Foot disorders

A variety of disorders can affect the feet. A bunion is an abnormal enlargement of the joint (the first metatarsophalangeal joint, or MTPJ) at the base ofthe great or big toe (hallux). It is caused by inflammation and usually results from chronic irritation and pressure from poorly fitting footwear.

A corn is a small, painful, raised bump on the outer skin layer. A callus isa rough, thickened patch of skin.

Hammertoe is a condition in which the toe is bent in a claw-like position. Itcan be present in more than one toe but is most common in the second toe.

A heel spur is a bony projection on the sole (plantar) region of the heel bone (also known as the calcaneous). This condition may accompany or result fromsevere cases of inflammation to the structure called plantar fascia. This associated plantar fascia is a fibrous band of connective tissue on the sole ofthe foot, extending from the heel to the toes.

A displacement of two major bones of the foot (hallux valgus) causes bunions,although not everyone with this displacement will develop the joint swellingand bone overgrowth that characterize a bunion. One of the bones involved iscalled the first metatarsal bone. This bone is long and slender, with the big toe attached on one end and the other end connected to foot bones closer tothe ankle. This foot bone is displaced in the direction of the four other metatarsals connected with the toes. The other bone involved is the big toe itself, which is displaced toward the smaller toes. As the big toe continues tomove toward the smaller toes, it may become displaced under or over the second toe. The displacement of these two foot bones causes a projection of bone on the inside portion of the forefoot. The skin over this projection often becomes inflamed from rubbing against the shoe, and a callus may form.

The joint contains a small sac (bursa) filled with fluid that cushions the bones and helps the joint to move smoothly. When a bunion forms, this sac becomes inflamed and thickened. The swelling in the joint causes additional pain and pressure in the toe.

Bunions may form as a result of abnormal motion of the foot during walking orrunning. One common example of an abnormal movement is an excessive amount of stress placed upon the inside of the foot. This leads to friction and irritation of the involved structures. Age has also been noted as a factor in developing bunions, in part because the underlying bone displacement worsens overtime unless corrective measures are taken.

Wearing improperly fitting shoes, especially those with a narrow toe box andexcessive heel height, often causes the formation of a bunion. This forefootdeformity is seen more often in women than men. The higher frequency in females may be related to the strong link between footwear fashion and bunions. Infact, in a recent survey of more than 350 women, nearly 90% wore shoes thatwere at least one size too small or too narrow.

Because genetic factors can predispose people to the hallux valgus bone displacement, a strong family history of bunions can increase the likelihood of developing this foot disorder. Various arthritic conditions and several geneticand neuromuscular diseases, such as Down syndrome and Marfan syndrome, cause muscle imbalances that can create bunions from displacement ofthe first metatarsal and big toe. Other possible causes of bunions are leg-length discrepancies, with the bunion present on the longer leg, and trauma occurring to the joint of the big toe.

Symptoms of bunions include the common signs of inflammation such as redness,swelling, and pain. The discomfort is primarily located along the inside ofthe foot just behind the big toe. Because of friction, a callus may develop over the bunion. If an overlapping of the toes is allowed, additional rubbingand pain occurs. Inflammation of this area causes a decrease in motion with associated discomfort in the joint between the big toe and the first metatarsal. If allowed to worsen, the skin over the bunion may break down causing an ulcer, which also presents a problem of potential infection. (Foot ulcers canbe particularly dangerous for people with diabetes, who may have trouble feeling the ulcer forming and healing if it becomes infected.)

A thorough medical history and physical exam by a physician is always necessary for the proper diagnosis of bunions and other foot conditions. X rays canhelp confirm the diagnosis by showing the bone displacement, joint swelling,and, in some cases, the overgrowth of bone that characterizes bunions. Doctors will also consider the possibility that the joint pain is caused by or complicated by arthritis (which causes destruction of the cartilage of the joint), gout (which causes the accumulation of uric acid crystals in the joint), tiny fractures of a bone in the foot (stress fractures), or infection and may order additional tests to rule out these possibilities.

The first step in treating a bunion is to remove as much pressure from the area as possible. People with bunions should wear shoes that have enough room in the toe box to accommodate the bunion and avoid high-heeled shoes and tight-fitting socks or stockings. Dressings and pads help protect the bunion fromadditional shoe pressure. The application of splints or customized shoe inserts (orthotics) to correct the alignment of the big toe joint is effective formany bunions. Most patients are instructed to rest or choose exercises thatput less stress on their feet, at least until the misalignment is corrected.In some cases, physicians also use steroid injections with local anesthetic around the bunion to reduce inflammation.

If conservative treatment is not successful, surgical removal of the bunion may be necessary to correct the deformity. This procedure is called a bunionectomy, and there are many variations on the operation, which is usually performed by a surgeon who specializes in treating bone conditions (orthopedics) orby one who specializes in treating the foot (podiatry). Surgeons consider the angle of the bone misalignment, the condition of the bursa, and the strength of the bones when they choose which procedure to use. Most bunionectomies involve the removal of a section of bone and the insertion of pins to rejoin the bone. Sometimes the surgeons may move ligaments (which connect bone to bone in the joint) or tendons (which connect bone to muscle) in order to realignthe bones. After this procedure, the bones and other tissues are held in place while they heal by compression dressings or a short cast. The individual must refrain from vigorous exercise for six weeks.

Often, modifications in footwear allow a good prognosis without surgery. If surgery is necessary, complete healing without complications requires approximately four to six weeks. Even after surgery corrects the bone misalignment, patients are usually instructed to continue wearing low-heeled, roomy shoes toprevent the bunion from reforming.

Corns and calluses are one of the three major foot problems in the United States. The other two are foot infections and toenail problems. Corns and calluses affect about 5% of the population.

Corns usually appear on non-weight-bearing areas like the outside of the little toe or the tops of other toes. Women have corns more often than men, probably because women wear high-heeled shoes and other shoes that do not fit properly. Corns have hard cores shaped like inverted pyramids. Sharp pain occurswhenever downward pressure is applied, and a dull ache may be felt at other times.

A hard corn is a compact lump with a thick core. Hard corns usually form on the tops of the toes, on the outside of the little toe, or on the sole of thefoot.

A soft corn is a small, inflamed patch of skin with a smooth center. Soft corns usually appear between the toes.

A seed corn is the least common type of corn. Occurring only on the heel or ball of the foot, a seed corn consists of a circle of stiff skin surrounding aplug of cholesterol.

Calluses occur most often on the heels and balls of the feet, the knees, andthe palms of the hands. However, they can develop on any part of the body that is subject to repeated pressure or irritation. Calluses are usually more than an inch wide--larger than corns. They generally don't hurt unless pressureis applied.

A plantar callus, a callus that occurs on the sole of the foot, has a white center. Hereditary calluses develop where there is no apparent friction, run in families, and occur most often in children.

Corns and calluses form to prevent injury to skin that is repeatedly pinched,rubbed, or irritated. The most common causes are:

  • Shoes that are tootight or too loose, or have very high heels
  • Tight socks or stockings
  • Deformed toes
  • Walking down a long hill, or standing or walking on a hard surface for a long time.

Jobs or hobbies that cause steady or recurring pressure on the same spot canalso cause calluses.

Corns can be recognized on sight. A family physician or podiatrist may scrapeskin off what seems to be a callus, but may actually be a wart. If the lesion is a wart, it will bleed. A callus will not bleed, but will reveal anotherlayer of dead skin.

Corns and calluses do not usually require medical attention, unless the person who has them has diabetes mellitus, poor circulation, or other problems that make self-care difficult.

Treatment should begin as soon as an abnormality appears. The first step is to identify and eliminate the source of pressure. Placing moleskin pads over corns can relieve pressure, and large wads of cotton, lamb's wool, or moleskincan cushion calluses.

Using hydrocortisone creams or soaking feet in a solution of Epsom salts andvery warm water for at least five minutes a day before rubbing the area witha pumice stone will remove part or all of some calluses. Rubbing corns just makes them hurt more.

Applying petroleum jelly or lanolin-enriched hand lotion helps keep skin soft, but corn-removing ointments that contain acid can damage healthy skin. Theyshould never be used by pregnant women or by people who are diabetic or whohave poor circulation.

It is important to see a doctor if the skin of a corn or callus is cut, because it may become infected. If a corn discharges pus or clear fluid, it is infected. A family physician, podiatrist, or orthopedist may:

  • Remove (debride) affected layers of skin
  • Prescribe oral antibiotics to eliminate infection
  • Drain pus from infected corns
  • Inject cortisoneinto the affected area to decrease pain or inflammation
  • Perform surgery to correct toe deformities or remove bits of bone.

Most corns and calluses disappear about three weeks after the pressure that caused them is eliminated. They are apt to recur if the pressure returns.

Bursitis, a painful, inflamed fluid-filled sac, can develop beneath a corn. An ulcer or broken area within a corn can reach to the bone. Infection can have serious consequences for people who have diabetes or poor circulation.

Hammertoe is described as a deformity in which the toes bend downward with the toe joint usually enlarged. Over time, the joint enlarges and stiffens as it rubs against shoes. Other foot structures involved include the overlying skin and blood vessels and nerves connected to the involved toes.

The shortening of tendons responsible for the control and movement of the affected toe or toes cause hammertoe. Top portions of the toes become callused from the friction produced against the inside of shoes. This common foot problem often results from improper fit of footwear. This is especially the case with high-heeled shoes placing pressure on the front part of the foot that compresses the smaller toes tightly together. The condition frequently stems from muscle imbalance, and usually leaves the affected individual with impairedbalance.

A thorough medical history and physical exam by a physician is always necessary for the proper diagnosis of hammertoe. X rays can help to confirm the diagnosis.

Wearing proper footwear and stockings with plenty of room in the toe region can provide treatment for hammertoe. Stretching exercises may be helpful in lengthening the excessively tight tendons.

In advanced hammertoe cases, where conservative treatment is unsuccessful, surgery may be recommended. The tendons that attach to the involved toes are located and an incision is made to free the connective tissue to the foot bones. Additional incisions are made so the toes no longer bend in a downward fashion. The middle joints of the affected toes are connected together permanently with surgical hardware such as pins and wire sutures. The incision is thenclosed with fine sutures. These sutures are removed approximately seven to ten days after surgery.

Heel spurs are a common foot problem resulting from excess bone growth on theheel bone. The bone growth is usually located on the underside of the heel bone, extending forward to the toes. One explanation for this excess production of bone is a painful tearing of the plantar fascia connected between the toes and heel. This can result in either a heel spur or an inflammation of theplantar fascia, medically termed plantar fascitis. Because this condition isoften correlated to a decrease in the arch of the foot, it is more prevalentafter the age of six to eight years, when the arch is fully developed.

One frequent cause of heel spurs is an abnormal motion and mal-alignment of the foot called pronation. For the foot to function properly, a certain degreeof pronation is required. This motion is defined as an inward action of thefoot, with dropping of the inside arch as one plants the heel and advances the weight distribution to the toes during walking. When foot pronation becomesextreme from the foot turning in and dropping beyond the normal limit, a condition known as excessive pronation creates a mechanical problem in the foot.In some cases the sole or bottom of the foot flattens and becomes unstable because of this excess pronation, especially during critical times of walkingand athletic activities. The portion of the plantar fascia attached into theheel bone or calcaneous begins to stretch and pull away from the heel bone.

At the onset of this condition, pain and swelling become present, with discomfort particularly noted as pushing off with the toes occurs during walking. This movement of the foot stretches the fascia that is already irritated and inflamed. If this condition is allowed to continue, pain is noticed around theheel region because of the newly formed bone, in response to the stress. This results in the development of the heel spur. It is common among athletes and others who run and jump a significant amount.

An individual with the lower legs angulating inward, a condition called genuvalgus or "knock knees," can have a tendency toward excessive pronation. As aresult, this too can lead to a fallen arch resulting in plantar fascitis andheel spurs. Women tend to have more genu valgus than men do. Heel spurs canalso result from an abnormally high arch.

Other factors leading to heel spurs include a sudden increase in daily activities, an increase in weight, or a change of shoes. Dramatic increase in training intensity or duration may cause plantar fascitis. Shoes that are too flexible in the middle of the arch or shoes that bend before the toe joints willcause an increase in tension in the plantar fascia and possibly lead to heelspurs.

The pain this condition causes forces an individual to attempt walking on hisor her toes or ball of the foot to avoid pressure on the heel spur. This canlead to other compensations during walking or running that in turn cause additional problems to the ankle, knee, hip, or back.

Heel spurs and plantar fascitis are usually controlled with conservative treatment. Early intervention includes stretching the calf muscles while avoidingre-injuring the plantar fascia. Decreasing or changing activities, losing excess weight, and improving the proper fitting of shoes are all important measures to decrease this common source of foot pain. Modification of footwear includes shoes with a raised heel and better arch support. Shoe orthotics recommended by a healthcare professional are often very helpful in conjunction with exercises to increase strength of the foot muscles and arch. The orthotic prevents excess pronation and lengthening of the plantar fascia and continuedtearing of this structure. To aid in this reduction of inflammation, applyingice for 10 to 15 minutes after activities and use of anti-inflammatory medication can be helpful. Physical therapy can be beneficial with the use of heatmodalities, such as ultrasound, that create a deep heat and reduce inflammation. If the pain caused by inflammation is constant, keeping the foot raisedabove the heart and/or compressed by wrapping with an ace bandage will help.

Corticosteroid injections are also frequently used to reduce pain andinflammation. Taping can help speed the healing process by protecting the fascia from reinjury, especially during stretching and walking.

When chronic heel pain fails to respond to conservative treatment, surgical treatment may be necessary. Heel surgery can provide relief of pain and restore mobility. The type of procedure used is based on examination and usually consists of releasing the excessive tightness of the plantar fascia, called a plantar fascia release. Depending on the presence of excess bony build up, theprocedure may or may not include removal of heel spurs. Similar to other surgical interventions, there are various modifications and surgical enhancements regarding surgery of the heel.

Usually, heel spurs are curable with conservative treatment. If not, heel spurs are curable with surgery. About 10% of those that continue to see a physician for plantar fascitis have it for more than a year. If there is limited success after approximately one year of conservative treatment, patients are often advised to have surgery.

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