Healthy Feet Are Happy Feet
February 03, 2010
By Dr. Brigette F. Kuhn
DR. BRIGETTE F. KUHN
Chief of Podiatry at Hawaii Medical Center
Where did you receive your schooling and training?
I did my undergraduate work at DePauw University in Indiana, where I received my bachelor’s degree in chemistry. Then I went to Ohio for medical school and attended Ohio College of Podiatric Medicine. From there, I went to do one residency in Connecticut at the Newington VA. Then I came out to Tripler for a second residency in lower-extremity surgery.
Do you have a sub-specialty?
I do general podiatry, which encompasses all foot problems from heel pain, bone spurs, trauma, bunions, hammertoes, dermatitis, tendonitis, nail fungus, corns, calluses and dry/cracked skin to gait abnormalities. However, I see a lot of diabetic patients, which is my sub-specialty.
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Can you talk about diabetes and how it affects the feet?
Unfortunately, diabetes is a problem that affects the entire body. Many patients with diabetes lose the feeling in their feet. They become more prone to developing ulcers. Circulation also may become diminished in some patients, and they don’t heal as well. This gives them higher chances of amputations. Limb loss is a big thing that can result from circulation problems.
With circulation loss, are the feet usually the first to be affected?
That’s pretty much it. Because it is so important to check, I have a technician come into my office to do circulation testing, which is recommended to be done once a year for the diabetic patients, unless problems are found where I want to re-evaluate. Insurance companies also are now starting to cover diabetic shoes, which are shoes that are made wider, with more room for the toes. And we also can get customized inserts to go inside the shoes to remove pressures from the foot. Little changes like that are huge.
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So should all patients with diabetes see a podiatrist regularly, or only if they experience problems or complications?
According to the ADA (American Diabetes Association), it is recommended that diabetic patients see a podiatrist (who has also done a residency in podiatry) and an eye doctor at least once a year, unless a problem is found, or more often for callous/toenail/ulcer care. In those cases, we follow them more closely.
Besides circulation, can you explain what else you look for in an examination?
I complete a full lower-extremity/foot exam, where I check the nerve sensation, musculoskeletal, circulation, dermatology/skin, toe-nails and gait. A lot of patients because of the diabetes often have difficulty cutting their nails because fungus can get into the nails, making them really thick and hard to cut. It is really not recommended that diabetic patients cut their own toenails because chances of infection are higher, as well as possible slower healing.
Aside from the problems you often see with diabetic patients, what other common problems do patients come in for?
I see and treat anything that affects the feet. A lot of symptoms present are aggravated (not necessarily the cause) by the type of work we do, what kind of shoes we wear, our activity level, being overweight and not taking care of our feet. I see quite a bit of ingrown nails. And even a lot of coral and sea urchin stuck in the foot.
Of these problems, which are preventable and how?
As far as bunions and hammertoes, those are usually due to heredity. You inherit your foot type, but they can get worse over the years and can become more problematic, depending on the type of shoes you wear. Most of the time it does not develop just because of the shoes you wear. Ingrown nails can be prevented mostly by the way the nails are cut. You need to cut them straight across, making sure that you see the end of the nail. A lot of times people only cut what nail they see. Often times, a little piece of nail is hidden under the skin, and that can be a sharp edge that drags against the skin itself, causing irritation and an ingrown toenail. However, if the toenail shape changes or becomes incurvated, this needs to be addressed differently by a podiatrist. For heel pain, people should wear supportive shoes and make sure to replace shoes once the sole wears down. Worn soles causes gait changes, resulting in abnormal stresses and symptoms. If this does not help, a gait problem may need to be addressed by a podiatrist. And I always recommend that patients check their feet and shoes every day.
Are toenail injuries that result in the nail blackening and falling off common? What causes that to happen? It is common, and a lot of times it is caused from some kind of trauma. Ill-fitting shoes, where the shoes are too short, the toe box is too narrow or your nail is too long can injure the nail plate and cause blood to build up, and the nail can actually lift up. You know when a marathon or a longer run happened because they start coming in with black toenails.
So the only way to prevent it is to get shoes with the correct fit?
Yes. But even a small thing like having a seam in your sock at the wrong place pressing on your nail for some time can cause trauma, because there’s not much skin between the nail and bone. But if you lose a nail, another one will grow in. It just takes time.
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If the nail is black, do you usually recommend that it be removed?
I like to leave it on as long as it is not loose or there is no gap, because if the nail is loose it can be ripped off, and if there’s a gap bacteria can get under the nail and cause an infection. This is just like a blister: Most times you want to leave it alone, unless it is causing irritation, then it should be tended to differently.
Since you started practicing, have there been any new treatments or technologies that have really helped provide better care for your patients?
The main one is just refining the types of surgeries, so many procedures are now less radical, and different approaches to symptoms. There are less traumatic techniques of doing the surgery, which results in a shorter duration of healing time. Many surgeries offer less-invasive techniques with smaller incisions. I also like to incorporate physical therapy in a lot of my treatments because it may help patients recover faster. My goal is to develop a treatment regime with the patient that will help him recover faster. It is absolutely important the patient participate in the treatment regime for best results.
Is there anything on the horizon within the field of podiatry that will further the treatment of patients?
The podiatrist’s focus and specialty are becoming more well-known. Patients are being referred to podiatrists sooner - this is helping patients get back to work faster because their primary care physicians are now utilizing our specialty more. And this is so beneficial, especially for diabetic patients. Prevention is key. I’d rather see these patients often to prevent problems rather than once the problems occur and get out of hand. So it’s mainly the fact that primary care physicians and patients themselves are utilizing podiatrists more. This is the biggest thing.