Foot pain
Dr Koepsel Interview
Kirk A. Koepsel, D.P.M., M.B.A., is a board certified podiatric surgeon in foot and ankle surgery by the ABPFAS. He graduated cum laude with a BS degree from the California State University in Long Beach and as valedictorian from the California College of Podiatric Medicine with BMS and DPM degrees. Dr. Koepsel has developed an expertise in the biomechanics of foot and ankle function and its relationship to foot pain. He is the immediate past President of the Texas Podiatric Medical Association. He practices in Houston, Texas, where he serves as an attending clinical instructor for the Harris County podiatric surgical residency program.
Pain.com: Why did you decide to specialize in the treatment of foot pain?
Dr. Koepsel: My first real experience in dealing with someone with foot pain was with a family member who suffered from rheumatoid arthritis. This crippling disease made it extremely difficult for her to walk even short distances because of extreme pain in her feet. She would see a podiatrist on a regular basis and her doctor was able to treat her in such a way as to make it possible for her to go for long periods of time with minimal pain in her feet. This doctor, with some simple techniques, was able to make this woman's life bearable, significantly improving the quality of her life. She loved her podiatrist and would say that after seeing him she could almost dance out of his office. I was always drawn to medicine as a career. My original intention was to work in public health in third world countries. After having spent some time working for the National Institute of Public Health in Columbia, South America, I realized that it was not what I wanted to do. When I returned to the United States and began seriously considering medicine as a career, I visited with a number of doctors in a variety of specialties. I was surprised to find that the podiatrists I met seemed to be the most satisfied with their careers. The variety and complexity of foot problems causing pain also surprised me. Now, after 15 years in practice, I have found treating foot pain to be both challenging and rewarding. Much of what I am able to do can significantly improve the quality of life for my patients.
Pain.com: Do you ever recommend non-traditional methods to treat foot pain?
Dr. Koepsel: My education and training is grounded in the allopathic approach to medicine. That is to say, my approach to the diagnosis and treatment of foot pain is founded in the scientific method and backed by published research. But, as the saying goes, the more you learn the more you realize you don't know. No one has all of the answers when it comes to treating foot pain. Some patients don't fit the mold and traditional therapies don't seem to work. When I encounter patients like this, the first thing I do is obtain a second opinion. Our practice has four doctors and we consult with one another on a regular basis. Other times I may seek a second opinion from other colleagues or other specialists. If I am not able to obtain satisfactory answers or responses to treatment plans, I may turn to non-traditional methods. I think it is a mistake for patients to forego the traditional approaches of medicine and to start with non-traditional care. Often times they are just prolonging their pain and, in other instances, they may actually get worse. I am a strong believer in the nutritional basis for health and healing. I have used chiropractic care, although I don't really view this as "non-traditional". In other instances I have suggested treatments such as chelation therapy for my patients who have significant lack of circulation and are not surgical candidates for vascular reconstruction. In other patients with nerve or tendon damage I may recommend magnet therapy. There are a lot of "magic potions" advertised and on the market. Patients, desperate for answers and a solution to their pain, can fall prey to false claims and promises. I ask my patients to let me guide them through these non-traditional alternatives and monitor their progress if they have found or heard of something they want to try. When I decide to use a non-traditional therapy, I choose from those that have strong anecdotal evidence and some basis of research subjecting the claims of success of these products to the scientific method.
Pain.com: Would you treat foot pain differently than other pain?
Dr. Koepsel: Treating foot pain can be a little tricky. The foot is challenging because it is a weight bearing structure that is influenced by multiple factors. Foot pain can be caused by a local problem in the foot or it may be due to something more distant from the foot itself. In understanding and treating foot pain successfully, it is essential to understand the musculoskeletal mechanics of the body, particularly the lower extremities. Podiatrists call this biomechanics. No other medical specialty studies biomechanics of the lower extremities in the depth as that taught to the podiatric specialist. Nerve compression in the back, hip or knee can cause foot pain. Muscle imbalances in the leg and skeletal alignment problems cause foot pain, and metabolic disorders such as diabetes or gout can cause foot pain. Foot disorders can also contribute to pain in the leg, knee, hip and back. I don't know that the actual treatment of foot pain differs that much from the treatment of other pain, but understanding the underlying cause or mechanics associated with the pain is the key to successful treatment. For example, a very common complaint of foot pain is heel pain. This pain occurs in the bottom of the heel and tends to be worse first thing in the morning or after getting up from sitting. One of the key elements contributing to this condition is an imbalance in the muscles in the leg. In this instance, the calf muscles are overly tight. A x-ray may demonstrate a spur on the heel and many might consider this spur to be the cause of the pain. In fact, the spur has very little to do with the pain. It is a secondary reaction to the effect that the calf muscle may have on the foot. Rarely do we have to remove this spur to permanently cure the patient from heel pain, but we always address the tight calf muscle by teaching proper calf stretching exercises. On occasion I have gotten patients better with doing nothing more that showing them how to properly stretch their calf muscles. Understanding the nature and origin of pain is the key to successful treatment.
Pain.com: What are the major concerns of foot pain patients regarding pain medication, i.e., addiction, and side effects?
Dr. Koepsel: My experience with patients concerning pain medications or medications in general is that they just don't want to have to take them. They want to get over what is causing their pain and get on with their lives without the use of drugs. The most common concern my patients have is about a drug causing stomach upset or nausea. Some patients have a concern about the effects cortisone will have on their bodies, and others are concerned about the addictive nature of the drug or the need for repeated use so that they can continue with their normal activities. Fortunately, the use of drug therapy is only temporary in a vast majority of my patients. Most foot pain patients will respond to the right combination of physical therapy and appropriate biomechanical control with the use of orthotics and/or surgery.
Pain.com: Are opioids the best drugs for foot pain?
Dr. Koepsel: Opioids are a useful class of drugs for pain control and I use them when needed. To undertreat pain has the potential of setting up physiologic responses that make long term pain control more difficult or may actually lead to a chronic pain syndrome. I don't believe that they are necessarily "the best" drugs for the treatment of foot pain because there is no one "best drug". The drug of choice has often to do with the nature and underlying cause of the pain. Drug or drug combinations can be as varied as the types of pain that patients experience. When I have a patient that requires prolonged use of addictive narcotics, I will work with that patient in consultation with a pain management specialist. The pain management specialist is best equipped with the knowledge and expertise to deal with the pain side of the equation. Pain is a symptom of some underlying origin. I focus my attention on determining the origin of the pain and treating that aspect of the condition. Quite often the tests that we order, such as a bone scan, MRI or CT, will not show us what we need to see. It takes the experience and the expertise of someone knowledgeable in the local anatomy and biomechanics of the body part to uncover the source of the pain.
Pain.com: What are the most effective drugs for the treatment of foot pain and what are their side effects?
Dr. Koepsel: A common drug used in the treatment of foot pain is an injectable steroid compound. These drugs are very effective in the treatment of acute and chronic foot pain. When used, these drugs should be used sparingly and intermittently. At the dosages given to treat foot pain they are very safe with minimal risk of side effects or complications. One of the most common side effects of injectable cortisone, if given repeatedly in the same location, is a shrinking of the soft tissue structures it is being injected into. Steroids will weaken tendons if they are injected directly into the tendon and will thin cartilage on the surface of joints when injected into the joint. Over time, the tissue will recover from these effects if the drug is not used repeatedly over a short period of time. My rule of thumb is to not give more than three injections into the same location over a twelve-month period and to wait at least three weeks between injections. This of course depends on the dosage and strength of the cortisone I am using and the purpose for which I am using it. In some instances my intention with the use of the drug is to take advantage of these effects such as the shrinking of soft tissues in scarred and damaged tissue. Patients who have diabetes should be warned in advance of using the drug that their blood sugar levels might be temporarily elevated. Also, high dosages of cortisone given on a prolonged basis can cause an elevation in the blood pressure, osteoporosis, stomach lining irritation or ulceration and weight gain.
Another class of drugs commonly used in the treatment of foot pain is the non-steroidal anti-inflammatory drugs. These drugs can be used for long periods of time with relative safety. However, a common side effect is stomach lining irritation. In some instances this can lead to bleeding in the gastrointestinal tract. Because of the relative frequency with which these drugs are used, a number of patients end up suffering from this complication and millions of health care dollars are being spent to treat the side effects of these drugs. Fortunately, a new class of drugs, is being developed that possess little to no side effects of this nature.
Pain.com: What are the chances of a foot patient becoming addicted to pain medication?
Dr. Koepsel: The use of narcotic pain medication carries the risk of addiction. It is sad when I have a patient who is actively seeking pain medication on a continual basis. In some instances this seems to be the only alternative for them. In other instances it is due to a psychological dependence or even addiction to the drug. Chronic pain can cause depression, especially in someone who was very active before they developed their foot pain.
Some of the drug companies and many pharmacies are now monitoring patterns of prescription drug abuse. They will notify the doctors when a patient is obtaining pain medication from more than one doctor. When this happens, the patient's complaint of pain loses credibility and treatment becomes even more difficult. When faced with situations like this, I always refer the patient to a pain management specialist and work in consultation with them.
Any patient who takes narcotics over a prolonged period of time runs the risk of addiction. The goal of any treatment plan should be to determine the cause or mechanism of pain and to move the patient in the direction of treatment that reduces the need for pain control through the use of narcotics. My advice to all physicians of any specialty who are treating foot pain with prolonged or repeated use of narcotics is to consult with a podiatrist who is knowledgeable about lower extremity function and biomechanics. My advice to foot specialists who are treating difficult pain management patients is to consult with a knowledgeable pain management specialist. The opportunities for success are much greater with these difficult patients if the physicians will work in consultation with one another and as a team.
Pain.com: What does the future hold for foot pain patients? Are there drugs and treatments in our future that will alleviate pain for foot patients?
Dr. Koepsel: There are some promising new drugs on the market and drugs being investigated for the treatment of pain. New drugs, which have the same potency for the control of pain without the addictive side effects, are being developed. New modalities for blocking pain at the spinal level are becoming available and being investigated. New imaging techniques, such as ultrasound, are being developed for foot related problems, which show promise in the diagnosis of soft tissue injury that may be missed by x-ray, MRI, or CAT scan.
As long as there are people who suffer from chronic pain, for whatever reason, there will be those doing research on how to better diagnose and treat these disorders. In the past ten years, there has been tremendous growth in the research of pain management and diagnosis. An entire new medical specialty has evolved, the pain management specialist. These new medical specialists are a welcomed partner in the treatment of patients with chronic foot pain. These patients had far fewer options for treatment just a few years ago.
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