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 calluses

Around toes, usually little toe, bottom of feet or areas exposed to friction.

Hard, dead, yellowish skin.

Wide (box-toed) shoes; soft cushions under heel or ball of foot or customized or gel insoles for calluses. Doughnut-shaped pads for corns.

Ingrown toenails

Toenails. Nail curling into skin causes pain, swelling, and, in extreme cases, infection.

Sandals, open-toed shoes.

Bunions and bunionettes (tailor's bunion)

Big toe (bunions) or little toe (bunionettes).

The following can occur alone or in combination:

Metatarsus primus varus. The first (big toe) metatarsal bone shifts away from the second, and the big toe points inward.

Medial exostosis. This 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

Soft, wide-toed shoes or sandals. Bunion shields or splints. Thick doughnut-shaped moleskin pads, custom-made orthotics or foot slings if necessary. Avoid shoes with stitching along the side of the "bump."

the second toe crosses over it.

Morton's neuroma (also called interdigital neuroma)

Inflammation of the nerve usually between the third and fourth toes and bottom of foot near these toes.

Cramping and burning pain, or electric-shock sensation. The condition may produce a thick protective sheath around the 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.

Wide (box-toed) shoes. Orthotic or insole with pad that reduces stress on the painful area.

Hammertoe or claw toe

Usually second toe but may develop in any or all of the three middle toes.

Toes form hammer or claw shape. In hammertoe, the first knuckle of the toe is mainly affected. In claw toe the entire toe is deformed. No pain at first, increasing as tendon becomes tighter and toes stiffen.

Wide (box-toed) shoes. Toe pads or specially designed shields, splints, caps, or slings. (Splints or slings not for people with diabetes.)

Front-of-the-Foot Pain

Metatarsalgia Ball of the foot. Acute, recurrent, or chronic pain without a known cause.

Wide (box-toed) shoes. Orthotic with pad that reduces

metatarsal pressure. Gel cushions. Metatarsal bandage.

Stress fracture

Most often in the area beneath the second or third toe.

Sudden pain when injury occurs, which persists.

Low-heeled shoes with stiff soles.

Sesamoiditis Ball of foot beneath big toe.

Pain and swelling. Low-heeled shoe with stiff sole and soft padding inside.

Heel and Back-of-the-Foot Pain

Plantar fasciitis or heel spurs

Back of the arch right in front of heel.

At onset, some people report a tearing or popping sound. Pain, most severe with first steps after getting out of bed, decreasing after stretching, returning after inactivity.

Over-the-counter foot insole (cut quarter-size hole surrounding painful area). Possible night splints. Orthotics if necessary.

Bursitis of the heel

Center of the heel.

Pain, with warmth and swelling. Increases during the day.

Heel cup.

Haglund's deformity (pump bump)

Fleshy area on the back of the heel.

Tender swelling aggravated by shoes with stiff backs.

Soft shoes. Heel pads. Possible orthotic to support heel.

Achilles tendinitis

Achilles tendon: area along the back between calf muscles and heel.

Pain worsens during physical activities (particularly running), after which the tendon usually swells and stiffens. If it ruptures, popping sound may occur

Insoles, tendon strap, heel cups.

followed by acute pain similar to a blow at the back of the leg.

Arch and Bottom-of-the Foot Pain

Tarsal tunnel syndrome

Anywhere along the bottom of the foot.

Numbness, tingling, or burning sensations, pain, most commonly felt at night.

Specially designed orthotics to relieve pressure.

Flat feet or posterior tibial tendon dysfunction (PTTD)

The arch. No arch. Often no pain or discomfort. Three stages in 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.

For children, possible custom-made insoles.

High arches (hollow feet)

The arch. High arches. Lower 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 Dancing

Sufficient cushioning to absorb shock and pressure, which should be 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.