Heel Pain

Heel pain is a vague term that describes pain located in the back, sides, or bottom of one's feet. One of the more common types of heel pain occurs in the bottom of the foot. The pain isworse after periods of rest. Some even state that they feel like they are walking on a stone. This commonly caused by a process known as plantar fasciitis.

Within this process, the bottom of the feet may hurt upon standing. This pain is usually located at the bottom inside part of the heel. It may actually gradually get better after walking; but after a period of rest or extended periods of activity, the pain is once again felt.

The plantar fascia is a ligamentous structure that originates on your heel bone and fans out and inserts into the toes. The purpose of the plantar fascia is to hold the muscles of the foot in close relationship to the bones and also to provide some support in the arch of the foot. When the toes move upward against the foot, the plantar fascia stretches taught and pulls the heel bone closer to the ball of the foot. This is the mechanism that that provides the arch support.

Plantar fasciitis is most often caused by improper mechanics of the foot. The three fascial bands may encounter swelling or micro tears causing an inflammatory response and the associated pain people relate.

Many people have referred to this entire process as heel spurs. At times, there can be a heel spur present with plantar fasciitis. The heel spur is not the problem but rather a result of the problem. It forms because of the pulling of the plantar fascia. There are people who have heel pain without the presence of a heel spur. Conversely, there are people who have heel spur present, without heel pain.

If you have heel pain, a podiatric physician should evaluate you. While the explanation of the problem is very helpful, the doctor will need to feel all of the structures around the heel and possibly take x-rays to confirm the diagnosis and look for the presence of a heel spur.

After a history and physical, your podiatrist will be able to discuss the problem and treatments with you. Some of the treatments are aimed at relieving the symptoms while others are aimed at controlling how your feet move and function while walking. There are even times when your doctor might suggest surgical intervention for this problem.

The purpose of this newsletter is to educate and not replace the advise of a medical professional. If you should have any questions, please seek the assistance of a podiatrist or other health professional that will be able to further the discussion and recommend appropriate interventions.

If you are experiencing any of the symptoms addressed, we strongly recommend that you seek the advice of your podiatrist for proper diagnosis.

Bone Health

Most of us are avid TV watchers, so I'm sure we are all familiar with the many ads drug companies generate to promote a healthier lifestyle. Let's face it, as we get older, our bodies may need some help. There are weight loss, smoking cessation, asthma, impotency, and heartburn drugs. Today we will focus on bone mineralization. Often we have seen actress Sally Field on the commercial explaining how she takes her Boniva tablet once a month to maintain healthy bones. Because there are so many bones in the feet, Podiatrists are especially interested in maintaining patient's healthy bone. In this article, we will go over bone mineral homeostasis - the process of maintaining a constant healthy bone.

There are two major components that are important to bone composition; calcium and phosphate. These must be maintained in order for a person to have healthy bones. One could think of calcium and phosphate as being cars, and the drivers of the cars would be Vitamin D and parathyroid hormone (PTH). These are the main regulators of making sure that bone mineralization stays regular.

PTH and Vitamin D regulate bone mineralization and affect the body in different ways. PTH's main goal is to increase calcium and decrease phosphate. PTH has three destinations; bone, kidney, and intestine. In the bone, PTH is responsible for a process which we call osteolysis. Osteolysis is where calcium is pulled from the blood and put into the fluid around the bone, the extra cellular fluid (ECF).

In the kidney, PTH is going to stimulate the kidney to increase absorption of calcium and magnesium and decrease the phosphate reabsorption. The intestine is indirectly affected by increased absorption of calcium and phosphate.

Vitamin D on the other hand has quite different functions. Vitamin D would be the primary regulator of bone mineralization. You see, vitamin D is what we would call the "front man", it doesn't do the actual work. The liver and kidney make vitamin D into its active form called calcitrol. Vitamin D likes to go the same places as PTH; bone, kidney, and intestine. In the bone it's going to increase bone formation by increasing calcium and phosphate resorption.

Vitamin D in the kidney is responsible for decreased calcium and phosphate excretion. Increases in absorption of calcium and phosphate also take place in the intestine.

Now that was a lot to take in - or out. Maybe you would be more familiar with the term osteoporosis.

This is the gradual loss of bone mass to the point that the skeleton is compromised. Osteoporosis mainly affects older women who have decreased calcium intake. It would be ainteresting to note that the daily calcium intake for women older than 65 years should be 1500mg. If you enjoy dairy products, shellfish, green leafy vegetables, and tofu, then you have daily added calcium intake.

A popular pharmaceutical calcium therapy is the popular drug Boniva. Boniva is a calcium supplement that can be taken as a daily tablet, once a month tablet, or an injectible which is taken every 3 months.

The key to healthy bones in the body and longevity is to ensure that calcium levels are met.

By allowing a healthy lifestyle, bone mineralization homeostasis can be achieved and maintained.

If you are experiencing any of the symptoms addressed, we strongly recommend that you seek the advice of your podiatrist for proper diagnosis.

The Effects of Tobacco on Your Feet

As many people now know, the use of tobacco products can be detrimental to your health. Many people understand the vast number of respiratory ailments, ranging from emphysema to lung disease and cancer can occur as a result of smoking tobacco. Does anyone understand that smoking can also affect your feet?

One of many ingredients in tobacco is nicotine. Nicotine is believed to have many effects in the human body, both positive and negative. As any smoker will attest, nicotine has a calming effect. Many scientists are researching the effects of nicotine on the human body. Nicotine and its derivatives have been studied for its potential beneficial role in patients with Parkinson's disease and decreased attention span. Much of the literature clearly states that it is the nicotine receptors in our brain that need this purified nicotine or an analogue. The nicotine from tobacco does not provide this benefit.

The immediate effects of nicotine on the body include:

  • Increase in blood pressure
  • Increase in heart rate
  • Thickening of blood
  • Narrowing of arteries
  • Decrease in skin temperature
  • Increase in respiration
  • Vomiting, and
  • Diarrhea

Long term effects of nicotine on the body include:

  • Blockage of blood vessels, thus a slower heartbeat than a non-smoker's at rest
  • Depletion of vitamin C
  • Reduction in the effectiveness of the immune system - making it harder to fight off dangerous infections
  • Cancer of the mouth; throat; and lungs
  • Cancer of the upper respiratory tract
  • Hurting physical fitness in terms of performance and endurance
  • Bronchitis and/or emphysema
  • Stomach ulcers
  • Weight loss
  • Dryness and wrinkling of skin, often times giving the skin a leathery appearance
  • Production of abnormal sperm, causing birth defects

Of importance in this discussion is the effect that nicotine has on your arteries, the blood vessels that carry blood away from your heart.

Nicotine has an effect on the sympathetic nervous system (part of the nervous system involved in the classic "fight or flight" response); part of this effect is to cause the blood vessels within the body to constrict. Since, hopefully, the same amount of blood is still going through the body, this results in a net increase in the pressure within the system (think of what happens when you squeeze a garden hose). Why is it bad? The increase in pressure has to come from somewhere, and that's the heart that is trying to pump against this. Also, higher pressure can lead the "blowing up" of blood vessels, called aneurysms (think again of that garden hose and what happens if you hold it bent for too long).

As we all age, there are plaques building up on the inside walls of our arteries. Some people have this peripheral vascular disease (PVD). It is commonly recognized in the hands and feet because these are the points farthest away from the heart where the blood vessels are the smallest.

This PVD in combination with the effects of nicotine can lead to a painful lack of blood flow to our feet. Our skin is a living organ, which means it needs to have nourishment to remain healthy. The arteries are the conduits to bring that nourishment to all aspects of our body.

People relate to sharp, deep stabbing pains. Some people even relate to having very painful ulcerations, or openings in their skin. When ulcerations occur, it can sometimes be very difficult and time consuming for the skin to heal. When there is an opening in the skin, an infection can begin and spread throughout the human body, which can ultimately lead to amputation or even death in the worst cases. Appropriate wound care should be initiated after a thorough examination has taken place.

Smoking can play a vital role in your everyday health as well as in the health of your feet. As you know, your feet are important. They get you to the many places you have to go. Be wise, take care of your feet, and see your podiatrist.

The following are just a few of the thousands of links regarding tobacco:

If you are experiencing any of the symptoms addressed, we strongly recommend that you seek the advice of your podiatrist for proper diagnosis.

Diabetic Ulcers

Non-traumatic lower extremity amputation most often occurs as a result of a diabetic foot problem, skin ulcers. The development of skin ulcerations on a patient with diabetes can be caused by any number of things. Some include, pressure from poorly fitted shoes and trauma to the foot and toes. Patients with Peripheral Neuropathy are more likely to develop ulcers because they have loss the sensation in their feet. Most times they will simply notice stains on their socks and footwear.

Unfortunately, even those diabetic patients who take all the proper steps in maintaining their foot care can still get an ulcer. An ulcer is the primary opening for infection that can affect both the soft tissue and the bone. It is very important to stay off your feet once you notice your ulcer. Continuing to walk on it will cause the infection to spread and penetrate deeper into your foot. Delayed treatment of diabetic ulcers can lead to amputation and even mortality

Debridement of the wound is the first steps in treating this condition. Thick layers of skin (corns and calluses), which should be carefully removed until a satisfactory border is present, may cover ulcers. Your podiatrist may require that you wear special footwear, have a culture done, or get x-rays.

Additional treatments for ulcers other than local wound care include hyperbaric oxygen (HBO), growth factors, and electrical stimulation. Even after successful treatment, there is a very high probability of reoccurrence. Continue to thoroughly inspect your feet and see your podiatrist on a regular basis.

Dr. Horsley recommends that all diabetics:

  1. Become educated on diabetic foot care
  2. Wash and dry feet thoroughly
  3. Inspect your feet daily (or have someone else do it for you)
  4. Wear properly fitting shoes
  5. Wear seamless socks
  6. Do NOT walk around barefoot
  7. Visit your podiatrist regularly

If you are experiencing any of the symptoms addressed, we strongly recommend that you seek the advice of your podiatrist for proper diagnosis.

Calluses

What is a Callus?

Calluses develop from a buildup of dead skin cells that become thick and hard on the foot. Usually found on either the heel, the ball of the foot, or inside the big toe, calluses develop as a result of excessive rubbing and pressure. Calluses that have a deep-seated core known as a nucleation are called Intractable Plantar Keratosis.

What causes Calluses?

Some of the most common reasons people develop calluses are:

  • Obesity
  • Deterioration of the fat pad located on the bottom of the foot
  • Wearing high heeled shoes
  • Wearing shoes that do not fit properly
  • Flat feet
  • High arched feet

What treatments are available?
When treating a callused foot, do not cut or trim them with a razor blade. This will only make the condition worses and is particularly dangerous for those with diabetes. The best thing to do is wear an orthotic that has been fitted for you by your podiatrist. They will redistribute your weight to relive the pressure being placed on your callus.

If you are experiencing swelling, inflammation, discharge, or pain, your toenail is probably infected and you should seek the treatment of a podiatrist. He or she may trim or remove the infected nail with a minor surgical procedure.

Plantar Fibromatosis

Plantar Fibromatosis is a common soft tissue mass found in the foot
and one of the most common lesions found on the sole of the foot. It
is a locally aggressive idiopathic proliferative fasciitis of the
plantar aponeurosis or subcutaneous thickening of the plantar
fascia. It is usually bilateral and frequently seen in children and
young adults. In older people it is often associated with
Dupuytren's contracture of the palmar fascia of the hand. The basic
microscopic pathology of Dupuytren's contracture and plantar
fibromas is about the same. The causes are obscure, but trauma does
not play an important role. The disease usually occurs in adult
males after 40 years. A relatively small number of cases are
bilateral. Whether these tumors are familial is not clear, although
cases have been recorded in multiple members of a family. Compared
with palmar fibromatosis, the plantar variety is rare, although the
exact incidence is not known, since a large number of theses cases
are not reported. The lesion was described by Dupuytren, and later
it was described in more detail by Ledderhose.

In Allen and Woolner's series of 69 cases, 35% were 30 years of age
or younger, including two cases that were present at birth. Among
200 consecutive cases, which were reviewed at the Armed Forces
Institute of Pathology between 1960 and 1978, 111 (55%) occurred in
patients 30 years or younger. Of the 11 cases, 22 were children 10
years or younger. Aviles et al., reported that 77% of their cases
were encountered in patients older than 45 years. Zamora et al.,
Journal of Hand Surgery, 1994 showed that there is an increase in
transforming growth factor beta in the early phase of Dupuytren's
contracture and Plantar Fibromatosis.

As far as clinical findings are concerned, the lesion (plantar
fibroma) appears as a firm, single, subcutaneous thickening or
nodule that adheres to the skin and is located in the middle and
medial portion of the sole of the foot. It may be asymptomatic, but
it may cause mild pain after long standing or walking.

Locke has classified plantar fibromatosis as proliferative(increased
fibroblasts and cellular activity), active(nodules are formed), and
residual(decreased fibroblastic activity).

One should consider surgery if there is pain and a change in the
course of the lesion (increase in size, contracture).

Surgical incisions may be linear, S-shaped or zig-zag. The surgeon
needs to perform a wide excision of the mass. The patient should try
to remain non-weight bearing for 3 weeks if possible.

Some complications are recurrence, nerve entrapment, skin slough,
scarring, hematoma, and arch fatigue. Simple excision appears to be
a poor method of treatment. Allen et al. noted recurrences in 15 of
28 patients treated by simple excision. Patients who underwent local
excision had a 57% incidence of recurrence at the excision site,
whereas those who underwent side excision (fasciectomy) with or
without skin graft had a more favorable result (8% recurrence).

Mallet Toes

What are mallet toes?

A mallet toe occurs when the tip of the toe functions in a non-straightened manner. The tip of the toe is pointed down toward the sole of the shoe causing pain, discomfort and sometimes an infection. These infections are of major importance to the diabetic foot which is at a higher risk for abscess ulcerations, osteomyelitis (bone infection) and digital amputations.

It is very common to have a corn on the tip or top of a mallet toe due to rubbing against the sole and/or top of the shoe. The corn (hyperkeratotic lesion) is hard lifeless tissue which is discolored and looks bad.
This deformity alone has caused embarrassment when others see it sticking out like a "sore thumb". Sometimes a circular, light, hypo pigmented spot appears from the toe and shoe friction while other times a circular, dark, hyper pigmented spot discolors the skin on the toe. Changes in skin color can be permanent with a mallet toe deformity when left untreated.

Several other factors can lead to a good mallet toe going bad. Poor circulation, diabetes, edema (swelling) and non-leather shoes are examples of conditions that endanger the well being of a mallet toe. Complicating factors will produce sores on a mallet toe with puss, infection and drainage. Sometimes this scenario makes the toe begin to swell to almost twice its normal size, putting pressure on the surrounding toes causing those toes to be affected with lesions, sores, abscessed ulcerations and swelling too. Aching toes will alter ones walking pattern (gait cycle) and a cane or crutch could possibly be needed. Sometimes a lot of pain is present while other times absolutely no pain or discomfort is noticed because of nerve damage, decreased sensations in the feet from possibly a stroke or diabetes.

Most recently, sensory disorders in a patient's foot were caused by a closed head injury incurred during a snowmobile accident. Hemi paralysis of his right side required physical therapy to help regain function of his entire right side. Hard work and determination resulted favorable results for use and function of his right arm and lower extremity but the nerve damage is taking a long time to return to normal.

He decided to join some friends on a week long ski trip where he took beginner ski lessons and was able to manage this task quite well. The trip was uneventful, safe and he had a lot of fun on the slopes. Upon return he noticed some drainage from his second toe right foot coming from the side of his toenail. The toe was red and slightly swollen at the tip and around the eponychium (cuticle). The nail was partially detached and loose. His mallet toe deformity was exacerbated from the friction of his ski boot and he was unable to feel the pain secondary to the nerve damage existing in his foot and leg.

Without anesthesia, I removed the offending portion of his nail and had him soak his foot twice a day. No antibiotics were given and a week later the redness and infection were gone.

What causes a mallet toe?

Often times the bones and muscles in the toes are imbalanced causing mallet toes. You are more likely to develop mallet toes if you:

  • Are on your feet for the majority of the day
  • Participate in sporting activities on a regular basis
  • Already suffer from arthritis
  • Have nerve damage to your back, leg or foot
  • Have too high of an arch or very flat feet
  • Wear shoes that "just fit" or are too small
  • Have a toe deformity from birth

Some conservative treatments you could try are:

  • Wearing shoes with a large toe box
  • Toe crest or buttress pad
  • Gel toe shields and /or caps

Some surgical treatments your Podiatrist could try are:

  • Arthroplasty or partial bone/joint removal
  • Joint fusions in the toe
  • Flexor tenotomy or lengthening (spelling)
  • Amputation of the tip of the toe

For more information on this subject, or to schedule an appointment with a footDrHorsley Podiatrist, please call (877) 372-6048

Gout

Gout is a disease in which tissue deposition of monosodium urate crystals occurs in and about the joints with acute or chronic arthritis. It initially is seen in men aged thirty to sixty years. In women it usually occurs after menopause. But, gouty attacks can be precipitated by trauma, certain foods, alcohol intake, diuretics, and kidney failure. Kidney excretion is the major route of uric acid disposal.

Gout may be divided into the following phases: asymptomatic, acute gouty arthritis, intercritical gout (follows acute attack), and chronic tophaceous gout manifested by monosodium urate crystal (tophi) deposited in the soft tissues of the body.

Classifications of gout include primary-elevated serum urate levels or urate deposition appears to be a consequence of disorders of uric acid metabolism not associated with another acquired disorder, secondary-gout is a minor feature secondary to a genetic or acquired process, uric acid overproduction-about 10% of patients excrete excessive amounts of uric acid into the urine, and uric acid undersecretion-the majority of patients show a relative deficit in the renal excretion of uric acid.

Clinical features include acute gouty arthritis most commonly at the 1st metatarsophalangeal joint of the big toe. 10% of the patients have no recurrence, but up to 60% of patients experience a second attack in less than a year. The ankle, tarsal area and knee are commonly affected. Affected joints are usually red, hot, swollen, and extremely tender. Diffuse erythema is present. A patient may be awakened at night from the pain. High grade fever may be associated with acute attacks. The most common sites for tophi are the base of the great toe, Achilles tendon, elbow, knees, wrists, and hands. About 10-20% of patients with primary hyperuricemia develop uric acid kidney stones. Renal disease is the most common complication of gout except for the arthritis.

On x-ray one may see soft tissue swelling, and joint effusions, rat-bite erosions, cyst-like or punched-out erosions. Many lesions are expansile with overhanging margins(Martel's sign) that are displaced away from the axis of the bone. Joint spaces are preserved until late in the disease. Ankylosis and joint subluxation may occur in advanced cases. Gouty tophi (white, chalky crystals) may be seen within soft tissues.

The diagnosis of gout is confirmed by the presence of strongly negatively birefringent monosodium urate crystals identified on joint aspiration.

Treatment for acute gout includes colchincine, NSAIDS(indomethacin, sulindac, naprosyn, ketoprofen), corticosteroids, and glucocorticoids.

Treatment for chronic gout includes colchicines, allopurinol, and probenecid and sulfinpyrazone.

Prevention of recurrence can be obtained by avoiding foods high in purines like anchovies, organ meat, liver, spinach, mushrooms, asparagus, oatmeal, cocoa, sweetbreads, shellfish, beans, peas, and lentils as well as avoiding alcohol, aspirin, and diuretics.

Bibliography

  • Banks, Alan S., et al McGlamry's Comprehensive Textbook of Foot and Ankle Surgery. Philadelphia:Lippincott Williams and Wilkins, 2001.
  • Ferri, Fred F., The Care of the Medical Patient.Philadelphia:Mosby, 2001.

Common Nail Problems

In order to ensure fewer nail problems, the shoe selection is important. The shoes must be wide and tall enough to accommodate your feet. If you trim your own nails, try to cut the nails straight across without going into the corners. If you have circulation problems or diabetes, please see your podiatrist before doing any self-care.

Ingrown Toenails

An ingrown toenail, or onychocryptosis, occurs when the nail grows down into the skin instead of outward (happening most often to the big toe). It can cause the toe to become infected and may be very painful. Redness, irritation, swelling, and an uncomfortable feeling of warmth are associated with an ingrown toenail. The best ways to prevent ingrown toenails include trimming your nails properly, guarding your feet from trauma, and wearing shoes that provide adequate room for your toes.

What causes Ingrown Toenails?
Many things can cause ingrown toenails.

The following are a few of the most common causes:

  • Cutting toenails incorrectly
  • Toenails are too large
  • Toes curl, either congenitally or from diseases such as arthritis
  • Frequent stubbing of the toes
  • Wearing shoes that are too tight

What treatments are available?
As soon as an ingrown toenail is noticed it should be treated. If the toenail is not infected, you may find relief in these simple steps:

  • Soak your feet in warm salt water
  • Dry them with a clean towel
  • Rub on an antiseptic solution
  • Cover the toe with a bandage

If there are no signs of infection, your doctor will cut the ingrown portion out. Depending on the severity and the presence or absence of infection, the side of the nail may need to be removed back to the level of the cuticle. Antibiotics may also be required if infected.

Pain may be along the side that the nail is ingrown or even throughout the entire toe. Walking seems to make the pain worse. To evaluate the problem, your podiatrist will evaluate the toe around the affected area.

Fungal nails

Fungal nails tend to be thick, crumbly, and discolored. Fungal nails can be very difficult to trim without the assistance of a podiatrist.

You will need to talk to your podiatrist regarding treatment of fungal nails. Treatment can include solutions, creams, removal of problematic nails, or even oral medications.

Toenails can have changes similar to the ones that are present in fungal nails without the presence of a fungus. Your foot doctor can examine the nails to determine if a fungus is present or if there is another underlying condition.

Black and blue nails

Black and blue nails are most often caused by a traumatic event. Many times this happens from sport activities or a heavy object falling onto the toe. There could be pain associated with this discoloration if the injury is sudden.

Your podiatrist should examine the nail and the rest of your foot to ensure that there is no infection present. Treatment can include doing nothing, drilling a hole into the nail plate to relieve the pressure, or removal of the entire nail plate.

You should discuss the treatment choices with your podiatrist.

If you are experiencing any of the symptoms addressed, we strongly recommend that you seek the advice of your podiatrist for proper diagnosis.

Onychomycosis – Fungus Nail

Have you ever gone over someone's house and been ashamed to take off your shoes? Ever gone to the beach and buried your feet in the sand? Do you wear closed toed shoes because you are ashamed of toenails? Don't worry, you are not alone. This is what millions of Americans experience. If you have dry, yellow, brittle, and discolored toenails, you may have Onychomycosis, better known as fungus nail. With Onychomycosis, the nail has been penetrated by bacteria or some type of fungi. In this article we will discuss Onychomycosis and treatment options.

How would you know if you had onychomycosis? Your podiatrist will be able to diagnose your condition. In order to do so, debridement of the nail plate saving the most proximal section is advised. Three tests can be performed on the nail clippings. The most accurate diagnostic test of onychomycosis is the PAS test. PAS is very specific and less operator dependent. Onychomycosis usually doesn't affect children and is increasingly common as one gets older.

In order to manage Onychomycosis, your podiatrist can suggest three treatment options; debridement of the nail, oral therapy, and topical therapy. Debridement of the nail is going to give the patient satisfaction temporarily because the fungus nail can and will possibly grow back. Oral therapy requires the patient to follow a pill regimen and may have drug reactions with other medications that a patient is taking. Oral medications may also irritate your liver. Topical therapies cause no harm to the patient. They can be taken with other medications without harm to the liver.

There are many nonprescription treatments for onychomycosis. Natural oils have been shown to be effective in its control. Camphor, menthol, eucalyptus oil, cedar leaf, nutmeg oil, thymol, clove, and tea tree oil have all been used. The way these over the counter products work is that they kill fungus on the surface of the nail where the discoloration, brittleness, and dryness occur. Many podiatrist have topical products which contain the essential ingredients. These ingredients not only clear up the current fungus on the nail but promote healthy nail growth. One such topical antifungal is NailEsse. NailEsse can be used on both hands and feet. Daily use on requires daily application on the hands for 6-8 months and 8-12 month period for toenails. The current fungus on the nail will be killed and the new nail that grows will be fungus free. This product should be available at your local podiatrist office.

The key to treating fungus nail is to make sure that you visit your podiatrist so you can accurately be diagnosed and treated. Just because you have an abnormal nail, it may not necessarily be onychomycosis. Home remedies are not effective as treatment your podiatrist can provide. The correct combination of oils in topical antifungals is key to effective treatment.