This section provides common foot disorder information. We have also provided links to valuable podiatry information sites on the Internet. We have listed below only a few of the more common foot problems encountered in our offices on a daily basis.

Common Disorder Articles

What is a Podiatrist?

A Podiatrist, Doctor of Podiatric Medicine (DPM), is the only health care professional whose total training focuses on the foot, ankle and related body systems. After obtaining an undergraduate degree, the podiatric doctor spends four years in a college of podiatric medicine to obtain a doctorate degree. Many podiatrists further their education by participating in a post-graduate residency program at an approved hospital or university. Following their doctorate degree, each podiatrist must pass national and state examinations in order to be licensed by the state in which he or she will practice.

The podiatric physician cares for people of all ages. Common disorders of feet include bunions, heel pain/spurs, hammertoes, neuromas, ingrown toenails, warts, corns, calluses, sprains, fractures, infections, and injuries. If your podiatric surgeon is certified by the American Board of Podiatric Surgery, he or she has successfully completed a credentialing and examination process and has demonstrated knowledge of podiatric surgery. This includes the diagnosis of general medical problems and surgical management of foot diseases, deformities, and trauma of the foot, ankle and related structures.

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Athlete's Foot (Tenia Pedis)

Description

Athlete's foot is caused by a fungal infection of the skin on the foot and is by far the most common fungal infection of the skin. The infection can be either acute or chronic. The chronic form of the disease is often associated with fungal-infected toenails. The acute form of the infection most often presents with scaling between the toes with occasional small blisters and/or fissures. As the blistering breaks, the infection spreads and can involve large areas of the skin on the foot. The burning and itching that accompany the blisters may cause great discomfort that can be relieved by opening and draining the blisters or applying cool water compresses. The infection can also occur as isolated circular lesions on the bottom or top of the foot. As the skin breaks down from the fungal infection, a secondary bacterial infection can ensue.

The diagnosis of tinea pedis is generally made based upon the clinical presentation. A definitive diagnosis is made by taking a scraping of the skin and culturing it. It may take up to three weeks for the culture to grow the fungus. In some instances the culture may present a false negative result because the skin scraping was inadequate. Some doctors may perform a KOH prep of a skin scraping. This is examined under a microscope and may reveal elements that can make the diagnosis.

Treatment should be directed at controlling the fungal infection and treating any secondary bacterial infection with oral antibiotics. Soaking the feet in Epsom salts and warm water is helpful. Wearing sandals to reduce moisture accumulation and heat generated by closed shoes will also help in the control and spread of the infection. Other conditions that mimic acute athlete's foot are contact dermatitis and pustular psoriasis.

The chronic form of athletes foot is a relatively noninflamatory type of infection. It is characterized by a dull redness to the skin and pronounced scaling. It may involve the entire bottom of the foot giving a "moccasin" appearance. It generally does not itch or result in the formation of blisters. This form of the disease frequently has an associated fungal infection of the toenails. There are good topical and oral medications available for the treatment of this condition.

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Bunions

Description of the Condition

One of the more common conditions treated by podiatric surgeons is the painful bunion. Patients with this condition will usually complain of pain when wearing certain shoes, especially snug fitting dress shoes. Treatment may involve shoe gear modification, padding and orthoses. When this fails to provide adequate relief, surgery is often recommended. There are several surgical procedures to correct bunions. Selection of the most appropriate procedure for each patient requires knowledge of the level of deformity, review of the x-rays and an open discussion of the goals of the surgical procedure. Almost all surgical procedures require cutting and repositioning the first metatarsal. In the case of mild to moderate bunion deformities the bone cut is most often performed at the neck of the metatarsal (near the joint).

The classic bunion, medically known as hallux abductovalgus or HAV, is a bump on the side of the great toe joint. This bump represents an actual deviation of the 1st metatarsal and often an overgrowth of bone on the metatarsal head. In addition, there is also deviation of the great toe toward the second toe. Shoes are often blamed for creating these problems. This is inaccurate. It has been noted that primitive tribes, where going barefoot is the norm, will develop bunions. Bunions develop from abnormal foot structure and mechanics which place an undue load on the 1st metatarsal. This leads to stretching of supporting soft tissue structures such as joint capsules and ligaments with the end result being gradual deviation of the 1st metatarsal. As the deformity increases, there is an abnormal pull of certain tendons, which leads to the drifting of the great toe toward the 2nd toe. At this stage, there is also adaptation of the joint.

The most common symptoms associated with this condition are pain on the side of the foot. Shoes will typically aggravate bunions. Stiff leather shoes or shoes with a tapered toe box are the prime offenders. This is why bunion pain is most common in women whose shoes have a pointed toe box. The bunion site will often be slightly swollen and red from the constant rubbing and irritation of a shoe. Occasionally, corns can develop between the 1st and 2nd toe from the pressure the toes rubbing against each other. On rare occasions, the joint itself can be acutely inflamed from the development of a sac of fluid over the bunion called a bursa. This is designed to protect and cushion the bone. However, it can become acutely inflamed, a condition referred to as bursitis.

Early treatment of bunions is centered on providing symptomatic relief. The use of pads and cushions to reduce the pressure over the bone can be helpful for mild bunion deformities. Functional foot orthotics, by controlling abnormal pronation, reduces the deforming forces leading to bunions in the first place. These may help reduce pain in mild bunion deformities and slow the progression of the deformity. When these conservative measures fail to provided adequate relief, surgical correction is indicated. The choice of surgical procedures (bunionectomy) is based on a biomechanical and radiographic examination of the foot. Because there is actual bone displacement and joint adaptation, most successful bunionectomies require cutting and realigning the 1st metatarsal (an osteotomy). Simply "shaving the bump" is often inadequate in providing long-term relief of symptoms and in some cases can actually cause the bunion to progress faster. The most common procedure performed for the correction of bunions is the 1st metatarsal neck osteotomy, near the level of the joint. This refers to the anatomical site on the 1st metatarsal where the actual bone cut is made. Other procedures are preformed in the shaft of the metatarsal bone or are selected by the surgeon.

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Diabetic Foot Care

Diabetic patients are particularly at risk for significant foot problems that can lead to the loss of their feet or legs. The most common cause of hospitalization for the diabetic patient is foot infections. Foot related problems for the diabetic patient are responsible for significant time off work. Foot ulcerations can take weeks or months to heal.

here are two conditions that are associated with diabetes that put the patient at risk. The first is called neuropathy, which is a nerve condition that frequently affects the feet. There is a gradual loss in the patient's ability to perceive the protective sensations. The protective sensations are the ability to feel pain, to feel the difference between hot and cold, sharp and dull, vibration, and excessive pressure. This loss of sensation can become quite profound. Patients can step on sharp objects or cut themselves and not feel pain. They may burn themselves with scalding water and not be aware of it, and they can develop pressure sores and infections and experience little or no pain.

Because of this condition, diabetic patients must be constantly aware of their feet and inspect them daily. They should avoid walking barefoot and always check the temperature of their bath water or foot baths prior to immersing their feet. Special care should be taken when trimming the toenails. The sharp trimming of corns and calluses and over-the-counter corn removers should be avoided. Shoe gear must be appropriately fitted to avoid areas of irritation. Frequently this condition causes a burning pain that makes sleeping difficult. Other patients may feel like their feet are ice cold and have difficulty warming them. These patients must not use heating pads or hot water bottles to warm their feet or they risk burns to the skin that may not heal and could lead to the loss of their foot or leg.

The other condition is called angiopathy, which is the loss of blood circulation to the feet and legs. Loss of circulation results in prolonged healing of cuts or sores on the feet. In severe cases it can lead to gangrene and limb loss. This condition is often accompanied by thinning of the skin, loss of hair growth and color changes to the feet. The feet are cool to the touch and can be very sensitive, making it painful to walk for even short distances.

Of course, the diabetic may have both of these conditions. In this situation, the patient is at significant risk of limb loss and must be monitored very closely.

Common problems the diabetic might encounter are ingrown or fungal toenails, thick calluses on the bottom of the feet, or corns on or between the toes. These relatively simple problems are the precursors of more significant problems. Our recommendation is that diabetic patients have their feet checked on a regular basis by a podiatrist. If they notice any areas of possible skin irritations, sores, or infection, they should be treated professionally by a podiatrist. If they notice a change in the shape of their feet, the arches falling, or notice swelling of sudden onset, they should be seen by a podiatrist. The diabetic patient's best defense against infections and possible loss of feet or legs is prevention by daily inspection and having regular foot exams.

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Foot Orthotics

A prescription foot orthosis is an in-shoe brace which is designed to correct for abnormal foot and lower extremity function. In correcting abnormal foot and lower extremity function, the prescription foot orthosis reduces the strain on injured structures in the foot and lower extremity, allowing them to heal and become non-painful. In addition, prescription foot orthoses help prevent future problems from occurring in the foot and lower extremity by reducing abnormal or pathological forces acting on the foot and lower extremity. A prescription foot orthosis is more commonly known by the public as a "foot orthotic".

Podiatrists prescribe two main types of prescription foot orthoses for their patients, accommodative orthoses and functional foot orthoses. Both types of prescription foot orthoses are used to correct the foot plant of the patient so that the pain in their foot or lower extremity will improve. However, accommodative and functional foot orthoses are generally made using different materials and may not look or feel the same. Both types of prescription foot orthoses are nearly always prescribed as a pair to allow more normal function of both feet.

Accommodative foot orthoses are used to cushion, pad or relieve pressure from a painful or injured area on the bottom of the foot. They may also be designed to try to control abnormal function of the foot. Accommodative orthoses may be made of a wide range of materials such as cork, leather, plastic foams, and rubber materials. They are generally more flexible and soft than functional foot orthoses.

Accommodative orthoses are useful in the treatment of painful callouses on the bottom of the foot, diabetic foot ulcerations, sore bones on the bottom of the foot and other types of foot pathology. The advantages of accommodative orthoses are that they are relatively soft and forgiving and are generally easy to adjust in shape after they are dispensed to the patient to improve comfort. The disadvantages of accommodative orthoses are that they are relatively bulky, have relatively poor durability, and often need frequent adjustments to allow them to continue working properly.

Functional foot orthoses are used to correct abnormal foot function and also correct for abnormal lower extremity function. Some types of functional foot orthoses may also be designed to accommodate painful areas on the bottoms of the foot. Functional foot orthoses may be made of flexible, semi-rigid or rigid plastic or graphite materials. They are relatively thin and easily fit into most types of shoes.

Functional foot orthoses are useful in the treatment of a very wide range of painful conditions of the foot and lower extremities. Big toe joint and lesser toe joint pain, arch and instep pain, ankle pain and heel pain are commonly treated with functional foot orthoses. Since abnormal foot function causes abnormal leg, knee and hip function, functional foot orthoses are commonly also used to treat painful tendinitis and bursitis conditions in the ankle, knee and hip. The advantages of functional foot orthoses are that they are relatively durable, infrequently require adjustments and more likely to fit into standard shoes. The disadvantages are that they are relatively difficult to adjust and relatively firm.

In order to design and fabricate a prescription foot orthosis, the podiatrist must perform a biomechanical examination of the foot and lower extremities. Angular measurements are taken of the toes, foot, ankle, knees and hip to determine the amount and level of any structural or functional deformities. This examination is done while the patient is on an examining table and also while standing. The podiatrist will also do a walking gait analysis of the patient to determine how their foot and lower extremity functions during these activities. Abnormalities from the biomechanical examination and gait examination are noted in the patient's chart for future consideration in the design and fabrication of the prescription foot orthosis.

The podiatrist then next must make a three dimensional model of the patient's feet in order to make a prescription foot orthosis. This is done by applying plaster splints to the patient's foot. The resultant three-dimensional model of the foot is then used along with a detailed orthosis prescription from the podiatrist to have the prescription foot orthoses made for the patient. Most podiatrists have a specialty podiatric orthosis laboratory make their orthoses.

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Fungal Toenails

Description

The most common cause of yellowed, thick and /or deformed toenails is a fungal infection of the toenail. The fungus that infects the nail, most commonly, is the same fungus that causes athletes foot. It tends to be slowly progressive, damaging the nail to a greater and greater degree over time. The infection usually starts at the tip of the nail and works its way back. It usually is not painful and often not noticed until it has gotten well established. A single toenail or any number of nails can be affected. It can also occur on just one foot. Over time, the nail becomes thickened, crumbly, and distorted in appearance. Sweaty feet contribute to the initial infection process and contribute to its spread. The fungus prefers an environment that is moist, dark and warm, which is why it affects the toenails much more often than fingernails. It does not spread through the blood stream. The infection limits itself to the nails and skin. It is often found in association with areas of dry scaly skin on the bottom of the foot or between the toes. The dry scaling skin is frequently found to be chronic athletes' foot. It is not highly contagious, and family members are almost as likely to contract it from some other source as they are from the family member who has the infection. Keeping common showering areas clean is recommended, and sharing shoes should be avoided.

Diagnosis

Not all thicken or yellowed toenails are caused by a fungal infection. Injury to a toenail can cause the toenail to grow in a thickened or malformed fashion. This can be due to an established fungal infection or may be due to the damage caused to the nail root when it was injured. In these instances, treatment with anti-fungal medications will not correct the malformed nail. Other causes of thickened toenails are small bone spurs that can form under the toenail and psoriasis. Taking a scraping of the toenail and culturing it makes the diagnosis.

Treatment

It is best to treat the condition as soon as it is noticed. In early cases, over the counter medications may be sufficient. It is also important to treat any concomitant athlete's foot that may be present. In more advanced cases, a prescription medication may be needed. There are effective topical and oral medications available for the treatment of fungal toenails. If sweating feet are a problem, changing shoes and socks during the day is recommended. There are some topical medications available that help to reduce the sweating of the feet. On occasion, your doctor may recommend removing the toenail.

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Heel Pain, Heel Spurs

Description

The most common form of heel pain, is pain on the bottom of the heel. It tends to occur for no apparent reason and is often worse when first placing weight on the foot. Patients often complain of pain the first thing in the morning or after getting up to stand after sitting. The pain can be a sharp, searing pain or present as a tearing feeling in the bottom of the heel. As the condition progresses there may be a throbbing pain after getting off your feet or there may be soreness that radiates up the back of the leg. Pain may also radiate into the arch of the foot.

To understand the cause of the pain one must understand the anatomy of the foot and some basic mechanics in the function of the foot. A thick ligament, called the plantar fascia, is attached into the bottom of the heel and fans out into the ball of the foot, attaching into the base of the toes. The plantar fascia is made of dense, fibrous connective tissue that will stretch very little. It acts something like a shock absorber. As the foot impacts the ground with each step, it flattens out lengthening the foot. This action pulls on the plantar fascia, which stretches slightly. When the heel comes off the ground the tension on the ligament is released. Anything that causes the foot to flatten excessively will cause the plantar fascia to stretch greater that it is accustom to doing. One consequence of this is the development of small tears where the ligament attaches into the heel bone. When these small tears occur, a very small amount of bleeding occurs and the tension of the plantar fascia on the heel bone produces a spur on the bottom of the heel to form. Pain experienced in the bottom of the heel is not produced by the presence of the spur. The pain is due to excessive tension of the plantar fascia as it tears from its attachment into the heel bone. Heel spur formation is secondary to the excessive pull of the plantar fascia where it attaches to the heel bone. Many people have heel spurs at the attachment of the plantar fascia without having any symptoms or pain. There are some less common causes of heel pain but they are relatively uncommon.

There are several factors that cause the foot to flatten and excessively stretching the plantar fascia. The primary factor is the structure of a joint complex below the ankle joint, called the subtalar joint. The movement of this joint complex causes the arch of the foot to flatten and to heighten. Flattening of the arch of the foot is termed pronation and heightening of the arch is called supination. If there is excessive pronation of the foot during walking and standing, the plantar fascia is strained. Over time, this will cause a weakening of the ligament where it attaches into the heel bone. When a person is at rest and off of their feet, the plantar fascia attempts to mend itself. Then, with the first few steps the fascia re-tears causing pain. Generally after the first few steps, the pain diminishes. This is why the heel pain tends to be worse the first few steps in the morning or after rest.

The diagnosis of heel pain and heel spurs is made by a through history of the course of the condition and by physical exam. Weight bearing x-rays are useful in determining if a heel spur is present and to rule out rare causes of heel pain such as a stress fracture of the heel bone or the presence of bone tumors.

Taping and oral anti-inflammatory agents can sometimes be helpful. Functional foot orthotics might be considered. A functional orthotic is a device that is prescribed and fitted by your foot doctor which fits in normal shoes like an arch support. Unlike an arch support, the orthotic corrects abnormal pronation of the subtalar joint. Thus orthotics address the cause of the heel pain; abnormal pronation of the foot. Surgery to correct heel pain is generally only recommended if all other treatment has failed. There are some exceptions to this course of treatment and it is up to you and your doctor to determine the most appropriate course of treatment. Following surgical treatment to correct heel pain the patient will generally have to continue the use of orthotics. The surgery does not correct the cause of the heel pain. The surgery may eliminate the pain but the process that caused the pain will continue without the use of orthotics. If orthotics have been prescribed prior to surgery they generally do not have to be remade.

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Ingrown Toenails

Description

Ingrown toenails are due to the penetration of the edges of the nail plate into the soft tissue of the toe. It begins with a painful irritation that often becomes infected. With bacterial invasion, the nail margin becomes red and swollen often demonstrating drainage or pus. In people who have diabetes or poor circulation this relatively minor problem can be become quite severe. In this instance a simple ingrown toenail can result in gangrene of the toe. These patients should seek medical attention at the earliest sign of an ingrown toenail. There are several causes of ingrown toenails: a hereditary tendency to form ingrown toenails, improperly cutting the toenails either too short or cutting into the side of the nail and ill-fitting shoes can cause them. Children will often develop ingrown toenails as a result of pealing or tearing their toenails off instead of trimming them with a nail clipper. Once an ingrown toenail starts, they will often reoccur. Many people perform "bathroom" surgery to cut the nail margin out only to have it reoccur months later as the nail grows out.

Treatment for ingrown toenails is relatively painless. The injection to numb the toe may hurt some, but a skilled doctor has techniques to minimize this discomfort. Once the toe is numb, the nail margin is removed and the nail root in this area is destroyed. The doctor may use an acid to kill the root of the nail, but other techniques are also available. It may take a few weeks for the nail margin to completely heal, but there are generally no restrictions in activity, bathing or wearing shoes. Once the numbness wears off, there may be some very mild discomfort. A resumption of sports activities and exercise is generally permitted. There are very few complications associated with this procedure. Reoccurrence of the ingrown toenail can occur a small percentage of the time. Continuation of the infection is possible which can be controlled easily with oral antibiotics. On occasion, the remaining nail may become loose from the nail bed and fall off. A new nail will grow out to replace it over several months. With removal of the nail margin, the nail will be narrower and this should be expected.

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Neuroma

Description

Neuromas are the swelling of nerves that are the result of compression or trauma. They are often described as nerve tumors. However, they are not in the purest sense a tumor. They are a swelling within the nerve that may result in permanent nerve damage. The most common site for a neuroma is on the ball of the foot. The most common cause of neuroma in ball of the foot is the abnormal movement of the long bones behind the toes called metatarsal bones. A small nerve passes between the spaces of the metatarsals. At the base of the toes, the nerves split forming a "Y" and enter the toes. It is in this area the nerve gets pinched and swells, forming the neuroma. Burning pain, tingling, and numbness in one or two of the toes is a common symptom. Sometimes this pain can become so severe it can bring tears to a patient's eyes. Removing the shoe and rubbing the ball of the foot helps to ease the pain. As the nerve swells, it can be felt as a popping sensation when walking. Pain is intermittent and is aggravated by anything that results in further pinching of the nerve. When the neuroma is present in the space between the third and fourth toes, it is called a Morton's Neuroma. This is the most common area for a neuroma to form. Another common area is between the second and third toes. Neuromas can occur in one or both of these areas and in one or both feet at the same time. Neuromas are very rare in the spaces between the big toe and second toe, and between the fourth and fifth toes.

A puncture wound or laceration that injures a nerve can cause a neuroma. These are called traumatic Neuromas. Neuromas can also result following a surgery that may result in the cutting of a nerve.

The diagnosis of Neuromas is made by a physical exam and a thorough history of the patient's complaint. Conditions that mimic the pain associated with Neuromas are stress fracture of the metatarsals, inflammation of the tendons in the bottom of the toes, and arthritis of the joint between the metatarsal bone and the toe. Because nerve tissue is not seen on an x-ray, the x-ray will not show the neuroma. A skilled foot specialist will be able to actually feel the neuroma on his exam of the foot. Special studies such as MRI, CT Scan, and nerve conduction studies have little value in the diagnosis of a neuroma. Additionally, these studies can be very expensive and generally the results do not alter the doctor's treatment plan. If the doctor on his exam cannot feel the neuroma, and if the patient's symptoms are not what is commonly seen, then nerve compression at another level should be suspected.

Treatment for the neuroma consists of cortisone injections, orthotics, chemical destruction of the nerve, or surgery. Cortisone injections are generally used as an initial form of treatment. Cortisone is useful when injected around the nerve, because it can shrink the swelling of the nerve. This relieves the pressure on the nerve. Cortisone may provide relief for many months, but is often not a cure for the condition. The abnormal movements of the metatarsal bones continue to aggravate the condition over a period of time.

To address the abnormal movement of the metatarsal bones, a functional foot orthotic can be used. These devices are custom-made inserts for the shoes that correct abnormal function of the foot. The combination treatment of cortisone injections and orthotics can be a very successful form of treatment. If there is significant damage to the nerve, failure to this treatment can occur. When there is permanent nerve damage, the patient is left with three choices: live with the pain, chemical destruction of the nerve, or surgical removal of the nerve.

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Plantar Warts

Description

The common wart is known as verruca vulgaris. They are caused by a viral infection of the skin. This occurs as a result of direct contact with the virus. They do not spread through the blood stream. They occur more commonly in children than adults. When they occur on the bottom of the foot, they are called plantar warts. This name is derived from the location of the foot on which they are found; the bottom of the foot is called the plantar aspect of the foot. A common misconception is that plantar warts have seeds or roots that grow through the skin and can attach to the bone. The wart may appear to have a root or seeds, but these are in fact small clusters of the wart just beneath the top layer of the skin. The wart cannot live in any tissue except the skin. Moist, sweaty feet can predispose to infection by the wart virus. They can be picked up in showers and around swimming pools. They are not highly contagious, but being exposed in just the right situation will lead to the development of the wart. Avoiding contact in the general environment is nearly impossible. If a member of the family has the infection, care should be taken to keep shower and tile floor clean. Children who have plantar warts should not share their shoes with other people. Young girls often share shoes with their friends and this should be discouraged.

Diagnosis

The warts have the appearance of thick, scaly skin. They can occur as small, single warts or can cluster into large areas. These clustered warts are called mosaic warts. They often resemble plantar callouses. A simple way to tell the difference between a wart and a callous is to squeeze the lesion between your fingers in a pinching fashion. If this is painful, it is likely that the lesion is a wart. A callous is generally not painful with this maneuver but is tender with direct pressure by pressing directly on the lesion. Othe lesions on the bottom of the foot that are often confused with plantars warts are porokeratoses and inclusion cysts.

Treatment

There are a variety of ways to treat warts. The over-the-counter medications have a difficult time penetrating the thick skin on the bottom of the foot, so they do not work well in this area. Professional treatment consists of burning the wart with topical acids, freezing with liquid nitrogen, laser surgery or cutting them out. All methods have the possibility of the wart coming back. Surgical excision of the wart has the highest success rate with a relatively low rate of recurrence. There is some mild discomfort with this procedure and it takes several weeks for the area to completely heal. Normal activity can generally be resumed in a few days depending on the size and number of warts that have been removed. The risks associated with surgical removal of warts are the possibility of infection, or the formation of a scar, which can be painful when weight is applied while walking.

Laser removal of the wart works by burning the wart with a laser beam. The area must be numbed with an anesthetic prior to the procedure. There is little advantage to removing warts with a laser unless the warts are very large (mosaic warts) or there are a large number to be removed. The risks associated with the use of the laser are the same as for cutting the warts out. These risks include infection and the development of a scar after healing. A new type of laser has been developed to treat several different types of skin lesions called the Pulsed Dye Laser. This new laser has promise in the effective treatment of warts.

Freezing the wart with liquid nitrogen is another form of treatment. This form of treatment when the warts are on the bottom of the foot can be very painful and take several days or weeks to heal.

Topical acids can also be a useful means of treating warts. The advantage to this form of treatment is the fact that they are nearly painless and there is no restriction of activity. The down side to this form of treatment is that it frequently requires several treatments and the failure rate is higher than surgical excision of the wart.

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