“Don’t knock the weather.  If it didn’t change once in awhile nine out of ten people couldn’t start a conversation.”  ~Kin Hubbard

One thing I didn’t know about Ohio until I moved here is that the weather is crazy.  It’s unpredictable.  It’s interesting.  It can go from 60 degrees and sunny to 30 degrees and snowy in one afternoon.  I am still in awe of these peculiar meteorological  conditions, and I find myself discussing them with my patients daily.  This winter has seemed looooonnnnggg and chilly, and I have seen a record number of patients with a common foot problem that has ties to this cold weather.  It is a condition known as Raynaud’s (pronounced  ray-NOHZ) disease, and 1 out of every 10 Americans suffers from it. 

The reason most patients with Raynaud’s come to my office is that they have noticed their toes turning colors.  In this condition the toes first turn white, then blue, then red.  These color changes can be associated with discomfort like tingling, burning, numbness, stinging, or throbbing.  The reason for this is that in Raynaud’s the small blood vessels that supply blood to your skin clamp down in response to cold temperatures or stress.   Often just one or two toes or fingers are involved, and not everyone experiences all three colors.  In most patients Raynaud’s is more of an annoyance than a disability. 

Raynaud’s can be broken up into two types, primary and secondary.  Both types are nine times as likely to affect women.  Primary Raynaud’s is the most common type and is not associated with any other type of disease.  This type is usually discovered between the ages of 15 and 30 and may have a genetic link (a parent, sibling or child may have it as well).  It occurs more in people who live in cold climates (think Ohio from October or November to April or May).

Secondary Raynaud’s (aka Raynaud’s phenomenon) is associated with certain diseases, occupations, and chemicals.  Autoimmune diseases like Lupus, Scleroderma, Rheumatoid arthritis, and Sjogren’s syndrome are linked with Raynaud’s as are other conditions such as carpal and tarsal tunnel syndromes, and thyroid dysfunction.  Jobs that involve working with vibrating tools and repetitive motions like playing the piano for long periods of time can also cause a type of the phenomenon.  Smoking and caffeine are also known triggers.   I wonder how many of my patients on a blustery winter day find solace in a cigarette and a nice hot cup of coffee?

Most of the time people with Raynaud’s don’t really develop any complications, but occasionally I will see patients who develop blisters or sores on the tips of their toes.  Very rarely Raynaud’s can lead to gangrene and result in amputation.    

If you think you may have Raynaud’s come visit our offices at Advanced Foot and Ankle Care.  First of all, we will try to find the reason you have this condition whether it be smoking, your body’s response to stress, a compressed nerve, or an underlying autoimmune disease.  We may rule out causes of secondary Raynaud’s with vascular testing, blood tests, and nerve blocks.  You may be referred to a rheumatologist or your primary care physician if we feel that your problem is serious enough that you could benefit from medication to open your blood vessels and promote circulation. 

Most of the time Raynaud’s can be treated by dressing warmly and avoiding situations in which your hands and feet come into direct contact with the cold.  Wearing a hat outside in the winter is important because a lot of body head escapes through your head.  I recommend that my patients wear socks to bed and put an extra blanket at the foot of the bed.  I may recommend that they avoid over the counter cold medications that contain pseudoephedrine, birth control pills, and beta blockers (for the latter two, after consulting their ob-gyn and family physician).  And then there’s everyone’s favorite recommendation: Moving to the Caribbean.  On Doctor’s orders, of course J

Dr. Hillarie Amburgey

Diabetic therapeutic shoes are, in my opinion, one of the most important parts of my job.  Diabetic shoes help save feet, plain and simple.  According to the American Diabetes Association, each year 600,000 diabetic patients get foot ulcers, resulting in over 80,000 amputations. 

As a podiatric physician I try to embrace preventative care modalities such as regular diabetic foot exams and diabetic shoes to prevent my patients from getting foot ulcers. My patients will tell you that I’m a stickler about these things.  I do understand patient concerns over cost, but the vast majority of insurances cover diabetic shoes and insoles.  It is widely accepted that preventative medicine is the best medicine, and not only the monetary cost but also the emotional and physical cost of an amputation makes money spent on diabetic shoes and insoles money well spent.  So, what makes diabetic shoes and insoles so different from your run-of-the-mill shoe?  Which patients need them?  And how do you know if insurance will cover them?  Read on for the low down on diabetic shoes.

The Definition: Diabetic shoes can also be referred to as extra depth or therapeutic shoes.  They are specially designed shoes intended to reduce the risk of skin breakdown in diabetics with co-existing foot problems (such as neuropathy, poor circulation, and foot deformities). 

Why They’re So Special: 

• Diabetic shoes are extra deep to accommodate diabetic insoles or orthotics. 
• They have a built in firm heel counter to provide medial and lateral rearfoot stability.
• The toe box of the shoe is higher so there is plenty of room for toes (even ones that like to stick up like hammertoes). 
• There is little to no stitching on the inside of a diabetic shoe.  The stitching is on the outside.  Sometimes even the smallest prominence can irritate and cause skin breakdown in a diabetic foot. 
• The collar around the ankle of the shoe is padded.
• The tongue of a diabetic shoe is thick and padded to help secure the foot back in the shoe.
• The end of the toe box of the shoe is protective to keep toes from being hurt when stubbed.
• Diabetic shoes have a non-skid sole to prevent falls. 
• They are specially fitted by measuring the length and width of your foot.
• They are also equipped with a special multi-density diabetic insole that prevents back and forth movement (also known as sheering) of the foot in the shoe.  A diabetic shoe isn’t really a diabetic shoe without this insole.  Most insurances pay for 3 pairs of these insoles yearly, and they should be changed every 4 months to get the maximum benefit.

Insurance Coverage:  It is rare that we come across an insurance plan that does not provide coverage for diabetic shoes and insoles.  Medicare has a Diabetic Shoe Benefit, and they have a pretty clear-cut policy regarding this coverage.  Even if you don’t have Medicare, many other insurances follow Medicare guidelines, and our office is happy to check out your insurance’s specific requirements.  According to Medicare.com to be eligible for diabetic shoes:

• You must have diabetes and one or more of the following conditions:
  • Nerve damage in your feet with calluses on either foot
  • Poor circulation in either foot
  • Deformity of either foot
  • Calluses on either foot that could lead to ulcers
  • A history of past foot ulceration
  • Partial or complete foot amputation
• You must have a prescription for the shoes. Our office can help you with this part.
• You must have documentation from the doctor managing your diabetes that you are in fact being treated for diabetes.  Our office contacts this physician and provides them with the necessary paperwork for this. 
• If you are enrolled in Medicare Part B, after you have paid your yearly deductible, you will pay 20% of the approved Medicare amount for the shoes and inserts.  You can think of this as the shoes and insoles being on sale for 80% off. 
• If you receive your Medicare through a Medicare Advantage Health Plan then you may owe little to nothing depending on the plan, but you will have to follow your plan’s steps for approval.  Our office will be happy to help you with that part too.
• You will save money on your shoes if you order from a Medicare-approved provider.  Beware of telemarketers, mail-order companies, and shoe stores who may or may not be participating suppliers. 

If you are a diabetic and would like to enquire about diabetic shoes and insoles we at Advanced Foot and Ankle Care would be happy to answer any questions that you may have about them.  We have quite a few shoes on display in each of our offices as well as a catalog and a website with even more shoes.  Our diabetic shoes come in a variety of styles from athletic to dress, walking to casual.  I feel confident that we have a shoe to fit your needs.

Hillarie Amburgey, DPM

The summer after my sophomore year of college I taught pre-school swimming lessons at my local YMCA.  Imagine my surprise last week when one of my old swimming students was conducting occupational interviews for a high school project (I feel SO old!) and asked for my input.  I filled out my interview and emailed it back to her.  This got me to thinking about how many people, even people reading this blog, know very little about podiatry.  Whenever I see a patient who is preparing for college or a patient who is the parent of a student preparing for college, I can’t say enough good things about my chosen field.  I love what I do, and I would love to share my profession with all of you.  To do that, here is a copy of the interview I filled out earlier this week.  Welcome to Podiatry 101.

Name:  Hillarie  Sizemore Amburgey           

Occupation:  Podiatrist (Foot and Ankle Surgeon) at Advanced Foot and Ankle Care

Years of Experience:4.5

       How would you describe what you do? 

I diagnose and treat foot and ankle problems in adults and children.  I specialize in congenital disorders, sports injuries, diabetic foot care, and minor and reconstructive surgery of the feet and ankles.

       What is your average day like? 

No day is alike, which is one of the things I love the most about my job.  I typically see patients in my office 5 days a week and do surgery a half or whole day a week.  If I have a patient that I am seeing in the hospital then I go see them (round on them) either on my lunch break or after regular work hours.

What kind of hours do you work? Do you have to work weekends, holidays or call?

I work from 8-5pm in the office 5 days a week.  On days that I have surgery then I am at the hospital by 6:45 or 7am.  If I have a patient in the hospital then my day usually ends around 7pm.  I am on call every 3^rd week and weekend.  Our office is closed Christmas Eve, Christmas, New Years Eve, New Years Day, Memorial Day, Independence Day, Labor Day, and Thanksgiving. 

       What kind of training or education did you complete?

I completed undergraduate college in 3 years, and then went to a podiatric medical school for 4 years.  Then I completed 3 years of residency training.

How long did it take for you to find a job once you completed your education or training?

I found a job before I completed residency. 

       Do people in your occupation all have a similar job duty or is there variety?

There is some variety.  All podiatrists have surgical training; however some prefer not to do surgery.  Podiatrists are employed in private practice, at hospitals, wound care centers and sports medicine clinics.  Some very specialized podiatrists just specialize in the treatment of foot problems in children.

      What is your favorite part of your job? 

The interaction with my patients.  They are constant sources of jokes and the weather forecast.  I laugh and cry with them.  And I am always learning new things from them. 

       What is your least favorite part of your job?

The pressure to change my treatment plan or what I think is best for my patient because their insurance won’t pay for it, and they can’t afford it.  It is a shame that insurances and people with no medical education have so much influence on patient care.

       How did you decide on your career?

I shadowed a podiatrist and liked what I saw.  I felt that he had a good quality of life, was helping people every day, and had a great relationship with his patients.

What are three qualities that would help someone succeed in your career (e.g. creative, organized)?

You will need to be…….

        1.      Self-motivating- You will need to push yourself through school and residency.  The learning never ends.  I still study every week. 

        2.      Likeable- A medical practice is still a business, and your business will fail if your customers don’t like you.  If your patients like     you they are more likely to take your advice and refer you to their friends and family.

        3.      Compassionate- Foot pain and problems get in the way of people’s lives in a big way.  People that can’t walk without pain are more likely to lead sedentary lives and become depressed.  It’s important to remember this and to try to empathize with your patients.

       Would you encourage young people to pursue your occupation?

If it’s what they really want to do, yes.  If they see a future of sports cars, tropical vacations, and mansions in their future, then they should probably look into doing something else with their life.  Healthcare has changed quite a bit in the past 10 years, and I believe it will change a lot more in the next 5-10 years.  The cost of a medical education is around $200,000.00, and in this day and age of decreased reimbursements (payments) that is a big financial burden.  For many physicians it can take upwards of 30 years to pay off these loans. 

       What are some fun facts or interesting stories from your job?

I have a lot of funny and gross stories.  Sometimes patients come in with maggots crawling out of their foot wounds.  This is cleaning the wound of dead tissue and is actually good for it (but we usually clean them off anyway). 

I have also used leeches to stimulate blood flow to a foot with decreased circulation. 

I would estimate that about 5 times a week (at least!) I am asked why I would want to look at peoples feet every day.  And I usually (Jokingly) respond that I have a foot fetish.  Then I go on and on about all the things that I love about my job J.  

Hillarie Amburgey, DPM

One of the most common questions I am asked by parents is about their child’s knees.  Parents bring their child or adolescent into the office concerned with the fact that they are either “knock-kneed” or “bow-legged”.  “Is this normal?” they ask with a worried expression on their face.  The vast majority of the time I am able to reassure them that the funny angulation of their child’s legs is just a natural part of development.  I am asked about this often enough that I thought it warranted a formal blog explanation of when these two conditions are okay and when they deserve further investigation.     

Knock-knee, known to the medical community as genu valgum, is a condition when the knees are angled in and touch each other when the legs are straightened.  The feet may not be able to touch.  This is seen as a normal occurrence in children ages 3-5 and may persist as late as age 8.   There is also a second normal episode from ages 12-14.  Outside of these age ranges the knees usually straighten up.   

Persistent knock-knee can be the result of obesity (most commonly), Rickets (deficiency of Vitamin D, calcium, or phosphate), or an injury to the growth plate in the leg.  Over time abnormal genu valgum can lead to problems in the developing foot as well as early onset knee osteoarthritis. 

 The opposite of knock-knee is bow-leg, known as genu varum in the medical community.  In this condition the legs bow outward in relation to the thigh.  This is normally seen at birth and can continue for the first 4 years of life.  We also believe that chubby babies who walk early (at about 9 months) have bowed legs because of the weight and stress being put on the leg bones which are still partially soft cartilage at this age. 

Genu varum, like genu valgum, may be caused by Rickets.  Another disease process that should be considered, especially in the case of bowing of only one leg, is Blount’s disease.  Blount’s disease is caused by growth arrest of the inside portion of the growth plate just below the knee.  The outside of the leg continues to grow but the inside doesn’t.  There are two forms of Blount’s, one occurring in infancy and one in adolescence.  Bowed legs, like knock-knees can also be cause by traumatic injury to the growth plate of the leg.  In adults bowed legs are often seen in certain occupations like jockeys and rodeo cowboys.

As a physician, if I see a patient that I believe has abnormal knock-knees or bowed legs I take a detailed medical history and do a physical exam, taking measurements of the legs.  I also get x-rays of both legs and take measurements from them.  Both Blount’s disease and Rickets have specific characteristics on x-ray.  Also a child with Rickets will appear weak and may have other skeletal abnormalities as well.  

In the case of Rickets the first line of treatment should be correction of the underlying deficiency.  In a young child with bowed legs, treatment can be as simple as bracing.  In persistent cases of either deformity, surgical treatment may be warranted for permanent correction. 

I hope this short explanation of these two conditions proves useful.  If I help even one parent not lose sleep over their child’s bow-legged appearance then I have done my job.  Or at lease saved someone an office visit co-pay J.   As always, if you have any further questions or would like your child to be evaluated by a doctor for either of these conditions, at Advanced Foot and Ankle Care we have four willing and able doctors at four convenient locations to meet your needs!

Hillarie Amburgey, DPM

Shaq tore his.  So did David Beckham.  And this week, as the world watched at the 30^th Olympic Games, Chinese hurdler, Liu Xiang ruptured his.  If you’ve been watching coverage of the London games or regularly watch Sportscenter, you probably know I’m referring to these athletes’ Achilles tendon injuries.  All three of these men were virtually gods in their sport when an Achilles tendon injury brought them down to the level of mere mortals, unable to even compete.

It comes as no surprise that the Achilles tendon itself derives its name from a demigod (half god, half man).  Greek mythology tells the story of Achilles, son of the goddess Thetis.  Thetis dipped Achilles into the River Styx to protect him after she received a prophecy of his death.  His mother held him by his heel as she dipped him into the river.  The protective water didn’t touch his heel, making it more vulnerable.  During the Trojan War, Paris killed Achilles by shooting a poisoned arrow, striking Achilles in his weak heel.   

The Achilles tendon connects the two large muscles of the calf, the soleus and gastrocnemius to the heel.  The two muscles come together to create the Achilles tendon, the largest and strongest tendon in the body.  The tendon itself extends from about midway down your calf to the back of your heel, about 6 inches (or 15 centimeters).   It functions to lift your heel up and point your toes down.  

So, if the Achilles tendon is so strong how is it so vulnerable to injury (hint: the answer is not found in Greek mythology)?  A lot is required of the Achilles, especially in activities that require a lot of running, jumping, and kicking.  When the tendon is overworked it can become inflamed (tendinitis) and tiny tears may develop.  This leads to the formation of scar tissue (tendinosis), which makes the tendon less flexible.   In some cases when the inflexible tendon is stretched it snaps or tears.   If you’ve seen the video of David Beckham’s tendon rupture you know that a rupture can be quite dramatic.  The rupture is often accompanied by a loud pop, and I’ve had several patients tell me that they thought that they had been shot in the back of the ankle when their tendon snapped.   Any of these Achilles tendon injuries are painful, but a tear or rupture can be nearly disabling, leading to the inability to even walk normally. 

Treatment of an Achilles tendon tear or rupture can be either nonsurgical (casting) or surgical (open repair, followed by casting).   There are hundreds of studies that support either treatment approach.  All of the above athletes underwent surgical repair because this approach usually ensures the fastest return to activity and has been shown to be more durable.  At Advanced Foot and Ankle Care our doctors, including myself, are all well equipped to discuss your treatment options and create a plan tailored to your needs and goals.   We will have you back shooting like Shaq, bending like Beckham, and leaping like Liu in no time. 

Hillarie Amburgey, DPM