Joe Crosby: 00:16 Welcome to the elevator podiatrist, the show where we ask common foot and ankle questions to top podiatrists from around the country. There's no appointment or copay required for this one on one Q and A, only free advice from individuals who have devoted their lives to all things feet. I'm your host Joe Crosby. And today I'm joined by Dr. Hilaree Milliron podiatrist with Atlantic Foot and Ankle Associates in Florida.
Dr. Milliron: 00:35 My name is Hilaree Milliron. I've been in practice for about nine years now. I'm in my ninth year. Originally I did not intend to be a podiatrist. I started exploring medical careers when I was in college and looking when I was in pre-med and kind of looking around the medical field with what suited my interests. I like to be busy with my hands a lot. So the idea of being, you know, just maybe a primary care doctor or someone that you know, kind of looks at computer and labs and says, Hey, you know, you know, take this medicine, I'll see you back in three months. And looking at lab values all day did not interest me in the slightest. I wanted to be busy with my hands and having a lot of diverse patient interactions throughout the day to make the day fly by. And that is exactly what I got in podiatry. So with podiatry I've been able to do anything from, you know, counsel patients on, you know, diabetic issues, complex infections, go into sports injuries and complex reconstructive surgeries of the foot. So there, the diversity is, I see it every day, every day, and I walk into a patient's room, it's a different room everyday and then the days fly by. So that's why I enjoy what I do. And, and I got into it. I knew I wanted to be in medicine to some degree, but I just didn't know what type until I started researching and found podiatry through a lady that I had chatted back in college and I saw it and I was like, Hey, this is pretty neat. And it suits my needs to be constantly, I guess, stimulated or you could call it to not get bored if you want to be frank.
Joe Crosby: 02:22 Absolutely. That, that seems to be a common theme, a common theme there with the, with several people I've spoken with, podiatrists I've spoken with where, you know, they started out one direction. They knew they wanted to do something in the medical field. They started out, you know, in orthopedic or something like that and you know, met a podiatrist. So that's where it always stems from. They met a podiatrist and, and that's just kind of where it seems to always STEM from, you know, and just fall in love with it immediately, almost. So.
Dr. Milliron: 02:46 Right. Being an athlete too and having a lot of injuries, did prompt me to look into it a little further actually. So I mean, I was thinking orthopedics or physical therapy or something like that. And then I started looking at podiatry and, and also you can, you can actually tailor your schedule to be whatever you need it to be at the time in your life. Like, if you want to do a lot of surgery, you can, if he wants to take call, you can, if you don't want to, you can find somebody to partner up with that can do the things that you don't particularly want to do or like to do. So works out really well.
Joe Crosby: 03:21 What we're talking about today is a tendinitis. And I know you've dealt with some, some tendinitis issues recently in the last year or so. And definitely wanna get into that. But you know, just kind of start out in a broad, a broad term here around tendinitis. What is a tendon and what is tendinitis, how are the two related?
Dr. Milliron: 03:42 So a tendon is a band of an elastic stretchy tissue that actually connects a muscle to a bone. So the tendons and your body throughout head to toe allow movement. So that's the primary function of a tendon is to move something, to use your muscle to move a bone or a body part. So tendinitis happens when you get a deterioration of the elasticity or the stretchiness of that tissue due to usually some type of wear and tear. Statistically people who are probably in their 20s or under do not get tendinitis. It's more rare. People who, you know, you start it based on personal experience. You, you get into your thirties and you start having these things happen, you know, wear and tear, it's going to happen to the best of us whether you're active or not. And so there are genetic factors associated with it. You can have, you know, really tight, strong muscles. You can have a foot shape that makes you move your foot or your body in a certain way that provokes something. You can have a job that makes you do repetitive things or an activity you like to do that has, you know, repetition involved that will make a tendon start to not do the things that you like it to do. And then, you know, it creeps up on you usually with pain or tenderness or swelling or something that then makes you think, okay, what's this?
Joe Crosby: 05:11 What are some of the symptoms that you see with a normal case of tendinitis?
Dr. Milliron: 05:14 Usually a patient would come in with some type of pain and the description can be a little different. Sometimes it's a pain that you know, is sharp that dulls and gets better with activity. Sometimes it's a pain that stays with you and does not go away. A lot of times that pain's associated with a particular emotion and that's what helps us define, you know, without things like MRIs, it helps us to get an idea of, okay, this may be what's going on with you based on different examinations. And the location helps us to decide what it might be. Sometimes you'll have swelling, sometimes it'll be, you know, something you can deal with and sometimes it'll be something that needs more acute treatment or ceasing your activity that you've been doing or something based on our conversations that we have that the visit will provoke certain questions by me. Cause if you come in and you're, for instance, you have a job that has you on your feet all day in certain shoe gear on a certain type of floor then I'll start asking you questions about that to try to figure out what it is without hopefully ordering too many expensive tests. Sometimes they're required. We will order x-rays. Sometimes you'll see bone spurs on an X Ray and that's another conversation we can have about the spurs. The spurs are not, they're not the problem. A lot of patients that come in and you see a spur on your x-ray or you were told you have a spur on your x-ray and everyone comes in worried about that and wanting that to be addressed. But the spur is actually the byproduct of the problem, not the actual cause. The cause is usually a tightness or a pull of where the tendon attaches to the bone. And what happens at that attachment is it pulls on the bone. You get little tiny, what's called a micro tear, basically a microscopic tearing of the tendon at that insertion point or where it attaches to the bone that gets inflamed and then it calcifies and it forms a spur over a long time. So it's not something that just suddenly came up and, and the spur is poking on something. That, but that's what people think. When you see something pointy, you think, okay, that needs to go away.
Joe Crosby: 07:27 What are some of the common things that could also lead to tendinitis?
Dr. Milliron: 07:32 Pretty much anything that requires a repetitive motion that's the same, like I run. So that is definitely a repetitive motion. A constant, you know, every step you take, you get a pull on, for instance, your Achilles tendon primarily to propel yourself forward for your next step. Or walking. You could be a speed Walker. You've got the same, you know, repetitive thing going on. It could be something with your job. Combined with muscle imbalances over time. You can acquire muscle imbalances from, you know, doing the same thing over and over again. And to be frank with you with this as well, no one stretches enough. Nobody knows what to do really with stretching until your body gives you some indicator of like Hey, something's hurting. You need to do something about it. So then we all, you know, start to stretch and try to do things that we really should have been doing all along to prevent tendinitis and other wear and tear issues, but no one really reacts. Or nobody is proactive. As much as we are reactive, we are always reacting to symptoms that we get throughout life instead of being proactive like we really should be, but no one does. And that's what we're here for. We're here to kind of get you back on track.
Joe Crosby: 08:55 Most people would, They're probably, they've probably heard of Achilles tendonitis or at least the Achilles tendon. There are other types of tendonitis out there. Posterior let me see. Posterior tibial tendonitis. I think you've, you personally dealt with is it paraneal tendinitis.
Dr. Milliron: 09:16 Yeah. And that's a thing. I'll talk about that in a minute too, about how, you know, you kind of have to do and, and I have not been doing what I know I should do to prevent, but on some level.
Joe Crosby: 09:27 Okay. So I guess what are the differences between these, these types of tendinitis and what would it be the most common ones you see on a day to day basis?
Dr. Milliron: 09:38 I would say the most common thing we do see as Achilles tendinitis, but the difference between them to answer your question is the location. There are so many tendons below the knee that we deal with and different muscles, the largest tendon is the Achilles tendon, but most people know where that's located. They've heard that in some point in their life and they know the location of it. The other two are more that would, you know, we mentioned them to the patient when they come in with a problem on either the inside of the ankle or the outside. And they've not heard those words before until we mentioned to them that, that that's a possibility. But the Achilles is most common. It's in the back of the ankle. The posterior tibial tendon is responsible for holding the arch up. So when a patient comes in and they have a collapsed arch or a flat foot, usually that tendon has been stretched a little too much and can get inflamed and start hurting. at some point. The peritoneal tendon is on the outer part of the ankle and it's the opposite. If you have a higher arch, your foot will turn in a little bit more and pull that outer tendon. And that one is more susceptible to getting inflamed, which is my personal problem. So I am currently dealing with that.
Joe Crosby: 10:54 We as a culture, we are a DIY culture. We want to try to fix something ourselves before we go and even, you know, go to a doctor's office. So what are some DIY or at home tendinitis treatments? And then once those don't work or don't work enough what would be the in office medical treatments for tendonitis?
Dr. Milliron: 11:14 So DIY things. Most people are pretty good to know that when you have something that's sore, R.I.C.E. Therapy is that Go-To you get rest, ice, compression and elevation. So a lot of people will put ice on it, you know, kind of stay off it or reduce the activity that seems to provoke it. Sometimes people put either some type of a brace or an ACE bandage or something on there and elevate if it's swollen. So it's those indicators of, of pain and swelling or your body telling you that something's wrong and you do have to listen to it. A lot of people will get on YouTube and look at videos of people doing different types of KT tape. That's a new, you know, a popular thing to do for any type of inflammation or joint support, muscle support. There are many videos, but I would caution you to make sure that you know what problem you're trying to address before you try to look up the appropriate taping method. Usually we'll guide you with what to do in the office by giving you first a diagnosis or what we think the diagnosis may be. And then kind of guide you on those things of what to do. Maybe show you how and strap you up in the office with KT tape or some other type of strapping tape and show you how to support it. And then you could continue to do that at home. But it's really based on the location. So rest, ice, compression and elevation are really the first first line of treatment. No matter what you're doing. We will tell you to do that when you come in here as well. The things that we will also tell you that usually is not what the athlete in particular wants to hear is that the activity that is provoking the problem needs to stop. That's usually not something anybody wants to hear me included. Because I was out from running for four months last year, about a month to listen to myself. You know, physician treat myself. It's kind of a, you know, always everyone laughs at that as physicians being the worst patients. That's true. So you stop the provoking activity, get with the program, you know, listen to your body. All the RICE therapy helps as well. The problem is is if you're doing your activity or whatever you know, is gonna irritate it and it gets better, you might be able to get by without completely stopping the motion altogether and you might get better with physical therapy and other non I guess life altering treatments, things that won't really stop you in your tracks. If your activity hurts more. If with more motion it gets worse, then that's usually something we have to go and immobilize you. That would be the treatment that we do probably most often. A lot of people try DIY things at home and come in when things get really bad, and when they get really bad, sometimes you just have to rest completely and we will put you sometimes in a boot and make the extremity not move at all just to give it a good rest and then see how that does over time. And give your body the rest of it to kind of, you know, craving at the time cause it's not working out to do the other things. But a lot of times if things are going badly, we will order more imaging. We will decide, you know, if that's the right thing to do or if we just want to rest you and then see how things do and then order more imaging that may or may not be more expensive based on your insurance plan. Sometimes we will decide to do that or not do it immediately based on what's going on. So every situation is very individual.
Joe Crosby: 14:52 You kind of already answered this one with, you know, by mentioning stretching, but you know, we're, we're deep into fall sports now. Football I think soccer might be, that may be a spring. But football especially is what comes to mind. So you know, for these athletes out there, that's, I mean, that's the one thing they don't want to hear is, you know, you gotta come off, you got to come off the foot. You've got to come off the field you know, for an extended period of time. But I guess what is one piece of advice you could give for preventing it, you know, whether, whether it's professional athlete, high school athlete or someone just out there walking their dog every day. What's that one piece of advice you would give to everybody? Just, you know, as far as that, that first line of prevention?
Dr. Milliron: 15:33 Stretching is really the key. So if you're really listening to your body, it'll tell you some things. You, you'll have a little tinge of burning or a little, you know, irritation or something that you've kind of like, Hey, what does that, and if you listen to it, you'll know, okay, that, you know, maybe I either need to warm up a little bit more before I do that. Or maybe, you know, try some of those, you know, KT taping things, you know, maybe, maybe just kind of, I mean, stretching would be the number one thing to increase. I would say to try to figure out, okay, where, where is it hurting? There are a lot of, if you even type in and you're doing a Google search, which I know can be, you know, scary, he'll type in something, they'll tell you something horrific and then you're scared. So then you can all Google and you say like, you know, pain in the back of my heel or back of my ankle, it'll kind of guide you to what's going on. And there's a lot of good information out there. It's not all bad and it's not all scary, but that would be probably the number one thing would be increasing your stretching. Sometimes we'll have you do, you know, like an oral anti-inflammatory, knowing that an oral antiinflammatory is not going to cure anything. It just reduces the inflammation or the pain it gets you by is what it does. So it's definitely not a cure. It just gets you by. And while you're doing the other good things, ideally, you know, the other rest, ice, compression, modifying your activity, all of those other good things to do. But alone it won't fix it. But I would say maybe that'll get you by, you know, until you're able to either, you know, take a good rest or get through your season or something like that. But when you're young if you, I would, I would caution if you do have tendinitis and you are young and you have, you know, football season, there might be a bigger issue to look into. So I would say come in for an appointment based on that, you know, just to rule out anything bad. Another thing that you can do that sometimes makes a huge difference is the arch support in your shoe to support those joints, reduce the alignment of the foot that may or may not be contributing to the pull of the tendon. That would be another good thing to have evaluated. So if a patient comes in and they have pain, we will often take x-rays to kind of look at the alignment of your foot and examine you to find out what may contributing to that problem that can be prevented. In addition to stretching. But the arch support is often, I guess some people do not see the value in it. Some people don't see the value of, you know, coming in and getting an x-Ray for a problem that they know they didn't fall and break a bone. So why are you x-raying my foot? We get that a lot. Well, it's because there are many contributing factors. You could come in with, you know, a high arch like we were talking about earlier and you've got, you know, the different bones that need supporting the way your foot moves when you're standing on it versus when you're sitting in my exam chair. Those are differences that can be accommodated in an insert and accounted for with different padding options and, and all kinds of other, you know, things that lead to other conversations that may make something make sense to you that didn't before.
Joe Crosby: 18:41 How bad does it really need to get before, you know, start to, start to talk about surgery?
Dr. Milliron: 18:46 Yea, tendinitis usually gets better with rest. So, I mean, usually you should exhaust all nonsurgical treatment options beforehand. So another treatment option that we did not discuss. There are some en vogue injectables that are related to both STEM cell injections and STEM cell inducer injections that are, are very popular nowadays. They're very expensive cause they're not covered by insurance plans. But they do have a place in this discussion because you've got of course your rest, your ice, your compression, your possible immobilization in the boot. Like we were talking about earlier that nobody likes to do that. But if you have surgery, you're going to be immobilized for quite a while. Probably at least a couple of months before you're allowed to start moving again based on some major tendon surgeries, especially the Achilles tendon, which if that tendon, I mean that is a surgery we never jump into lightly because the consequences can be high. The wounds healing, you know, in the back of that area can be slow. So if there's any other complicating factors, that would be a discussion that you would have with your surgeon. I like to make sure that the patient's not going to get better with anything else. Those injectables are, I had them done in my ankles, they are effective. How effective? We don't know. We can't give you a guarantee with it. And that's the difficult part of that conversation is that you know, you're gonna spend a lot of money on these injections, but I can't give you any kind of a guarantee. So but what the injections do is they recruit STEM cells, your STEM cells, to come to that area to help heal tendon with actual tendon tissue. So you've got regular tendon healing. So let's say that you've got tendinitis that tendon's pulling and it's tearing a little bit, but you don't have like two separate pieces. So you don't have an actual, you know, tear in two that has to be repaired. So you've got these little tiny tears throughout. So I always liken them to a piece of string cheese that you take like a little itty bitty piece of string cheese and you pull a little piece off that is gonna hurt a lot. You know, it hurts a lot to the point where you can't walk and just to have that little tiny tear, but the whole piece is still intact. So that would require, you know, for you to think about that and the amount of time that would take off for you to recover from wouldn't really make a lot of sense, you know? But if it's not torn in two it just doesn't require surgery. The body is amazing. It'll heal itself if you let it. But normally it will heal the scar tissue. So that opens up another can of worms because scar tissue is not as stretchy as the original stuff. So you've got that. It can heal with original tendon, which is you know, stretchy the original tissue. It's an ideal situation. So your tendon will heal. It'll just heal with scar tissue if you let it rest and do all those other things, which can be fine, but you might need physical therapy afterwards to get that stretchiness back. So there, there is a whole process to this and that's why, you know, we have many discussions with patients, usually several followup visits of, of what's coming, what's the next step. Because it is, there are multiple steps in the recovery from tendon issues because it's not like you come in, you get better, and then you just move on with your life. Usually when you have an issue with a tendon, you might have it again because we were all gonna forget when we don't have pain anymore. We're gonna forget to do all those things and those stretches are going to get put by the wayside because we don't have time for that today. You know, and it's going to be forgotten until you get another pain again. And then we're like, okay, now we're back. You know? And then patients get frustrated with that. I do too. But it's just one of those things where, you know, your, your brain prioritizes things and you're going to forget it. But in a perfect world, you'd continue to do all these things and never get it again. But you know, we're, we're gonna forget and you may have to be reminded every now and then to do those things by me. I will be honest with you and tell you I'm just as bad. I forget just like everybody else and things affect me just like they do everybody else.
Joe Crosby: 23:08 This will be my, the final question here, and this is always my favorite question to ask, but everybody seems to have a good, a good home remedy story. So what, what's the, this is, you know this, this, this doesn't have to be tendonitis specific, but what's the, what's your favorite or the, I guess it'd be your favorite or the strangest DIY or home remedy that you've ever seen someone do to themselves to, to, to fix something on their foot?
Dr. Milliron: 23:33 You know, I thought about this question and I couldn't think of just one, but I kind of wanted to turn it around because it's not strange. I mean, I don't call it strange anymore, but it used to be considered strange. But I kinda liked the idea of it. And then it seems to be controversial. I'm not sure why because CBD is very en vogue now and it seems to be helping a lot. I don't know if there are any and I don't if there are, I would love to know about them any long term, you know, studies on it that are being started on the oral CBD oil and how it's just reducing inflammation like crazy throughout the entire body. A lot of patients are using it and they're using what's called full spectrum which seems to have a higher concentration of the more effective components. But patients are getting some really good results from both that and acupuncture. So those two things are not to be discounted. I think some people still look at 'em like, you know, that, yeah, you're making that up or you know, that doesn't make any sense, you know, in the medical world. But I think it does have a place because there are things that, that we don't know and you can't, you know, we don't know everything. I can't ever tell somebody that they're wrong. They're, they're feeling something and it seems like it's helping. Then I say, Hey, go for it. Whatever. You know, there are some strange herbal remedies. I've it's some Chinese herbs that I didn't get the name of it, but so this will qualify as something strange, but it stains the whole leg red. So it looks kind of scary. Like you know, like I don't know, it looked like blood everywhere, but it stained the whole leg red, but supposedly, Hey, it was anti-inflammatory and it helps. So I was like, Hey, whatever, if you want a red leg, you go right ahead with that red leg. If you want to soak it in some red and you know, herbal, whatever it was go right ahead. If you can get past the whole thing that your leg is bright red.
Joe Crosby: 25:38 Well, I know we've talked, I've talked with a couple other doctors in, you know, there's the weird ones of wrapping your foot in cabbage and stuff like that. And people swear that it pulls inflammation out. So, I mean, who knows?
Dr. Milliron: 25:50 So it might be anti-inflammatory and like anti-inflammatory diets. I do not discount those either because I mean there, there are so many things that affect other systems in the body. And inflammation is a process that happens, not just, you know, down in our area, but everywhere for a variety of reasons and, you know, I'm sure if it's helpful down there, it's probably helpful throughout the whole body. You know.
Joe Crosby: 26:13 So you mentioned the full spectrum CBD. Is that something that, that doctors are actually prescribing now?
Dr. Milliron: 26:18 We don't prescribe it. It's available over the counter dispensed by certain individuals. I believe. I mean, if we wanted to, we could provide it in the office. For as a product that's for sale, but there are so many different opportunities to purchase it in different businesses. And I have been you know, they're, they're not all created equal is a buyer beware. So you have to kind of know what you're looking for. As far as the the full spectrum seems to be the most potent and the most people get more relief from that than they do anything else. The topicals, I would imagine would have more leeway and you know, the ins and outs and how much freedom they would have to make the product of different concentrations rather than the oil that you put under your tongue, that, that full spectrum. But that does go throughout the body and it might have interactions with other medications that you would definitely want to ask to her about that before you start taking it.
Dr. Milliron: 27:17 I want to thank Dr. Milliron for joining me today, and I wanna thank you for listening to the elevator podiatrist.