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Dr. Michael Smith (Host): Foot and ankle injuries and painful conditions can make it really tough to stay active. This is GW Medical faculty associates podcast, the podcast from GW Hospital. I'm Dr. Mike. Let’s talk with Dr. Zung Le and Julie Rosner. Both are podiatrists and clinical professors at the GW School of Medicine and Health Sciences. Dr. Le, how common are foot and ankle injuries?

Zung Le, DPM, FACFAS (Guest): They’re pretty common, but they range from problems that are considered quite mild—oftentimes may not really require any specific medical care—but oftentimes they can become quite debilitating causing a lot of problems with walking, standing.

Host: Yeah, yeah. How about just staying active, right? We want more and more of our patients, our family members, our friends to be active throughout life, and these kinds of injuries, right, often become the reason why they can't stay active. So when you look at that non-athlete population, Dr. Le, what are the most common—maybe the top three—most common injuries that you deal with?

Dr. Le: I would say the most common problems for the typical person who’s not an athlete would probably be a lot of problems related to heel pain, specifically a problem called plantar fasciitis. Foot arthritis is also relatively common. With regards to the feet, arthritis most often times effects the big toe joint. It can affect other joints of the foot as well, but the big toe joint—most commonly—is the joint that develops this problem. Another very common problem that a lot of folks get is pain related to the ball of the foot. That’s the part where it’s close to the base of the toes. There could be numerous problems that actually effect that part of the foot. Things as simple as just some swelling that could take place there. Sometimes there could be nerve related problems in that part of the foot as well.

Host: Okay. Yeah. I definitely want to come back to those three common injuries and talk a little bit more about how you guys approach treating those conditions, but I wanted to ask Dr. Rosner when should somebody actually seek help from a professional like yourself? Whether they're dealing with the plantar fasciitis or maybe some pain that they're not even sure what it is. At what point, what are the signs and symptoms that tell you they need to go see somebody?

Julie Rosner, DPM (Guest): Excellent question. So generally my rule of thumb with patients is once pain kind of starts, that’s a warning signal that something isn’t quite right. Usually at that point I recommend patients to kind of take a break if they're kind of a weekend warrior type or even an elite athlete of backing down of some of the activities. If pain persists despite taking some conservative measures such as rest, ice, maybe an over the counter anti-inflammatory medication, or they’re really just having difficult with everyday functioning—like just basic walking, getting out of bed, doing things around the house—that’s definitely when I'd say some in and get checked out.

Host: Yeah. Great advise there. So Dr. Rosner, when somebody finally does come to see a specialist like you, a podiatrist, can you tell us a little bit about the typical workup that the patient can expect? Tell us a little bit of the role of the podiatrist say versus a medical doctor or a physical therapist.

Dr. Rosner: Sure. So patients can expect to come into the office and we’re going to ask them a little bit about their symptoms. So how did they first start noticing the pain? When did they notice the pain? How long has the pain been there? What have they done? We ask them a quite in-depth history about everything that they’ve been experiencing and when they experience these symptoms. Then we’ll put the patient through a physical examination that’s comprehensive. So we’re checking all parts of the feet, and usually we compare both feet to compare one side to the other, not just the side that is troubling to the patient. That way we kind of know what normal is for them in comparison to what may be hurting them. The examination can include a variety of different things of poking on different parts of the foot and ankle, moving the foot and ankle in different ways, having the patient stand, walk. Depending on the symptoms, they may be sent for additional tests such as an x-ray.

We’re a little bit different in the sense of a primary care physician or a physical therapist because physical therapy is really looking to the rehab of things and trying to get the patient on the backside of an injury. They kind of help them become more functional after the acute situation or the primary pain dies down. A primary care physician often will offer a lot of really great tips to begin with, but the podiatrist comes in when those problems are somewhat lingering and needs just that extra little bit of attention to really get past that acute problem.

Host: Right, right.

Dr. Rosner: Then some cases are chronic conditions too.

Host: So Dr. Le, I wanted to ask you. I think most people, most of my audience, most of my listeners are familiar with a Doctor of Podiatry or podiatrist. I'm not so sure they understand the extensive education and training that you go through. Can you tell us a little bit about the education and training that you went through to become a podiatrist?

Dr. Le: Yes. It is a little confusing. There’s a reason for that. The profession of podiatry itself has gone some changes over the last decade or two. A lot of these changes happened so quickly that it wasn’t really easy to keep the public aware of the advances in the training of podiatrists. Currently a podiatrist would complete a standard four year of undergraduate study. Following that would be four years of school at a podiatry medical school. Following that, you would complete three years—It’s typical now that most people complete three years of residency training program. Additionally many podiatrists would now, in addition to that, complete a fellowship that would further specialize or subspecialize in a particular field within foot and ankle surgery. This could be reconstructive type surgery. It could be focused on, in some cases, trauma. In some cases it could be more deformity correction. In many cases it could be related specifically to complications of diabetic foot problems. So it’s very comparable to a lot of other medical specialties.

Host: Right, right. I thank you for that summary because I think that’s going to help a lot of my listeners understand exactly what you guys go through to be able to practice in podiatry. It’s very extensive. It’s the same amount of years as medical school as a matter of fact. So let’s bring it back to those three common injuries that you brought up, Dr. Le. Let’s talk first about plantar fasciitis because that’s something that I think more people are aware of. There’s a lot of websites now with all kinds of treatments for plantar fasciitis, whether that’s shoes or insoles. Whatever that is. There’s all kinds of information out there. Some of it I think may be a little wrong. So I want to use this as an opportunity and allow you, Dr. Le, to teach us a little bit more about what exactly is plantar fasciitis and how do you treat it?

Dr. Le: Okay. Plantar fasciitis is easily the top three conditions that a podiatrist would see on a daily basis. Plantar fasciitis is basically a problem with a ligament that sits in the heel of the foot. The ligament is called a plantar fascia, hence the term plantar fasciitis, which involves pain, swelling, inflammation of this particular ligament. Particularly at the area of the heel. The problem could come about from a variety of reasons, but most commonly due to shoe wear that’s not offering enough support. You could also develop plantar fasciitis from physical activities that might be more taxing, more stressful than your body is used to. Sometimes it can be due to body weight. Occasionally sometimes plantar fasciitis just happens without any clear connection to any prior problems or antecedent events.

There are lots of treatments nowadays with the technology, but the foundation of the treatment is still primarily providing adequate support for the arch. Often times this can come from a good fitting shoe, but most commonly you'll need more than just a good shoe. Often times you'll need arch support or some type of shoe insert. There are some over the counter prefabricated type shoe inserts that people could try. In some cases, it’s enough. For more recalcitrant cases of plantar fasciitis, often times custom foot orthotics are required because they're a better fit for the foot and they often time offer much more support than what you can find in a retail store, for example.

The other very important part of treating plantar fasciitis is aggressive stretching. A big component of plantar fasciitis is sometimes due to loss of flexibility in the foot, which is not uncommon in most people over time as we get older. So a big focus of the treatment is aggressive stretching. So that can be done through self-stretching. Or sometimes for more, again, recalcitrant cases may need the aid of a physical therapist. I think for most cases, aggressive stretching and adequate shoe support including shoe inserts are successful in treating plantar fasciitis.

For cases that are more recalcitrant, tend to be more stubborn, often times a steroid injection may be necessary to help relieve the pain. Then with the current technology, there’s a few other new options that are now available too. These options are usually reserved when standard treatment has failed.

Host: Right. So the go-to here is making sure we've got the right shoes and that aggressive stretching. In most cases, that’s going to help, at least, for most patients. Is that correct?

Dr. Le: Right. I would say for many cases with adequate support, shoe inserts or perhaps even custom orthotics in some cases and aggressive stretching, fortunately, will solve the problem in many cases without needing to consider a more advanced treatment for plantar fasciitis.

Host: Dr. Rosner, I think to be fair, I asked Dr. Le for his top three conditions that he sees. Why don’t you share with us what are your top three conditions that you see? Pick one of those to teach us a little bit about and how you treat it.

Dr. Rosner: Well, I do have to agree with Dr. Le that those are definitely some of the top three conditions that we see. But a couple of other things that we certainly see a bit of would definitely be ankle injuries, such as ankle sprains. That has to be one of the more common injuries that a lot of people come in with, particularly people who like to be athletic on weekends or do a lot hiking and sport activities. So that one is pretty common. So usually when patients sprain their ankles, it’s on the outside of the ankle, which is the side of the little toe. It usually happens when somebody kind of bends their foot and it rolls under them a little bit. There’s different degrees of sprains that can happen. Anything from a pretty mild sprain to something that’s pretty severe.

Depending on what a patient comes in with will determine the treatment. So a pretty minor sprain might be something pretty easy to treat. Just ice. So typical RICE principle. So rest, ice, elevation, and compression. Maybe need an ankle brace for a short period of time and can generally return to activity pretty quickly. Then there are some more severe injuries that are almost as bad as breaking a bone without actually breaking one, which would potentially require immobilization and a walking boot, removal from physical activity. Even possibly down the line depending on how patients do with physical therapy, which is so key in recovering from these types of injuries, possibly even surgery to repair ligaments in the future.

Host: Right. Well, listen docs. I really appreciate the time that you spent and all the great information that you just taught my audience. That’s Dr. Zung Le and Julie Rosner, podiatrists at GW Hospital. Thanks for checking out this episode of GW Medical Faculty Associates Podcast. Please visit gwdocs.com to get connected with doctors Le and Rosner or another provider. If you found this podcast helpful, please share it on your social channels and be sure to check the entire podcast library for topics of interest to you. Be sure to check back soon for the next podcast. I'm Dr. Mike Smith. Thanks for listening.