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Alyne: Hey, ladies, do your feet hurt? Even if they don't, you may be hurting them with the shoes so many of us love to wear. Here to tell us more is Dr. Benjamin Jackson, an orthopedic foot and ankle surgeon with Prisma Health.

This is Flourish, a podcast brought to you by Prisma Health. I'm Alyne Ellis. Welcome, Dr. Jackson.

Dr Ben Jackson: Hey, how are you doing today?

Alyne: Oh, doing great. Thank you so much for your time today.

Dr Ben Jackson: Oh, happy to help.

Alyne: So I assume that you see a lot of women who may have damaged their feet over a period of time because of the shoes that they wear.

Dr Ben Jackson: Absolutely. That's definitely a group of patients that I see.

Alyne: And let's begin with the kinds of things that perhaps do the most damage. Can high heels or pointed shoes do a lot of damage to your feet?

Dr Ben Jackson: Well, I think damage is a relative thing. And so I think there are definitely certain conditions that are exacerbated by high heels. Some people have pain in the ball of their foot. The fancy doctor word for that is called metatarsalgia. Yes, I had to go to medical school just to learn how to pronounce that. But that's a condition where you have pain in the ball of your foot. And obviously, when you're wearing anything like a high heel, that can cause more of that. And so that's something that can definitely be exacerbated with high heel wear.

Alyne: And what about pointed toes?

Dr Ben Jackson: Those can definitely exacerbate conditions like a bunion, which is the curvature of big toe. We have a curvature of the small toe that's called a bunionette. And so both those can help contribute to those conditions and kind of exacerbate themselves.

Alyne: So, if you wanted to take a different shoe approach and say wear a platform shoe, are those a better option for a lot of women than high heels?

Dr Ben Jackson: For certain conditions, yes, absolutely. So I think that there are certain conditions. Clearly, things like stress fractures, even a platform high heel is better. What they're really better for is actually Achilles tendon problems. So the Achilles tendonitis, as you probably know well is the main kind of tendon, the largest tendon in your body and it connects the calf muscle into the heel. Often folks who have Achilles tendon problems, wearing a platform high heel actually helps make that better, believe it or not, because it elevates that heel and takes some of the stress off the Achilles tendon. So this can be helpful, particularly for that condition.

Alyne: So, what about if I just tone down the amount of time I wore high heels, would that make a big difference? How much time could I wear them without doing damage?

Dr Ben Jackson: Again, I think it depends on the condition that you have. So a lot of that is kind of what we call activity as tolerated. So as long as it's not hurting you, generally it's not kind of doing damage. When folks have, again, that condition called metatarsalgia or if you have a stress fracture in your foot, high heels can definitely exacerbate that. If you have something like a stress fracture, we would typically recommend wearing a stiffer soled shoe, more like a tennis shoe or athletic shoe, and then not wearing something like a high heel for six to eight weeks. So that's definitely a condition that it can make worse. You need to take some time off from wearing those.

Alyne: So something like that would mean I shouldn't even be wearing them for a special occasion, for example.

Dr Ben Jackson: You could. But as I tell folks, you're kind of going to pay for it. So it depends how special that occasion is. So if there's some special occasion, you may do it for a limited period of time, but it's definitely going to make that worse at least for the next few days.

Alyne: Now, what about flats? Are those better for your feet than what we've already discussed?

Dr Ben Jackson: They can be definitely in several ways. One, as you mentioned, so what we described kind of the pointed toe in kind of doctor and shoe speak is what we call the toe box. So the toe box is how wide the front of your foot is. The wider the front of the foot is, it helps some conditions have less pain associated with them. A few of those conditions would be like a bunion or bunionette. Another condition that's really common is called a Morton's neuroma. And that's where you have some inflammation of a nerve in the front of the foot that's exacerbated by the foot being squeezed tightly. So often folks that wear narrower toe box shoes, that makes that condition worse. And when they wear a flat or wider toe box shoe or even go barefoot, it helps make that condition better.

Alyne: And what about flip-flops?

Dr Ben Jackson: Flip flops, you know, in general, I don't have a problem with those shoes. They are not great for stress fractures though. So if you have a stress fracture, you really want something with more of a rigid sole to it. And so I think that that's one particular condition that can be made worse. Now, the other thing, just not regarding the foot, but the ankle, obviously there's less support in the ankle with a flip-flop or a shoe like that. And so that's something that you want to consider when choosing that shoe. But in general, a flip-flop is okay. There's some support to it, but not much support at the ankle, but it does have a wider toe box area.

Alyne: And how about going barefoot? I know for example, people who have plantar fasciitis, going barefoot is not a particularly good idea.

Dr Ben Jackson: So I think it kind of depends on the timing of it. So the reason why people kind of perceive plantar fasciitis is difficult, is because with that particular condition, typically what folks come and they tell me as far as the normal history of that is that pain with the first step in the morning. And so that pain is very exquisite. Many folks describe it as a hot poker sticking them in the bottom of their heel, which just sounds uncomfortable. And so often, that condition is worse with the first step in the morning when people are typically barefoot. Often they kind of walk it off as they say, and typically after 10 or 15 steps, it starts getting better and better. As long as you stay up on your feet, you're okay. So that's why people will kind of perceive that as being more of a barefoot condition, although it's not necessarily exacerbated by having a bare foot. It's just when generally people experience most of that pain and so that's why they kind of associate it with going barefoot.

Alyne: And can going barefoot cause problems?

Dr Ben Jackson: It can. And so I think that there are certain conditions that that can definitely make worse. So again, we talk about stress fractures of the foot. There is more stress across the foot when you're going barefoot. You know, for a while and maybe a decade or so, there's that kind of craze of barefoot running. We saw a really significant increase in stress fractures of the front of the foot with the barefoot running, because there's definitely more stress associated with that. The shoe takes a lot of stress off of the foot, provides cushion and support to it. And so particularly for something like a stress fracture, going barefoot can exacerbate that particular problem.

Alyne: Well, that certainly leads me into a question that is really worth pursuing when you're going to be exercising and running. How should you pick the right athletic shoe?

Dr Ben Jackson: That's a great question and something I get very commonly. So, I think a few rules of thumb is, one, you want to find a good fitting shoe. I think that is one of the most important things. So because shoes that are too small from a length standpoint can cause issues with your toenails. It can even cause bruising of your toenails or, even extreme situations, it can cause you to lose your toenails. So you don't want that.

You want the appropriate width of a shoe too. And that's something that people often overlook. So I would say, from a high fashion standpoint, the pointed shoes are much more high fashion, but are obviously significantly less functional. If somebody ever wants to prove that to themselves, they can take a sheet of paper and they could stand on that sheet of paper and outline their foot, just like you did in kindergarten, we outlined your hand and make a turkey. You can outline your foot and you can see that outline without any shoe, kind of pushing in on it. And then put your shoe on top of it and you'll see how much wider your foot is particularly than a high fashion shoe, like a high heel shoe or something like that. Your foot is much wider than that shoe, so it's putting a lot of pressure on it.

So when you're looking for an athletic shoe, you want to make sure you have a good fit from a length and width standpoint. And then you want to make sure you have the appropriate shoe for that particular activity. So if you're going ballet dancing, you probably don't want a running shoe for that and vice versa. So I think you want to find a sport appropriate shoe.

And then there are obviously brands that they're out there for certain shoes. They've got hiking brands and running brands. And so I think generally going to a reputable store, they can help you with those. I think many of the national brands for the most part don't make too many bad shoes. And also I think with shoes, like many things in life, you kind of get what you pay for. I typically don't recommend people buy the least expensive shoe, and so at least getting somewhere in that kind of middle ground, I think, is helpful. So getting a good fit from a length standpoint and a width standpoint, getting a sports specific shoe and getting something to at least kind of in that medium price range in broad brush strokes will get you a pretty good fitting shoe that'll do the task you're looking for it to do.

Alyne: You mentioned outlining your foot, but the size of your foot can change particularly as you get older or you gain weight or maybe you're pregnant. Maybe you could fill us in a little bit on how much your foot can change.

Dr Ben Jackson: Absolutely. So that is a great question. Believe it or not, it's actually something we're doing a clinical study on right here at Prisma Health. So we're actually doing a study. Currently, we bought pressure mat. We will then to step on that pressure mat. And currently, we've enrolled actually a thousand patients into that study to try and help understand what is "normal." So what is a normal arch, what is a high arch and what is more of a flat foot type person? It's interesting. A study like that has not really been done before. So we're leading in the front on that at Prisma Health, actively doing that research right now. So we hope to be able to get to you and maybe get back with you more about that soon. So that's one thing we're trying to understand more about.

But you mentioned pregnancy, that's a very common thing that I hear. Believe it or not, that's actually going to be a separate study that we plan on doing once we're done with this first study in the pressure mat, is trying to do a longitudinal study looking at women and how their foot changes during the pregnancy period. We do notice certain hormones particularly progesterone can help to lengthen tendons and relax them, which is important for the birthing process. We do believe that the foot size and shape changes particularly with pregnancy. So that's something that we're going to be doing a study on because I hear women tell me frequently their foot change to half sizes, sometimes even a whole size. And oftentimes, their arch drops some compared to their pre-partum state. So we look to investigate that more and, again, we hope to get back with you once we have the results of that.

You mentioned just, in general, as people do get older, sometimes folk's foot does get flatter. So that's something we're trying to learn more about as well. When we look at the condition of what we call a symptomatic flatfoot or what folks are now calling a progressive collapsing foot deformity is the latest lingo for that. What we find is the age group at least that has the most surgery for this seems to be women, typically Caucasian women that are in their 40s or 50s seem to have the most at least surgery for that. So we believe that's the group that has the most painful flatfoot. We're not sure why that demographic has it more. It's a bit unclear, but we're doing some studies to try and investigate that further as well.

So there are changes with arch height as you grow. It's kind of interesting in children, actually, their arch height, it gets higher as they grow, probably until about age eight or nine. And then it kind of is what it is until maybe you get some changes later in life or in pregnancy. So it's really a moving target as far as your foot shape and position in life, which is why oftentimes maybe wearing the shoe that you wore five or 10 years ago may not be the right size and fit for you now.

Alyne: And moving on with this, how does the type of shoe that you wear affect the rest of your body?

Dr Ben Jackson: So I think in several different ways. Typically, we'll just take running shoes, for example. The reason why running shoes are very helpful because they're shock absorbing. The foot is your body's first line of shock absorption. The shoe can help with that as well.

That's why, again, I mentioned that barefoot running craze. So they were wearing the minimalist shoes or even truly running barefoot. There's really more of a minimalist shoe, we saw more stress fractures because there was less cushion to the foot. And when there's less cushion, there was more shock that was sent to the foot and the knee and the hip and the lower back area as well. That's one area where the shoe can really affect your whole body.

Alyne: So when should you see a doctor about foot pain.

Dr Ben Jackson: Foot pain is something that is incredibly common. Many times, like many orthopedic conditions, will kind of resolve on its own. Everybody kind of gets a sprain or strain here or an ache or a pain there. The kind of red flags for me are a few things. One of them is pain is progressively increasing. So you start to have some pain and then few days later, the pain is worse. And a few days later, it continues to get worse. That's definitely very concerning from my standpoint.

And also pain that doesn't get better. So if you're starting, let's say a new exercise or running program, you start to get some pain in your foot. You say, "Hey, I'll take a week or so off." You try running again and it's still hurting, "I'll take another week off." And then even after that second week off, you're still having pain, I think that's a time that you come see an orthopedic foot and ankle surgeon for that problem. That's one reason.

Then the other reason is for deformity. Things like,a bunion or a bunionette or hammertoes or progressively collapsing foot or more of a deformity type problem that start as a deformity frequently before they even become painful. So those are reasons that you want to see an orthopedic foot and ankle surgeon, because some of those deformities can be either slowed down or prevented from getting worse. So that's one of those things, kind of a stitch in time saves nine. That's something you may want to come see an orthopedic foot and ankle surgeon for.

Alyne: And what do you finally recommend that we do to take care of our feet in general? Pedicures, for example, or other things like that?

Dr Ben Jackson: Pedicures are great for several reasons. As long as you're going to a place that uses sterile equipment for the work that they're doing and doesn't trim the nails too far back, I think those can be very helpful in preventing things like ingrown toenails. Kind of keeping corns and calluses trimmed I think is very helpful.

And then I think lotioning the foot is helpful. Particularly some folks just seem to have drier skin or sweatier skin. And both extremes, those can cause trouble. So if the skin is very dry and is cracking, the skin is the best barrier to infection. So if you get deep calluses or dry and cracking skin, that can be an entrance wound for infection, and those can actually be pretty serious infections that can develop. So it's something where lotioning can be very helpful. Again, you mentioned like a pedicure often they do that there. So that's one area on the dry cracking skin, make sure that you keep that lotioned. Keeping the calluses and corns soft, so they're not getting hard and cracking. One, because it's painful and, two, because that can be a source of infection.

Then you kind of get particularly in South Carolina, in the Prisma Health area of the world, a lot of foot sweat. And so if the foot stays sweaty, that can actually cause a problem as well, typically from fungal infections in the feet. Something like an athlete's foot. Typically what that looks like for patients is it's the most common infection between the toes.

So what you'll see is it's just like I tell folks, if you were to be in a pool or an ocean or a bathtub for a long time and your hands or body gets wrinkly. And the same thing, your foot gets wrinkled. When it gets wrinkled like that, the skin becomes very soft and can crack. It can also be a source of infection, because again, that cracking, that barrier of the skin to infection and that cracking can lead to infection.

Where that most commonly starts is kind of in between the toes. So making sure you keep the area in between your toes dry, particularly for folks that are sweaters, as I like to say, folks that sweat a lot and not something you wear in the winter, but a sweater person. Typically, drying in between the toes is helpful. Change your socks one to two times a day can be helpful, particularly if you're working outside, like in landscaping or something like that. Or drying off in between the toes after you shower, so that can be really helpful. I particularly counsel my diabetic patients on that because they're a little bit higher risk for getting these fungal infections in between the toes. So literally, taking the towel and drying off in between your toes, almost flossing in between the toes is particularly helpful for preventing that type of infection if you're more of a sweating type of a person.

Alyne: Is there anything else you'd like to add?

Dr Ben Jackson: The area that we haven't really touched on too much is a concept of an ingrown toenail. So, toenails can cause problems. So I think the single biggest thing that I would mention about toenails is not cutting them too short, particularly around the corners of the toenails. So an ingrown toenail is literally when the edge of the nail, typically it's of your big toe, truly goes into the skin. And when it grows into the skin, as we mentioned with several other conditions, it causes cracking in the skin and that can lead to infection getting in. So that's what ingrown toenail is. It's an infection because the toenail is literally growing into the skin. Hence, they kind of common sense name there.

The best way people can prevent that is not cutting the nail short enough that it can grow into the skin. So as long as you leave your nail longer than that area where you look at your nail and there's color to it and then at the end of your nail, it turns white. As long as you leave some of that white area where it's gone beyond where the skin attaches, you will never get an ingrown toenail. And so I think that's one of the easy things that folks can do to help prevent ingrown toenails, is not cutting those particularly edges of the big toe too short that doesn't allow it to grow in and really helps prevent a lot of problems down the road.

Alyne: Well, thank you so much for all this really great information. I know that we rely on our feet and sometimes we take them for granted. So I really appreciate you talking to me.

Dr Ben Jackson: Oh, well, happy to help.

Alyne: Dr. Benjamin Jackson is an orthopedic foot and ankle surgeon with Prisma Health. For more information and other podcasts like this one, head on over to prismahealth.org/podcast.

This has been Flourish, a podcast brought to you by Prisma Health. I'm Alyne Ellis. Stay well.