Episode Transcript
[00:00:06] Speaker A: Hi, I am your host, Deena Coleman, with aging in America with parent projects. We are back with Doctor Richie, and I could not be more happy. She is not only a brilliant doctor, but a friend, and it's so nice to have her in studio with us.
Our last episode with her was all about fall prevention, ways to prevent it and really get to the core with your aging loved ones on could this be something they're at risk for? So please go back and listen to that one. I think you will learn a lot on not only ways to prevent it, but really, are you at risk with your loved ones? So thank you for that. And as we jump into this one, let's kind of just jump in. I know we're very excited to talk. We've been talking off air. So go ahead, tell us about arthritis, which is our subject we're starting with.
[00:00:53] Speaker B: Yeah. So thank you again for having me. It's always fun to come and provide patient education. It's absolutely something that I'm very passionate about.
And arthritis is a topic that we had kind of figured would be resonating with a lot of your audience, maybe even some of the adult children.
And I think one of the most important things with any foot pain that people experience is to realize that some foot pain can be, I'll say, expected, but it's not necessarily normal to have.
[00:01:20] Speaker A: Pain, which I think is very important. Sorry to interrupt, but that alone, I think, is hands down one of the most important lines. Because then you're saying, just because you're getting older doesn't mean you should have this pain.
[00:01:34] Speaker B: Right.
[00:01:34] Speaker A: Okay, keep going. Because I think that is so important.
[00:01:36] Speaker B: And sometimes, you know, we'll have patients come in, like, I'll have patients come in, usually somewhere between the 60 to 80 range. And there is something that's now getting progressively worse. It's kind of a slow, chronic build pain that now is starting to limit daily function. Like, ah, I can't do the things that I love to do initially, but now I can't even get up and go to the mailbox and go to cook my dinner without getting this pain. And so helping get the answer for what's causing that pain is really important. Unfortunately, sometimes it's arthritis.
[00:02:09] Speaker A: Yeah.
[00:02:09] Speaker B: We don't have great treatments for arthritis yet.
The medical world is working very hard on regenerative therapy and some options for cartilage replacement, but we're not quite there.
[00:02:19] Speaker A: Okay, good to know.
[00:02:20] Speaker B: Yet again, it's emerging. There's a lot of it that's happening that we don't have the evidence on yet, but we can talk a little bit, maybe about some of those things. But anytime I have a patient coming in, the things I think that are really important is there are lots of simple things we can do to help improve pain, maybe eliminate, but I very rarely will promise cures, but improve pain and improve function. So if we can do those two goals, and this is where getting to know what is your goal? If it's, I want to be able to go golf. All right, well, let's figure out what is it during golf that really causes the most disaster or pain? Something as simple as x rays can give us a lot of information. Most podiatrists and foot and ankle surgeons will have x ray in their office available that they don't have to send people out to, then have another appointment to then go through those things. And so we can usually get answers pretty much right away.
Sometimes patients have pain that they think is arthritis and it's not. There's something bigger or something maybe more dangerous that's happening. So those, again, anything that is pain in the foot and ankle, have it checked out because maybe there's something else going on.
[00:03:26] Speaker A: Yeah. And I feel like it's one of those things where, why wouldn't you, I know it's not always easy to get to doctors or you want to, let's be honest, get to a doctor. But if you are experiencing foot and ankle pain, which we talked about in the last episode, is truly kind of your, everything. It's your way. You're getting around and walking and doing things. Yeah. Like, like Doctor Richie said, let's get that looked at.
[00:03:49] Speaker B: Yeah.
[00:03:50] Speaker A: Right away, if you can.
[00:03:51] Speaker B: And there are options for helping with arthritis, but some of the symptoms that patients will experience. So if we talk a little bit about what arthritis is, arthritis is when the joints, the cartilage in the joint starts to wear out. The one we're going to kind of focus on today, it's kind of the wear and tear arthritis osteoarthritis, which is most common in the foot and then in the ankle. We actually don't see as much wear and tear arthritis more often. We'll see post traumatic arthritis. So last time we talked about falls, fall risk. Again, I'm very big in the advocacy role of prevention, but what do we do if your parent fell? We know that unstable ankle fractures, and again, they're outside of the scope of today's conversation, but an unstable ankle fracture really does need to be addressed with surgery.
[00:04:39] Speaker A: Okay. Thank you. I was gonna ask for that. That's good to know.
[00:04:43] Speaker B: Yep. Very much like hip fractures. We know that, unfortunately, the morbidity associated with fractures in our elderly patients is really high. And where that morbidity pretty much rests, the body is built to move. Movement is medicine. Movement is life. And so if you have an unstable ankle where the joint is literally, you're not able to stand and walk on it, then, unfortunately, your ability to recover drops dramatically. And when you can't get up and recover, unfortunately, the prognosis for how long you're gonna live starts to also go down. And we've looked at this with evidence based medicine and studies, and it's been very clearly delineated that patients do better with surgery. This is also something that I'm very passionate on, more in the provider side and lecturing in conferences about high risk management of fractures and ways that we can improve outcomes for our patients. So we know that data, we know what the options are for today's conversation, focusing on your parent. They fall. They have a fall. What do we do now? Right.
[00:05:42] Speaker A: So that's always the question, what are the next steps?
[00:05:45] Speaker B: And so it gets scary. Like, wait, my parent is 78. Why are you gonna do a surgery on them? And again, that goal is, look, I wanna get your dad up on post op day one, and obviously supported with appropriate devices.
[00:06:01] Speaker A: Yeah. You're not sending them home on saying.
[00:06:03] Speaker B: And we wanna get them to a recovery point where they're able to walk and live their life.
What is difficult about fall, specifically, is once you come through the hospital, you get admitted for your fracture, you have a surgery.
The ability to go home is highly variable, depending on upper body strength, overall health, what your home environment is like. When I practice in San Francisco, we would have patients that had 18 steps to get into their home, and then it's a multi split level. Not every patient will get to go home right after surgery, but hopefully, and again, Noelle talked about this too. We have a short term bridge to something like a skilled nursing facility. Build up that strength, since we didn't have the opportunity to do that ahead of time, because a fall is unpredictable, and then we kind of get a rehab back to the home when patients come in with arthritis. So let's say they fell in their forties and they recovered, and they had a surgery then, and they're healthy, but their ankle joint wore out, because we know that that is the long term repercussion, an injury. We damage the cartilage, the cartilage is going to wear out. And now they have arthritis.
What happens sometimes with arthritis is you can start to get asymmetrical wearing so the joint doesn't wear out evenly, but you can actually start getting tips in the ankle. And so you can imagine if you're standing on a platform that's tilting you to the side, that starts to change the way you walk, that can affect your hip, your knee, your back, everything starts to. And, you know, you deal with this all the time, too.
[00:07:37] Speaker A: But even for everyone else, I'm like, oh, gosh, I can just see this change in people.
[00:07:41] Speaker B: And unfortunately, patients are scared. I don't want to go through surgery. And that's fair. And I'm definitely not wanting to push surgery for our elderly population. But I do think it's important with any treatment decision, patients are going to think about. I love the acronym brain. So, benefits, what is the benefit of this surgery? Or let's just say intervention. Cause it could be anything, right? What is the benefit? What is the risk?
What are the alternatives? So if I don't do it, what else, what else could we do instead?
What is your intuition? This is my favorite one. We all know about risk, benefits, alternatives. That's pretty standard in medicine overall. But I loved this one about intuition.
[00:08:21] Speaker A: Me too.
[00:08:22] Speaker B: What does your gut tell you about what this other person is saying they can provide? Because if your gut response is, no, this doesn't make sense to me, I don't like this. I do think patients should listen to that. But then the other important follow up is not now.
[00:08:37] Speaker A: So that's the answer.
[00:08:38] Speaker B: So if I don't do this thing now, what's going to be the long term complication or side effect or thing that will happen? And so if we take that and we think about a fall, a traumatic ankle fracture, what is the benefit? Okay, we want to get you up and walk right away, and we can't do that with your ankle joint completely unstable. You know, we're gonna put various types of fixation in, put you in a cast, hold it steady, and you can at least use it to pivot, transfer, get to the toilet, kind of do the surgery.
[00:09:05] Speaker A: You're activities daily getting you in your home.
[00:09:08] Speaker B: Exactly. What is the risk? It's surgery.
[00:09:10] Speaker A: Yeah.
[00:09:11] Speaker B: You don't wanna minimize the risks of surgery. Are there opportunities to do that through less invasive opportunities? Again, that's a discussion for independent fractures and independent providers. Alternatives. The alternative would be a cast. What's the downside? The cast you can't walk on because you're unstable. And so now we're changing your treatment algorithm completely. Now, you are not able to put any pressure on it. So now, if you're trying to pivot just to the toilet and you can't put that other foot down and you fall again, now, maybe you broke a hip, maybe you broke your arm. Now, you can't use crutches. Now you're bed bound. Right. Like. And unfortunately, we watch these devastating things happen to people, and so, to me, that's not a good alternative. Right.
[00:09:54] Speaker A: I was gonna say that just. And it happens. You're not exaggerating. So when you say that, it really is like you're risking taking all these other things on when we understand there are their own risks to surgery, but it could be the easiest solution.
[00:10:10] Speaker B: Right?
[00:10:10] Speaker A: Yeah.
[00:10:11] Speaker B: And it's also fair. Again, this is very case by case.
[00:10:14] Speaker A: Yes.
[00:10:14] Speaker B: And there are gonna be patients that maybe are already bound to a wheelchair. They're not very healthy, medically, anyway. So then we have to ask, well, what is the benefit of getting them up and walking right away when they don't get up and walk right away anyway? And that is a fair answer. And that, I think, is, again, very specific, and I think there are plenty of surgeons that would absolutely agree. Maybe the benefit of surgery here really isn't that good, and we treat it with a cast, knowing that that could.
[00:10:41] Speaker A: Be a great solution.
[00:10:43] Speaker B: You're already in a wheelchair. What is the benefit that we're really trying to provide? So, again, I really like that algorithm or the acronym brain.
[00:10:50] Speaker A: I loved it.
[00:10:50] Speaker B: I never heard that before. I actually, my own procedure, someone had said it to me, and I was just like, I've been talking about rbas forever, and I've never had the I and the n. And those are so important.
[00:11:01] Speaker A: Well, I think, too, as a woman and as a mother, I always, always say, trust your gut. Trust your gut. And I really believe. I do believe this, that we really have this mother women sense. And so I think I. It really is it. You're in with this doctor. Do you believe what they're saying? And I think that really comes into play.
[00:11:22] Speaker B: And you want to have a comfortable rapport with your physician in whatever specialty you're working with. And I think it's. I'm a huge proponent of second opinions for patients. If they feel like, okay, I don't know, something's not really resonating. Something maybe doesn't make sense. Go get another opinion. See if it's the exact same recommendations. Again, there are more than one way to do things, so you may get a different solution, but maybe that solution resonates better with you. So I don't think that that's a bad thing, but it can complicate it, because now you have two solutions to choose from.
[00:11:54] Speaker A: Right. And at that point, you really are choosing. You don't even know where to start, really. And I get the second opinion, and I do believe in it as well, but. Right. Like, to your point, you really are. Like, well, now what do I do? Yes.
[00:12:06] Speaker B: Or even having a sounding board. Like, I've had patients where a vascular surgeon is recommending something for a particular reason, and the patient's like, ooh, I don't know about this, and they'll ask me about it, and I'm not a vascular surgeon, but we are dealing with something in their lower extremity that the vascular system affects. And so I can give them my opinion about how it would make sense or kind of support another opinion or provide maybe a different insight. Like, if you're not feeling comfortable with it, let's get another opinion from another surgeon in that regard and see what they say, because it's not my area of expertise, and I'm not really qualified to answer those.
[00:12:42] Speaker A: But you'll hear the question and you'll want to discuss it, and it makes.
[00:12:45] Speaker B: Sense to me as your foot ankle surgeon, but let's maybe get another set of eyes on there.
[00:12:51] Speaker A: So many doctors that go into these lower extremities.
[00:12:53] Speaker B: Oh, it's crazy. Yeah.
[00:12:56] Speaker A: Okay, so a little thing you touched on I'd like you to touch more on was well before we got on the air, but gel, the gel phenomenon, because I mistook what this is. So I would love for you to explain it. Yeah.
[00:13:07] Speaker B: So, oftentimes, arthritis will present slowly, and it kind of starts with that. It takes a while to get moving, to gel. It takes a while for those joints to kind of get fluid.
[00:13:19] Speaker A: And you mean this every day? Every morning. Every morning. I just want to make sure. Every morning. Got it.
[00:13:24] Speaker B: And sometimes, too. Then you get moving. You're good. And, like, I've had patients tell me I can't stop because if I sit down for a while, it takes me 30 minutes or more to kind of get gelled again and get moving.
And again, unfortunately, as the cartilage starts to wear out, there is some swelling and there is some stiffness that will present. But movement is good for joints. And so actually, what we don't want to do if you have arthritis is say, stop being active. But what happens is it hurts. You're literally grinding the cartilage off.
Patients are like, look, doc, I know you want me to walk x amount of steps every day. But it hurts. It can't.
[00:14:04] Speaker A: It's that dumb, really?
[00:14:05] Speaker B: Yeah.
[00:14:06] Speaker A: Yeah.
[00:14:06] Speaker B: So then what are the alternatives? What can we do? And there are lots of solutions that, again, something as simple as an orthotic device, which is an insole that we can create either for the patient specifically.
[00:14:17] Speaker A: We brought some. And Doctor Richie, you have some insults to show us. Yeah.
[00:14:21] Speaker B: So we have lots of different options. And again, this is very specific, patient specific. So consult your healthcare provider to kind of get the most appropriate recommendation for you. But when we think of orthotic devices, which, again, this is one kind of example of what they kind of look like, you can get functional orthotics, and you can get accommodative orthotics, and they do have two very different goals. So a functional orthotic is actually going to help support the function of the foot.
[00:14:49] Speaker A: Okay. Makes sense.
[00:14:50] Speaker B: Very much like eyeglasses.
[00:14:51] Speaker A: Okay.
[00:14:51] Speaker B: As soon as you take them off, they didn't change your vision. They're not working. But when you use them, they help support, improve you. And so a custom molded functional orthotic is going to be designed to help the foot function in specific ways. Depending on your specific pathology, where your foot is not functioning proper, there may be a lot of things that need to be built into it. But if you have a pretty normal foot type, some patients actually would do really good with an over the counter orthotic. And so the ones that I think are really useful, again, we can put a list of some options.
[00:15:24] Speaker A: That's what I was there to say. They'll be on our website when we air the episode because there are some.
[00:15:29] Speaker B: Really great over the counter products now. But what's hard is you won't have me standing there to be like, this one's not worth $50. This one's not worth $20. So the key features of a good over the counter orthotic is you want something functional, is you want something that you can't just bend it with your hand.
[00:15:46] Speaker A: Okay.
[00:15:46] Speaker B: So this actually has some rigid. You can feel that.
[00:15:49] Speaker A: Yeah.
[00:15:49] Speaker B: Has some good rigid support to it.
[00:15:51] Speaker A: I know I have black shirt on.
[00:15:53] Speaker B: Yeah, I realize I have a black jacket, too. Versus something that is accommodative over the counter. So these are based off of a generic foot, off of a shoe size of an average foot with this. But you can see this one. I can take it and I can squish it. I can literally, like, ring.
That one is much more firm.
[00:16:10] Speaker A: Yeah.
[00:16:11] Speaker B: So accommodative is meant to just support the structure that you have. But you can see there's a little arch that's kind of built into there to kind of help.
[00:16:19] Speaker A: And is that the same thing here?
[00:16:21] Speaker B: Exactly the same.
[00:16:22] Speaker A: Okay.
[00:16:23] Speaker B: But what we have to have with either of these over the counter devices is a relatively normal arch.
[00:16:29] Speaker A: Got it.
[00:16:30] Speaker B: Which some patients don't have, especially elderly patients, because not only they may, they have a really flat foot or a really high arched foot, but they may also have some arthritis where their foot is rigid or stiff. So if I put them in this over the counter device and they have a really rigid flat foot, that is only gonna hurt. Not worth your $40 or $50 or whatever it is, or, heaven forbid, more. Yeah, in my opinion. This is only an opinion. Anything over the counter that's more than.
[00:16:55] Speaker A: 50, $60, it's probably not worth it at that point. Would you say get a custom? Yeah.
[00:17:01] Speaker B: Yeah. Invest in a custom because it's not custom. And so what you're really getting, it's not really worth more than about $50. Again, it's an opinion you can do.
[00:17:11] Speaker A: No, and it makes sense, though. Like, you are spending money that's absolutely $50 over the counter.
[00:17:16] Speaker B: Absolutely.
[00:17:17] Speaker A: I don't know the cost of custom, but if you're going to be spending 50, 60, $70.
[00:17:22] Speaker B: Yeah.
[00:17:23] Speaker A: It may be worth it to go that route.
[00:17:25] Speaker B: Absolutely.
[00:17:25] Speaker A: Yeah.
[00:17:26] Speaker B: And it's important to note, too, that Medicare does not cover custom orthotics.
[00:17:30] Speaker A: That's interesting.
[00:17:31] Speaker B: So it would be a cash pay service.
The other things, if you have flexible spending accounts, health savings accounts, you can absolutely use those on medical devices such as orthotics. But there are very few exceptions to why that would cause. Usually, even with secondary insurances, if it gets denied, typically they deny it across the board. So I'm gonna make a sort of general statement that Medicare does not cover custom.
[00:17:54] Speaker A: I think it's safe to say that for that. Yeah.
[00:17:57] Speaker B: So again, just so that families know.
[00:17:58] Speaker A: Kind of what going in, and so.
[00:18:00] Speaker B: You can also call and you should get rates because there are differences in what different places will charge for custom.
[00:18:06] Speaker A: Well, I think that's kind of like what we touched on last episode, calling your, your local home health agency. There's no harm in doing the same with this. I mean, truly like, it could, I don't know, again, the cost. But if we're saving $30, I don't know, but why not check it out?
[00:18:22] Speaker B: Right. And I like to give patients a very realistic discussion about where they spend their dollars that they're paying out of pocket, because you could spend, you know, $400 on a custom orthotic, or you can invest in a really good shoe. So let's talk about shoes, because I have to say, the simplest thing is just getting better shoes. Now, good shoes aren't cheap.
[00:18:44] Speaker A: Correct.
[00:18:45] Speaker B: But a really good shoe can go a long way.
[00:18:47] Speaker A: I was just gonna say, I feel like you're right. They're nothing. Probably cheaper than if you were to do surgery or $400 for orthotic.
[00:18:57] Speaker B: Because the other problem with this is this is only going to be as good as a shoe that someone's willing to put it in.
[00:19:03] Speaker A: Yes.
[00:19:04] Speaker B: Even ones that we can make that are, you know, slimmer and maybe three quarter length. You know, there are things we can build into it to accommodate more types of shoes. But you still have to put it in your shoe.
[00:19:14] Speaker A: Yeah.
[00:19:14] Speaker B: And so if you step. Aren't going to do that, then they spent a bunch of money on something they're not using.
[00:19:19] Speaker A: So give us some shoe brands. Or is there maybe not brands, but is there something we should be looking for for aging loved ones?
[00:19:26] Speaker B: Okay, we're gonna do. I call it not me, but, like, they call it the three point shoe evaluation, because now there is so much better shoe technology. There are a lot of excellent brands out there that there isn't just one brand that I would recommend. There are multiple. So. But again, I won't be there standing with you when you're shopping with your loved ones. So. And not every brand, I don't want to say, resonates, but not everybody loves the same brands. So the things you want to look for, three. Three key things. The heel counter. So when you check the back of the shoe, you want something that gives a little resistance. So this one's not that resistant. Like, I can squeeze it pretty good, but it's not one that's totally, like, I can't totally flop it in there. Like, there is some resistance there.
[00:20:08] Speaker A: Yeah.
[00:20:08] Speaker B: To support the back of the foot, or what we call the hind foot.
[00:20:11] Speaker A: Okay.
[00:20:12] Speaker B: The other one is going to be torsion. So you can take the shoe and you can try to twist it. You know, can I wring it out like a towel?
[00:20:17] Speaker A: And we want. That depends.
[00:20:19] Speaker B: Okay, so. But you want to get a gauge on how much flexibility the shoe has. So if you have weak ankles and you roll your ankles all the time, you have instability. Again, for your parents, where they get a lot of ankle sprains or in their life, they've had a lot. You don't want a super flexible shoe because we do worry that it's possible that you could not have the support in the shoe that you need. This is, again, where a lot of this is going to be very patient specific, but you can get a gauge for how flexible the shoe is. The most important one, in my opinion, is the push down test. So you'll take the shoe and you want to push down. Let's see.
[00:20:55] Speaker A: Bring it closer to me.
[00:20:56] Speaker B: Push down where you want to see. Can I take the back of the shoe and touch the toe? They're all going to bend at the toes. So this is right where your first joint should be bending. That's normal. When I push with all my weight, I can't collapse this area, which is the arch right where those laces are. This area is stable, so that gives good support. Oh, a lot of shoes right now. You can just fold them in half.
[00:21:25] Speaker A: I was gonna ask you, is this something we really will notice?
[00:21:28] Speaker B: Absolutely.
[00:21:29] Speaker A: Wow.
[00:21:30] Speaker B: And most especially our elderly patients, a lot of them just need better support. So I'm okay with a shoe that has a little flexibility as long as.
[00:21:38] Speaker A: It has better support.
[00:21:40] Speaker B: Because the other problem is if you start to get a really rigid shoe, that everything is really, you know, all three of those things are tight and not.
[00:21:47] Speaker A: You're not comfortable.
[00:21:48] Speaker B: They're not, maybe not comfortable. Kind of heavy.
[00:21:50] Speaker A: Yeah.
[00:21:51] Speaker B: And so again, if you have Parkinson's, you have more of a shuffling kind of gait. You don't want a real heavy, clunky shoe because that could lead to faults. So that's where it's necessarily there. But those three, the most important one again, to me is the push down. You want that shoe to have a little arch support.
[00:22:09] Speaker A: Well, Doctor Ritchie, I again, am just blown away by how much, you know, that visual alone, I think is going to help so many people when they are giving advice or helping with their aging loved one. I never knew that. And now I feel like that's all.
[00:22:22] Speaker B: I'm going to watch for. My husband walks around the shoe stores now and he does that and he's like, people keep looking at me funny. I'm like, don't even worry about it, just push down harder. Yep.
[00:22:30] Speaker A: Test it. You can't worry about that. We got safety to think about.
So for those who are listening and maybe watching, if you do go to our YouTube channel, arantprojects, you can actually watch this whole interview again to see what we just, or we, Doctor Richie just did with the shoe. I think that is incredible. So thank you again, before we leave, anything we missed, I know there's so much. We could talk about anything, what we talked about. You want to just kind of recap?
[00:22:58] Speaker B: The last thing that I just want to touch on is, again, the stability idea. If your patient or your parent has deformity, sometimes like a significant flat foot deformity, so much that the ankles are starting to roll in, they're unsteady. Maybe they're getting ankle arthritis because of the wear and tear of the position of the foot. Sometimes they may need more advanced bracing, like something like an AFO device. Again, these are custom molded, but as an alternative to surgery, which again, a lot of times, knowing what all your options are, this can provide a lot of stability. Where your patient again, or your parents, they can put this on. We can do it with Velcro, we can do them with laces. Noelle talked about the grabbers to help get some of these things on and off, but stabilizing the foot and the ankle to help reduce pain, improve function, lots of opportunities that we can intervene to keep your parents safe. I love it. And keep them active.
[00:23:49] Speaker A: I love it. I love it so much. Well, thank you so much, friend and doctor, for being here and for sharing your time, talents and treasures with us. Incredible.
[00:23:58] Speaker B: Thank you so much for having me.
[00:24:05] Speaker C: Well, that's it for the team this week, and thanks for joining us. If you've enjoyed the content, remember to subscribe and share this episode on the app that you're using right now. Your reviews and your comments, they really help us expand our reach as well as our perspectives. So if you have time, also drop us a note. Let us know how we're doing for tips and tools to clarify your parent project, simplify communication with your stakeholders and verify the professionals that you choose. You can find us on YouTube. Follow us on Instagram and Facebook. Thanks again for trusting us until our next episode. Behold and be held.
[00:24:37] Speaker A: Thank you for listening to this parent projects podcast production.
To access our show notes, resources or forums, join us on your favorite social media platform or go to parentprojects.com.
this show is for informational and educational purposes only.
Before making any decisions, consult a professional credential in your local area.
This show is copyrighted by Family Media and Technology Group, Inc.
And parent projects, LLC.
Written permissions must be granted before syndication or rebroadcast.
