Flippin’ Over Flip-flops by JoAnne Lafferty, PT, DPT

Spring is here, the weather is warming, and many can’t wait to slip into that favorite pair of flip-flops; but are you aware of all the down sides to these lightweight, open, airy and frequently cute shoes? The reality: flip-flops really are a flop.

The typical construction of flip-flops is often a flat, thin piece of rubber or synthetic material with a strap across the front of the foot or a thin piece of material between the toes. Because of this construction, flip flops can be the cause of multiple foot disorders. Flip-flops lack support for the heel, they lack support for the arch of the foot, and the thin sole construction greatly reduces the ability of the shoe to absorb shock.  Flip-flops also create excessive work for your foot simply to keep the shoe on your foot.

A poorly supported foot can lead to mechanical stress at the feet, knees, hips and even the lower back. This stress can result in joint pain, muscle aches, fatigue and even injury to any of these areas. When walking in flip-flops, you may notice your endurance for walking long distances is greatly reduced because of this leg fatigue.  Plantar fasciitis [pain along the bottom of the foot and heel], achilles tendonitis [inflammation and pain of the distal insertion of the Achilles tendon], and metatarsalgia [pain at the ball of the foot], are common disorders that are often precipitated by or exacerbated by wearing flip-flops due to the flimsy construction of the sandal..   

The lack of shock absorption of the sandal while you are walking causes a chronic pounding of the heel against the pavement. Repetitive stress to the heel and the foot increases susceptibility to stress fractures of these regions. Repetitive pounding of the foot results in increased compressive forces throughout the entire lower extremity and lower back, again, potentially leading to pain and fatigue. The increased pressure at the heel can also cause thick callusing of the heel.

The ineffective suspension system used to keep the sandal on the foot is frequently the cause of falls, slipping on steps and getting your shoe “caught” on things.  In fact, wearing flip-flops causes an alteration to the way people walk, typically resulting in shortened step length in an attempt to keep the shoe on the foot. This change in gait pattern can lead to any of the above-mentioned disorders.

If you are going to wear flips flops, consider four suggestions. Be sure the sole of the sandal is made from a thick, dense material. The flip-flop should have contouring for the arch and the heel, thus providing some mild support to the foot. The sandal should have some type of strap around the heel to help the shoe stay on the foot. Lastly, don’t wear flip-flops all day, every day. Wear them for short periods when you are not anticipating long distance walking.   

Dr. Sonam Ruit of Martin Foot and Ankle of York, Lancaster, Hanover and Shrewsbury, PA  has written an article on the following subject:

Adult Acquired Flat Foot Deformity (or Posterior Tibial Tendon Dysfunction)

by Sonam Ruit, D.P.M.

This is a flat foot deformity seen on adults due to progressive weakening of the tendon overlying the inside of the ankle known as posterior tibial tendon. This is an extremely important tendon of the foot and ankle, arising from the back of the leg and attaches to multiple sites in the foot, primarily at the inside hindfoot bone known as Navicular. It acts as a stirrup to hold the arch up and provides good inside ankle stability as well as restores our normal arch height. As this tendon weakens, the arch slowly starts to collapse, initially easily controlled with good custom orthotics and proper rehab of the weakened tendon. However as the tendon weakens and is left untreated for a long period of time, the foot then takes a more rigid form of flat foot along with associated arthritic changes due to malposition of the joints. This will lead to abnormal gait, increased pain, inflammation, fatigue, swelling along the tendon, as well as, along the arch, and joints of the ankle, hindfoot and mid foot.

Adult acquired flat foot deformity or PTTD has no single causation, rather it is multifactorial. Of many, the two primary causes are trauma (or acute rupture) of the posterior tibial tendon and chronic degeneration or progressive untreated childhood flatfoot and tight calf muscles. This then leads to chronic weakening (or slow loss) of tendon strength giving rise to complete rigid flat foot deformity at later ages. There are different stages of flat foot deformity, stage I, II, III and IV.  Stage I being mild and Stage IV being severe with degenerative arthritis and ankle involvement.

Early detection and treatment of posterior tibial tendon dysfunction can keep the deformity from progressing to further stages in the adult flat foot scheme. Conservative treatment is often able to decrease pain and the progression of flat foot deformity. Conservative treatments range from anti-inflammatory meds, biomechanical stabilization with proper custom molded orthotics, PTTD bracing, rehab to strengthen the posterior tibial tendon and calf stretching regimen. Slightly more symptomatic patients will also need temporary immobilization in a boot or casts and then will resume rehab and transition into regular shoes with orthotics. However, complex flat foot deformities that fail all conservative measures will require surgical intervention. There are a wide variety of surgical procedures and will depend on the severity of the deformity. Surgical procedures range from simple tendon augmentation, transfer, bone realignment to corrective fusion procedures along with release of the calf muscle. Therefore seeing the proper physician, getting early diagnosis and early treatment can make a huge impact in the quality of your life in the later years.

Sonam Ruit, D.P.M.

Martin Foot and Ankle's own Dr. Bronwyn Wilke has recently taken a trip with her husband, Eric, to Africa, where they hiked to the top of Mount Kilimanjaro. Kilimanjaro is the highest mountain in Africa and a goal for many to achieve climbing during their life time. African Travel Resource states, "The trek to the summit is a magnificent and spectacular 5 to 9 night undertaking, to rank amongst the greatest outdoor challenges on the planet." 

Dr. Wilke recently read a Blog article (see link below) about a group who also climbed Kilimanjaro.  But they did it barefoot.  Below are her reflections and comments about her wonderful adventure and what her feet experienced,  as well as her thoughts on climbing barefoot.

http://www.grindtv.com/outdoor/blog/32592/climbing+expedition+a%20ttains+summit+of+mt+kilimanjaro--barefooted/

Dr. Wilke writes:

Several months of shopping and then breaking in my boots.  Four and a half days up where the terrain included mud (in the rainforest), sand, rocks, shale and snow and ice up on the glacier.  Summit night -  I vividly remember the stinging, burning pain of the ice cold wind as it snuck into every crevice it could find.  I was extremely thankful for my waterproof north face boots, sock liners and smartwool socks.  Although it was as the sun was rising, I was very aware when the warmers in my boots and gloves cooled after reaching their 8 hour limit. A day and a half down initially sliding down the scree or loose gravel for four hours then again climbing over rocks and into the sand and mud of the rainforest. 

This is how my feet experienced 30 miles of climbing Mt. Kilimanjaro last month.  On the last day of the descent I can imagine going barefoot would have felt great, relieving the jamming of toes into the front end of my boots, sinking into the soft warm mud of the rainforest. Aside from those final hours, my boots were one of the most important pieces of equipment I had on the mountain (second only to my husband). Reading about barefoot climbers is amazing and risky. As a climber I am thoroughly impressed by their achievement. Clearly the Old Mutual Barefoot Kilimanjaro Team did their due diligence in preparing and toughening their feet.  As a physician I could not recommend this to anyone due to the associated risks of injury. A simple cut or scrape could prematurely end the climb - a devastating end to months of preparation and investment.  The risk of cold injury and frost bite in the extreme environment of the summit is significant and could result in loss of a digit or chronic pain.

Article written by Dr. Bronwyn Wilke, D.P.M

I recently read an article by a woman's fashion magazine listing shoes that every woman should have.  I was stunned that sneakers did not make the list!  A good solid walking/hiking athletic shoe is number one on my list of must have shoes.  Athletic shoes are the one line of shoegear that is focused on function and has research dedicated to product performance.  I appreciate that the basis of the article was fashion.  What woman doesn't have her glam moments?  But for every moment of glamour and less than practical shoe choices there is a moment of relief when the shoes are taken off.  If you've strutted in pumps you appreciate the NYC exec who runs to appointments in her suit and sneakers with her dress shoes in her purse.  If you have danced in peep toes or platforms you understand Kim William's character wearing sneakers under her wedding gown in "Father of the Bride".  No matter how gorgeous the shoe it cannot be sexy if you have to limp.  As a lover of stilletos, pumps, peep toes, sandals and boots I must draw attention to the unsung hero of every womans closet - the sneaker.  If you are having trouble finding a sneaker that is right for you, your foot health professional will give you guidance on foot deformity and appropriate sneaker choices.  Come see us in York, Lancaster, Shrewsbury, or Hanover.  We are Podiatrists that specialize in you.

By Dr. Bronwyn Wilke D.P.M  F.A.C.F.A.S.

Bunions are not just the nasty bump you saw sticking out of the side of your grandmother’s shoe.  They are a progressive foot deformity that can appear as early as the teen years.  Over time the great toe moves toward the smaller toes, making the great toe joint prominent on the inside of the foot.  Bunions are hereditary and the deformity can be worsened by pointy toed shoes.

In the early stages there is no pain with this deformity.  As a bunion progresses shoes become irritating to the bump.  Patients will usually start to wear wider shoes to accommodate the bump, and stretching out of the shoe over the bunion can be seen.  With the joint out of alignment the cartilage will start to degenerate and become arthritic.  Pain changes from an irritation over the bump from shoes to a deeper ache in the joint as the cartilage is destroyed.  If a bunion is not treated, compensation can be seen throughout the foot.  Hammertoe formation of the second toe is caused by the great toe pushing the second toe out of position.  Callouses can be seen across the forefoot and along the great toe as the mechanics of the foot and the way a step is taken changes because of the deformity.

Treatment early on for bunions includes orthotics.  An orthotic is a shoe insert that controls the mechanics/function of the foot and its joints. Podiatrist recomment  using an orthotic early on to slow down progression of a bunion deformity and ease pain.  This is important in juvenile bunions where surgery runs the risk of disrupting the growth plates. 

The type of surgery necessary to correct a bunion depends on the severity of the deformity.  It is generally an outpatient procedure, where the patient can go home the same day the procedure is performed.  The majority of bunion procedures allow the patient to walk in a special shoe or protective boot immediately after surgery.  No high impact activity (such as jogging or aerobics) is allowed until the bone heals which generally takes 6-8 weeks.  Very severe bunions may require a cast and several weeks on crutches.  Physical therapy after surgery helps restore motion to the joint and ensures the patient walks without a limp.

If a bunion is neglected and allowed to progress, the joint becomes arthritic.  Treatment options include arthritis medicines to control the pain and stiff soled shoes to limit motion at the joint.  Surgical treatments include joint replacement and fusion/arthrodesis.  Joint replacement maintains motion at the great toe joint placing a piece of metal to give a smooth surface for the joint to glide.  Joint replacement patients can start walking inmmediately after surgery.  Joint arthrodesis fuses the great toe to the long bone behind it, eliminating motion and pain.  Joint fusion takes 6-8 weeks for the bone to heel and a cast and crutches are used during this time. 

Ideally, bunions should be treated before the joint becomes arthiritic.  Maintaining alignment of the joint will prevent deterioration of the cartilage and the pain associated with arthritis. 

If you are near the York, PA; Lancaster, PA; Hanover PA;  or Shrewsbury PA area and are having these symptoms, Please call our office for treatment.  1-800-456-0076.