So, when you rupture your Achilles tendon, and it’s done more in Europe than in this country, but not everybody has to have a complete rupture like you did.  There are ways to rehab somebody not operatively.  In this country, most people who are relatively healthy usually get it fixed.  I usually talk to people about both sides, but I think your recovery is more predictable if you fix it.  So, some people like you, if you’ve rupture it, you do okay or you don’t notice it that much.  It’s hard to tell when you see somebody.  You come in, and you ruptured your foot last week.  It’s hard to tell if that person is going to be like you, or if that person’s going to walk all the time with a limp?  It’s a little bit of a judgment call, and you talk to people about what they’re activity levels are.  Talk to them about the risks of the surgery are, and then a lot of times, they just let the patients choose.

[1:01:33]

Sometimes you can have those nodules in your plantar fascia.  The plantar fascia is when you pull your toes up, you feel that structure tighten up in your arch.  That’s your plantar fascia.  Sometimes, you can have nodules in there called plantar fibromatosis.  Usually, you don’t need to do anything about it unless it causes pain.

[1:02:15]

No, that’s a whole other talk, but diabetes is very common.  The main I would tell you is from my standpoint in orthopedics, the biggest thing that causes a lot of problems is that with diabetes you often lose the sensation in your feet.  As you lose your protective sensation, these are the people that start getting ulcers.  So, if you do all the things to maintain your circulation, there’s ways that your circulation could be improved.  We don’t really have a good way to prevent you to prevent you from getting the neuropathy or the loss of sensation.  The best advice is to first see your primary care doctor and get an early diagnosis.  The second thing is to keep your blood sugar under as tight a control for as long as possible.  That’s probably the best thing you can do to prevent the neuropathy, but if you’re diabetic, you need to be looking at your feet every day.  Diabetics don’t heal wounds the same way nondiabetics do.  They have more problems healing wounds.  So, a small blister or a small wound, even if it’s pretty minor, you have to take it seriously in treating it very aggressively to get it heal.

[1:03:45]

It depends on how deep the ulcers are and where the location is.  In people with trouble with sensation, the biggest thing is you have to stop walking on your foot.  If you have an ulcer on the bottom of your foot, it’s a pressure ulcer just like people lying in bed are getting pressure ulcers.  It’s on the bottom of your foot, and the only way to get it to heal is to take the pressure off.  So, we have wound clinics where we work in which has ways to get pressure off.  You can do it with a cast or some of these different braces or things like that.  You have to get the pressure off to get it to heal.

[1:04:30]

No.  You can live with it.  When you say reverse it, the problem is that a lot of times, you have symptoms related to it.  There’s numbness and funny feelings in your feet.  There are medicines that can dampen that.  As far as taking some medicine that restores the sensation in your feet, there isn’t anything that does that.  So, you have to figure out how to live with it and prevent the things that it can cause.  So, usually once you have neuropathy, you have to be pretty careful with the shoes that you pick.  Once you have any deformity, it’s always good to use molded inserts like a soft molded insert that goes inside your shoes.

Yes, ma’am?  Back there in the red.

[1:05:34]

That’s a bunion.  Very common.  Again the easiest thing to do is get shoes that fit your foot better.  It’s not symptomatic.  You try and modify the shoes first.  If that doesn’t work, there’s a lot of nonsurgical treatments.  You can’t really put something on the toe and hold and straight.  That may help the symptoms a little bit, but once you take it off, the toe is going to back.  So, there are certain ways to correct that.

There’s a fairly high recurrence rate in bunions, and the reason that is is that people undercorrect them to begin with.  So, you say why do people undercorrect them.  The reason is  because people with the deformities are younger people, and they’re trying to get back to work. So, they do a surgery that’s a smaller surgery so they have a quick recovery.  Sometimes that will help for about 5 years or so, but as you get older, the toe starts going back over again.  So, if you undercorrect the deformity, there’s a high chance it’s going to come back, but if you correct it all the way, it does very well.

Yes?

[1:07:15]

Pain in the ball of your foot, like under your big toe?  The second toe?  Yeah.  Usually, that’s related to the joint, your metatarsal-phalangeal joint, or MTP joint, where the toe meets the foot.  As that gets tender, usually people with longer metatarsals have more pain because that’s the area where most of the pressure concentrates when you go up on your toes.  It’s the first stage of hammertoe.  That joint gets irritated.  The treatment for the most part if you get a good arch support, you can probably relieve a lot of the symptoms.  If you have a deformity of the toe, there’s some little things you can put in your shoe.  If your toes are getting cocked up like that, there are little things you can put on your shoe that let your toe lay down, then that redistributes the weight off the pad into the arch of your foot. So, if you don’t have a big deformity and you’re not having a problem with your shoe, usually you can treat that within inserts or some type of arch support.

Yes?

[1:08:34]

We’re trying to answer both those questions with a research study.  Most of the people who get better get better within a month or six weeks.  They’re seeing the difference.  We don’t really restrict them a lot.  Obviously, it does hurt to get a needle jabbed into your Achilles tendon, again we do it on Friday afternoon.  I tell them to put ice on it and take it easy for about a week, but I don’t really restrict them more than that.  There’s no boot or brace you have to put them in.

The way our study’s working is we have to fill out these pain scores before they do it.  Then, we get the pain scores at two weeks, four weeks, six weeks, three months, and a year, and the success rate of all the people we’ve put in our study is we haven’t had to do surgery on any of them.  There aren’t people there giving me a hug in two weeks saying this is the greatest thing they ever had, but on the flipside most of them are saying they feel better.  Fifty, 60% of them say they feel better to the point where they’re not going to physical therapy.  They’re not doing a shoe modification, and they’re not wanting to do surgery.

So, what we’re to try and follow them for a while and find out whether it’s a lasting effect, but for the cost of one injection and no hospitalization and no surgery, there’re really no loss time from work.  I think it’s really a reasonable option.

Yes, ma’am?

[1:10:28]

No, like in the back of your lower leg?  Like along your Achilles tendon?  Stretching is good.  For Achilles tendon problems, one of the things that we promote is a thing called negative stretching.  It’s basically, if it’s my left foot that’s affected, you stand on a step.  You go up on your toes on both feet.  Then, you shift your weight all the way to your left foot.  Then, you go all the way on your left foot and you slowly go down.  It gives you an eccentric muscle, and the theory is that it’s supposed to be better for the tendon.

Yes, sir?

[1:11:28]

It’s on the top of this foot?  No change in alignment of this foot?  Yeah.  Both feet. This is like a collegiate competitive runner?  Does it ever prevent him from running?  I’d probably just cross train him as much as I can.  I don’t know, probably an overuse issue.  Just cross train him as much as you can, especially if it’s both feet.  That goes against an injury.  Get him a bike.  I think you stumped me on that one.

Yes, ma’am?

[1:13:17]

In general, if all you’re doing is the first toe, my standard answer is it takes about 2.5, 3 months to get you back full time in a shoe.  So, usually you’re protected weight bearing with crutches for a full month.  You start putting more and more weight on it.  By three months, you should be on a shoe.  Again, the success rate is related to the initial correction that you get.  I think the struggle making your decision on a surgery is depending on the deformity, you have to choose a surgery that will fully correct the surgery.  You have to be realistic.  I’m not one of those guys that tells you to do this surgery and you’ll be back to work and running in a month.  It’s not really worth it to go through surgery if you don’t fully correct it.  I mean, because you’re going to be doing it again in 10 years.

Okay. Oh, yes?

[1:14:29]

I think the ibuprofen is mainly for pain.  I think the anti-inflammatory effects have been overly promoted.  It’s not going to help you with swelling.  The main reason you take it is for pain.  The main risk is stomach problems.  So, you have to be careful if you’re prone to get ulcers in your stomach or if you have stomach upset or reflux or things like that.  You have to be careful with the anti-inflammatories, but it’s one of the most common medicines prescribed.  It’s pretty safe.  You’ve got your Tylenol® and Aleve® and Motrin®.  You can’t take Aleve® and Motrin® together.  They do the same thing.  Tylenol® is a different kind of medicine.  So, you can mix Tylenol® with Motrin®.  You can mix it with Alve®.  Don’t mix Aleve® and Motrin®.

Okay.  Yes?

[1:15:39]

You mean the wound doesn’t heal? Was it like surgery for a broken ankle?  There’s a lot of reasons why bones don’t heal. A lot of it has to do with the severity of the injury.  It has to do with how it’s fixed.  Sometimes, the alignment of the foot can affect whether it heals or not.  Most ankle fractures heal.  Perhaps the biggest problem we have with ankle fracture is it’s a little bit stiff afterwards or it’s a little more prone to arthritis.  If it doesn’t heal, I think the first thing you have to look at if you had surgery is how you fixed it.  Sometimes, either you didn’t put enough screws in, or you didn’t fix it stable enough for the bones to heal.  Diabetics in general have more difficulty in healing bones.  So, there’s some medical reasons why fractures don’t heal.

[1:16:58]

I would think that would be unusual.  So, there would be some reason that you want to look for that’s fixable so they can walk on it.

Yes?

[1:17:22]

Microscopic in the sense that you use a microscope to do it? Now, the main areas are used a lot in spine surgery.  It’s also used a lot in hand surgery or where you’re reattaching vessels or things like that.  I’m not sure if you meant arthroscopic which is a way of looking inside joints.  So, mostly in the ankle, you do arthroscopic surgery, but not necessarily microscopic.

Alright.  Well, thank you for coming out.  It’s been a pleasure talking to you.  Usually, when I have these things, there’s always leftover food.  So, feel free to grab a bottle of water and a cookie for the ride home, and that way, we don’t have to take them out.

Thank you for coming, and if you have any questions, I’ll be happy to talk to you later.