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Interactive Learning : HealthCast Transcripts

Episode 13 : Vascular Disease and the Foot

Release Date: March 22, 2007

Dr. David Meyerson: Hi, I'm Dr. David Meyerson, cardiologist at Johns Hopkins and your host for Vascular Disease Foundation's HealthCast. We are so privileged to bring you excellent science from peer- reviewed sources and experts in their fields so that you can better with vascular disease, you can prevent vascular disease and we can treat it appropriately so it does not limit your functional capacity. That is our goal, public awareness and we do this as a public service. With me in studio is Dr. Kerry Stewart. He's the Director of Exercise Physiology at Johns Hopkins, a good friend and a frequent companion on many of these HealthCasts. Kerry, I'm so happy that you're here today.

Dr. Kerry Stewart: And thanks for being a host David.

Dr. David Meyerson: And it's my pleasure. And on the telephone line is a Podiatrist, a foot and ankle surgeon, the Director of the Timonium Foot and Ankle Center in Lutherville, Maryland, Dr. Jordan Stewart. Dr. Stewart, thank you for being with us today.

Dr. Jordan Stewart: Thank you for having me today.

Dr. David Meyerson: It's a privilege. There used to be a joke about the organs of the body having an argument and the brain says, "I'm the most important" and then the heart says, "No, no, no I'm the most important" and then if we got a little bit off color, you know, something to do with bowel function, if that's not working right, it said, "I'm the most important." But finally, a quote from Abraham Lincoln and this is truly from Abraham Lincoln and it's very short and it's very sweet and it says, "When my feet hurt, I can't think." And it turns out that April is foot health awareness month and the Vascular Disease Foundation has told you repetitively that the blood vessel diseases that we talk about effect every areas of the body and what would be more appropriate than to look from the bottom, up. Why vascular disease seen from the perspective of the foot is so important and why it can be a clue to things going on in other areas of the body and for that reason, it is so integral to everything that we talk about here at Vascular Disease Foundation and on HealthCast. So Dr. Stewart, Dr. Jordan Stewart, foot and ankle surgeon, Podiatrist, Director of Timonium Foot and Ankle Center in Lutherville, Maryland again, Jordan I know you personally, so it's no disrespect if I call you by your first name.

Dr. Jordan Stewart: Not at all.

Dr. David Meyerson: And obviously you know me well, so feel free to call me David as well.

Dr. Kerry Stewart: I know you from head to toe actually.

Dr. David Meyerson: Why is it so important - one of the things that we could talk about is what are the important things that people with vascular disease should recognize in their feet? Some people say that when the hair isn't appropriately growing on the foot or if the skin is shiny and tight or if they have a sore that doesn't heal, what are some of the things that you see that give you pause, that make you think that somebody has significant vascular disease.

Dr. Jordan Stewart: When I do an initial assessment on any patient, one of the elements that I examine is the vascular system and that includes the palpating the pulses, checking for the capillary refill times in the toes to make sure that the blood is appropriately filling in the toes and --

Dr. David Meyerson: So you press the digits of the foot?

Dr. Jordan Stewart: Correct, we press the toes --

Dr. David Meyerson: So that you would be a master of press the digitation?

Dr. Jordan Stewart: Yes I am.

Dr. David Meyerson: Excellent.

Dr. Jordan Stewart: And we press the toes --

Dr. Kerry Stewart: A digitizer.

Dr. Jordan Stewart: We press the toes to see if the blood is refilling appropriately. We feel the pulses. I will ask the patient if they experience pain in the back of their legs, intermittent claudication, especially patients who we know have documented heart disease, stroke, a little more attuned to looking for vascular disease in them, however patients who don't have pulses in their foot, a lot of times I will be the first one who recognizes vascular disease.

Dr. David Meyerson: Do people come to you with sores that don't heal for example?

Dr. Jordan Stewart: Absolutely. One of the big things with the vascular patient is that they will have a cut and two, three weeks will go by and they're not healing and they're very concerned as to why this isn't healing and basically they're not getting enough flow to the foot to heal these wounds and that can be a big concern.

Dr. David Meyerson: Now one form of disease that we see -- I guess there are many causes of people having less than appropriate feeling and sensations in their feet, isn't that right?

Dr. Jordan Stewart: Correct. The main ones that we see in my practice are diabetes.

Dr. David Meyerson: Right.

Dr. Jordan Stewart: Alcoholism.

Dr. David Meyerson: Uh-huh [affirmative].

Dr. Jordan Stewart: Lower back issues, people who have injuries to their lower back.

Dr. David Meyerson: So the spinal nerves, for example, don't transmit those sensations well.

Dr. Jordan Stewart: Correct. Those are the main causes and the overwhelming cause is diabetes that we see a decrease sensation in.

Dr. David Meyerson: And why is it so dangerous for people who have diminished sensation in their feet, their lower extremities to ignore foot care and not get regular, meticulous foot care. Why is that so dangerous?

Dr. Jordan Stewart: Well, it's important because once the sensation is lost to the foot, they're at risk for stepping on foreign bodies that the person with intact sensation would otherwise be able to sense. For example, if there's a piece of glass on the floor, if the floor is hot, if they're outside on the beach, if they're outside on a hot pavement, they can actually burn their feet. I've had patients fall asleep next to space heaters and develop third degree full thickness burns to their feet and a lot of times in conjunction, if they are diabetic and have neuropathy and their vascular status, it ultimately will end up in an amputation.

Dr. David Meyerson: Jordan, one of the – I remember when I was in training as a medical resident, there was a forty-five-year-old gentleman who his daughter was playing with jacks, you know those --

Dr. Jordan Stewart: Right.

Dr. David Meyerson: -- pointy little objects, onesies, twosies, threesies --

Dr. Jordan Stewart: Yeah.

Dr. David Meyerson: -- and he had stepped on one and didn't realize. He had some pain. He wasn't totally unaware, but he didn't take care to that it healed well. He didn't seek medical attention for it, tried to get it taken care of by himself and as a diabetic, it seemed to just get worse and worse and worse and finally the area became gangrenous and in fact, he lost part of his foot.

Dr. Jordan Stewart: Right.

Dr. David Meyerson: That is a real danger, isn't it?

Dr. Jordan Stewart: I see that on a daily basis and I can specifically think of one patient that I had during my training that stepped on a piece of glass, a thirty-five-year-old diabetic patient who had advanced neuropathy and it festered in her foot for about two weeks before she really noticed it. Her foot then became red, hot, swollen, probably the size of a softball, maybe even larger and unfortunately at age thirty-five, she lost the front of her foot and due to non-healing, she ended up losing her leg and in fact, last week I saw another patient in the emergency room who developed an ulceration on the bottom of his foot because his cat had picked up a soda bottle cap and it landed in his shoe and he walked on it for about three days before he bothered to look at the bottom of his foot and saw that this soda cap had imprinted an ulceration basically into his foot from the soda cap.

Dr. David Meyerson: The -- I'm sure you see a lot of people with complaints of swelling of the leg. Do you ever see complaints about people with one sided swelling?

Dr. Jordan Stewart: Yes, unilateral leg swelling does occur.

Dr. David Meyerson: We had a previous program where we talked about deep vein thrombosis --

Dr. Jordan Stewart: Yes.

Dr. David Meyerson: And have you seen people that come with the lower leg that is swollen after a long plane ride or some other injury perhaps or after orthopaedic surgery --

Dr. Jordan Stewart: Yes absolutely. Anytime that I have a patient that either has undergone orthopaedic surgery or surgery that I might perform, if there's any concern or complaint of any leg or calf tenderness or calf swelling, pain, you know it is not something that we play around with and they're immediately sent for a doppler study to rule out a deep vein thrombosis.

Dr. David Meyerson: Tell me again. I think our audience has heard this once before, but tell me about the doppler study.

Dr. Jordan Stewart: The doppler study will evaluate deep veins in the legs to look if there's an occlusion of these vessels.

Dr. David Meyerson: Now basically these are just sound and radio waves that have no pain, no discomfort, it's a very simple test.

Dr. Jordan Stewart: Very simple, non- invasive test that just uses an ultrasound probe to visualize the deeper tissues in the leg and to see if the vessel is rotted off or not and identifying this as important because these types of clots can break off and go to the lungs and in fact, cause sudden death.

Dr. David Meyerson: Absolutely. We've talked about that on this program a couple of times before and I can't over emphasize that in importance. If you have one-sided leg swelling or pain unexplained, talk to the doctor, ask him is this a possibility that this could be deep vein thrombosis or a blood clot in the deep veins in the legs. Jordan, let me go on to another area, what about -- we talked that's a unilateral or one-sided leg swelling, what -- have you seen people who come in and they say, "Doctor, both of my legs are swelling." And you do a foot and ankle, surgical evaluation and find that there's nothing particularly wrong, but then the swelling in your judgement probably is cardiac in origin.

Dr. Jordan Stewart: Yeah, there are cardiac swelling, especially in the elderly population. There's a lot of venous insufficiency that we deal with and this is a significant vascular problem that I think needs to be addressed. Anybody with lower leg swelling is at risk for ulcerations in their legs as the veins are unable to bring fluid back up to the heart to be re- circulated, it actually leaks out into the soft tissue and these are the patients that we'll see with discolored skin, hyper pigmented skin and as this tissue becomes more swollen, the skin is unable to hold the fluid in and the skin will, in fact, ulcerate especially in areas where the skin is very thin which are areas over the ankle and over the shin and this can lead to significant problems. Mainly that these issues need to be addressed is compression and making sure that the cardiologist has the hypertension under control and if they need to be any fluid pills to reduce the amount of fluid. I think it's hard for elderly patients to control this because the compression stockings that need to be worn can be somewhat difficult to get on and I think compliance

Dr. David Meyerson: Especially with arthritic hands.

Dr. Jordan Stewart: Yes. And compliance is an issue and I think that you know, it's a difficult thing to manage. It is a bilateral lower extremity swelling.

Dr. David Meyerson: So just to clarify that, there are times -- this is for our audience – there are times when leg edema or bilateral leg swelling is coming from a heart function that is less than as efficient as it used be.

Dr. Jordan Stewart: Right.

Dr. David Meyerson: And that would be treated in one way, but you're also saying that with venous insufficiency, the heart may be just fine, but it's the veins of the lower legs that get weak. There are valves in the veins of the legs that may not work, is that right?

Dr. Jordan Stewart: Correct.

Dr. David Meyerson: The valves are unable to close sufficiently and as a result this blood is leaking back and it has nowhere to go other than into the soft tissue and this is what can cause discoloration in the legs.

Dr. David Meyerson: And one other important thing Jordan is that if the leg begins to ooze fluid, they're that swollen, when it begins to ooze that amber, that clear fluid that comes out --

Dr. Jordan Stewart: Uh-huh [affirmative].

Dr. David Meyerson: -- that ooze out is also a portal of entry for bacteria to come in.

Dr. Jordan Stewart: Absolutely. Any break in the skin is a portal of entry for bacteria and this leads us -- places the patient at significant risk for infection. And healing as well, these patients aren't able to heal their wounds as well because the tension on the skin is increased and it prevents oxygen from getting to the skin. That's in fact, what causes the breakdown in the skin so it's very important that lower extremity swelling is controlled from many reasons to prevent infection, to prevent breakdown of skin, to prevent potential blood clots and overall cardiac function as well.

Dr. Kerry Stewart: And Jordan, you mentioned the color of the skin is a good indication of certain conditions. What about the temperature of the skin?

Dr. Jordan Stewart: There are people who do have normal blood flow and they get a vaso spastic phenomenon. Some people may know it as Raynaud's Phenomenon where there's actually as spasm of the distal blood vessels which gives the sensation --

Dr. David Meyerson: Yeah the three of us are medical professionals, but I don't want to go too deep into jargon for our listeners.

Dr. Jordan Stewart: Vasospasm is basically the blood vessels will close off to a degree and not allow blood to get to the toes as much and they'll have a sensation of their feet being cold. As well as vascular disease, patients with severe vascular disease who aren't getting enough blood flow to their feet, can have significantly cold feet so I think it's important to question the patient as to when these events are occurring. People who have intermittent coolness to their feet, a lot of times it's when they're exposed to cooler weather. I find that in my office, sometimes if the temperature in the office isn't ideal, a lot of patient's feet might be cool, however their pulses are well intact. However, there are other patients who have non palpable pulses, pulses that we cannot feel with our hand and their feet are very cold and their leg is very cold, so there should be a gradual decrease in the temperature from the middle of the leg down to the foot. That is normal.

Dr. David Meyerson: Certainly Jordan, a wound, or even a small wound associated with fever and associated with warmth would be a danger sign for you, right?

Dr. Jordan Stewart: Absolutely.

Dr. David Meyerson: And what happens -- sometimes people will say they have a little sore and some red streaking going up the leg.

Dr. Jordan Stewart: Right. These are signs of infection. I think anybody with vascular disease or any other underlying disease that places them at risk for infection need to know the signs of infection. Anybody that I identify with vascular disease, I will sit them down and talk about the signs of infection that include redness, swelling, warmth, pain and loss of function of the specific area. You have to ingrain these signs and symptoms into your head as a patient and identify them. There's nothing wrong with calling the doctor and letting them know that you are identifying these signs because the time that you don't call the doctor, could be the time spent where the situation could be treated and every second counts when you're dealing with poor blood flow. If you can eradicate an infection, you really have a good chance of saving a limb.

Dr. David Meyerson: So we've talked about some of the things that might make patients contact you and become more aware. Things that they shouldn't wait to get evaluated, but what are the things that you might counsel a patient on a preventative nature? In other words, you know somebody has peripheral vascular disease, you know they have some sort of neuropathy, they don't have good sensation in their feet either from perhaps a vascular disease or spinal issues or diabetes or any of the other several causes of neuropathy. What do you tell them in terms of proper care, in terms of prevention? Is there something about shoe? What about foot care on a regular basis? What about examining their feet? What are your suggestions?

Dr. Jordan Stewart: Well, my suggestions are, I tell every patient who has any of these above issues that you just mentioned that they are not to walk barefoot and I can't stress that enough and barefoot is equivalent -- if you are wearing socks and nothing else, that is still barefoot. Every patient, I make it a point to be sure that they have a pair of hard soled shoes that they can wear in their home, a pair of sandals or slippers that have a hard soled bottom, a protective interface. The patients need to check the bottom of their feet daily. They need to check in between their toes daily. A lot of these patients develop calluses which is a build-up of skin and these calluses place patients at risk for infections and what we call ulcerations.

Dr. Kerry Stewart: Should they be cutting their own toes, or should they be seeing a podiatrist.

Dr. Jordan Stewart: They should be seeing a podiatrist if they are deemed to be at risk after an initial assessment, they should be seeing a podiatrist every eight to ten weeks.

Dr. David Meyerson: What would be the risk Jordan, of cutting your own toes, toenails?

Dr. Jordan Stewart: The risk of cutting your toes is that you number one, you're not using sterile instrumentation. Number two, you could potentially cut into tissue that should not be cut and --

Dr. David Meyerson: And you -- if they're neuropathic to begin with, then cutting -- what we're trying to do is avoid cuts in the skin for infection.

Dr. Jordan Stewart: Correct, correct.

Dr. David Meyerson: So they're just inviting the same things that we're trying to prevent.

Dr. Jordan Stewart: Correct. And I think also having them come on a regular basis forces them to address their feet and have these issued looked at because realistically, unfortunately patients do overlook some of these things and they need to have their calluses trimmed. Calluses are risk factors for what we call ulceration and by trimming them down, it reduces the risk. Making sure the shoes fit appropriately. I make sure that all my patients who have neuropathy and vascular disease check water temperature with their elbow.

Dr. David Meyerson: Oh how smart is that.

Dr. Jordan Stewart: The neuropathy can actually affect the hands as well, so I have had patients burn their feet in a bathtub. You make sure that they put their elbow under the water temperature because the sensation is generally preserved at the level of the elbow.

Dr. David Meyerson: You know that is -- look, I've been a cardiologist for twenty some odd years and that's the first time I've ever heard such -that's a great suggestion. I've never heard that before.

Dr. Jordan Stewart: Yes, it's very effective and it really can prevent burns. We do see burns from water. Making sure when they go on vacation at the beach that they don't walk barefoot on the beach. I mean, we all -- those of us who do have intact sensation know how painful hot sand can be if you walk around and don't know that it's there, you can develop full thickness burns to the feet.

Dr. David Meyerson: And as Abraham Lincoln said, "When my feet hurt, I can't think."

Dr. Jordan Stewart: Exactly. And I hear that every day. If your feet hurt, you can't get through life.

Dr. David Meyerson: Yeah and so there's another line in that joke about which of the organs are most important, but it is -- your dad being an exercise physiologist and I have spoken about things that when you have disability, when you cannot remain active, your blood pressure goes up, your weight goes up, your lipids are -- your cholesterol and different types of cholesterol are not as healthy and all of your activity levels suffers so that maintaining good foot health is a little bit more important than most people believe.

Dr. Jordan Stewart: Absolutely.

Dr. Kerry Stewart: And from my perspective as an exercise physiologist who advises people to be active to help prevent some of the problems that he's talked about, we also emphasize the need for all this foot care because if they can't walk, they're not getting the cardiovascular benefits that would come from being active.

Dr. David Meyerson: My special guest today has been Dr. Jordan Stewart. He is trained as a Podiatrist and foot and ankle surgeon, he is Director of Timonium Foot and Ankle Center in Lutherville, Maryland, Dr. Jordan Stewart. Jordan, thank you so much. This has been enormously informative, very, very valued. For the Vascular Disease Foundation, for Dr. Kerry Stewart, I'm Dr. David Meyerson, thank you for listening. We'll see you next time.


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