Patient Education

Achilles Tendon Injuries

Click here for a video presentation about achilles tendon injuries.

Ankle Sprain

Click here for a video presentation about ankle sprains.

Apophysitis (Pediatric Heel Pain)

Heel pain can also occur in children, most commonly between ages 8 and 13, as they become increasingly active in sports activity in and out of school. This physical activity, particularly jumping, inflames the growth centers of the heels; the more active the child, the more likely the condition will occur. When the bones mature, the problems disappear and are not likely to recur. If heel pain occurs in this age group, podiatric care is necessary to protect the growing bone and to provide pain relief. Other good news is that heel spurs do not often develop in children.

Arthritis

Arthritis, in general terms, is inflammation and swelling of the cartilage and lining of the joints, generally accompanied by an increase in the fluid in the joints. Arthritis has multiple causes; just as a sore throat may have its origin in a variety of diseases, so joint inflammation and arthritis are associated with many different illnesses.

Arthritis and the Feet

Arthritis is a frequent component of complex diseases that may involve more than 100 identifiable disorders. If the feet seem more susceptible to arthritis than other parts of the body, it is because each foot has 33 joints that can be afflicted, and there is no way to avoid the pain of the tremendous weight-bearing load on the feet.

Arthritis is a disabling and occasionally crippling disease; it afflicts almost 40 million Americans. In some forms, it appears to have hereditary tendencies. While the prevalence of arthritis increases with age, all people from infancy to middle age are potential victims. People over 50 are the primary targets.

Arthritic feet can result in loss of mobility and independence, but that may be avoided with early diagnosis and proper medical care.

Some Causes

Besides heredity, arthritic symptoms may arise in a number of ways:

• Through injuries, notably in athletes and industrial workers, especially if the injuries have been ignored (which injuries of the feet tend to be).
• Through bacterial and viral infections that strike the joints. The same organisms that are present in pneumonia, gonorrhea, staph infections, and Lyme disease cause the inflammations. 
• In conjunction with bowel disorders such as colitis and ileitis, frequently resulting in arthritic conditions in the joints of the ankles and toes. Such inflammatory bowel diseases seem distant from arthritis, but treating them can relieve arthritic pain.
• Using drugs, both prescription drugs and illegal street drugs, can induce arthritis.
• As part of a congenital autoimmune disease syndrome of undetermined origin. Recent research has suggested, for instance, that a defective gene may play a role in osteoarthritis.

Symptoms

Because arthritis can affect the structure and function of the feet it is important to see a doctor of podiatric medicine if any of the following symptoms occur in the feet:

• Swelling in one or more joints
• Recurring pain or tenderness in any joint
• Redness or heat in a joint
• Limitation in motion of joint
• Early morning stiffness
• Skin changes, including rashes and growths

Some Forms of Arthritis

Osteoarthritis is the most common form of arthritis. It is frequently called degenerative joint disease or “wear and tear” arthritis. Although it can be brought on suddenly by an injury, its onset is generally gradual; aging brings on a breakdown in cartilage, and pain gets progressively more severe, although it can be relieved with rest. Dull, throbbing nighttime pain is characteristic, and it may be accompanied by muscle weakness or deterioration. Walking may become erratic.
It is a particular problem for the feet when people are overweight, simply because there are so many joints in each foot. The additional weight contributes to the deterioration of cartilage and the development of bone spurs.

Rheumatoid arthritis (RA) is a major crippling disorder and perhaps the most serious form of arthritis. It is a complex, chronic inflammatory system of diseases, often affecting more than a dozen smaller joints during the course of the disease, frequently in a symmetrical pattern—both ankles, or the index fingers of both hands, for example. It is often accompanied by signs and symptoms—lengthy morning stiffness, fatigue, and weight loss—and it may affect various systems of the body, such as the eyes, lungs, heart, and nervous system. Women are three or four times more likely than men to suffer RA.

RA has a much more acute onset than osteoarthritis. It is characterized by alternating periods of remission, during which symptoms disappear, and exacerbation, marked by the return of inflammation, stiffness, and pain. Serious joint deformity and loss of motion frequently result from acute rheumatoid arthritis. However, the disease system has been known to be active for months, or years, then abate, sometimes permanently.

Gout (gouty arthritis) is a condition caused by a buildup of the salts of uric acid—a normal byproduct of the diet—in the joints. A single big toe joint is commonly the affected area, possibly because it is subject to so much pressure in walking; attacks of gouty arthritis are extremely painful, perhaps more so than any other form of arthritis. Men are much more likely to be afflicted than women, an indication that heredity may play a role in the disease. While a rich diet that contains lots of red meat, rich sauces, shellfish, and brandy is popularly associated with gout, there are other protein compounds in foods such as lentils and beans that may play a role.

Diagnosis

Different forms of arthritis affect the body in different ways; many have distinct systemic affects that are not common to other forms. Early diagnosis is important to effective treatment of any form. Destruction of cartilage is not reversible, and if the inflammation of arthritic disease isn’t treated, both cartilage and bone can be damaged, which makes the joints increasingly difficult to move. Most forms of arthritis cannot be cured but can be controlled or brought into remission; perhaps only five percent of the most serious cases, usually of rheumatoid arthritis, result in such severe crippling that walking aids or wheelchairs are required.

Treatment

The objectives in the treatment of arthritis are controlling inflammation, preserving joint function (or restoring it if it has been lost), and curing the disease if that is possible.

Because the foot is such a frequent target, the doctor of podiatric medicine is often the first physician to encounter some of the complaints—inflammation, pain, stiffness, excessive warmth, injuries. Even bunions can be manifestations of arthritis.

Arthritis may be treated in many ways. Patient education is important. Physical therapy and exercise may be indicated, accompanied by medication. In such a complex disease system, it is no wonder that a wide variety of drugs have been used effectively to treat it; likewise, a given treatment may be very effective in one patient and almost no help at all to another. Aspirin is still the first-line drug of choice for most forms of arthritis and the benchmark against which other therapies are measured.

The control of foot functions with shoe inserts called orthoses, or with braces or specially prescribed shoes, may be recommended. Surgical intervention is a last resort in arthritis, as it is with most disease conditions; the replacement of damaged joints with artificial joints is a possible surgical procedure.

Athlete's Foot

Athlete's foot is a fungal infection that develops in the moist areas between your toes and sometimes on other parts of your foot. Athlete's foot usually causes itching, stinging and burning.

Symptoms

The signs and symptoms of athlete's foot can be numerous, although you probably won't have all of them. They include:

• Itching, stinging and burning between your toes
• Itching, stinging and burning on the soles of your feet
• Itchy blisters
• Cracking and peeling skin, especially between your toes and on the soles of your feet
• Excessive dryness of the skin on the bottoms or sides of the feet
• Toenails that are thick, crumbly, ragged, discolored or pulling away from the nail bed
• Onychomycosis — a fungal infection of the nail — may develop with or without other signs and symptoms of athlete's foot

When to see a doctor

If you have a rash on your foot that doesn't improve or worsens after you've followed home and lifestyle remedies, see your doctor. See your doctor sooner if you notice excessive redness, swelling, drainage or fever, or if you have diabetes and suspect you have athlete's foot.

Causes

Athlete's foot is closely related to other fungal infections, including ringworm and jock itch. A group of mold-like fungi called dermatophytes causes these infections. These microscopic organisms are normal inhabitants of your skin, and their growth stays in check as long as your skin is clean and dry. However, dematophytes thrive in damp, close environments.

Athlete's foot thrives in thick, tight shoes that squeeze the toes together and create warm, moist areas between them. Damp socks and shoes and warm, humid conditions also favor the organisms' growth. Plastic shoes, in particular, provide a welcoming environment for fungal growth and infection.

Risk Factors

You are at higher risk of athlete's foot if you:

• Are a man
• Frequently wear damp socks or tightfitting shoes
• Share mats, rugs, bed linens, clothes or shoes with someone who has a fungal infection
• Walk barefoot in public areas where the infection can spread, such as locker rooms, saunas, swimming pools, communal baths and showers
• Have a weakened immune system

Complications

Athlete's foot can lead to complications, including:

• Secondary infections. Athlete's foot, a fungal infection, can create an environment that invites a secondary bacterial infection. By producing an antibiotic substance, the fungus can kill off vulnerable bacteria and favor the overgrowth of hardier, resistant bacteria. In turn, the bacteria release substances that can cause tissue breakdown — soggy skin and painful eroded areas between the toes.
• An allergic response. After an episode of athlete's foot, proteins might enter your bloodstream, leading to an allergic reaction that may cause an eruption of blisters on your fingers, toes or hands (dermatophytid or "id" reaction).

Treatment and Medications

If your athlete's foot is mild, your doctor may suggest using an over-the-counter antifungal ointment, lotion, powder or spray. If your athlete's foot doesn't respond, you may need a prescription-strength topical medication or an oral (systemic) medication.

Over-the-counter medications

There are numerous over-the-counter (OTC) medications on the market. Medicated powders also will help keep your feet dry. OTC medications include:

• Butenafine (Lotrimin Ultra)
• Clotrimazole (Lotrimin AF)
• Miconazole (Desenex, Zeasorb, others)
• Terbinafine (Lamisil AT)
• Tolnaftate (Tinactin, Ting, others)

Prescription medications

If athlete's foot is severe or doesn't respond to over-the-counter medicine, you may need a prescription-strength topical or oral medication.

Topical medications

These include clotrimazole and miconazole.

Oral medications

These include itraconazole (Sporanox), fluconazole (Diflucan) and terbinafine (Lamisil). Side effects from oral medications include gastrointestinal upset, rash and abnormal liver function. Taking other medications, such as antacid therapies for ulcer disease or gastroesophageal reflux disease (GERD), may interfere with the absorption of these drugs. Oral medications for athlete's foot may alter the effectiveness of warfarin, an anticoagulant drug that decreases the clotting ability of your blood.

Your doctor may prescribe an oral antibiotic if you have an accompanying bacterial infection. In addition, your doctor may recommend wet dressings, steroid ointments, compresses or vinegar soaks to help clear up blisters or soggy skin.

Wash and dry the affected area. Then, apply a thin layer of the topical agent once or twice a day for at least two weeks, or according to package directions. If you don't see an improvement after four weeks, see your doctor.

If your athlete's foot recurs frequently, your doctor may recommend that you use a medication continuously.

Prevention

These tips can help you avoid athlete's foot or ease the symptoms if infection occurs:

• Keep your feet dry, especially between your toes. Go barefoot to let your feet air out as much as possible when you're home.
• Go with natural materials. Wear socks that are made of natural material, such as cotton or wool, or a synthetic fiber designed to draw moisture away from your feet.
• Change socks and stockings regularly. If your feet sweat a lot, change your socks twice a day.
• Wear light, well-ventilated shoes. Avoid shoes made of synthetic material, such as vinyl or rubber.
• Alternate pairs of shoes. Don't wear the same pair every day so that you give your shoes time to dry between wearings.
• Protect your feet in public places. Wear waterproof sandals or shower shoes in communal showers, pools, fitness centers and other public areas.
• Treat your feet. Use powder, preferably antifungal, on your feet daily.
• Don't share shoes. Sharing risks spreading a fungal infection.

Source: http://www.mayoclinic.com/health/athletes-foot/DS00317

Bonespurs

Bone spurs, also called osteophytes, are bony projections that develop along the edges of bones. The bone spurs themselves aren't painful, but they can rub against nearby nerves and bones and cause pain.

Bone spurs can form on any bone, and they often form where bones meet each other — in your joints. But, they can also be found where ligaments and tendons connect with bone. Bone spurs can also form on the bones of your spine.

Most bone spurs cause no symptoms and may go undetected for years. What treatment, if any, that you receive for your bone spurs depends on where they're located and how they affect your health.

Symptoms

Most bone spurs cause no signs or symptoms. Often you don't even realize you have bone spurs until an X-ray for another condition reveals the growths.

But some bone spurs can cause:

• Pain in your joints
• Loss of motion in your joints

Location determines other symptoms
Where your bone spurs are located determines where you'll feel pain and whether you'll experience any other signs or symptoms. For instance:

• In your knee, bone spurs may make it painful to extend and bend your leg. Bone spurs can get in the way of bones and tendons that keep your knee operating smoothly.
• On your spine, bone spurs can push against your nerves, or even your spinal cord, causing pain and numbness elsewhere in your body.
• On your neck, cervical bone spurs can protrude inward, occasionally making it difficult to swallow or painful to breathe. Bone spurs can also push against veins, restricting blood flow to your brain.
• In your shoulder, bone spurs can restrict the range of motion of your arm. Bone spurs can rub on your rotator cuff, a group of tendons that help control your shoulder movements. This can cause swelling (tendinitis) and tears in your rotator cuff.
• On your fingers, bone spurs may appear as hard lumps under your skin, making your fingers appear disfigured. Bone spurs on your fingers may cause intermittent pain.

Causes

Bone spurs usually occur as a result of a disease or condition — commonly with osteoarthritis. As osteoarthritis breaks down the cartilage in your joint, your body attempts to repair the loss. Often this means creating new areas of bone along the edges of your existing bones.

Bone spurs are the hallmark of other diseases and conditions, including:

• Diffuse idiopathic skeletal hyperostosis (DISH). This condition causes bony growths to form on the ligaments of your spine.
• Plantar fasciitis. A bone spur, sometimes called a heel spur, can form where the connective tissue (fascia) connects to your heel bone (calcaneus). The spur results from chronic irritation or inflammation of the connective tissue, but the spur itself doesn't cause the pain associated with plantar fasciitis.
• Spondylosis. In this condition, osteoarthritis and bone spurs cause degeneration of the bones in your neck (cervical spondylosis) or your lower back (lumbar spondylosis).
• Spinal stenosis. Bone spurs can contribute to a narrowing of the bones that make up your spine (spinal stenosis), putting pressure on your spinal cord.

May be a normal part of aging
Bone spurs can also form on their own. They may be a normal part of aging. They've been found in older people who don't have osteoarthritis or other diseases.
Your body may create bone spurs to add stability to aging joints. Bone spurs may help redistribute your weight to protect areas of cartilage that are beginning to break down. For some people, bone spurs may actually provide a benefit, instead of being a painful condition.

Tests and Diagnosis

If you experience joint pain, your doctor will conduct a physical exam to better understand the pain you're feeling. He or she may feel around your joint to determine exactly where your pain is coming from. Sometimes your doctor can feel a bone spur, though sometimes bone spurs form in spots that can't be easily felt.
To confirm a diagnosis, your doctor may order imaging tests to get a look at your joints and bones. Some common ways of looking for bone spurs include:

• X-ray exams
• Computerized tomography (CT) scans
• Magnetic resonance imaging (MRI) scans

Bunions

A bunion is an enlargement of the joint at the base of the big toe—the metatarsophalangeal (MTP) joint—that forms when the bone or tissue at the big toe joint moves out of place. This forces the toe to bend toward the others, causing an often painful lump of bone on the foot. Since this joint carries a lot of the body’s weight while walking, bunions can cause extreme pain if left untreated. The MTP joint itself may become stiff and sore, making even the wearing of shoes difficult or impossible. A bunion–from the Latin "bunio," meaning enlargement–can also occur on the outside of the foot along the little toe, where it is called a "bunionette" or "tailor’s bunion."

Symptoms

• Development of a firm bump on the outside edge of the foot, at the base of the big toe.
• Redness, swelling, or pain at or near the MTP joint.
• Corns or other irritations caused by the overlap of the first and second toes.
• Restricted or painful motion of the big toe.

Corns & Calluses

Corns and calluses are protective layers of compacted, dead skin cells. They are caused by repeated friction and pressure from skin rubbing against bony areas or against an irregularity in a shoe. Corns ordinarily form on the toes and calluses on the soles of the feet. The friction and pressure can burn or otherwise be painful and may be relieved by moleskin or padding on the affected areas. Never cut corns or calluses with any instrument, and never apply home remedies, except under a podiatrist’s instructions.

Cracked Heels

What are cracked heels:

Cracked heels are a common foot problem that are often referred to as heel fissures. Cracked heels are commonly caused by dry skin (xerosis), and made more complicated if the skin around the rim of the heel is thick (callus). For most people this is a nuisance and a cosmetic problem but when the fissures or cracks are deep, they are painful to stand on and the skin can bleed - in severe cases this can become infected.

What does a cracked heel look like:

The skin is normally dry and may have a thick callus which appears as yellow or dark brown discolored area of skin, especially along the inside border of the heel. Cracks in the skin are usually obvious.

What are the symptoms of cracked heels:

If the cracks are bad enough there will be pain on weight bearing, that is not there when weight is off the heel. The edges or rim around the heel will generally have a thicker area of skin (callus). Wearing open or thin soled shoes usually make the symptoms worse.

What causes cracked heels:

Some people tend to have a naturally dry skin that predisposes them to the cracks. The thickened dry skin (callus) around the heel that is more likely to crack is often due to mechanical factors that increase pressures in that area (eg the way you walk).

Other factors that can be involved in the cause of cracked heels include:

• prolonged standing (at work or home, especially on hard floors)
• being overweight (this increases the pressure on the normal fat pad under the heel, causing it to expand sideways - if the skin is not supple and flexible, the pressures to 'crack' are high)
• open back on the shoes (this allows the fat under the heel to expand sideways and increases the pressure to 'crack')
• some medical conditions predispose to a drying skin (eg autonomic neuropathy in those with diabetes leads to less sweating; an underactive thyroid lowers the body's metabolic rate and there is a reduction in sweating, leading to a dryness of the skin)
• skin conditions (eg psoriasis and eczema)

Self treatment for cracked heels:

Applying an oil based moisturizing cream twice daily is really important to get on top of this problem. A pumice stone can be used to reduce the thickness of the hard skin. After looking at the 'tomato' analogy above it should be obvious why it is important to avoid open backed shoes or thin soled shoes.

Never try to reduce the hard skin your self with a razor blade or a pair of scissors. There is a risk of an infection developing and taking too much off.

Podiatric management of cracked heels:

The podiatric treatment of cracked heels may involve the following:

• investigating the cause of the problem, so this can be addressed
• removing the hard thick skin by debriding it (often the splits will not heal if the skin is not removed). This may need to be done on a regular basis. Regular maintenance may be the best way to prevent the problem.
• if very painful, strapping may be used to 'hold' the cracks together while they heal (a maintenance program after this to prevent recurrence is very important).
• prescription and advice regarding the most appropriate moisturizer or emollient.
• advice about footwear and self care of the problem.
• insoles may be used to alter the way you walk to prevent the thick skin from developing (these are indicated in cases of heel callus and are not suitable for all cases).
• a heel cup may be used to keep the fat pad from expanding sideways. This is worn in the shoe and can be very effective at prevention if used regularly.
• on rare occasions some Podiatrists and Dermatologists have used a tissue 'glue' to hold the edges of the skin together, so the cracks can heal.

Source: http://www.epodiatry.com/cracked_heels.htm

Diabetic Foot

A diabetic foot ulcer is an open sore or wound that most commonly occurs on the bottom of the foot in approximately 15 percent of patients with diabetes. Of those who develop a foot ulcer, six percent will be hospitalized due to infection or other ulcer-related complication.

Diabetes is the leading cause of nontraumatic lower extremity amputations in the United States, and approximately 14 to 24 percent of patients with diabetes who develop a foot ulcer have an amputation. Research, however, has shown that the development of a foot ulcer is preventable. 

Diabetes: Startling Statistics

Diabetes mellitus is a chronic disease that affects the lives of nearly 24 million people in the United States, nearly 6 million of whom are unaware that they even have the disease. In 2007 alone, 1.6 million new cases of diabetes were diagnosed in people aged 20 years or older. The disease is marked by the inability to manufacture or properly use insulin and impairs the body’s ability to convert sugars, starches and other foods into energy. The long-term effects of elevated blood sugar (hyperglycemia) are damage to the eyes, heart, feet, kidneys, nerves and blood vessels.

Symptoms of hyperglycemia may include frequent urination, excessive thirst, extreme hunger, unexplained weight loss, tingling or numbness of the feet or hands, blurred vision, fatigue, slow-to-heal wounds and susceptibility to certain infections. People who have any of these symptoms and have not been tested for diabetes are putting themselves at considerable risk and should see a physician without delay. 

Part of keeping your diabetes in control is testing your blood sugar often. Ask your doctor how often you should test and what your blood sugar levels should be. Testing your blood and then treating high blood sugar early will help you to prevent complications.

The socioeconomic costs of diabetes are enormous. In 2007, the total annual economic cost of diabetes was estimated at $174 billion -- about $116 billion of which are direct costs from the disease with $58 billion indirectly related. Diabetes is the sixth leading cause of death by disease in the United States, and individuals with diabetes are two to four times as likely to experience heart disease and stroke. 

The growth of the disease worldwide is especially alarming. The World Health Organization (WHO) expects the number of new diabetes cases to double in the next 25 years from 135 million to nearly 300 million. Much of this growth will occur in developing countries where aging, unhealthy diets, obesity, and sedentary lifestyles will contribute to the onset of the disease.

According to a recent survey, about 86,000 lower limbs are amputated annually due to complications from diabetes. Diabetes is the leading cause of end-stage kidney disease, accounting for about 44 percent of new cases. Diabetes is also the leading cause of new cases of blindness among adults aged 20 to 74.

While there is no cure for diabetes, there is hope. With a proper diet, exercise, medical care and careful management at home, a person with diabetes can keep the most serious of the consequences at bay and enjoy a long, full life.

How Do You Get Diabetes?

No one knows why people develop diabetes, but once diagnosed, the disease is present for life. It is a hereditary disorder, and certain genetic indicators are known to increase the risk of developing diabetes. Type 1, previously known as insulin-dependent diabetes mellitus or juvenile-onset diabetes, afflicts five to ten percent of diagnosed cases of diabetes. This type occurs most frequently in children and adolescents, and is caused by the inability of the pancreas to produce the insulin needed for survival. Type 2, previously called noninsulin-dependent diabetes mellitus or adult-onset diabetes, affects the other 90-95 percent of all diagnosed cases of diabetes, many of whom use oral medication or injectable insulin to control the disease. The vast majority of those people (80 percent or more) are overweight; many of them obese, as obesity itself can cause insulin resistance.

Certain characteristics put people at a higher risk for developing Type 2 diabetes. These include:

• A family history of the disease
• Obesity
• Prior history of developing diabetes while pregnant
• Being over the age of 40
• Being a member of one of the following ethnic groups: African American, Native American, Latino American, Asian American, Pacific Islander

African Americans are 1.7 times more likely to have diabetes than the general population, with 25 percent of African Americans between the ages of 65 and 74 diagnosed with the disease. Hispanic Americans are almost twice as likely to develop type 2 diabetes, which affects 10.6 percent of that population group. Native Americans are at a significantly increased risk for developing diabetes, and 12.2 percent of the population suffers from the disease. In some tribes, as many as 50 percent of its members have diabetes.

Of all the risk factors, weight is the most important, with more than 80 percent of diabetes sufferers classified as overweight.

The Role of Your Podiatric Physician

Because diabetes is a systemic disease affecting many different parts of the body, ideal case management requires a team approach. The podiatric physician, as an integral part of the treatment team, has documented success in the prevention of amputations. The key to amputation prevention in diabetic patients is early recognition and regular foot screenings, at least annually, from a podiatric physician.

In addition to these check ups, there are warning signs that you should be aware of so that they may be identified and called to the attention of the family physician or podiatrist.  They include:

• Skin color changes
• Elevation in skin temperature
• Swelling of the foot or ankle
• Pain in the legs
• Open sores on the feet that are slow to heal
• Ingrown and fungal toenails
• Bleeding corns and calluses
• Dry cracks in the skin, especially around the heel

Wound Healing

Ulceration is a common occurrence with the diabetic foot and should be carefully treated and monitored by a podiatrist to avoid amputations. Poorly fitted shoes, or something as trivial as a stocking seam, can create a wound that may not be felt by someone whose skin sensation is diminished. Left unattended, such ulcers can quickly become infected and lead to more serious consequences. Your podiatric physician knows how to treat and prevent these wounds and can be an important factor in keeping your feet healthy and strong. New to the science of wound healing are remarkable products that have the appearance and handling characteristics of human skin. These living, skin-like products are applied to wounds that are properly prepared by the podiatric physician. Clinical trials have shown impressive success rates.

Flatfoot (Adult)

Click here for a video presentation about the flatfoot condition.

Flatfoot (Pediatric)

Flatfoot is common in both children and adults. When this deformity occurs in children, it is referred to as “pediatric flatfoot,” a term that actually includes several types of flatfoot. Although there are differences between the various forms of flatfoot, they all share one characteristic—partial or total collapse of the arch. Most children with flatfoot have no symptoms, but some children have one or more symptoms. When symptoms do occur, they vary according to the type of flatfoot. Some signs and symptoms may include:

Types of Pediatric Flatfoot

Various terms are used to describe the different types of flatfoot. For example, flatfoot is either asymptomatic (without symptoms) or symptomatic (with symptoms). As mentioned earlier, the majority of children with flatfoot have an asymptomatic condition.

Symptomatic flatfoot is further described as being either flexible or rigid. “Flexible“ means that the foot is flat when standing (weight-bearing), but the arch returns when not standing. “Rigid” means the arch is always stiff and flat, whether standing on the foot or not.

Several types of flatfoot are categorized as rigid. The most common are:

• Tarsal coalition . This is a congenital (existing at birth) condition. It involves an abnormal joining of two or more bones in the foot. Tarsal coalition may or may not produce pain. When pain does occur, it usually starts in preadolescence or adolescence.
• Congenital vertical talus. Because of the foot’s rigid “rocker bottom” appearance that occurs with congenital vertical talus, this condition is apparent in the newborn. Symptoms begin at walking age, since it is difficult for the child to bear weight and wear shoes.

There are other types of pediatric flatfoot, such as those caused by injury or some diseases.

Diagnosis and Treatment: Non-surgical

In diagnosing flatfoot, the foot and ankle surgeon examines the foot and observes how it looks when the child stands and sits. The surgeon also observes how the child walks and evaluates the range of motion of the foot. Because flatfoot is sometimes related to problems in the leg, the surgeon may also examine the knee and hip.

X-rays are often taken to determine the severity of the deformity. Sometimes an MRI study, CT scan, and blood tests are ordered.

If a child’s flatfoot is asymptomatic, treatment is often not required. Instead, the condition will be observed and re-evaluated periodically by the foot and ankle surgeon. Custom orthotic devices may be considered for some cases of asymptomatic flatfoot.

In symptomatic pediatric flatfoot, treatment is required. The foot and ankle surgeon may select one or more approaches, depending on the child’s particular case. Some examples of non-surgical options include:

• Activity modifications. The child needs to temporarily decrease activities that bring pain as well as avoid prolonged walking or standing.
• Orthotic devices. The foot and ankle surgeon can provide custom orthotic devices that fit inside the shoe to support the structure of the foot and improve function.
• Physical therapy. Stretching exercises, supervised by the foot and ankle surgeon or a physical therapist, provide relief in some cases of flatfoot.
• Medications. Nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen, may be recommended to help reduce pain and inflammation.
• Shoe modifications. The foot and ankle surgeon will advise you on footwear characteristics that are important for the child with flatfoot.

When is Surgery Needed?

In some cases, surgery is necessary to relieve the symptoms and improve foot function. Foot and ankle sugeons perform a variety of techniques to treat the different types of pediatric flatfoot. The surgical procedure or combination of procedures selected for your child will depend on his or her particular type of flatfoot and degree of deformity.

Gout

Gout is a disorder that results from the build-up of uric acid in the tissues or a joint—most often the joint of the big toe. An attack of gout can be miserable, marked by the following symptoms:

• Intense pain that comes on suddenly—often in the middle of the night or upon arising.
• Redness, swelling, and warmth over the joint—all of which are signs of inflammation.

What Causes Gout?

Gout attacks are caused by deposits of crystallized uric acid in the joint. Uric acid is present in the blood and eliminated in the urine, but in people who have gout, uric acid accumulates and crystallizes in the joints. Uric acid is the result of the breakdown of purines, chemicals that are found naturally in our bodies and in food. Some people develop gout because their kidneys have difficulty eliminating normal amounts of uric acid, while others produce too much uric acid.

Gout occurs most commonly in the big toe because uric acid is sensitive to temperature changes. At cooler temperatures, uric acid turns into crystals. Since the toe is the part of the body that is furthest from the heart, it’s also the coolest part of the body—and, thus, the most likely target of gout. However, gout can affect any joint in the body.

The tendency to accumulate uric acid is often inherited. Other factors that put a person at risk for developing gout include: high blood pressure, diabetes, obesity, surgery, chemotherapy, stress, and certain medications and vitamins. For example, the body’s ability to remove uric acid can be negatively affected by taking aspirin, some diuretic medications (“water pills”), and the vitamin niacin (also called nicotinic acid). While gout is more common in men aged 40 to 60 years, it can occur in younger men and also occurs in women.

Consuming foods and beverages that contain high levels of purines can trigger an attack of gout. Some foods contain more purines than others and have been associated with an increase of uric acid, which leads to gout. You may be able to reduce your chances of getting a gout attack by limiting or avoiding the following foods and beverages: shellfish, organ meats (kidney, liver, etc.), red wine, beer, and red meat.

Diagnosis and Treatment

In diagnosing gout, the foot and ankle surgeon will take your personal and family history and examine the affected joint. Laboratory tests and x-rays are sometimes ordered to determine if the inflammation is caused by something other than gout.

Initial treatment of an attack of gout typically includes the following:

• Medications. Prescription medications or injections are used to treat the pain, swelling, and inflammation.
• Dietary restrictions. Foods and beverages that are high in purines should be avoided, since purines are converted in the body to uric acid.
• Fluids. Drink plenty of water and other fluids each day, while also avoiding alcoholic beverages, which cause dehydration.
• Immobilize and elevate the foot. Avoid standing and walking to give your foot a rest. Also, elevate your foot (level with or slightly above the heart) to help reduce the swelling.

The symptoms of gout and the inflammatory process usually resolve in three to ten days with treatment. If gout symptoms continue despite the initial treatment, or if repeated attacks occur, see your primary care physician for maintenance treatment that may involve daily medication. In cases of repeated episodes, the underlying problem must be addressed, as the build-up of uric acid over time can cause arthritic damage to the joint.

Hallux Rigidus (Stiff Big Toe)

Click here for a video presentation about hallux rigidus (stiff big toe).

Hammertoe

A hammertoe is a contracture—or bending—of the toe at the first joint of the digit, called the proximal interphalangeal joint. This bending causes the toe to appear like an upside-down V when looked at from the side. Any toe can be involved, but the condition usually affects the second through fifth toes, known as the lesser digits. Hammertoes are more common to females than males. 

There are two different types:

• Flexible Hammertoes:
  These are less serious because they can be diagnosed and treated while still in the developmental stage. They are called flexible hammertoes because they are still moveable at the joint.
• Rigid Hammertoes:
  This variety is more developed and more serious than the flexible condition. Rigid hammertoes can be seen in patients with severe arthritis, for example, or in patients who wait too long to seek professional treatment. The tendons in a rigid hammertoe have become tight, and the joint misaligned and immobile, making surgery the usual course of treatment.

Symptoms

• Pain upon pressure at the top of the bent toe from footwear.
• The formation of corns on the top of the joint.
• Redness and swelling at the joint contracture.
• Restricted or painful motion of the toe joint.
• Pain in the ball of the foot at the base of the affected toe.

Heel Pain

In our pursuit of healthy bodies, pain can be an enemy. In some instances, however, it is of biological benefit. Pain that occurs right after an injury or early in an illness may play a protective role, often warning us about the damage we've suffered.

When we sprain an ankle, for example, the pain warns us that the ligament and soft tissues may be frayed and bruised, and that further activity may cause additional injury.

Pain, such as may occur in our heels, also alerts us to seek medical attention. This alert is of utmost importance because of the many afflictions that contribute to heel pain.

Heel Pain

Heel pain is generally the result of faulty biomechanics (walking gait abnormalities) that place too much stress on the heel bone and the soft tissues that attach to it. The stress may also result from injury, or a bruise incurred while walking, running, or jumping on hard surfaces; wearing poorly constructed footwear; or being overweight.

The heel bone is the largest of the 26 bones in the human foot, which also has 33 joints and a network of more than 100 tendons, muscles, and ligaments. Like all bones, it is subject to outside influences that can affect its integrity and its ability to keep us on our feet. Heel pain, sometimes disabling, can occur in the front, back, or bottom of the heel.

Heel Spurs

A common cause of heel pain is the heel spur, a bony growth on the underside of the heel bone. The spur, visible by X-ray, appears as a protrusion that can extend forward as much as half an inch. When there is no indication of bone enlargement, the condition is sometimes referred to as "heel spur syndrome."

Heel spurs result from strain on the muscles and ligaments of the foot, by stretching of the long band of tissue that connects the heel and the ball of the foot, and by repeated tearing away of the lining or membrane that covers the heel bone. These conditions may result from biomechanical imbalance, running or jogging, improperly fitted or excessively worn shoes, or obesity.

Disease and Heel Pain

Some general health conditions can also bring about heel pain.

• Rheumatoid arthritis and other forms of arthritis, including gout, which usually manifests itself in the big toe joint, can cause heel discomfort in some cases.
• Heel pain may also be the result of an inflamed bursa (bursitis), a small, irritated sack of fluid; aneuroma (a nerve growth); or other soft-tissue growth. Such heel pain may be associated with a heel spur or may mimic the pain of a heel spur.
• Haglund's deformity ("pump bump") is a bone enlargement at the back of the heel bone, in the area where the achilles tendon attaches to the bone. This sometimes painful deformity generally is the result of bursitis caused by pressure against the shoe and can be aggravated by the height or stitching of a heel counter of a particular shoe.
• Pain at the back of the heel is associated with inflammation of the achilles tendon as it runs behind the ankle and inserts on the back surface of the heel bone. The inflammation is called achilles tendinitis. It is common among people who run and walk a lot and have tight tendons. The condition occurs when the tendon is strained over time, causing the fibers to tear or stretch along its length, or at its insertion on to the heel bone. This leads to inflammation, pain, and the possible growth of a bone spur on the back of the heel bone. The inflammation is aggravated by the chronic irritation that sometimes accompanies an active lifestyle and certain activities that strain an already tight tendon.
• Bone bruises are common heel injuries. A bone bruise or contusion is an inflammation of the tissues that cover the heel bone. A bone bruise is a sharply painful injury caused by the direct impact of a hard object or surface on the foot.

Stress fractures of the heel bone also can occur, although infrequently.

Heel Spur

Patients and doctors often confuse the terms heel spur and plantar fasciitis. While these two diagnoses are related, they are not the same. Plantar fasciitis refers to the inflammation of the plantar fascia--the tissue that forms the arch of the foot. A heel spur is a hook of bone that can form on the heel bone (calcaneus) and is associated with plantar fasciitis.

Who gets heel spurs?

Heel spurs are common in patients who have a history of foot pain caused by plantar fasciitis. In the setting of plantar fasciitis, heel spurs are most often seen in middle-aged men and women, but can be found in all age groups. The heel spur itself is not thought to be the primary cause of pain, rather inflammation and irritation of the plantar fascia is thought to be the primary problem. A heel spur diagnosis is made when an X-ray shows a hook of bone protruding from the bottom of the foot at the point where the plantar fascia is attached to the heel bone.

Why did I get a heel spur?

The plantar fascia is a thick, ligamentous connective tissue that runs from the calcaneus (heel bone) to the ball of the foot. This strong and tight tissue helps maintain the arch of the foot. It is also one of the major transmitters of weight across the foot as you walk or run. That's why tremendous stress is placed on the plantar fascia.

When a patient has plantar fasciitis, the plantar fascia becomes inflamed and degenerative (worn out)--these abnormalities can make normal activities quite painful. Symptoms typically worsen early in the morning after sleep. At that time, the plantar fascia is tight so even simple movements stretch the contracted plantar fascia. As you begin to loosen the plantar fascia, the pain usually subsides, but often returns with prolonged standing or walking.
Heel spurs form in some patients who have plantar fasciitis, and tend to occur in patients who have had the problem for a prolonged period of time. While about 70 percent of patients with plantar fasciitis have a heel spur, X-rays also show about 50 percent of patients with no symptoms of plantar fasciitis also have a heel spur.

Treatment of heel spurs is the same as treatment of plantar fasciitis. Because these problems are related, the treatment is the same. The first step in the treatment of a heel spur is short-term rest and inflammation control. Here are the steps patients should take in order to cure the symptoms of plantar fasciitis and heel spurs:

• Rest
  The first treatment step is avoiding activities that aggravate symptoms. For example, take a few day off jogging or prolonged standing to try to rest the painful foot. Just resting usually helps eliminate the most severe pain, and will allow the inflammation to begin to settle down.
• Apply Ice Packs
  Icing will help diminish some of the symptoms and control the heel pain. Icing is especially helpful after an acute exacerbation of symptoms. 
• Exercises and Stretches
  Exercises and stretches are designed to relax the tissues that surround the heel bone. Some simple exercises, performed in the morning and evening, often help patients feel better quickly.
• Anti-Inflammatory Medications
  Anti-inflammatory medications help control pain and decrease inflammation. Over-the-counter medications are usually sufficient, but prescription options are also available.
• Shoe Inserts
  Shoe inserts are often the key to successful treatment of plantar fasciitis. The shoe inserts often permit patients to continue their routine activities without pain.
• Night Splints
  Night splints are worn to keep the heel stretched out when you sleep. They prevent the arch of the foot from becoming contracted at night, and is hopefully not as painful in the morning

These treatments alone will cure the plantar fasciitis pain in most patients. Be forewarned that the symptoms will not resolve quickly. Most patients find relief within about three months, and over 90 percent within one year.

If the pain does not resolve, an injection of cortisone can decrease the inflammation of plantar fasciitis. However, many physicians do not like to inject cortisone around the heel because potentially serious problems can happen cortisone injections in the heel area. The two problems that cause concern are fat pad atrophy and plantar fascial rupture. Both problems occur in a small percentage of patients, but they can worsen heel pain symptoms.

A new treatment for heel spurs chronic plantar fasciitis is being investigated. This treatment, called extracorporeal shock wave therapy, or ESWT, uses energy pulses to induce microtrauma to the tissue around the heel spur. This microtrauma is thought to induce a tissue repair process by the body. ESWT is recommended in patients who have failed the previously mentioned treatments, and are considering surgical options.

After successful treatment, how can I prevent heel spur pain from coming back?
To prevent the recurrence of heel spur symptoms after treatment, proper fitting footwear is essential. Many people use shoe inserts to relieve pressure over the tender area. Custom orthotics can also be made if there appears to be a problem with the mechanical structure of the foot. It is also important to continue the stretching and exercises. These simple exercises will help maintain the flexibility of the foot and prevent the plantar fasciitis pain from returning.

What if the symptoms of the heel spur do not resolve?
In a small number of cases (usually less than 5 percent), patients may not experience relief after trying the recommendations listed above. It is important that conservative treatments (such as those listed above) be performed for AT LEAST a year before considering surgery. Time is important in curing the pain from heel spurs, and insufficient treatment before surgery may subject you to potential complications from the procedure. If these treatments fail, your doctor may consider an operation to loosen the plantar fascia, called a plantar fascia release.

Because the diagnosis of heel spurs can be confused with tarsal tunnel syndrome (as described earlier), most surgeons advocate performing a tarsal tunnel release (or at least a partial tarsal tunnel release) along with the plantar fascia release. This surgery is about 80 percent successful in relieving pain in the small group of patients who do not improve with conservative treatments.

Source: http://orthopedics.about.com/cs/generalinfo2/a/heelspur.htm

Jones Fractures

Click here for a video presentation about Jones fractures.

LisFranc (Midfoot) Fracture-Dislocation

Click here for a video presentation about LisFranc (midfoot) fracture-dislocation.

Neuromas

Neuromas are enlarged, benign growths of nerves, most commonly between the third and fourth toes. They are caused by bones and other tissue rubbing against and irritating the nerves. Abnormal bone structure or pressure from ill-fitting shoes also can create the condition, which can result in pain, burning, tingling, or numbness between the toes and in the ball of the foot. Conservative treatment can include padding, taping, orthotic devices, and cortisone injections, but surgical removal of the growth is sometimes necessary.

Peroneal Tendon Tears

Click here for a video presentation about peroneal tendon tears.

Plantar Fasciitis

Both heel pain and heel spurs are frequently associated with an inflammation of the band of fibrous connective tissue (fascia) running along the bottom (plantar surface) of the foot, from the heel to the ball of the foot. The inflammation is called plantar fasciitis. It is common among athletes who run and jump a lot, and it can be quite painful.

The condition occurs when the plantar fascia is strained over time beyond its normal extension, causing the soft tissue fibers of the fascia to tear or stretch at points along its length; this leads to inflammation, pain, and possibly the growth of a bone spur where it attaches to the heel bone.

The inflammation may be aggravated by shoes that lack appropriate support, especially in the arch area, and by the chronic irritation that sometimes accompanies an athletic lifestyle.

Resting provides only temporary relief. When you resume walking, particularly after a night's sleep, you may experience a sudden elongation of the fascia band, which stretches and pulls on the heel. As you walk, the heel pain may lessen or even disappear, but that may be just a false sense of relief. The pain often returns after prolonged rest or extensive walking.

Posterior Tibial Tendon Dysfunction (PTTD)

Click here for a video presentation about Posterior Tibial Tendon Dysfunction (PTTD).

Toenail Disorders

Barometers of Health

Toenails often serve as barometers of our health; they are diagnostic tools providing the initial signal of the presence or onset of systemic diseases. For example, the pitting of nails and increased nail thickness can be manifestations of psoriasis. Concavity—nails that are rounded inward instead of outward—can foretell iron deficiency anemia. Some nail problems can be conservatively treated with topical or oral medications while others require partial or total removal of the nail. Any discoloration or infection on or about the nail should be evaluated by a podiatric physician.

Nail Ailments

Ingrown Toenails
Ingrown nails, the most common nail impairment, are nails whose corners or sides dig painfully into the soft tissue of nail grooves, often leading to irritation, redness, and swelling. Usually, toenails grow straight out. Sometimes, however, one or both corners or sides curve and grow into the flesh. The big toe is usually the victim of this condition but other toes can also become affected.

Ingrown toenails may be caused by:

• Improperly trimmed nails (Trim them straight across, not longer than the tip of the toes. Do not round off corners. Use toenail clippers.)
• Heredity
• Shoe pressure; crowding of toes
• Repeated trauma to the feet from normal activities

If you suspect an infection due to an ingrown toenail, immerse the foot in a warm salt water soak, or a basin of soapy water, then apply an antiseptic and bandage the area.

People with diabetes, peripheral vascular disease, or other circulatory disorders must avoid any form of self treatment and seek podiatric medical care as soon as possible.

Other "do-it-yourself" treatments, including any attempt to remove any part of an infected nail or the use of over-the-counter medications, should be avoided. Nail problems should be evaluated and treated by your podiatrist, who can diagnose the ailment, and then prescribe medication or another appropriate treatment.

A podiatrist will resect the ingrown portion of the nail and may prescribe a topical or oral medication to treat the infection. If ingrown nails are a chronic problem, your podiatrist can perform a procedure to permanently prevent ingrown nails. The corner of the nail that ingrows, along with the matrix or root of that piece of nail, are removed by use of a chemical, a laser, or by other methods.

Fungal Nails
Fungal infection of the nail, or onychomycosis, is often ignored because the infection can be present for years without causing any pain. The disease is characterized by a progressive change in a toenail's quality and color, which is often ugly and embarrassing.

In reality, the condition is an infection underneath the surface of the nail caused by fungi. When the tiny organisms take hold, the nail often becomes darker in color and foul smelling. Debris may collect beneath the nail plate, white marks frequently appear on the nail plate, and the infection is capable of spreading to other toenails, the skin, or even the fingernails. If ignored, the infection can spread and possibly impair one's ability to work or even walk. This happens because the resulting thicker nails are difficult to trim and make walking painful when wearing shoes. Onychomycosis can also be accompanied by a secondary bacterial or yeast infection in or about the nail plate.

Because it is difficult to avoid contact with microscopic organisms like fungi, the toenails are especially vulnerable around damp areas where people are likely to be walking barefoot, such as swimming pools, locker rooms, and showers, for example. Injury to the nail bed may make it more susceptible to all types of infection, including fungal infection. Those who suffer from chronic diseases, such as diabetes, circulatory problems, or immune-deficiency conditions, are especially prone to fungal nails. Other contributing factors may be a history of athlete's foot and excessive perspiration.

Prevention

• Proper hygiene and regular inspection of the feet and toes are the first lines of defense against fungal nails.
• Clean and dry feet resist disease.
• Washing the feet with soap and water, remembering to dry thoroughly, is the best way to prevent an infection.
• Shower shoes should be worn when possible in public areas.
• Shoes, socks, or hosiery should be changed more than once daily.
• Toenails should be clipped straight across so that the nail does not extend beyond the tip of the toe.
• Wear shoes that fit well and are made of materials that breathe.
• Avoid wearing excessively tight hosiery, which promote moisture.
• Socks made of synthetic fiber tend to "wick" away moisture faster than cotton or wool socks.
• Disinfect instruments used to cut nails.
• Disinfect home pedicure tools.
• Don't apply polish to nails suspected of infection—those that are red, discolored, or swollen, for example.

Treatment of Fungal Nails
Treatments may vary, depending on the nature and severity of the infection. A daily routine of cleansing over a period of many months may temporarily suppress mild infections. White markings that appear on the surface of the nail can be filed off, followed by the application of an over-the-counter liquid antifungal agent. However, even the best over-the-counter treatments may not prevent a fungal infection from coming back.
A podiatric physician can detect a fungal infection early, culture the nail, determine the cause, and form a suitable treatment plan, which may include prescribing topical or oral medication, and debridement (removal of diseased nail matter and debris) of an infected nail.
Newer oral antifungals, approved by the Food and Drug Administration, may be the most effective treatment. They offer a shorter treatment regimen of approximately three months and improved effectiveness. Podiatrists may also prescribe a topical treatment for onychomycosis, which can be an effective treatment modality for fungal nails.
In some cases, surgical treatment may be required. Temporary removal of the infected nail can be performed to permit direct application of a topical antifungal. Permanent removal of a chronically painful nail that has not responded to any other treatment permits the fungal infection to be cured and prevents the return of a deformed nail.
Trying to solve the infection without the qualified help of a podiatric physician can lead to more problems. With new technical advances in combination with simple preventive measures, the treatment of this lightly regarded health problem can often be successful.

Nail Care Tips

• Proper hygiene and regular inspection of the feet and toes are the first lines of defense against fungal nails.
• Clean and dry feet resist disease.
• Washing the feet with soap and water, remembering to dry thoroughly, is the best way to prevent an infection.
• Shower shoes should be worn when possible in public areas.
• Shoes, socks, or hosiery should be changed more than once daily.
• Toenails should be clipped straight across so that the nail does not extend beyond the tip of the toe.
• Wear shoes that fit well and are made of materials that breathe.
• Avoid wearing excessively tight hosiery, which promote moisture.
• Socks made of synthetic fiber tend to "wick" away moisture faster than cotton or wool socks.
• Disinfect instruments used to cut nails.
• Disinfect home pedicure tools.
• Don't apply polish to nails suspected of infection—those that are red, discolored, or swollen, for example.

Your podiatric physician/surgeon has been trained specifically and extensively in the diagnosis and treatment of all manner of foot conditions. This training encompasses all of the intricately related systems and structures of the foot and lower leg including neurological, circulatory, skin, and the musculoskeletal system, which includes bones, joints, ligaments, tendons, muscles, and nerves.

Turf Toe (Sesamoiditis)

Click here for a video presentation about turf toe (sesamoiditis).

Warts

Warts are caused by a virus, which enters the skin through small cuts and infects the skin. Children, especially teenagers, tend to be more susceptible to warts than adults. Most warts are harmless and benign, even though painful and unsightly. Warts often come from walking barefooted on dirty surfaces or littered ground. There are several simple procedures which your podiatric physician might use to remove warts.