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)

    Metatarsalgia

    Morton's Neuroma

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.

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

Sports Medicine  and  Traumatic Injuries

    Fractures

    Tendonitis

    Shin Splints

    Sprains

Conditions Related to Systemic Diseases

   Diabetes   

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.

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 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..

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 drugs 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)

    Calluses and Plantar Keratoses

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 (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)

    Ulcers