Foot Health
Abscess
What is it?
An abscess is a collection of pus under the skin. Abscesses are considered localized infections that can cause pain and illness. An abscess can initiate the growth of aggressive infections and spread to other parts of the body. When an abscess develops on the foot, the area involved may become red, hot, swollen, and tender. This infection can spread and ultimately affect other tissues in the foot and leg requiring aggressive treatments. When abscesses become large and go untreated, the infection can spread to the bone and lead to a bone infection (osteomyelitis). Once the bone becomes infected, more extensive surgery may be necessary to resolve the infection.
What causes it?
Abscesses can be caused by many factors. Patients that have depressed immune systems are much more at risk for developing an abscess. Diabetes is an example of a disease where one’s immune system is compromised. A small break in the skin or a blister can start the formation of an abscess. Poor hygiene can also contribute to abscess development and must be addressed during the course of any treatment. Abscesses can form on the feet and can be extremely painful. Abscesses tend to grow in warm moist places. The foot is a frequent site for this condition. Trauma is another cause of abscess formation. When direct injury occurs to the foot or any part of the body resulting in a break in the skin, a pathway for infection is created.
How is it treated?
Abscesses can be treated conservatively or surgically depending on the extent of the abscess formation. Initially, the treatment should consist of rest and staying off of the affected limb or body part. Warm soaks and moist heat can help alleviate the pain associated with abscess formation. Antibiotics are usually given to the patient to fight off the infection. Depending upon the extent of the abscess and the organism involved, oral antibiotics may not be enough to fight off the infection. Drainage of the abscess may be warranted if the infection does not resolve. If the abscess is surgically treated IV or oral antibiotics may be administered. During the healing process, the wound should be kept clean and close monitoring of the condition should be performed. Even after the abscess appears healed monitoring of the area should be performed to prevent reoccurrence.
Achilles Tendonitis
What is it?
The Achilles tendon is the thickened cord or fibrous band that runs down the back of one’s leg and attaches to the heel bone. A prime function of this muscle or tendonous structure is to assist in moving the foot up and down. Athletes at all competitive levels, frequently encounter problems with this tendon. It is subject to injury from a direct impact, can suffer from over use or excessive training, or can just start hurting as a result of shoe pressure. The patient with an Achilles tendonitis will most often have pain and swelling in the lower portion of the tendon just above the heel, will have discomfort when moving the foot upwards thus stretching the tendon, and will probably note that the condition has worsened over time. These patients can have significant discomfort and will frequently take themselves out of physical activities prior to visiting the physician.
What causes it?
Although we are unsure why certain individuals are more prone to develop this problem than others, there are certain factors, which seem to appear in the “cause” column, Trauma or injury to the Achilles tendon itself is an obvious cause of subsequent tendonitis. An abnormality in the way that one walks or what the medical authorities refer to as improper biomechanics can also create excessive strain upon the Achilles tendon resulting in localized swelling and pain. Over use, excessive training and improper stretching can also result in Achilles tendon injuries. The bottom line though, in most cases of Achilles tendonitis, is the same…pain, reduced range of motion, localized swelling, and a potential long term problem that is usually slowly responsive to therapy.
How do you treat it?
In discussing the treatment approaches to an Achilles tendonitis, we must first mention the necessity of a thorough examination by a specialist. Fractures of the heel bone, partial ruptures of the tendon itself, and localized soft tissue problems must all be carefully considered and ruled out. The specific treatment of an Achilles tendonitis might include physical therapy, shoe padding (lifts to raise the heel), possible orthotics, oral anti-inflammatory medication, some form of immobilization, and reduced physical activity until the condition improves. Surgery, although mentioned for completeness I is rarely used, it should be mentioned that this painful and often disabling condition, while frequently slow to respond, will usually improve and resolve with therapy over time.
Ankle Sprain
What is it?
Ankle sprains are one of the most common conditions we treat in our office. Take a wrong step, walk on uneven ground or be active in athletics, and sooner or later, you will probably have an ankle sprain. By definition, an ankle sprain is a type of injury involving some degree of ligamentous trauma, be it over stretching, partial rupture, or total tear. Along with this ligament injury is some level of ankle joint instability, which can become an invitation for future reinjury and weakness. Ankle sprains usually involve either the inside or outside aspects of the ankle. The outer variety being the much more prevalent due to its weaker structures and greater tendency for injury. The typical presentation of an ankle injury is acute pain, swelling, bluish-black bruising or discoloration, loss of motion and one’s inability to weight bear without discomfort. A thorough examination by a foot specialist is recommended in order to rule out other problems such as fractures, tendon ruptures, and dislocations.
What Causes It?
The actual cause of an ankle sprain is trauma that creates excessive strain, stretching or tension on the inherent ligamentous structures resulting in subsequent injuries and disability. The ankle joint will only move so far and then something has to give. In certain isolated cases, a bone will fracture but in the vast majority of cases, a ligament is over stretched, partially tears or totally ruptures. Pain is the unmistakable common denominator with simple weight bearing often becoming an impossible task. Severe instability of the foot upon attempting to put weight on the injured foot usually means a more sever injury. The trained specialist in his or her examination will be able to largely assess the degree of injury, the probable mechanism of injury, and the chances for partial to total recovery.
How Do You Treat It?
The treatment approach to a sprained ankle is largely determined by how soon after the injury it is seen. Assuming that we are dealing with a fresh injury, seen within hours to a few days of the trauma, our first line of treatment should be to assess the degree of injury and then to reduce the soft tissue swelling. Immobilizing the injury site is used to limit unnecessary motion along with rest, elevation, ice and compression to reduce the pain. Physical therapy and rehabilitation are then used to reestablish ankle joint stability and strength. Orthotics are sometimes used for the purpose of supporting the foot and ankle while reducing any allowable abnormal range of motion. Surgery is occasionally used to strengthen the ankle joint ligaments in those cases involving chronic instability and a frequent history of sprains.
Athlete's Feet
What is it?
You do not have to be a member of a sports team to get athlete’s foot. In fact you don’t even have to play a sport. The condition itself usually results from an overgrowth of a particular fungus organism. In most cases, the areas between the toes and the arch of the foot are most often involved. Athlete’s foot may appear in different stages, each with its own presentation. For instance, the acute stage may have blisters or have intense itching. In addition, there may be maceration between the toes; and occasional drainage. The chronic condition is characterized more by a dry and scaly appearance and rarely itches. There is some confusion as to how this skin condition can be transmitted but at the present time, the consensus of opinion is that there is some type of contagious capacity. In short, you might be able to catch it from the next guy or gal, so watch your barefoot walking! Occasionally, an athlete’s foot condition will become infected and require more extensive therapy. In actuality, the threat of subsequent infection is probably a prime reason for treating more aggressively the earlier stage of the condition. One might think what is really so bad about a little itching between the toes. Well, by itself, probably not a whole lot. But in those cases where that little itching develops into a more involved complication, then we might be facing a more serious problem which might require a more extensive treatment plan.
What causes it?
The treatment for athlete’s foot depends on the severity of the condition. At the first sign of an athlete’s foot condition, I would recommend a short trial period of a medicinal preparation available at the pharmacy in spray or cream varieties. Following several days use, if the condition persists, I would recommend a visit to the foot specialist. If you have a lower stage infection a stronger topical cream or gel might work. Infections between the toes are a little harder to treat because the area stays moist. This might require a gel and possibly occlusion with saran wrap at night. The vesicular form of athele’s foot is the hardest to treat. Sometime oral medication is used to jump start the treatment. The vesicular form is very contagious and you need to protect those around you. Proper diagnosis and treatment is needed to prevent these conditions from becoming more serious.
Bunions
What are they?
Bunions are those unsightly enlargements or bumps that occur on the inside areas of your feet. A bunion deformity can cause a wide range of problems for the patient and consequently can involve a varied approach to o treatment. An important point to consider in the understanding of this problem is that it is a progressive deformity. In other words, a bunion will in most cases worsen with time. No one can predict how fast the deformity will progress or to what extent it will cause debility or symptoms but most authorities would agree that sooner or later, it will worsen. Bunions, by nature, can cause pain in certain shoes, become a common site for arthritic changes, lead to secondary compensatory problems such as hammertoes or pain in the fat pad area. They may cause serious aesthetic or shoe wear concerns for certain individuals especially women who have to wear higher styled type shoes. Whatever the extent of involvement, a bunion deformity should warrant consideration by the patient and some level of professional evaluation by a foot specialist.
What causes them?
The possible causes of a bunion deformity are numerous and can only be numerically reduced pending a thorough examination by the foot specialist. Hereditary tendencies for bunions to occur in members of the same family, ranks high as a potential cause. Another frequent culprit is that of our manner of walking and in what type of shoe we wear over the bunion. In short, the particular mechanics of one’s walking style could be such that abnormal forces, pressures, and anatomical changes could result in a bunion deformity. Various arthritic conditions such as osteoarthritis, rheumatoid arthritis and gout can also lead to deformities of the first metatarsal joint and a bunion. An important fact to keep in mind is that. Generally speaking, shoe can aggravate an existing bunion deformity but will not initially cause one to occur.
How do you treat them?
The treatment options for bunion deformities include a wide range of therapeutic approaches. An early approach might include shoe modifications, padding, physical therapy and occasional injection care for the existing symptoms. Functional orthotics or foot supportive devices can, in many cases, reduce the involved abnormal forces and slow the progression of the bunion. In short, this means that the orthotics might prevent the bunion from worsening and may even reduce any existing discomfort. Surgical correction of the involved deformity is still another viable option and should be discussed thoroughly with your foot specialist. There are three levels of bunion deformities and each require specific surgical approaches. The bottom line is that a bunion deformity is not a condition to ignore or neglect. A good clinical evaluation is a primary and highly recommended first line defense in the management of this condition.
Calluses
Calluses on the bottom of the foot are about as common as any condition we see on the foot. Years ago, we used to judge a man’s working ability or performance by the condition of his hands. It was quite simple, a good hard worker had callused hands and as for his feet, they just weren’t part of the job interview. Calluses, like corns, are thickened layers of skin, which are nature’s response to excessive friction and pressure. Initially, a hot spot or blister may be present but if the pressure continues, a callus will often form. These lesions will usually form beneath weight bearing, bony segments of the foot. Characteristically this includes the metatarsal heads or ball of the foot, the heel, and the under surface of certain toes. Contrary to frequent belief, calluses do not grow and spread by any living intention. However, they are capable of involving adjacent skin areas as a result of continued friction and pressure characteristic of certain areas of the foot.
Not all calluses cause discomfort. A callus may be small, medium, or large in area but thin and diffuse in thickness. These are normally non-painful and can be effectively dealt with by paddings, insoles, and certain types of abrasive treatment procedures. On the other hand, calluses may become deep and punctuate with circular type cores in their center. These are the ones that can indeed cause grief and most often will lead to a visit at the local foot doctor’s office. This painful type of callus may be due to an underlying problem in bone structure, a particular type of skin condition, or perhaps a response to a foreign body. Various treatment methods are available by the foot specialist that are geared towards re-establishing proper balance and weight distribution. As with many problems of the foot one could try to accommodate these lesions with padding, try to control foot strike and function by an arch supportive device or correct the orthopedic condition that exists. These problems should be seen as early as possible so as to minimize the necessary treatment involved.
Cellulitis
What is it?
A cellulitis is an infection of the soft tissue. This type of infection is much different from osteomyelitis, which is an infection of the bone. A cellulitis of the foot or lower leg is usually red, hot, swollen, and tender. A classic description of cellulitis is “red streaking” leading up the foot or leg. Patients that are immunocompromized or have weak immune systems are more likely to suffer from cellulitic episodes. A cellulitic foot or leg can be very painful and can cause the patient a great deal of disability. If a cellulitis is not properly and aggressively treated, the infection may spread quickly through the surrounding tissues and become even more serious requiring more aggressive treatment.
What causes it?
A cellulitic infection can be caused by a number of factors. A “streptococcus” organism is the most common cause of cellulitis in the lower extremity. In diabetics we many times see mixed infections causing cellulites. These means that there are more than just one organism. Some patients are more susceptible to cellulitic infections and have frequent flare-ups of this localized soft tissue involvement. In cases of recurrent cellulitic episodes, the lymph nodes can become scarred from the infection and will become activated when the patient suffers from a stressful or traumatic event. A small break in the skin, an ulceration, or an infected toenail may lead to cellulitis. Poor hygiene may also predispose one to a cellulitic infection as well as diabetes mellitus.
How do you treat it?
Cellulitic infections are usually treated with antibiotics. Since cellulitis is caused by a particular organism, an antibiotic is the standard of care. Occasionally, when the infection is not localized and seems to be spreading aggressively, an oral antibiotic may not be sufficient and IV antibiotics are then used. Sometimes if an abscessed area exists it must be treated to let the antibiotics get to the infected area. The major complaints by the patient with a localized cellulitis are most often pain and swelling. Therefore, elevation of the foot/leg is very important as is sufficient pain control. Patient and doctor observation is another crucial factor in the management of this condition. If a patient suffers from foot ulcerations or has breaks in the skin, a careful ongoing monitoring program is needed to prevent the spread of the infection.
Corns
What are they?
Corns are the hard, thickened areas of skin, which frequently are located on the top, ends, and outer portions of toes. Corns are our body’s response to chronic friction and pressure. The response is to build up skin to protect the area of friction. Often times, an underlying section of bone beneath the corn is the culprit. As the skin builds up so does the pressure and pain to the area. III fitted shoes, abnormal toe structure, and arthritic conditions are common causes of these annoying lesions.
How do you treat them?
It seems obvious that with most any existing ailment of the body, one of three things can happen. The condition can improve and go away, it can stay the same or it can become worse. Corns are an orthopedic condition and either one has to accommodate the deformity to try to make it go away or correct the deformity. First of all, it is essential to check and modify if necessary, one’s shoes so as to minimize excessive pressure at the area involved. Quite often, wearing a better-fitted shoe is enough to remedy the problem. Secondly, one should stay away from store bought medicinal pads and sharp cutting instruments as possible remedies. Self-abuse through the improper use of these items can often result in more serious damage to the skin. A third and most important suggestion for the person with a painful corn is that he seeks professional care. Appropriate care for this problem is often necessary in order to correct or at least, prevent further progressive changes. Treating one’s own foot problem is not necessarily detrimental when performed carefully and under the right conditions. The diabetic, the older aged individual, or the person with obvious circulatory problems are certainly in need of professional care and should not attempt self-treatment procedures. There are some surgical approaches to the treatment of corns to attempt to permanently correct the condition. Everyone can live with a non painful corn, but when the pain interrupts one’s daily walking, it often requires professional management.
Diabetic Feet
What is it?
Diabetes is a disorder that affects many people in our society. Diabetes mellitus is a condition in which the body is unable to transport sugar from the blood to the cells. People who suffer from this disease cannot produce or use insulin, which is necessary to keep the sugar under control. Many sufferers of this disease will complain of constantly being thirsty, hungry, and frequently having to urinate. Diabetic patients often have problems with their circulation, which can result in foot pain, and problems. If this disease is not identified and goes untreated, it can lead to severe health issues and occasionally death. This disease process can affect your kidneys, eyes, sense of feeling in your feet and the circulation to the foot.
What causes it?
Diabetes mellitus can be caused by a number of factors. If there is a family history of diabetes, one’s chances of developing this disorder significantly increases. Over weight people are also at risk, since the body is in a constant battle with the elevated sugar. As one gets older, a certain type of diabetes, ¬type II (non-insulin dependent) becomes prevalent. On the other hand, type I diabetes (insulin dependent), is more prevalent in the young. African Americans and Hispanics are also more susceptible to this disease. If any of the above facts apply to you, an evaluation visit to your family doctor is suggested.
How do you treat it?
The effective treatment of diabetes mellitus begins with patient cooperation and compliance. The patient needs to understand that this disease can be severe and that a strict diet as well as faithful use of all medication is necessary to keep this disease under control. Some patients may need to inject insulin while others might need to take various oral medications. Careful monitoring of one’s blood sugar on a daily basis is essential since it will give both the patient and doctor an idea of how well the sugar is controlled. Periodic trips to your foot doctor are also needed. Many diabetics have problems with their feet and if regular monitoring is not followed, subsequent complications can readily occur. Active ongoing patient participation is an essential aspect in the clinical management of this disease.
Diabetic Periodic Care
It is essential to thoroughly evaluate and periodically manage the diabetic patient. We know that diabetics can specifically have impaired circulation, reduced sensation, and a greater tendency to develop infections, ulcerations and other skin problems. Early detection, periodic monitoring, and judicious care are essential in the prevention and management of diabetic complications. The lower legs and feet are primary locations for these problems to occur. Professional care and supervision can be highly effective in minimizing the complication tendencies of patients with diabetes. Periodic care for these patients can range from a simple examination of one’s feet to more involved treatments of such problems as diabetic arthropathy (diabetic arthritis), peripheral neuropathy (loss of feeling), vascular complications, and ulcerations. The podiatrist will examine the feet to make sure that there is adequate blood supply and sensation (feeling) to the feet. A decrease or loss in one or both can lead to infection and potentially more serious problems. In many cases, the podiatrist will involve by referral, other medical specialists to participate in the total team approach to managing the existing diabetic problems. Many diabetics are seen by their foot specialists on a periodic basis for general foot care. It is important to keep the nails properly trimmed so that they do not become ingrown and cause infection. This is important as many diabetics can not fight infections as well as people without the disease. Also, the skin of diabetic patients is thinner and more susceptible to injury than that of non-diabetic persons. It is important to reduce the calluses to relieve pressure over the bony prominences of the feet. If there is too much callus build-up, the skin may break down and lead to an ulceration. An ulceration can become infected and possibly lead to more serious consequences requiring more involved care.
Flat Feet
What are they?
A flat foot condition exists when there is a marked flattening or lowering of the longitudinal arch. The foot actually appears collapsed in the midsection area and during walking or standing. It seems rolled-in so that the inside of the foot contacts the ground. These patients will frequently complain of wearing out or breaking down their shoes rapidly because of the foot position. Common symptoms or complaints from patients with flat feet include fatigue, cramping, bunions, corns, calluses, shin splints and heel pain. It should be noted however, that not all flat feet are problems, nor do they all require treatment. Pain should be the number one motivating force to seek treatment. Congenital flat feet or those present at birth frequently are not clinical problems while those developed over time often need additional consideration. Particular concerns are those feet that have a normal appearing arch during non-weight bearing periods but assume a more flattened appearance during standing. These feet are frequently excessively pronating or rolling-in at the arch and are the ones that most often produce clinical symptoms.
What causes them?
The possible causes of flat feet comprise a lengthy list. As mentioned earlier, a congenital type or one present at birth may well reflect a developmental embryonic condition. Certain types of flat feet are considered acquired and develop later in life possible due to injury, anatomic abnormalities or various arthritic conditions. Perhaps, the most frequently seen type of flat foot and the one potentially most problematic is that of the excessively pronated foot. This foot type results from faulty mechanics during walking and standing periods and has the capability of causing a host of secondary problems if not managed properly.
Treatment
In most cases, the treatment of the pronated flat foot involves prescribed orthotics or foot and ankle supportive devices. These effectively reduce the in-rolling tendency and help to support the foot and ankle during gait. Other less frequently used approaches in the management of various flat foot conditions include shoe modifications, injections, oral anti-inflammatory medications, physical therapy and if all else fails and the pain persists, surgery. A foot specialist will carefully evaluate this condition in order to identify its probable type, cause and to select the most effective therapy plan available.
Foot Odor
The topic of foot order is obviously a personal and sensitive subject. Rarely is it the primary discussion at an evening party and when brought up between close friends, only occasionally does it receive more than a bashful grin. But in all seriousness, offensive foot odors can be a real problem. For many so afflicted, it is common to ignore the condition or accept is as one would hair loss or freckles. However, it should be emphasized that this condition is very treatable. Professional care is available to treat the cause and effects of foot odor. In the majority of cases, a successful resolution of the problem is readily attainable.
Foot odor in general, is usually a manifestation of excessive perspiration. For many, the hands and feet are frequent sites of pooling with resultant wet areas and occasional skin discoloration. Thus, our first line of attack in treating this problem is to effectively reduce or minimize excessive perspiration. An attempt is made to limit the use of nylon stockings and socks which traditionally promote perspiration. Shoes should be changed rather frequently and the use of breathable leathers as opposed to the more occlusive synthetic shoe materials is encouraged. Topical applications, soaks, and occasional oral medications are given for the purpose of reducing the output of perspiration.
Perhaps the most important factor involved in this condition is the chemical make-up of perspiration itself, for it is this factor indeed, which causes odor. The old saying, “You are what you eat,” certainly applies in this case. Dietary intake modifications are essential in order to affect the end result. Obviously, garlic, onions and other higher spiced foods must be greatly reduced until the condition is well under control. It is important to keep in mind that an offensive foot odor is a treatable condition, and once the causative factor is identified, one that can usually be remedied.
Fungus Nails
What are they?
Not all discolored, thickened, or deformed nail plates are due to fungus infections. Indeed, many are due to trauma, congenital (birth) changes and other conditions such as drug use, high fever ailments and circulatory problems. The actual fungus nail itself is one that is diagnosed through clinical cultures and identification of the involved organism. It is usually a thickened and yellowish-brown discolored nail plate surface. In most cases, the infection starts at the end of the toenail and progressively involves the remainder of the plate. The vast majority of fungus nails are asymptomatic or painless and for many, are more of a cosmetic problem than anything else. Most authorities agree that fungus nails are not contagious between people but a progressive involvement from one toe to another is still a confusing issue for many.
How do you treat them?
The treatment methods available for fungus nails are about as numerous as are the varieties of nails themselves. Oral medications are available but their use is expensive, long term and not without potential hazardous changes to the blood. Before starting oral medications for fungused nails one should have a nail culture to make sure it is fungus we are trying to treat. Laboratory tests to determine liver profiles should be taken prior to starting the medication and again at 6 weeks. Localized reduction and periodic care of the nails are purely temporary and resemble the use of Kleenex in treating the common cold. Although beneficial on a limited scale, this form of treatment is geared toward preventing the condition from worsening. Various types of topical medications are available both over the counter and by prescription, which can be effective. Many patients prefer the use of a topical medication over an oral or systemic drug. An additional method of treatment that is frequently used is to surgically remove the involved nail plate and treat the underlying fungus infection on the nail bed area. Once the hardened plate is removed, the open exposure allows more effective penetration by topical products and medications. Other methods of treatment, less frequently used, are also available. In short, numerous treatment methods are available for the approach to fungus nails. A primary evaluation and decision must be made as to how serious the problem is to the patient. Whether to treat aggressively or periodically observe the condition are viable considerations for the patient. Fungus nails are frequently perplexing and persistent conditions both from a diagnostic and then a therapeutic standpoint. Perhaps, in the near future, more effective medication will become available which will facilitate the management of this problem.
Gout
What is it?
Gout is a disorder that involves elevated levels of uric acid in the blood. The crystals from the uric acid then settle from the blood stream into various joints of the body, and most commonly, the big toe joint. Gout is a chronic disease that begins with recurring attacks. When an attack develops, it can last several days and the joint becomes swollen, red and extremely painful. Patients often complain of not being able to tolerate a sheet resting on their big toes or other parts of their feet such as their heels or even their ankles. The foot is commonly affected because it is subjected to continued pressure in walking, increased exposure to trauma and its greater tendency for anatomic blood pooling to occur.
What causes it?
Gout is a metabolic condition that is somewhat common in the general population. Men in their 4th to 5th decades of life suffer from gout seven to eight times more often than women. There is also genetics involved with this certain disease and if someone in your family suffers from this condition you are at an increased risk for developing this disease. Alcohol tends to worsen this condition and trigger frequent attacks. The use of diuretics or “water pills” can also trigger the settling of uric acid in the blood and can lead to frequent episodes of painful gouty attacks.
How do you treat it?
The treatment of gout usually begins with reducing the pain and swelling by keeping the patient off weight bearing and to elevate and rest the affected area. Anti-inflammatory medications help to reduce the pain and swelling and also help to remove the uric acid from the body. Steroid injections into the joint also aid in the reduction of pain and swelling. The avoidance of alcohol and foods that contain high levels of protein is advisable to prevent gouty flare-ups. Drinking a lot of water is also suggested to dilute the levels of uric acid in the body. Once a patient develops gout and has had recurrent episodes, preventive oral medications can be taken to prevent and/or minimize future attacks. Surgery should be considered only when all other forms of treatment have failed. The surgery itself, would involve a remodeling of the affected joint or joints.
Acute Gout Attack
What is it?
An acute gout attack is an inflammatory process that occurs in a joint secondary to a high concentration of uric acid in the blood. It is most commonly seen in the middle age, elderly and is much more common in men. It can occur in any joint in the body but is most commonly seen in the big toe joint followed by the knee and the ankle. It is extremely painful and is characterized by a red, hot, swollen joint. Patients who are undergoing acute gout attacks are usually in extreme pain and find it most difficult to even bear weight during normal walking. Sometimes just the touch of the bed sheets over the area can illicit a great deal of pain.
What causes it?
An acute gout attack results when elevated levels of uric acid in the blood cause crystals to settle into certain joints. The body’s defense mechanism tries to fight the foreign material and an inflammatory process is initiated. Uric acid is a metabolic end product that is normally found in certain foods. People that experience “gouty attacks” have increased levels of uric acid for a variety of reasons. Often very rich foods like alcohol, chocolate, seafood, and meats can precipitate attacks. Sometimes the medication we take can cause the body to increase the uric acid levels. The uric acid crystals settle in joints in one’s arms and legs because of the decreased temperature seen in the extremities. The crystals are recognized as foreign material and the body fights it like an infection. The area becomes swollen, red, hot and extremely painful. This is one of the most painful conditions we treat.
How do you treat it?
Acute gout attacks are usually treated with a combination of therapies. Oral medications such as anti-inflammatories, analgesics and colchicine are most commonly used to treat this disorder. Often times, local injections into the affected joint will help relieve symptoms. Various other treatments include warm compresses, elevation of the involved area, physical therapy, and the use of pain relievers such as narcotics. The goal of treatment in acute gout attacks is to end the “flare up” and convert the patient’s condition to the chronic state. Going on a low purine diet can help prevent reoccurring attacks. Certain oral medications are available on a long-term basis to help prevent recurrent attacks and possible systemic damage. One should consult his or her family physician or internist for information on these medications.
High Arches
What is it?
A high arched foot is one where there is a marked elevation of the longitudinal arch both on and off weight bearing. This type of foot by itself is usually not a problem but tends to cause other difficulties, which frequently require treatment. For instance, the high arched foot creates excessive pressure on the ball of the foot and frequently produces thick and uncomfortable calluses. Hammertoes are also common with this foot type, which may cause problems with certain shoes. In addition, the high arched foot is notoriously known as a poor shock absorber, frequently resulting in discomfort and bursitis in the heel.
What causes it?
The three main causes of high arched feet include congenital development (at birth), trauma or injury (involving nerve damage) and certain neurological conditions. It is important to thoroughly evaluate a high arched foot in order to determine its probable cause. The type of therapy selected will then have a much better chance for success. It should be kept in mind that not all high arched feet require treatment. In the absence of symptoms or progressive soft tissue changes, clinical treatment may be unwarranted.
How do you treat it?
The treatment of the high arched foot is directed at supporting the elevated mid section of the foot, providing shock absorptive benefits to those areas in need and improving the functional mechanics of the foot and ankle. Orthotics prescribed by a foot specialist are the most effective means of accomplishing these objectives. The high arched foot usually responds well in a relatively short period of time to the use of orthotic supportive devices. In certain rare case where the condition is excessive and defies therapeutic control, surgery might become a consideration.
Ingrown Nails
What are they?
Ingrown toenails are one of the most common conditions we see in our offices. The problem is just what its name implies. The nail plate is too large for the under covering or bed and one or both sides are pressing into the skin. Ingrown nails can result from several possible causes such as improper cutting, abnormal nail structure and localized injury to the plate. The appearance of the toe involved may range from a sensitive redness and slight inflammation to a full-blown infection of the toe with pus and bleeding usually evident. The object of course, is to prevent the infectious stage from taking place and to remedy the problem earlier in its development.
How do you treat them?
Adequate prevention of ingrown nails can be accomplished in most cases by proper trimming and judicious self-care. The nail plate should be carefully trimmed so as to follow the fleshy curve at the end of the toe. Under no circumstance, should a sharp instrument be used or inserted to cut diagonally back into the corners of the nail. Leaving a jagged nail edge, a loose piece, or inadvertently cutting the skin can predictably lead to problems. In those cases where injury has occurred with a subsequent ingrown nail, professional assistance by a foot specialist is suggested. The doctor is well trained and equipped to treat such a problem and with little to no discomfort to the patient. Ingrown nails may seem simple enough but in actuality have sidelined many a person from his or her daily activities. These annoying and painful nail conditions are frequently encountered in various athletic activities. Soccer, jogging, racquet sports, football, basketball, and baseball all involve running and often lead to digital problems such as ingrown nails. Antibiotic medication, disinfectant soaks, and inactivity are not the total solution. It is essential to reduce and/or remove the offending spicule or nail edge that is causing the problem. Sometimes this can be done to give temporary relief or attempt to permanently correct the condition.
Neuromas
What are they?
Neuromas are nerve irritations that involve typically an enlarged or swollen segment of the nerve itself. In some cases, these neuromas can actually resemble a small grape in size and can cause significant discomfort to the patient. The individual with such an affliction will often complain of numbness, tingling, and/or burning sensations, which radiates into or involves two adjacent toes. Sometimes neuromas can be exquisitely painful. Most patients relate having to remove the shoe and rub their feet. In most cases, the neuroma will be located between the third and fourth digits of one foot with burning sensation involving the bottom of the metatarsal fat pad and the two involved toes. A second commonly involved site is between the second and third toes of the foot. The typical neuroma usually does not have redness, heat, swelling, or any apparent range of motion loss. Pressure on the bottom of the foot with manipulation of the involved digits will frequently produce the painful symptoms. Neuromas, generally speaking, do not go away on their own but usually require some form of professional care.
What causes them?
The most frequently agreed upon cause of neuromas is that of trauma or injury. This trauma might be the acute kind like a twisting of the foot or stepping on something or it might be the chronic kind like repeated micro-trauma from an excessively flat foot. The problem however, is that the onset of the neuroma pain might not appear for quite some time after the noted trauma. In other words, an injury to the foot may have occurred some two or more months prior to any neuroma formation but nevertheless, a cause and effect relationship still exists. Shoes might aggravate an existing neuroma but usually do not play a causative role.
How do you treat them?
The usual range of conservative care through surgical procedures applies in the approach to neuroma care. Appropriate shoe selection and modifications is a good start in trying to relieve pressure and allow additional room for the foot during walking. Various forms of physical therapy and localized injections of anti-inflammatory medication can frequently be helpful in the treatment of this annoying problem. Surgical procedures armed at identifying and removing the involved section of irritated nerve can provide a more permanent resolution in many cases. A few new treatments have been used over the past few years. The first is a series of neurolytic injections where an alcohol is injected into the nerve to try to destroy it this has not been very successful. The second is a surgical approach to try to release the ligament over the neuromal. This also has had limited success. A discussion of possible recurrence rates, disability involvement, and procedural expectations should take place between the patient and foot specialist prior to surgery.
Neuropathy
What is it?
Neuropathy is a condition that affects the nerves in the body. Each nerve has a special covering and when that covering is damaged, the nerve doesn’t function normally. A “tingling” sensation or a feeling of “pins and needles” may be a warning sign to the patient that their nerves are functioning abnormally. When the condition of neuropathy worsens, the patient may lose complete feeling in different parts of their body. Most commonly, neuropathy tends to affect the hands and feet. When the hands and feet become neuropathic, it is very difficult for one to carry out their activities of daily living.
What causes it?
Many diseases such as, diabetes, alcoholism, vitamin deficiencies, trauma and certain drugs can cause neuropathy. The most common cause of neuropathy is diabetes mellitus. In diabetes, the elevated sugar affects the nerves and can result in pain or loss of sensation. If the sugar is not well controlled, the neuropathy progressively worsens and can cause serious disability in one’s life. Sometimes with quick diagnosis and treatment this is reverible. Other times after extended period of numbness it is not reversible. Simple tasks such as walking barefoot or soaking your hands and feet can be potentially dangerous in the neuropathic patient. Constant monitoring of water temperature before bathing is essential in preventing unintentional burns or injury.
How is it treated?
A neuropathy can be a very difficult condition to treat. In general, a doctor can treat the symptoms that accompany nerve damage however; certain types and stages of nerve damage are permanent. Oral medications can be given to control the pain and other associated nerve-like symptoms. Newer medications are actually in some cases restoring partial feeling it the neuropathy is not too advanced. With advanced nerve damage in the hands and feet, it is essential for the patient to be cognizant of all precautions. It is mandatory for patients with neuropathies of the feet to constantly wear shoes and socks. Examination of the bottom of one’s foot is required as well as checking the inside of shoes before putting them on. Having another family member evaluate the temperature of the water before bathing can help prevent unnecessary burns to the hands and feet. Neuropathy can be a very devastating condition. However, the more one knows about this ailment, the more effective is the clinical management.
Orthotics
What are they?
Foot orthotics are supportive devices that are designed specifically for the purpose of controlling foot motion, improving one’s postural stability, reducing shock impact, and/or improving weight distribution. In most cases, these devices are functional in the sense that they also improve one’s biomechanical performance during gait. A plaster impression is taken of your feet and used in the selection and fitting of a prescription orthotic. The particular information regarding anticipated cost, durability and use may vary depending upon the type of orthotic and should be discussed with your foot specialist.
What do they do?
Imagine if you will, standing barefoot in moist sand with the arch being filled by the smooth sandy undersurface. The heel and ball of the foot leaves a mild depression in the sand while the toes grip the ground without resistance. If one could stand like this for lengthy periods of time, he or she would probably not have sore feet, would experience less fatigue and probably would not have many of those commonly encountered forefoot skin problems such as corns, calluses and ingrown nails. The problems come from standing on cement, asphalt or other non-yielding surfaces. Other causes for foot problems include wearing confining shoes, which further limit foot flexibility, and from lengthy periods of ambulation, which add fatigue and strain to one’s body. Orthotics assist in restoring supportive comfort by bringing the ground surface up to the foot. They serve to improve postural stability, distribute one’s weight more evenly and improve the mechanical functioning of the foot and ankle. Although orthotics do not cure every ache and pain in the foot, they are a wonderful approach in providing maximum comfort through improved biomechanics. Standing comfortably in sand is not necessarily an unreachable feeling even while wearing your everyday shoes.
Osteomyelitis
What is it?
Osteomyelitis is an infection of the bone. In order for the bone to become infected, a pathogenic or infection producing organism must gain access to the involved site. There are two basic types of osteomyelitis; acute and chronic. Acute osteomyelitis is one in which there is an “active” infection. The skin surrounding the wound is usually red, warm, swollen, and frequently has a foul smelling discharge from the wound site. Chronic osteomyelitis is just how it sounds; “a chronic or long-standing infection”. The difference between acute and chronic osteomyelitis is that the acute form shows the traditional clinical signs of infection where the chronic form usually does not. Chronic osteomyelitis frequently involves exposed bone. However, the redness, heat, swelling, and malodorous drainage is usually not present.
What causes it?
Osteomyelitis can be caused by a number of factors. An aggressive infection that breaks through the skin and penetrates the bone is usually the way it works. A simple opening in the skin from an ulcer, trauma, or surgery can cause this condition. If the infection is not quickly treated, an osteomyelitis may form. Diabetics are often prone to developing this type of bone infection. The reason is that many diabetics do not have adequate feeling on the bottom of their feet and will develop ulcers without being aware of the problem. The infection then progresses and is often not treated in time to prevent a bone infection. If you have an “opening” or localized wound site on your foot that seems to be slow or non-healing, a foot specialist should be consulted.
How is it treated?
Osteomyelitis can be treated either conservatively or aggressively depending on the severity of the condition. Conservative treatment would consist of intravenous antibiotics without removing bone. This treatment is frequently utilized initially until lab studies identify the actual organism causing the infection. A more specific medication may be used in an IV fashion to more effectively treat the infection while further studies are done to evaluate the extent of bone involvement. Once this information is available via bone biopsy, bone scan, MRI or x-rays, the offending bone should be removed as well as using IV antibiotics.
Plantar Fasciitis
What is it?
Plantar fasciitis involves a localized swelling, irritation, and/or bursitis of the thickened fibrous bands supporting the bottom of one’s foot. These tendon like bands run length wise from underneath the heel and fan out into the metatarsal heads or fat pad area of the foot. In most cases, painful symptoms arise at or near the point at which the bands are attached to the heel. When a person stands, these fibrous bands stretch and elongate under the pressure and pull on the heel. Eventually, a heel spur or calcium deposit may actually form in response to this constant pulling. Many of the patients who have this condition seem to have a similar presentation. There is frequently pain upon rising out of bed in the morning. The first few steps are excruciating but reduce quickly in their intensity. Later in the day, the individual with plantar fasciitis will notice pain after sitting and then getting up again. The pain is mostly localized to the heel and arch areas with occasional radiation of discomfort up the back of the leg. Well-padded shoes are helpful but rarely rectify the condition.
What causes it?
We are unsure as to why certain people get plantar fasciitis while others do not. Trauma, repetitive stress and strain, overweight conditions, hereditary tendencies, and various soft tissue abnormalities can all playa causative role but as of yet, a clear and identifiable culprit has not been found. We can however, discuss why the pain onset seems to follow with rising or weight bearing periods after sitting. In a lying down or sitting position, the long plantar fascial bands are relaxed and contracted. There is little to no pulling on the heel and therefore, absent pain in most cases. Once we stand, these bands suddenly elongate or stretch, thus putting a strain on the bottom of the heel. Considering the fact that this pulling pressure is of a cumulative nature, sooner or later, symptoms may arise.
How is it treated?
The treatment of a plantar fasciitis condition initially includes stretching exercises, shoe modifications, foot taping and padding, possible injection of an anti-inflammatory medication, physical therapy, and the use of oral medications. Orthotics, which provide support and stability to the foot and ankle, improve weight distribution, and increase lower extremity function are in most cases, an essential part of therapy. Controlling the arch during weight bearing along with conservative care can make 90% of true plantar fascial pain become asymptomatic. In certain cases where conservative care has failed to relieve the involved discomfort and disability, surgery might then become a consideration.
Plantar Warts
What are they?
Warts are encapsulated or walled off growths of viral tissue. Plantar warts on the feet are frequently painful with squeezing type pressure. In the vast majority of cases, the growth of a wart is preceded by some sort of skin puncture, wound defect or breakdown in the normal skins defense barrier that in all probability, allows an entry site for contamination. A lot of patients report getting warts after showering in a public place or at the swimming pool. Keeping the foot moist is one of the ways that the skin breaks down making us susceptible to warts. Once the wart makes a home in our skin it can spread to other parts of our foot. Whether we all have inactive or potential wart viruses circulating in our bodies or gain the virus through the wound is as of yet unclear. An interesting and often confusing distinction must be made between certain calluses and plantar warts. Skin lines or striations can be seen passing through callus tissue whereas they will pass around a wart. Painful calluses in the ball of the foot are the commonly misdiagnose as warts. In addition, plantar warts, upon close examination, will often demonstrate small black dots which when trimmed will bleed. These are tiny blood vessels, which become caught in the growth itself and are absent in regular callus tissue. A final line of distinction in identifying a wart is in its response to pressure. Squeezing a wart will usually produce extreme pain as opposed to similar pain from direct pressure on calluses.
How do you treat them?
Warts that appear on the hands and fingers are usually more responsive to therapy than are those on the feet. The professional methods of treatment available for plantar warts include just about everything from chemical applications, surgery to putting duct tape over the wart. Because there are so many treatments it tells us that sometimes the treatment works and sometimes it doesn’t. Some warts respond quickly and some do not. Each foot specialist seems to have his or her own favorite treatment methods that prove effective in the majority of cases. Usually the initial treatment is to try topical medication over a 6-10 week period. During that time it is important to keep the feet dry. There are certain medications that are giving to try to stop the feet from sweating. If topical treatments don’t seem to be working or the warts are starting to spread then there is always trying to excise the warts.
Stress Fractures
What are they?
As the name implies, a stress fracture is a break in the bone, which results from cumulative and/or repetitive strain to a particular site. These fractures are most commonly seen affecting the long bones or metatarsals of the foot. More specifically, they seem to involve most often, the three middle metatarsals with the second metatarsal being to most common. Pain in varying degrees is usually the chief complaint and it may or may not be accompanied by swelling and discoloration. A lump or soft tissue enlargement is frequently present over the site involved. Stress fractures are often problems because of their tendency to be missed or neglected. In most cases of metatarsal stress fractures, the actual bone break does not show on a regular x-ray for about ten days to two weeks from its onset. These fractures should be identified as soon as possible and properly managed by a specialist in order to insure a good result and prevent unnecessary disability.
What causes them?
The main cause of a stress fracture is that of cumulative or repetitive strain to a particular bone site. A long day on cement floors at a mall, an unusually hard hike or exercise walk, or maybe a long march in the military or as a member of a marching band can all qualify as possibly overstressing a metatarsal bone leading to a fracture. Cumulative strain to a particular site involves smaller stress loads that are repeated over a lengthy period of time. Either heavy strain for a short time period or lighter loads repeated over a longer time period can produce localized stress fractures. Usually, an x-ray taken after about ten days from the injury onset will identify the fracture site. Occasionally, more sophisticated tests are performed such as bone scans which are capable of making an earlier diagnosis.
How do you treat them?
A stress fracture is treated in much the same manner as most any other bone break. The area involved must be protected, supported, and immobilized to some extent. Motion at the fracture site has to be controlled so as to allow proper healing to occur. In most cases, a protective fracture shoe is used to accomplish these goals. The patient should limit his or her walking and should be followed up by a foot specialist to monitor the healing process.
Toe Fractures
What are they and what causes them?
Few injuries to the foot produce more pain than that of a fractured or broken toe. The mechanism or cause of a toe fracture seems embarrassingly obvious yet seemingly unavoidable. A sudden blow or stubbing of a toe against a heavy non-yielding object, an impact injury involving something dropping on top of a toe or that common injury of catching a small toe on the leg of a piece of furniture in your bedroom can each cause a fracture. The toe hurts high on the pain scale, swells and turns reddish pink, and after a day or so takes on a bluish bruised type of discoloration. If these signs are present and you just don’t want to move that toe, then the chances are that you have a fracture.
How do you treat them?
It is at this point that we frequently find an area of public confusion regarding the treatment of toe fractures. Many of our patients and those not seeking medical care believe that toe fractures will heal by themselves and do not really need supervised medical attention. They tell us that there is nothing to do about a broken toe except tape it to the next toe. We disagree and would like to point out several facts on this issue. 1: Fractures of the toe should be seen professionally in order to evaluate the extent of the injury. In other words, not all fractures are the same and some will heal much faster then others while certain ones may not heal at all. A proper evaluation and management are necessary to insure the best possible result. 2: Certain fractures may involve deviations or crooked positioning of the involved toe after the injury. These need to be set in proper alignment. Little toes that are angled outward can develop severe and painful corns. These should be treated early on by a specialist in order to prevent future disability and possible problems. 3: Proper treatment of a fractured toe should involve some level of immobilization splinting and support. Ignoring the injury and enduring the pain do not create an optimal environment for fracture healing. In closing, these injuries occur with sudden onset, extreme pain, and obvious shoe wear difficulties. Proper evaluation, management, and periodic monitoring are recommended procedures for this problem.
Ulcers
What are they?
An ulceration is an absence of or defect in the normal lining of the skin layers (epidermis and dermis). In a sense, an ulceration is a hole or cavity in the skin that may be wet or dry and potentially, very resistive to healing. Patients with diabetes, poor circulation and those that are bedridden may have increased tendencies to develop ulcerations. The symptom level, clinical appearance, and response to therapy are largely dependent upon the type and location of the ulceration and the health of patient.
What causes them?
There are many types of ulcers including those caused by loss of sensation of the skin, decreased blood flow, pressure to a specific area of the foot and ulcers due to problems with the valves in the veins. The diabetic ulceration is caused by an unhealthy condition of the nerves. Because the nerves are debilitated, they do not function properly and result in a loss of sensation. A diabetic patient may step on a needle or other object in the shoe and not even be aware of the problem due to reduced sensation. The skin will eventually break down and result in an ulceration. Ischemic ulcerations are ulcers that are caused by decreased blood flow and poor blood supply to the feet due to calcified arteries or blockages of the blood vessels. These are the most painful of all the ulcers. Because the skin is not getting the nourishment it needs to survive from the arteries, it begins to die. This often leads to an ulceration. A pressure ulceration is caused when a portion of the foot is left in contact with an area such as a bed mattress for an excessive period of time. This type of ulceration is commonly seen in patients that are bedridden and unable to move on their own. The pressure to the area cuts off the blood supply, which can cause tissue death leading to an ulceration. A venous stasis ulceration occurs due to an incompetent or faulty valve between the superficial and deep veins in the legs. This results in fluid being backed up into the superficial veins. Eventually there is too much fluid in the leg. The fluid has nowhere to go and so it begins to weep onto the skin. Eventually an ulceration will occur.
How do you treat them?
There are many different treatments for ulcers and the type of ulceration involved largely determines the specific method of care. In general, ulcers are treated with debridement (removal) of the surrounding tissue and any nonviable tissue. This will help relieve pressure from the ulcer. Some patients are treated with non-weight bearing of the foot to help decrease pressure on the ulcer. Topical wound gels and creams are also used to keep certain ulcers clean and hydrated. Some gels even help remove dead tissue. The treatment of ischemic ulcerations may require revascularization procedures by a vascular surgeon to increase the blood supply to the feet. Venous stasis ulcers are often treated with compression dressings to help squeeze the fluid out of the legs and back into circulation. These ulcers are also treated with wound gels. Appropriate ulcer therapy can be very effective but often requires time, patience and cooperation on the part of the patient.