FOOT CARE

The ankles support the entire body weight and ankle injuries are very common. Each year, approximately 2 million patients are treated for ankle sprains and strains and ankle fractures are one of the most common injuries treated by podiatrists.

Anyone, from the most well-conditioned athlete to the most sedentary person, can experience an ankle injury. Usually, the cause is accidental (e.g., stepping into a pothole, slipping while getting out of the car). People who are overweight and those who wear high-heeled shoes are at an increased risk for ankle injuries.

Ankle injuries usually involve a sudden, unexpected, loss of balance that results in a sharp twist of the ankle. A strain occurs when a muscle or tendon overstretches. A sprain, which is more serious, occurs when strong connective tissue that connects one bone to another (ligaments) become overstretched.

In some cases, a ligament tears and may pull a fragment of bone with it. When a piece of bone is pulled away, it is known as an avulsion fracture.

Sprains may account for 85% of all ankle injuries and about 45% of all sports-related injuries. It is estimated that as many as 50% of patients who experience an ankle sprain will have a recurrence.

Most (approximately 85%) ankle sprains and strains are inversion injuries in which the foot twists inward, damaging the lateral ligaments on the outside of the foot. Pronation injuries to the medial ligaments on the inside of the foot, which are caused by twisting the foot outward, are less common.

Sprains are graded on a scale of 1 to 3 (mild, moderate, and severe), depending on the degree of tearing to the ligaments. In most cases, x-rays are performed to rule out a fracture or dislocation.

• Treatment usually involves RICE - rest, ice, compression, and elevation:
• Rest involves keeping off the injured ankle as much as possible. Crutches may be used to enable the patient to move around when necessary, without placing weight on the injury. An air cast or splint may be used to support the ankle for support and severe sprains may require a hard cast.
• Ice is used to reduce swelling. Ice packs are usually applied for 20 minutes at a time every hour as long as swelling persists.
• Compression involves supporting the ankle and foot with a firmly (not tightly) wrapped elastic bandage, compression stocking, or gel wrap. If swelling causes the bandage to become tight, it should be loosened immediately.
• Elevation helps to minimize bruising and swelling. The foot should be kept above heart level as often as possible during the first 48 hours.

Nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen, may help to reduce pain, swelling, and inflammation. Due to potentially severe gastrointestinal and cardiovascular side effects, NSAIDs should only be used as instructed.

In some cases, prolonged swelling caused by the formation of excessive scar tissue occurs and the physician may request x-rays to check for small, previously undetected bone fragments, or damage to the joints.

Most ankle strains and sprains heal in 2 to 6 weeks, with proper treatment. Severe injuries may take as long as 12 weeks to heal and may require physical therapy to restore full muscle balance and strength. Physical therapy may involve stretching the Achilles tendon, as well as coordination and speed exercises. During this time, the ankle may require taping or bracing to provide support until full function is regained.

Patients who experience an ankle injury are at risk for recurrent injury during and following recovery and should take precautions. Shoes that provide stability and support are a prudent investment, and supplemental bracing with a specially fitted elastic wrap may be recommended. In some cases, custom orthotics are prescribed to help provide ankle stability after an injury.

Ankle sprains rarely require surgery. However, if a person experiences persistent pain or recurrent ankle sprains, surgical repair of the ankle ligaments may be necessary. A badly torn ligament may need to be surgically reattached to the bone, for example, or a chronically unstable ankle may be strengthened by removing a piece of tendon from one side of the foot and attaching it to the weakened area for support.

These procedures usually require the foot and ankle to be placed in a cast for up to 2 months. The success rates for these procedures are high, and up to 85% of patients eventually return to full activity.

If chronic pain is a problem, an arthroscopic surgical procedure may be necessary to remove bone fragments, scar tissue, and damaged cartilage.

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Are your feet, blistered, cracked, or peeling between your toes? Do they itch? Do the soles of your feet show signs of redness or scaling? If you said yes to any of these questions, you may have athlete's foot. Athlete's foot is a fungus that thrives in warm, moist, and enclosed environments. The fungus breeds in places like snug, poorly ventilated shoes, damp sweaty socks, locker rooms, and gym shower floors.

Athlete's foot is usually a harmless infection that is often treated successfully with an over-the-counter anti-fungal medicine such as Micatin, Tinactin or Desenex. If it is not treated, your skin may develop blisters and cracks that can lead to a secondary bacterial infection. Athlete's foot should clear up within a week or two of beginning treatment. If it does not, you should seek medical care. It is important to use all of the anti-fungal cream that is prescribed for you. While your skin may look better with treatment, the infection can remain for some time afterwards and could recur.

• Athlete's foot is not very contagious. One family member may have it without infecting others living in the same house. The fungus will not grow on dry, normal skin. Follow these tips to prevent athlete's foot:
• Keep your feet clean.
• Dry feet well after bathing.
• Apply powder between the toes.
• Wear sandals that give the foot good support often.
• Wear socks that wick moisture away and keep the feet dry.

• Cotton and wool socks absorb sweat and keep the feet dry. Avoid socks made of synthetic material. Other tips to help keep your feet dry include:
• Change socks daily or more frequently if they become damp.
• Choose shoes such as sandals, canvas, or those made with leather uppers to allow your feet to breathe.
• Air-out shoes between wearings or alternate shoes daily.

While common and recurring in adults, athlete's foot rarely affects children before puberty. The basic rule to follow to avoid athlete's foot is to keep your feet clean and dry, especially in hot weather.

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Well, it has finally happened. That ugly, angry, big toe deformity that made your mother hide her bare feet and limp around has suddenly appeared on your foot...and it hurts. Your formerly stylish pumps are stretching to accommodate the bump and area barely wearable. You never thought it would happen, but the idea of walking through a shopping mall sounds more like torture than fun.

Chances are, you have a bunion. The bone in the joint at the base of the big toe is enlarging and causing discomfort by rubbing against your shoes. By the end of the day, there’s a deep, aching pain in that joint and all you want to do is sit down and take your shoes off.

Contrary to popular opinion, bunions aren't caused by ill-fitting shoes; footwear may aggravate them, but the don't cause them. Bunions are often hereditary and develop from a weakness in the foot's bone structure. All the bones and ligaments which make up the foot's arches and joints are very mobile and flexible. When the move out of alignment due to faulty foot function, the big toe joint is overloaded, causing it to unlock and dislocate. This doesn't happen all at once. Bunions develop gradually but continuously, and can cause pain at various levels of enlargement.

With bunions, the best defense is a good offense. In the early stages, there are a variety of effective treatments. If left undiagnosed and untreated until the bunion is in an advanced stage, a significantly more serious deformity must be addressed, and that can mean more discomfort and loss of mobility.

Treatment begins with isolating the cause of the problem so that some of the more uncomfortable symptoms do not develop. Early intervention can involve exercise, modification of foot wear, and prescription orthotics aimed at stabilizing any structural weakness in the foot. The emphasis at this stage is on managing the problem by keeping it from getting worse. Anti-inflammatory medication can also help during acute episodes of bunion pain.

There are also various surgical methods to correct a bunion deformity. Obviously, the less deformity there is to correct, the better the surgical outcome. That doesn't mean that surgery should be the first course of action; it is not. Again, early diagnosis -- based on a thorough examination and X-rays -- made by an experienced podiatrist, can determine which course of treatment will be the most effective.

There are some bunions that ultimately require surgery. This is a pain-based decision, when the sufferer notices significant changes in the position of the big toe or when they begin altering their walking style to favor the bunion joint. When a bunion bothers you during reasonable daily activity, while wearing reasonable footwear, it may be time to consider a surgical remedy.

As with any surgery, it is important to select the right procedure and to rigorously adhere to the podiatrist's specific recommendations for follow-up care. There have been remarkable advances in foot surgeries and treatment options during the past decade, but there is still no magic wand to make bunions -- or the pain they can cause -- disappear overnight.

There are three basic objectives of bunion surgery: to relieve pain, to correct structural abnormalities, and to restore function. In the final analysis, recovery and outcomes are better if these are the reasons bunion surgery is performed.

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Diabetes can be dangerous to your feet—even a small cut could have serious consequences. Diabetes may cause nerve damage that takes away the feeling in your feet. Diabetes may also reduce blood flow to the feet, making it harder to heal an injury or resist infection. Because of these problems, you might not notice a pebble in your shoe—so you could develop a blister, then a sore, then a stubborn infection that might cause amputation of your foot or leg.

To avoid serious foot problems that could result in losing a toe, foot, or leg, be sure to follow these guidelines.

• Inspect your feet daily. Check for cuts, blisters, redness, swelling, or nail problems. Use a magnifying hand mirror to look at the bottom of your feet. Call your doctor if you notice anything. (If your eyesight is poor, have someone else do it for you.)
• Wash your feet in lukewarm (not hot!) water. Keep your feet clean by washing them daily. But only use lukewarm water—the temperature you'd use on a newborn baby.
• Be gentle when bathing your feet. Wash them using a soft washcloth or sponge. Dry by blotting or patting—and make sure to carefully dry between the toes.
• Moisturize your feet—but not between your toes. Use a moisturizer daily to keep dry skin from itching or cracking. But DON'T moisturize between the toes—this could encourage a fungal infection.
• Cut nails carefully—and straight across. Also, file the edges. Don't cut them too short, since this could lead to ingrown toenails.
• Never trim corns or calluses. No "bathroom surgery"—let your doctor do the job.
• Wear clean, dry socks. Change them daily.
• Avoid the wrong type of socks. Avoid tight elastic bands (they reduce circulation). Don't wear thick or bulky socks (they can fit poorly and irritate the skin).
• Wear socks to bed. If your feet get cold at night, wear socks. NEVER use a heating pad or hot water bottle.
• Shake out your shoes and inspect the inside before wearing. Remember, you may not feel a pebble—so always shake out your shoes before putting them on.
• Keep your feet warm and dry. Don't get your feet wet in snow or rain. Wear warm socks and shoes in winter.
• Never walk barefoot. Not even at home! You could step on something and get a scratch or cut.
• Take care of your diabetes. Keep your blood sugar levels under control.
• Don't smoke. Smoking restricts blood flow in your feet.
• Get periodic foot exams. See your podiatrist on a regular basis for an examination to help prevent the foot complications of diabetes.

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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.

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.

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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Does the second toe next to the big toe of your foot bump into the front of your shoes? If so, you will probably develop, or already have, a hammertoe. While hammertoes can develop on any toe, they usually occur in the second toe. The toe becomes bent and painful and buckles under. The top of it rubs against the inside of the shoe. Over time, this effects the toe joints and tendons causing the toe to reshape itself. Eventually the toe has a claw-like appearance. Pressure on top of the toe leads to a hard corn developing over the bones of the toe.

• Symptoms of hammertoe include:
• Pain at the tip of the toe where it hits the shoe.
• A toe that buckles under.
• A callus or hard corn on top of the toe.
• Redness and inflammation.

• Causes of hammertoe include:
• Heredity.
• Wearing shoes that are too tight or too narrow.
• A flat front arch.
• A bunion may cause the big toe to slide under the second toe.

• To prevent hammertoes:
• Wear shoes that are the proper length and width.
• Apply a donut-shaped pad to the top of the toe to reduce friction and irritation.
• Stretch the toes often.
• Tape the toes to maintain symmetry.
• Take ibuprofen or aspirin to relieve pain and inflammation or take acetaminophen for minor pain.

Hammertoes occur not only from wearing shoes that are too short, but also as a result of muscle and nerve damage caused by diabetes. Shoe inserts do not help hammertoes. Stretching the foot and doing activities that do not bother them will decrease discomfort.

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Heel pain is one of the most common forms of foot pain in adults. It often occurs as a result of daily activities and exercise. The heel bone (calcaneus) is the largest bone in the foot and the heel is the first part of the foot to contact the ground during walking.

Two structures located on the bottom (sole) of the foot are primarily associated with heel pain: the plantar fascia, a band of fibrous connective tissue, and the flexor digitorum brevis muscle, which supports the arch and flexes the four small toes.

Normally, as the foot absorbs the weight of the body during walking, the arch area joint locking mechanism provides about 80% of the stability of the foot. The other 20% of biomechanical stability is provided by the plantar fascia and muscles, tendons, and ligaments. (See Anatomy of the Foot and Ankle).

Gait abnormalities can cause inflammation of the structures attached to the heel bone, resulting in heel pain. Inflammation of the plantar fascia, called plantar fasciitis, is the most common cause of heel pain.

Plantar fasciitis often causes pain that is more severe following a period of rest (e.g., after sleeping or sitting).

Sometimes, muscle strain and tension pull at the origin site on the bottom surface of the heel bone producing an inflammatory response that begins making new bone. This interim condition is called periostitis. The forming bone spur grows forward in the direction of this pulling. Heel spurs can irritate nerves and cause pain.

Heel pain is most common in active people over the age of 40. This increased prevalence may result from a decrease in the elasticity of the plantar fascia and a slowing of the healing process with age. Heel pain also is relatively common in active children and adolescents between the ages of 8 and 13. Pediatric heel pain frequently occurs on the bottom rear of the heel or the sides.

Heel pain occurs in both heels (bilaterally) in less than 30% of cases. The left heel is commonly the first to be affected. The opposite heel may follow with similar symptoms, often as a result of compensation.

Misalignments caused by abnormalities in the structure of the feet increase the risk for heel pain.

• Other risk factors include the following:
• Engaging in strenuous exercise (especially repetitive jumping and running)
• Obesity
• Standing for prolonged periods
• Wearing shoes that do not fit properly

To reduce the risk for heel pain, it is important to wear shoes or sneakers that fit correctly and to warm up properly before exercising.

The most common cause for heel pain is inflammation of the fibrous connective tissue on the sole of the foot (plantar fasciitis).

• Other causes include the following:
• Achilles tendonitis
• Bone bruises
• Excessive pronation (tendency of the foot to roll inward)
• Haglund's deformity (bony growth at the back of the heel that usually occurs when shoes repeatedly aggravate tissue and underlying bone)
• Heel spurs (also called bone spurs)
• Inflammatory conditions (e.g., ankylosing spondylitis, diffuse idiopathic skeletal hyperostosis, rheumatoid arthritis, bursitis)
• Sever's disease (relatively common condition in active growing children and adolescents)
• Soft-tissue sarcoma of the foot (rare)
• Stress fractures
• Tarsal tunnel syndrome (nerve entrapment that may cause pain on the sole of the foot)

Heel pain varies in severity. In most cases of plantar fasciitis, pain is more severe following periods of inactivity (e.g., in the morning), subsides with activity, and increases in severity with prolonged activity. This occurs because inactivity causes the muscles in the foot to tighten, increasing the strain on the plantar fascia and aggravating heel spurs, if they are present. The muscles stretch with mild activity and the heel pain subsides. Prolonged or strenuous activity increases inflammation and the severity of heel pain.

Other symptoms of plantar fasciitis include swelling, redness, and heat.

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The big toe is the most common location for ingrown toenails. When the edge of the nail cuts into the soft tissue surrounding the toenail, swelling, redness, and pain result. If the nail is allowed to continue growing this way, major discomfort occurs. Prompt care is needed because the cut can easily become infected. These infections can be especially dangerous in people, such as diabetics, with poor circulation.

• Ingrown toenails are caused by two things:
• Improper trimming of the toenail. Always cut toenails straight across leaving them a little longer at the corners. This ensures that the skin is not cut by the sharp ends of the nail. Use nail clippers to make neat cuts. Do not cut too close or tear away a nail with your fingers or dull scissors. Finish the edge with a nail file.
• Tight shoes or stockings that press the nail into the skin. Always wear shoes, socks, or stockings that give your toes plenty of room.

• To care for an ingrown toenail:
• Soak the toe in warm water.
• Press a small amount of wet cotton under the nail to prevent it from further cutting the skin.
• Repeat this several times a day until the nail grows out.

• Get medical care when signs of infection develop such as:
• Pain swelling or tenderness.
• Red streaks extending away from the wound.
• White or yellow drainage or pus.
• Fever of 100 degrees or higher with no other known cause.

People with diabetes or those who have circulatory problems should see their healthcare provider if they develop ingrown toenails.

Ingrown toenails will return until you eliminate their cause. Make sure to wear comfortable, well fitting shoes, and to trim your toenails correctly.

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