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Foot Pain: High Arches and Flat Feet

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• Introduction
• Causes
• Risk Factors
• Prevention
• Shoes
• Insoles and Orthotics
• Foot Injury Treatment
• Toe Pain
• Forefoot Pain
• Heel Pain
• Arch Pain
• Resources

Description

An in-depth report on the causes, diagnosis, treatment, and prevention of


foot pain.

Alternative Names

Bunions; Corns; Hammertoe; Plantar Fasciitis

Arch Pain

Tarsal tunnel syndrome results from compression of a nerve that runs through
a narrow passage behind the inner ankle bone down to the heel. It can cause
pain anywhere along the bottom of the foot. It is often associated with
diabetes, back pain, or arthritis. It may also be caused by injury to the ankle
or by a growth, abnormal blood vessels, or scar tissue that press against the
nerve. Magnetic resonance (MR) imaging and the dorsiflexion-eversion test are
being used to diagnose this syndrome.

Treatment for Tarsal Tunnel Syndrome. Pain from tarsal tunnel syndrome may
be relieved by treatment with orthotics, specially designed shoe inserts, to
help redistribute weight and take pressure off the nerve. Corticosteroid
injections may also help. Surgery is sometimes performed, particularly if
symptoms persist for more than a year, although its benefits are under some
debate. Tarsal tunnel syndrome caused by known conditions, such as tumors or
cysts, may respond better to surgery than when the cause is not known.
Recovery from this surgery can take months before a person can resume
normal activity. It should only be performed by experienced surgeons.

Flat Feet

Flat feet, or pes planus, are a defect of the foot that eliminates the arch.
The condition is most often inherited. Arches, however, can also fall in
adulthood, in which case the condition is sometimes referred to as posterior
tibial tendon dysfunction (PTTD). This occurs most often in women over 50 but
it can occur in anyone. The following are risk factors for PTTD:

• Wearing high heels for long periods of time is a particular risk for flat
feet. In such cases, over the years, the Achilles tendon in the back of
the calf shortens and tightens, so the ankle does not bend properly. The
tendons and ligaments running through the arch then try to compensate.
Sometimes they break down and the arch falls.
• Some studies have indicated that the earlier one starts wearing shoes,
particularly for long periods of the day, the higher the risk for flat
feet later on.
• Other conditions that can lead to flat feet or PTTD include obesity,
diabetes, surgery, injury, rheumatoid arthritis, or use of
corticosteroids.

Some research suggests that flat feet in adults can, over time, actually exert
abnormal pressure on the ankle joint that can cause damage. One indirect
complication of flat arches may be urinary incontinence or leakage during
exercise. The less flexible the arch, the more force reaches the pelvic floor,
jarring the muscles that affect urinary continence. Nevertheless, whether flat
feet pose any significant problems in adults is unknown. For example, a 2002
study on athletes with flat feet indicated that they had no higher risk for leg
or foot injuries than athletes with normal arches.

Treatment for Flat Feet in Children. Children with flat feet often outgrow
them, particularly tall, slender children with flexible joints. One expert
suggests that if an arch forms when the child stands on tip-toes, then the
child will probably outgrow the condition.

Treatment for Flat Feet in Adults. In general, conservative treatment for flat
feet acquired in adulthood (posterior tibial tendon dysfunction) involves pain
relief and insoles or custom-made orthotics to support the foot and prevent
progression.

In severe cases, surgery may be required to correct the foot posture, usually
with procedures called osteotomies or arthrodesis, which typically lengthen the
Achilles tendon and adjusting tendons in the foot. One procedure uses an
implant to support the arch. These procedures have potential complications and
conservative methods should be tried first.

Abnormally High Arches

An overly-high arch (hollow foot) can cause problems. Army studies have found
that recruits with the highest arches have the most lower-limb injuries and
that flat-footed recruits have the least. Contrary to the general impression,
the hollow foot is much more common than the flat foot.

Clawfoot, or pes cavus, is a deformity of the foot marked by very high arches
and very long toes. Clawfoot is a hereditary condition, but can also occur when
muscles in the foot contract or become unbalanced due to nerve or muscle
disorders.
Claw toe is a deformity of the foot in which the toes are pointed down and
the arch is high, making the foot appear claw-like. Claw toe can be a condition
from birth or develop as a consequence from other disorders.

Foot pain

Highlights

Overview

Foot pain is a very common problem. About 75% of people in the U.S. have
foot pain at some time in their lives. Most foot pain is caused by shoes that
do not fit properly or force the feet into unnatural shapes (such as pointed-
toe, high-heel shoes).

The force exerted on the foot with each step is about 50% greater than the
persons body weight. In a typical day, the feet support several hundred tons.

The elderly have a very high incidence of foot pain, reported at 87% in one
study.

Shoe Size Changes


Wearing correctly sized shoes could cure many foot pain problems. Feet
change in size during the day (larger late in the day) and with the weather
(smaller during cold weather). In addition, the size and shape of feet change
with age. Older people should not assume they wear the same size shoe as
when they were younger. Before buying new shoes, they should have their feet
measured.

Diabetic Foot Problems

Most hospitalizations of people with diabetes are due to foot problems.


Several factors commonly affecting diabetic patients can cause serious foot
problems, such as poor circulation that inhibits wound healing and nerve
problems leading to decreased sensation in the feet and legs.

According to the American Diabetes Association, about 82,000 lower


extremity amputations related to diabetes were performed in 2002. The
incidence of amputation among people with diabetes is 10 times that of people
who do not have the condition. However, vigilant foot care could reduce the
risk of amputation by 44 - 85%.

Foot Injuries

Foot injuries are very common and often result from athletic activities. It is
important to wear the right shoe for the specific sport. For example, a
running shoe that is cushioned may not offer the support necessary for playing
tennis.

Many foot injuries can be treated by the individual without a doctors care.
Injuries such as sprains and strains can benefit from the RICE treatment:
Rest, Ice, Compression, and Elevation.

Introduction

The foot is a complex structure of 26 bones and 33 joints, layered with an


intertwining web of over 120 muscles, ligaments, and nerves. It serves the
following functions:

• Supports weight
• Acts as a shock absorber
• Serves as a lever to propel the leg forward
• Helps to maintain balance by adjusting the body to uneven surfaces

Since the feet are very small compared with the rest of the body, the impact
of each step exerts tremendous force upon them. This force is about 50%
greater than the person's body weight. During a typical day, people spend
about 4 hours on their feet and take 8,000 - 10,000 steps. This means that
the feet support a combined force equivalent to several hundred tons every
day.

About Foot Pain

Given what the foot must endure, it is not surprising that about 75% of
Americans experience foot pain at some point in their lives. According to one
study, chronic and severe foot pain is a serious burden for one in seven older
disabled women. To compound problems, the lower back is often affected by
injuries or abnormalities in the feet.

Foot pain is generally defined by one of three sites of origin: the toes, the
forefoot, and the hindfoot.

The Toes. Toe problems most often occur because of the pressure imposed by
ill-fitting shoes.

The Forefoot. The forefoot is the front of the foot. Pain originating here
usually involves one of the following bone groups:

• The metatarsal bones (five long bones that extend from the front of
the arch to the bones in the toe)
• The sesamoid bones (two small bones embedded at the top of the first
metatarsal bone, which connects to the big toe)

The Hindfoot. The hindfoot is the back of the foot. Pain originating here can
extend from the heel, across the sole (known as the plantar surface), to the
ball of the foot (the metatarsophalangeal joint).

Foot Problems and Their Locations


Condition Location Symptoms Recommended
Footwear
Toe Pain
Corns and Around toes, Hard, dead, yellowish Wide (box-toed)
calluses usually little toe, skin. shoes; soft cushions
bottom of feet under heel or ball of
or areas exposed foot or customized
to friction. or gel insoles for
calluses. Doughnut-
shaped pads for
corns.
Ingrown Toenails. Nail curling into skin Sandals, open-toed
toenails causes pain, swelling, shoes.
and, in extreme
cases, infection.
Bunions and Big toe (bunions) The following can Soft, wide-toed
bunionettes or little toe occur alone or in shoes or sandals.
(tailor's (bunionettes). combination: Bunion shields or
bunion) splints. Thick
Metatarsus primus doughnut-shaped
varus. The first (big moleskin pads,
toe) metatarsal bone custom-made
shifts away from the orthotics or foot
second, and the big slings if necessary.
toe points inward. Avoid shoes with
stitching along the
Medial exostosis. This side of the "bump."
is a bony bump at the
base of the big toe,
which protrudes
outward. Area next to
bony bump is red,
tender, occasionally
filled with fluid. Toe
joint may be inflamed.

Hallux valgus. This is


a deformity in which
the bone and joint of
the big toe shift and
grow inward, so that
the second toe
crosses over it.
Morton's Inflammation of Cramping and burning Wide (box-toed)
neuroma (also the nerve usually pain, or electric- shoes. Orthotic or
called between the shock sensation. The insole with pad that
interdigital third and fourth condition may produce reduces stress on
neuroma) toes and bottom a thick protective the painful area.
of foot near sheath around the
these toes. nerve that feels like a
ball. This may be
detected by pressing
top to bottom on the
top of the foot using
one hand and moving
the other hand from
side to side. Morton's
neuroma is aggravated
by prolonged standing
and relieved by the
removal of the shoes
and forefoot massage.
Hammertoe or Usually second Toes form hammer or Wide (box-toed)
claw toe toe but may claw shape. In shoes. Toe pads or
develop in any or hammertoe, the first specially designed
all of the three knuckle of the toe is shields, splints,
middle toes. mainly affected. In caps, or slings.
claw toe the entire (Splints or slings not
toe is deformed. No for people with
pain at first, diabetes.)
increasing as tendon
becomes tighter and
toes stiffen.
Front-of-the-Foot Pain
Metatarsalgia Ball of the foot. Acute, recurrent, or Wide (box-toed)
chronic pain without a shoes. Orthotic with
known cause. pad that reduces
metatarsal pressure.
Gel cushions.
Metatarsal bandage.
Stress Most often in Sudden pain when Low-heeled shoes
fracture the area beneath injury occurs, which with stiff soles.
the second or persists.
third toe.
Sesamoiditis Ball of foot Pain and swelling. Low-heeled shoe
beneath big toe. with stiff sole and
soft padding inside.
Heel and Back-of-the-Foot Pain
Plantar Back of the arch At onset, some people Over-the-counter
fasciitis or right in front of report a tearing or foot insole (cut
heel spurs heel. popping sound. Pain, quarter-size hole
most severe with first surrounding painful
steps after getting area). Possible night
out of bed, splints. Orthotics if
decreasing after necessary.
stretching, returning
after inactivity.
Bursitis of the Center of the Pain, with warmth and Heel cup.
heel heel. swelling. Increases
during the day.
Haglund's Fleshy area on Tender swelling Soft shoes. Heel
deformity the back of the aggravated by shoes pads. Possible
(pump bump) heel. with stiff backs. orthotic to support
heel.
Achilles Achilles tendon: Pain worsens during Insoles, tendon
tendinitis area along the physical activities strap, heel cups.
back between (particularly running),
calf muscles and after which the
heel. tendon usually swells
and stiffens. If it
ruptures, popping
sound may occur
followed by acute pain
similar to a blow at
the back of the leg.
Arch and Bottom-of-the Foot Pain
Tarsal tunnel Anywhere along Numbness, tingling, or Specially designed
syndrome the bottom of burning sensations, orthotics to relieve
the foot. pain, most commonly pressure.
felt at night.
Flat feet or The arch. No arch. Often no For children,
posterior tibial pain or discomfort. possible custom-
tendon Three stages in made insoles.
dysfunction PTTD:
(PTTD)
Pain and weakness in
the tendon.

The arch flattens but


is still flexible.

The foot becomes


rigid and possibly
painful at the ankle.
Sometimes people
report fatigue, pain,
or stiffness in the
feet, legs, and lower
back.
High arches The arch. High arches. Lower
(hollow feet) back pain, possible
tendency to lower limb
injuries.

Note: These conditions are discussed in detail in this report.

Causes
Nearly all causes of foot pain can be categorized under one or more of the
following conditions:

• Shoes. The causes of most foot pain are poorly fitting shoes. High-
heeled shoes concentrate pressure on the toes and are major culprits
for aggravating, if not causing, problems with the toes. Of interest,
however, was a British study, in which 83% of older women experienced
some foot pain. In the study, 92% of them had worn 2-inch heels at
some point in their lives. Foot problems, however, were significant even
in women who regularly wore lower heels.
• Temporary Changes in Foot Size and Shape. Temperature, and therefore
weather, affects the feet: they contract with cold and expand with
heat. Feet can change in shape and increase in size by as much as 5%
depending on whether a person is walking, sitting, or standing.
• Poor Posture. Improper walking due to poor posture can cause foot pain.
• Medical Conditions. Any medical condition that causes imbalance or poor
circulation can contribute to foot pain.
• Inherited Conditions. Inherited abnormalities in the back, legs, or feet
can cause pain. For example, one leg may be shorter than the other,
causing an imbalance.
• High-Impact Exercising. High-impact exercising, such as jogging or
strenuous aerobics, can injure the feet. Common injuries include corns,
calluses, blisters, muscle cramps, acute knee and ankle injuries, plantar
fasciitis, and metatarsalgia.
• Industrial Cumulative Stress. Because of the effects of work-related
repetitive stress on the hand, there has been considerable interest in
the effect of work-stress on foot pain. According to one 2000 analysis,
there is very little evidence for any significant impact of work on various
foot disorders, including hallux valgus, neuroma, tarsal tunnel syndrome,
toe deformity, heel pain, adult acquired flatfoot, or foot and ankle
osteoarthritis. In general, the foot is designed for repetitive stress,
and few jobs pose the same stress on the feet as many do on the
hands. Nevertheless, certain professions, such as police work, are
associated with significant foot pain. More research is needed.
Medical Conditions Causing Foot Pain

Arthritic Conditions. Arthritic conditions, particularly osteoarthritis and gout,


can cause foot pain. Although rheumatoid arthritis almost always develops in
the hand, the ball of the foot can also be affected.

Diabetes. Diabetes is an important cause of serious foot disorders. (See


table: "Diabetes and Foot Problems.")

Diseases That Affect Muscle and Motor Control. Diseases that affect muscle
and motor control, such as Parkinson's disease, can cause foot problems.

High Blood Pressure. High blood pressure can cause fluid buildup and swollen
feet. The effects of high blood pressure on the nervous and circulatory
systems can cause pain, loss of sensation, and tingling in the feet, and can
increase the susceptibility for infection and foot ulcers.

Blood pressure is the force applied against the walls of the arteries as the
heart pumps blood through the body. The pressure is determined by the force
and amount of blood pumped and the size and flexibility of the arteries.

Obesity. Weight gain can cause foot and ankle problems. According to survey
data presented at the 2005 annual meeting of the American Academy of
Orthopaedic Surgeons, an increased body mass index (BMI) raised the risk for
foot and ankle pain.

Osteoporosis. Osteoporosis, in which bone loss occurs, can cause foot pain.

Click the icon to see an image of osteoporosis.

Pregnancy. Pregnancy can cause fluid buildup and swollen feet. The increased
weight and imbalance of pregnancy contributes to foot stress.

Other Diseases. Diseases that affect the nervous and circulatory systems,
such as anorexia, can cause pain, loss of sensation, and tingling in the feet, as
well as increase the susceptibility for infection and foot ulcers. Several
conditions -- including heart failure, kidney disease, and hypothyroidism --
can cause fluid buildup and swollen feet.

Medications. Some medications, such as calcitonin and drugs used for high
blood pressure, can cause foot swelling.
Diabetes and Foot Problems

Foot problems are the leading cause of hospitalizations for patients with
diabetes. Foot problems develop from problems in the blood vessels and in the
peripheral nervous system (the nerves that reach the limbs). About half of
patients with diabetes have nerve damage (neuropathy), which can cause
numbness, pain, and weakness in the feet or other parts of the body.
Diabetes can also cause changes in the bone structure and soft tissue of the
feet.

• Infections and Ulcers. People with diabetes are at particularly high risk
for infections, such as those resulting from blood vessel injury, which
may be severe enough to cause ulcers in the legs and feet. If an
infection does not heal, it may spread to the bone (called osteomyelitis).
Numbness from nerve damage, which is common in diabetes, compounds
the danger posed by even minor infection since the patient may not be
aware of injuries. Untreated minor infections can easily develop into
severe complications. Poor blood flow in those with diabetes makes it
more difficult for wounds to heal, which can lead to more severe
infections. Being overweight also increases the risk for foot infections.
About one-third of foot ulcers occur on the big toe. Some research
suggests that early risk factors for ulcers here may be problems with
movement in the toe or ankle.
• Charcot Foot. Charcot foot or Charcot joint (medically referred to as
neuropathic arthropathy) is of particular note. Between 1 - 2.5% of
people with diabetes have this condition. It is caused by abnormalities in
the nerves in the feet, which can numb the feet so that the sufferer
does not feel pain at first and is not aware of injury. Instead of resting
an injured foot or seeking medical help, the patient often continues to
walk, causing further damage. Early changes appear like an infection,
with the foot becoming swollen, red, and warm. A seriously affected
foot can become deformed. The bones may crack, splinter, and erode,
and the joints may shift, change shape, and become unstable.
• Risk for Amputations. Extensive surgery may be required, and, in
extreme cases, amputation may be necessary. Diabetes is responsible
for more than half of all the lower limb amputations performed in the
U.S. each year, and every year there are more than 86,000 foot
amputations due to this disease. According to a 2002 study, 25% of
these amputations are performed on the toe, 6% mid-foot, 38% below
the knee, and 21% above the knee. The remaining 10% of amputations
are performed on the hip, pelvis, knee, and other sites.
• Risk for Falling. The numbness caused by nerve damage makes patients
with diabetes four times more likely to fall than those who do not have
the disease.

Prevention of Foot Disorders in Diabetes

Preventive foot care could reduce the risk of amputation in people with
diabetes by 44 - 85%. Some tips for preventing problems include the
following:

• Patients should inspect their feet daily and watch for changes in color
or texture, odor, and firm or hardened areas, which may indicate
infection and potential ulcers.
• When patients wash their feet, the water should be warm (not hot), and
the feet and areas between the toes should be thoroughly dried
afterward. Check water temperature with the hand or a thermometer
before stepping in.
• Moisturizers should be applied, but not between the toes.
• Corns and calluses should be gently pumiced and toenails trimmed short
and the edges filed to avoid cutting adjacent toes. Use an emery board,
not a metal file, to avoid cutting your skin when you file your nails.
• Patients should not use medicated pads or try to shave the corns or
calluses themselves.
• Well-fitting footwear is very important. In a 2001 study, 30% of
diabetes patients wore shoes that were too narrow. Patients should also
avoid high heels, sandals, thongs, and going barefoot. Specific
therapeutic shoes, boots, and insoles do not appear to add advantage
over careful attention and monitoring of the feet. However, people who
are not attentive might do better with such footwear. For example,
custom-molded boots (such as the Conformer Diabetic Boot) are
designed to increase the surface area over which foot pressure is
distributed. This reduces stress on the ulcers and allows them to heal.
Special insoles (such as the Rocker insole) have also been designed to
reduce pressure on the front of the foot.
• Shoes should be changed often during the day.
• Wear socks, particularly with extra padding (which can be purchased).
• Patients should avoid tight stockings or any clothing that constricts the
legs and feet.
• Foot pain, numbness, or tingling is worse at night. Diphenhydramine
(Benadryl) may help.

You should consult a specialist in foot care if you have any problems with your
feet.

Treating Foot Disorders in Diabetes

About one-third of foot ulcers will heal within 20 weeks with good wound care
treatments. Some treatments are as follows:

• Antibiotic therapy. However, research published in 2005 suggests that


long-term antibiotic therapy may not be enough to heal many infections.
• In virtually all cases, wound care requires debridement, the removal of
injured tissue until only healthy tissue remains. Early treatment with
debridement can increase the chances of saving toes and feet from
amputation. Debridement may be done with chemicals (enzymes),
surgery, or irrigation. Hospitalization and intravenous antibiotics for up
to 28 days may be needed for severe foot ulcers.
• Hydrogels (Nu-Gel, Intrasite Gel, Scherisorb, Clearsite, Duoderm,
Geliperm) are proving to be effective in healing ulcers and are
noninvasive and soothing. They should be applied and covered with a
dressing.
• Charcot foot is initially treated with strict immobilization of the foot
and ankle. Some centers use a cast that allows the patient to move and
still protects the foot. A 2001 British study concluded that a single
dose of pamidronate, a bisphosphonate, reduces bone turnover,
symptoms, and disease activity. When the acute phase has passed,
patients usually need lifelong protection of the foot using a brace
initially and custom footwear.
• For diabetic neuropathy, surgical decompression (relief of pressure) of
swollen nerves in the legs and feet can improve sensation and reduce
pain.
Several recent investigative measures include the following:

• A new gene therapy may prevent nerve damage in patients with


diabetes. The therapy stimulates growth of a patients own natural
protein. Because it does not introduce foreign proteins, unlike some
other gene therapies, the therapy does not cause adverse immune
reactions. Initial results are promising. Clinical trials of this new
therapy are currently underway.
• Several treatments that use human skin equivalent or HSE (Dermagraft,
Apligraf, Regranex) are now available. These therapies stimulate new
cell growth and help heal skin ulcers or use cultures of human skin cells.
Studies are showing that HSE promotes healing, and the risk for
rejection of such grafts is low. Adverse effects include infections at
other sites.
• Silver-containing wound dressings (Acticoat, Silverlon) have shown
promise for wound care in some studies due to their anti-microbial
properties, and may provide new avenues for managing diabetic ulcers.
However, one study suggested that silver may be toxic to some cell
types.
• Administering hyperbaric oxygen (oxygen given at high pressure) is
showing promise in promoting healing and preventing amputation.
• Granulocyte-colony stimulating factor, also called G-CSF (filgrastim,
Neupogen, Amgen), is showing promise as an effective alternative to
antibiotics. Studies are reporting that G-CSF accelerates healing and
significantly reduces the need for surgery.
• Total-contact casting (TCC). This approach uses a cast that is designed
to contact the exact contour of the foot and distribute weight along the
entire length of the foot. It is usually changed weekly. In one trial, it
healed ulcers in nearly 90% of selected patients. It is also useful for
Charcot foot.
• A device that compresses the foot (NuPulse) appears to increase
circulation, reduces edema (swelling), and improves wound healing.
• Light therapy called monochromatic near-infrared photo energy (MIRE)
may help reduce pain, improve balance, and improve sensation in the
feet of patients with peripheral neuropathy.
Click the icon to see an image of foot inspection.

Risk Factors

Nearly everyone who wears shoes has foot problems at some point in their
lives. Some people are at particular risk for certain types of pain.

Age

The Elderly. Elderly people are at very high risk for foot problems. In one
study, 87% of older people reported at least one foot problem. Feet widen
and flatten, and the fat padding on the sole of the foot wears down as people
age. Older people's skin is also dryer. Foot pain, in fact, can be the first sign
of trouble in many illnesses related to aging, such as arthritis, diabetes, and
circulatory disease. Foot problems can also impair balance and function in this
age group.

Children. Foot pain is fairly common even in children. Heel pain is common in
very active children ages 8 - 13, when high-impact exercise can irritate
growth centers of the heel.

Gender

Women are at higher risk than men for severe foot pain, probably because of
high-heeled shoes.

Older Women. Severe foot pain appears to be a major cause of general


disability in older women. In a British study of women ages 50 - 70, 83%
reported foot problems. In another study, 14% of older disabled women
reported chronic, severe foot pain, which played a major role in requiring
assistance in walking and in daily activities.

Pregnant Women. Pregnant women have special foot problems from weight gain,
swelling in their feet and ankles, and the release of certain hormones that
cause ligaments to relax. These hormones help when bearing the child but can
weaken feet.

Occupational Risk Factors

An estimated 120,000 job-related foot injuries occur every year, about a


third of them involving the toes. A number of foot problems -- including
arthritis of the foot and ankle, toe deformities, pinched nerves between the
toes, plantar fasciitis, adult acquired flat foot, and tarsal tunnel syndrome --
have been attributed to repetitive use at work.

For example, in a study of New York police officers who walked an average of
3 miles a day, 20% experienced foot pain at the end of their workday.
(Insoles can relieve much of this pain.) No studies, however, have scientifically
distinguished between injuries due to work versus those due to regular use.
This is an important issue because of its potential impact on disability claims.

Sports and Dancing

People who engage in regular high-impact aerobic exercise are at risk for
plantar fasciitis, heel spurs, sesamoiditis, shin splints, Achilles tendon, and
stress fractures. In one study of aerobic dance instructors, for example,
nearly one-third reported injuries in the feet and ankles. Even young athletes
are at risk for stress fracture, particularly if they exercise 6 or 7 days a
week. Women are at higher risk for stress fractures than men are.

Medical and Physical Conditions

Excess Weight. Anyone who is overweight puts increased stress on the feet
and is at risk for foot or ankle injuries.

Diabetes. People with diabetes are at particular risk for severe foot infections
and must take special precautions.

Other Medical Conditions. Many other medical conditions, such as


osteoarthritis, rheumatoid arthritis, and gout, predispose people to foot
problems, as do inherited abnormalities.
Smokers

A 2000 study reported that smokers are at higher risk for blisters, bruises,
sprains, and fractures, most likely because they tend to be less fit than
nonsmokers. They also may heal less quickly, which, some evidence suggests,
affects some foot surgeries.

Prevention

The American Podiatric Medical Association offers the following tips for
preventing foot pain:

• Don't ignore foot pain -- it's not normal. If the pain persists, see a
doctor who specializes in podiatry.
• Inspect feet regularly. Pay attention to changes in color and
temperature of the feet. Look for thick or discolored nails (a sign of
developing fungus), and check for cracks or cuts in the skin. Peeling or
scaling on the soles of feet could indicate athlete's foot. Any growth on
the foot is not considered normal.
• Wash feet regularly, especially between the toes, and be sure to dry
them completely.
• Trim toenails straight across, but not too short. (Cutting nails in corners
or on the sides increases the risk for ingrown toenails.)
• Make sure shoes fit properly. Purchase new shoes later in the day when
feet tend to be at their largest, and replace worn out shoes as soon as
possible.
• Select and wear the right shoe for specific activities (i.e., running shoes
for running).
• Alternate shoes. Don't wear the same pair of shoes every day.
• Avoid walking barefoot, which increases the risk for injury and
infection. At the beach or when wearing sandals always use sunblock on
the feet, as you would on the rest of your body.
• Be cautious when using home remedies for foot ailments. Self-treatment
can often turn a minor problem into a major one.
• It is critical that people with diabetes see a podiatric physician at least
once a year for a checkup. People with diabetes, poor circulation, or
heart problems should not treat their own feet, including toenails,
because they are more prone to infection.
Skin Creams and Foot Baths

Skin creams can help maintain skin softness and pliability. Taking a warm
footbath for 10 minutes two or three times a week will keep the feet relaxed
and help prevent mild foot pain caused by fatigue. Adding 1/2 cup of Epsom
salts increases circulation and adds other benefits. Taking footbaths only when
feet are painful is not as helpful.

A pumice stone or loofah sponge can help get rid of dead skin.

Massage Therapy

Reflexology is a type of massage therapy that manipulates hands and feet. A


pleasant exercise using this method can be done while taking a bath. Use the
thumb, index, and middle finger to rotate each toe in a circular motion. Then,
make a fist and rotate it slowly around the bottom of the foot. Finally, gently
twist each foot as if wringing wet clothes, moving the top and bottom in
opposite directions.

Correct Walking and Foot Exercises

Correct Walking. In addition to wearing proper shoes and socks, walk often
and correctly to prevent foot injury and pain. The head should be erect, the
back straight, and the arms relaxed and swinging freely at the side. Step out
on the heel, move forward with the weight on the outside of the foot, and
complete the step by pushing off the big toe.

Foot Exercises. Exercises specifically for the toe and feet are easy to
perform and help strengthen them and keep them flexible. Helpful exercises
include the following:

• Raise and curl the toes 10 times, holding each position for a count of
five.
• Put a rubber band around both big toes and pull the feet away from
each other. Count to five. Repeat 10 times.
• Pick up a towel with the toes. Repeat five times.
• Pump the foot up and down to stretch the calf and shin muscles.
Perform for 2 or 3 minutes.
Preventing Foot Problems in Childhood

Early Development. The first year of life is important for foot development.
Parents should cover their babies' feet loosely, allowing plenty of opportunity
for kicking and exercise. The child's position should be changed frequently.
Staying too long on the stomach can strain the feet. Children generally walk
between 10 and 18 months. They should not be forced to start walking early.
Wearing just socks or going barefoot indoors helps the foot develop normally
and strongly and allows the toes to grasp. Going barefoot outside, however,
increases the risk for injury and other conditions, such as plantar warts.

Shoes. Children should wear shoes that are light and flexible, and since their
feet perspire greatly, their shoes should be made of materials that breathe.
Footwear should be replaced every few months as the child's feet grow.
Footwear should never be handed down.

Sports. High-impact sports can injure growing feet, and parents should be
sure that their children's feet are protected if they engage in intensive
athletics.

Shoes

In general, the best shoes are well cushioned and have a leather upper, stiff
heel counter, and flexible area at the ball of the foot. The heel area should
be strong and supportive, but not too stiff, and the front of the shoe should
be flexible. New shoes should feel comfortable right away, without a breaking
in period.

Getting the Correct Fit

Well-fitted shoes with a firm sole and soft upper are the best way to prevent
nearly all problems with the feet. They should be purchased in the afternoon
or after a long walk, when the feet have swelled. There should be a 1/2 inch
of space between the longest toe and the tip of the shoe (remember, the
longest toe is not always the big toe), and the toes should be able to wiggle
upward. A person should stand when being measured, and both feet should be
sized, with shoes bought for the larger-sized foot. It is important to wear
the same socks as you would regularly wear with the new shoes. Women who
are accustomed to wearing pointed-toe shoes may prefer the feel of tight-
fitting shoes, but with wear their tastes will adjust to shoes that are less
confining and properly fitted.

The Sole

Ideally, the shoe should have a removable insole. Thin, hard soles may be the
best choice for older people. Elderly people wearing shoes with thick inflexible
soles may be unable to sense the position of their feet relative to the ground,
significantly increasing the risk for falling. Some research suggests that thick
soles may even be responsible for foot injury in younger adults who engage in
high-impact exercise.

The Heel

High heels are the major cause of foot problems in women. Although people
believe that foot binding is a problem limited to Chinese women of the past,
many fashionable high heels are designed to constrict the foot by up to an
inch. Women who insist on wearing high-heeled shoes should at least look for
shoes with wide toe room, reinforced heels that are relatively wide, and
cushioned insoles. They should also keep the amount of time they spend
wearing high heels to a minimum.

Laces

The way shoes are laced can be important for preventing specific problems.
Laces should always be loosened before putting shoes on. People with narrow
feet should buy shoes with eyelets farther away from the tongue than people
with wider feet. This makes for a tighter fit for narrower feet and looser for
wider. If, after tying the shoe, less than an inch of tongue shows, then the
shoes are probably too wide. Tightness should be adjusted both at the top of
the shoe and at the bottom. Where high arches cause pain, eyelets should be
skipped to relieve pressure.

Breaking in and Wearing the Shoes

If shoes do require breaking in, moleskin pads should be placed next to areas
on the skin where friction is likely to occur. Once a blister occurs, moleskin is
not effective. Shoes should be changed during the day and rotated in their
use. As soon as the heels show noticeable wear, the shoes or their heels
should be replaced.

Special-Purpose Footwear

People should avoid extreme variations between their exercise, street, and
dress shoes.

Exercise and Sports. Shoes purchased for exercise should be specifically


designed for a person's preferred sport. For instance, a running shoe should
especially cushion the forefoot, while tennis shoes should emphasize ankle
support. Athletic socks are almost as important as shoes. Experts often
recommend padded acrylic socks.

Occupational Footwear. Because a number of occupations put the feet in


danger, workers in high-risk jobs should be sure their footwear is protective.
For example, non-electric workers at risk for falling or rolling objects or
punctures should wear shoes with steel toes and possibly other metal foot
guards. Electric workers should wear footgear with no metal parts (or
insulated steel toes) and rubber soles and heels. Chemical workers should wear
shoes made of synthetics or rubber, not leather.

Shoes for Sports


Aerobic Sufficient cushioning to absorb shock and pressure, which should be
Dancing many times greater than shock from walking. Arches that maintain
side-to-side stability. Thick upper leather support. Box-toe.
Orthotics may be required for people with ankles that over-turn
inward or outward. Soles should allow for twisting and turning.
Cycling Rigid support across the arch to prevent collapse during pedaling.
Heel lift. Cross-training or combo hiking/cycling shoes may be
sufficient for the casual biker. Toe clips or specially designed shoe
cleats for serious cyclers. In some cases, orthotics may be needed
to control arch and heel and balance forefoot.
Running Sufficient cushioning to absorb shock and pressure. Fully bendable
at the ball of the foot. Sufficient traction on sole to prevent
slipping. Consider insole or orthotic with arch support for problem
feet.
Tennis Allows side-to-side sliding. Low-traction sole. Snug fitting heel with
cushioning. Padded toe box with adequate depth. Soft-support arch.
Walking Lightweight. Breathable upper material (leather or mesh). Wide
enough to accommodate ball of the foot. Firm padded heel counter
that does not bite into heel or touch anklebone. Low heel close to
ground for stability. Good arch support. Front provides support and
flexibility.

Cosmetic Foot Surgery

Taking fashion to extreme limits, some women have turned to cosmetic surgery
as a drastic way to fit into high-heel shoes. Procedures include surgical
shortening of the toes, narrowing of feet, or injecting silicone into the pads
of feet. The American Orthopaedic Foot and Ankle Society (AOFAS) and
other medical podiatric associations have expressed concern over this
apparently growing trend. The AOFAS strongly advises against cosmetic foot
surgery and urges consumers to carefully consider the relative risks and
benefits of undergoing unnecessary surgical procedures.

Insoles and Orthotics

Insoles are flat cushioned inserts that are placed inside the shoe. They are
designed to reduce shock, provide support for heels and arches, and absorb
moisture and odor. In general, they can be very helpful for many people. For
example, in a study of foot pain in New York police officers, more than 60%
of them reported more comfort and less foot pain after using insoles. People
respond very differently to specific insoles. What may work for one person
may not for another. The thickness of socks must be considered when
purchasing insoles to be sure they do not squeeze the toes up against the
shoes.

Purchasing Insoles. Insoles can be purchased in athletic and drug stores. Shoe
stores that specialize in foot problems often sell customized, but more
expensive, insoles. In general, over-the-counter insoles offer enough support
for most people's foot problems. Most well-known brands of athletic shoes
have built-in insoles.

Brands and Materials. There are many types of insoles available. They are
composed of various materials, such as cork, leather, plastic foams, and
rubber materials. Very beneficial insoles are now made from viscoelastic
polymers (such as Sorbothane, Airplus, Spenco, Dr. Scholl's Massaging Gel,
and others), which are gel-like materials that act both as liquids and solids.
In a 1999 military study comparing Sorbothane with foam insoles, Sorbothane
offered better protection against heel strikes while marching and running.

Heel Cushions for Shortened Achilles Tendons. People who have developed
short, tightened Achilles tendons, usually women who have worn high-heeled
shoes for prolonged periods, should consider using heel cushions. Like insoles,
heel cushions are inserted inside the shoes. They should be at least 1/8 inch
thick, but not more than 1/4 inch thick.

Orthotics

For severe conditions, such as fallen arches or structural problems that cause
imbalance, podiatrists or physicians may need to fit and prescribe orthotics,
or orthoses, which are insoles molded from a plaster cast of the patient's
foot. Orthotics are usually categorized as rigid, soft, or semi-rigid.

Rigid Orthotics. Rigid orthotics are used to control motion in two major foot
joints that lie directly below the ankle. They are often used to prevent
excessive pronation (the turning in of the foot) and are useful for people who
are very overweight or have uneven leg lengths. Some experts warn that rigid
orthotics may cause sesamoiditis or benign tumors that form from pinched
nerves.

Soft Orthotics. Soft orthotics are designed to absorb shock, improve balance,
and remove pressure from painful areas. They are made from a lightweight
material and are often beneficial for people with diabetes or arthritis. They
need to be replaced periodically, and because they are bulkier than rigid
orthotics, they may require larger shoes.

Semi-Rigid Orthotics. Semi-rigid orthotics are designed to provide balance,


often for a specific sport. They are typically made of layers of leather and
cork reinforced by silastic.

Orthotics vs. Insoles. Before seeking prescription orthotics, people with less
severe problems should consider testing the lower-priced over-the-counter
insoles. One study found that 72% of people reported less foot pain from
store-purchased insoles compared to 68% of those who had them custom
made.

Foot Injury Treatment

If you suspect that bones in a toe or foot have been broken or fractured, you
should call a doctor, who will probably order x-rays. It should be noted that a
person is often able to walk even if a foot bone has been fractured,
particularly if it is a chipped bone or a toe fracture.

Over-the-Counter Pain Relievers

Over-the-counter nonsteroidal anti-inflammatory drugs (NSAIDs) are


commonly used to treat mild pain caused by muscle inflammation. Aspirin is the
most common NSAID. Others include ibuprofen (Motrin, Advil, Nuprin, Rufen),
ketoprofen (Actron, Orudis KT), naproxen (Aleve, Naprelan), and tolmetin
(Tolectin). A gel containing ibuprofen can be applied to sore joints.
Acetaminophen (Tylenol) is not an NSAID, and although it is a mild pain
reliever, it will not reduce inflammation. It is important to note that high
doses or long-term use of any NSAID can cause gastrointestinal disturbances,
with sometimes serious consequences, including dangerous bleeding. No one
should take NSAIDs for prolonged periods without consulting a doctor.

RICE (Rest, Ice, Compression, and Elevation)

The acronym RICE stands for rest, ice, compression, and elevation, the four
basic elements of immediate treatment for an injured foot.

• Rest. Patients should get off injured feet as soon as possible.


• Ice. Ice is particularly important to reduce swelling and promote
recovery during the first 48 hours. A bag or towel containing ice should
be wrapped around the injured area on a repetitive cycle of 20 minutes
on, 40 minutes off.
• Compression. An Ace bandage should be lightly wrapped around the area.
• Elevation. The foot should be elevated on several pillows.
Minor injuries like sprains may be treated at home if broken bones are not
suspected. The acronym RICE is helpful in remembering how to treat minor
injuries: "R" stands for rest, "I" is for ice, "C" is for compression, and "E" is
for elevation. Pain and swelling should decrease within 48 hours, and gentle
movement may be beneficial, but pressure should not be put on a sprained
joint until pain is completely gone (one to several weeks).

Toe Pain

A corn is a type of callus, a protective layer of dead skin cells that form due
to repeated friction. It is cone-shaped and has a knobby core that points
inward. This core can put pressure on a nerve and cause sharp pain. Corns can
develop on the top or between toes. If a corn develops between the toes, it is
may be called a soft corn if it is kept pliable by the moisture from
perspiration.

Corns develop as a result of friction from the toes rubbing together or against
the shoe. They often occur from the following:

• Shoes, socks, or stockings that fit too tightly around the toes
• Pressure on the toes from high-heeled shoes
• Shoes that are too loose can also cause corns due to the friction of the
foot sliding within the shoe
• Deformed and crooked toes

Preventing Corns and Calluses and Relieving Discomfort. To prevent corns and
calluses and relieve discomfort if they develop:

• Do not wear shoes that are too tight or too loose. Wear well-padded
shoes with open toes or a deep toe box (the part of the shoe that
surrounds the toes). If necessary, have a cobbler stretch the shoes in
the area where the corn or callus is located.
• Wear thick socks to absorb pressure, but do not wear tight socks or
stockings.
• Apply petroleum jelly or lanolin hand cream to corns or calluses to soften
them.
• Use doughnut-shaped pads that fit over a corn and decrease pressure
and friction. They are available at most drug stores.
• Place cotton, lamb's wool, or mole skin between the toes to cushion any
corns in these areas.

Removing Corns and Calluses. To remove a corn or callus, soak it in very warm
water for 5 minutes or more to soften the hardened tissue, then gently sand
it with a pumice stone. Several such treatments may be necessary. Do not
trim corns or calluses with a razor blade or other sharp tool. If the cutting
instrument is not sterile, infection can result, and it is easy to slip and cut
too deep, causing excessive bleeding or injury to the toe or foot.

Medicated Solutions and Pads. There are numerous over-the-counter pads,


plasters, and medications for removing corns and calluses. These treatments
commonly contain salicylic acid, which may cause irritations, burns, or
infections that are more serious than the corn or callus. Use caution with
these medications. The following people should not use them:

• Patients with diabetes


• Patients with reduced feeling in the feet due to circulation problems or
neurological damage
• Patients who do not have the flexibility or eyesight to use them properly

Bursitis of the Toe

Bursitis is an inflammation of the fluid filled sacs that protect the toe joints.
Ingrown Toenails

Ingrown toenails can occur on any toe but are most common on the big toes.
They usually develop when tight-fitting or narrow shoes put too much pressure
on the toenail and force the nail to grow into the flesh of the toe. Incorrect
toenail trimming can also contribute to the risk of developing an ingrown
toenail. Fungal infections, injuries, abnormalities in the structure of the foot,
and repeated impact on the toenail from high-impact aerobic exercise can also
produce ingrown toenails.

An ingrown toenail is a condition in which the edge of the toenail grows into
the skin of the toe. The big toe is most commonly affected. Symptoms include
pain, redness, and swelling around the toenail.

Caring for Toenails. Toenails should be trimmed straight across and long
enough so that the nail corner is not visible. If the nail is cut too short, it
may grow inward. If the nail does grow inward, do not cut the nail corner at
an angle. This only trains the nail to continue growing inward. When filing the
nails, file straight across the nail in a single movement, lifting the file before
the next stroke. Do not saw back and forth. A cuticle stick can be used to
clean under the nail.
Treatments. To relieve pain from ingrown toenails, try wearing sandals or
open-toed shoes. Soaking the toe for 5 minutes twice a day in a warm water
solution of Domeboro or Betadine can help. People who are at increased risk
for infections, such as those with diabetes, should have professional
treatment.

Antibiotic ointments can be used to treat ingrown toenails that are infected.
Apply the ointment by working a wisp of cotton under the nail, especially the
corners, to lift the nail up and drain the infection. The cotton will also help
force the toenail to grow out correctly. Change the cotton daily and use the
antibiotic consistently.

In severe cases, more intensive treatments are needed. Surgery involves


simply cutting away the sharp portion of ingrown nail, removal of the nail bed,
or removal of a wedge of the affected tissue. Three nonsurgical methods
involve using chemicals (usually phenol), cauterization (heating), or lasers to
remove the skin. A major review of studies reported that the use of phenol
along with simple separation of the nail was more effect than surgery alone in
preventing recurrence, although infections were more common after the
chemical procedure.

Bunions

A bunion is a deformity that usually occurs at the head of one of the five long
bones (the metatarsal bones) that extend from the arch and connect to the
toes. A bunion typically develops in the following way:

• Most often it occurs in the first metatarsal bone (the one that attaches
to the big toe). A bunion may also develop in the bone that joins the
little toe to the foot (the fifth metatarsal bone), in which case it is
known as a bunionette or tailor's bunion.
• A bunion begins to form when the big or little toe is forced in toward
the rest of the toes, causing the head of the metatarsal bone to jut
out and rub against the side of the shoe.
• The underlying tissue becomes inflamed, and a painful bump forms.
• As this bony growth develops, the bunion is formed as the big toe is
forced to grow at an increasing angle towards the rest of the toes. One
important bunion deformity, hallux valgus, causes the bone and joint of
the big toe to shift and grow inward, so that the second toe crosses
over it.

Bunions can be caused by several conditions:

• Narrow high-heeled shoes with pointed toes can put enormous pressure
on the front of the foot.
• Injury in the joint may cause a bunion to develop over time.
• Genetics play a role in 10 - 15% of all bunions.

Flat feet, gout, arthritis, and occupations (such as ballet) that place undue
stress on the feet can also increase the risk for bunions.

Shoes and Protective Pads. Pressure and pain from bunions and bunionettes can
be relieved by wearing appropriate shoes, such as the following:

• Soft, wide, low-heeled leather shoes that lace up


• Athletic shoes with soft toe boxes
• Open shoes or sandals with straps that don't touch the irritated area

A thick doughnut-shaped, moleskin pad can protect the protrusion. In some


cases, an orthotic can help redistribute weight and take pressure off the
bunion. Nonsteroidal anti-inflammatory drugs (NSAIDs) or corticosteroid
injections may offer some pain relief.

Surgery. If discomfort persists, surgery may be necessary particularly for


more serious conditions, such as hallux valgus. There are over 100 surgical
variations ranging from removing the bump to realigning the toes.

The most common surgery, an office procedure known as bunionectomy,


involves shaving down the bone of the big toe joint. In one procedure the
surgeon uses a very small incision, through which the bone-shaving drill is
inserted. The physician shaves off the bone, guided by feel or x-ray. It is
not a cure, but patient satisfaction is high and results are long-lasting.
Click the icon to see an illustrated series detailing bunion removal.

More extensive surgeries may be required to realign the toe joint. Although
there are variations of each, they generally involve one or more of the
following:

• Osteotomy (cutting and realigning the joint). Long-term studies on


osteotomies report that 90% or more of patients are satisfied with the
procedure.
• Exostetectomy (removal of the large bony growth. Only useful when
there is no shift in the toe bone itself.)
• Arthrodesis (removal of damaged portion of the joint, followed by
implantation of screws, wires, or plates to hold the bones together until
they heal.) This is the gold standard for very severe cases or when
previous procedures have failed. Good results have been reported in
most patients.
• Arthroplasty (removal of damaged portion of the joint with the goal of
achieving a flexible scar). This offers symptom relief and faster
rehabilitation than arthrodesis, but has risk for deformity and some
foot weakness. It tends to be used in older patients. Biologic or
synthetic implants for supporting the toes are showing promise as part
of this procedure.
• Tendon and Ligament Repair. If tendons and ligaments have become too
loose, the surgeon may tighten them.

In severe cases, surgeons are testing bone grafts to restore bone length in
patients who have had previous bunion surgeries or when damage from
osteoarthritis has occurred.

Complications, though uncommon in even the most complex procedures, can


include:

• Continued pain
• Infection
• Possible numbness
• Irritation from implants used to support the bone
• Sometimes, the metatarsal bone is excessively shortened.
Recovery from more invasive procedures, such as arthrodesis or osteotomy,
may take 6 - 8 weeks before a patient can put full weight on the foot. In
such cases, patient will need to wear a cast or use crutches. Elderly patients
may need wheelchairs.

Hammertoes

A hammertoe is a permanent deformity of the toe joint in which the toe bends
up slightly and then curls downward, resting on its tip. When forced into this
position long enough, the tendons of the toe contract, and it stiffens into a
hammer- or claw-like shape.

Hammertoe is most common in the second toe but may develop in any or all of
the three middle toes if they are pushed forward and do not have enough
room to lie flat in the shoe. The risk is increased when the toes are already
crowded by the pressure of a bunion. Lying down for long periods, diabetes,
and various diseases that affect the nerves and muscles put people at risk.

Click the icon to see an image of a hammertoe.

Treatment for Hammertoe. At first, a hammertoe is flexible, and any pain it


causes can usually be relieved by putting a toe pad, which are sold in drug
stores, into the shoe. To help prevent and ease existing discomfort from
hammertoes, shoes should have a deep, wide toe area. As the tendon becomes
tighter and the toe stiffens, other treatments, including exercises, splints,
and custom-made shoe inserts (orthotics) may help redistribute weight and
ease the position of the toe.

Surgery. Surgery may be needed in some severe cases. If the toe is still
flexible, only a simple procedure that releases the tendon may be involved.
Such procedures sometimes only require a single stitch and a Band-Aid. If the
toe has become rigid, surgery on the bone is necessary, but it can still be
performed in the doctor's office. A procedure called PIP arthroplasty involves
releasing the ligaments at the joint and removing a small piece of toe bone,
which restores the toe to its normal position. The toe is held in this position
with a pin for about 3 weeks, then the pin is removed. A 2000 study reported
that after 5 years, 92% of patients who had arthroscopy were still pain free.

Forefoot Pain

The incidence of forefoot pain and deformity increases with age. With early
diagnosis, conservative therapy is often successful in treating common
disorders of the forefoot. When a cause cannot be determined, any pain on
the ball of the foot is generally referred to as metatarsalgia. It is most likely
caused by improper footwear, particularly high heels, or by high-impact
activities.

Calluses

Calluses are composed of the same material as corns, hardened patches of


dead skin cells. Calluses, however, develop on the ball or heel of the foot.
The skin on the sole of the foot is ordinarily about 40 times thicker than skin
anywhere else on the body, but a callus can even be twice as thick. A
protective callus layer naturally develops to guard against excessive pressure
and chafing as people get older and the padding of fat on the bottom of the
foot thins out. If calluses get too big or too hard, they may pull and tear the
underlying skin.

Risk factors for calluses include the following:

• Poorly fitting shoes


• Walking regularly on hard surfaces
• Flat feet

Of note, in people with diabetes, the presence of calluses is a strong


predictor of ulceration, particularly in those who have a history of foot ulcers.

Neuromas

A neuroma usually means a benign tumor of a nerve. However, Mortons


neuroma, also called interdigital neuroma, is not actually a tumor. It is a
thickening of the tissue surrounding the nerves leading to the toes. Mortons
neuroma usually develops when the bones in the third and fourth toes pinch
together, compressing a nerve. It can also occur in other locations. The nerve
becomes enlarged and inflamed. The inflammation causes a burning or tingling
sensation and cramping in the front of the foot. Tight, poorly-fitting shoes,
injury, arthritis, or abnormal bone structure may also cause this condition.

Treatment for Neuromas. Pain from Morton's neuroma can be reduced by


massaging the affected area. Roomier shoes (box-toe shoes), pads of various
sorts, and cortisone injections in the painful area are also helpful. A
combination of cortisone injections and shoe modifications provides better
immediate relief than changes in footwear alone.

If these treatments are not effective, the enlarged area may need to be
surgically removed. In one long-term study of one surgeon's experience, 85%
of patients reported satisfaction as being good to excellent nearly six years
after surgery. About 65% were pain free. Some numbness is common
afterward but it rarely bothers patients. Occasionally, the nerve tissue may
re-grow and form another neuroma.

Stress Fracture

A stress fracture in the foot, also called fatigue or march fracture, usually
results from a break or rupture in any of the five metatarsal bones (mostly
the second or third). These fractures are caused by overuse during strenuous
exercise, particularly jogging and high-impact aerobics. Women are at higher
risk than men are. A fracture in the first metatarsal bone, which leads to the
big toe, is uncommon because of the thickness of this bone. If it occurs,
however, it is more serious than a fracture in any of the other metatarsal
bones because it dramatically changes the pattern of normal walking and
weight bearing.

Treatment for Stress Fractures. Patients should seek treatment if pain


persists for 3 weeks. In a study of young athletes, treatment after that time
was associated with a lower chance for returning to their sport. Surgery may
be needed if conservative measures fail. In most cases, however, stress
fractures heal by themselves if rigorous activities are avoided. It is best to
wear low-heeled shoes with stiff soles. Some physicians recommend moderate
exercise, particularly swimming and walking. Occasionally, a physician may
recommend wearing a special wooden shoe and a compressive wrap to make
walking more comfortable.
Sesamoiditis

Sesamoiditis is an inflammation of the tendons around the small, round bones


that are embedded in the head of the first metatarsal bone, which leads to
the big toe. Sesamoid bones bear much stress under ordinary circumstances;
excessive stress can strain the surrounding tendons. Often there is no clear-
cut cause, but sesamoid injuries are common among people who participate in
jarring, high-impact activities, such as ballet, jogging, and aerobic exercise.

Treatment for Sesamoiditis. Rest and reducing stress on the ball of the foot
are the first lines of treatment for sesamoiditis. A low-heeled shoe with a
stiff sole and soft padding inside is all that is usually required. In severe
cases, surgery may be necessary.

Heel Pain

The heel is the largest bone in the foot. Heel pain is the most common foot
problem and affects 2 million Americans every year. It can occur in the front,
back, or bottom of the heel. General treatment guidelines are as follows:

• The American Orthopaedic Foot and Ankle Society (AOFAS) suggests


shoe inserts, medications, and stretching as a first line of therapy for
heel pain. One study found that 95% of women who used an insert and
did simple stretching exercises for the Achilles tendon and plantar
fascia experienced improvement after 8 weeks.
• If these treatments fail, the patient may need prescription heel
orthotics and extended physical therapy.
• Heel surgery to relieve pain may be performed for heel spurs, plantar
fasciitis, bursitis, or neuroma.
• Surgery is not recommended until nonsurgical methods have failed for at
least 6 months and preferably up to 12 months. Nonsurgical treatments
for heel pain are effective in 90% of patients.

Plantar Fasciitis and Heel Spur Syndrome

Plantar Fasciitis and Heel Spurs. Plantar fasciitis is a common foot problem
that accounts for 1 million office visits per year. Plantar fasciitis occurs from
small tears and inflammation in the wide band of tendons and ligaments that
stretches from the heel to the ball of the foot. This band, much like the
tensed string in a bow, forms the arch of the foot and helps to serve as a
shock absorber for the body. The term plantar means the sole of the foot,
and fascia refers to any fibrous connective tissue in the body. Most people
with plantar fasciitis experience pain in the heel with their first steps in the
morning. The pain also often spreads to the arch. The condition can be
temporary or may become chronic if the problem is ignored. In such cases,
resting provides relief, but only temporarily.

Heel spurs are calcium deposits that can develop under the heel bone as result
of the inflammation that occurs with plantar fasciitis. Heel spurs and plantar
fasciitis are sometimes blamed interchangeably for pain, but plantar fasciitis
can occur without heel spurs, and spurs commonly develop without causing any
symptoms at all.

Causes of Plantar Fasciitis. The cause of plantar fasciitis is often unknown. It


is usually associated with overuse during high-impact exercise and sports and
accounts for up to 9% of all running injuries. Because the condition often
occurs in only one foot, however, factors other than overuse are likely to
responsible in many cases. Other causes of this injury include poorly-fitting
shoes, lack of calf flexibility, or an uneven stride that causes an abnormal and
stressful impact on the foot.

Treatment Goals. The three major treatment goals for plantar fasciitis are:

• Reducing inflammation and pain


• Reducing pressure on the heel
• Restoring strength and flexibility

Embarking on an exercise program as soon as possible and using NSAIDs,


splints, or heel pads as needed reduces the risk for future surgery. Pain that
is not relieved by NSAIDs may require more intensive treatments, including leg
supports and even surgery.

Exercises to Restore Strength and Flexibility. Stretching the plantar fascia is


the mainstay therapy for restoring strength and flexibility. One exercise
involves the following:

• Put the hands on a wall and lean against them.


• Place the uninjured foot on the floor in front of the injured foot. The
injured foot in back should have the heel off the floor.
• Stretch the back leg and foot gently.

With stretching treatments, the plantar fascia nearly always heals by itself
but it may take as long as a year, with pain occurring intermittently. A
moderate amount of low-impact exercise (such as walking, swimming, or
cycling) also seems to be beneficial.

Medications to Relieve Pain and Reduce Inflammation.

• NSAIDs. Inflammation and pain is most commonly treated with ice and
over-the-counter nonsteroidal anti-inflammatory drugs (NSAIDs) such
as aspirin or ibuprofen (Advil).
• Corticosteroids. Corticosteroids, or steroids, are powerful anti-
inflammatory agents. An injection of a steroid plus a local anesthetic
(such as xylocaine) may provide relieve in severe cases of plantar
fasciitis. (Steroid injections are not used for pain that is only due to
heel spurs). For athletes or performers who need immediate relief, an
effective method is to administer the steroid dexamethasone using a
procedure called iontophoresis, which introduces the drug into the foot's
tissue using an electrical current.

Reducing Pressure on the Heel. Several approaches can relieve pressure on the
heel, including:

• Sturdy Shoes and Insoles. It is important to wear comfortable but


sturdy shoes that have thick soles, rubber heels, and a sole insole to
relieve pressure. (An insole with an arch support might also be helpful.)
Cutting a round hole about the size of a quarter in the sole cushion
under the painful area may help support the rest of the heel while
relieving pressure on the painful spot itself. Heel cups are not very
useful. When combined with exercises that stretch the arch and heel
cord, over-the-counter insoles may offer the same relief as prescribed
orthotics. A 2001 study indicated, however, that patients may comply
better with custom-made orthotics.
• Night Splints. Some evidence suggests that splints worn at night may be
helpful for some people. One device, for example, uses an Ace bandage
and an L-shaped fiberglass splint to keep the foot stretched while the
patient is sleeping. This allows the muscle to heal. One study reported
that nearly any splint, regardless of cost, is equally effective in about
three-quarters of patients. Although patient compliance may be better
with custom-made prescribed orthotics than with tension night splints,
one study has found they are equally effective in improving pain.
• Elevated Heels. Some people report that mild symptoms may be relieved
with the use of shoes or cowboy boots that have elevated heels. This
approach, however, may not work in some people and is not recommended
for anyone with a moderate to severe condition. (Heel cups have not
been proven to be very useful.)

Extracorporeal Shock Wave Therapy. In 2002, the FDA approved


extracorporeal shock wave therapy (ESWT) for treatment of plantar fasciitis.
ESWT is increasingly being used as an alternative to surgery for patients who
have not responded to other treatments. The therapy uses low-dose sound
waves to injure the surrounding tissues in the heel, which triggers healing of
the tissues that are causing the pain. ESWT is performed at an outpatient
surgical facility and involves local anesthesia and conscious sedation. Several
long-term studies have shown benefits lasting a year or more, although other
short-term studies have suggested that the treatment is ineffective. Results
are not usually seen until at least 3 months after treatment.

Surgery. Surgery is appropriate in about 5% of patients, typically those who


have disabling heel pain for at least a year that does not respond to other
treatments. A typical surgery is called instep plantar fasciotomy. It relieves
pressure on the nerves that are causing pain by removing and therefore
releasing part of the plantar fascia.

The standard procedure uses a large incision and takes about 2 months to
resume complete normal activity. A less invasive variant uses a procedure
called endoscopy that employs small incisions and is proving to be effective.

For either approach, some studies report good to excellent pain relief in 80 -
90% of patients. In one study, however, half of the patients were dissatisfied
because the procedure didn't work or because recovery took too long. In
another 2000 study, about 15% of the patients reported long-lasting
complications, including pain from scar tissue and continued heel pain. Pain is
more likely when more than half of the plantar fascia was released during
surgery.
Wearing a below-the-knee walking cast after the operation for two weeks may
reduce the need for pain relief and speed recovery time compared to use of
crutches.

Botox. Research shows that injections of botulinum toxin (Botox), a protein


used to temporarily paralyze certain muscles, reduces pain and improves
patient's ability to walk.

Bursitis of the Heel

Bursitis of the heel is an inflammation of the bursa, a small sack of fluid,


beneath the heel bone. Nonsteroidal anti-inflammatory drugs (NSAIDs) such
as aspirin or ibuprofen (Advil) and steroid injections will help relieve pain from
bursitis. Applying ice and massaging the heel are also beneficial. A heel cup or
soft padding in the heel of the shoe reduces direct impact when walking.

Haglund's Deformity

Haglund's deformity, known medically as posterior calcaneal exostosis, is a


bony growth surrounded by tender tissue on the back of the heel bone. It
develops when the back of the shoe repeatedly rubs against the back of the
heel, aggravating the tissue and the underlying bone. It is commonly called
pump bump because it frequently occurs with high heels. (It can also develop in
runners, however.)

Treatment for Haglund's Deformity. Applying ice followed by moist heat will
help ease discomfort from a pump bump. Nonsteroidal anti-inflammatory drugs
(NSAIDs) such as aspirin or ibuprofen (Advil) will also reduce pain. Your
doctor may recommend an orthotic device to control heel motion.
Corticosteroid injections are not recommended because they can weaken the
Achilles tendon.

In severe cases, surgery may be necessary to remove or reduce the bony


growth. According to one study, however, surgery was not effective for over
30% of patients and, in fact, 14% experienced a worse condition afterward. A
more recent study reported that surgery cured 90% of cases, but full
recovery required 6 months to 2 years. Experts advise patients to try all
conservative measures before choosing surgery.
Achilles Tendinitis

Achilles tendinitis is an inflammation of the tendon that connects the calf


muscles to the heel bone. It is caused by small tears in the tendon from
overuse or injury and is most common in people who engage in high-impact
exercise, particularly jogging, racquetball, and tennis.

An inflamed or torn Achilles tendon causes intense pain and affects mobility.

People at highest risk for this disorder from these activities are those with a
shortened Achilles tendon. Such people tend to roll their feet too far inward
when walking, and may bounce when they walk. A shortened tendon can be due
to an inborn structural abnormality, or it can develop from regularly wearing
high heels.

Evidence is uncertain about the best way to treat either acute or chronic
Achilles tendinitis. Some approaches include:

Treatments to Relieve Pain and Reduce Inflammation. Nonsteroidal anti-


inflammatory drugs (NSAIDs) such as aspirin or ibuprofen (Advil) may help to
ease pain and reduce inflammation. It is also helpful to apply ice four or five
times a day for 20 to 30 minutes. (Note: Corticosteroid injections are
sometimes used, although evidence suggests they don't help very much, while
also posing a risk for rupture of the tendon.)
Gentle Stretching. Gentle calf muscle stretches may also help reduce the pain
and spasms. If the calf is swollen, elevating the leg is recommended. Exercise
is safe when the heel is no longer swollen or tender, even if pain is still
present. If pain increases with exercise, stop immediately.

Laser Therapy. Low-level laser therapy that emits energy directed at pain
trigger points has helped some patients. No strong evidence supports its use
to date, however.

Surgery vs. Nonsurgical Treatment. If pain continues, the ruptured tendon will
require a cast and perhaps surgery. Although some experts believe a cast is
sufficient in many cases, without an operation, the tendon has a 38% chance
of rupturing again. Some experts suggest surgery for active persons and
nonsurgical treatment for older people.

Surgery requires a long incision with a postoperative period of immobilization


that can average 6 weeks. Complications can include a significant surgical scar,
infection, and muscle atrophy, although surgery reduces pain and preserves
foot function in the long term. Less invasive techniques are being tested. In
one study, selected patients with ruptured tendons were hospitalized for about
5 days and fitted with special footgear (Variostabil that continuously raised
the back of the foot). The footgear was effective for most patients, and the
tendon ruptured again in only 5% of these cases.

Excessive Pronation

Pronation is the normal motion that allows the foot to adapt to uneven walking
surfaces and to absorb shock. Excessive pronation occurs when the foot has a
tendency to turn inward and stretch and pull the fascia. It can cause not only
heel pain, but also hip, knee, and lower back problems.

Arch Pain

Tarsal tunnel syndrome results from compression of a nerve that runs through
a narrow passage behind the inner ankle bone down to the heel. It can cause
pain anywhere along the bottom of the foot. It is often associated with
diabetes, back pain, or arthritis. It may also be caused by injury to the ankle
or by a growth, abnormal blood vessels, or scar tissue that press against the
nerve. Magnetic resonance (MR) imaging and the dorsiflexion-eversion test are
being used to diagnose this syndrome.

Treatment for Tarsal Tunnel Syndrome. Pain from tarsal tunnel syndrome may
be relieved by treatment with orthotics, specially designed shoe inserts, to
help redistribute weight and take pressure off the nerve. Corticosteroid
injections may also help. Surgery is sometimes performed, particularly if
symptoms persist for more than a year, although its benefits are under some
debate. Tarsal tunnel syndrome caused by known conditions, such as tumors or
cysts, may respond better to surgery than when the cause is not known.
Recovery from this surgery can take months before a person can resume
normal activity. It should be performed by only experienced surgeons.

Flat Foot

Flat foot, or pes planus, is a defect of the foot that eliminates the arch. The
condition is most often inherited. Arches, however, can also fall in adulthood,
in which case the condition is sometimes referred to as posterior tibial tendon
dysfunction (PTTD). This occurs most often in women over 50, but it can occur
in anyone. The following are risk factors for PTTD:

• Wearing high heels for long periods of time is a particular risk for flat
feet. In such cases, over the years, the Achilles tendon in the back of
the calf shortens and tightens, so the ankle does not bend properly. The
tendons and ligaments running through the arch then try to compensate.
Sometimes they break down, and the arch falls.
• Some studies have indicated that the earlier one starts wearing shoes,
particularly for long periods of the day, the higher the risk for flat
feet later on.
• Other conditions that can lead to PTTD include obesity, diabetes,
surgery, injury, rheumatoid arthritis, or use of corticosteroids.

Some research suggests that flat feet in adults can, over time, actually exert
abnormal pressure on the ankle joint that can cause damage. One indirect
complication of flat arches may be urinary incontinence or leakage during
exercise. The less flexible the arch, the more force reaches the pelvic floor,
jarring the muscles that affect urinary continence. Nevertheless, whether flat
feet pose any significant problems in adults is unknown. For example, a 2002
study on athletes with flat feet indicated that they had no higher risk for leg
or foot injuries than athletes with normal arches.

Treatment for Flat Feet in Children. Children with flat feet often outgrow
them, particularly tall, slender children with flexible joints. One expert
suggests that if an arch forms when the child stands on tip-toes, then the
child will probably outgrow the condition. For certain children, minimally
invasive surgery to implant temporary corrective screws into the arch may be
an option.

Treatment for Flat Feet in Adults. In general, conservative treatment for flat
feet acquired in adulthood (posterior tibial tendon dysfunction) involves pain
relief and insoles or custom-made orthotics to support the foot and prevent
progression.

In severe cases, surgery may be required to correct the foot posture, usually
with procedures called osteotomies or arthrodesis, which typically lengthen the
Achilles tendon and adjusting tendons in the foot. One procedure uses an
implant to support the arch. These procedures have potential complications and
conservative methods should be tried first.

Abnormally High Arches

An overly-high arch (hollow foot) can cause problems. Army studies have found
that recruits with the highest arches have the most lower-limb injuries and
that flat-footed recruits have the least. Contrary to the general impression,
the hollow foot is much more common than the flat foot.

Clawfoot, or pes cavus, is a deformity of the foot marked by very high arches
and very long toes. Clawfoot is a hereditary condition, but can also occur when
muscles in the foot contract or become unbalanced due to nerve or muscle
disorders.
Claw toe is a deformity of the foot in which the toes are pointed down and
the arch is high, making the foot appear claw-like. Claw toe can be a condition
from birth or develop as a consequence of other disorders.