The length of your toe-nails is important on race day.  They should be properly clipped and filed.  If your nails are too long they will bang at the front of the sneaker's toe box which will result in black and blue toenails, which usually become nails that will fall off after race day - or ingrown toe nails.

Keeping skin smooth and hydrated is important year round for runners.  If you have cracked heels, those can be painful while pounding the pavement and an easy entry portal for bacteria and fungus.  Removing calluses the day before a race isn't recommended.  A week before is perfect timing- which gives the skin a chance to rebound.  Using blister bandages on sore spots is a good treatment option, as well as anti-chafing lubricants.  Silicon based ones are the best, BodyGlide is a good anti-chafing product.  I sell a few options for moisturizers in my office, depending on your level of severity.

Another good year long practice is spraying your shoes out to kill the viruses that cause warts or fungus.  Athlete's foot infections, are named that for a reason! Fortinia is a good brand of shoe spray and I sell it in my office.  Also, if you feel that your feet are very sweaty, try to apply an over the counter roll-on antiperspirant to dry them out.  If that doesn't work, the Podiatree company also makes a good product to reduce sweating  that I sell in my office.

Preferably, change to a different pair of sneakers for the next running day to allow your shoes to dry out.  Therefore, it's always a good idea to have two pairs of the same sneaker that you alternate with from one day to the next.

After a long distance run, such as a marathon, expect that your feet will be swollen.  Immediately elevating and icing will help to reduce this inflammation and help to prevent pain. Massaging the feet will also give you some immediate relief.  You can use a tennis ball or racquetball while sitting or standing, while applying pressure, roll the ball along your arch or any other hot spot that needs attention.

That brings me to stretching.  There are many theories on stretching.  I believe in it and think it becomes much more vital as we age.  Here is a very informative list made up by Aurora healthcare that demonstrates some good stretching.  Don't run the race "cold", warm up before hand.  A round of jumping jacks, running in place, and then stretching will get you warmed up!

Training for a marathon may be the hardest thing that you do - but the rewards of finishing it will out way the blood, sweat and tears created getting to the finish line.  But, I'm always available should your sore feet need some advice before or after race day.  Good luck!

Dr. Jennifer Tauber, is a podiatrist at New Canaan Podiatry, LLC.  107 Cherry Street New Canaan, CT 06840.

Friday, October 12, 2018

What Exactly is a Medical Pedicure?

What's the difference between a regular pedicure and a medical pedicure at New Canaan Podiatry?

When I embarked on opening my own practice, I knew that I wanted to offer medical pedicures to my patients.  This was the result of practicing podiatric medicine over the past 14 years - and realizing that I am treating an increasing number of patients who have warts and fungus on their skin and nails. Most of these patients are woman and most of them get regular pedicures at nail salons.

There is no coincidence that over the past 15-20 years there has been an astronomical increase in nail salons popping up on every street corner.  These places are convenient, not that expensive - and best of all quick!  However, the downside to these salons is that they cannot keep their tools clean and they do spread fungus, the virus that causes warts and bacteria.

So when a patient asks me: "Why would I pay the extra money to go to a Podiatrist's office to have my pedicure?"  I'll give you several reasons why - but the most important reason of all - it's clean!

When I inform patients of this, their immediate response is: "Dr. Tauber, the nail salon I go to is very clean!  They put a liner in the tub and they "sterilize" their equipment".

First of all, never get a pedicure in a tub that has a filter!  Even if they "disinfect" in between clients, if they do not remove the filter and disinfect that - whatever was in the person's bath before you i.e skin cells, blood, bacteria, fungus, viruses - will circulate into your pedicure bath as well.  GROSS! Yes, a  liner in a filter-less tub is great, and the concept of sterilizing their equipment is even better.  However, because my office sterilizes equipment several times a day, I can guarantee that most salons are not following appropriate protocol.  Why do I know that?  Because it takes a lot of time and it is expensive!

Still convinced they are sterilizing their instruments?  Let me take you through the process of sterilization.  In my office, start to finish, the process takes 1 1/2 hours - and that's just for one batch of instruments.   Have you ever seen the autoclave in action at your salon?  If they are actually sterilizing their instruments, it would be running ALL DAY LONG!

First, instruments are soaked and scrubbed in a germicide liquid.  Then they placed into a ultrasonic cleaner to remove any debris that didn't come off in soaking.  The instruments are placed into sterilization pouches, and from there they go into an autoclave.  The autoclave needs to reach a certain temperature to kill all viruses, bacteria and fungus that aren't killed in the first two cleaning processes. The pouch that is used will change colors only if it reaches the temperature set for sterilization.  In other words, I can stop the process after soaking and place the instruments into sterilization bags - but that does not mean that they are sterile.  Check the bag next time you are at a salon.

Instruments soaking
Ultrasonic cleaner
Autoclave has to reach a certain high temperature, and the drying time takes 30 minutes alone!

Pouch changes color with certain temp

Now you know they have been appropriately sterilized

My pedicure chair is pipeless, and filter-less.  It has to be filled from the sink and into a disposable liner that is changed in between clients.  Thus eliminating contamination or cross-contamination in between clients. I'm in the office to address any concerns, such as: excessive callusing that needs to be pared away, wart, ingrown toenail or any other issue that only a Podiatrist should be treating.  A licensed cosmetologist will perform your medical pedicure.  This means that in order to maintain her license with the state of CT she needs to maintain a certain number of educational hours in order to renew her license every two years - and if already have had a bad pedicure and end of with a fungal toenail, she can make your nail look normal!!

Dr. Jennifer Tauber is a Podiatrist at New Canaan Podiatry, LLC.  107 Cherry Street, New Canaan, CT.  203-548-7688.

Kids Shouldn't Be Sidelined by Heel Pain

A common complaint among my young, athletic patients is heel pain.  Typically, this complaint will come from a boy between the ages of...