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Common foot Problems
 

Dr. Ian H. Beiser's Podiatry Page

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Dr. Beiser is a podiatrist serving patients in the Washington, DC, area

He is a partner in Foot and Ankle Specialists of the Mid-Atlantic, LLC,  a diverse group of foot and ankle specialists, dedicated to providing advanced and comprehensive foot and ankle care

1145 19th St., NW  Suite #203
Washington, DC 20036
(202) 833-9109

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Contents

Office Information
Credentials
Board Certification
Foot Information
    Foot Problems
    Normal Foot
    Diabetic Foot
    Heel Pain
    Bunions
    Other conditions
    Foot Surgery
      Absorbables
    Fungal Nails
    Orthotics

What is Podiatry?
Health links
 

 

 

 

Click on a topic listed below or click here to start at the beginning

Introduction
    Foot Deformities and Biomechanical Problems
        Flat Feet (Pes Planus)
        High Arched Feet (Pes Cavus)
        Metatarsalgia
        Morton's Neuroma
        Tarsal Tunnel Syndrome
        Bunions (Hallux Abducto Valgus
        Tailor's Bunions
        Hammertoes
    Sports Medicine  and  Traumatic Injuries
        Heel Pain and Plantar Fasciitis
        Fractures
        Tendonitis
        Shin Splints
        Sprains
    Conditions Related to Systemic Diseases
        Diabetes   
            Nerve Problems (Peripheral Neuropathy)
            Deep Space infections
            Circulation Problems (Peripheral Vascular Disease, PVD)
            Charcot Joint ( Diabetic Neurotrophic Osteoarthropathy)
        Arthritis    
            Osteoarthritis
            Rheumatoid Arthritis
            Gout
    Conditions of the Toenails
        Fungal Toenails (Onychomycosis)
        Ingrown Toenails (Onychocryptosis)
    Conditions of the Skin
        Athlete's Foot (Tinea Pedis)
        Calluses and Plantar Keratoses
        Corns (Heloma Durum)
        Soft Corns (Heloma Molle)
        Warts
        Dry Skin and Cracking of the Skin (Xerosis and Fissures)
        Ulcers
            Neuropathic ulcers
            Ischemic ulcers
            Venous Stasis Ulcers
           
Decubitus ulcers or pressure sores


Common Foot Problems

The components of our feet normally work together to share the pressures of daily activities. They are able to sustain thousands of steps and a cumulative force equal to several hundred tons on an average day of walking. However, sometimes things go wrong. There are many causes of foot pain. Many of these problems are due to overuse. Other problems may be due to hereditary, congenital or systemic factors. Diseases such as diabetes peripheral vascular disease and rheumatoid arthritis are notorious for their effects on the feet. Often, external variables such as shoe wear or hard floor surfaces exacerbate these conditions.

Foot Deformities and Biomechanical Problems

    Flat Feet (Pes Planus)

"Flat Foot" is a rather vague term which refers to a foot which pronates excessively or remains in an excessively pronated position during stance and gait. Flat feet may be caused by any one of many different conditions such as a tight heel cord (Achilles tendon), congenital deformities(e.g.  calcaneovalgus and congenital vertical talus), structural deformities of bone and joints in the foot or leg (e.g. forefoot varus, metatarsus adductus, tibial torsion, genu valgum etc..), abnormally loose ligaments (ligamentous laxity/ Ehler's-Danlos syndrome), tendon ruptures (particularly the Tibialis posterior tendon) as well as a host of others. Flat feet can be considered flexible or rigid. With a flexible flatfoot, there may be a relatively high arch when the foot is not bearing weight. This then collapses with weightbearing. A rigid flatfoot as its name implies, remains flat (pronated) at all times.

The pronation associated with flat feet may contribute to many other problems in the foot or elsewhere. When the foot pronates excessively, the arch collapses , causing the knee to also roll inward. This may lead to knee pain due to the resultant  uneven weight distribution at the knee joint. Similarly, the hip and lower back may also become painful as a result of abnormal function of the foot. Within the foot itself, the abnormal pronation results in hypermobility and instability of various joints. This often results in the development of bunions, hammertoes, heel pain and arthritis of the midfoot. Flat feet are most commonly treated with orthotic devices (orthoses) which help to reduce abnormal pronation and hold the foot in a more ideal position. Some conditions may require surgical treatment to obtain optimal results.

    High Arched Feet (Pes Cavus)

The opposite of a flat foot is a high arched (Cavus) foot. This extreme is not good either and may lead to a number of equally troublesome conditions. The cavus foot is one which remains in a supinated, high-arched position. These are often rigid or semi-rigid .While excessive pronation leads to instability, inadequate pronation results in poor shock absorption during gait. This may also cause pain in the knees, hips and lower back. Symptoms commonly occur in the heel and at the ball of the foot (metatarsalgia), areas which bear the most weight. The abnormal shape of the foot may also result in tendon imbalances causing hammertoes. A shock-absorbing orthotic may be effective in reducing symptoms associated with this condition. Surgery may also be indicated in some cases.

    Metatarsalgia

Metatarsalgia refers to pain at the ball of the foot, at the head of one or more metatarsal bones. It is basically a bruise of the bone or an inflammation of the soft tissue around the joint between a metatarsal and a toe bone( a metatarsophalangeal joint). This often occurs as a result of overuse, excessive walking or running without adequate cushioning beneath the bones at the ball of the foot. This  occurs commonly in people with a high arched, rigid foot, especially if the normal fat pad at the ball of the foot has become thin (atrophied). metatarsalgia may also occur in people with flat feet, often as a result of instability of the bone behind the big toe (1st metatarsal bone). In this case, the 1st metatarsal bone does not bear as much weight as it should and the weight is transferred to the 2nd metatarsal (the bone behind the 2nd toe) which subsequently becomes inflamed and painful because of the extra pressure. Metatarsalgia may be easily confused with stress fractures or neuromas.  Short term relief may be obtained by wearing adhesive felt or foam padding around the inflamed area as well as cushioned insoles. Long term relief is often provided with orthotics designed to redistribute weight more evenly.

    Morton's Neuroma

A Morton's neuroma is an enlarged nerve that occurs most commonly between the base of the 3rd and 4th toes at the ball of the foot. It may also occur between other toes less commonly. Common symptoms are sharp pain, burning, tingling, numbness or cramping. Symptoms occur most commonly while wearing tight or none-supportive shoes but may also occur while wearing athletic shoes, particularly after certain activities such as using a treadmill or stair machine at the gym. Sometimes special padding placed under the foot to raise and separate the metatarsal bones or an orthotic may be effective at reducing symptoms. Cortisone injections may also be effective. It is also important to wear shoes that fit properly. Neuromas are frequently resistant to treatment and may need to be excised surgically to obtain relief. An alternate treatment that can be utilized instead of surgery is called sclerosing therapy. Sclerosing therapy is the chemical destruction of the neuroma with a series of alchohol injections. Chemical destruction of a neuroma is often accomplished by injecting a small amount of a 4% mixture of ethyl alcohol (about 0.5cc) into the area of the neuroma on a weekly basis and usually requires between 4 and 8 treatments.

    Tarsal Tunnel Syndrome

Tarsal Tunnel Syndrome is a foot condition that is analogous to the wrist condition, Carpal Tunnel Syndrome. Both are caused by entrapment of a nerve in a tight compartment. In the case of tarsal tunnel syndrome, the Tibial nerve which runs through the tarsal tunnel on the inner side of the ankle becomes compressed which results in symptoms such as tingling, burning, numbness and pain on the bottom or toe area of the foot. This may at times be confused with conditions such as plantar fasciitis or  Morton's neuroma. The entrapment may be caused by an abnormal mass in the tarsal tunnel such as an enlarged vein, a cyst or a tumor. It may also be caused by flat feet and excessive pronation which result in squeezing of the nerve by the ligament that normally covers it. In the latter case, orthotics may be an effective treatment since, by reducing pronation,  they may eliminate the squeezing effect that abnormal pronation exerts on the nerve. If there is a physical mass putting pressure on the nerve it may require surgery to decompress the nerve. Diagnosis of tarsal tunnel syndrome is often made with an Electro-Myelogram(EMG) and Nerve Conduction Velocity studies(NCV). NCV Studies measure the speed of impulses through a nerve. If the speed is slower than normal, there is evidence of nerve disease such as  tarsal tunnel syndrome.

   Bunions (Hallux Abducto Valgus, Hallux Valgus, H.A.V.)

A bunion is an abnormal prominence located on the side of the foot, just behind the big toe. Hallux Abducto Valgus refers to a deformity associated with a bunion in which the big toe (Hallux) is angled excessively toward the 2nd toe. The Hallux Abductus Angle may be used to quantify the amount of Hallux Abducto Valgus deformity (see diagrams    ). Hallux Abducto Valgus and Bunions are usually associated with flat feet ( hyper-pronating feet/ pes planus). Excessive pronation (flattening of the foot) leads to instability of the  first metatarsal bone which drifts up and out towards the side of the foot. The Intermetatarsal Angle is used to quantify the amount of this drift to the side (see diagrams    ). The big toe drifts the opposite direction toward the 2nd toe. The bunion prominence is often caused by some enlargement of the head of the 1st metatarsal bone as well as the position of the 1st metatarsal bone as it protrudes from the side of the foot. Conservative measures such as wearing wide shoes and padding may help to provide some relief of symptoms but do nothing to remove the deformities. If conservative measures fail to  provide relief, surgical correction of the deformity should be considered. The most common surgeries  for bunions are done as outpatient procedures. The patient is usually able to walk the same day using a post-op shoe (although activities should be limited and the foot elevated as much as possible for at least the first three days.) There are many types of bunion surgery and post-operative limitations will vary depending on the severity of the condition and the procedures chosen.

               

( More about bunions and surgical options)

   

Tailor's Bunions

Tailor's bunions are similar to standard bunions but are found on the outside of the foot at the 5th metatarsal (behind the baby toe) instead of at the inner side of the foot behind the big toe. Years ago, tailors often sat on the floor sewing, with their legs crossed. The outside of their feet were therefore subject to pressure and irritation. An enlargement of the head of the 5th metatarsal bone could easily become inflamed. Today, tailors usually do not sit on the floor. Instead, people who wear shoes that are too narrow or pointy are most susceptible to this condition. However, shoes are not the cause of the  condition; They only aggravate it. The actual cause is structural and is seen most often in people who's feet are very flexible and "splay" or spread wide when standing.  Conservative measures such as wearing wide shoes and padding may help to provide some relief of symptoms but do nothing to remove the deformities. If conservative measures fail to  provide relief, surgical correction of the deformity should be considered. Surgeries  for tailor's bunions are done as outpatient procedures. The patient is usually able to walk the same day using a post-op shoe (although activities should be limited and the foot elevated as much as possible for at least the first three days.)

 

Hammertoes

Hammertoes refer to a deformity in which one or more toes are bent or contracted. As a result of this contracture, a joint in the toe sits up high rather than laying down flat. The toe is then more likely to rub against the toe box of a shoe and become painful. Chronic friction and pressure from shoes on a hammertoe may result in a painful bursitis or a painful corn. Bursitis is the inflammation of a fluid filled sack that may form at a site of irritation.  Symptoms may be reduced by wearing shoes with ample room in the toe area. Sometimes, padding may also help to relieve some pain. Corns are merely a localized build-up of dead skin and can be trimmed periodically to provide temporary relief of pain. The only way to permanently straighten the position of the toe is with a surgical procedure. This procedure itself is painless and often done under local anesthetic. There is usually only mild pain post-operatively. Walking, although often limited for a few days, is usually allowed immediately.

 

   

Sports Medicine  and  Traumatic Injuries

    Heel Pain and Plantar Fasciitis

There are many causes of heel pain. However, plantar fasciitis, also known as heel spur syndrome, is the most common, by far. The pain is usually localized to the bottom of the heel towards the inside of the foot. The arch may also be painful.  With this condition, pain is typically most severe with the first few steps after a period of rest. The pain my then subside and then return after extended periods of standing. There is usually no specific traumatic event that is responsible for the condition. It is usually the result of overuse, e.g. too much standing, walking or running. There are several common contributory factors such as weight gain, foot type, shoes. Flat shoes or going barefoot are the worst. Athletic shoes are usually the best. The plantar fascia is a fibrous band or ligament that connects the ball of the foot with the heel and helps to support the arch. When this band gets stretched too much or overused, inflammation results, often at the location where it attaches to the heel bone. A heel spur may develop as a result of chronic pulling by the plantar fascia. However, it should be noted that the pain is not caused by the spur. In fact, in some of the most severe cases, there is no spur at all. In other instances, an X-ray may be taken for an unrelated condition and an extremely large but non-painful spur may be seen. Other causes of heel pain include gout, stress fracture, bone tumors, nerve entrapment and thinning of the fat pad beneath the heel.  Pain at the back of the heel is usually not plantar fasciitis. (Pain at the back of the heel is often due to an inflammation of the Achilles tendon, enlargement of the heel bone or bursitis.)

Treatment for plantar fasciitis should be directed at resting the plantar fascia, providing support for the arch area and limiting pronation.  This is often accomplished with the use of supportive strapping with athletic tape, arch supports and orthotics. Heel lifts may also be helpful. Anti-inflammatories, pills as well as cortisone injections, may be effective as an adjunctive treatment by speeding up the reduction of   inflammation. However, if used alone, anti-inflammatories rarely lead to resolution of the condition. Stretching exercises, physical therapy and night splints may also be helpful. The majority of cases respond to non-surgical treatment although it may take several weeks to reach a comfortable level. Orthotics are often the most effective way to provide long term relief of symptoms and to prevent recurrences. In those cases that do not respond adequately to conservative measures, surgical release of the plantar fascia may be considered. However, a new non-surgical treatment called Extracorporeal Shockwave Therapy (ESWT) is now available as an option for recalcitrant plantar fasciitis. ESWT was approved by the FDA recently for the treatment of chronic heel pain. It has been in use for several years on thousands of patients in Europe and has been successfully used to restore patients with chronic plantar fasciitis to a normal, active lifestyle. ESWT is a non-invasive procedure that uses high intensity sound waves similar to what is routinely used to treat kidney stones. The treatment is usually performed in the office or in an outpatient surgical center. The procedure is performed under local anesthesia and takes about 30 minutes. The shockwaves are directed at the plantar fascia and stimulate an inflammatory healing response.  (Click here for more about heel pain)

    Fractures

A fracture is another name for a broken bone. A fracture can occur due to a specific traumatic event such as twisting one's ankle or falling from a ladder. However, they may also occur as a result of fatigue and overuse.  This type of fracture is known as a stress fracture. A common example of this is a fracture of a metatarsal bone following excessive walking. People with osteoporosis are at a greater risk of developing stress fractures due to the resultant weakening of bone associated with osteoporosis. Symptoms of stress fractures include redness, swelling and pain. Treatment of fractures usually involves casting or splinting and may require surgical stabilization. The aggressiveness of treatment depends on factors such as the amount of displacement or instability of the break as well as the location of the fracture.

    Tendonitis

Tendons are the cord-like structures that connect muscles to bones. Tendonitis is a general term describing an inflammation of a tendon. Tendonitis often results from overuse rather than an isolated traumatic event although either case is possible. The most common tendons at risk of tendonitis in the foot are the Achilles tendon at the back of the heel, the posterior tibial tendon on the inner side of the foot, the peroneal tendons on the outer side of the foot and the extensor tendons on the top of the foot. Rest and avoidance of repeated stress to the tendon is an extremely important component of treatment for this condition. Posterior Tibial Tendonitis/Dysfunction is a common condition that is usually associated with a flat foot condition and excessive pronation. Sometimes orthotics are an effective means of reducing or eliminating symptoms. Otherwise, surgery may be required to realign the foot to reduce the abnormal pronatory stresses.In the case of Achilles tendonitis, heel lifts are often an effective way of reducing tension. Sometimes a soft cast or special shoe or walking cast are utilized to provide for full or partial immobilization. Ice applications and anti-inflammatory medications  often help to reduce some of the pain and inflammation. Chronic cases may result in tenosynovitis and damage to the tendon that may need to be treated surgically.

    Shin Splints

Shin splints occur when  inflammation develops along the leg bone where muscles attach. This is often the result of excessive pronation  and overuse. Running is the most common activity associated with shin splints. Initial treatment consists of rest, ice, anti-inflammatories and bandaging. Orthotics (special shoe inserts) are often effective at providing long term control of symptoms.

    Sprains

A sprain is another name for a torn ligament. Ligaments are fibrous bands that usually run between two bones across a joint and which help to limit certain types of motion in order to provide joint stability. One of the most common sprains occurs at the ankle. The ligaments that run along the outside of the ankle often tear if the foot is twisted abruptly with a lot of force. There are actually 3 separate ligaments along the outside of the ankle that may be torn. When a single ligament is torn it may be referred to as a 1st degree sprain. A 2nd degree sprain involves 2 ligaments etc...Sprains often become quite inflamed and painful. Initial treatment (the 1st 36 hours)  usually involves rest, ice, compression, elevation. Anti-inflammatory medication such as ibuprofen (Advil, Motrin) or Naproxen( Aleve) and many others will help control some of the pain as well as the inflammation.  X-rays should be obtained to be sure there is not an associated ankle fracture. Longer term treatment often includes the use of a bandage or splint to provide some stability to the ankle and to help prevent additional twisting of the ankle. Recent studies indicate that walking with a bandage or soft cast may be better than casting because of the beneficial effects of ankle joint motion during the healing   period. Some acute ankle sprains may be treated surgically. In these cases, the torn ligaments may be sewn back together. Chronic ankle sprains may require surgery to stabilize the ankle and prevent recurrences,

 

Conditions Related to Systemic Diseases

   Diabetes   

Diabetes is a disease in which either not enough Insulin is produced by the pancreas (Type 1) or the insulin that is produced is not recognized by the cells of the body (Type 2). As a result, both types of diabetes lead to abnormally high blood sugar concentrations. High blood sugar (glucose) levels can lead to coma and death. In addition, chronic diabetes, through mechanisms that are still not completely understood, often results in complications involving many of the organ systems throughout the body. Some commonly affected organs are the kidneys(nephropathy), the eyes(retinopathy), the nerves(neuropathy) and the blood vessels( vascular disease). It is the neuropathy and vascular disease that may have a devastating effect on the feet. Both of these conditions can lead to amputation, particularly if the feet are neglected.

       Nerve Problems (Peripheral Neuropathy)

Neuropathy, the nerve disease associated with diabetes, often results in numbness and loss of protective sensation of the feet. Neuropathy can be the first manifestation of undiagnosed diabetes that prompts the patient to seek medical attention. Although pain is by definition an unpleasant experience, it is nonetheless a very important mechanism to alert us to danger. Without the ability to detect pain, one could walk around all day with a pebble in one's shoe and not know it. This could result in the development of an ulcer. Also, an infection could go unnoticed,  until  irreversible damage has already occurred. Neuropathy is probably responsible for more cases of ulcers, infections and amputations than vascular disease. There are several tests that can be utilized to determine the presence of peripheral neuropathy. The Semmes-Weinstein monofilament test is a simple way of determining whether neuropathy has advanced to the stage at which there is a loss of protective sensation. This is a simple test in which a small filament of plastic, similar to bristle on a hair brush, which has been calibrated to bend at a specific amount of force, is touched to the skin. If it can be felt, there is adequate sensation to protect against the development of ulcers. If not, there is a loss of protective sensation and the person is at risk for ulceration.

In addition to the loss of the ability to detect painful stimuli, some cases of neuropathy also result in a chronic, burning pain in the absence of any harmful stimulation. This neuropathic pain is often most severe at night, when resting and the person is not focusing on other things.

There is no effective treatment  to reverse the loss of protective sensation in the person with neuropathy once it has developed. But tight sugar control has been shown to reduce the risk of developing neuropathy in the first place. There are several treatments that may be used to try to reduce the discomfort associated with neuropathic pain but they are often ineffective. Mild neuropathic pain sometimes responds to capsacin cream applied 4 times daily. Sometimes Elavil is effective. Electrical stimulators have also been used to try to reduce neuropathic pain.

Neuropathy may also be seen in some people without diabetes. Alcohol abuse is another leading cause of neuropathy. It may also be  caused by certain drugs used to treat cancer and AIDS. Much of the early neuropathy research  was related to the study and treatment of Hanson's disease (leprosy). Fortunately, Hanson's disease is now very rare.

Deep Space Infections

Those with neuropathy are susceptible to the development of deep space infections in the foot. Deep space infections have a high morbidity and may lead to amputation if not identified early . There are several compartments in the foot surrounded by various layers of muscle and connective tissue. The compartments in the foot communicate with compartments of the leg through tunnel-like spaces around the tendons that travel through both the leg and the foot. This allows for easy spread of the infection from the foot to the leg.  Frequently, there is no pain in the foot due to neuropathy. A deep space infection is a surgical emergency requiring hospitalization, immediate incision and drainage, and intravenous antibiotics.This type of infection can also easily cause blood poisoning (sepsis).

      Circulation Problems (Peripheral Vascular Disease, PVD, PAD)

The circulatory system is composed of the heart which pumps the blood, the arteries which carry the blood to the rest of the body and the veins which carry the blood  back to the heart. Peripheral Arterial Disease occurs when the arteries become clogged and are not able to deliver enough blood to the extremities. Peripheral Arterial Disease, peripheral vascular disease, arteriosclerosis and atherosclerosis are often used synonymously. Peripheral Arterial Disease is often abbreviated as PAD. Similarly, Peripheral Vascular Disease is often abbreviated as PVD. Since this condition involves disease of the arteries, PAD is the more specific and accurate terminology. (The veins, which carry blood from the  extremities back to the heart,  are also part of the vascular system but are not involved in this particular condition). Diabetics are more prone to the development of peripheral arterial disease than the non-diabetic.  However, one certainly does not have to be diabetic to develop vascular disease. With peripheral vascular disease, arteries in the leg that carry blood to the foot become clogged. The earliest sign of PVD may be intermittent claudication which is a severe cramping of the leg or thigh that occurs while walking, usually at a predictable distance measured in blocks, and which may resolve after a period of rest. As the vascular disease worsens with time, the distance one can walk prior to feeling claudication pain becomes shorter.

A later sign of PVD is rest pain. This is pain that is often felt at rest when laying in bed. Typically, the pain is relieved by putting the feet down on the floor which allows the blood to flow down to the feet more easily.

PVD may also result in ischemic ulcers or gangrene. These develop when the tissues of the feet do not get enough blood flow. Without enough blood, the tissues do not get enough oxygen and they die.Once gangrene develops, the tissue death is not reversible and an amputation is often required.   

Many limbs can be saved with procedures to restore blood flow to the feet. This may be accomplished in some cases with angioplasty, where a balloon is fed through the arteries and used to open the blockage. Sometimes a stent is used to keep the area open. Other cases may benefit from a bypass procedure in which a vein or synthetic tube is used to bring blood around the blockage.

        Charcot Joint ( Charcot Foot, Diabetic Neurotrophic Osteoarthropathy)

It has been estimated that 2% of people with diabetes develop Charcot Joint. This is a condition in which certain joints, most commonly the midfoot, collapse and degenerate. This occurs only in people who have peripheral neuropathy. The earliest stage consists of a red, hot, swollen foot. This is often mistaken for an infection. X-rays will often show severe destruction and erosions of the involved joints. Later stages are without the inflammation but may show either a completely flattened arch or  the classical "rocker-bottom " foot. This can be a big problem since ulcers often develop beneath the collapsed bone.   

Treatment for a Charcot joint is aimed at reducing weightbearing pressure. This may be accomplished by using a wheelchair, complete bed rest or a contact cast. The treatment is usually continued until the inflammation has subsided and the bones have begun to fuse together. This may take 3 months or longer.Once the inflammation has subsided, treatment is aimed at preventing the development of ulcers and further breakdown. This is often accomplished with molded shoes and/or braces. Sometimes surgery may be needed to reconstruct the foot or to eliminate a prominent deformity.  (More about the diabetic foot)

   

    Arthritis    

        Osteoarthritis

Osteoarthritis (Degenerative Joint Disease) is the most common form of arthritis to affect the feet. In this condition, there is a progressive deterioration of the cartilage that serves as a lubricant between the two bones that come together in a joint. As a result, the joint may become stiff, painful and enlarged with reduced joint range of motion. There may be a genetic propensity to develop this condition, particularly when multiple joints are affected. Mechanical factors are also an important cause of many cases. For example, a person with an abnormally long first metatarsal bone may develop osteoarthritis of the big toe joints (1st metatarsophalangeal joints) as a result of chronic "jamming" of those joints. Trauma is also a common cause of degenerative joint disease. For example, dropping a heavy object onto the big toe joint may result in osteoarthritis of that joint several years after the occurrence of the traumatic event.    Joint pain from osteoarthritis may initially be treated with oral anti-inflammatory medications (NSAIDS) e.g. Ibuprofen (Advil, Motrin), Naproxen ( Aleve,Naprosyn), and many others. Orthotic devices may sometimes be of help. If conservative measures fail to alleviate symptoms, surgical intervention may be indicated. This can consist of salvage procedures to remodel the joint (arthroplasty) or   procedures to fuse the joint (arthrodesis). Joint implants may also be utilized. Several types of implants have been used over the years. However, joint implants in the foot in general are not as effective as the implants used in other areas such as the hip and knee.

        Rheumatoid Arthritis

Rheumatoid arthritis is an autoimmune ( the afflicted person's immune system, which normally protects against germs such as bacteria and viruses, treats the afflicted person's own body, particularly the joints, as if it were an invader.)  disease that affects the whole body but which has specific manifestations in the foot. Many joints in the body may be affected , particularly the joints of the hands and feet. Symptoms may consist of morning stiffness (usually lasting more than 30 minutes), pain, swelling and deformity of multiple joints. The disease is characterized by periodic flare-ups and periodic remissions. The deformity and disability gets worse with time.

Rheumatoid arthritis often leads to a chronically painful, deformed foot. The classic appearance of a rheumatoid foot consists of the following: a large bunion deformity,   the big toe drifts toward or under the 2nd toe (a hallux valgus deformity), the other toes drift outward and are also contracted upward,  and  the bones at the ball of the foot are very prominent with loss of the protective fat pad cushion beneath them. Heel pain may also be associated with this condition. It is not uncommon for painful lumps, rheumatoid nodules, to appear on the bottom of  the feet.

Many medications can be used to help control the pain, inflammation and remissions of the flare-ups. In conjunction with appropriate medications, specially molded shoes or accommodative orthotic shoe inserts may improve the ability to walk comfortably. Frequently,especially in more advanced cases,  foot surgery may be the best means of improving the deformity and reducing foot pain..

        Gout

Gout is a condition in which a joint becomes red, hot and painful because of a build-up of uric acid crystals. It was once associated with   eating rich foods but this not currently believed to be a major factor. Instead, gout is usually caused by either the body producing too much uric acid as a byproduct of metabolism or the body not being able to excrete enough uric acid through the kidneys and urine. When uric acid levels are high, it is deposited in various joints where it can crystallize. This results in a severe inflammatory response that produces the redness, swelling and pain. The most common joint to be affected, by far, is the big toe joint (1st metatarsophalangeal joint). It may occur in other joints much less frequently. The symptoms usually arise without warning, often at night. The pain is often described   as being so painful that light contact with bed sheets is excruciating . The pain and inflammation generally subside within about ten days. Pain in the big toe joint that occurs without heat, swelling and redness is usually not attributable to gout. Recurrent attacks of gout can lead to gouty arthritis in which the joint may erode and permanent damage occurs.  This often leads to chronic pain and stiffness which may be confused with osteoarthritis.

An attack of gout is usually treated with an oral anti-inflammatory medication such as Indomethacin. Occasionally an injection is necessary. Longer-term medications may also be used to block excessive uric acid production or to assist in the elimination of excess uric acid in the blood.

          

Conditions of the Toenails

    Fungal Toenails (Onychomycosis)

       

Fungal nails are often yellow, thick and deformed. But the appearance varies widely with the discoloration being brown,  green, black or white.  This condition occurs when a fungal organism invades the nail, settles in and makes itself at home there. When we typically hear the word infection, we often think of an associated inflammatory response with signs and symptoms such as pain, fever,redness, heat, swelling and pus. However, unlike bacterial infections and acute fungal infections of the skin, onychomycosis is generally not inflammatory (although in some cases, the skin around the nail may become quite inflamed . Classically, onychomycosis has been characterized by an infection of  a certain species of yeast (Candida) or one of the 'dermatophytes' (certain species of fungi that feed off of skin and skin structures such as toenails). However, recent studies have shown that many  other types of  fungi are now also common pathogens causing onychomycosis.

Fungus often causes the nail to become extremely thick (onychauxic) and deformed. This can result in nails which are very difficult to cut. Thick nails are not always the result of fungus. Trauma to the nail (such as dropping a heavy object on the toe) may result in permanently thick, deformed nails. Thick, deformed nails may start curling around if not trimmed, resulting in a "ram's horn" appearance (onychogryphosis).In some of these cases, the nail edge may cut into the flesh of the toe.

Historically, fungus in the toenails has been very difficult to eliminate. Although it is often caused by  the same organisms (e.g. one of the dermatophytes) that causes athletes foot, it is resistant to treatment due to the anatomy and other properties of the nail. Because of the lack of blood supply and thickness of the nail, topical antifunguals( such as Lotrimin Cream, Tinactin or Micatin) are not effective. Older oral medications such as griseofulvin have failed to provide a lasting cure and had many bad side effects. Newer oral agents such as Lamisil (terbinafine) and Sporonox (itraconazole) have recently been approved by the FDA for the treatment of fungal nails. Although they do not provide a cure 100% of the time, the cure rate is significant, greater than 50%  (although the number may vary depending on which study you read), which certainly beats a historical cure rate of close to 0% . Occasionally, surgical procedures may also be considered. Laser treatment is also now being used to try to eradicate fungal toenails.  (For more about fungal nails and antifungal treatments click here.)

   Ingrown Toenails (Onychocryptosis)

                       

An ingrown toenail occurs most commonly when the side of the nail causes a break in the skin adjacent to it . This is often due to improper cutting of the nail, particularly if the nail is cut too short, and is more likely to occur if the nail has a high side-to-side curvature or if it is excessively wide. Ingrown nails occur almost exclusively in the toenails rather than the finger nails because of the role that weightbearing plays in its development. Onychocryptosis may occur when the nail is cut too short and the  forces of the ground against the bottom of the foot push the fleshy tip of the toe up and into the leading edge of the nail.  Tight shoes or trauma may also contribute to the development of an ingrown toenail. As the nail grows out, the short, curved, side of toenail cuts into the skin in front of it and eventually causes a break in the skin. This break in the skin may serve as a portal of entry for germs which may result in an infection or inflammation around the toenail, often referred to as a paronychia. (Although ingrown nails are their most common cause, paronychias may be found sometimes without any evidence of an ingrown nail. For instance, they are sometimes found with fungal nails and some paronychias may be caused by yeast rather than bacteria.) Soaks and antibiotics alone are usually not effective treatment for an ingrown toenail. To obtain relief, a part of the nail must usually be removed. This is usually painless once the toe has been numbed with some local anesthetic. In many cases, medication may be applied to prevent regrowth of the ingrowing corner of the toenail (matrixectomy) .

 

Conditions of the Skin

    Athlete's Foot (Tinea Pedis)

Athlete's foot  is a fungal infection of the skin of the feet. In spite of its name, you don't have to be an athlete to get it.  The most common locations are between the toes and on the bottom  of the feet.  The 'acute' type of Tinea Pedis often includes signs and symptoms such as redness, small blisters, burning and itching. When this occurs between the toes, maceration (an accumulation of moisture on the skin surface resulting in a white,pale, wet appearance), erosions (a breakdown of the skin surface with a raw, red appearance) and fissures (cracks in the skin) are also common. A secondary bacterial infection may also result which may be red, hot and swollen. The 'chronic' type of Tinea pedis is usually drier and more scaly than the acute variety.This usually occurs on the bottom of the foot and may extend up the sides as well.   Topical anti-fungals are often effective in the treatment of Athlete's foot. In cases where there is a secondary bacterial infection, antibiotics may also be required.

    Calluses and Plantar Keratoses

Increased thickness of the outer layer of skin is referred to as hyperkeratosis. Common examples of hyperkeratotic lesions in the foot are corns and calluses. These conditions are usually the result of increased friction and pressure on a specific location on the foot. The friction and pressure stimulates cells in the skin to produce an increased amount of 'keratin' which makes the skin in that area feel hard. This can be extremely painful. When the hyperkeratosis is spread out over a wide area, it is known as a callus (or tyloma). If the pressure is concentrated in a smaller area on the bottom of the foot, an intractable plantar keratosis (IPK) or plantar heloma is formed. This often has the appearance and feeling of a small pebble buried in the ball of the foot. These are often treated by periodic trimming of the hard, dead skin. A podiatrist will often be able to provide special shoe inserts or orthotics which may be effective in reducing the recurrence of these conditions and in some cases he or she may suggest surgery to try to eliminate or reduce the severity of the condition.

   Corns (Heloma Durum)

A corn is a form of hyperkeratosis which is found on the top of one of the toe joints. These are usually associated with a hammertoe deformity. A hammertoe deformity is a rigid or flexible contracture of  a toe which results in the toe being bent so that one of the toe joints sticks up higher than it should. The corn is formed in response to the toe rubbing against the toe box of the shoe. Attempts can  be made to find shoes that have more room in the toe area and padding can be applied to reduce pressure to the high points of the toe. Temporary relief may be attained by periodic trimming of the corns by a podiatrist .However, the podiatrist may be able to provide a more permanent solution by performing surgery to straighten the toe. This is often done under local anesthetic, often in the office or in an outpatient surgery center and usually involves minimal pain.

   

    Soft Corns (Heloma Molle)

A soft corn is similar to a hard corn (heloma durum)  but is found between the toes rather on top of them. This condition is produced as a result of pressure between two adjacent toes . Tight shoes are often a precipitating factor but there is usually an underlying deformity such as an enlargement of a part of one of the toe bones, a hammertoe deformity or a hallux valgus (a deformity of the big toe which pushes against the other toes). The moisture that accumulates between the toes gives the soft corn its distinct appearance by causing the skin to become white and soft. Treatment is similar to treatment for a hard corn and often requires a surgical procedure to obtain long-lasting relief of symptoms.

     Warts

Warts (Verruca plantaris)  are caused by the Human Papilloma Virus and are not the result of increased pressure and friction as are corns, calluses and other hyperkeratotic conditions. They are often confused with IPK lesions. They are called "Plantar Warts", (not "Planter's".) The word plantar simply refers to the bottom of the foot. This helps to distinguish it from other warts that occur elsewhere on the body. Plantar warts are notoriously difficult to eradicate. They are typically well-defined and have a rough, cauliflower-like, hyperkeratotic surface. The vascular supply to the verruca appear as multiple black pinpoint dots  that are often seen throughout the lesions. The dots represent small blood vessel endings and  bleed when they are trimmed. Warts are often more tender when they are squeezed than when they are simply pushed directly. There are many different treatments for plantar warts because there is not any one routinely successful treatment. Several common treatments include chemical destruction with topical acids and other medications such as Bleomycin, freezing , laser surgery and simple excision. Non-surgical methods of treatment are generally painless and does not leave a scar but may take several weeks or months to effect a cure. Surgical treatments, whether with a blade or laser, leave a scar. There is the potential for the scar to be painful so care must be taken to avoid scarring over weight bearing surfaces.

Unusual appearing 'warts' should also be distinguished from  various types of skin cancer such as verrucous carcinoma and other malignancies of the skin. Other malignant lesions that may be found on the foot are basal cell carcinoma, squamous cell carcinoma and malignant melanoma. Questionable lesions should be excised and biopsied.

    Dry Skin and Cracking of the Skin (Xerosis and Fissures)

Dry skin may occur because of a reduction of oils in the skin. Rather than moisturizing feet as one might suspect, hot baths and soaking often remove oils in the skin and lead to dryness. Going barefoot or wearing certain shoes without socks may result in friction that removes oil from the skin and also leads to dryness. Painful cracks (fissures) may result on the bottom of the feet or at the back of the heels. These fissures may  become inflamed or infected. To prevent this from developing, avoid hot baths, avoid soaking feet and apply moisturizers to feet, particularly after bathing. Try to use a 'cream' or 'ointment' rather than a 'lotion'. The greasier the better. Prescription creams and ointments are also available if the response to over-the-counter products is not sufficient.

    Ulcers

An ulcer is a condition in which there is death of skin tissue (necrosis) resulting in an opening in the skin. (Similarly, a gastric or peptic ulcer is a break in the integrity of the lining of the stomach or gastrointestinal lining.) The skin serves an important role as a barrier to germs. When an ulcer develops in the skin, bacteria can enter the body and cause an infection.  A variety of different disease processes are responsible for ulcerations of the foot.  Effective treatment depends on correctly diagnosing the cause of the ulcer. A description of the most common ulcers follows:

Neuropathic ulcers occur when there is a nerve disease that results in numbness or the inability to feel pain. Although none of us likes to experience pain, it is an important warning sign and lets us know there is a problem that needs to be addressed. This type of ulcer is frequently associated with diabetics, who often develop a nerve condition known as peripheral neuropathy. Chronic abuse of alcohol may also result in neuropathy.  Neuropathic ulcers are most commonly seen on the bottom of the foot.  These ulcers may often start as a callus and may be hidden by a callus. These ulcers often occur in the presence of good blood circulation and will often heal well once weightbearing pressure is removed from them. The frequency  of these ulcerations may  be reduced by performing daily foot inspections, wearing properly fitting shoes and seeing a podiatrist regularly. Deep depth or custom molded shoes with special inlays or orthoses may also be required.  (More about the diabetic foot)

Ischemic ulcers  are caused by poor blood circulation (peripheral vascular disease or atherosclerosis.) The arteries, which carry blood from the heart to the rest of the body, become clogged. When this happens, not enough blood reaches the feet and tissue in the feet die and ulcerate due to lack of oxygen.  These ulcers are   often associated with diabetes since diabetics have an increased prevalence of vascular disease. They may also be seen in patients who are not diabetic but who have peripheral vascular disease. These ulcers most commonly involve the toes  rather than the bottom of the foot. These ulcers often lead to gangrene. These ulcers may also be painful although some people such as diabetics may have both neuropathy and vascular disease in which case they could have ischemic ulcers that are also painless.  (More about the diabetic foot)

Venous Stasis Ulcers occur in people whose veins are diseased. People with vein disease may have normal arteries with adequate blood going to the tissues in the feet. However, the veins in the legs, which carry the blood from the feet to the heart, in these cases have faulty valves. The faulty valves result in the blood being unable to make it  up the legs. The blood  then pools in the legs and feet. This then triggers a series of events which result in ulceration of the skin. Venous stasis ulcers occur most commonly on the lower legs rather than on the feet.  The skin around the ulcer is often discolored brown and there is usually a great deal of swelling in the legs and feet.  Treatment of stasis ulcers involves the of control of any infection and the control of swelling. Zinc oxide bandages (Unna boots) or compression stockings may be effective methods to reduce swelling and promote healing.

Decubitus ulcers or pressure sores are seen in bed ridden or wheelchair-bound patients. Decubitus ulcers are caused by the inability to move in response to prolonged pressure. The prolonged pressure results in tissue death and ulceration. These often occur under bony prominences such as the back of the heels. These ulcers may be prevented by moving and turning the bedridden person frequently so as to reduce prolonged pressure to any one site. There are also special air mattresses that can be used as well as foam heel protectors that keep the heels elevated slightly off the bed. Once an ulcer develops, the dead tissue should be surgically removed to allow the remaining healthy tissue to heal.

 

 

Ian H. Beiser, D.P.M., F.A.C.F.A.S, F.A.S.P.S.

Foot and Ankle Specialists of the Mid-Atlantic, LLC
1145 19th St., NW  Suite #203
Washington, DC 20036
(202) 833-9109

 
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