5. Elevator Podiatrist - Plantar Fasciitis - Dr. Howard Finkelstein
Dr. Howard Finkelstein was featured on the Elevator Podiatrist podcast and offered insight into plantar fasciitis.
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Q&A Transcript
Joe Crosby: Welcome to the elevator podiatrist, the show where we ask common foot and ankle questions to top podiatrists from around the country. There's no appointment or copay required for this one on one Q and A, only free advice from individuals who have devoted their lives to all things feet. I'm your host Joe Crosby, and today I'm joined by Dr. Howard Finkelstein podiatrist at Foot and Ankle Associates of Florida.
Dr. Finkelstein: I started out my career not as a podiatrist but initially as an education major. And while I was going through it, I found that I had a passion for the sciences. So my focus was on the sciences. As a result, I had a professor who was quite the influence on me, encouraged me to do some volunteer work in a hospital. So in doing so, they rotated me through different departments. And one of the departments I landed into was the department physical therapy. I fell in love with it, thought it was very rewarding working with the folks, patients, staff, everybody. And I set my sights on becoming a physical therapist. So I went to PT school and I graduated as a physical therapist and worked in physical therapy for about four or five years down at a major teaching hospital in Miami, Jackson Memorial Hospital and had a fantastic experience, but while I was there, you know, I always felt that there was something more that I wanted to do a little bit more direct with the patients and to follow through with them and to quite frankly be a little bit more independent of what I would do. And in doing so, I had encountered a variety of different positions, disciplines, orthopedists, neurologists, pediatric general surgeons, vascular surgeons, work with them all. And there was a newer, younger breed of podiatrists who is coming through who are well-trained surgery and such wound care. And it was kind of interesting because they seem the happiest of everybody who came through physician wise and their patients just loved them. And I thought, well, what's going on here? So I wound up, striking up some dialogue with this podiatrist. He was kind enough to invite me into his office to shadow him, which I did. And I really enjoyed what I saw. What I hadn't encountered was that he treats a variety of people of all ages from newborns actually all the way up the elderly and everything from conservative care to surgical. They covered the entire gamut and patients were great. They seemed to have a good rapport with the doctor. They were appreciative and the doctor thoroughly enjoyed what he was doing. So I thought, you know what, this isn't so bad. So I went onto the next chapter of my life, could apply to podiatry school, was fortunate enough to enter and here I am 30 plus years later. So that's how I kind of tripped into podiatry was not initially on my radar. But I'm glad it turned out to be.
Joe Crosby: From reading your bio, even, you know, I see that education has kinda been woven throughout your position now even as a podiatrist. So putting your educator skills to the test, how would you describe it, and what we're talking about today is plantar fasciitis, how would you describe plantar fasciitis to a five year old who has heel pain?
Dr. Finkelstein: Well, the good news is most five-year-olds don't have it, so I don't have to be saddled with that, but basically that's the most simplest way I can put it together is that in short, there's a ligament on bottom of the foot, which we call the plantar fascia, and it runs the entire bottom portion of the foot from behind the toes, all the way to the heels. And when we walk, our foot stretches and that stretching of the foot results in the stretching of this ligament called the Plantar Fascia. And this happens with every single step we take with every sport we participate in. And in doing so, in some instances, that pulling effect makes the heel bone inflamed, where that ligament, that Plantar Fascia hooks into, and when that puppy gets inflamed, it is very, very painful. It can be very debilitating. Uh, people would oftentimes complains that, "man, I can't even get out of bed in the morning." And, uh, so in that regard, it, it's one of the most common things we see, it can be the most debilitating and, but yet in the same token, it's one of the simplest things that can be remedied in most cases.
Joe Crosby: Some would probably call this job security for podiatrists, but after doing some research, and you know, correct me if I'm wrong, but I read that approximately 10% of people will deal with some kind of pain associated with plantar fasciitis in their lifetime. One does that statistic still stand? Does that sound right to you? And what percentage of your total patients are you treating for plantare fasciitia on a daily basis?
Dr. Finkelstein: Well, I can tell you in our practice, not just for myself and my partners, I mean, we're fortunate enough to have fairly busy practice and see a fair number of patients and I will tell you 10% would be probably an accurate number, maybe just a tad higher. I think that one of the reasons why we see it so frequently is number one, it's undertreated. By that. I mean is folks, many times will first present it to your primary doctor or even orthopedics. They'll be placed on a anti-inflammatory. They might even take the over the counter products such as Advil or Aleve or such. They might see the orthopedist to come through just your shoot gear or maybe do some stretching, perhaps go to physical therapy. And although that can be effective, most of the time people, they don't go to the doctor until it's almost beyond the scope of return and they're in a pretty bad way. So unfortunately those remedies don't typically work, so we'll see them when they're really sore. I think we see a bit more now than we have in the past, just by virtue of the shoes people wear. We're more of a relaxed or casual society these days and a lot of people walk around, at least in Florida and, you know flip flops, sandals barefoot, still big. So it has to do much with the activity levels, but also the shoes that we wear. The other big thing is odd as this may sound as a lot of homes, at least in Florida, are built with hard surfaces, tile, ceramic, wood floors. And as I said is the barefoot state. So people do a fair amount of walking around barefoot or stocking foot and all those things contribute to the formation of the plantar Fascia. You know, Plantar Fascia occurs for a number of reasons. It's both a structural and mechanical issue. Structural meaning how your foot is put together with the way the good Lord made you and mechanical as far as how it functions when you're walking, your gait pattern, your walking pattern. So it's a combination of this structure activity, how much standing, how much sitting, how much walking the terrain as I mentioned, the shoes you wear, going barefoot, stocking foot, the hard surfaces. And of course athletics. That's a big one too because we're a society that we like to engage in activities and athletics and working out. But we typically want to just dive right into the activity. And very seldom do we spend time stretching. So that lack of stretching creates a lot of problems and folks, not just with Plantar fasciitis and other problems, other muscular, tendon, ligament stresses and strains. So we tend to see that and that population as well.
Joe Crosby: Hearing you say that, is this, you know, in your years as a podiatrist, is this something that's getting worse across the population?
Dr. Finkelstein: I don't know if I would say it's getting worse. I, you know, I've been doing this for several years. I would say it's been pretty much the same. I mean, it's the same habits get passed on from generation to generation, I guess you can say. The only thing we try to do is we try to educate people more about footwear, particularly as it relates to their athletics because different shoes for different types of sporting events can and oftentimes do make a difference. So in that regard, I think there has been some improvement over the years because the manufacturers have taken note of that. And many of them, they make a lot of glitzy shoes, you know, with different types of presentations for sales purposes. But, there's also several shoes out there that are very well designed and very well designed for specific foot types and activities.
Joe Crosby: When is heel pain indicative of something more than just plantar fasciitis?
Dr. Finkelstein: That's a great question. There's several things that we need to look at as far as the differential diagnosis and a lot has to do as far as what gives us an idea of which road we need to blaze has to do with patient history as far as how long it's been there. Was there any trauma involved, swelling, bruising, things of that sort; when it hurts. So differential diagnoses can be stress fractures or fractures of the heel bone. We have seen that. Sometimes there's something called the tarsal coalition where there's a abnormal bridging between two bones that can contribute to heel pain or pain within the area. Maybe misrepresents itself to the patients thinking it was mostly of the heel. There can be nerve impingements, whether it's in the foot or the ankle. Sometimes we even see it emanating from the back. We've had people come down to us that, uh, they think they have a heel problem and interviewing them and examining them we discover that it turns out it very well may be a back problem. Sure enough, we send them to the orthopedist or the neurologist and they get assessed. And low and behold, there was a back issue underlying all the time. This is not to say you can't have two problems going at the same time, but oftentimes in those cases, the dominant problem, ironically enough is coming from the back. So those are just some of the few considerations.
Joe Crosby: Episode one, I spoke with doctor Dr. Michael King, who you're familiar with out of Nashville. And we spoke a bit about Plantar Fasciitis, primarily heel pain and shoe wear. But he would tell patients put your shoes by your bed in the mornings. You have morning heel pain, put your shoes by your bed. Uh, but those are all, you know, so you're not retiring. Those retiring the tendons. What treatments offer the best relief for heel pain and plantar fasciitis?
Dr. Finkelstein: Well, typically as I tell my patients, it's not one item. Usually it's not one pill. It's not one injection. It's a combination. It's sort of like grandma's soup. It's not one ingredient that makes it taste great. It's a lot of different ingredients, a little bit of luck, meaning attention. So when we treat plantar fasciitis, we have to approach it from all the angles. First and foremost, we want to reduce the inflammation. And then the second thing is we want to eliminate any type of structural and mechanical cause that we spoke of earlier. So as far as limiting the inflammation, that can include anything searches a cortisone injection within the area, the heel, oral antiinflammatories, which are aspirin base, basically like a fancy or stronger Advil or Aleve. Sometimes steroids such as prednisone. Sometimes topicals is different topical agents can be applied. Of course other modalities through physical therapy such as heat or cold depending on personal preference, ultrasound, laser light therapy, stretching exercises. As far as controlling it, that's where it boils down to the shoes and the perhaps an appliance of the shoe that helps support the arch, whether it's generic or custom. It can also include in addition to that, a routine stretching and being on guard as you were discussing before, Joe. And that is wearing shoes in the house or wear some sort of good house shoe to basically cushion the blow with every step you take. Which goes back to my statement earlier about going barefoot or stocking foot on the hard surfaces.
Joe Crosby: As far as the seriousness of Plantar Fasciitis, one how serious is it? How serious can it get? Are there stages to the condition? Can it lead to other issues as well?
Dr. Finkelstein: Well, absolutely. You know, if you're hurting, it's the old joke if your feet hurt, you hurt all over. So what happens when we see people that have had it for a long, long time, where it's chronic, they can come in with secondary problems or secondary problems associated with, with inflammation of other body parts. So they can come in with a different part of your foot that's sore in addition to the heel and ankle and Achilles tendon, the volunteer foot, their calf muscle, even their knees or hip or their back. The old joke is that every joint, every bone is linked to each other, like a link in a chain. So as you can imagine, if you pull on one link, you other links follow. So if you're having problems in your foot and you pull on that one link, that can also reflect itself. If it's been going on long enough in a knee problem where he can take a sleeping giant, so to speak, meaning an underlying problem in the knee of the hip and wake it up. So those are the things we see. We can see problems elsewhere. Again, that's the knees, the hips, even the back. So that's one of the issues that we encounter. And at that point in time, we kind of have to peel away the onion one layer at a time. Of course we'll address the elephant in the room, which is the bounding heel pain. But if there's other issues such as a knee that's killing them, then we would refer them accordingly. For instance, to the orthopedists to make sure that there's no separate inherent problem in the knee other than just to be an aggravated from the altered walking pattern.
Joe Crosby: What types of shoe gear are best to wear to minimize plantar fasciitis pain?
Dr. Finkelstein: Well, in one simple word cushion, it's all about Cushion and shock absorption. And then the second thing tight second is the appropriate support within the shoe itself. So for instance, there's folks that have flat feet. So we're not only dealing with a problem of a plantar fasciitis, but also the abnormal components of what a flat foot contributes to the whole process. So there'll be certain shoes that are more beneficial by design, by your design, for a flat foot than say somebody who has a high arch, which would require a different type of shoe and obviously a different type of insole so that's the consideration with the shoes. But the underlying issue is having a shoe with some degree of cushion to it. Some people also find that if they have a shoe that has a bit of a heel to it, not a high heel but a bit of a heel to it, it helps as well. And the reason for that is that the Achilles can oftentimes play a role in plantar fasciitis because the Achilles hooks into the back of the heel where the plantar fascia hooks into the bottom of the heel and the two of those guys, you kind of having a tug of war with every step you take. So if the achilles a shorter tight, it can contribute to the plantar fasciitis. So by having a heel, you're putting the Achilles more in a relaxed position because you're putting some slack in line by lifting up the heel and that can help as well. So there's a lot of different moving parts to this.
Joe Crosby: Are you familiar with Crocs, the shoes?
Dr. Finkelstein: Oh yea, love them?
Joe Crosby: Are those a viable shoe option for plantar fasciitis?
Dr. Finkelstein: Yeah, what I usually do is, that's one of my favorite shoes to recommend for around the house. Okay. They're easy to slip on, usually to slip off. They're cushiony and what's really nice about them is that their product, the material is really well made. They don't compress, at least not that easily. So for instance, the new fad right now is the shoes and the flip flops as well as the house shoes made with a memory foam, which isn't bad when it's new. But unfortunately what we've been finding is that they tend to lose their memory. They develop Amnesia, so they compress. The Crocs very seldom do that. So that's one of my favorite shoes for in and around the house. And Florida being the barefoot state or the flip flops state, fortunately Crocs makes a variety of flip flops, Mary James, the traditional Dutch boys shoes. I mean they have a whole selection nowadays, but the main principle with them is the materials that they employ.
Joe Crosby: Awesome. That's good to hear. I'm gonna start working on that Crocs sponsorship.
Dr. Finkelstein: Is that something you guys have going on?
Joe Crosby: No, that's just a joke.
Dr. Finkelstein: Let me put this bug in your ear. If we could sell Crocs in the office, I could sell those things all day. You have no idea how many of those things I refer out.
Joe Crosby: I love reading about weird home remedies that people have tried for, you know, different medical conditions. But this one, I'm not sure where it even comes from. So I read, I read somewhere stuff online about wrapping your feet and cabbage or lettuce and that's supposed to help with the plantar fasciitis pain. So what's, what are some of the weirdest home remedies that you've actually heard or even seen a patient do for Plantar Fasciitis?
Dr. Finkelstein: Well, the most interesting one, I remember, it's funny you should ask me that question because as soon as that you did, it just popped in my mind. This goes back several years. I had this nice little lady probably in her early seventies, but a very active lady and she came in to see me for the plantar fasciitis. So I walked in the room and it smelled like meatballs with garlic. When I walked in the room, I thought maybe she has her lunch with her. So I walked in, I introduced myself, I asked her what was going on and she's telling me and she still has her shoes on. And finally I said well, can you go ahead, let's take off your shoes and take a look at those. Let me do this because I have a poultice on. I said, well, what, what's a poultice? She said I'll show you. So she pulls off her shoe and under her socks. She has some Saran wrap and in the Saran wrap, she has bacon, garlic and I think bacon garlic and one other item and she had it smeared all on the bottom of the foot wrapped underneath the Saran wrap and she said that that would draw out the inflammation. So she shows this to me and she says, well, what do you think of that? I said, I think it's making me hungry, but I don't think it's going to help your foot. That was the weirdest thing I remember in the treatment of plantar fasciitis
Joe Crosby: Without incriminating any patients out there listening. What's the weirdest thing you've ever seen a patient do to their feet as a home remedy for really any condition?
Dr. Finkelstein: Oh, that's an easy one. I tell this story all the time to my residents. I had this fellow, it goes back a few years ago, comes in kind of a weathered looking guy kind of a cowboy looking guy. Came in actually with his cowboy boots and his hat, his shirt, and you can tell this man's been out in the sun and really Nice fellow. He comes in, he's wearing his boots and he says to me with his little southern drawl, he says I have a wart on the top of my foot that I need you to take off. I said, okay, well let's have a look see. So he takes off his boots and I look on the top of his foot, and there is an absolute bloody mess with skin that let's just say, not to turn people off, it didn't look very good and it just reeked of infection. And I said, what happened here? And he says, well, I had this wart. He says, so I decided to take it off myself first. I said, well, how did you try to take it off? He says, I took a soldering iron to it and I thought I was hallucinating and hearing things and I thought to myself, well, the man's not diabetic. He doesn't have any neuropathy when I examined him. That had to have hurt like a son of a gun. So I said well didn't that hurt you. He goes, well, heck yeah. When did you do this? He goes, two weeks ago I said, well, I got to tell you right now you have an infection down here. We need to clear up the infection, get this wound healed up and then we can reassess this. So I put him on antibiotics, took care of his wounds and over the course of several weeks we got it to heal up. And sure enough, this so called wart, it looked like it was growing back. So at that point I, I excised and I sent it to the pathologists and guess what it was? It was skin cancer. He had a squamous cell carcinoma. Which can look like a wart. And then when that came back, I said to him, I said, did you, have you ever been seen by a dermatologist or anything like that? Cause apparently he was out in the sun so much. He said, no. I said, I'm going to send you over to the dermatologist. I think you need a good once over so I sent him to the dermatologist. Then he came back, oh, about a month or two later, and he told me that they found all kinds of goodies on his body, but fortunately nothing serious, like a malignant melanoma. Not that squamous cell could be a walk through the park. And he asked me, he says, do you like fruit? I said, yeah, sure. He says, I'll sen you some over. I grow fruit. Well bout a week later, one of the girls comes in the back and says, Mr. So-and-so sent over some fruit to you. I said, okay, just put it in my office. They said, no, no, there's some gentlemen here with some dollies with some fruit. So he said, well, just put it in the back, in the lunch room for everybody to enjoy it. So I went back there and there was crates of oranges and limes and lemons and grapefruit, and there was a nice little card in there. And I read the card and he was thanking me. Very, very nice man. And on the card was the name of his company. And I thought, this is weird. So I looked up the company online and it turns out that he's one of the largest citrus producing individuals in the state of Florida, and he sells his products to a minute made talking to the guy. You would never know it. Looking at him, you would never know it. He was as down to earth as can be and he was still working out in his field. I remember that. In fact, he still comes to me every now and again. He's a real nice guy. And I tell him I always tell his story to other people because it was just so different.
Joe Crosby: I want to thank Dr Finkelstein for joining me today, and I want to thank you for listening to the elevator podiatrist. Make sure you listen in the next week to see if we can secure Crocs as a sponsor.