Experiencing foot pain? Why it's time to stop ignoring it

During my third appointment with Dr. Hartley Miltchin, I sat in a small, comfortable treatment room and turned one of Elvis’s black leather boots over in my hands. “You’re one of the few people who’ve gotten to touch that boot,” Miltchin informed me. It was a size 9, slightly worn at the heel, and appeared in Spinout, Double Trouble and Frankie and Johnny. Miltchin could tell just by looking at it that Elvis was a straight walker — and he could tell by looking at my feet that I am not.

Miltchin, a measured speaker with an easygoing manner and collar-length curls slicked behind his ears, has practised podiatry in Toronto for 29 years. The walls of his clinic are lined with diplomas, certificates and signed celebrity photos of the likes of Geraldo and Goldie Hawn, although he can’t disclose which are on his wall because they’re clients and which are there simply because he owns their shoes. (In addition to ministering to famous feet, Miltchin has amassed the world’s largest privately owned collection of celebrity footwear: 350 pairs worn by everyone from Madonna to Michael Jordan.) “Some people think I have a foot fetish,” he says. “But my thing is shoes.” He even has a giant Skechers sneaker suspended right above the reception area, like a sporty pinata at a children’s party.

I’d booked my first appointment with Miltchin two months earlier because my feet hurt. In fact, they’d been hurting for a while, but seeing a podiatrist had always ranked at the bottom of my list of appointments to make, trumped by trips to the doctor, the dentist and, I’m ashamed to admit, the hair salon. (I didn’t even see a podiatrist after breaking a toe during a windsurfing mishap a few summers ago.)

Ignoring foot pain is the normal human response, Miltchin admits, but not the right one. In fact, it’s akin to ignoring a mysterious rattle under the hood of your car. The trouble with foot pain — and engine rattles — is that they seldom go away on their own and usually indicate that something is very wrong and only likely to get worse.

In my case, sore feet had already led to a twitchy knee and sore back, not that I’d ever connected the three. “It’s the Tower of Pisa effect,” Miltchin said. “If the foundation isn’t solid, the structure above won’t function properly either.” Recent studies published in the Journal of Foot and Ankle Research have corroborated the connection between foot pain and issues higher up; one of the latest found women who overpronate (meaning your feet roll inward with every step) develop significant low back pain as a result.

“Most people’s feet turn in about three degrees,” Miltchin told me. “You overpronate slightly below average, so that’s good.” He was watching closely as I sauntered self-consciously down the hallway. This was the gait-analysis part of the initial appointment, to help pinpoint the underlying reason for my foot pain.

Why our feet hurt While I took in Miltchin’s foot-themed objets d’art during my walkabout, he was noting more than just my pronation problem. “You have a little spring in your step too,” he said. This turned out not to be a good thing. Miltchin produced a skeletal model of the foot, and the anatomy lesson commenced. On the bottom of your feet is a thick band of tissue, called the plantar fascia, which runs from heel to toes. “It’s not a muscle, tendon or ligament, so it can’t stretch,” said Miltchin.

When we walk, we land on our heels, then rise up on our toes, and all our weight is supported by this rigid band. “Sometime, usually in your mid-30s, it starts to tug,” Miltchin said. This pulling can cause micro-tears that create pain and inflammation, or plantar fasciitis, the most common cause of heel pain. “It doesn’t matter if you’re 90 pounds or 300 pounds, what job you do or what shoes you wear — everyone’s susceptible,” he said. “If you overpronate when you stand or walk, it means your body is unbalanced, which causes more tugging and a greater risk of heel pain.”

My springy walk was a factor too. “When you climb stairs, you’re on the balls of your feet, right?” Miltchin asked. “So your heels never touch the ground?” I’d never thought about it before, but it was true. “People who have a more rigid body type and less flexible calf muscles have a tighter Achilles [the], which I noticed when you were walking.” A tight Achilles may contribute to plantar fasciitis by putting extra tension on the fascia.

While Achilles tendonitis causes pain when you walk or climb, the biggest sign you might be suffering from plantar fasciitis is a stabbing pain in your feet when you get up in the morning. It usually goes away but may resurface after long periods of sitting or standing. Plantar fasciitis is also related to another foot problem: heel spurs. I had never heard of heel spurs, until Miltchin slid the X-ray he’d taken of my feet up onto a lighted screen. There, on the shadowy blur of my right heel, was a small, slightly curved piece of bone jutting out like a fishhook.

It looked as though it should hurt, but it didn’t. In fact, I would never have known I had a heel spur without an X-ray. “It’s just another sign that your fascia band is tugging at your bone as it tries to gain length,” Miltchin told me. “It ends up peeling away from the bone, and with that tear comes swelling and inflammation — that’s the part that hurts.”

And, as if that weren’t enough, it wasn’t the only thing sticking out on my X-ray. Just below the base of my big toes were two small bumps, the beginnings of (horror!) bunions. I tried blaming them on my mother, who can no longer tolerate fancy footwear of any kind, but Miltchin said I inherited my unbalanced gait, not the bunions themselves. Once again, the problem is the way I walk.

Miltchin settled himself on a stool by my feet and looked over his glasses at me. “Your bunions are not horrific — they’re just beginning,” he said. (I waited for the “but.”) “But they do get worse.” To illustrate, he tossed up the X-ray of another patient, a woman in her 80s. Whoa. Her X-ray showed four perfectly aligned toes, but her big toe jutted out to the side at an impossible angle. I wondered how the poor woman could wear shoes.

“Most people think bunions are bumps that grow on the sides of feet, but what you’re seeing is actually the head of the bone — it’s not something growing, but bone moving,” Miltchin said. “If you overpronate, when your heel hits the ground, your foot rolls toward the big toe as you propel yourself forward.” This is tough on the toe because, unlike straight walkers, overpronators hit their big toes harder every time they walk. “It puts extra stress on the toe joint and pushes it out to the side, so that the bones and joints become misaligned, causing a bunion.”

By this point I was feeling fairly despondent, so Miltchin tried to cheer me up. He explained that bunions are very common — even Marilyn Monroe had them (he could tell by her shoes, of which he has three pairs). Then he told me about the treatment options. “Most people think they can just come in, and I’ll shave off their bunions, and that’s it,” he said. “But that’s a myth — I only shave in the morning before I get to the office.” (Podiatrist humour.)

For bad bunions, the solution is a surgical one. If you go the conventional hospital route, Miltchin says, you may wait a year for a consultation with an orthopedic surgeon, then another one to three years for surgery. The surgery is done under general anesthetic and involves “filleting” the bone with hammer- and chisel-type tools.

Miltchin took a blue pen and drew a two-inch line on my left foot near the big toe to show how long the incision would be, then added train tracks to represent 20 stitches. “You may need one or more screws to hold the bone in place; you’ll probably need Percocet for the pain, and you’ll be in a cast for six to eight weeks.” He wasn’t really selling it, but there is another option: minimally invasive surgery. It’s a procedure Miltchin performs himself, in his office, under local freezing. “People don’t have time to be off their feet. This procedure takes 20 minutes, and you can walk out of the office and keep walking through the healing process.”

This time, his pen marked three small dots on my foot. “I also cut the bone in three places, but it’s precision cutting to eliminate the bunion and bring the big toe back into alignment.” Because the incisions Miltchin makes are so small, he uses a special instrument to guide him. Called a Xiscan, it’s a modified fluoroscopy device originally used to detect fuselage cracks at NASA.

To demonstrate its powers, he trained the thing, which is kind of like a large microscope with X-ray vision, on my shiny, silver-buckled boots. Cute and sensible, I’d thought when I bought them. “See how cramped your toes are in those boots?” Miltchin asked. Sure enough, there were the bones of my foot on the screen, and it was hard not to miss the fact that my baby toe was slammed up against its neighbour. A predilection for pointy shoes is another way to aggravate bunions, Miltchin said. “It’s like squeezing five cars into three parking spaces.”

After an in-office bunion removal, patients are fitted with surgical shoes for six weeks, and they return once a week for a fresh bandage. The only rules are no running or jumping, but you can still exercise on a stationary bike or elliptical machine. “In minimally invasive keyhole surgery, there are no stitches, no metal screws, no cast, no crutches, and you can take Tylenol for the pain,” Miltchin says. The problem is there are only a handful of podiatrists qualified to perform the procedure in Canada, which is why he sees patients from Whitehorse to Charlottetown, and many points in between.

Fortunately, my feet weren’t far enough gone to warrant surgery, minimally invasive or otherwise. But, left untreated, bunions can become so painful (and pointy) that they restrict the activities you do and the shoes you can wear. “I tell patients that bunions are not necessarily an emergency and don’t always require surgery; it just depends on how much they interfere with your life.”

Walk this way Although my heel spur is here to stay, to solve the rest of my problems — Achilles tendonitis, plantar fasciitis and how to prevent my bunions from getting bigger — Miltchin recommended what he called an “aggressive” orthotic (i.e., not the kind you can pick up at the drugstore). “Some doctors use physiotherapy, acupuncture or cortisone injections, which are all nice treatments and may reduce the inflammation, but they don’t solve the underlying problem,” he said. “What we need to do is take your foot from rolled to straight to stop the tugging and heal the plantar-fascia tear.”

In the old days, orthotics were bulky, ungainly things you automatically associated with elderly people shuffling around in tan loafers. Not so anymore. These days they can be as thin as a couple of millimetres and fit discreetly into any shoe. You just want to ensure they’ve been made specifically for your feet, because, Miltchin said, everyone pronates differently.

“Orthotics are to feet what glasses are to the eyes — they put things in better focus. But if you don’t have them custom-made, it’s like putting the same scrip in everyone’s glasses.” Orthotics cost between $500 and $700, and although they need to be replaced every one to three years, it’s better than the $4,000-plus price tag for bunion surgery. I opted for orthotics. Miltchin obligingly made plaster casts of my feet and sent the casts off to the lab.

Three weeks later, my orthotics arrived, one thin pair with the heel cut out for everyday shoes, and one full orthotic to provide more stability and shock absorption in my running shoes. I was told I’d need to buy new runners. Miltchin scrawled “Neutral shoe, no motion control” on a small square of paper. (The problem with the built-in motion control common in athletic shoes is that it’s a one-size-fits-all solution that is actually of little benefit to the wearer and could decrease the efficacy of the orthotics.) Finally, Miltchin put me on a wearing schedule, building from 15 minutes a day, so I could relearn how to walk. “You’ve never walked balanced in your life before, so it takes a little getting used to.”

So . . . don’t forget your feet Miltchin was right: I was quite conscious of the orthotics in my shoes at first and found it actually a little tiring to have to walk properly. But within about a week, I didn’t notice them at all. In a recent study, researchers at the University of Salford in Manchester found orthotics relieved back pain after just 16 weeks, so fingers crossed. After a month of wearing them, I went back so that Miltchin could check my progress.

My one regret is that I didn’t visit his clinic years ago, when my feet first started hurting. “People think it’s normal to have foot pain,” Miltchin said. “But it’s not. And trust me, if a bump started to grow here” — he pointed to his cheek — “you’d be in the same day.” Still, I’m happy with my new orthotics, and I hope that in addition to relieving my foot/knee/back pain, they’ll also help prevent me from having misshapen Marilyn Monroe feet. With luck, I’ll be walking as straight as Elvis in no time.

For more, see the five things Miltchin says you should do to improve your foot health.