COMMON FOOT CONDITIONS IN PERTH

Description

The plantar fascia is located in the sole of the foot. It is a tough fibrous band that stretches from the under surface of the heel bone and runs under the foot, fanning out to attach to the base of the toes and functions to maintain the foot arch. The medial aspect of the band (region towards the midline of the body) has a thicker and denser structure. This band can become inflamed or injured, termed plantar fasciitis. A common cause of heel pain is “heel spur syndrome”, an inflammatory condition of the plantar fascia at its attachment site into the heel bone and in severe cases, a heel spur, due to a strain or to overuse.

Incidence 

The greatest incidence of plantar fasciitis is seen in middle-aged men and women. Strain is also caused in those who partake in high-impact sport, constant exercise or long hours of work duty. The overweight are also prone to plantar fasciitis because of the increased load on their feet.

Symptoms

It generally starts as a dull pain in the arch or on the bottom of the heel and may progress to a sharp persistent pain. It tends to feel worse in the morning due to the sudden elongation of the plantar fascia tissue band, which has contracted during the night. As in other overuse injuries, the pain develops at the beginning of a workout, but may diminish during running, only to recur at the finish or later.

Causes

The most common cause of this condition is an overuse and stress on the fascia or pulling away from the heel bone usually associated with poor support from the bony arch of the foot. This causes an inflammation and the pain. Every step taken is an aggravation and the condition worsens. The pulling away from the bone by the fascia causes inflammation and may lead to the development of a bone spur as new bone is laid down. The inflammation causes the pain, not the spur. Occasionally, local nerves may become sensitised.

Factors that may cause or contribute to the development of this painful heel condition. 

• Biomechanical abnormalities of the foot or lower leg i.e. flat pronated feet, high arched rigid feet, tight calf muscles 
• Tight plantar fascia 
• A sudden increase in training intensity
• Inappropriate/improper shoes for the activity or foot 
• Toe running, hill running 
• Soft terrain, e.g. running on sand 
• Age and decreased fatty heel pad 
• A result of an injury 
• Arthritic or other medical inflammatory condition 
• Possible associated nerve entrapment 

Treatment

Treatment is aimed at reducing inflammation, restoring tissue strength and flexibility and improving any biomechanical abnormality. 

• Ice packs for 15-20 minutes, several times daily, especially after activity
• Contrast footbaths – warm and cold. Immerse the feet in one footbath for 2-3 minutes, then alternate to the other and repeat the process 
• Stretches for the plantar fascia and calf muscle 
• Massage of the heel and plantar fascia 
• Well-fitting shoes with a supportive arch, heel pad and heel cup 
• Weight loss 
• Foot taping to reduce stress on the plantar fascia and improve foot biomechanics 
• Anti inflammatory medication – oral and/or topical 
• Podiatry assessment for biomechanical abnormalities requiring orthotics 
• Physiotherapy, laser, acupuncture and shockwave therapy etc 
• Cortisone injections 
• Podiatric Surgical review for possible fascia release 
• Podiatric Surgical review for possible nerve problem

Definition

Achilles Tendinitis is an inflammation of the large tendon in the back of the lower leg known as the “Achilles tendon”. There are cases without the usual process of inflammation and this is termed tendonosis or tendonopathy. The inflammation and pain is associated with physical activity and overuse. In some instances the pulling of the Achilles tendon can result in spurring or calcification of the tendon at the site of insertion at the back of the heel. This may be associated directly with the Achilles tendonitis/tendonosis or appear as an isolated entity. The thin lining of the tendon called the paratenon may become inflamed being a similar in symptoms.

Incidence

Achilles tendinitis/tendonosis can occur at any age and is common in active individuals, particularly those involving running or jumping. However as one gets older, the achilles loses some of its resilience, with more tendency to the condition. As one ages the tendon becomes more like a “brittle rope” rather than a thick strong “elastic band”. 

Poor circulation to the Achilles tendon contributes to the tendinitis/tendonosis being a chronic condition. 

In some cases rupture of the tendon may occur. The Tendon lining can also be involved in the pathology.

Symptoms

The following symptoms are often associated with Achilles tendinitis: 

• Pain may be immediate in onset or may begin gradually and worsen with activity 
• Swelling may be localised or diffuse 
• Pain when pressing along the tendon course or specific site 
• Pain at the back of the heel 
• Limping to avoid weight bearing 
• Crepitus or creaking with movement along the tendon

Causes

• Physiological changes to the tendon tissue with age 
• Overuse, (“too much - too soon”) 
• Biomechanical abnormalities of the foot and leg including flat feet, tight leg muscles, high arched feet all causing bowing or overload of the tendon 
• Poor or inappropriate training regime or surfaces 
• Inappropriate footwear 
• Direct trauma 
• Other: Various arthritic conditions, nutritional, hormonal or metabolic abnormalities may affect the health of the tendon

Treatment

• Rest 
• Anti-inflammatory and/or analgesic medication 
• Physical therapies: ice, heat, massage, electrotherapeutic modalities (ultrasound, TENS, myofascial therapy techniques) 
• Gentle calf stretching 
• Heel raise – short term 
• Prevention: o Address any biomechanical abnormalities o Warm up before and after exercise o Address the cause eg. Footwear, training regime 
• Injection therapy or surgical intervention may be required in some instances

Description

Bunions are one of the most common deformities of the forefoot. There is displacement of the first metatarsal bone towards the mid-line of the body and a simultaneous displacement of the great toe away from the mid-line (and towards the smaller toes). This causes a prominence of bone on the inside margin of the forefoot, this is termed a “bunion”, with continued drifting of the great toe (hallux) towards the smaller toes. The smaller toes may also be forced into a clawed position and ride up over the big toe. There are different stages of bunion development, depending on the severity of the angulation of the big toe. Arthritis can also develop producing pain within the joint.

Incidence

Bunions are common in people who have a family history of the deformity. Women are more prone to developing bunions than men, most likely due to a predisposition to the condition, and sometimes triggered by poor footwear. Wearing narrow, tight, confining or high-heeled shoes can greatly accelerate the formation of a bunion. Middle age to older people are more likely to suffer with bunions. Bunions can affect children and young people.

Symptoms

Redness, inflammation, pain and/or stiffness around the big toe 

• Moderate to severe discomfort at the bunion when wearing shoes 
• Calluses and corn development on the outside of the big toe, between the big toe and the second toe and/or underneath the big toe and ball of the foot 
• There may be overlapping of the second toe causing a hammer toe 
• Skin over the bunion may breakdown causing an ulceration which can become infected

Causes

Foot mechanics – pronated/flat feet producing excess load of the 1st toe joint 

• Family history of bunions. However it is the foot type that is hereditary, not the bunion 
• Poor/tight footwear – particularly in those already predisposed to bunions 
• Arthritic conditions 
• Trauma or previous surgery around the great toe joint

Treatments

Treatments vary depending on the severity of pain and deformity. The main goal of early treatment is to relieve pressure on the bunion and smaller toes and to diminish the progression of joint deformities;

• Padding the bunion to protect the bony prominence from shoe pressure 
• Wearing correctly fitting footwear that have a wide and deep toe box. 
• Corns and calluses can be managed by Podiatry treatment. 
• Medications, such as anti inflammatory drugs or cortisone injections may be used to ease pain and inflammation. This is especially useful if there is an associated bursitis. 
• Foot orthoses - realign the foot to a more “normal” position and can assist in balancing the muscles around the big toe, stabilising the joint and halting or slowing bunion development. 
• Surgery – When conservative treatment does not provide satisfactory relief from symptoms, when the condition interferes with activities, or there is concern with the foot shape, surgery may be necessary. Evaluation by a podiatric surgeon is advised at the first sign of concern, pain or discomfort, so that severe deformity can be avoided.

Description

A contracted toe is often termed a clawed, mallet or hammertoe. This depends on the level and the amount of flexibility that the deformity displays. In simple terms it is best described as a buckling of the toe. This is a common condition and causes problems when footwear rubs on the top of the toes producing corns or callus. The tips of the toes may also be affected due to ground contact.

Incidence

Clawed/hammer toes are common in people who have a family history of the deformity. Women are more prone to having discomfort, most likely due to poor footwear. Wearing narrow, tight, confining or high-heeled shoes can greatly accelerate the formation of clawed toes and associated corns. Men may have trouble in certain sports footwear or work wear. Hammertoes are often associated with a bunion.

Symptoms

• Redness, inflammation, pain and/or stiffness top of toes 
• Pain around the “balls” of the feet due to retraction of toes causing dysfunction 
• Possible associated bunion 
• Calluses and corns at the toes and/or the ball of the foot 
• There may be overlapping toes 
• Inflammation around the joints of the toes and possible fluid under the skin around the joint (bursitis)
•  Skin over the toe joints may breakdown causing an ulceration which can become infected 
• Toenails may become thickened or distorted

Causes

• Foot mechanics – pronated/flat feet producing tendon imbalance. 
• Family history 
• Poor/tight footwear – particularly in those already predisposed 
• Rheumatoid and other arthritic conditions 
• Neurological problems effecting muscles of the lower leg

Treatment

Treatments vary depending on the severity of pain and deformity. The main goal of early treatment is to diminish the progression of joint deformities, these include;

• Padding, strapping or toe splints 
• Wearing correctly fitting footwear that have a wide and deep toe box 
• Corns and calluses can be managed by Podiatric treatment. 
• Foot orthoses. - For example, if flat feet are the cause, custom-made functional foot orthoses may be required to help support and control abnormal foot movement and make the foot more stable to assist in balancing the tendons, stabilising the joints and halting or slowing progression of the deformity. 
• Surgery – When conservative treatment does not provide satisfactory relief from symptoms, or when the condition interferes with activities, surgery may be necessary. Evaluation by a podiatric surgeon should be sought at the first sign of pain or discomfort, so that severe deformity can be avoided.

Description

Many people have minor but yet irritating problems with corns and callus. In some cases this can be very painful and interfere with activity. Excess pressure or friction on various regions of the foot can lead to the production protective skin tissue which subsequently may become excessively thick and painful. This is termed hyperkeratosis. Callus being a diffuse distribution of keratin tissue and a corn a more impacted and dense site. 

The heels are a common area of concern with dry, thick, cracked skin and often described as unattractive. 

Corns and calluses may occur on the ball of the foot due to abnormal weight distribution and loading through the foot. They can be isolated over one or two metatarsal head regions or across the whole ball of the foot. 

The toes may also be affected especially if they are clawed and footwear impinges on them. Corns can be present on the top, the tips and between toes.

Causes

Some people have a greater genetic tendency to produce such irritating skin tissue. Some skin conditions produce excess keratin tissue. Smoking has a documented link to increased hyperkeratosis or thickening of the skin. Areas of increased pressure or overload from ground forces increase the potential for callus. Feet that are either high arched or flat have altered pressure regions and at risk of corns and calluses. Footwear irritation contributes to calluses and corns. Clawed or retracted toes or any region of prominence of the foot is subjected to excess force and hence corn or callus. Dehydration can increase callus and corns with fissuring, more common on the heels

Signs and Symptoms

Regions of notable thickening of the skin are noted. There may be no associated discomfort but may be unsightly. The skin tissue may become so dense that it is inflexible or become deed seated like a “plug”. There can be associated splitting and fissuring with surrounding redness. Some areas are more painful than others. There may be so much pressure at the corn site that there is soft tissue breakdown beneath the corn in the form of an ulcer. Some callus may have associated blistering.

Treatment

Treatment usually consists of removal of the offending thickened corn or callus. The application various paddings may be useful depending on the site. Moisturising type creams may be required. Many patients are happy with this treatment and manage the problem with regular Podiatry visits. Other situations require assessing and addressing the cause. This may include assessment of the foot type and balancing abnormal forces with various insoles or orthotic devices. 

Some regions of the foot can be treated with surgical procedures to correct the mal position or remove bony growths causing the problem. In some individuals corn and calluses may develop into ulcers. This is serious in people with diabetes or conditions leading to poor circulation. Dr Marino, Podiatric Surgeon can assist you with surgical consultation.

Description

An interdigital corn is often termed a soft corn. It is a dense thickening of skin between the toes at regions where there is impingement or rubbing. Often the condition is present between the 4th and 5th toes or with deranged toes. This depends on the shape, level of bony prominence and the amount of flexibility that the toe displays. In simple terms it is best described as impingement between two prominences. This is a common condition and causes problems when footwear contributes to constriction.

Symptoms

• Redness, inflammation or pain between toes 
• Pain associated with a small thickened area of the toe 
• Often associated with deformed toes or prominences 
• There may be overlapping toes 
• Skin may breakdown causing an ulceration which can become infected 
• A white smelly region may be noted between the toes

Causes

• Foot mechanics – pronated/flat feet producing toe deformities 
• Prominence of joint or small bone spur of toe 
• Poor/tight footwear 
• Rheumatoid or other arthritic conditions 
• Previous damage to toes

Treatment

Treatments vary depending on the severity of pain and deformity. The main goal of early treatment is to remove the impingement;

• Padding/strapping 
• Wearing correctly fitting footwear that have a wide and deep toe box 
• Corns and calluses can be managed by Podiatric treatment. 

Foot orthoses to realign the foot to a more “normal” position and assist in balancing the tendons, stabilising the toe joints and halting or slowing progression of the deformity. 

Surgery – When conservative treatment does not provide satisfactory relief from symptoms, or when the condition interferes with activities, surgery may be necessary. Evaluation by a podiatric surgeon should be sought at the first sign of pain, any concern or discomfort, so that severe deformity can be avoided.

Foot care is important for people with diabetes. As the disease progresses it can affect both the blood and nerve supply to your feet. Therefore the maintenance of good foot care and regular foot screenings is of utmost importance. 

People with long standing diabetes and/or poorly controlled blood glucose levels are more prone to foot complications. Such complications may involve the blood supply, nerves and joints of the feet. Such people are more prone to infection and poor healing. At worst, situations arise that may require surgical amputation of the affected part.

Blood Supply/Circulation

The arteries supplying blood to the feet and toes are affected by diabetes. This results in less blood flowing through the arteries. This lack of blood flow effects the tissues and therefore any cut or wounds to the feet will not heal quickly. This increases your risk of infection or an ulcer. If the blood supply is reduced there is inadequate nutrition of the tissues and if damaged or infected the body has reduced ability to heal and also reduce the ability of any antibiotic reaching the site.

Signs of Poor Blood Supply

• Sharp cramping in legs or feet when walking short distances 
• Sharp cramping or pain in legs or feet when resting or sleeping 
• Feet are cold to touch 
• Skin appears red/blue colour 
• Slow to heal cuts or abrasions 
• Loss of hair on toes and top of foot 
• Dry thin skin 
• Weak, distorted or slow growing nails

Nerve Supply 

Diabetes affects your nerves. It may only be temporary but is more likely to permanent damage. The degree of nerve damage is often related to the length of time you have had diabetes and the stability of your blood glucose levels. Low, high or irregular blood glucose levels causes damage to small nerves. This is termed neuropathy. 

Neuropathy increases the risk of injury as you loose protective sensation and/or motor nerve functions. Hence, without protective sensation you may fail to notice injuries and consequently fail to care for them appropriately.

Signs of Neuropathy

• Pain or burning feeling in the feet 
• Hot or cold sensation 
• Numbness 
• Pins and needles or tingling in the feet 
• Weakness of the feet or legs 
• Some instability 
• Injury, lesions or ulcers without pain 
• Sharp shooting pains in the feet and or legs

Basic Foot Care

As a precaution to avoid injury to your feet the following steps should be performed daily.

1. CHECK YOUR FEET: This is important as the sensation to your feet may be impaired. If you have trouble reaching your feet use a mirror to check the soles of your feet. You should be aware of any cuts, scratches, abrasions, blisters, cracks, corns and calluses. 
2. Cuts and blisters should be treated appropriately and corns and calluses removed by a Podiatrist on a regular basis. This is important in reducing your risk of infection and ulceration. 
3. Wash your feet well and dry them carefully, check between toes. 
4. Moisturise with a suitable cream (avoid cream between the toes). 
5. Use clean cotton or woollen socks that are not too tight. 
6. Protect your feet indoors and out with shoes that fit well. 
7. Take extreme care or avoid heaters, hot water bottles or cold to your feet. 
8. Seek professional advice with foot care. 
9. Avoid corn plasters or any products with acids unless directed to do so by a trained health care professional. 
10. In case of injury, wash and pat dry the area. Apply a good antiseptic (eg. Povidone Iodine) and cover with a sterile dressing. If no improvement is noted within 24hrs seek professional help to avoid complications.

You should check your feet daily; with regular assessment of your feet carried out by your doctor, podiatrist or diabetic nurse. Seek professional help if you have any open wounds, corns/calluses, ingrown toenails or if you are unable to care for your own toenails, if your feet are unusually red or swollen or if you have any concerns regarding your foot health.

The medical terminology for flat feet is “pes planus”. It refers to a foot type that has lost its arch and as it suggests appears rather flat compared to the average foot. Some of these feet are simply shaped that way with a particular bone structure and look similar both weight bearing and non weight bearing. Some feet appear relatively normal off the ground but when standing they flatten. This is due to either the foot being flexible or the foot bone structure having a mal alignment causing the flattening. This flattening motion is termed PRONATION. The influence of the leg can also cause pronation. Any person involved in athletic activity or spending a large amount of time on there feet may be recurrently suffering from or predisposing themselves to injury and symptoms due to pronation.

The opposite of the flat foot is the high arched foot type. This is termed “pes cavus”. This foot type also can be classed as flexible or rigid. A flexible pes cavus is one that when standing the high arch appearance of the foot reduces somewhat but the rigid type tends to maintain its shape. Pes cavus also predisposes to problems of the foot and leg. The arched or inward tilting/motion of the heel with stance is termed SUPINATION.

PRONATION and SUPINATION, both of these are normal natural movements that occur during standing, walking and running, however excessive amounts, excessive duration or abnormal timing during stance in either direction results in injury and pain.

PRONATION is the inward rolling or flattening out of the foot that helps to absorb shock as the foot hits the ground during the initial phase of gait (walking).

SUPINATION is the outward rolling or arching of the foot that helps to push or propel a person forward as the foot leaves the ground.

The amount of pronation and supination that occurs during gait is variable and dependent upon a number of factors. Some of these include:

• Skeletal lower leg and foot alignment 
• Footwear 
• Angle and nature of surface 
• Speed of gait 
• Muscle, tendon or ligament tightness and weakness 
• Neuro-muscular, arthritis or other disease states

Common Conditions 

Common Conditions include heel pain, shin splints, stress fractures, achilles pain, knee pain, ankle pain and in some cases lower back pain, to name a few. The foot type can also be the cause for bunions, clawed toes and nerve entrapment problems. Injuries and problems of this nature that are left poorly treated are often ongoing and very frustrating to sufferer.

Early detection is essential in reducing the frequency and severity of injury or problems.

At one time flat feet/fallen arches were considered a “deformity” that prevented entry into the armed forces due to the correlation between this foot type and foot/leg problems.

Parents are often concerned with children and this foot type, often being a normal variant or family trait. There may be no associated pain. It will not always cause problems in adulthood but the likelihood is higher depending on the type of flat or high arched foot type. The foot should be assessed to determine this.

Pain related to poor foot position should be addressed. This requires special insoles or orthotics to assist in maintaining the foot in a more neutral or normal position. The appropriate insole or orthotic device for either a pes planus or pes cavus foot type is prescribed following assessment of the foot and lower limb mechanics by the podiatrist. See “Orthotics”.

Fungal infection of the nail is termed “onychmycosis”. 

It is a condition, which produces problems from simple nail discoloration through to a thickened, brittle and crumbly appearance. Usually this is not painful but a secondary infection may also occur, producing inflammation at the nail borders and toe. Often there can be fungal influence between the toes (tinea) or the condition may affect either one or multiple nails. Multiple fungal organisms have been identified with some being more resistant than others.

Treatment consists of adequate diagnosis, removal of the offending fungal tissue, possible confirmation with laboratory testing and either topical or oral anti fungal medications. Occasionally, the nail may be required to be removed to give it the best chance to re grow without infection. This condition may prove stubborn to resolve.

Laser or photodynamic light therapy is also a method in treating nail fungal infections. This is a painless process requiring no medication where the fungas is destroyed via the specific light frequency used in treatment.

CentrePod Podiatry Podiatrist can assess and assist with this problem.

Other Nail Problems 

These include conditions such as Psoriasis, Eczma, Trauma, Splitting, Bacterial infections, Clubbing, Other discolouration, Melanoma etc. The Podiatrist will determine the likely diagnosis and referral may be required in some cases to exclude other causes.

Athlete’s Foot 

Also known as tinea pedis is a fungal infection of the skin that causes scaling, flaking, and itch of affected areas. It is typically transmitted in moist communal areas where people walk barefoot, such as showers or bathhouses the disease requires a warm moist environment, such as the inside of a shoe, in order to incubate. 

Tinea pedis most often manifests between the toes, with the space between the fourth and fifth digits most commonly afflicted.

Antifungal treatment will be required. 

CentrePod Podiatry Podiatrists can assess and treat this condition.

Heel pain that occurs at the back of the heel in children is often termed calcaneal apophysitis, which simply means; inflammation of the growth plate of the heel bone. It is also known as ‘Severs disease’ but it is not a disease as such. It is basically irritation and trauma to the growth plate region (growth cartilage) of the heel bone and often the result of chronic strain on the Achilles tendon or excess weight bearing pressure. The pain is known to decrease as the child grows and the growth plate matures and closes.

Incidence

Young active males aged between 8 and 14 years of age are affected more commonly than girls.

Symptoms

The symptoms often involve pain at the back of the heel. A slight limp may also be noticed. The child may also have a reduced amount of ankle joint motion. The Achilles tendon insertion site is often tender with palpation and lateral compression. The pain is often felt to be worse after activity. Constant pain and swelling are more commonly seen in chronic cases. X-Rays usually fail to represent any significant findings apart from a fragmented growth plate but may be required to exclude other causes of pain.

Causes

A number of factors may contribute to the occurrence of this heel pain.

• Tight Achilles tendon 
• Rapid growth 
• Trauma 
• Reduced heel shock absorption 
• Abnormal foot biomechanics 
• Poor footwear or training regimes 
• Overweight

Treatment

The goal of treatment is to reduce symptoms and address any causative factors contributing to the heel pain. Remember, this form of heel pain is self-limiting and will resolve with growth plate closure but the time taken for this can vary between children. This commonly occurs between the ages of 12 and 15 (sometimes later depending on child development). In the mean time the following treatments may be suggested:

• Rest with activity or training regime alterations 
• Address any abnormalities of biomechanics of the feet with insoles or orthotics 
• Physical therapies eg ice and heat treatments 
• Anti inflammatory medication 
• Stretching exercises 
• Heel raise in shoe 
• Increase shock absorption in footwear/insoles 
• Appropriate footwear

Description

This is often referred to as “pigeon toed” gait and is a common condition that produces concern with parents. The medical terminology for this is “Adducted Gait”. It may be present in either one or both limbs. Often parents are worried with the appearance of the leg and foot position in comparison to other children. In some cases the condition may affect the child’s ability to run or perform sporting activity adequately. A proportion of the cases will resolve themselves with growth as the bone positions develop but some may continue to remain if left untreated.

Symptoms

Some children may complain of muscle soreness of the legs but more often, there is no pain or discomfort with this condition but the child may be conscious of the mal alignment and may avoid some activity. Shoes may wear excessively or scuff each other as the child walks.

Causes

The condition may have several factors contributing to the severity and can be divided into four main regions of origin. Some may be easily identified at birth but others only as the child develops with differing milestones. The main regions are the HIP, UPPER LEG or FEMUR, LOWER LEG or TIBIA and the FOOT.

The hip level may have problems associated with:

• Excessive internal rotated position of the hip in the socket with development (termed – excess anteversion) 
• Tight muscles that produce internal rotation at the hip 
• Inadequate external rotator muscles to balance the hip position 
• Tight or contracted ilio-femoral ligaments holding the mal position 
• Anteriorly placed hip socket

The femoral level cause is associated with:

• Femoral ante torsion, which simply means that there is an excessive twist of the bone inwardly. This is “programmed” in the body’s development to twist outward and therefore may simply not have commenced this action as yet or is slower in this phase.
• This type of intoeing is clinically noted to have the knee also rotating or squinting towards the midline of the body along with the whole leg and foot.

The Tibial level cause is associated with:

• Soft tissue contracture at the knee holding the tibia internally positioned 
• The tibia which may display an internal twist which again is developmental and “programmed” to de rotate with maturation into adult hood. Any delay in this will be seen as a pigeon toed mal position
• If the condition is at this level only, then the hip and knee position will be OK but the foot and lower leg turned inwards.

The Foot level cause is associated with:

• Overpowering muscles from the leg producing internal curving of the foot 
• Overpowering or spasms of a foot muscle pulling the big toe towards the midline of the body 
• Joint or bone malposition of the forefoot producing an adducted or inward orientation of the metatarsals and forefoot (metatarsus adductus)

If the condition is at this level only, then only the foot is in turned and the hip, knee and lower leg being OK.

Treatment

The level of the deformity must be diagnosed before any advice or treatment is valid. In certain cases the majority of the problem may be isolated to one of the above-mentioned levels and in others the problem may be a compounding of small anomalies at each level, which add to become considerable. Treatment may involve specific stretching, splints, casting, manipulations, awareness/modification of walking or sleeping patterns and inserts in shoes. Depending on the deformity and stage of detection, surgical intervention may be required. It is best if the problem is identified early so that conservative measures can be adopted to assist in correction of the problem.

One of the most common toenail problems is the “ingrown nail”. The medical terminology for this is onychocryptosis (very impressive and sounds like a big deal). The ingrown nail is usually due to either, a wide nail, a curved nail, pulpy flesh at the nail border or pressure from footwear or adjacent toe onto the nail border. This can become inflamed and often infected. Treatment consists of trimming and removing the offending nail border and occasionally antibiotics are prescribed if infection is present.

The above represents a rather severe problem but the toe does not have to look like this to be problematic. Often a mild non noticeable ingrown nail can be just as painful.

Permanent correction includes removing the offending nail border along with the growth plate region responsible for the distorted shape, so the likelihood of return is extremely minimal. There are several methods for this and the appropriate technique will depend on the nail shape, infection, amount of nail and tissue etc. This will be discussed by the podiatrist. The procedure can be performed with local anaesthesia but some may choose to have general anaesthesia. It is a surgical procedure with a good outcome. The procedure can be performed in the rooms but more complex nails or if general anaesthesia is preferred, the hospital outpatient setting is required. Approximately 80% of sufferers of this condition choose or require this procedure.

Some ingrown nails also have a complicating factor with a small area of excess bone growth under the nail. Again, this will be assessed by the podiatrist and xrays may be required to evaluate this. This small bony prominence is call a “sub ungual exostosis or osteochondroma” and usually causes the nail to become extremely curved. If present, this small mass is best being removed surgically.

Fungal Infection

Fungal infection of the nail is termed “onychmycosis”. It is a condition, which produces problems from simple nail discoloration through to a thickened, brittle and crumbly appearance. Usually this is not painful but a secondary infection may also occur, producing inflammation at the nail borders and toe. Often there can be fungal influence between the toes (tinea) or the condition may affect either one or multiple nails. Multiple fungal organisms have been identified with some being more resistant than others.

Treatment consists of adequate diagnosis, removal of the offending fungal tissue, possible confirmation with laboratory testing and either topical or oral anti fungal medications. 

Occasionally, the nail may be required to be removed to give it the best chance to re grow without infection. This condition may prove stubborn to resolve. Laser or photodynamic light therapy is also a method in treating nail fungal infections. This is a painless process requiring no medication where the fungus is destroyed via the specific light frequency used in treatment.

CentrePod Podiatry podiatrists can assess and assist with this problem.

Other Nail Problems

These include conditions such as Psoriasis, Eczma, Trauma, Splitting, Bacterial infections, Clubbing, Other discolouration, Melanoma etc. The Podiatrist will determine the likely diagnosis and referral may be required in some cases to exclude other causes.

Description

Patello-femoral pain is one of the most common causes of knee pain involving the patella (knee cap) as well as surrounding soft tissue. It can result in diffuse or sharp pains felt either surrounding or behind the patella or deep inside the knee and can sometimes be associated with referred pain to the back of the knee. The condition is often referred to as “runner’s knee” or “chondromalacia patella”.

Incidence

Patello-femoral syndrome is a common condition experienced in all ages, especially active or sports people. It affects to some degree one in two adolescent athletes and one in four adult athletes.

Symptoms

The pain is due to an overuse inflammatory syndrome at the back of the knee cap causing pain and swelling. It tends to be aggravated by any bent knee activity, such as running, kneeling, squatting, sitting for prolonged periods, or stairs with going down worse than up. Often, this is associated with creaking or grinding sensations under the knee cap.

Causes

In the normal knee, the patella glides up and down through a groove in the bottom end of the femur. When the knee is flexed (bent), then the pressure between the patella and femur is increased, prolonging and/or repeatedly causing this increased pressure can lead to irritation, which in turn causes an inflammatory response. This pressure is increased if the patella does not ride smoothly through the groove, but ‘tracks’ more to one side. This is the effect of a muscle imbalance between the medial (inside) muscles called vastus medialis and the lateral (outside) muscles of the thigh. The inside usually being weaker or placed at a mechanical disadvantage with the leg internally rotating through the walking or running cycle. Tight outer fascia or retinaculum of the patella can also contribute to pulling the patella outward. A leg that internally rotates with flattening of the foot also has this effect. Any imbalance results in the patella rubbing against the femur unevenly. The inflammation causes pain, swelling, further muscle imbalance and may lead to roughening of the cartilage of the underside of the patella.

Other factors that contribute to this type of pain include:

• Previous knee injuries 
• Poor lower limb biomechanics including pronated or flat feet, internal knee position (squinting patella), narrow groove in the femur, wide hips increasing femur angle (Q angle), asymmetrical patella, knocked knees 
• Tight outer leg muscles or fascia/retinaculum 
• Weak inner leg muscles 
• Enhanced training schedule 
• Surface terrain used for activity 
• Technique deficiency

Treatment

The treatment for this condition is aimed at reducing pain and inflammation and restoring the correct mechanics of the joint.

• Resting the knee i.e. avoid any activity that causes pain. Continuing painful activity will aggravate the condition. In particular, avoid activities such as squatting, kneeling, stairs, sitting for prolonged periods with knees bent etc.
• Ice therapy, applied with leg straight for 20 minutes 2-3 times a day and after any activity 
• Anti-inflammatory medication may be prescribed 
• Physiotherapy including ultrasound, electrical stimulation, taping and exercises 
• Appropriate assessment and correction for abnormal lower limb mechanics, including the effect of foot malposition requiring orthotic devices prescribed by the podiatrist 
• Correct muscle training, stretching and strengthening of the thigh muscles 
• Proper training principles i.e. warm up and down, gradual increases in activity level. Non-weight bearing activities such as swimming may be more appropriate during initial treatment. 
• Proper footwear for the nature of activity and foot type 
• Maintain desirable body weight
• Braces or supports to hold patella in groove 
• Possible surgery to release tight fascia, remove damaged cartilage or re align the angle of the patella tendon

Provided treatment is commenced prior to the onset of significant changes to the patella joint surface, conservative treatment has a high rate of success.

Description

An intermetatarsal neuroma is a type of nerve entrapment or irritation. It most frequently involves the forefoot nerve that supplies sensation to ball of the foot and adjacent sides of the 2nd and 3rd and/or 3rd and 4th toes, but can also affect other toes of the foot. A neuroma is a benign thickening of the nerve that develops when the nerve between two metatarsal heads is traumatised. A neuroma is a reactive, degenerative process. An intermetatarsal bursitis (inflamed bursa) is often in association and exacerbates symptoms.

Incidence

Women are affected at least four times more than men and the condition can affect adults of any age.

Symptoms

The symptoms vary in severity from an occasional pins and needles, numbness or burning sensation to a sudden pain on the sole of the ball of the foot, which can bring the sufferer to a halt. The pain frequently radiates forwards into one or two toes. A painful attack typically occurs suddenly after a period of walking or standing on a hard or possibly uneven surface. Shoes, which constrict the forefoot or are higher heeled, may precipitate or worsen the pain, and removing the shoe and massaging or squeezing the forefoot often gives relief as does rest.

Causes

Several factors contribute to its occurrence. Any condition that causes constriction or irritation of the nerve can lead to the development of an intermetatarsal neuroma. 

• Abnormal shearing stresses in the area due to excessive pronation/flattening of the foot 
• Unstable feet often associated with bunions etc 
• Highly arched feet with retracted toes. 
• Footwear which constricts the forefoot i.e. high heels 
• Trauma

Treatment

The goal of treatment is to reduce or eliminate symptoms as to maintain a normal lifestyle. It is expected that the vast majority will gain significant improvement from therapy. Treatment may be conservative (non-surgical) or surgical. Non surgical treatment is usually attempted before surgical intervention.

Conservative Treatment

• Padding and/or strapping to reduce the pressure of weight bearing on the affected area and also to improve functional alignment 
• Footwear recommendations 
• Appropriately designed orthoses or arch supports to restrain abnormal pronation 
• Physical modalities 
• Anti-inflammatory and analgesic medication as indicated 
• Cortisone injection or other injection therapy

These conservative non-surgical therapies may provide complete or partial relief of symptoms. However, on occasions minimal or no relief is achieved conservatively. This means that the condition is more sinister and requires more assertive treatment.

Surgical Treatment

A neurectomy or surgical removal of a neuroma is performed when conservative treatment proves ineffective. This can be performed by either local or general anaesthetic. The initial choice of incision is on the top of the foot to allow walking as soon as possible (as shown below). The procedure is usually on a day case basis. The decision to surgically intervene is based on the severity of symptoms following clinical review and diagnostic modalities.

Orthotics have been an integral part in the treatment of various foot and lower leg problems by correcting malposition or reducing the ill effects of faulty biomechanics. Research in this field has lead to advancements in the understanding of the biomechanics of foot function and hence improved rationale with treatment regimes. Foot orthoses have proved to be an important adjunctive or primary therapy for many individuals.

Orthotics are of either rigid, semi rigid or flexible in design and manufacture. This depends on the foot type and amount of control required. In some cases a rigid device may not be required but the podiatrist, following assessment, determines the appropriate course.

Pre manufactured insoles are used in some situations which can assist in certain circumstances where indicated, with the Podiatrist incorporating possible modifications. These are often used as a diagnostic indicator for more permanent devices. Custom prescription Orthotic devices have greater efficacy.

Prescription of orthotic devices requires biomechanical assessment by the Podiatrist to determine the problem to be addressed. Biomechanics is the study of the mechanical and physical laws which determines the way in which our body moves and functions. Problems can arise if the mechanical relationship between the foot, ankle, knee, hip and lower back is not correct. This includes both bony alignment and muscle function. These biomechanical anomalies can be rectified once identified.

Following the biomechanical and musculoskeletal assessment of the lower limb and foot, an impression or computer scan of the foot is taken. The Podiatrist then prepares this for prescription and custom manufacture of the orthotic devices in the Podiatry Orthotic Lab.

Biomechanical assessment of the lower limb is an integral part in the management of recreational and elite athletes in order to identify any predisposing factor to injury. You will note that many athletes or sports men and women use strapping and taping to minimise injury. In the same way, athletes with predisposing factors are often issued with custom devices to maximise them having a more appropriate lower limb alignment and function.

Some Common Conditions Assisted by Orthotics 

• Heel Pain 
• Foot and Ankle Pain and Recurrent Sprains 
• Flat Feet 
• Imbalance 
• Achilles Tendonitis 
• Other Tendonitis
• Shin Pain 
• Knee Pain 
• Hip Pain 
• Lower Back pain 
• Limb Length Imbalance
• Bunions and Clawed toes 
• Morton’s Neuroma

Definition

Hallux rigidus is a term used to describe a restricted amount of ‘upward motion’ or dorsiflexion of the big toe joint. The restriction of motion and pain associated with hallux rigidus is often attributed to a mechanical jamming of the joint and/or the presence of arthritis. X-ray investigation will often illustrate a loss of joint space with the presence of osteophytes (small bone fragments) and other indicators of arthritis.

Incidence

Hallux rigidus may affect the adolescent to adult populations but often early signs of limitation in joint function can be identified with certain foot types in the younger age group which may develop into significant hallux rigidus. This usually being a foot type that overloads the 1st toe joint.

Symptoms

These include the following with not all necessarily present; 

• Intermittent pain of the great toe joint that is worsened by activity 
• Pain may be exacerbated with high heeled footwear or cold, damp weather 
• Joint stiffness and decreased or loss of motion 
• Grating may be noted in the joint 
• Local swelling and redness 
• Pain over the bony prominence (exostosis) with footwear 
• Pain along the joint line 
• Callus and corns on the mid bottom region of great toe 
• A cocked up end portion of the great toe with possible nail distortion 
• Walking either intoed or out toed to prevent excess load on the joint 
• Pain of the ball of the foot due to walking differently and hence overloading this region 
• A bunion or angulation of the big toe towards the 2nd may be present 
• The flexing region of the sole of the shoe is more towards the toes than normal

Causes

Hallux rigidus may result from a number of different factors outlined below: 

• The mechanical jamming or impingement of the top (dorsum) of the big toe joint resulting in arthritis formation. 
• The shape of the metatarsal head 
• A long or short first metatarsal may result in increased pressure or abnormal forces through the joint 
• Elevated first metatarsal causing excess load and malfunction through the joint 
• A pronated or ‘flat foot’ 
• Trauma to the joint eg stubbing, sport or activity such as soccer, dance etc 
• Arthritic conditions such as rheumatoid, gout, joint infection etc

Treatment

• Anti inflammatory medication to assist in pain reduction 
• Mobilisation joint exercises in early signs of limitation 
• Local anaesthetic and or cortisone injections 
• Footwear modifications eg. Extra depth/width or rocker bar sole 
• Address biomechanical factors such as flat feet etc that cause overload of the 1st toe joint with appropriate insoles/orthotics prescribed by the Podiatrist 

Surgical procedures: May include some or all of the following

• Removal of excess bony spurs or fragments 
• Removal of inflamed joint tissue 
• Release contracted tissue to enhance joint motion 
• Removal of portions of damaged cartilage 
• Correcting position of 1st metatarsal 
• Removal of degraded joint surface and creating a modified and greater joint space to improve motion
• Possible joint implant 
• Fusion of the eroded joint

Dr Nick Marino, Podiatric Surgeon can assist you with this problem.

Onychomycosis

Onychomycosis is estimated to affect up to 1.6 million Australians. Current available treatments include topical antifungal nail lacquers that are applied daily/weekly and oral medications. The frustration of months of topical application and long term oral medication can lead to non-compliance and failed therapy. Oral medications can also produce adverse effects, limiting suitability.

Photodynamic Therapy

Photodynamic Therapy offers treatment not requiring medication or active patient involvement. Photodynamic therapy has now been developed and adapted for the successful treatment of fungal nails without damaging side effects.

How Does It Work?

Micro organisms including bacteria, viruses and fungi all possess a cell wall, whereas typical human cells have a cell membrane. Photodynamic therapy (PDT) involves the use of photochemical reactions mediated through the interaction of photosensitising agents, light, and oxygen. Following application of gel photosensitising agent, the pathological site is exposed to a specific wavelength of light (630nM). This mediates cellular toxicity/damage inducing fungal cell death without affecting surrounding tissue. The nail is restored with growth

Description

Plantar warts or plantar verruca are dense, benign lesions of the bottom or the weight bearing aspect of the foot caused by infection with the human papilloma virus (HPV). Verruca means “wart” and plantar means “the region of the bottom surface of the foot”. Once the skin is infected with the virus it may remain latent within the deep skin layers or develop and become clinically observable. The plantar verruca may appear in either a solitary, multiple or mosaic type pattern. It does not cross the blood barrier and therefore difficult for the body to fight the virus. Verruca may appear in other areas of the foot, for example on the top of the bridge etc but these have different characteristics to the plantar verrucae. They tend to be more prominent whereas the plantar verruca tend to be flatter because with weight bearing the wart gets pushed into the foot and becomes deep seated.

Incidence

Plantar warts may occur at any age but more commonly affect the young, elderly and immunosuppressed.

Causes

The wart virus may be attained with use of shared facilities such as swimming pools, sport centres and gymnasiums. Another method of inoculation may occur through a mechanical or micro injury of the skin. Hence wart infections are likely to occur during barefoot activities or when the skin has been wet for some time e.g. swimming, sweating and showering. Unfortunately as the virus may remain latent within the skin layers it is still able to spread to other hosts. It is also known that the virus is prevalent and difficult to treat in those with poor immunity.

Signs and Symptoms

Common features of plantar warts include: Loss of skin pattern, presence of many minute dark spots being the tips of blood vessels, callus formation, pain with compression and sometimes with weight bearing. Symptoms may vary from nil to severe pain and discomfort depending on the size and location of the plantar wart. Pain may be elicited with lateral compression of the verrucae. Spot bleeding may occur with removal or injury of the skin or callus overlying the wart due to its vast blood supply.

Treatment

In some cases the virus may regress spontaneously anywhere between 2 weeks to over 2 years but this is not predictable. If there is concern with the possible spread of the virus or pain is present from the wart, the following treatment options may be considered.

• Cryotherapy or freezing of the wart 
• Keratolytic agents to break down skin tissue 
• Caustic agents to chemically “burn” the wart 
• Electrocautery to destroy the lesion 
• Curettage or surgically “scooping out” the lesion 
• Surgical excision requiring stiches to close the wound 
• Others including: Homeopathy - zinc supplementation to boost immune, Cimetadine tablets (gastric ulcer tablets), Various chemical injections, Duct tape, Needling the lesion; Wives tail remedies (banana peel on the wart, taping a coin over the lesion)

Combinations of the above treatments may be considered in the event that the virus and or lesion is stubborn or becomes resistive to a particular treatment. The removal of a particular wart may prove successful but on occasions surrounding dormant virus may produce more warts, not necessarily being the original wart returning. Patience is required in the treatment of this condition. Healing at the site of the wart removal may take some time.

Description

“Shin Splints” is a term to describe shin pain along the front and or inner aspect of the shin associated with overuse or overload of the shin bone and or the adjacent muscles. The shin pain may be due to an increase in pressure within the muscle of the calf (compartment syndrome) or in some instances a result of inflammation of the lining of the shin bone (periostitis) and in extreme cases stress fracture of the shin bone.

Incidence

Shin pain can occur at any age and is most commonly seen in athletes or higher activity individuals, particularly in those involved in jumping or running activities.

Symptoms

• Pain along the inner and or outer borders of the shin 
• Pain may worsen with activity and ease with rest. 
• Feeling of deep shin pain and or persistently tight musculature 
• Pain may be elicited by pressing along the shin bone or its adjacent muscles 
• The shin border may have a localised region of greater pain 
• The shin border may have small areas of prominence associated with pain.

Causes

• Repetitive loading or overuse 
• Abnormal biomechanics of the foot and/or leg 
• Tight musculature 
• Training regime 
• Training surfaces 
• Footwear 
• Trauma

Treatment

Treatment may vary according to the causative factors of the individuals shin pain. Some treatments commonly utilised are:

• Rest and adjustment of training regime to reduce the impact on the shins and to prevent further damage 
• Anti-inflammatory medications 
• Assessment of foot and lower limb biomechanics 
• Foot strapping
• Orthoses 
• Myofascial therapy 
• Acupuncture or Dry Needling 
• Footwear advice 
• Physiotherapy 
• Surgical intervention may be required in some instances 

Prevention:

• Warm up before and after exercise 
• Improve muscle strength and flexibility 
• Avoid sloping and uneven surfaces 
• Gradual build up of training load, incorporate rest days 
• Address any abnormal biomechanical factors

Description

Tailors bunions are a common deformity of the forefoot. There is displacement of the fifth metatarsal bone outwards away from the mid-line of the foot and a simultaneous displacement of the fifth toe towards the fourth. This causes a prominence of bone on the outside or upper margin of the fifth metatarsal head region; this is termed a “Tailors Bunion” or “Bunionette”. Continued drifting of the fifth toe towards the fourth toe may force it into a clawed position and ride up over or under the toe. There are different stages of Tailors Bunion development, depending on the severity of the angulation of the fifth toe or prominence of the fifth metatarsal head. Arthritis can also develop producing pain within the joint.

Incidence

Tailors Bunions are common in people who have a family history of the deformity. Women are more prone to developing Tailors Bunions than men, most likely due to a predisposition to the condition, and sometimes triggered by poor footwear. Wearing narrow, tight, confining or high-heeled shoes can greatly accelerate the formation of a Bunionette.

Symptoms

• Redness, inflammation, pain and/or stiffness around the fifth toe joint 
• Moderate to severe discomfort at the Bunionette when wearing shoes 
• Calluses and corn development on the outside of the fifth toe or between the fifth and the fourth toe 
• There may be overlapping or under riding of the fifth toe 
• Skin over the Bunionette may breakdown causing an ulceration which can become infected

Causes

• Foot mechanics 
• Family history of Tailor’s Bunions. 
• Poor/tight footwear – particularly in those already predisposed to Tailors Bunions 
• Arthritic conditions
• Trauma or previous surgery around the 5th toe joint.

Treatment

Treatments vary depending on the severity of pain and deformity. The main goal of early treatment is to relieve pressure on the bunionette and smaller toes and to diminish the progression of joint deformities; 

• Padding the bunionette to protect the bony prominence from shoe pressure 
• Wearing correctly fitting footwear that have a wide and deep toe box. 
• Corns and calluses can be managed by podiatric treatment. 
• Medications, such as anti inflammatory drugs or cortisone injections may be used to ease pain and inflammation. This is especially useful if there is an associated bursitis. 
• Foot orthoses - realign the foot to a more “normal” position and can assist in balancing the muscles and tendons, stabilising the joint and halting or slowing bunionette development. 
• Surgery – When conservative treatment does not provide satisfactory relief from symptoms, when the condition interferes with activities, or there is concern with the foot shape, surgery may be necessary. Evaluation by a Podiatric Surgeon should be sought at the first sign of concern, pain or discomfort, so that severe deformity can be avoided.