By Michelle Meadows
The human foot has 26 bones, 33 joints, and more than 100 tendons, muscles, and ligaments. With such a complex structure, a lot can go wrong. While some foot problems are inherited, many occur because of years of wear and tear.
Signs of foot trouble include pain, excessively dry skin, thickened or discolored nails, swelling, redness, and unusual sensations. "Consumers should know that these symptoms are not normal," says Joshua Kaye, D.P.M, a podiatrist in Los Angeles. "Whatever the problem is, don't bury it in your shoe and hope it will go away."
Pain in the feet can trigger pain in the legs, hips, and back. Some foot problems can even signal a larger disease, which is why the American Podiatric Medical Association (APMA) suggests that people take their socks off when they go to their primary care physician for a regular checkup. In a recent APMA survey of more than 600 people, 73 percent said their feet were not routinely inspected at doctor visits.
Toenails that are rounded inward instead of outward could signal iron deficiency anemia. Kidney disease, heart disease, high blood pressure, and circulatory problems can cause the feet to swell. Tingling or numbness in the feet and slow-healing wounds could be signs of diabetes or other serious diseases, according to the APMA. Chronic stiffness in the toes could be a sign of arthritis.
"Changes in the structural appearance of the foot can also be signs of abnormalities such as tendon rupture, rheumatoid or osteoarthritis, or neuropathic disease," says Barbara Buch, M.D., acting clinical deputy director of the Food and Drug Administration's Division of General, Neurological and Restorative Devices.
According to the American Diabetes Association, about 20 million people in the United States have diabetes, a disease in which the body does not produce or properly use insulin. But while nearly 15 million have been diagnosed with diabetes, another 6 million people are unaware that they have it.
"A problem that seems minor for many people, like a fungal infection or sores on the feet, can become catastrophic in someone with diabetes or other circulatory problems," says Jonathan Wilkin, M.D., former director of the FDA's Division of Dermatologic and Dental Drug Products. Diabetes is the leading cause of non-traumatic foot amputations each year.
People with diabetes may experience neuropathy in the feet, a condition that affects the nerves and the ability to feel pain and heat or cold. "Someone without sensation in the feet can literally step on a nail and not know it," says Amir Assili, D.P.M, a podiatrist in Gaithersburg, Md. Assili says a 28-year-old man who came in complaining of a loss of sensation in both feet was diagnosed with diabetes soon after.
Another major foot problem linked to diabetes is poor blood circulation. High levels of blood sugar damage the blood vessels, making them less able to supply the skin and other parts of the body with blood. Poor circulation interferes with the ability to heal and raises the risk of infection. Minor cuts or even cracks from dry skin can turn into ulcers, small red sores that can become deep and infected. Foot amputations may be necessary when an infection reaches bone and spreads beyond a manageable extent.Doctors normally treat diabetic foot ulcers by cleaning them and applying wound dressings, or with surgical debridement, which removes contaminated tissue from a wound to prevent infection. In severe cases, reconstructive procedures that reshape the foot may be needed to prevent undue pressure on the foot.
During the past few years, the FDA has approved new products to treat chronic foot ulcers that are not responding to standard methods. Examples are Apligraf, made by Organogenesis Inc. of Canton, Mass., and Dermagraft, made by Smith and Nephew in La Jolla, Calif.
"The optimal approach," Assili says, "is to prevent ulcers from occurring through tight blood sugar control and regular visits to an endocrinologist." People with diabetes should also see a podiatric physician at least once a year and practice the basics of good foot care that apply to everyone--wearing comfortable socks and shoes and maintaining foot hygiene. Those who have been diagnosed with decreased circulation or neuropathy with loss of protective sensation should be seen by their podiatric physician more frequently.
Feet should also be checked daily by the patient or family members for any cuts and sores. "Early detection is important because a problem can quickly turn serious," Assili says. People with diabetes and other circulatory problems should never try to treat their own feet, because of the risk of infection.
As stylish as they may be, high heels and shoes that squeeze the feet are linked to a host of foot problems. Painful bunions, which are misaligned toe joints, are much more common in women than men. Poorly fitting shoes don't cause bunions, but can aggravate existing ones.
Some people with bunions can eliminate pain with conservative approaches such as wearing bunion pads, avoiding high heels, and buying comfortable shoes that are shaped like their feet and that provide more toe room.
Other common problems from tight shoes include nerve growths called neuromas, corns, calluses, blisters, and hammertoes, a condition in which the toes are bent like a claw.
"Shoes should be comfortable right when you buy them," says Jane Andersen, D.P.M., a podiatrist in Chapel Hill, N.C. "You should be able to wiggle your toes. And shoes should have a strong sole that flexes at the ball of your foot."
Consumers also should make sure that they're wearing the right size. "Most adults don't have their feet measured when they buy new shoes," Andersen says, "but your shoe size can change as you get older because the feet can spread and lengthen."
Buch says one way to ensure that you get the right shoe size is to stand on a blank piece of paper and trace the outline of your feet on the paper with a pen at home. "Your shoe choice should completely cover the outline of your foot," Buch says, "with no lines showing outside the shoe when the shoe is placed on top of the outline you traced."
The foot has more than 250,000 sweat glands. It's the mixture of sweat and bacteria in our shoes and socks that makes feet smelly. "Clean, dry feet can lower the risk of both foot odor and fungus infections," says Kaye.
Feet should be washed every day with soap and lukewarm water, especially between the toes, and then dried completely with a soft towel. Any mild soap or antibacterial hand soap works fine.
"People spend a lot of time shampooing and conditioning their hair and applying soaps and lotions to their body, but then probably don't spend 10 seconds washing their feet," Kaye says. "Washing the feet with a wash cloth or similarly abrasive product is important because it helps remove the dead skin, bacteria, and fungus." For patients who can't reach their feet during a shower because of obesity, arthritis, or instability, Kaye recommends using a long-handle brush like a shower back brush.
People who want to soak their feet should use warm, soapy water, Kaye says. "Soaking feet in Epsom salt can cause excessive drying of skin," he says. "This is an important consideration for diabetics or with those who have existing dry or fragile skin. Consider soaking feet in warm water with a small amount of liquid dishwashing solution that has skin softeners. There is no benefit in soaking feet in Epsom salt compared to regular table salt."
Some people tell Kaye they soaked their feet in very hot water because they were trying to kill bacteria. He says, "Unfortunately, that type of home treatment often results in skin burns. If someone is diabetic or has poor circulation, hot water bottles or heating pads also shouldn't be used on the feet."
Applying moisturizing lotion on the feet after bathing can alleviate dry skin. "During dry winter months, apply a small amount of lotion a few times per day," Kaye says. "Inexpensive generic creams are usually equally effective as expensive brand-name products."
Kaye estimates that half of the ingrown toenails he treats are due to improper nail clipping. "Toenails should be trimmed straight across and not too short," he says. "Many people incorrectly cut the corners, leaving a small point of nail that then grows into the skin or they accidentally cut the skin."
People who pamper themselves with a salon pedicure also need to make sure that proper cutting and safety measures are followed. In the last few years, there have been reports of infections linked to nail salon whirlpool footbaths that hadn't been properly cleaned or disinfected.
Andersen suggests that people check to see that salons and their employees are licensed. "You could ask how they clean their tubs and instruments and how often," she says. "Some people bring their own instruments." People with diabetes should exercise caution when having salon treatments, and may be advised by their physicians to avoid treatments by anyone other than a trained podiatric or medical specialist.
Wearing inadequate and worn-out shoes is a common mistake for athletes, says James Losito, D.P.M., team podiatrist for the Miami Heat basketball team and professor of podiatric biomechanics at Barry University in Miami Shores, Fla.
"Running shoes should be discarded after 200 miles to 400 miles of use and they should fit correctly," Losito says. "There should be a thumb-width of length between the longest toe and the end of a shoe. Failure to wear the correct shoe size can result in runner's toe, calluses, ingrown nails, fungal nail infections, and hammertoe deformities."
People also should purchase the right shoe for the sport. "Many injuries occur because someone is wearing a running shoe while playing basketball," Losito says.
Another common cause of athletic injuries is doing too much too soon. "Both overuse training habits and worn-out shoes could result in stress fractures, heel pain or heel spur (plantar fasciitis) or shin splints," he says. "It is important to start out slowly and increase distance, duration, and pace gradually. For runners, I recommend no more than a 10 percent increase per week."
Walking or jumping on hard surfaces and failing to stretch and do warm-ups may also cause shin splints, plantar fasciitis, and heel spurs. Losito says, "There is no solid evidence to confirm that stretching actually decreases the likelihood of injuries, but it makes sense to maintain flexibility through gentle stretching, especially following exercise."
According to the American Academy of Podiatric Sports Medicine, the most common pain associated with jogging is runner's knee, which can be caused by rolling in or down on the foot. With aerobics, rising on the toes can cause an inflamed Achilles tendon. Stress fractures can be caused by running and other repetitive strain. Sharp pain, bruising, or swelling after a foot injury warrants medical attention. Contrary to popular belief, it's possible to walk, even if a foot bone is broken.
Orthotic devices are intended to make the feet more comfortable, minimize stress on the foot, or improve an abnormal or irregular walking pattern. An orthotic device could be a conservative approach to a foot problem, a preventive measure to avoid problems, or a useful support after foot surgery.
According to the American Academy of Orthopaedic Surgeons, orthotic devices commonly used include bunion shield pads, arch pads for people with a flat foot, and heel inserts for people with plantar fasciitis. These devices are sold over-the-counter (OTC) at drugstores and sporting stores. They can be custom made and also sold by podiatrists, physical therapists, or orthotic companies.
Consumers might do well to try a less expensive OTC orthotic device first. "But if the problem doesn't go away after six weeks, you may need to seek a professional consultation and a custom orthotic may be indicated," says Eddy Gosschalk of Southern California Orthotics and Prosthetics. "People who are at risk for developing wounds or who have an unusual foot shape tend to need a custom orthotic." To create a custom orthotic, a plaster cast is taken of your foot and sent to a laboratory.
Most orthotic devices are considered "Class I exempt" by the FDA. This category means they are exempt from pre-market notification requirements. But they still must be manufactured under a quality assurance program, be suitable for intended use, be adequately packaged and properly labeled, and have establishment registration and device-listing forms on file with the FDA. Legally marketed Class I devices are subject to the least regulatory control because they present minimal potential for harm to the user. But when orthotic devices make a new health claim or a claim for certain treatments, or use a fundamentally different technology, they must go through FDA clearance.
The types of OTC products for foot health include pain medicines such as nonsteroidal anti-inflammatory drugs and products that treat athlete's foot, corns, calluses, blisters, and warts.
Depending on the intended use, some OTC foot products, such as lotions for moisturizing the skin, are considered cosmetics and not drugs. There are medicated powders and creams to treat athlete's foot. For corns and calluses, there are nonmedicated pads to improve comfort when walking, as well as medicated pads and patches that work to get rid of dead skin. Similar products are used to shrink warts. These products are typically made of salicyclic acid. They should be used with care so that healthy skin isn't harmed, and they should never be used by people with diabetes or poor foot circulation.
Matthew Holman, Ph.D., a scientist in the FDA's Office of Nonprescription Products, says consumers need to pay close attention to drug labels. "Consumers should read the indications, directions, and warnings carefully," Holman says. "A product won't be effective if you are trying to treat a condition that's not in the label. If it says to only use the product on intact skin with no open sores, that's important. If a product isn't working or the condition becomes worse, you need to seek a doctor's advice." People with heart disease, diabetes, and circulation problems should never self-treat because of the risk of infection.
Prescription drugs for treating the feet include pain medicine, antibiotics for infections, and antifungal medicine. For instance, an ingrown toenail may require antibiotic or antifungal treatment if it becomes infected. For bunions and hammertoes, a cortisone injection may be given to relieve inflammation and pain.
Fungal nails make toenails thick, brittle, and discolored to white, yellow, or brown. The fungus grows deep in the nail bed, and it won't go away on its own. It also can spread to other toenails. "Discolored nails aren't always from fungus," says Andersen. "They could also be from trauma due to exercise or psoriasis, so we take a fungal culture to make a diagnosis."
Penlac (ciclopirox), made by Dermik Laboratories of Berwyn, Pa., is an example of a topical antifungal. It is generally used daily for several months for mild to moderate nail fungus. Side effects include irritation and redness around the nails. Oral medications for fungal infections, including fungal nails and athlete's foot, are Lamisil (terbinafine) made by Novartis Pharmaceuticals of East Hanover, N.J., and Sporanox (itraconazole), made by Janssen Pharmaceuticals of Titusville, N.J. These medicines travel through the bloodstream to attack the fungus. The tablets are taken daily for about 12 weeks. It takes about nine months for a healthy nail to grow in.
The most commonly reported side effects of the oral antifungals are headaches and stomachaches. In 2001, the FDA put out a public health advisory about both drugs and announced labeling changes. Both drugs have been associated with serious liver problems resulting in liver failure and death in rare cases. The FDA and the maker of Sporanox also warned against using Sporanox for those who have a heart condition, because of safety concerns.
Patients using these drugs should immediately report symptoms of persistent nausea, anorexia, fatigue, or vomiting, upper right abdominal pain or jaundice, dark urine, or pale stools. A simple blood test is used to check liver function during treatment.
Common types of foot surgery include surgery to correct bunions, surgery for fungal nails when medications don't work, and surgery to reduce arthritis pain. For people who have chronic ingrown toenails, a procedure called matrixectomy may be used to prevent recurring problems. Andersen says, "We numb the toe and remove the smallest amount of the nail on the side, usually about one-eighth of an inch, and then use a chemical to kill the root or remove the root of the nail surgically."
Sometimes, bunions can be treated without surgery, but when bunions limit or affect one's daily activities, bunion surgery may be appropriate. Pain is the big factor here. Kaye says, "Bunion surgery may also be warranted if there is chronic inflammation and the person gets no relief from nonsteroidal anti-inflammatory drugs and other conservative treatments."
Kaye says there are two main components to bunion problems. "One problem is the pain associated with shoe pressure against the bony enlargement," he says. "The second condition is a stiff toe joint that causes internal joint pain during movement of the big toe. Both or either of these problems can occur."
Advanced surgical techniques have improved outcomes for bunion surgery. The type of surgery needed depends on the patient's age, activity level, and degree of deformity. Kaye says he doesn't only remove the "bump of bone," which won't usually produce lasting results. "We realign the bone and use a surgical screw for stable bone alignment," he says. Recovery time usually takes about four weeks.
"The precision in which the bone is cut, shaped, and realigned is critical," Kaye says. Though consumers may see lasers publicized to treat bunions, lasers can't cut bone or correct bunions, he says. Lasers are not cleared by the FDA for these indications.
According to the American College of Foot and Ankle Surgeons, there have also been advances in less invasive foot and ankle surgery. Newer surgical plates and screws let surgeons repair fractures with less trauma. Smaller incisions mean less bleeding and tissue damage.
In ankle arthroscopy, surgeons look at the ankle joint with a fiber optic camera system. This technique has been applied to knee surgery for several years, but now it's being used for bones and joints in the foot and ankle. This type of surgery can relieve inflammation from arthritis and ligament damage, with reduced recovery time as compared to open surgical procedures.
Before considering any surgery, people should always explore and discuss the nonsurgical options with their doctor, and the benefits and risks of surgery. It is also important to consider the doctor's experience and results with the procedure.
The American Orthopaedic Foot & Ankle Society (AOFAS) has released statements warning about trends in cosmetic surgery to improve the appearance of the foot. "Some women are getting surgeries to shorten toes and narrow their feet so they can fit into fashionable shoes," says Sharon Dreeben, M.D., chairwoman of the AOFAS Public Education Committee and an orthopedic surgeon in La Jolla, Calif.
"A woman recently called asking if I would inject collagen into her heel, and she will probably go doctor shopping to find someone who will do it," Dreeben says. "Some people want more padding to have cushion for high heels. But cosmetic foot surgery can result in chronic pain, infection, and nerve injury."
Dreeben has had to fix problems from cosmetic foot surgery that went wrong. "One woman had bunion surgery even though she hadn't been experiencing pain," she says. "She ended up with more problems, including nerve pain and difficulty walking."
The AOFAS defines cosmetic foot surgery as surgery that is aimed at only improving appearance. Dreeben says, "Foot surgery should only be used if the goal is to provide pain relief, improve function, or enhance quality of life during normal activities of daily living."
"I tell people: One difference between cosmetic surgery on the face and cosmetic surgery on the feet is that you don't walk around on your face. When you readjust one piece in the foot, it can affect everything."
The most common cause of heel and arch pain is painful stretching or tearing of the plantar fascia, which runs along the bottom of the foot and supports the arch of the foot. Extracorporeal shock wave treatment is an outpatient procedure in which a medical device uses shock waves to relieve chronic heel pain. A dome filled with water is placed against the heel so shock waves pass through. The shock waves increase blood flow to trigger the healing process so that inflammation and pain subside.
FDA-approved devices for this procedure are the Ossatron, made by SanuWave Inc. of Marietta, Ga.; The Epos Ultra, made by Dornier MedTech, Kennesaw, Ga.; and the Orsabone Pain Relief System, made by Orthometrix Inc., White Plains, N.Y. People who have bleeding disorders, who are taking blood-thinning medication, or who are pregnant, should not undergo shock wave therapy. Complications can include mild neurological symptoms and tears in the tissue in the bottom of the foot.
Discolored toenails. Infection can spread to other nails. Fungal infection can be picked up in damp areas like swimming pools and locker rooms. Clean, dry feet help prevent it. Treatments are topical and oral antifungal medications and, in severe cases, surgery to remove the nail.
Nails whose corners or sides dig painfully into skin, often causing infection. Can be caused by improper nail trimming, pressure from shoes that are too small, injury, fungus infection, heredity, and poor foot structure. Trim toenails straight across to prevent problems. Soak the foot in soapy water, apply antiseptic, and bandage. Wear well-fitting shoes. If a toenail is painful or infected, the doctor may remove the ingrown portion.
A skin disease that can spread from the feet to other parts of the body and is caused by fungus. This disease doesn't typically spread from person to person. Signs are dry, scaly skin; itching; inflammation; and blisters. Athlete's foot can be prevented by daily washing with soap and water, drying feet, changing sweaty shoes and hose and socks regularly, and wearing shoes or sandals in public environments like the locker room or pool.
Caused by a virus that enters the skin through small cuts and infects the skin. Children tend to be more susceptible than adults. Most warts are harmless, though they can be unsightly and painful. They can be caused by walking barefoot on dirty ground. Treatments include over-the-counter and prescription topical acids, and laser or surgical removal.
Misaligned big toe joints that can become swollen and tender. The first joint of the big toe slants outward, angling the big toe toward other toes. Bunions tend to run in families, but can be aggravated by tight shoes. Conservative treatment includes padding, choosing shoes with wide toe box, and orthotic devices. Pain medicines and surgery to relieve pain may be needed in severe cases, but should not be done for cosmetic purposes.
The toes are bent like a claw. This condition occurs most frequently with the second toe because of bunion slanting. It can be caused by muscle imbalance or can be made worse by tight shoes or tight socks. Pain medicine or orthotic devices may help. Surgery may be needed to realign toes.
Caused by skin friction, especially from poorly fitting shoes. A band-aid should be worn until the blister heals, and socks should be worn with shoes. If the blister breaks, it should be washed, and an antiseptic and sterile bandage applied. It shouldn't be popped. It should be drained only by a professional.
Protective layers of dead skin cells. Calluses appear on the soles of the feet, and corns appear on top of toes. They are caused by friction from skin rubbing and shoes. Pain may be relieved by moleskin or padding. They should never be cut with an instrument.
Stretching or tearing of the plantar fascia, which runs along the bottom of the foot and supports the arch of the foot. Heel pads, pain medicines, or cortisone injections may help. Other conservative care includes splinting, stretching, avoiding walking barefoot, and physical therapy. Shock wave treatments use shock wave energy to relieve inflammation and are an alternative to surgery.
Enlarged benign growths of nerves, most commonly between the third and fourth toes. This nerve condition is caused by bones rubbing against and irritating the nerves. It is also caused by abnormal bone structure or pressure from poorly fitting shoes. It may cause pain, burning, or numbness between toes and in the ball of the foot. Treatment includes padding, taping, orthotic devices, and cortisone injections. Sometimes, surgical removal is required.
Calcium growths on the underside of the foot bones often associated with plantar fasciitis. Pain may occur if there is inflammation. Treatments range from exercise and custom-made orthotics to anti-inflammatory medication.
Ordre des podiatres du Québec
www.ordredespodiatres.qc.ca
American Podiatric Medical Association
www.apma.org
(800) FOOTCARE
American Orthopaedic Foot and Ankle Society
www.aofas.org
(206) 223-1120