The foot is a complex structure of 26 bones
and 33 joints layered with an intertwining web of 126 muscles,
ligaments, and nerves. The average person spends four hours on
their feet and takes between 8,000 and 10,000 steps each day.
The feet are very small relative to the rest of the body, and
the impact of every step exerts tremendous force upon them --
about 50% greater than the person's body weight. During an average
day the feet support a combined force equivalent to several hundred
tons. In addition to supporting weight, the foot acts as a shock
absorber and as a lever to propel the leg forward, and it serves
to balance and adjusts the body to uneven surfaces. It is not
surprising, then, that about 75% of Americans experience foot
pain at some point in their lives. According to a recent study,
chronic and severe foot pain is a serious burden for one in seven
older disabled women. To compound problems, the lower back is
often affected by injuries or abnormalities in the feet.
Foot pain is generally defined by one of three
sites of origin: the toes; the front of the foot (forefoot); or
back of the foot (hind foot). Toe problems most often occur because
of the pressure imposed by ill-fitting shoes. Pain originating
in the front of the foot usually involves the metatarsal bones
(five long bones that extend from the front of the arch to the
bones in the toe) and the Sesamoid bones (two small bones imbedded
at the top of the first metatarsal bone, which connects to the
big toe). Pain originating in the back of the foot can affect
parts of the foot extending from the heel, across the sole (known
as the plantar) to the ball of the foot.
Nearly everyone who wears shoes has foot problems
at some point in their lives. Foot pain is fairly common even
in children. Heel pain, for instance, is common in very active
children between the ages of 8-13, when high impact exercise can
irritate growth centers of the heel. Women are at higher risk
than men for severe foot pain, probably because of the high incidence
of wearing high-heeled shoes. In fact, severe foot pain appears
to be a major cause of general disability in older women. In one
study, 14% of older disabled women reported chronic, severe foot
pain, which played a major role in requiring assistance in walking
and in daily activities. Elderly people, in any case, tend to
have problems because their feet widen and flatten and the fat
padding on the sole of the foot wears down as they age. Plantar
fasciitis is most common in people over 50. Anyone who is overweight
puts increased stress on the feet and is also at risk for foot
or ankle injuries. People who engage in high impact sports, such
as tennis, jogging, or racquet ball, or whose work involves heavy
lifting and walking are prone to foot injuries, especially Achilles
tendinitis, stress fractures, and plantar fasciitis. Many medical
conditions and inherited abnormalities predispose people to foot
problems. Pregnant women not only gain weight but also often experience
swelling in their feet and ankles. Pregnancy also releases hormones
that cause ligaments to relax, which helps in bearing the child
but can weaken feet. People with diabetes are at particular risk
for foot infections and should take special precautions.
General Conditions Causing Foot Pain
The causes of most incidents of foot pain
are poorly fitting shoes. High-heeled shoes are major culprits
for aggravating, if not causing, problems in the toes, where the
most pressure is exerted. Other conditions can also cause or exacerbate
foot pain. Weather affects the feet; they contract in cold and
expand in hot weather. Foot size can also increase by 5% over
the day and change shape and size depending on whether a person
is walking, sitting, or standing. Improper walking due to poor
posture or inherited or medical conditions that cause imbalance
or poor circulation can contribute to foot pain. Often one leg
is shorter than the other, causing an imbalance. High impact exercising,
such as jogging or strenuous aerobics, can injure the feet. Common
injuries include corns, calluses, blisters, muscle cramps, acute
knee and ankle injuries, plantar fasciitis, and metatarsalgia.
Medical Conditions Causing Foot Pain
Arthritic conditions, particularly osteoarthritis
and gout, can cause foot pain. Although rheumatoid arthritis almost
always develops in the hand, the ball of the foot can also be
affected. Osteoporosis, in which bone loss occurs, can also cause
foot pain. Diabetes is a particularly serious cause of foot pain,
infection, and ulcers, and, without proper foot care, can result
in amputation. Diabetics with foot deformities, such as claw toes,
or bunions are at particular risk. Anorexia, high blood pressure,
and other diseases that affect the nervous and circulatory systems
can cause pain, loss of sensation, and tingling in the feet, as
well as increase the susceptibility for infection and foot ulcers.
A number of conditions, including pregnancy, heart failure, kidney
disease, and hypothyroidism, can cause fluid build-up and swollen
feet. The increased weight and imbalance of pregnancy contributes
to foot stress. Diseases that affect muscle and motor control,
such as Parkinson's disease, also cause foot problems. Some medications,
such as calcitonin and drugs used for high blood pressure, can
cause foot swelling.
Causes of Toe Pain
Corns. A corn is actually a
form of a callus -- a protective layer of dead skin cells composed
of a tough protein called keratin. A corn itself is cone-shaped
and usually develops if a shoe rubs against the toes for a prolonged
period. As the skin thickens, the corn forms a knobby core that
points inward. Hard corns develop on toe joints, usually on the
little toe. A shoe that squeezes the front of the foot may cause
one toe to rub against another forming a corn between the toes,
which is usually soft. These corns can be painful, however, if
they harden and rub against each other.
Ingrown Toenails.Ingrown toenails
can occur in any toe but are most common in the big toes. They
usually develop when tight fitting or narrow shoes put too much
pressure on the toenail and force the nail to grow down into the
flesh of the toe. Incorrect toenail trimming can also contribute
to the risk of developing an ingrown toenail. Fungal infections,
injuries, abnormalities in the structure of the foot, and repeated
pressure to the toenail from high impact aerobic exercise can
also produce ingrown toenails.
Bunions.A bunion is a deformity
that usually occurs at the head of the first of five long bones
(the metatarsal bones) that extend from the arch and connect to
the toes. The first metatarsal bone is the one that attaches to
the big toe. The big toe is forced in toward the rest of the toes,
causing the head of the first metatarsal bone to jut out and rub
against the side of the shoe; the underlying tissue becomes inflamed
and a painful bump forms. As this bony growth develops, the bunion
is formed as the big toe is forced to grow at an increasing angle
towards the rest of the toes. A bunion may also develop in the
bone that joins the little toe to the foot (the fifth metatarsal
bone), in which case it is known as a bunionette or tailor's bunion.
Bunions often develop from wearing narrow, high-heeled shoes with
pointed toes, which puts enormous pressure on the front of the
foot and causes the foot and toes to rest at unnatural angles.
Injury in the joint may also cause a bunion to develop over time.
Genetics play a factor in 10% to 15% of all bunion problems; one
inherited deformity, hallux valgus, causes the bone and joint
of the big toe to shift and grow inward, so that the second toe
crosses over it. Flat feet, gout, and arthritis increase the risk
for bunions.
Hammertoes. A hammertoe is a permanent
deformity of the toe joint in which the toe bends up slightly
and then curls downward, resting on its tip; when forced into
this position long enough, the tendons of the toe contract and
it stiffens into a hammer- or claw-like shape. Hammertoe is most
common in the second toe but may develop in any or all of the
three middle toes if they are pushed forward and do not have enough
room to lie flat in the shoe. The risk is increased when the toes
are already crowded by the pressure of a bunion. Lying down for
long periods, diabetes, and various diseases that affect the nerves
and muscles put people at risk.
Causes of Pain in the Front of the Foot
The incidence of forefoot pain and deformity
increases with age. With early diagnosis, conservative therapy
is often successful in treating common disorders of the forefoot.
Calluses.Calluses are composed
of the same material as corns -- hardened patches of dead skin
cells formed from keratin -- but calluses develop on the ball
or heel of the foot. The skin on the sole of the foot is ordinarily
about forty times thicker than skin anywhere else on the body,
but a callus can double this normal thickness. A protective callus
layer naturally develops to guard against excessive pressure and
chafing as people get older and the padding of fat on the bottom
of the foot thins out. If calluses get too big or too hard, however,
they may pull and tear the underlying skin. Calluses can develop
from wearing poorly fitting shoes and walking on hard surfaces.
People with flat feet are at an increased risk of developing calluses.
In people with diabetes, particularly those who have had foot
ulcers, the presence of calluses is a strong predictor of subsequent
ulceration.
Neuromas.Neuromas occur when
the tissue surrounding a nerve becomes enlarged and inflamed causing
a burning or tingling sensation and cramping. Morton's neuroma
is the most common neuroma in the foot and usually develops when
tight, poorly fitting shoes, often those with high-heels, cause
the third and fourth metatarsal bones to pinch together compressing
an underlying nerve. Injury, arthritis, or abnormal bone structures
may also cause this condition.
Stress Fracture.A stress fracture
in the foot, also called fatigue or march fracture, usually occurs
from a break or rupture in any of the five metatarsal bones (mostly
in the second or third). Fracture in the first metatarsal bone
that leads to the big toe is uncommon because of the thickness
of this bone. If it occurs there, it is more serious than fractures
in the other metatarsal bones, because it dramatically changes
the pattern of normal walking and weight bearing. (Stress fractures
can also occur in the heel area.) They are caused by overuse during
strenuous exercise, particularly jogging and high-impact aerobics.
Sesamoiditis.Sesamoiditis is
an inflammation of the tendons around the small, round bones that
are imbedded in the head of the first metatarsal bone, which leads
to the big toe. Sesamoid bones bear much stress under ordinary
circumstances; excessive stress can strain the surrounding tendons.
Often there is no clear-cut cause, but sesamoid injuries are common
among people who participate in jarring, high impact activities,
such as ballet dancing, jogging, and aerobic exercise.
Metatarsalgia. When a cause cannot
be determined, any pain on the bottom of the foot where the metatarsal
bones connect to the four lesser toes is generally referred to
as metatarsalgia.
Causes of Pain in the Heel and Back of
the Foot
The heel is the largest bone in the foot.
Heel pain is the most common foot problem and affects two million
Americans every year. It can occur in the front, back, or bottom
of the heel.
Plantar Fasciitis.Plantar fasciitis
occurs from small tears and inflammation in the wide band of tendons
and ligaments —the connective tissue — which stretches
from the heel to the ball of the foot. This band, much like the
tensed string in a bow, forms the arch of the foot and helps to
serve as a shock absorber for the body. (The term plantar means
the sole of the foot and fascia refers to any fibrous connective
tissue in the body.) Plantar fasciitis is usually a result of
overuse from high-impact exercise and sports and accounts for
up to 9% of all running injuries. Because the condition often
occurs in only one foot, however, factors other than overuse may
be responsible in some cases. Other causes of this injury include
poorly fitting shoes or an uneven stride that causes an abnormal
and stressful impact on the foot. Pain often occurs suddenly and
mainly in the heel. The condition can be temporary or may become
chronic if the problem is ignored. In such cases, resting provides
relief, but it is only temporary.
Bursitis of the Heel.Bursitis
of the heel is an inflammation of the bursa, a small sack of fluid
tissue, beneath the heel bone.
Haglund's Deformity.Haglund's
deformity (also commonly called pump bump and known medically
as posterior calcaneal exostosis) is a bony growth surrounded
by tender tissue on the back of the heel bone. It develops when
the back of the shoe, almost always one with a high heel, repeatedly
rubs against the back of the heel, aggravating the tissue and
the underlying bone.
Tarsal Tunnel Syndrome.Tarsal
tunnel syndrome results from compression to a nerve that runs
through a narrow passage behind the inner ankle bone down to the
heel. It is caused by injury to the ankle, such as a sprain or
fracture, or by a growth that presses against the nerve.
Achilles Tendinitis.Achilles
tendinitis is an inflammation of the tendon that connects the
calf muscles to the heel bone. Achilles tendinitis is caused by
small tears in the tendon from overuse or injury. It is most common
in people who engage in high-impact exercise, particularly jogging,
racquetball, and tennis. People at highest risk for this disorder
are those with a shortened Achilles tendon, which can be due to
an inborn structural abnormality or can be acquired after wearing
high heels regularly. Such people tend to roll their feet too
far inward when walking and bounce when they walk.
Heel Spurs.Heel spurs are calcium
deposits that develop over time into a sharp bony growth under
the heel bone. They often result from improper foot movement during
running or walking, poorly fitting shoes, and excessive body weight.
As a spur develops the soft tissue in the heel becomes irritated
and swells, putting pressure on the nerves and causing pain. Pain
may increase with age as the fatty tissue on the bottom of the
foot wears away. It should be noted, however, that plantar fascia,
bursitis, stress fractures, and tarsal tunnel syndrome are more
likely to be the cause of heel pain than spurs.
Excessive Pronation.Pronation
is the normal motion that allows the foot to adapt to uneven walking
surfaces and to absorb shock. Excessive pronation occurs when
the foot has a tendency to turn inwardly and stretch and pull
the fascia. It can cause not only heel pain, but hip, knee, and
lower back problems.
Arch and Bottom-of-The- Foot Pain
Flat Foot.Flatfoot, or pes
planus, is a defect of the foot, in which there is no arch at
all. Flatfoot is usually hereditary or caused by diseases of the
muscles and nerves. Arches can fall, however, under certain conditions.
At particular risk are women who have habitually worn high-heels
for long periods. In such cases, the Achilles tendon that runs
down the back of the calf to the heel bone is not stretched, so
over the years, it shortens and tightens. The ankle, then, does
not bend properly, and tendons and ligaments running through the
arch try to compensate. Sometimes, they then break down and the
arch falls. Some studies have indicated that the earlier one starts
wearing shoes, particularly for long periods of the day, the higher
the risk for flat feet. One indirect outcome of flat arches may
be urinary incontinence or leakage during exercise. The less flexible
the arch, the more force reaches the pelvic floor, jarring the
muscles that affect urinary continence.
Clawfoot and Abnormally High Arches.Clawfoot, or pes cavus, is a deformity of the foot marked
by very high arches and very long toes. Clawfoot is a hereditary
condition, but it can also occur when muscles in the foot contract
or become unbalanced due to nerve or muscle disorders. An overly
high arch (hollow foot), in general, can cause problems. Army
studies have found that recruits with the highest arches have
the most lower-limb injuries and that flat-footed recruits have
the least. Contrary to the general impression, the hollow foot
is much more common than the flat foot.
Preventing Foot Problems in Childhood
The first year in a person's life is important
for foot development. Parents should cover their baby's feet loosely,
allowing plenty of opportunity for kicking and exercise. The child's
position should be changed several times. Staying too long on
the stomach can strain the feet. Children generally walk between
10 and 18 months; they should not be forced to start walking early.
Wearing just socks or going barefoot indoors helps the foot develop
normally and strongly and allows the toes to grasp. Going barefoot
outside, however, increases the risk for injury and other conditions,
such as plantar warts. When outdoors, shoes should be light, flexible,
and made of natural materials that "breathe". (Children's feet
perspire greatly.) Footwear should be changed every few months
as the child's feet grow. Footwear should never be handed down.
High impact sports can injure growing feet, and parents should
be sure that their children's feet are protected if they engage
in intensive athletics.
Foot Care
Toenails should be trimmed short and straight
across. Filing should be straight across as well using a single
movement, lifting the file before the next stroke. The file should
not saw back and forth. A cuticle stick can be used to clean under
the nail. Skin creams can help maintain skin softness and pliability.
Taking a warm foot bath for 10 minutes two or three times a week
will keep the feet relaxed and help prevent mild foot pain from
fatigue. Adding 1/2 cup of Epson salts increases circulation and
adds other benefits. Taking foot baths only when feet are painful
is not as helpful. A pumice stone or loofah sponge can help get
rid of dead skin. Hiking or strenuous walking can cause blisters.
To prevent them, one study reported that treating feet with antiperspirants
before setting out may be helpful. Reflexology is an Oriental
massage therapy that manipulates hands and feet. A pleasant exercise
using this method can be done while taking a bath. Use the thumb,
index and middle finger to rotate each toe in a circular motion.
Then, make a fist and rotate it slowly around the bottom of the
foot. Finally, gently twist each foot as if wringing wet clothes,
moving the top and bottom in opposite directions.
Foot Care for People with Diabetes.
Daily foot care is extremely important for people with diabetes
who are at risk for nerve damage and poor blood flow to the feet.
Preventive foot care could reduce the risk of amputation in people
with diabetes by 44% to 85%. Patients should make a daily inspection
and watch for changes in color or texture, odor, and firm or hardened
areas, which may indicate infection and potential ulcers. When
washing the feet, the water should be warm (not hot) and the feet
and areas between the toes should be thoroughly dried afterward.
Moisturizers should be applied, but not between the toes. Corns
and calluses should be gently pumiced and toenails trimmed short
and the edges filed to avoid cutting adjacent toes. Patient should
not use medicated pads or try to shave the corns or calluses themselves.
People with diabetes should avoid high heels, sandals, thongs,
and going barefoot. Shoes should be changed often (three times
a day if possible). They should not wear tight stockings or any
clothing that constricts the legs and feet. A new hand-held device
that uses a nylon fiber brush may enable the physician to identify
nerve damage that can lead to ulcers by pressing it against several
points on the foot and eliciting the patient's response to the
pressure.
A person with diabetes should check with a
specialist in foot care for any problems. Hospitalization and
intravenous antibiotics for up to 28 days may be needed for severe
foot ulcers in diabetic patients. In one study, intravenous therapy
using ofloxacin or penicillin for only seven days followed by
an oral antibiotic was adequate treatment. A number of treatments
(Dermagraft, Apligraf, Regranex) are now available that stimulate
new cell growth and help heal skin ulcers or use cultures of human
skin cells, although their benefits are still unproven. Granulocyte-colony
stimulating factor, or G-CSF (filgrastim, Neupogen, Amgen) is
showing promise as an effective alternative to antibiotics. One
small study shows that treatment with human nerve growth factor
(NGF) may safely prevent and reverse some of the nerve damage
caused by diabetes. One study indicated that administering hyperbaric
oxygen (given at high pressure) promoted healing and helped prevent
amputation. There was no follow-up however, and more research
is needed. According to a new study, the wearing of magnet-laden
socks seems to reduce or eliminate the pain associated with diabetes
induced foot disorders.
Shoes
Well-fitted shoes are the best way to prevent
nearly all problems with the feet. They should be purchased in
the afternoon or after a long walk, when the feet have swelled.
The shoe should have adequate cushioning, 1/2 inch of space should
be left between the largest toe and the tip of the shoe, and the
toes should be able to wiggle upward. A person should stand when
being measured, and both feet should be sized, with shoes bought
for the larger-sized foot. Women who are used to wearing overly
pointed-toe shoes may assume that tight-fitting shoes are normal,
hence increasing the risk for many foot disorders. New shoes should
have padding, a flexible sole, and should always feel comfortable
right away without requiring a period of breaking-in. Ideally,
the shoe would have a removable insole. Elderly people wearing
shoes with thick inflexible soles also may be unable to sense
the position of their feet relative to the ground, significantly
increasing the risk for falling. Some experts recommend that older
people wear thin hard soles. More research is needed to determine
if thick soles are actually responsible for foot injury in younger
adults who engage in high impact exercise.
If shoes do require breaking-in, moleskin
pads should be placed next to areas on the skin where friction
will occur. Shoes purchased for exercise should be specifically
designed for a person's preferred sport. The heel area should
be strong and supportive (but not too stiff) and the front of
the shoe flexible. As soon as the heels show noticeable wear,
the shoes or heels should be replaced. If a person insists on
wearing high-heeled shoes, the heel should be wedge-shaped. (Even
in these cases, the heel height should not be extreme.) People
should avoid extreme variation between exercise footwear, street,
and dress shoes. Shoes should be changed during the day.
The way shoes are laced can be important for
preventing specific problems. Laces should always be loosened
before putting shoes on. People with narrow feet should buy shoes
with eyelets farther away from the tongue than people with wider
feet. This makes for a tighter fit for narrower feet and looser
for wider. If, after tying the shoe, less than an inch of tongue
shows, then the shoes are probably too wide. Tightness should
be adjusted both at the top of the shoe and at the bottom. Where
high arches cause pain, eyelets should be skipped to relieve pressure.
Although people believe that foot-binding
is a problem limited to Chinese women of the past, it should be
noted that fashionable high-heels are designed to constrict the
foot by up to an inch. High heels are the major cause of foot
problems in women and one study suggests that wearing high-heels
may even lead to arthritis of the knee. Fortunately, according
to a recent survey, nearly half of working women now wears flats;
about one quarter wears pumps less than 2 1/4 inches in height
and another quarter wears athletic shoes. Only 3% reported wearing
shoes with heels higher than 2 1/4 inches. Women who insist on
high-heels should at least look for shoes with wider toe room,
reinforced heels that are relatively wide, and cushioned insoles.
They should also reduce the amount of time they spend wearing
high-heels. The American Orthopaedic Foot and Ankle Society now
awards a Seal of Approval to women's shoes that they determine
are healthy.
Correct Walking and Exercise
In addition to wearing proper shoes and socks,
a person should also walk often and correctly to prevent foot
injury and pain. The head should be erect, back straight, and
the arms relaxed and swinging freely at the side. A person should
step out on the heel, move forward with the weight on the outside
of the foot, and complete the step by pushing off the big toe.
A person should prepare for long hikes by putting moleskin pads
on the heel and other parts of the foot that might be rubbing
on the shoe. At the end of a hike, the foot should be checked
for irritation and redness. Gentle stretching and heel lifts after
warm-up and before running can help prevent Achilles tendinitis
and heel pain.
Insoles and Orthotics
Insoles. Insoles are flat cushioned
inserts that are placed inside the shoe; they can be obtained
in athletic and drug stores. They are designed to reduce shock,
provide support for heels and arches, and resist moisture and
odor. Most well-known brands of athletic shoe have built-in insoles.
Dr. Scholl's is the most popular insole, but many others are now
available, including Pedifix, Sorbothane, Implus, Footfit and
Kiwi. Prices for these insoles range from $5 to $20. The Spenco
orthotic arch support is a high-end insole that can be molded
by putting it into boiling water for two minutes. It is sometimes
recommended by health practitioners. In general, over-the-counter
insoles offer enough support for most people's foot problems.
Shoe stores that specialize in foot problems often sell customized,
but more expensive, insoles. The thickness of socks must be considered
when purchasing insoles to be sure they do not squeeze the toes
up against the shoes. Women who have worn high-heels for prolonged
periods and have developed short, tightened Achilles tendons should
consider heel cushions, which are inserted inside the shoe and
should be at least 1/8 inch high but not more than 1/4 inch. People
respond very differently to specific insoles and what may work
for one person may not for another.
Orthotics. For severe conditions, such
as fallen arches or body-structural problems that cause imbalance,
podiatrists or physicians may need to fit and prescribe orthotics,
or orthoses, which are insoles molded from a plaster of Paris
cast of an individual's foot. Orthotics are usually categorized
as rigid, soft, or semi-rigid. Rigid orthotics are often used
to prevent excessive pronation (the turning in of the foot) and
are useful for people who are very overweight or have uneven leg
lengths. Some experts warn that rigid orthotics may cause sesamoiditis
or benign tumors that form from pinched nerves. Soft orthotics
are made from a light weight material and are often beneficial
for people with diabetes or arthritis. They need to be replaced
periodically, and because they are bulkier than rigid orthotics,
they may require larger shoes. Semi-rigid orthotics are usually
made of layers of leather and cork reinforced by silastic. They
are often used for athletes, in which case they are designed for
a specific sport. The cost of examinations, casting, and x-rays
is high but may be covered by some insurance plans.
Before seeking prescription orthotics, people
with less severe problems should consider testing the lower-priced
over-the-counter insoles. One study found that 72% of people reported
less foot pain from store-purchased insoles compared to 68% of
those who had them custom made.
Treatment for Acute Pain and Injury
Over-the-Counter Pain Relievers. Over-the-counter
nonsteroidal anti-inflammatory drugs (NSAIDs) are commonly used
to treat mild pain caused by inflammation of muscles. There are
dozens of these drugs, but aspirin is the most common of them.
Others include ibuprofen (Motrin, Advil, Nuprin, Rufen), ketoprofen
(Actron, Orudis KT), naproxen (Aleve, Naprelan), and tolmetin
(Tolectin). It is important to note that high doses or long-term
use of any NSAID can cause gastrointestinal disturbances, with
sometimes serious consequences, including dangerous bleeding.
No one should take NSAIDs for chronic pain without consulting
a physician. A gel containing ibuprofen can be applied to sore
joints. Acetaminophen (e.g., Tylenol) is not an NSAID,
and although it is a mild pain reliever, it will not reduce inflammation.
RICE. The acronym RICE (rest, ice,
compression, elevation) is used to remind people of the four basic
elements of immediate treatment for an injured foot. People should
get off injured feet as soon as possible (Rest). Ice is particularly
important to reduce swelling and promote recovery during the first
forty-eight hours. A bag or towel containing ice should be wrapped
around the injured area on a repetitive cycle of 20 minutes on,
40 minutes off (Ice). An ace bandage should be lightly wrapped
around the area (Compression). The foot should be elevated on
several pillows (Elevation).
X-Rays. If people suspect that bones
in a toe or foot have been broken or fractured, they should call
a physician, who will probably order x-rays. It should be noted
that often a person is able to walk even if a foot bone has been
fractured, particularly if it is a chipped bone or a toe fracture.
Treatments for Toe Problems
Treatment for Corns. Warm-water soaks
soften corns so that gentle rubbing with a pumice stone afterward
can remove dead tissue. Several such treatments may be necessary
before the corn has been removed. The area should be protected
with small, doughnut-shaped pads, available at any pharmacy. Soft
corns are treated by placing lamb's wool pads between the toes
to reduce perspiration. Over-the-counter pads or plasters containing
salicylic acid are effective in removing hard corns. The pad should
be cut to the size of the corn and applied to the skin. After
leaving it in place for a day or two, the pad is removed and the
foot soaked for 20 minutes in warm water. The area is then gently
buffed with pumice, and the procedure repeated until the corn
has been removed. Such medications carry a risk for irritation,
chemical burns, or infection, particularly for older people or
people with diabetes. These medications are also highly flammable.
Salicylics do not eliminate the friction that caused the corn
in the first place, so the problem will probably come back unless
correct shoes are worn. If the corns are well-developed, a physician
or podiatrist may trim them, using a scalpel to thin the corn.
This should only be done by professional, however, and not attempted
as a do-it-yourself project.
Treatment for Ingrown Toenails. To
relieve pain from ingrown toenails, the pressure from the nail
can be relieved by wearing sandals or open-toed shoes. Soaking
the toe in warm water for five minutes twice a day in a solution
of Domeboro or Betadine solutions can be beneficial. Antibiotic
ointments may be used; they should be gently applied using a wisp
of cotton, which should be worked under the nail, especially around
the corners, to lift the nail up and drain the infection. The
cotton will also help force the toenail to grow out correctly.
The cotton should be changed daily and the antibiotic used consistently.
People who are at increased risk for infections, such as those
with diabetes, should have a professional treat the problem. Surgery
may be necessary in some cases.
Treatment for Hammertoe. At first,
a hammertoe is flexible, and any pain it causes can usually be
relieved by putting a toe pad, which are sold in drug stores,
into the shoe. To help prevent and ease existing discomfort from
hammertoes, shoes should have a deep, wide toe area. As the tendon
becomes tighter and the toe stiffens. Other treatments, including
exercises, splints, and custom-made shoe inserts (orthotics),
may help redistribute weight and ease the position of the toe.
Surgery may be needed in some severe cases. It is performed on
the tendon or soft tissue if the toe is still flexible. If the
toes have become rigid, however, surgery involves the removal
of a small piece of bone in order to return the toe to its normal
position. The procedure is done in the doctor's office under local
anesthetic. Afterward, the patient will wear a splint and a surgical
shoe for a week if surgery only involved the tendon and soft tissue
or for up to four weeks if bone was removed.
Treatments for Problems in the Front of
the Foot
Treatment for Calluses. Calluses protect
the feet and often do not need to be treated, but if a callus
causes pain, several treatments are effective. Sanding the callus
with a pumice stone after bathing is very helpful. Soft cushions
placed in the heel of the shoes or under the ball of the foot
can help relieve pain. Specially fitted shoe inserts are also
helpful. Liquid solutions or medicated pads treated with salicylic
acid, the same chemical used to treat corns, are also effective
in removing calluses (For precautions, see Corns, above).
If calluses are well-developed and cause pain, professional trimming
is recommended.
Treatment for Bunions.Pressure
and pain from bunions and bunionettes can be relieved by wearing
appropriate shoes: soft, wide, low-heeled leather shoes that lace
up; athletic shoes with soft toe boxes; or open shoes or sandals
with straps that don't touch the irritated area. A thick doughnut-shaped,
moleskin pad can protect the protrusion. In some cases, an orthotic
can help redistribute weight and take pressure off the bunion.
NSAIDs, nonsteroidal anti-inflammatory drugs, may also offer some
relief from pain. If discomfort persists, surgery may be necessary.
An office procedure, known as bunionectomy or osteotomy, involves
shaving down the bone of the big toe joint. A variation of these
procedures uses only a very small incision, through which the
bone-shaving drill is inserted. The physician shaves off the bone,
guided by feel or x-ray. Neither variation of bunionectomy is
a cure. Bunion surgery involves realigning the big toe joint and
bone as well as tendons and ligaments. In severe cases, the metatarsal
may also be repositioned. Recovery takes six to eight weeks and
a patient may need to wear a case or use crutches, but patients
are generally satisfied with the results at six months. Longer-term
studies are needed. Complications can include shortening of the
metatarsal, which may be prevented or reduced using a procedure
called fixation osteotomy, which uses a plate and screw device
to hold the bone in place. Some surgeons are testing bone grafts
to restore bone length in patients who have had previous bunion
surgeries. A simpler initial procedure that allows correction
of the deformity without cutting or fusing the bone may be appropriate
for some patients.
Treatment for Morton's Neuroma.Pain from Morton's neuroma can be reduced by taking off the
shoe and massaging the area. Roomier shoes, pads of various sorts,
and cortisone injections in the painful area are also helpful
in relieving pain. If these treatments are not effective, the
enlarged area may need to be surgically removed. Surgery is usually
successful and the patient can walk immediately afterward. Sometimes
the nerve tissue may regrow and form another neuroma.
Treatment for Stress Fractures.In most cases stress fractures heal by themselves as long
as rigorous activities are avoided. It is best to wear low-heeled
shoes with stiff soles. Some physicians recommend moderate exercise,
particularly swimming and walking. Occasionally, a physician may
recommend wearing a special wooden shoe and a compressive wrap
to make walking more comfortable.
Treatment for Sesamoiditis. Rest
and reducing stress on the ball of the foot are the first lines
of treatment for sesamoiditis. A low-heeled shoe with a stiff
sole and soft padding inside is all that is required usually.
In severe cases, however, surgery may be necessary.
Treatment for Heel Pain and Problems in
the Back of the Foot
General Guidelines.Nonsurgical
treatments for heel pain are effective in 90% of patients. The
American Orthopaedic Foot and Ankle Society (AOFAS) suggests trying
shoe inserts, medications, and stretching first. One study found
that 95% of women who used an insert and did simple exercises
that stretched their Achilles tendon and plantar fascia experienced
improvement after eight weeks. If these methods fail, then the
patient may need prescription heel orthotics and extended physical
therapy. Heel surgery to relieve pain may be performed for heel
spurs, plantar fasciitis, bursitis, or neuroma. Surgery is not
recommended until nonsurgical methods have failed for at least
six months and preferably 12 months.
Treatment for Plantar Fasciitis.The first goals of treatment for plantar fasciitis are rest
and reduction of inflammation. The inflammation and pain is most
commonly treated with ice and taking over-the-counter nonsteroidal
anti-inflammatory drugs (NSAIDs). Wearing comfortable shoes that
have thick soles and rubber heels is recommended. A sole cushion
(available in drug stores) placed in the shoe will provide added
relief and cut down on stress to the heel. Cutting a round hole
about the size of a quarter in the sole cushion under the painful
area will offer support to the rest of the heel while relieving
pressure on the painful spot itself. When combined with exercises
that stretch the arch and heel cord, over-the-counter insoles
may offer better relief than prescribed orthotics. Heel cups are
not very useful. A moderate amount of low-impact exercise (such
as walking, swimming, or cycling) seems to be beneficial. It also
helps to stretch the plantar fascia: put your hands on a wall
and lean against them, with the uninjured foot on the floor in
front of you and the injured foot placed behind so that the heel
is not touching the floor, stretch or bounce gently. Fortunately,
the plantar fascia heals by itself but it may take as long as
a year, with pain occurring intermittently. Pain that is not relieved
by NSAIDs may require more intensive treatments. Leg casts are
effective. One device uses an Ace bandage and an L-shaped fiberglass
splint, which the patient wears while sleeping; it keeps the foot
stretched, allowing the muscle to heal. A walking cast may be
better than even steroid (usually cortisone) injections, which
are often used to reduce inflammation in severe cases. For athletes
or performers who need immediate relief, an effective method is
to administer the steroid dexamethasone using a procedure called
iontophoresis, which introduces the drug into the foot's tissue
using an electrical current. Embarking on an exercise program,
as soon as possible -- with NSAIDs, splints, or heel pads depending
on the patient's needs -- reduces the risk for future surgery.
In extreme cases, so-called release surgery may be needed to relieve
pressure on the nerves that are causing pain. It is nearly always
very successful, although it requires a large incision and takes
about two months to resume complete normal activity. For selected
patients, a newer procedure called endoscopic plantar fascia release
may be appropriate; it is less invasive and may take less time
for recovery. Another investigative procedure called orthotripsy
uses shock waves directed at the affected heel. In one study,
17 out of 30 patients reported improvement.
Treatment for Bursitis. NSAIDs and
steroid injections will help relieve pain from bursitis. Applying
ice and massaging the heel is also beneficial. A heel cup or soft
padding in the heel of the shoe will reduce direct impact when
walking.
Treatment for Achilles Tendinitis.
Like most athletic injuries, Achilles tendinitis should be treated
as early as possible. NSAIDs may help to ease pain from Achilles
tendinitis and reduce inflammation. It is also helpful to apply
ice four or five times a day for 20 to 30 minutes. Gentle stretches
may also help reduce the pain and spasms. If the calf is swollen,
elevating the leg is recommended. Exercise is safe when the heel
is no longer swollen or tender, even if pain is still present.
If pain increases with exercise, however, the person should stop
immediately. If pain continues, the ruptured tendon will require
a cast and perhaps surgery. Although some experts believe a cast
is sufficient in many cases, without an operation, the tendon
has a 38% chance of rupturing again. Surgery requires a long incision
with a postoperative period of immobilization that can average
six weeks. Complications can include a significant surgical scar,
infection, and muscle atrophy. Less invasive techniques are being
tested. Some experts suggest surgery for active persons and nonsurgical
treatment for older people. In one study, selected patients with
ruptured tendons were hospitalized for about five days and fitted
with special footgear that continuously raised the back of the
foot (Variostabil). It was effective for most patients and the
tendon ruptured again in only 5% of these cases.
Treatment for Tarsal Tunnel Syndrome.
Pain from tarsal tunnel syndrome may be relieved by treatment
with orthotics, specially designed shoe inserts, to help redistribute
weight and take pressure off the nerve. Corticosteroid injections
may also help. Surgery is sometimes performed to relieve pressure
on the nerve, but unfortunately, studies are showing that this
surgery is often not beneficial.
Treatment for Haglund's Deformity (Pump
Bump). Applying ice followed by moist heat will help ease
discomfort from a pump bump. NSAIDs will also reduce pain. Physicians
may recommend an orthotic device to control heel motion. In severe
cases, when these treatments do not relieve pain, surgery may
be necessary to remove or reduce the bony growth. Corticosteroid
injections are not recommended because they can weaken the Achilles
tendon.
Treatment for Heel Spurs. Most heel
spurs do not cause pain. If they do, NSAIDs and insoles may be
sufficient. If the pain persists, surgery may be recommended,
which involves cutting and releasing the plantar fascia and removing
the spurs. The surgery can be risky and leave scarring that may
be more painful than the original problem. Recovery usually requires
immobilization of the foot and use of crutches for about two weeks.
Surgery should be a last resort.
Treatment for Arch Problems
Treatment for Flat Feet. Army studies
that have found that recruits with low arches have less risk for
injury in the lower parts of the body raise the question of when
and if to correct for flat feet. Children, with flat feet, for
instance, often outgrow them, particularly tall, slender children
with flexible joints. One expert suggests that if an arch forms
when the child stand on tip-toes, then the child will probably
outgrow the condition. In severe cases, however, flat feet impair
the ability to walk and require custom-made shoe inserts or even
surgery. An insole known as the Dynamic Stabilizing Innersole
System (DSIS) appears to significantly improve flat feet in children.
This insole responds appropriately according to the severity of
the condition and does not over-correct for mild cases of flat
feet.
If you are a Munson Healthcare patient and have a compliment,
concern, or complaint, please contact one of our Patient
Liaisons.
