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Saturday, October 27, 2012

Scared Straight: Foot X-Rays that will scare you into better shoes.

Halloween Edition:

Scared Straight: 
X-Rays that (hopefully!) will scare you into better shoes...

I wanted to talk about why having a shoe with a thick rigid sole is so crucial for proper foot care. 

I have a patient who was kind enough to give me permission to use his story and his x-rays. He is a healthy thirty-something year old man who had a horrible motorcycle accident nine years ago. 

When I walked in the exam room, I immediately noticed that his complexion was grey and he looked like he was going to vomit. We talked and he told me that the last time he saw a Podiatrist he was told that he might need an amputation. I quickly eased his fears by telling him that we would only be talking about shoes and inserts and that we should be able to greatly improve his foot by making some simple, non-painful, non-surgical changes to his current shoes and inserts.  

He said that three days ago he was walking and heard a 'pop' and felt a pain in his right foot. He stated he didn't have any specific injury but was simply walking. I checked the shoes that he had been walking in and they had an extremely thin, flexible sole. 

Let's take a look at his first x-ray (Ignore the arrows please):

The three screws were placed across his Lisfranc's joint after the motorcycle accident. On the day of the accident, he was wearing a shoe with a flexible sole and, when his foot twisted, multiple bones were broken in the midfoot area and ankle. The surgeon had to perform a joint fusion by placing screws across the Lisfranc's joint. The idea behind this is that if you fuse the joint - you stabilize the joint, limit motion and thereby limit pain. Since the accident, he's always had some degree of foot pain but has managed to stay active. 

After the surgery, he didn't realize that he needed to stop walking barefoot and wearing flip-flops and that, after an injury like this, he needed to limit himself to shoes with a thick rigid sole for maximal protection. Not knowing this, he spent the last nine years wearing improper shoe gear.

 Let's take a closer look at those screws...


If you look closely, can you see that two of the three screws are broken? The two that are most vertical are the broken screws and, unfortunately, it is harder to see that the one on the right is broken in half - but it is.

My point being, if nine years worth of walking barefoot and wearing flip-flops causes enough stress through the Lisfranc's joint to break two titanium screws - what is all that stress and strain doing to your joints?

The strange part of this story is the problem is not the broken screws or the Lisfranc's joint. 

The problem is that he was wearing a flimsy sole shoe and the one  titanium screw that is intact and doing it's job of limiting motion across the joint was not allowing any motion and his body needed motion to walk. The stress on his foot was too much and his body found the motion he needed by breaking the third metatarsal. 

Take a look at the arrows. The real problem - the thing that is currently causing him pain - is the new broken bone on the third metatarsal. 

We placed him in a below-the-knee walking boot for two weeks and had him come back two weeks later for x-rays. 

Two weeks later, the third metatarsal fracture is more easily visualized because it is forming a 'bone callus', which is the body's way of trying to heal itself.

What's interesting is that the broken screws don't matter. They aren't causing any pain so they don't need to be removed. The plan is to heal the current fracture and, once it is healed, make sure he:

*Wears Rx Crocs 'Relief' around the house as a bedroom slipper
*Never walk barefoot or wear flimsy shoes or flip-flops
*Wears New Balance 928 as a walking shoe
*Wears custom-molded inserts 
*Wear dress shoes that have a thick rigid sole with a metal shank
*Wear a Tri-Lock Brace for sports and increased activities 

And he should be able to lead a normal, healthy, active life! 

The moral of the story is: protect your feet!
You'll have a healthier, happier life with less pain and injuries...

My best to all of you!

Dr. Cathleen A. McCarthy



Dying4Chocolate said...

Hi Cathleen,
I remember you saying in a previous post that even if the shoe is deemed a good shoe, if it causes pain something is wrong. Since reading that, I have taken it into consideration when buying shoes. I am a college student so during the week I am mostly sitting. However, on the weekends I work retail and am standing an average of six hours a day. I originally replaced my flats with Privos but they didn't have enough support. From there I went to Dansko Vedas. They gave me the most support and by the end of the day, I had no foot or leg pain! However, I started to notice that when I wear them (or any shoe) for longer than 2 days in a row and am standing/walking for a long period of time, my left arch starts to hurt. It feels like its strained or like something is pulling at it. I have high arches so all of my shoes have arch support. I know that Dansko is supposed to be a good brand so I don't understand why one arch(and only one)hurts after wearing them for so long. Does this mean I need something even more supportive? I've read your posts about foot pain and follow all of the steps with the exception of getting the NewBalance 927. I even wear my Crocs Specialist with the rear strap around the house. I know this was lengthly and I thank you so much for reading this and posting so many great articles. It really has helped me and my family!

Calgary Podiatrist said...

Just where did he get the idea that his feet will be amputated? lol.
Anyways, nice story Doc.

Doctor of Podiatry Discusses and Recommends Shoes. said...

Hi Dying for Chocolate,
I sympathize with you! I worked retail and it's very tough on the feet.

You may need to add arch support for more comfort. Not all Dansko shoes accommodate arch support but I believe the Dasko Veda will. Try a good over the counter arch support like Spenco or Rocket Dog and see how they feel. If they feel good, you might be a good candidate for custom-molded orthotics, which some insurance companies will pay for. Even if you have high arches, I would recommend arch support. An analogy I like to use is - your arch is similar to a bridge - even though a bridge is an arch, engineers still put struts under it to give added support and decrease strain.

When I was on my feet all day, I also would wear compression socks, which also helps decrease pain and swelling. Also, no one has a matching set of feet. They are always at least subtly different - and occasionally, depending on the patient, completely different! Do you have a limb length discrepancy that may be putting too much pressure on one foot versus the other? Do you compensate when you walk due to lower back, hip or knee pain? Do you have a tilted pelvis? There are many things that can cause one foot and not the other to hurt. If the pain continues, I would recommend you follow up with a Pod to get an evaluation. In the meantime, getting arch support is an excellent place to start!

I hope this has been helpful and thank you for reading!

Doctor of Podiatry Discusses and Recommends Shoes. said...

Hi Calgary Podiatrist,
The patient told me that his surgeon told him that he might lose his leg nine years ago and that was why he was avoiding doctors ever since!
Hope all is well in Calgary!

Dying4Chocolate said...

Thank you, that helps a lot! I looked up the Spenco inserts. Does it make a difference if one is labeled an orthotic and has a "hard moldable" arch and the other is labed a soft cushion arch?

Mikey Bravo said...

This is really interesting. I will have to call and see if I can set up an appointment with my podiatrist in Dallas TX. I have never thought about this before. It would be awesome if I could get some relief. Thank you so much for this great article!

Doctor of Podiatry Discusses and Recommends Shoes. said...

Hi Dying4Chocolate,
Try the hard-moldable orthotic first. That one gives more biomechanical control. The soft one is more for geriatrics who need more cushion and are more sedentary.

Doctor of Podiatry Discusses and Recommends Shoes. said...

Hi Mikey,
Check out my article entitled, "My Feet Hurt: Top Ten Things to do to relieve foot pain today."
Has more ideas for helping with foot, knee, hip and lower back pain.
Thanks for reading!

Daniel said...

Hi Dr. Cathleen,

Great informative piece on the importance of supportive shoes that offer ample cushioning and protection. The new trend however seems to be minimalist shoes, such as Vibram Five Fingers. Even New Balance is making minimalist shoes and Nike has been making minimalist shoes for quite some time, aka the Nike Free. These are all designed to be minimalist athletic shoes to promote "barefoot" exercising however is it possible that this may lead to long term side effects such as stress fractures?

As an avid athletic/basketball player, many of the shoes have reduced the outsole to provide a smaller contact distance between the foot and the ground. I play outdoors on concrete and this has greatly affected my as my feet are sore for the next two the three days, every morning when I wake up. Are there any specific insoles that you would recommend that are available for the public? I currently use Spenco Polysorb Cross Trainer Insoles.

Also, if you couuld provide some extra information for me, that would be greatly appreciated. I am a member of the Product Management Team for the Diabetic Shoes HuB and a vast majority of the shoes we carry offer great support, shock absorption and cushioning. Is there a specific brand and style that you would recommend to your patients for ample cushioning and support? Your informative opinion would be of great use to me as I help customers find their "right" shoe.

Doctor of Podiatry Discusses and Recommends Shoes. said...

Hi Daniel,

In my opinion, the minimalist shoes are horrible. I don't care what anybody says - my entire career is based on what happens to the foot and ankle when they are unprotected. Occasionally, you will have someone who claims that the minimalist shoes are wonderful and, hey, more power to him or her but in my opinion - it's just a matter of time till that person develops anything from stress fractures, an acute fracture, tendonitis, plantar fasciitis, degenerative joint disease, osteoarthritis, calluses, bunions, hammertoes as well as potential knee, hip and lower back issues.

The shoe companies encourage this 'trend' because, quite frankly, they are making a lot of money telling people what they want to hear versus what is actually the truth! In my opinion, it's pandering to an unsuspecting public and unethical. Can you imagine a dermatologist telling you to be 'natural' and not wear any sunscreen or a dentist encouraging you to be 'natural' and not floss your teeth. People want to hear that it's okay to wear crappy shoes and wear flip-flops and some people can even get away with it for a certain amount of time but it's just a matter of time till the s*** hits the fan!

If you have 'biomechanically challenged' feet - forget the minimalist shoes and get into a great running shoe like New Balance 1540 or a Brooks Beast and a better basketball shoe that has a thick, rigid, protective sole. You are not only going to decrease your chance of injury, you are going to have less pain and mechanical strain and - you will play better! Getting into better shoes and proper arch support should improve your game.

People don't want to hear it - but it's the truth!

I know I have only answered half your questions but I am going to finish answering the rest tomorrow when I have more time to talk about inserts.

Hope all is well!
Dr. Cathleen A McCarthy

Doctor of Podiatry Discusses and Recommends Shoes. said...

Hi Daniel,

To answer you questions about over-the-counter arch support - I recommend Powerstep, Superfeet (REI has them), Spenco (not the cushion ones but the ones with actual arch support that have cushion on top of them) and Rocket Dog, which you can purchase at running stores and online.

For diabetic patients or anyone with poor circulation or nerve damage, I would recommend an accommodative insert, which offers support but is made of special materials that decrease the chances of developing blisters, corns and ulcers. In the case of these people, I would refer them to a Podiatrist to get an annual check.

Hope this was helpful!

Anonymous said...

Dr. McCarthy,

I love reading your blog and have been trying to follow your guidelines re. supportive shoes. I have high arches, no foot pain now althugh I had PF several years ago. Because of my high arches I find that even shoes with backs will flop if I don't grip with my toes. Actually some backless clogs, if the enclosed portion is deep/high enough, provides walking comfort without me having to do toe grips to keep them on!

I really like Haflinger clogs for this reason as a house slipper....thick rigid sole, broad toe box as you recommend. What are your thoughts re. this issue with high arches?

Thanks so much.


Dying4Chocolate said...

Who would the Jambu Lido and Jambu Netherlands be a good shoe for? I've heard that their thick rigid sole is good and that they do well as far as giving the foot more biomechanical control. I think I read that it had something to do with the way it positions the foot in the shoe and how it propells the foot forward. I could be wrong though. Just wondering what you thought of them. :) Thanks again for your earlier advice on the inserts!!

Doctor of Podiatry Discusses and Recommends Shoes. said...

Hi Linda,
I'm sorry for the delayed response!

Higher arches are always a challenge. It's much easier to control a flat foot because all you have to do is pick up and support the arch with a custom molded orthotic. With high arches, orthotics are great but you run into problems with the top of the foot rubbing on the shoe and causing pain and what are called 'exostosis', which are are build up of bone spurs that can become painful, cause blisters and even nerve compression problems.

Patients with high arches always seem to have more challenges with finding comfortable shoes. My advice is: stick to the basics of finding a shoe with a thick rigid sole, get either custom molded orthotics or an excellent over the counter insert, a wide soft toebox and always strive to find a shoe with proper rearfoot control. Once you have met this criteria, go with the shoe that is most comfortable! You should not have to break in shoes so, once you find a shoe that fits the criteria and feels great, stick with the brand as your 'go-to' shoe. Danskos are my go-to shoe but they typically do not work for patients with high arches.
I hope that was helpful and I would love to hear any feedback on what works for your high arched feet!

Doctor of Podiatry Discusses and Recommends Shoes. said...

Dear Dying4Chocolate,
The Jambu Lido and Netherland are both excellent shoes! They both have thick rigid protective soles, wide toeboxes and great midfoot and rearfoot control. If you get them, I would love to hear your feedback.
Happy Thanksgiving...