Episode 53: The Heart-Foot Connection: Why Your Feet Are Warning You About Heart Disease with Dr. Ronald Talis

Show Notes

Most of us have been to the doctor hundreds of times, and not one of those doctors has ever taken a good look at our feet. Yet your feet are the foundation of your entire body, the one structure that connects you to the ground, and one of the earliest places where metabolic and cardiovascular disease quietly announces itself.

In this episode, Dr. Ravi Kumar sits down with Dr. Ronald Talis, a board certified podiatrist who practices alongside Dr. Kumar in North Carolina. The conversation walks through the human foot from the ground up. Twenty six bones. More than thirty joints. Over a 100 muscles, tendons, and ligaments. A structure that transforms from a flexible shock absorber into a rigid lever with every single step you take. And a structure that, in the modern Western world, we have been quietly weakening our entire lives just by wearing shoes.

Dr. Talis explains why “shod” populations have predictably weak feet, why the foot of someone who grew up barefoot on uneven ground looks fundamentally different from a foot that has spent its life in a shoe, and why the foot has been written off in modern medical training as a “dumb hand” when it is arguably one of the most sophisticated pieces of biomechanical engineering in the body. He walks through pronation and supination as a normal corkscrew motion of the subtalar joint, why the cardiology marketing myth of pronation as inherently bad has driven a $150 shoe industry, and how the foot’s locking and unlocking midfoot mechanism is what allows humans to be uniquely bipedal runners.

The conversation then moves through the most common foot problems most of us will face. Plantar fasciitis, which is almost always a misnomer because there is no actual inflammation, and which responds far more to flexibility work and strengthening than to anti inflammatories. Flat feet and the role of the posterior tibial tendon. Bunions as a hereditary structural problem rather than a “shoe injury.” Ingrown toenails as a true biological conflict between nail tissue and the body. Toenail fungus and athlete’s foot, including the surprisingly effective black tea soak that uses tannic acid to shrink overactive sweat glands. And warts, where Dr. Talis lays out the fascinating use of cantharidin, the blistering beetle derivative also known as Spanish fly, to trigger a localized immune response that lets your own body “hunt” the wart virus systemically.

Finally, the two of them connect the foot to the rest of the body. Why a darkening, dusky, or cold toe is often the very first sign of peripheral arterial disease and, by extension, coronary artery disease. Why diabetic patients should be taking their shoes and socks off at every visit. And why a fit athlete who wants the healthiest possible foot should spend part of every workout barefoot on a controlled surface, doing plyometric and proprioceptive drills that rebuild the small intrinsic muscles that modern shoes have allowed to atrophy.

Episode Resources

• Dr. Ravi Kumar on LinkedIn
• Premier Foot and Ankle NC website

In this episode, you will discover:

• The visual markers of a healthy foot: Even skin tone, hair growth on the dorsum (a sign of adequate blood flow), healthy nails with no wounds, and an arch that sits somewhere between medium and moderately high. Excessively high or excessively low arches are both structural red flags
• Why being “shod” creates weak feet: Western society wears built up arches on hard flat surfaces, leaving the intrinsic foot musculature underused. People raised barefoot on uneven ground (sandy beaches, irregular terrain) develop visibly stronger, more muscular feet. There is no formal diagnostic code for “weak feet,” but the phenomenon is real and underlies a huge amount of day to day foot fatigue and pain
• The corkscrew subtalar joint: The subtalar joint sits below the ankle and moves in three planes simultaneously, like a wine bottle corkscrew turning and descending. That motion is what unlocks the midfoot for shock absorption (pronation) and then locks it again for push off (supination). Primates do not have this locking mechanism, which is why humans are uniquely bipedal runners
• Pronation is normal, not a defect: Pronation as a “problem” was popularized by a cardiologist running enthusiast, not by podiatry. Excessive pronation can be pathologic, and so can excessive supination, but both are normal and necessary parts of the gait cycle. Most of the “motion control” shoe market exists because pronation was successfully marketed as evil
• Shoes as casts: Dr. Talis frames modern footwear as effectively a soft cast. Just as a six week limb cast causes dramatic muscle atrophy, a lifetime of shoes prevents the intrinsic foot muscles from ever developing. Some footwear is necessary in modern life, but the trade off is real and worth managing deliberately
• Plantar fasciitis is rarely actually “itis”: The classic findings are a fascia thickened to five millimeters or greater on ultrasound and reduced flexibility. True inflammation is almost never found. Pain typically presents as first step pain in the morning or after long sitting, with point tenderness right where the fascia inserts on the heel. Many cases that get labeled plantar fasciitis are actually small muscle fatigue in the foot, but there is no billing code for “fatigued feet”
• The windlass mechanism: As your toes flex up at toe off, the plantar fascia tightens like a truss and dynamically pulls the arch into shape. The plantar fascia is increasingly viewed as a continuation of the Achilles tendon wrapping around the calcaneus, which is why heel cord stretching helps plantar fascia pain
• Neuromuscular drills: Standing on a pillow with your eyes closed is one of the simplest ways to build the small intrinsic foot musculature and proprioception. Toe yoga, picking up marbles with your toes, and short barefoot intervals on controlled surfaces all help rebuild “foot intelligence”
• Flat feet are mostly hereditary: True flat foot is usually a structural inheritance. Posterior tibial tendon dysfunction, the tendon that runs along the inside of the ankle, is a major adult driver of acquired flat foot. The pattern is unmistakable on exam
• Bunions, the truth: Bunions are not caused by tight shoes. They are a hereditary structural issue where the first metatarsal drifts medially while the big toe drifts laterally. Shoes can aggravate the deformity but they did not create it
• The ingrown nail conflict: An ingrown nail is a literal biological conflict between nail tissue and the surrounding skin. The body cannot mount a normal immune response against its own nail, so the problem persists until the offending edge is mechanically removed
• Black tea soaks for athlete’s foot: Athlete’s foot thrives in moisture. Tannic acid in black tea constricts sweat ducts and reduces moisture on the foot, which directly removes the environment fungi need to grow
• The cantharidin story: Cantharidin is derived from the blistering beetle (the historical “Spanish fly”). When applied to a wart, it creates a small blister that disrupts the wart and, more importantly, triggers a systemic immune response. The immune system, which had been ignoring the wart, suddenly recognizes the virus and can “hunt” other lesions on the body. This is functionally immunotherapy at the dermal level
• The foot as canary in the coal mine: The blood vessels in the feet are the smallest and the farthest from the heart, which is why peripheral arterial disease almost always shows up in the toes first. A cold, dusky, darkening, or hairless toe is one of the most reliable early signs of systemic vascular disease, and patients with peripheral arterial disease have a very high coincident rate of coronary artery disease
• Diabetes and the foot exam: If you are diabetic, take your shoes and socks off at every doctor visit, every time. Loss of protective sensation is the silent setup for ulceration, infection, and amputation. The neurological foot exam, including the Babinski reflex, is also a meaningful part of any comprehensive neurological assessment
• The barefoot athlete prescription: Spend a portion (not all) of every workout barefoot on a controlled surface doing plyometric and proprioceptive drills. This rebuilds the intrinsic musculature and the speed of firing in the small muscles of the foot. Football players cannot do an entire practice barefoot for obvious reasons, but every athlete can do part of a cool down barefoot

Key Takeaways

• The foot is a 26 bone, 30 plus joint, 100 plus muscle engineering marvel that transforms from a flexible shock absorber into a rigid lever with every step you take. It deserves attention, not the historical “dumb hand” dismissal
• Shoes are effectively casts. A lifetime of shoes leads to muscular atrophy of the intrinsic foot muscles. Some footwear is necessary in modern life, but spending controlled time barefoot is one of the highest leverage things you can do for foot health
• Pronation and supination are normal parts of the gait cycle, not pathologies. The “motion control” shoe industry was built on a marketed exaggeration, and a $150 shoe is often inversely correlated with foot health
• Plantar fasciitis is usually not inflammation. It is loss of flexibility in a thickened fascia and frequently coexists with weakness of the small foot muscles. Flexibility work, strengthening, and Achilles stretching are more important than anti inflammatories
• Standing on a pillow with your eyes closed builds proprioception and the small intrinsic muscles. Toe yoga and barefoot intervals on controlled surfaces rebuild “foot intelligence”
• Bunions, true flat feet, and high arches are largely hereditary structural traits. Shoes do not create them, although shoes can aggravate them
• Cantharidin, derived from the blistering beetle, is a beautiful example of immunotherapy at the skin level. It triggers a systemic immune response that lets your own body recognize and clear the wart virus
• A cold, dusky, hairless, or darkening toe is one of the earliest signs of peripheral arterial disease, which strongly predicts coronary artery disease. The foot is a window into your metabolic and vascular health
• If you are diabetic, take your shoes and socks off at every doctor visit. Loss of protective sensation is the silent precursor to ulceration and amputation
• For athletes who want the healthiest possible foot, dedicate part of every workout to barefoot plyometric and proprioceptive drills on a controlled surface

Transcript

[00:00:00 –> 00:02:27] Dr. Ravi Kumar: Welcome to the Dr Kumar Discovery podcast. I’m Dr. Ravi Kumar. Today, we’re talking about something that most of us completely ignore, and honestly most doctors ignore it too. The foot. I’ve been to the doctor hundreds of times in my life, and I’m not sure a single one has ever taken a good look at my feet. It just doesn’t happen. And yet, this is the foundation of your entire body. It’s the one structure that connects you to the ground, and it’s the reason we can do the things that make us uniquely human, walking and running upright. Your foot has 26 bones, over 30 joints, and more than a 100 muscles, tendons, and ligaments. It transforms from a flexible shock absorber into a rigid lever with every single step you take. It’s an engineering marvel that most of us have been slowly weakening our entire lives just by wearing shoes.

Today, I’m joined by Dr. Ron Talis. He’s a board certified podiatrist, and he’s gonna give us a deep dive into how the foot actually works, why modern life is making our feet weaker, and what you can do about the most common foot problems from plantar fasciitis and flat feet to bunions, toenail fungus, and even warts. We also talk about why your foot might actually be a window into your overall metabolic health. So before we do any of that, I wanna give you a quick disclaimer. Dr. Talis and I are both doctors, but we’re not your doctors. Everything we share here is for informational purposes only and meant to empower you with knowledge so you can make better decisions with your own health care provider. This show is also separate from my role as assistant professor at UNC. Alright. Let’s get into it. My name is Dr. Ravi Kumar. I’m a neurosurgeon in search of the causes of human illness and the solutions that help us heal and thrive. I want you to join me on a journey of discovery as I turn over every stone in search of the roots of disease and the mysteries of our resilience. The human body is a mysterious and miraculous machine with an amazing ability to self heal. Let us question everything and discover our true potentials. Welcome to the Dr Kumar Discovery. You look at someone’s foot, what is it what tells you that they have a healthy foot?

[00:02:27 –> 00:03:14] Dr. Ronald Talis: Thanks, Ravi. Uh, pleasure to be here with you. So, you know, anytime, the first thing you’re gonna see is the skin. You just look at this dermatological survey, you see the skin tone. A healthy foot, sort of the ideal foot, uh, actually has a healthy looking skin. The color is sort of that matches with the rest of their body. There’s hair on the foot that’s actually a good sign of blood flow to the foot is having hair there. Nails are are healthy as far as the there’s no wounds or anything like that. As far as the arch height and the structural component of it, you’re sort of in that kind of that range medium to to moderate high arch, but you’re not looking for anything that’s an excessive high arch or an excessively low arch. Those are really kind of your key takeaways from there, just add a quick look without even doing an exam.

[00:03:14 –> 00:03:19] Dr. Ravi Kumar: And, like, who would who has a healthy foot? Are there certain types of people who just tend to have healthy feet?

[00:03:19 –> 00:03:50] Dr. Ronald Talis: Well, I think to some extent, it’s people who use their feet, you know, and who are using their feet for either their that sport that they’re engaged in or are using their feet as part of their work or their or their lifestyle. My personal notice is that people who are barefoot oftentimes walking on these uneven surfaces develop strong muscular feet that are essentially healthy feet. As we become more and more shod, we lose some of that musculature, lose some of that strength, and so that takes away a little bit from our overall foot health.

[00:03:50 –> 00:03:53] Dr. Ravi Kumar: And so shod means wearing shoes. Correct?

[00:03:53 –> 00:03:54] Dr. Ronald Talis: Any kind of footwear. Yeah.

[00:03:54 –> 00:04:06] Dr. Ravi Kumar: Okay. So you you find that people who are tend to be barefoot more often and walking on uneven surfaces have more developed muscles in their feet, essentially?

[00:04:06 –> 00:04:41] Dr. Ronald Talis: Yeah. I mean, I think that as a society, Western society is what I’m speaking of, we all have very weak feet, generally speaking. The musculature is simply not developed, um, because we’re not engaging it. Right? You’re you’re in a shoe. The shoe has a built in arch surface, and you’re walking on hard, flat surfaces, so there’s just very little opportunity to gain that musculature from a day to day basis. Whereas if you take a person who grows up in The Caribbean, let’s say, on on sandy beaches, that that foot looks totally different. It it has just a a musculature to it and, uh, health to it, for sure.

[00:04:41 –> 00:04:53] Dr. Ravi Kumar: Yeah. So when when someone has is barefoot and they’re using the muscles in their feet, what does it do to the shape of the foot? Does the foot change shape or does it change the way it or is it just beefier? How would you describe it?

[00:04:53 –> 00:05:23] Dr. Ronald Talis: Yeah. It’s it’s a it’s a great question. So it’s not clear whether or not that really influences our type. I mean, there’s certainly the idea that as the musculature on the bottom of the foot becomes stronger, more robust, it pulls in those metatarsals, these are the bones behind our toes. It pulls them in and it accentuates the arch, but that’s kind of a little bit controversial whether that actually does that job or not, but you certainly do see these developed muscles on the foot that you can just sometimes look at and see.

[00:05:23 –> 00:05:36] Dr. Ravi Kumar: And someone who’s been, you know, not walking on uneven surfaces, they’re wearing shoes all the time, they have an atrophied foot, and does that look different besides just less muscle?

[00:05:36 –> 00:06:42] Dr. Ronald Talis: No. No. I mean, I I would say that the the biggest difference is that they’re gonna feel it in a in a different way. It doesn’t necessarily look different, but they’re going to notice these signs of fatigue and their their weakness effectively in many ways because feet are gonna be sore throughout the day, so they just had not had a chance to develop that that structure. You know, not to get too far afield, but we had discussed that, you know, there’s not really a code or a diagnosis for that. It just doesn’t it doesn’t exist, but that doesn’t mean that’s not a real phenomenon that that we’re seeing and that’s happening. But back to kind of the the look and and the structure, uh, I think it’s really just more that there there’s gonna be some things that are just this is what their foot type is gonna be, this hereditary. Some people are gonna be born with a high arch, some people are gonna be born with a low arch, but certainly you’re gonna see that accentuation of that type, and certainly as our tendons weaken, specifically I’m talking about the posterior tibial tendon, this is the tendon that’s on the inside of your ankle, um, as if that weakens, then you have a effectively a collapsed arch, and that that is a very profound look. That’s a unmistakable look and pattern.

[00:06:42 –> 00:06:46] Dr. Ravi Kumar: So you and I both walk around wearing shoes all day because we work in

[00:06:46 –> 00:06:46] Dr. Ronald Talis: Yeah.

[00:06:46 –> 00:06:52] Dr. Ravi Kumar: The same hospital, and we’re in the OR all the time. Uh, do we have weak feet, you and I?

[00:06:52 –> 00:07:03] Dr. Ronald Talis: Probably. I I mean, uh, I think I think we do compared to compared to what we could be. You you know? Okay. Certainly what our ancestors were like.

[00:07:03 –> 00:07:06] Dr. Ravi Kumar: Yeah. And does does that affect our health?

[00:07:06 –> 00:07:27] Dr. Ronald Talis: I think it does. I mean, I think it, I think it changes the way that we balance the way that our, our posture is, uh, certainly as we, um, get more sore throughout the day and where feet are tired, when we can’t, when we kinda stop, and we can’t do the things that we wanna do, I think there I think there’s a role, and that plays a plays a part in it, for sure.

[00:07:27 –> 00:07:50] Dr. Ravi Kumar: So let’s talk a little bit about the architecture of the foot, because it’s truly a marvel of evolutionary engineering. The foot has got a ton of bones and a ton of muscles. Maybe you can talk to that. And it’s designed with a very specific function that makes us excellent walkers and runners. Can you tell us about how the foot’s designed and how it helps us be human beings?

[00:07:50 –> 00:09:11] Dr. Ronald Talis: Yeah. No. Absolutely. So, I guess we’ll do a kind of a comparison and contrast. And I think sometimes when you compare what we’re not, you get just as good of an understanding of what we are. So, when you look at, like, the primate foot, this is a extremely flexible looks like a hand type of of appendage and that’s designed for climbing and grasping and and ours just is not right? So we don’t have that kind of flexibility. Ours is designed in a way that you can hit the ground your foot is going to become flexible. This is something called pronation in my language. So as our foot pronates it unlocks the bones in the middle of the foot and that effectively allows your arch to drop a little bit and as it does so, it gains this flexibility and we want that that’s you know, pronation’s kind of sort of become this bad word, but it’s actually a normal part of the gait phase. So as our mid foot unlocks this is the middle of the foot it unlocks and it allows the foot to become flexible. That’s by design so that we can accommodate terrain, so that we can adapt to our our ground. And then when you wanna push off and go and run away from that saber tooth tiger, you really need a rigid lever. So then we supinate, the foot twists, the heel twists, and that locks the middle of the foot down, and now we have this rigid lever to push off of. So, we go from our foot goes from a mobile adapter to a rigid lever. These are common terms that we would use.

[00:09:11 –> 00:09:39] Dr. Ravi Kumar: So that’s really interesting. You know? And for people at home to think about pronation and supination, which you were just talking about, uh, think of your hand. And when you are holding a bowl of soup, it’s not spilling, you’re holding it upright, that’s supination of your hand. And if you took that bowl and turned it upside down, let all the soup fall out of it, that’s pronation. Now with the foot, and correct me if I’m wrong, pronation is this inward churn

[00:09:39 –> 00:09:40] Dr. Ronald Talis: That’s right.

[00:09:40 –> 00:09:48] Dr. Ravi Kumar: And, uh, towards the middle, the medial side, the inside part of the foot, and supination is a churn towards the outside. Is that correct?

[00:09:48 –> 00:10:51] Dr. Ronald Talis: Yeah. That that’s exactly right. And and, in fact, just to get a little bit technical for for a second, and we can plan out of that if you need, the subtalar joint, this is a joint that is behind just below the ankle. Right? So a lot of people will say that their subtalar joint is the ankle, but it’s actually a separate structure. Um, there’s two bones, the talus and the calcaneus and the motion is actually triplanar, meaning it’s moving in three different planes, and the best way that I can relate it is that it’s a corkscrew. The way that a corkscrew will go in, turn, and go down. Go in, turn, and go down. Just like your imagine your your wine opener, right? You’re getting ready to have that bottle of your corkscrews going turning, and it’s also going down. And in a very similar way, that’s the way that our subtalar joint works. So as it goes through that motion and corkscrews, it’s pronating down, and then it’s going back into that position to supinate. And that sub taylor joint is actually then playing a role on the next joint complex downstream from it that’s going towards the toes, and that’s what either locks or unlocks the middle of the foot.

[00:10:51 –> 00:10:58] Dr. Ravi Kumar: Oh, very cool. So yeah. So, essentially, you’re accommodating terrain, you’re storing energy, and then you’re transforming the foot

[00:10:58 –> 00:10:59] Dr. Ronald Talis: That’s right.

[00:10:59 –> 00:11:05] Dr. Ravi Kumar: To launch off, and it becomes a very efficient mechanism for bipedal walking and running, it sounds like.

[00:11:05 –> 00:12:08] Dr. Ronald Talis: Oh, absolutely. And that’s that’s something that primates don’t have. Right? So primates are effectively are not going to be able to lock their midfoot. They don’t have that locking mechanism. Every joint has an axis, Sort of like a hinge of a door has an axis where the door is gonna swing through. That’s how it’s gonna move. What happens is you have a few joints in that in that middle of the foot. When their axes are aligned, when they’re parallel, then you have flexibility. When the axis change, and they converge, then they jam into each other, and you can’t open the door. So it’s locked. So that’s kind of the best way that I can explain that phenomenon. And the subtalar joint is the one that’s controlling the joint that goes past that point. Um, but again, that’s sort of one of the big differences between us and like, let’s say a gorilla. A gorilla, super strong, but they’re not gonna be able to lock that joint complex in the middle. So their arches always gonna be flexible, their arches always gonna collapse. They’re not gonna have that same push off ability to go spring into that next next running step.

[00:12:08 –> 00:12:21] Dr. Ravi Kumar: Yeah. That’s fascinating. So if pronation is a normal part of our physiology and the mechanism of our foot, why do we hear about it in a pathological sense with runners? Like, runners are having pronation problems.

[00:12:21 –> 00:12:40] Dr. Ronald Talis: I think that was a historical perspective, and actually, interestingly enough, did not come from the world of podiatry. It came from cardiology, a a cardiologist enthusiast who who was also like a runner and and just wanted to talk about this stuff. Absolutely, there can be a point where pronation is pathological. That’s an excessive amount of pronation.

[00:12:40 –> 00:12:40] Dr. Ravi Kumar: Okay.

[00:12:40 –> 00:13:19] Dr. Ronald Talis: Um, and certainly that that is also true of supination. But we need pronation as part of that normal gait cycle and same with supination, but it’s also created a genre, uh, of shoe wear and a and a merchandisable thing, right? Something that we can sell you, we can sell you a product that reduces your pronation because that’s evil. Right? So, it’s marketable in that way. Here’s the problem. The problem is pronation, and and we can fix it with with this device. You just have to, you know, fork out a $150 for it. So, it it’s so I think a lot of that idea and that rationale comes from from the marketing of that rather than the than the real science behind it.

[00:13:19 –> 00:13:27] Dr. Ravi Kumar: So someone goes to a running store and they say, hey, you’re over pronating. Should they buy a $150 shoe, or is there something else they should be doing?

[00:13:27 –> 00:14:39] Dr. Ronald Talis: Well, I I I think the cost of the shoe is sometimes inversely proportional to the to their overall health and the quality. And sometimes, the more technology that you put into these shoes, the the less it’s gonna do for you. But I I think that people are often talking about the motion control, that’s a big one in in the running kinda circles in in the shoe world, you want a motion control shoe, and and the motion that they’re referring to is excessive pronation. Um, it’s basically got a a built up, um, surface that stops a deeper heel cup effectively. All the things that are designed to kinda stop your body from from pronating in. And so I think that for the right foot, let’s let’s say a person that really does have a pathological amount of that, I I think that’s very reasonable. I’m not saying, oh, no, stay away from that. I just think that it’s certainly marketed as, like, the the thing you absolutely have to have, and that’s certainly not not true for any of us. Not pushing a brand, uh, it’s it’s really more of just a a fit. And for most of my patients, that comes down to trial and error, you know? And and sometimes we can look at it and say, okay, this kinda makes sense for you, but really it’s it’s fit, it’s trying it out, going for a run, it’s a test run, and you kinda just figure out what your body’s gonna do and how it responds to that shoe.

[00:14:39 –> 00:15:15] Dr. Ravi Kumar: Yeah. And you’ve told me in the past that you thought that shoes were essentially casts, and I’m talking like a bone cast. And if you’ve ever seen someone break a bone, you know, they put a cast on so the bones don’t move so they can grow together. And in that six week period of having that cast on, you know, even a kid’s muscles will atrophy significantly. It it is, like, remarkable how much atrophy there is when you don’t use a muscle. And if you saying that the shoe is essentially a cast is I mean, your prior comments about being shod weakens the foot, I mean, should we be looking for shoes that don’t cast our feet?

[00:15:15 –> 00:16:19] Dr. Ronald Talis: Yeah. I mean, certainly, there’s a movement for that. You know, you look at the popularity of the, like, the Vibram Five Fingers and these other minimalist style shoes, the Nike Airs, and and a whole bunch of them out there. Everyone wants to have that brand. I think it’s just a fine balance between protecting the foot from the environment, right, that’s around us there. I mean, we live around all kinds of things that are just not really pleasant on our feet and surfaces that we don’t want to engage in. And then also having something that gives us enough ability to use the musculature and to flex into it. And, um, I think to kind of steer it away from the actual shoe a little bit, there’s certainly there’s exercises and things that that we can do to improve the health of the foot and improve the musculature aside from from what you’re wearing. Uh, you know, all of us, we we live in a Western society, you’ve gotta wear the shoe for that fits that circumstance. I don’t see any of us putting on a suit and then going in vibing five fingers. It’s just not gonna work. Right? So we we have to match the reality of of our circumstance Yeah. With with that kind of stuff.

[00:16:19 –> 00:16:39] Dr. Ravi Kumar: Yeah. Definitely. So what about the the arches? I mean, because when we think of the arch, and you’ve already talked about this a little bit, we think about this arch that goes from the heel to the toes. You know? If you look from the side, you see this nice arch. Yeah. There’s actually a second arch that no one talks about, um, that goes the other way, correct? At 90 degrees?

[00:16:39 –> 00:18:29] Dr. Ronald Talis: Yeah. So we just kinda talk about that longitudinal arch versus the transverse arch. The way I think of it is, you could you could think of it like a Roman arch in in many ways. Right? So if you’re looking at a Roman arch, it’s not a two d structure, right, as we see it on a piece of paper. If you take that arch and you and you rotate that arch, and now you’re looking through it, that that has its own structure on a different plane. So, um, that that all kind of affects the the foot. One of the things I kinda wanted to hit in regarding that dialogue about arches is that our arch certainly has has bone structure to it. That’s part of what forms it, and those bones are held in place by ligaments. But the big thing that supports the arch for us is tendon. Right? It’s a it’s a muscular function. It’s not just bone structure, although that plays a huge role, of course, but our also our body is actively engaged, dynamically engaged in keeping that arch the way it wants it. So even the plantar fascia, we’ll talk about plantar fasciitis I’m sure, but our plantar fascia serves a role. Plantar fascia is just a dense band of tissue that starts from the heel and goes to the ball of the foot, and it engages something called the windblast mechanism. So as our toes flex up, the fascia tightens and that becomes another form of supporting the arch of the foot, just like a truss of a bridge. So that’s the best way that I can kind of explain it from an engineering standpoint. As it as it tightens, it pulls that arch into place and is another support work for it. And and our arch is also supported by by various tendons, the posterior tibial tendon that I mentioned that runs across from the inside of the ankle, the proteus longus tendon, which comes on from the outside of the ankle and and wraps around the foot and pulls down that big toe bone or the bone behind the big toe, the first metatarsal. So all these things help lock us in and and and create that dynamic structure. So it’s not purely set in stone. We’re we’re a living thing that is moving and reacting to the environment.

[00:18:29 –> 00:18:45] Dr. Ravi Kumar: Yeah. And the foot really is so much more dynamic than pretty much anything else in our body. Maybe our hands are are equal, but with all the other joints we think about in our body, which we get give so much attention to, uh, are pale in comparison in complexity to the foot.

[00:18:45 –> 00:19:24] Dr. Ronald Talis: Yeah. I I mean, I’m not sure why it’s gotten this or why it’s kinda gotten away from classic, you know, thinking in allopathic or osteopathic schools, but for whatever reason it largely has, sometimes though, the foot is sort of just written off as, as a dumb hand. That’s what it’s been kind of characterized as the foot is a dumb hand. You know, may maybe it’s the opposite. Maybe the hand is a nerdy foot. I, I don’t know what to, uh, how to describe it, but I I think that it has, for whatever reason, kind of lost a lot of study. It’s only now starting to come back and and be more looked at critically, like, how does this interact with our overall athleticism, our overall posture, and our health?

[00:19:24 –> 00:19:49] Dr. Ravi Kumar: Yeah. I mean, because I’ve been to the doctor, you know, hundreds of times throughout my life. I’m a doctor myself, and I don’t know if I’ve ever had a doctor look at my feet, honestly. Yeah. Because I’ve never had any bad foot problems. I’ve never had, you know, athlete’s foot or, you know, toenail funguses or things that you would normally probably ask your doctor to look at your feet for. So in the general examination, no one says, okay. Let’s take a look at your feet. It just doesn’t happen.

[00:19:49 –> 00:20:28] Dr. Ronald Talis: Yeah. I I I mean, I think that, you know, down your alley, it’s certainly part of a neurological exam, right? A comprehensive neurological exam. There’s there’s signs, the Babinski exam and and others. These are just ways of understanding whether a person has some connective issue, you know, neurological issue that changes our foot reflexes and structure. But it’s a big deal and it’s a, it’s actually a huge deal for our patients with diabetes and other protective, uh, sensation related issues where their doctors sometimes are not looking at their feet. And that’s absolutely something we encourage if especially if you have diabetes, you got to take your shoes and socks off every doctor visit just just make

[00:20:28 –> 00:21:08] Dr. Ravi Kumar: Hey, guys. If you’re enjoying this podcast or it’s helping you, please help me get it out to the rest of the world. All you need to do is rate and review it on Apple Podcasts. Share it with a friend, post it on Facebook, and that’s basically it. The algorithm rewards engagement. Every review, every mention puts this show in front of someone who’s looking for clear, no nonsense health information, the type of information that I’m putting in these podcasts. So thanks so much, and let’s get back to it. So let’s talk about plantar fasciitis, because you mentioned it just a second ago, and this is a a very common complaint when people have problems with their feet. What is plantar fasciitis, and what causes it?

[00:21:08 –> 00:22:34] Dr. Ronald Talis: So plantar fasciitis, you know, the it is kind of suggests inflammation, right? But, uh, interestingly enough, we’ve never really found inflammation in that area. So in many ways, it’s absolutely a misnomer. Really the structural things that we see that I think most people in my field would agree on is that the fascia does become thicker in people with chronic plantar fasciitis, usually five millimeters or greater in thickness. So that’s determined by ultrasound or other imaging. And also, certainly, it’s less rubber bandy, less springy, less flexible in in that way. And then a lot of it is just simply by the patient’s kind of history and and report and certainly by physical exam. So palpation, pain with palpation directly under where that heel, where the plantar fascia inserts into the heel, that’s a huge one. We think of that as plantar fasciitis unless proven otherwise. That’s really kind of what it is. It’s characterized mostly by heel pain. Patients will say, you know, dot first steps in the morning are extremely painful when I first get out of bed or after I’ve been sitting for a long period of time. Any kind of just pain right there in the heel is going to be most likely plantar fasciitis. And then certainly as we go through the pain in the arch, and I think this is sort of where I am differentiating, and my colleagues don’t often do that, but I think that’s where I think a lot of our pain is fatigue of those small musculature in the foot rather than a classic plantar fasciitis. Again, there’s no diagnostic code. We can’t bill the insurance company for a fatigued feet, so that gives rise to sort of maybe the over classification or the over diagnosis of plantar fasciitis.

[00:22:34 –> 00:22:39] Dr. Ravi Kumar: Okay. So, do you think all plantar fasciitis is just weak feet?

[00:22:39 –> 00:23:47] Dr. Ronald Talis: No. I mean, I think it you look at people that have a structurally quite normal foot, a healthy foot in many ways, but then, uh, just the there’s a wear and tear component. Our bodies will calcify some of that that tendon and tissue, uh, it becomes less flexible, it becomes less healthy. Certainly, you can have a traumatic injury to the plantar fascia that that’s happened to some famous athletes as they step back forcefully and then the toes are flexed up will cause a sudden tear within the fascia that can absolutely happen and is quite painful. So so I don’t think it’s purely, uh, a lack of strength and conditioning, but I I think certainly that plays a role and it’s also one of the best ways to help recover from plantar fasciitis is to strengthen the foot where you can and also improve the flexibility of the fascia and the Achilles tendon. Just from a quick anatomical structure perspective, a lot of anatomists are now considering the plantar fascia as really just a continuation of the Achilles tendon so that the Achilles tendon itself wraps around the bone of the heel bone and kind of gains the mechanical advantage of that. So there’s been some controversy in my field whether plantar fascia is its own unique structure or simply a continuation of the Achilles tendon.

[00:23:47 –> 00:23:53] Dr. Ravi Kumar: So is the function of the plantar fascia to basically flex in the foot? Well, the

[00:23:53 –> 00:24:33] Dr. Ronald Talis: plantar fascia doesn’t have musculature. Right? It’s not it’s not a muscle in itself, so it doesn’t have that that pull of it. So, either the plantar fascia is acting as an extension of the Achilles tendon as it pulls on the heel and then it pushes the foot down. So it forcefully pushes that, that foot down and helps improve the mechanical advantage of the tendon. That’s quite possible. And then also, as I had mentioned earlier, there’s that windlass mechanism. So as the toes get flexed up, as the toes dorsiflex or, like, toes to your nose, the toes are going up, they will tighten the fascia that runs to them, and that is gonna help lock the middle of the foot, making the foot more rigid when we go to push off of it. That’s the fascia’s main, uh, responsibility.

[00:24:33 –> 00:24:47] Dr. Ravi Kumar: So the the reasons behind plantar fasciitis are either wear and tear, degenerative changes like calcification, it could be weakness of the foot, putting too much stress, essentially, on the plantar fascia. Is that correct?

[00:24:47 –> 00:25:40] Dr. Ronald Talis: Yeah, absolutely, and I would add another one, which is lack of flexibility. Oh, it’s it’s a especially the flexibility that we’re talking about is that of the Achilles tendon, so it’s an overly tight structure in the back of the heel, so the as the Achilles tendon pulls really hard on the back of the heel, it it lifts the heel up sort of like a like a seesaw and as that happens, the fascia is tugged and stretched with it. So I think that a huge component of plantar fasciitis for people is a lack of flexibility in addition to the lack of the of the support musculature and strength. So, you know, we can do our interventions, you know, injections and other things of that nature, but a huge part of it is, patient stretching, improving the, their flexibility, especially the Achilles tendon and the plantar fascia itself, and then also strengthening all the support musculature around it. So I think the only thing I would add to to what you had stated was that flexibility component. That’s a huge one.

[00:25:40 –> 00:25:53] Dr. Ravi Kumar: So if someone has plantar fasciitis and they want to strengthen their foot and increase the flexibility of their foot and recover from plantar fasciitis, what what are your tips for getting over that?

[00:25:53 –> 00:29:08] Dr. Ronald Talis: Yeah. And I would say it’s not just for plantar fasciitis. Certainly, sometimes it becomes, you know, just like anything else, we don’t think about it until it’s a problem. Right? Not a problem until it’s a problem. So we’re engaging this conversation with patients who are experiencing pain, experiencing this problem, but it’s absolutely something that anyone can do and it’s certainly something I would encourage athletes to do. I think they’ll find that there are a lot of benefits for athletes to do these exercises and stretches anyway, whether they have the plantar fasciitis or not, but let’s, let’s get into some of them. So spending time barefoot, that’s a simple one. Walking on surfaces that can, that can support that controlled surfaces. Certainly if you’re in sport, if you’re in cleats or shoes, you know, you’re going to go ahead and do your main exercise in that. But then if you have the opportunity to do a cool down on a controlled surface, like turf, field, or grass, or anything like that, or sand, I think that’s hugely beneficial just to engage that musculature. But for the average person, the neurosurgeon, let’s say, who’s been standing on their feet all day doing a case, and then if they can go home, some, some simple things that they can do, one get barefoot. If you, if you can spend time with one foot balancing on a pillow or a soft surface, I think that’s fantastic. That’s a great exercise to do. Because as we lift up that other foot and keep that in the air, we’re asking our other leg, the down leg, to engage all these muscles and also build these neural neural connections. Right? So our body is not just about how strong we are, but it’s how fast these muscles are firing in relation to the stimulus around us. Right? So as as we’re trying to achieve balance, that’s a great one. I mean, certainly by standing barefoot on a pillow, one leg at a time, you’re gonna gain that because your body’s gonna have to achieve that balance quickly for you. So all your muscles are gonna contract and squeeze to try to grip the ground around you. Your peroneal tendons, as we mentioned, are gonna fire, try to stabilize you and stop you from from spraining an ankle effectively. So do that safely maybe with with a chair or a wall nearby that you can do but certainly as you build inability a a thing you can do is go from just standing on one leg to then doing that with your eyes closed. Now you’re taking away the visual component of this. Right? You’re not getting this visual feedback anymore about, hey, how do I need to balance? Now you’re just letting your whole your body just think about it and perceive these small changes in balance and you can certainly add other fun things to it like bouncing a ball and catching it while standing on one leg right? So now you’re responding your whole upper body is moving and so as that axis changes as that center of balance changes, now your foot has to catch up and respond quite quickly. So so that’s a great one. I don’t think it’s coincidental that certain tribes in Africa as a a test of a warrior’s ability to become a warrior in these various tribes, you have to do a prolonged period standing on one leg. I think it’s just fascinating that that they’ve somehow understood that there’s this balance component, this neuromuscular development component to that. Um, but other other exercises, certainly just even if you’re seated watching TV, relaxing, you can be barefoot and have a towel in front of you. And so you’re just effectively practicing with your toes, crunching up that towel, bringing the towel up to you, only using your toes to engage those flexors. Those are the muscles that bring the toes down. You can do that. That’s huge. Picking up things with your toes, all of those kinds of things. And the more you can use your foot, the better.

[00:29:08 –> 00:29:19] Dr. Ravi Kumar: So if someone has plantar fasciitis and they start doing these exercises, should they expect improvement just by doing these flexibility and strengthening exercises you’re talking about?

[00:29:19 –> 00:29:58] Dr. Ronald Talis: I think for most people, they probably will. I think that most people probably will gain some relief through stretching. One of my favorite stretches that I teach and and do myself is getting up against a vertical surface like a wall or a door and putting your foot up against it and allowing that surf in your body’s weight to kind of push everything up dorsiflex that you’re stretching the Achilles tendon you’re stretching the fascia so for many people it it will get better just with that maybe some ice, some massage, and sort of comes kind of becomes a periodic thing that’s just kind of, okay, I got a little bit of a pain here, and then it goes away. I think it’s for those where it doesn’t respond, then intervention from someone like me is is, uh, the next step.

[00:29:58 –> 00:30:07] Dr. Ravi Kumar: Yeah. And then say someone did that, and they come to your office, and they say, Dr. Talis, I’ve tried your strengthening and stretching exercises. I’m not getting better. What would you do for them?

[00:30:07 –> 00:30:53] Dr. Ronald Talis: Well, first line of treatment, I I think, is an injection, so I’m a huge fan. I know some people are. I’m sure there are people who are listening to this or any other professional would say, Oh, God forbid, we hate injections or never do steroid injections. There’s all these side effects. I haven’t found that to be the case. I think you, if you deliver an appropriate dose of steroid and you’re delivering it appropriately meaning it within the deep tissue you’re careful not to place that injection superficially we just don’t see those kind of side effects from that injection so I think it’s a wonderful initial line of treatment that really is not curative though but it breaks the cycle right it stops this this cycle of what’s happening. It’s almost like a reset button, and then it allows the patients to get deeper and deeper into their stretches and into their things that they’re gonna do to really heal it for themselves.

[00:30:53 –> 00:31:04] Dr. Ravi Kumar: Let’s talk about flat feet, because that’s another big one that people you hear about all the time and people complain about all the time. What is flat feet, and what kind of problems does it cause people?

[00:31:04 –> 00:32:56] Dr. Ronald Talis: So I think there’s a distinction between, well, a flat foot is is effectively foot that doesn’t have much of an arch. Right? And it’s something we can all just kind of see and you kind of perceive if someone just has has a foot that drops the arch, but there’s also other components of it besides that very obvious lack of an arch. So, the foot will oftentimes abduct away from the midline, so you’ll see people with more of a quote unquote duck footed type of walk as as their arch drops. That’s sort of the posture that they assume. The the back of the heel will roll in a little bit. So sometimes parents will bring kids to me and say, you know, Johnny’s wearing out his shoes very, very fast. All the insides of his shoes are all are all worn through. And so some of that are are all those postural changes. So as you and I had discussed, flat foot is is a tri planar kind of deformity, right? So it’s not just the sagittal plane that’s the arch, but it’s also the components of it where the foot is off to the side and the heel is rolled in. As far as problems that can occur, I think the biggest problems start at the feet. Most people are going to feel pain in the in the foot first. There’s going to be a component of fatigue. We see this especially in children. Parents will often tell us later on that the child just does not want to walk for prolonged distances, the child wants to be carried, the child wants to stop doing what they’re doing, and would rather just have a seat. So, so that fatigue is, and pain is usually the first thing within the foot, but certainly it can move higher and does move higher as this progresses. So a lot of patients will complain of anterior medial knee pain, so just kind of think about your your finger right on the front of that kneecap of that patella and then just sliding down towards the midline of the body. And that’s where sort of most people will feel that knee pain that’s generated from a flat foot. And of course, we we feel like as our bodies change and compensate and try to adapt because we’re we’re having pain, and then you

[00:32:56 –> 00:33:05] Dr. Ravi Kumar: start seeing pain in hips and lower back and etcetera. And what’s causing all this? Why are why are there feet flattening out?

[00:33:05 –> 00:33:42] Dr. Ronald Talis: I I mean, I think that some of it is just purely hereditary. It’s just the structure of the foot that they’re going to have, um, this is how some people are born with a more flat foot than than others, but absolutely, when people are noticing that, hey, I used to have a great arch, and then all of a sudden, now I don’t have an arch anymore. Right? So that that’s a big change, right, for people, especially in their forties and fifties, when all of a sudden they go from a medium to reasonable arch, now all of a sudden they don’t have an arch. So that is oftentimes a dysfunction of the posterior tibial tendon. That’s the one of the major tendons that support the foot and the arch specifically.

[00:33:42 –> 00:33:47] Dr. Ravi Kumar: Okay. So, what’s happening to the posterior tend, uh, tibial tendon? Is it weakening and?

[00:33:47 –> 00:34:32] Dr. Ronald Talis: It’s weakening. Okay. Yeah, absolutely. It can have a tear within the tendon, uh, it’s weakened in some way, shape, or form it’s simply no longer doing the job. So there’s, um, changes within the tendon itself the tendinopathy, uh, where the structure of the tendon can become calcified, it can become or split, right? Like, if there’s a tear within the tendon most commonly these tears are not transverse tear but most of the time these are longitudinal tears so the way I kind of describe that is it’s not like the rope has been torn all the way you can think of a rope that started to fray down the middle So these strands of rope are are just kind of fraying off the middle of the rope, and that has effectively weakened the tendon and not allowed it to continue its function of pulling. Right.

[00:34:32 –> 00:34:44] Dr. Ravi Kumar: And so in kids, you mentioned it’s from them just not walking a lot, having their parents carrying them around all the time. In adults, it’s this posterior tendinopathy or posterior tendon tears. Is that correct?

[00:34:44 –> 00:35:18] Dr. Ronald Talis: Children with a flat feet, with a symptomatic flat feet, will often not engage in behavior. Okay. It’s not the lack of engagement that causes the flat foot, but rather the it’s the flat foot that causes the lack of engagement. Right? They they just they don’t wanna keep they can’t keep up with their peers. They can’t run and play to the same extent. So it’s that it’s the structural change which is gonna start driving their behavior, not necessarily the other way. But certainly, as we have all seen in in the medical field an increase in childhood obesity, and as kids are getting bigger and bigger and less healthy, in other ways, that’s absolutely playing a huge role in their feet.

[00:35:18 –> 00:35:26] Dr. Ravi Kumar: So with kids and adults, the loss of the arch is usually from weakening of the posterior tibial tendon? Often.

[00:35:26 –> 00:35:57] Dr. Ronald Talis: Or it could it be Or it’s it’s a hereditary structural thing. So you can have children that are born with joints that are fused together, whether they ought not to be fused together. Uh, that’s something that we call a coalition, right? So, it’s just these, these two bones that are supposed to meet, that are supposed to articulate and become a joint, are fused together in some way, either cartilage or bone or fibrous. And what that creates is a structure that is oftentimes overly gaining towards a flat foot and puts more stress on the surrounding structures and tendons.

[00:35:57 –> 00:36:11] Dr. Ravi Kumar: So for those people who are developing a flat foot, they’re probably seeing their shoe size go up. They’re noticing that their arch is disappearing. What can they do? Can they do exercises to strengthen their posterior tibial tibial tendon and restore their arch height?

[00:36:11 –> 00:36:43] Dr. Ronald Talis: I think in the in the earliest cases, yes. In the very early cases, that that’s correct. I think that there’s a little bit of strengthening of the foot that can happen and, again, gaining flexibility of the Achilles tendon that’s a huge driver of these things. So, in the earliest cases, the mild cases, yes. In severe cases, especially if the foot kind of has changed and has locked into that pattern where it is a rigid flat foot, not a flexible flat foot, but a rigidly flat foot, then that’s not really gonna be easy to treat at home. So that’s when you come see somebody.

[00:36:43 –> 00:36:46] Dr. Ravi Kumar: And with someone with a flat foot, can they still be an athlete?

[00:36:46 –> 00:37:51] Dr. Ronald Talis: Yeah. Yeah. Absolutely. I I think that I think that we’ve somehow made it seem like it’s inherently a pathology, but I I think it’s just more a a type of normal. Right? So our population for just about everything follows sort of this bell curve. About 80% of us are gonna be sort of in that middle. 10% are gonna have a really high arch. 10% are gonna have a really low arch. So I I don’t think I don’t wanna come across and say that it’s that is the end all. It’s a pathology in itself. It’s just a type of normal. It’s the ones that are rigidly flat and that are symptomatic that need treatment. One of the bigger studies in in my profession came out of the Canadian army. There’s a huge study called Canadian Army Foot Study, and they just looked at all of these young soldiers that were going in into the service, and they actually looked at their arch height and found that many of the flat footed people just did just fine under significant duress, uh, the basic training that was military activities that were required. And so, we that’s kind of changed our thinking from a sort of a an idea of, like, this is inherently bad, won’t work, to, no, this is just a a type of normal, effectively.

[00:37:51 –> 00:38:00] Dr. Ravi Kumar: That’s interesting because does the military still not allow you to enter if you have flat feet? Well, it it’s interesting because, you know, I I’m also former military and

[00:38:00 –> 00:39:06] Dr. Ronald Talis: I was a military podiatrist, so I am uniquely qualified to answer this question. When you go to a medical exam, as every person who’s going into the military does, there’s sort of these key things that they want to see, and the military is checking for more flexibility issues and strength issues. So they’ll ask applicants to walk kind of on their heels, holding their feet up, that’s checking the strength of the tibialis anterior tendon. They’re asking them to walk on their tippy toes, checking for that ankle, and they are looking a little bit for arch height as well. And so I think that in extreme extreme cases, where you see a hyper pronated foot, sometimes that will get kicked back, but there’s such a huge range. And and certainly I’ve treated so many patients in the military with flat feet that you kinda wonder like, hey, maybe they’re not screening so so well here. And we’ve seen high performers with flat feet, people who are in special forces, special operations community, doing unbelievable difficult things, and and they have flat feet and they do just fine. So, I think that there is a, as I said, that it’s more of a a type of normal rather than pathology in itself. Yeah.

[00:39:06 –> 00:39:18] Dr. Ravi Kumar: Okay. Very cool. Well, let’s talk about bunions. Sure. Or for those of us who don’t know what a bunion is, can you explain it? Because I know everyone’s at least seen a bunion.

[00:39:18 –> 00:41:50] Dr. Ronald Talis: Yeah. Absolutely. So it’s the bone behind your big toe. So if you’re imagining your big toe, the bone behind the big toe called the first metatarsal has splayed out to the side away from the other toes. So it’s now becoming almost more reminiscent of the primate foot in many ways. So, it is that a kickback to our, you know, to our older days? Maybe. But the the first metatarsal is splaying out to the side and in doing so, very tight tendon is pulling the big toe in. So then you get that L shape or that or that triangular shape that’s that’s created, and therein is some of the problem. So that’s that’s effectively what a bunion is. And there’s a lot of angles that we look at and we try to classify everything, of course. So the angles that we’re primarily looking at are angles between the first metatarsal and the second metatarsal, and we’re also looking at the angle of the big toe onto its first metatarsal. So those are our major angles that we’re that we’re looking for in trying to classify the severity of the deformity, if you will. As far as how does this happen and why do people get it, it’s overwhelmingly hereditary. Someone someone has given people this foot type. It’s overwhelmingly hereditary. But certainly, there’s things that we do or that could potentially exacerbate this. Right? So any kind of tight shoe that points the toe in, and now every step that you take is pushing the metatarsal out to the side, relative than pushing the toe straight back onto the metatarsal that could potentially increase the bunion. Um, athletic activities, ballet is a tough one for feet for young developing feet, especially given the amount of point work and the stresses that are going through those feet. There is a component of a traumatic bunion that certainly has has been reported in the literature. I personally treated several traumatic bunions that can happen because of a of a weakening of a tendon on one side that has allowed the tendons to overpower it and then you get that sort of that deformity, that change over time, but overwhelmingly hereditary condition. As far as what happens Okay. A lot of people are purely asymptomatic. You can have a bunion, maybe you don’t like the look of it, but it doesn’t bother people, it just doesn’t, doesn’t change their day to day experience, And then other people are just complaining of significant pain from from the bunion, and and that pain is mostly coming from the fact that we are wearing shoes, and there’s a nerve that crosses right over that first metatarsal, over the bump, and that nerve is getting pressure put on it between the shoe and the bone. So, it’s sort of between a rock and a hard place, right, for that nerve. And so, that’s some of what makes them symptomatic.

[00:41:50 –> 00:41:57] Dr. Ravi Kumar: And, uh, so do you consider it a disease state, or do you consider it a natural progression for some people?

[00:41:57 –> 00:42:34] Dr. Ronald Talis: Yeah. I I think that people come to me and say, okay, I have a bunion. Should we go ahead and do surgery on it now? And I said, well, does it hurt? Does it bother you? And they’re like, no. No. I I I I see it. I don’t want I don’t want this to get worse. And and so I usually steer people away from surgery in those circumstances. So I think that if if it occurs and it is asymptomatic and it doesn’t hurt and it doesn’t bother people, then I would just absolutely leave it alone and certainly not treat it like a pathology. I think for those people where it is detracting from their quality of life, they can’t wear shoes, they can’t do athletic activity, or they can’t do the exercises they wanna do, all those kind of things, and that sort of becomes an indication to try to treat it. So for

[00:42:34 –> 00:42:40] Dr. Ravi Kumar: most people, will a bunion prevent them from doing performance activities like No. Mountain climbing, sports, or

[00:42:40 –> 00:43:16] Dr. Ronald Talis: I think I think for I think for most people, they actually tolerate it relatively quite well. I sort of have a, um, I have a biased population, right, because the people who are coming to see me are those who are coming because it bothers them for the most part, right? So there’s sort of this election bias in, in terms of what I encounter and what I engage in. But the but I think a lot of people have bunions and not all of them are getting surgery, not all of them need surgery, and they seem to be doing quite well. So, it’s not something that I would just look at and say, Oh, sorry, you’re screwed. Not, not quite that to that extent, right?

[00:43:16 –> 00:43:24] Dr. Ravi Kumar: Okay. So, if you do have a bunion, it’s not bothering you, should you wear a different type of shoe to prevent it from getting worse?

[00:43:24 –> 00:44:16] Dr. Ronald Talis: That’s a great question, and there there’s a lot of devices on the market that are geared towards bunion stretching and yoga toes and all these other kind of things that are designed to kind of pull the big toe out away from the other toes to reduce that L shape component of our foot. And, unfortunately, I haven’t seen a single reputable journal article or study that actually supports its use, that is actually gonna work for you. I I would say that just theoretically and and to me what logically what makes sense is wearing a shoe with a wider toe box when you can. That just makes too much sense. Um, and and I think that now fashion is slightly catching up with that. Also, in offering running shoes and offering other shoes that have a more square look to them. So, it’s, it’s getting easier, uh, and they’re not all ugly, which, which is a big one. I mean, if, I mean, you can, you can tell a person, hey, this is what’s really good for you, but if it doesn’t look right, it’s gonna be hard to to fight that.

[00:44:16 –> 00:44:28] Dr. Ravi Kumar: Yeah. You gotta look cool while you’re running. So, okay, let’s say someone’s has a bunion someone has a bunion, and it’s really causing them a lot of problems. They come to you, what would you do for them?

[00:44:28 –> 00:45:29] Dr. Ronald Talis: I think it starts with an with an exam and an x-ray, and that the the examination certainly includes an x-ray where we’re understanding the severity of the bunion. We’re looking at those angles. We’re inspecting for joint problems, specifically arthritis within the big toe joint, which is something that I kind of differentiate from also. So, my profession tends to differentiate between arthritis in the big toe versus a bunion, and not every bunion is arthritic, and certainly not every arthritic joint is a bunion. So those two are somewhat different. But for people who have bunions, I think the first step is getting a shoe wear change, right? It’s just a behavioral change. It’s changing the shoes, it’s trying a bunion pad or a shield that can be worn on the toe to prevent friction from the shoe hitting that nerve that we mentioned. I think those are those are the big ones that you can try in addition to, of course, using some ibuprofen or Tylenol or whatever you need for pain control, soaking your feet, massage, all the basic nonsurgical stuff. I think it’s that when those things fail, then we have a pretty serious conversation about surgical intervention.

[00:45:29 –> 00:45:32] Dr. Ravi Kumar: And what is the surgery you do for a bunion?

[00:45:32 –> 00:46:32] Dr. Ronald Talis: There are over a 100 described bunionectomies in the literature, which when you see a number like that, it usually tells you we don’t know what’s the best one to do. Okay. There was one, if there was just one absolutely best, there would not be a 100 described surgeries out there, which there certainly are. And I think that also the market is driving a little bit of this too. So as every medical supply company wants to introduce their newest screw and plate technology and their newest way of doing it, right now that’s kind of that mercantile driving of the medical practice, unfortunately. But I think what all bunionectomies have in place to some extent or another is we’re trying to realign and narrow the forefoot to some extent that kind of has to get done. You’re trying to get that metatarsal back in line with the other metatarsals, one way or the other, and you’re trying to get that big toe to be in line with its metatarsal, so the joint becomes congruent. Those are the big ones that regardless of the way you’re doing it, that that has to get done.

[00:46:32 –> 00:46:37] Dr. Ravi Kumar: Um, is it considered cosmetic surgery, or is it a something that’s covered by insurance?

[00:46:37 –> 00:47:13] Dr. Ronald Talis: Typically covered by insurance when patients meet the criteria of of pain. If it’s Okay. Painful and if it’s changing their lifestyle and impacting their quality of life, then it is a it’s no longer cosmetic, in most cases will be covered by the insurance. And I can tell you that from personal experience, people do quite well with bunionectomies, and they are able to regain a very high level, functionality that often, you know, is improved from where they started with, right? I mean, they’re coming they’re coming in pain, they can’t do the things they want to do. Now, I’ve just anecdotally found that many will come back and say, you know, gosh, I wish I had done this five years ago, or I wish I had done this, you know, even even sooner.

[00:47:13 –> 00:47:32] Dr. Ravi Kumar: Alright. Well, let’s transition over to dermatological issues with the foot. And this is something you mentioned at the very beginning. When you look at a foot, the first thing you look at is the skin. And there’s a lot of things that go wrong with the skin of the foot. It’s probably the most abused, uh, patch of skin on our whole body, honestly.

[00:47:32 –> 00:49:00] Dr. Ronald Talis: Yeah. I mean, I I can’t think of any other patch of skin that has that constant contact with the earth. Yeah. With its I mean, yes, there’s a medium between us, a shoe in most cases, but nothing else is go you’re not asking any other part of your body to hit the ground with two or three times body weight through multiple steps or or running. I mean, it just it just doesn’t happen. So I think it’s an an incredibly developed, uh, structure for sure that that unfortunately does get prone to certain problems. So, um, some of the some of the more common ones that patients will seek help for are fungal infections. Um, that’s that’s a big one. So fungal infection of the toe toenail and also of the skin in general, so we could just call the a fungal infection of the foot just for ease we’ll just call that an athlete’s foot, Uh, that’s common common terminology. Tinea pedis is perhaps the more technical term, but it’s it’s effectively where there is a fungal infection that’s growing on the foot. This will be characterized sometimes by a white, shiny kind of look in between the toes. People will see that. And also it can manifest itself as a white scaling on the bottom of the feet very oftentimes. So people will sometimes look at that and say, oh, just my feet are dry, I just have dry skin, but it’s actually the fungal infection that’s causing that that look. And unfortunately, the treatments are very, very different. So as they as they believe that they’re treating a dry foot, they’re actually feeding that fungus and making it worse in many instances. So how

[00:49:00 –> 00:49:04] Dr. Ravi Kumar: will they know if they have dry feet versus athlete’s foot?

[00:49:04 –> 00:49:23] Dr. Ronald Talis: I think that some of it is the is a clinical look. I think also things characterized by the itching, uh, and that it really just doesn’t resolve with basic lotions and things of that nature. It might look it for a second, and then it comes right back. So I I think those those are the big takeaways there.

[00:49:23 –> 00:49:30] Dr. Ravi Kumar: Okay. So what what is the yeast or the fungus that’s causing athlete’s foot? Is that tinea pedis, or is that the name of the disease?

[00:49:30 –> 00:50:10] Dr. Ronald Talis: Yes. There’s different varieties of it. Certainly, there are some that are higher virulence or or, you know, more pathological than than others. But I think that what they all kinda have in common is that fungus thrives in hot, wet, and dark environments. That’s what a fungus needs. It’s a living organism, right? And it’s, it’s ideal environment is hot, wet, and dark, which is exactly the inside of a shoe. Right? So when, when you, when you stick your foot in the shoe and you’re providing it everything that it wants to grow, it’s it’s a perfect environment for it. So, I I think that some of the treatment has to be taking away those things that kinda that kinda help feed it.

[00:50:10 –> 00:50:13] Dr. Ravi Kumar: So do people who don’t wear shoes get athlete’s foot?

[00:50:13 –> 00:52:39] Dr. Ronald Talis: I think that they do. Uh, they certainly can, and oftentimes, we’ll see that with nails, changes in their nails as well. Um, there there’s a host of other skin related problems that that come about in developing nations where people are, are not typically shod and, and kind of walking around through, mud in some circumstances and other kind of your, just your general environment. But the, ones that I’m talking about for, for most of my patients is primarily where it’s just the foot is wet and doesn’t have that ability to, to dry out properly and then kind of creates that environment that they thrive in. So just some, some basic tips or pointers that talk when possible. I recommend changing out your shoes from day to day if it’s feasible for people, If you can have a second pair of shoes that you use, don’t wear the same pair twice in a row. That’s hugely helpful if you can. It just gives it a whole twenty four hours or so for the leather or other material of the shoe to dry out, so so that improves. And I think there’s also probably a structural value of that too, but the certainly dermatological is there. For people with sweaty feet who are, who are in environments where they just have to sweat a lot in the shoe because of their work, you know, actually people who are outside working on power lines or they’re in a factory of some kind or whatever the circumstance may be where they’re where they’re sweating or there’s moisture in the area if possible change out those socks even during a lunch break, just a simple change in socks will, will, will be hugely helpful in reducing those kinds of conditions that lead to fungal changes. There’s certainly powders and antiperspirants, but I really don’t usually prescribe those or go down that path. Um, kind of a, a simple and, and fun, more homeopathic remedy for sweaty feet as, as sometimes patients will come in complaining of is just soaking your feet in a warm tea, uh, type of mix. So we’re just talking about, like, your regular black tea is fine, your the brand of your choice. Uh, obviously, you want to let it steep and not put your foot in in hot water, but as it sort of becomes a sort of a mildly warm, um, bath, what’s happening is that the tannins in tea, things that give that tea that bite is actually tannic acid. And that tannic acid is playing a role on the sweat glands. It’s making those sweat glands shrink. And so just a few, you know, maybe fifteen minutes at a time, once or twice a day is great. It’ll it’ll take a few weeks to really see the benefit of it, but it’s a wonderful treatment. It’s actually a little bit of just nice self care, uh, and it seems to play up a lot.

[00:52:39 –> 00:53:01] Dr. Ravi Kumar: That’s very interesting. So people are getting athlete’s foot from dark, wet environments. Their feet are locked in shoes where there’s no sunlight. They’re sweating and creating perspiration. So you’re recommending alternating to a different pair of shoes every day. So is two pairs enough? Like, one shoe one day and another shoe the next day, and then you’re back to the first pair.

[00:53:01 –> 00:53:24] Dr. Ronald Talis: I think financial circumstances are are what they are. And, certainly, for those people who have to buy their own work boots and work shoes, that’s, that’s simply not realistic, um, to ask these people to engage in, in all, and all that kind of stuff. But I think if you’re alternating and giving it a good twenty four hours in between shoes, that’s usually helpful. For our military folks, uh, I can tell you they’re all issued two pairs of boots. This has come standard. So that that is certainly a thing that that I encourage there.

[00:53:24 –> 00:53:27] Dr. Ravi Kumar: So and should they be disinfecting their shoes?

[00:53:27 –> 00:53:39] Dr. Ronald Talis: No. I don’t think there’s a reliable way to do it. I mean I mean, they certainly sell those things which are deodorizers and whatever else, but I I don’t think there’s a reliable way to to really do that. I wouldn’t I wouldn’t invest in that.

[00:53:39 –> 00:53:47] Dr. Ravi Kumar: Okay. And then your second tip is to change out your socks throughout the day, and I think this is something you said you guys did in the military quite a bit.

[00:53:47 –> 00:55:07] Dr. Ronald Talis: Yeah. Absolutely. Absolutely. Especially on a, on a long ruck march. It is very, very common. Good sergeants will make their team members do exactly that, where we’ll stop the march, you know, and everyone will change out their socks and then take care of their feet and then and then move on. And the idea is quite simple. As your feet get wet, as you get that macerated kind of out of the bathtub feel, the skin gets very, very soft and also weakened. Right? So now it’s becomes more prone to any kind of cuts, any kind of blistering, and now if you have a blistered pair of feet, that march is just absolutely miserable. So for for a lot of us, just getting that taken care of, taking care of your feet, even stopping in the middle of a of a ruck march, we’re talking about a march where it’s a forced march for some distance 10 plus miles, You’ve got a backpack on you, a heavy load, in some instances carrying 40 plus pounds and for some even 80 pounds. So, if they can stop in the middle of that, take a quick break and change out socks, it’s huge, that was commonly done in the military. And I think that’s a great, um, bit of advice for people who are working in professions that where they are getting in these kind of waterlogged environments, factory work of some kind or another, uh, or outdoor work, uh, you know, our linesman or, or whoever else might be doing stuff outside construction work. If you can take that moment during your lunch break, change out a pair of socks, I think that’ll be hugely helpful.

[00:55:07 –> 00:55:16] Dr. Ravi Kumar: So and for people who are suffering from athlete’s foot, taking a pair of socks to work or school, changing out in the middle of the day may will make a difference?

[00:55:16 –> 00:56:22] Dr. Ronald Talis: Oh, absolutely. It will. In in addition to the right antifungal treatment, right? For so I think we have to, we can’t just glance over that there’s no no treatment necessary. I think in in some cases where it is severe enough, you will need to add some kind of antifungal component whether that is, uh, if you were talking about fungal infections between the toes, you really want something that dries like a gel. I would avoid antifungal creams, even though that’s the first thing people want to do in many cases that will actually make the problem worse because it doesn’t allow that drying, it stays macerated so we prefer something that has a gel like application that will dry out as as it works. Okay. For the bottom of the foot, top of the foot, no problem creams are are are fine. And it’s certainly changing our socks and and just on that on that topic of of socks real fast, a little bit of material matters as well. So ideally, you want to find a sock material that is naturally wicking that wants to pull moisture away. So these tend to be more of the natural fibers like cotton, like wool in many circumstances. Whereas, when you go with the synthetic fibers, you tend to have something that just that does not wick away at all, and it just traps that moisture in.

[00:56:22 –> 00:56:44] Dr. Ravi Kumar: So someone with athlete’s foot, changing your shoes every day, changing your socks throughout the day, using antifungals if indicated, and then using also the socks should be wicking natural materials. And then the last one is tea, soaking your feet in black tea once or twice a day to reduce the amount that you sweat, which indirectly reduces your

[00:56:44 –> 00:56:52] Dr. Ronald Talis: Exactly right. Propensity for half the foot. Tannic acid that seems to play a role and affect the that those eccrine sweat glands somehow. It’s really interesting.

[00:56:52 –> 00:57:07] Dr. Ravi Kumar: That’s very interesting. No one’s ever told me that. So if you’re beating the t, you know, and I think most people have had athlete’s foot or something similar at some point in their lives. Okay. Let’s talk about toenail fungus because you mentioned this Yeah.

[00:57:07 –> 00:57:07] Dr. Ronald Talis: When you

[00:57:07 –> 00:57:32] Dr. Ravi Kumar: were starting to talk about fungal infections, because toenail fungus haunts some people. I mean, it is like something they get. They never get rid of. They don’t know how to get rid of it. And then you’ll also see very metabolically unhealthy people, people with diabetes, who every single toe on their foot is infected and, uh, with fungus, what can be done about this? Is it something you have to live with, or can you can you cure it?

[00:57:32 –> 01:00:57] Dr. Ronald Talis: It’s really hard. It’s really, really hard to cure, and the longer it’s been there, and the more severe the infection, the more embedded it is, the harder it is to cure, for sure. I think when you catch it early, where it’s sort of more superficial, it’s just sort of a color change, something doesn’t look quite right, okay, the nail maybe is a little bit more brittle In in some circumstances, we can cure those fairly reliably, but as it gets really rooted in, oh my gosh, it’s it’s tough. I I mean, it’s really a challenge to get rid of. It it it’s really one of the harder things, actually, that that that a treat because it’s just you’re really digging in to get it. So we’ll kind of talk about a little bit of it. The first thing I I would say is ideally, it starts with a with a good diagnosis because there is a common phenomenon called a runner’s nail that very closely mimics the appearance of a fungal toenail. So basically this is Okay. Where repeated micro trauma to the nail has caused it to change in its appearance. It becomes thicker, it often becomes darker. It sort of looks just like a fungal toenail. So I think you have to have some suspicion really a fungal infection or, or is this more micro trauma or, or is there another metabolic cause, right? Is there a vitamin deficiency of some kind that’s causing this nail to appear unhealthy? So starting with a diagnosis, that’s oftentimes clinical judgment, but certainly if you want to get more exact, just a nail trimming. You can just send a nail trimming off to the lab and we have a dermatopathologist that will look at the the nail and say, Yep, that’s that’s fungal or or no, this looks more like these kind of cells are more typical we see in in trauma. So before you invest all this time, all this money, all this everything into really kind of driving away the fungal infection, I’d I’d start with the right diagnosis for sure. But as far as once diagnosis is confirmed, what what can be done? That said, it’s it’s really a challenge. There are topical nail lacquers that have plus or minus, uh, some success. I would say the more superficial ones are definitely, uh, a great way to start with these with these lacquers. We’ve gone through so many different types and variations of them. I find that the best ones for us have been ones that have oleic acid in them. And what’s interesting about that, it’s not just an antifungal component, but they also have oleic acid, and this acid helps the antifungal component penetrate through the nail itself, through the nail plate. So, it gets, it gets home. So, that that’s one of the ones that we we send in delight. There are oral medications. One of the big names out there is trybenifen. It’s a generic drug. It’s been around a long time. It takes a long time to work for sure. It is processed by the liver. So that is something that we have to watch and monitor carefully to liver function tests to make sure that, this medicine is not hurting someone’s liver. There’s new and novel kind of approaches. There’s laser therapy, there’s a light therapy, which is really interesting where, um, sometimes the light what we’ll do is we’ll paint the nail with a dye, a special dye that attaches to the fungus. A light will activate free radicals within that dye, basically killing the fungal infection within itself that’s attached to it. That usually is a repeat treatment, which is not insurance covered. So, so that’s another thing that you have to kinda have to counsel people on sort of the costs, uh, of, of these treatments. And, of course, there’s some people who just don’t wanna have toenails anymore, and would, would rather have a surgical removal of the toenail in such a way that it doesn’t grow back. They’re just so sick of the, of the density and the changes to the nail.

[01:00:57 –> 01:01:09] Dr. Ravi Kumar: So if you let’s say you want toenails, but you don’t want toenail fungus, can you have the toenails removed, treat with an antifungal, and and have the nails grow back normal?

[01:01:09 –> 01:01:47] Dr. Ronald Talis: That’s an awesome question. It’s one that I’ve I’ve asked routinely, and unfortunately, I don’t have any good study to suggest that removing the nail improves the odds of the antifungal working. I mean, rationally, it makes sense. I mean, it it it does kinda make sense. I get it why that would why that would work. If you take away the nail plate, you allow the antifungal component increased exposure to this. You’re starting from scratch. I I totally understand the philosophy behind it. Unfortunately, I don’t know of a single study that’s proved it that actually shows that there is efficacy in these things that are improved by removing the nail first. And so if we can avoid taking off a nail, it probably should.

[01:01:47 –> 01:02:00] Dr. Ravi Kumar: So let’s say you live in a household and someone in your household has toenail fungus. Can you catch it from them, and is there anything you can do to avoid it if that’s if it is contagious?

[01:02:00 –> 01:02:34] Dr. Ronald Talis: That has been theorized. Again, you know, you know, I I don’t have proof of this. I mean, it it stands to reason. Right? I mean, if you bring this organism into the house and sharing showers and bathrooms, all these sort of intimate spaces and such, it makes a lot of sense. I don’t have a study that confirms that. My thought process is, I’m a huge fan of, for patients especially who have other kind of conditions, is white socks, and I say that so that the sock can be bleached. It helps kind of take away some of that fungal burden. They’re just kind of practicing normal hygiene around the house. I think all those all those things help, and probably are just your best shot.

[01:02:34 –> 01:02:46] Dr. Ravi Kumar: So right now, let’s say your best advice to someone who, let’s say, they just have one toenail, it’s got a fungus, they hate it, they want it gone, what is the best thing for them to do right now?

[01:02:46 –> 01:03:01] Dr. Ronald Talis: I think depending on the severity, either topical or oral Okay. Antifungal or a combination of thereof. Many of them are very conducive to that, to combining oral and topical therapies at the same time. And that’s probably where I would start.

[01:03:01 –> 01:03:03] Dr. Ravi Kumar: And how long does that take to eradicate

[01:03:03 –> 01:03:11] Dr. Ronald Talis: that infection? Months and months. I mean, you’re not gonna see those changes minimum three months, and in many circumstances, it’s much longer than that.

[01:03:11 –> 01:03:30] Dr. Ravi Kumar: Okay. Let’s talk about warts because I don’t know if I’ve ever met anyone who hasn’t had a plantar wart, um, or if they haven’t, they probably had one. They didn’t know about it. So what are they? I mean, because you hear about warts, and you think, oh, is this a fungus? Is this what is this? Why is it happening, and how do you get rid of it?

[01:03:30 –> 01:04:49] Dr. Ronald Talis: So warts are primarily a viral lesion, so it’s a viral infection, and the virus sort of makes a home for itself and creates all these environmental changes for itself, for its own benefit and value, right? And so what do what do they look like and how do we differentiate them from calluses? Uh, typically warts will change the skin lines. So, sometimes you’ll see skin lines running right through a callus and this is sort of normal. Then when you see the sort of the obliteration of these skin lines, there’s often a dark dot right inside the lesion itself. These kind of look like that. And for most of us who are seeing this as clinicians routinely, it just has that look, right? There there just sort of looks like a wart. Uh, and again, we can certainly biopsy it to confirm that is what it is. And it’s interesting that I’ve often found that there is a psychological component to this as well, where people who are under stress and duress of some kind or another do seem to manifest skin changes more. We know that that happens in, in other parts of the body as well. And you know, I trained in New York City and there was the particular phenomenon where these guys who were working on the stock exchanges all had this planter wart on their heels, and We just sort of jokingly referred to that as as a stockbroker’s work. Uh, so I think that I think that there’s a component really, uh, of stress. Uh, you see it a lot in teenagers, and there’s just these these these changes in our bodies manifesting that stress in in different ways.

[01:04:49 –> 01:05:10] Dr. Ravi Kumar: So it’s human papillomavirus. Right? This is the the group of viruses that are causing warts. Same, uh, group family of viruses that cause genital warts and cervical cancer. There is a HPV vaccine for cervical cancer, uh, that both boys and girls can get. If you get that vaccine, does it have any effect on plantar warts?

[01:05:10 –> 01:05:44] Dr. Ronald Talis: I have absolutely no idea. I I I have I have no idea. I I it’s it’s a phenomenal interesting idea. It’s it’s really an interesting question, and I don’t know it. I’m not sure that’s even been studied. Obviously, the vaccine was really pushed specifically for the cervical cancer risks, right? Right. That was the big one. It would be fascinating to then go back and look at that data, like, Hey, by the way, how what percentage of this population did get warts or refer or came back to a podiatrist office or a dermatologist office Mhmm. For for plantar warts. That would be fascinating. Yeah.

[01:05:44 –> 01:06:03] Dr. Ravi Kumar: And they’re very different. Just I mean, just so the audience knows, you can’t get a genital wart can’t infect your foot. Your foot wart can’t infect your genitals. It they’re all HPV viruses, but they have very specific requirements for where they infect skin on the body, essentially, epithelium on the body.

[01:06:03 –> 01:08:22] Dr. Ronald Talis: Yeah. I think I think that’s the perfect explanation for it. So for me, when I’m treating these things, a lot of it is trying to harness your body’s own immune system to try to attack the virus and get after it. And so one of the best ways that of course, there’s other kinda, like, homeopathic remedies that you might look up online, like duct tape or or whatnot, trying to put the duct tape on it or just which I think is really just sort of getting our body to recognize that there’s something there that it needs to fight off. For me, one of my favorite, uh, treatments in the office is a product called cantharidin or sometimes called cantharone. Interesting history here. This is the derivative of a blistering beetle, right? So these beetles out there that are found in nature will lay this kind of acid on their larvae to protect their larvae from other pests and other attackers, so it’s a defensive mechanism. But when we encounter it on our skin, it creates a blister as the name blistering beetle implies. In doing so, it harnesses your immune system. It tells your immune system that there’s something there, and now we’re sending all these white blood cells into the area to attack the wart. And what’s so interesting when we treat sort of these clusters of warts is that very often if you if you get that mother ship, that that first wart that kind of started it all, oftentimes after that, you’ll see all these other warts just turn black and just kind of, like, fall off. So it is as though our body has developed the antibodies that it needs through this process by harnessing the immune system to do it. Cantherone has been around for thousands of years in human history from ancient Chinese medicine to, uh, ancient Egyptian medicine and and is in some circumstances even considered aphrodisiac. So, uh, I’ve not tried it I’ve not tried it in that way. I’ll give you that that disclaimer. So I don’t know how it works in that in that context, but certainly for for treating warts, plantar warts, it’s phenomenal. It’s it’s absolutely my go to choice. I think an important reason for that is also that it does not scar. And that and that’s a big deal. So there’s other ways of getting rid of warts. So surgically excising them, cureting them, cauterizing them. There’s bleomycin and other types of acids that are applied. And, unfortunately, some of these have scarring effects, on the bottom of the foot. And, and I can just tell you, it’s not about cosmetics. The, the scar on the bottom of the foot is, is a big one for people. It really distracts and takes, and can be a huge source of pain for them. So, so that’s why so that’s why I prefer a non starring treatment, like, Canton, that that harnesses the body’s immune system.

[01:08:22 –> 01:08:27] Dr. Ravi Kumar: That’s very interesting. So where can can people buy this over the counter, or do they have to go to a podiatrist to get it?

[01:08:27 –> 01:08:42] Dr. Ronald Talis: No. So far, it’s not available over the counter. This is stuff that is that is typically made from a compounding pharmacy, um, and and it’s something that really a professional should apply, and and we’ve seen this become big in dermatology clinics as well as podiatry clinics both.

[01:08:42 –> 01:09:27] Dr. Ravi Kumar: And that you know, that’s very fascinating because there is something called the abscopal effect in oncology, where if you give a patient a PD L one inhibitor, which is, you know, basically a checkpoint inhibitor, tells your immune system, don’t rest. Be active. And then you radiate a melanoma on someone’s body. The immune system will go in there to clean up that killed melanoma, but then it’ll go out to the rest of the body and start attacking all the other melanoma because you exposed it. You activated the immune system and exposed it to tumor antigens, and now it’s going out and attacking the rest of the the metastatic disease. And I feel like this HPV and, uh, blistering beetle juice is basically the same type of phenomenon.

[01:09:27 –> 01:09:53] Dr. Ronald Talis: Yeah. I I think so. I think it’s it’s that we’ve we’ve given our immune system a profile of what to look for. Yeah. And now it now knows selectively what to hunt. Right? So those those T cells and other things are adapting to the particular structure of that virus, and and it knows this is the bad guy, and it’s gotta go after it wherever that wherever that is. So I I think it’s powerful medicine, and it makes all the sense in the world to me to try to harness our body’s own immune system, kinda cure these conditions.

[01:09:53 –> 01:10:15] Dr. Ravi Kumar: Okay. Let’s talk about heel cracks, and not everyone has had these. I have had them, and they and they are crazy painful, but they only happen in the summer when I’m wearing flip flops. And I’m wondering why does this happen, and what can you do about it? The only solution I found was wearing shoes. And can you explain, like, what’s going on here and what someone should do if they have heel cracks?

[01:10:15 –> 01:11:47] Dr. Ronald Talis: Absolutely. I think to to exactly kinda like what you said, it’s a it’s, again, a moisture issue, but this time, a a lack of moisture. It’s more common in the summertime. Everyone’s wearing flip flops, Church is notorious for that. You’re you’re sweating, um, but the air is drying that sweat around you and it’s drying that skin very rapidly, and so that’s causing our skin to react in that way, sort of like you videos or pictures of of a dry cracked earth baked under the sun, uh, and and that kind of a phenomenon. So I think that that’s what’s going on there. As far as treatment, look, I think what you said is perfect. If if dryness is the problem, then rehydrating, you know, kinda solves that problem. And in many cases, lotion or other kind of moisturizer in the area, even if it’s simple like Vaseline or CeraVe based type of thing, is totally fine with socks and shoes, and, and very often the problem goes away. I think we become more involved when it’s more severe. Fissures are deeper. Uh, there there’s cracks beyond dermal layer that are extremely painful. I think sometimes we’ll we’ll try to shave those down and plane those down to reduce the the amount of surface area that is gonna be cracked and also other home remedies. These ones that just don’t get better, believe it or not, even something like Krazy Glue works fantastically well. You know, and I have to be I have to be careful saying that as as a practicing provider, but, you know, it’s, uh, it’s true. For some of these heel fissures that just don’t get better any other way, these these tough, tough glues work phenomenally well, where you just kinda hold the skin that’s just tight together, and that glue creates seal around it. You know, I I I’m I’m careful in saying that. Okay. For For Don’t

[01:11:47 –> 01:12:03] Dr. Ravi Kumar: get your doctor first before you put crazy glue on your heel cracks. Okay. So, basically, by moistening the heel, covering it, preventing it from drying out, you can prevent these the heel from cracking. Are some people more prone to it than others?

[01:12:03 –> 01:12:28] Dr. Ronald Talis: Yeah. I think so. I mean, I think some people just get it and it’s very seasonal, you know, for for medic people, for for sure, and that, and it’s a shoe we’re driving it. Um, and and also as we discussed before, there could be a fungal component to it as well, right? Something that is is drying out that skin in the in that area causing these fissures. So there there’s there’s that also. I think it’s just it’s gotta be a clinical, um, judgment call there.

[01:12:28 –> 01:12:37] Dr. Ravi Kumar: Yeah. And what about the thickness of the callus on the foot? I mean, why do some people have very little callus and others have a a lot of callus?

[01:12:37 –> 01:13:41] Dr. Ronald Talis: Also, a tough question to answer. I think that there is there there’s really there’s two reasons. One is purely dermatological. Some people are just going to develop callus more than others. So that becomes the skin itself, right? That that is just some people can develop callus in a way and their callus can be harder. This is how you’re how you’re born and this is what your skin is going to do kind of a scenario. What’s troubling is that when you look at particularly calluses that grow in, so we call these IPKs since we’re Irattractable Plantar Keratoma, uh, which is just a fancy term for saying a callus is really, really dense and is growing into the skin rather than covering a surface area of it. And very often, those are formed by from pressure. So part of my job is trying to understand, is this purely dermatological or is there a pressure issue that’s happening where a person is overloading one particular area of the foot because of a bone change or a gait change or something is happening where there’s a tremendous amount of pressure going in one hot spot and your skin has to adapt to protect itself, and so it’s hardening in that way

[01:13:41 –> 01:14:04] Dr. Ravi Kumar: and creating micalles. And one other thing I wanted to talk about, and I’m not sure if this falls into the dermatological category, but it’s ingrown toenails. Because this is something I imagine you see a lot, and they’re Yeah. Crazy painful when you get them. Is there a way to prevent them? Well, first of all, why are they happening? What what’s actually happening? Is there a way to prevent them?

[01:14:04 –> 01:16:41] Dr. Ronald Talis: Yeah. I mean, ingrown toenails are a big part of our practice for sure. Our foot grows nail from a tissue called the matrix, and so that’s right behind the cuticle of the nail, where you could think of it as sort of that proximal nail fold, as we would call it, and that is the germinal tissue where nail is gonna grow out from. So nail doesn’t just grow from the from the front, it’s grown from the very back and the nail is being pushed out. So your newest nail and people don’t often understand that so your newest nail is at the very back, and then your oldest nail that’s getting pushed out is towards the front. So in some circumstances, we will have nail and matrix tissue that’s where the nail is growing from that’s on the sides and it’s growing underneath the skin and then it’s sort of like nail we can’t really see. And then as that nail grows, it is growing into the skin. So now we have this situation in our body where a structure that’s meant to be outside the body is growing into the body and our body does not like that, right? So it creates this whole inflammatory process around that, it can often lead to infections, you know, things. So that’s what an ingrown toenail is and of course, there’s there’s pain associated with that because of the amount of inflammation that that happens there. As far as how to prevent it, I think that the way you cut the nail, typically, you wanna cut the nail straight across. I think we’re all probably cutting our nails a little bit too short in many circumstances as well or getting too cutesy into the corner, uh, is is probably making that ingrown toenail happen more commonly than it ought to. Certainly, there’s structural changes that can happen. I don’t think it’s a coincidence that I see ingrown toenails more commonly in during pregnancy. For for pregnant ladies, they are their feet are swelling, they’re also carrying more weight, of course, and I think all of this is playing a role in in the ingrown toenail. It’s also very common among preteens, and I think some of that is, again, hormonal changes that are changing things for those kids, but it’s also maybe, somewhere in that line of thinking where the kid is kind of too old to let the parent cut their toenails for them, but they haven’t quite figured it out yet for themselves. So, they’re sort of in that, in that, uh, interesting junction during, uh, maturity. So, I think that happens as well. But of course it can happen to absolutely anybody. If you’re at home and you have an ingrown toenail and you’re not sure what to do, I think that the best thing you can start to do is soak your foot in warm water and Epsom salt. Uh, it’s a great home remedy that you can try. Try to push the skin edges away from the nail and reduce inflammation in that regard. And for many people, that works, and it works very well. It’s for those that is not gonna work and become really quite painful, then then you need a trip to come see us, and we’ll take care of that for you.

[01:16:41 –> 01:16:46] Dr. Ravi Kumar: So what are you gonna do if they come and see you?

[01:16:46 –> 01:17:19] Dr. Ronald Talis: Uh, well, I hate to say it now, cause no one’s gonna want to come in after they hear this. No, so, so typically we’ll numb the toe up. So it’s a local anesthetic that’s given to the toe. It numbs up the toe, and then we’re cutting the border back all the way to the very back of that proximal nail fold, which is far, far, far, farther than you would want to do at home for yourself. And, and many people try to do these kind of things for themselves, and they don’t get anywhere near where they ought to. They’ve just done enough just to make my job a little bit harder. It does not resolve the the issue. I think it’s just something that is just quite painful if the toe was not numbed.

[01:17:19 –> 01:17:31] Dr. Ravi Kumar: So is the the nail growing into the tissue back at the base by the germinal matrix, or is it growing into tissue at the end where the nail leaves the toe?

[01:17:31 –> 01:17:44] Dr. Ronald Talis: Yeah. I mean I mean, certainly certainly, the path that it’s on starts all the way back there. Right? That’s that’s sort of the trajectory of it. But in most cases, it does not become symptomatic until nearer to the end. Okay.

[01:17:44 –> 01:17:48] Dr. Ravi Kumar: So is there a special nail trimming technique you can use?

[01:17:48 –> 01:17:59] Dr. Ronald Talis: Cut cutting square trying to cut the nail straight across, leaving the nail a little bit more square shaped where feasible, not trying to get too much into the corner because that’s where that that toenail is gonna start to grow into the skin.

[01:17:59 –> 01:18:14] Dr. Ravi Kumar: So okay. Let’s wrap it up. This has been a master class in foot health. It’s been awesome. Thank you. If you were to leave our audience with some tips for having perfect foot health, what would what would they be?

[01:18:14 –> 01:19:07] Dr. Ronald Talis: Let’s start from the top. I think it’s not even necessarily what you’re doing to your feet. It’s what you’re doing to the to your whole body. If your weight is controlled, that’s probably the biggest one in this country, for sure. It is obesity. If you’re not stressing your body’s structure, the architectural structure with excess body weight, that’s already huge for you, of course. I would say avoiding those kinds of conditions like diabetes in many instances which are just notorious for foot, uh, problems that would be huge. And of course, not smoking or smoking cessation is another one. And we mentioned that because of the arterial component. Right? So we know that as you engage in this tobacco product use, it vasoconstricts the blood vessels chronically, causes peripheral arterial disease in many circumstances. And so those are are the big three that you can do that you wouldn’t think of, but they have a huge role on on your foot. So even stop so even before we get to the foot itself.

[01:19:07 –> 01:19:09] Dr. Ravi Kumar: And they’ll make the rest of your body healthier too.

[01:19:09 –> 01:19:10] Dr. Ronald Talis: Oh, of course.

[01:19:10 –> 01:19:29] Dr. Ravi Kumar: I mean, your whole vascular system is affected by metabolic disease, which is diabetes from weight gain, and it’s affected by nicotine. Nicotine’s horrible. It’s probably one of the worst drugs you can put in your body because of the not only the oxidative stress from smoking, but the vasoconstrictive effects like you just talked about.

[01:19:29 –> 01:20:16] Dr. Ronald Talis: Yeah. I I mean, look, it’s it’s not a coincidence. I mean, all all these things, your general health is gonna manifest itself everywhere, and especially the foot. And, you know, what’s interesting is a lot of times I’ll have patients that will come in and will will notice a problem with their toes. Right? The the toe is is darkening or dusky or very cold or something’s going wrong, and that leads us to do further evaluation. And it’s not surprising that patients who have peripheral arterial disease, we’re talking about bad blood vessels in the extremities, also have coronary artery disease. Right? So the same blood vessels are affecting very similarly. So in some cases, the foot becomes, uh, I guess, the canary in the coal mine. Right? The kind of the first sign that there’s gonna be a problem later on down the line. Yeah. In terms of our bass culture and and other places.

[01:20:16 –> 01:20:26] Dr. Ravi Kumar: I mean, that’s very interesting. The foot is essentially a window into metabolic health because of its location in your body and how it it would, like you said, be a canary in the coal mine.

[01:20:26 –> 01:20:51] Dr. Ronald Talis: Well, and exactly what to continue the canary in the coal mine analogy, it’s because the blood vessels in the foot are smaller. Right? They’re they’re further from your body, from your core, and they’re also smaller. So they’re gonna get affected by these various diseases first in many circumstances, but that doesn’t mean that there’s not disease further on down the line as well. We’re just gonna see it more clearly, and it’s gonna manifest itself in a more obvious way sometimes in in the tools.

[01:20:51 –> 01:21:05] Dr. Ravi Kumar: Okay. So you you said take care of your metabolic health. Don’t smoke. Lose weight. Let’s say you’ve got a fit athlete, and they want the healthiest foot so they can be Yeah. Best, uh, performing at whatever sport they’re in. What do they do?

[01:21:05 –> 01:21:51] Dr. Ronald Talis: A portion of your workout, not all your workout, but a portion of your workout, a cool down or whatever you need to do some form of plyometric exercise barefoot on a controlled surface. Barefoot. It would be hugely helpful. So, I mean, look, you’re not going to get a football player to do an entire practice barefoot. It’s simply not safe. I mean, you’ve got cleats. I mean, there’s a reason for that. Right? So, and depending on the sport and bicyclists and all, all this other stuff. So some of what we do just has to be an, an issue. But if you can have some time, uh, towards the end of a workout, whether it’s the end of a track workout or the end of, uh, of any kind of practice where you’re actually doing some of these exercises, some of these drills barefoot, this can be hugely helpful in developing that musculature and, and those small muscles, and their, and their fast and they’re speed with firing as well. That’s that’s a big one for sure.

[01:21:51 –> 01:22:40] Dr. Ravi Kumar: Okay. That’s that’s fantastic, and I think that’s kind of, like, this overarching theme that we’ve seen for years now since the book Born to Run came out is that, listen, we we have this foot that was designed for a purpose, and it wasn’t designed to be in a shoe. It was designed to be in contact with the Earth. It is our one connection to this Earth because we’re bipedal. We’re we only stand on two two extremities. The fact that, like you said, we’re shot all the time. We need some barefoot time, and it it’ll make your foot healthier, um, as long as you get that. So I think that’s really cool and very interesting. Thank you so much for coming on the show. This was fantastic. The audience wants to get ahold of you or see you as their doctor. I mean, how how would they get ahold of you?

[01:22:40 –> 01:22:58] Dr. Ronald Talis: Premierfootandanklenc.com. Uh, you can look us up on our website. That’s probably the simplest way. As you know, I’m in North Carolina working with you and other great docs at, uh, in Pinehurst and other places. So web page is probably a a fast way to do it, and certainly, we can help encourage a link there if they want. Okay.

[01:22:58 –> 01:23:00] Dr. Ravi Kumar: And do they need a referral to come see you?

[01:23:00 –> 01:23:16] Dr. Ronald Talis: Depends on their insurance. Okay. And I hate to I hate to say that, but that that is the truth. Some, some insurance plans allow for patients to see a specialist without a referral and and other plans don’t. And so it it really becomes an insurance driven conversation.

[01:23:16 –> 01:23:20] Dr. Ravi Kumar: Well, thanks so much for coming on the show. It was awesome. Cheers.

[01:23:20 –> 01:23:22] Dr. Ronald Talis: Okay. Take care.

[01:23:22 –> 01:24:31] Dr. Ravi Kumar: Okay. So I hope you enjoyed that conversation. Dr. Talis is an incredible wealth of knowledge, and I think this episode really drove home a point that most of us have never considered. Your foot is the foundation of your whole body, and we’ve been neglecting it, as a society in general. A few things that really stuck with me are, one, our shoes are basically casts. They’re weakening the muscles in our feet every single day. Two, something as simple as spending part of your workout barefoot on a controlled surface can make a real difference. And three, your feet can actually be a canary in the coal mine for bigger health issues like diabetes and vascular disease. Taking care of your overall metabolic health, managing your weight, not smoking, those aren’t just good for your heart. They’re good for your feet too. Okay. So that wraps it up for this episode. If you found this episode valuable, please share it with someone who you think might be able to use it or find it valuable as well. And until next time, stay curious, stay skeptical, and stay healthy.

Cheers.