The Arch of Your Foot

Podiatrists categorize feet by shape. We have an "ideal" foot shape, and anything that is not ideal we say is "deformed." The catch is that almost everybody has some degree of deformity! So don't be insulted if your podiatrist talks about your "deformed" feet—you're just like everyone else.

One aspect of your foot shape is the arch. The arch of your foot begins at the heel bone and goes forward to the ball of your foot—behind the toe joints. Your heel bone should make approximately a 10˚ angle with the floor, though you would need an X-ray to measure this exactly. High arched feet and low arched feet each present their own problems, so consult with Dr. Reddy or a podiatrist in your area to figure out how to best treat your unique feet!

If your foot is arched higher than normal, you have what is known in medical jargon as pes cavus. Some people are born with it, while others will have high arches due to muscle weakness. Muscle weakness, in turn, can be due to diabetes, neurological deficits, or trauma, so it's important to keep open lines of communication between podiatrists and other specialists. High arches can be treated with surgery or with orthotics, depending on the patient.

On the other hand, a flat foot is known as pes planus. Once again, some people are born with flat feet, while others get them later in life. The bones of your feet are held together by ligaments, and the less tension in your ligaments, the easier it is for the bones of your feet to flatten out. Young children have very flexible feet, so if they look flat, don't worry quite yet, because it could be normal! Your podiatrist will tell you if your child will "grow out" of his or her flat feet.

Adult feet can flatten out as part of the aging process or as a result of Charcot neuropathy. Whatever the case may be, definitely consult with your podiatrist, because he or she will tell you how to modify your lifestyle in response to your changing foot.

To Operate or Not to Operate

They say medicine is an art, not a science. You would like to think that your doctor knows what's best and that his or her recommendations will make you better. In some cases, this is true. We have come a long way in the last century. In other cases, the doctor is tasked to choose the lesser of two evils.

Last week, I was shadowing a podiatrist in a hospital. A 69 year old woman was admitted after being hit by a car. Luckily, her most severe injury was a fractured second metatarsal. (The metatarsals are long bones in the middle of the foot where the toes attach.) The fracture was displaced, meaning one piece of bone was slightly off to the side and not lined up with the other piece.

In general, bones will heal if you line up the pieces. In cases like this, surgery is needed to put the pieces together (called reducing the fracture), and the podiatrist will probably use pins or screws to keep the bone fragments aligned to ensure it heals properly.

However, for whatever reason, the patient refused surgery, and the doctor accommodated the patient's wishes. Ideally, we would like the bone to heal as best as possible. But do we want to put an elderly woman into the kind of trauma that surgery entails? Without surgery, the bone would heal—not properly, but it would heal. On the one hand, the bone might not hold and the woman could be back in the hospital years down the road. On the other hand, considering her activity level, she might happily live out the rest of her days and never worry about it again.

In podiatry school, we are tested with questions that have right and wrong answers. However, in practice, sometimes there are no "right" answers. In complex situations like this, podiatrists will not easily come to a decision, but rest assured knowing they are doing what they believe is best.

Bathroom Surgery

What follows is a story from what I observed in clinic as a student. A Spanish speaking, uninsured patient came into the clinic with an ingrown toenail. Not terribly exotic, as far as podiatry goes. However, he complicated the matter by attempting to trim away the growth—what the attending podiatrist referred to as "bathroom surgery." She then verbally expressed frustration to the three students in the room, in front of the patient, since the patient's work actually made the procedure more laborious.

I think there are two insights to be gleaned from this.

The first is for patients. Quite simply, leave the surgery to the doctors. Don't try to fix something on your own, because you might make it worse.

The second insight is for the doctors and is a bit more nuanced. When is it appropriate to criticize patients? Would you exploit a language barrier to say things you wouldn't say in front of an English speaking patient? Is it unreasonable for doctors to expect patients to avoid attempting to solve their own medical problems? We self-treat for colds and headaches. Maybe this patient believes (incorrectly) an ingrown toenail is in the same category.

Also, economic considerations will make an uninsured patient more likely to take matters into his own hands. The patient reasons that he can either self-treat or pay for the office visit. If self-treating works, the patient saves money, but if self-treating doesn't work, the patient might not bear any additional costs other than what he would have paid by seeing the doctor from the beginning. So, from the patient's perspective, why not give it a try?

Lastly, the patient simply could be nervous about going to the clinic and wants to avoid going as much as possible.

The intent of this post is not to criticize one doctor. Perhaps she is a phenomenal doctor who was having a bad day. In medical school, we are taught to have empathy for patients, but putting that lesson into practice is clearly difficult. The real lesson is that, while we are talking about the tiniest of ethics violations (if you even consider it a violation), we nevertheless hold ourselves to higher standards as health care professionals. That means having understanding for patients who do things that we discourage, like performing bathroom surgery.