Michael Smith, MD (Host): Meaningful Medicine is a Novant Health podcast bringing you access to leading doctors who answer questions they wish you would ask. From routine care to rare conditions, our physicians offer tips to navigate medical decisions and build a healthier future. Today I'm sitting down with Dr. Snow Daws and we're going to be talking about the causes and treatments for foot pain.

But before we begin, I always like to ask Dr. Daws, how did you get into orthopedics and what was your passion for becoming a surgeon?

Dr. Snow Daws: I knew from the very beginning of my medical career when I was in medical school that I wanted to work with my hands and have kind of direct access to patients. Prior to that, I was an athlete growing up. I had lots of injuries, during my career as a soccer player and so I spent a lot of time in the orthopedic office. In addition to the fact that I have five brothers. And so we literally lived there. Like somebody was always broken. So that was kind of my early access to medicine. And my orthopedic surgeon growing up was a very inspiring person and I really loved him. And so that kind of I was aware of it. I knew about the specialty, all those things. And then once I got to medical school, I loved the gratification of being a surgeon.

Like you can take someone to the operating room, you can fix a broken bone in an hour to two hours, and that feels very rewarding. So that's what I've always loved about it.

Host: I love that you've been a patient yourself. That's always a great way to enter into a field. So let's talk about foot pain. It's very common, but there's many different types, right? So what are the most common causes of foot pain? And is there a difference in men and women?

Dr. Snow Daws: There certainly are a lot of reasons for people to have foot pain. I would say the most common diagnoses I see in my clinic are plantar fasciitis or heel pain, and Achilles tendinitis. But there are lots of different things that people present for. There's lots of arthritis problems both in the ankle as well as all of the joints of the foot.

Big toe arthritis is very common. And then I also see a ton of sports injuries, so, ankle instability from chronic ankle sprains, Achilles tendon ruptures from weekend warriors. The best thing about my job is I have a ton of variety. I see all different ages and types of patients and all different kinds of pathology.

Host: Yeah, a lot of different things that can happen. It's funny you bring up the weekend warriors. I was one of them years and years ago. And I actually hurt my Achilles tendon. So I remember that very specifically. It was very painful and I was very happy for the doctors that helped me with that. Are there any practical at home tips that you can share with the audience, maybe to avoid some of this stuff. You mentioned a lot like fasciitis all that. So help us out. Like what can I do at home before I have to even maybe go see someone like you.

Dr. Snow Daws: So first and foremost, people always ask me about shoes. And a lot of people come to me and are like, I only have pain when I'm barefoot. And my answer is, we just don't go barefoot anymore. Our bodies are not made that way, and we really need to have support under our feet. So I really recommend avoiding, any of the barefoot trends, going barefoot most of the time.

Of course there's exceptions, right? But most of the time you should be in good supportive shoes. And then just general health stuff. You know, if you're having aches or pains or soreness, you know, just the basics, ice, heat, anti inflammatories, those things are always good to try. I often don't even mention them in my clinic because I assume everybody has done those things before they've come to me.

And then I'll realize at the end of the visit that they haven't. So if you start with that stuff and then we can get into all the other options that are available once you come to see us.

Host: Yeah, as you get to my age, sprains become, ankle sprains become, at least for me, common. I wanted to ask you, you mentioned heat, ice. What's the appropriate way to handle that? Is it ice first for a while, then heat? What do you recommend there?

Dr. Snow Daws: So I always say that ice is nature's anti inflammatory. So I like for people to use it when they have the initial onset of pain and swelling. It helps along with elevation. It helps with swelling and pain. And then once we get further along, I think heat can help, especially for muscle things, tendon things, joint stiffness, because heat allows us to warm up those muscles and joints.

So I often say heat before, ice afterwards. And then, if we're dealing with a chronic pain situation or something that's kind of long standing that we really have to manage, I always tell my patients, whatever works for you. I don't really care. If ice works better, do ice. If heat works better, do heat. Just try both, and whichever one is more helpful for your symptoms, do that.

Host: Excellent information there. I'm going to actually use that. Thank you very much. So, as we age, I mean, speaking of aging, Dr. Daws, are there exercises that patients should limit or avoid as they age? And if that's the case, what are the alternatives?

Dr. Snow Daws: My number one goal, any patient that I see, is keeping people active. So when people say, oh, my arthritis is getting worse, should I stop doing my activities to prevent it from getting worse? I always say no. I think you should keep doing what you're doing. Keep staying active because that is so important for your overall health and longevity.

So I want patients to keep being active. I do think as we age, the high impact activities like running can be detrimental. And I understand a lot of runners like they run for mental health. They run because they need the endorphins, they need all of those things. But I think that is one particular exercise that as we age, if we can avoid that and find other ways to be active and get our heart rate up and get the endorphins moving in our bodies, then that is great.

So, any low impact activities are great. Swimming, biking, pretty much any of the machines at a gym that are for cardio work great. I think walking is excellent and there's lots of ways to make walking more challenging. You know, incorporating hills, changing your speed up, rucking is kind of very popular now where people are walking with weights, which increases the difficulty but is still remaining low impact. So all of those are great.

Host: Yeah, I love my elliptical trainer. Keeps my back straight, which feels good, and when I'm done, ankles, knees feel great.

Dr. Snow Daws: Yeah, low impact and works great.

Host: So, when you see a lot of injuries, you know, I'm sure you see a lot of acute care situations, chronic care; what do you see the most though in your clinic? Are you dealing mostly with the acute situations or are you dealing more with the chronic pain issues in your clinic?

Dr. Snow Daws: I definitely see both. I mean, I would say almost 50-50 because we see a lot of acute injuries. We see ankle sprains. We see fractures. We see Achilles tendon ruptures, like all of that stuff. But then I see a ton of chronic pain. I see a ton of people with midfoot arthritis or ankle arthritis or, forefoot pain, especially in elderly people from deformities or arthritis or things like that.

My goal for everybody is to keep people functional, take care of their pain, and help them keep moving. You know, and you treat acute injuries very different because usually with acute injuries you can get people right into treatment, get them into therapy, or immobilize them, or get them on the correct anti inflammatory, or perform surgery, whatever it is, and kind of rapidly get them back to their previous level of activity.

With more chronic things like arthritis that we have to manage, then we just kind of set expectations, figure out a treatment plan, and get them going in that way as well.

Host: So you've touched a little bit in your clinic, some of the, I guess we call non surgical treatments that you offer. Can you go into that a little bit more? You've mentioned heat, you mentioned some other things. What specifically do you offer in the non surgical part of someone's treatment regimen?

Dr. Snow Daws: So almost with every patient, both acute and chronic pain type patients, or chronic injuries, shoes are important. So I've talk to pretty much everybody about shoes. Stiff, supportive shoes are generally what we recommend for most things that happen in the foot and ankle. We use inserts a lot. Not always, and not every problem is appropriate for an insert.

But there are many inserts that are very helpful for people's pain. So we're, you know, we're constantly talking about that. Anti inflammatories, there's lots of options out there. Over the counter anti inflammatories I think are a wonder drug. We have prescription strength medications that work. And then my clinic, we use a lot of injections and steroid injections and other types of injections can be very helpful for all types of arthritis, sometimes tendon problems. So those are some of the non surgical options that we talk about.

Host: You mentioned inserts, you know, if you go online nowadays, there's tons of easy to use, buy now, same day delivery inserts. I don't think that's the inserts you're talking about, right? Isn't it a little bit more specific to my needs when it comes to inserts?

Dr. Snow Daws: It's different for everybody. So, a long time ago, there was like the easy, over the counter, kind of foamy ones that didn't really offer any support, and then the custom inserts where you go to the place and you get fitted and all of that. But there's lots of options, you're exactly right, like all of our social media feeds are like covered in inserts, and I don't know if it's because I do what I do, but that's all I see on my social media are ads for different inserts.

But what I will say is now there are over the counter insert options that are great. They're well made, they're supportive, they can be very helpful. So I, what I usually tell patients is let's try this over the counter one. As long as they have an easy to insert foot, meaning they don't have this crazy deformity that needs correction or this really severe thing in their foot that I don't think of an over the counter insert would work.

But for most people, a little bit of arch pain, a little bit of plantar fasciitis, a little bit of Achilles tendonitis, a little bit of midfoot arthritis, an over the counter insert can actually be really great. And so I usually start there because I'm like, it's, that's a $35. And it might work great.

And if it doesn't, okay, then we'll do the custom route and you'll get insurance involved and we'll send you to the, you know, the person, the orthotist that custom makes it. But if we can get away with, you know, an over the counter insert, that's great. They're not all equal, right? Like I've ordered every single brand cause I'm always trying them out.

 There's some good brands and some not great brands that probably aren't worth it. But I usually try to figure that out with the patient.

Host: So you're a surgeon. So let's get into the surgery part of this discussion, right? That's what you like to do. I, can you share with us how you feel orthopedic foot surgery has advanced over the years, probably from when you were a resident to what's going on now. What have you seen change?

Dr. Snow Daws: There's probably two big changes. The first is how we rehabilitate our patients. So, when I first started, if you fixed a really bad ankle fracture, sometimes the patient would stay overnight in the hospital. Almost always you would put them in a cast, almost always they would not be able to put weight on the foot for six to eight, even 12 weeks.

And then you would put them in a boot and then you would let them start walking and then you would start physical therapy. And now we rehab people so much faster. So even for pretty severe ankle fractures or any other type of fractures, I let people walk almost always, unless there's some thing.

I try to get people walking at the two week visits. So we see them back. Get them out of their splint, take their stitches out, and put them in a boot and let them start walking. Start rehab at that visit. And we're finding that people do well with it. If you fix the fracture and it's nice and stable, then we can rehab people and get them back faster.

 So that is a huge change, is getting people walking, getting people out of the boot, getting people in therapy, and really getting them back to their previous level much more rapidly than we did before. So, that's a big change. The other big change is this whole smaller incision, more minimally invasive approaches.

And that is really everywhere. We see it in fracture care, we see it in Achilles tendon repair, we see it in management of bunions. So getting smaller and smaller incisions, but still having really good outcomes is a huge part of foot and ankle surgery now.

Host: You mentioned bunions. That's a big condition for a lot, a lot of people. Tell us about the bunion surgery. How often do you actually have to do the surgery? Because there's also a lot of over the counter claims of these patches and stuff that could melt away bunions and all this kind of stuff. Give us the truth about all that. What's really the treatment for bunions?

Dr. Snow Daws: So when we think about non operative stuff, I tell patients, if it doesn't hurt, never have the surgery. Like you should not have bunion surgery for cosmetic reasons. I tell people when it hurts all the time, when you can't get in shoes that are comfortable, when it's stopping you from doing what you want to do, that's the time to think about having surgery.

And I tell them there's, you go on Amazon, there's a million braces and straps and spacers and all these things. And what I tell them is a bunion deformity is a bony deformity. So there is no brace, no strap, nothing that will change it. It might straighten it for you to get in your shoes and maybe be a little bit more comfortable in your shoes. But when you take that thing off, you're still going to have a bunion.

Patients often think it's a growth or something on the side of their foot. And that's not it. It's literally your first metatarsal bone, just shifted over because of your bunion. And then when you think about surgery, it happened, you know, we perform bunion surgery a lot.

So, plenty of people get by with changing their shoes and not wearing high heels and things like that. But it's a very common surgery in my office, and I tell people there's greater than a hundred different surgeries described for bunion surgery, which means we don't have it all figured out.

Like there's lots of options and depending on the specific patient and their anatomy and exactly why and how they have the bunion, kind of determines how we fix them. Minimally invasive surgery is definitely a big and recent development in bunion surgery. It's actually been performed for at least 10 years in our field, but it's becoming more and more popular and patients are asking for it.

So I get a lot of patients that find me on the internet because I do it, and that's what they want. They like the appeal. And you've always heard patients always say, oh, my mom had bunion surgery and said it was the worst thing she ever did, and she would never do it again. And I think classically, that's how it was.

It was painful. It was prolonged recovery. They were off their foot, not walking on it for a long time. Many were casted. And minimally invasive surgery and just surgical technique in general allows us, again, to get people moving back faster. So I do minimally invasive surgery a lot. It's a fixing a bunion with four, like pretty small incisions. I would say, you know, two to three millimeter incisions and you can get a really great correction. And I tell people, you walk on it right away in a surgical shoe. I let you get into regular shoes much more quickly around the two week mark. Most people are getting into their regular shoes. Swelling can still be a problem. Range of motion is better. Pain is better. Correction is great. And so I've been really happy with it in my, in my clinic.

Host: Wow. So you're getting people back in their regular shoes in two weeks?

Dr. Snow Daws: Yeah, two weeks I take the stitches out and I tell them a regular shoe or any shoe that's comfortable, which sometimes is like a Croc or a Birkenstock or, you know, cause they're still gonna have swelling. They're still gonna have pain, you know, all of that. But most people come to their six week follow up in like I said, a Croc or a Birkenstock or their regular running shoes or something like that.

Host: That it wasn't like that 15, 20 years ago.

Dr. Snow Daws: Absolutely not.

Host: Yeah, no, that was, so that's right there, a great advancement. You know, just speaking of all that, you know, everything you're seeing, all the advancements in surgery, how we're treating foot pain, let's just kind of summarize in two ways. What are you most excited about when you look at some, maybe the advancements coming up and number two, what is your best advice for someone who has chronic foot pain?

Dr. Snow Daws: Number one, I'm excited about, and this has always been something that I'm excited about, I think foot pain really tortures people, because we're so dependent on our feet. So we have to get up, we have to move around, we have to do our jobs, we have to take care of our families, we have to do whatever activities we want to do. And foot pain really inhibits people in a very significant way. I think all orthopedic problems do, but the foot especially. It's so difficult for patients. And foot surgery is hard to recover from, and people have a hard time with it, especially when you think like, if I'm operating on the right side, the driving is, you know, such a big issue.

And what I am most excited about, especially as things advance and we get even faster and more efficient at helping people is that exactly like getting people through these times of foot pain that can be very debilitating and depressing for patients and helping them get back pretty rapidly.

As far as general recommendations, I mean, this goes for everybody. Wear good shoes. Take care of your feet, check them, make sure that they're well supported. Keep your joints and your muscles loose. Definitely stay active. Keep your weight down. I tell my patients, like, every pound of body weight is three to five pounds on your foot and ankle. So use that as motivation to get your weight down and keep it down and stay active. Staying active is really the best long term for your health and for your foot and ankle.

Host: Dr. Daws, fantastic information. Thank you for joining me today.

Dr. Snow Daws: You're so welcome. Thanks for having me.

Host: To find a physician, you can visit NovantHealth.org and for more health and wellness information from our experts, visit HealthyHeadlines.org. I'm Dr. Mike. Thanks for listening.