To Your Health -- CHRC Newsletter

Fall 2002

Brad Naylor, DPM, M.S.
PAMF Podiatric Medicine & Surgery

The foot works as an organ for locomotion. It is a mobile adapter for the body above; it is used to absorb shock and to cushion various other joints or structures. It also functions at times (or not, in a variety of pathological states) as a rigid lever in the act of propulsion in walking or running. Therein lie many of the varieties of foot problems that affect 4 out of 5 of us in the course of an average life span. This article will review the more common foot ailments and some interventions that Podiatrists or other health care providers find useful to get the afflicted appendage and attached patient back on the road in good working order.

Plantar Fasciitis

Among causes of pain which bring a person to his/her health care provider, none rates higher than heel pain, which can often be tracked to poor mechanics and/or choice of shoes. Plantar fasciitis (PF) is one of the more common diagnoses made by all primary care physicians and specialists treating foot disorders. It is usually associated with pain upon first arising from a night's rest and recurring after short periods of rest. The essence of PF and most over-use syndromes is that the tissue affected has been injured, either acutely or over a long drawn-out period, to the point that the act of simple everyday walking only furthers the inflammatory point. In PF this inflammatory point is usually on the bottom and slightly inside or toward the body's midline aspect of the heel bone (calcaneus) (see Fig. 1). There, the plantar fascia attaches to the heel by way of an elaborate soft tissue netting system called the periosteum. This net, made of blood vessels and fibrous tissue, covers all our bones. It possesses a minute anchoring system with small nerve fibers that in PF are at the source of this sometimes disabling pain.

Figure 1

Often with age and/or over-activity, muscles and tendons become tight or less flexible, and thus prone to having an excessive pulling effect on the attachment points of tendons. Commonly, the Achilles tendon, due to strong calf muscles that are used with everyday walking, becomes tighter with age and can cause early pull on the back of our heels. As one walks or runs, there is particular flexion at the ankle joint that is required for normal gait. This flexion should normally reach near to 10 degrees past the vertical "neutral" standing position. If there is an early pull from the tightened calf muscle and involved tendon structure, the heel is pulled upward from the posterior attachment of the Achilles and causes tension on the bottom of the heel at the plantar fascia attachment. This early pull or limited available flexion, "dorsiflexion", at the ankle joint is often referred to as an Equinus condition. Again, through this abnormal tightness and pulling on the back of the heel in an earlier point in the gait cycle, the plantar fascia is pulled, much like a strut or cable in a suspension system, and the periosteum is aggravated. Equinus can play havoc on the foot in a variety of ways. This abnormal and very strong force can lead to hyperpronation (rolling the foot too far inward) in a marginally unstable foot type. Hyperpronation is responsible for many other conditions affecting the foot and ankle.

In treating PF, one needs to address a few different areas affecting the foot and its function.

First is giving careful attention to supportive shoes with desirable features such as a stable or stiff heel counter (point of heel resting against back of the shoe), lace up varieties and stiffness in the shank area. This last shoe characteristic can be assessed in various ways, but usually a simple twist test can reveal how stiff the shank is. The more flexible or twistable the shoe is, usually the more flexible the shank is; thus the less the shoe will prevent pain from PF. The shoe can also be beefed up a bit with over the counter arch supports or functional foot orthoses in some instances. In this same realm, walking barefoot, wearing slippers or sandals contribute to PF becoming chronic.

Secondly in the treatment, proper stretching of the gastrocnemius (calf muscle) or Achilles tendon is usually paramount to long-term resolution. Done properly, stretching can neutralize the driving force of premature elevation of the back of the heel and, therefore, reduce the repetitive tension exerted on the plantar fascial attachment. This stretching can be performed thus: lean forward against a wall, with one foot placed behind the other, slightly "in toeing" the back foot, keeping the heel on the ground and the knee straight. Keep the front leg slightly bent at the knee. Hold the stretch for 10-15 seconds, feeling the pulling sensation in the upper calf muscle. Repeat this 15-20 times daily. Anti-inflammatory measures are also used in the treatment of PF.

I usually promote the use of direct ice massage for 10-20 minutes, one to three times daily, depending on activities and severity of pain. If one is actively participating in walking /running activities, the need for protective or anti-inflammatory measures will certainly be greater. Other
anti-inflammatory measures could include oral non-steroidal anti inflammatory medications or corticosteroid injections. The use of corticosteroid injection should be discouraged as first line treatment, because it may result in the worsening of the soft tissue injury and increased pain.

Plantar fasciitis is often aggravated by excess weight and ill-fitting shoes, but proper shoes, stretching and anti-inflammatory measures can aid in the steady diminishing of symptoms.

Bunions (Hallux Abducto Valgus)

Bunions are common in early or late adult life, but occasionally occur in young children or teens with strong family (genetic) history. Bunions are prominences usually at the base of big toes, either directly on the side or on top of the 1^st Metatarsal (long bones in feet). Bunion deformity usually occurs as a result of muscle and bone movement to dissipate forces applied in the act of walking. This "biomechanical" force is responsible for approximately 70% of bunion deformities. But shoes can aggravate or secondarily contribute to developing symptoms associated with bunions. Shoes are rarely, if ever, the sole cause of developing the deformity.

Conservative treatment of bunion pain is aimed to reduce the "force" affecting the foot by decreasing the degree of hyperpronation, again with stretching and shoe mechanical factors previously described. Patients usually entertain shoe therapy long before seeking professional consultation. Two additional factors in shoes are lasts from which the shoes are made, and the shape and height of toe box area. The last of a shoe is simply the relationship of the back of the shoe to the front. There is commonly an angle or curvature in the soles of many shoes when viewed from the undersurface. This relative change in back (rear foot) to front (forefoot) of the shoe is usually described as either more adductus (more angulated relationship of rear foot and forefoot portions) or rectus (straight) (see Fig. 2). Feet, like shoes have these same characteristics, some being more adductus, and some more rectus. One can imagine the pain or symptoms caused by improper shaped shoes. The toe box shape comes into play by causing or aggravating toe deformities. Pain of mild digital deformities, often caused by a callus or extra skin build-up at the toe joints, can be reduced with roomier or higher toe box shaped shoes. Surgical treatment is often recommended if pain continues. Usually, surgery is geared towards muscle/tendon - bone re-balancing rather than simple bunion/bump removal.

Figure 2

Ingrown Nails

Ingrown nails (onychocryptosis) commonly result from faulty nail trimming habits. In this condition the shape of the nail is usually more curved (incurvated) and the nail edge is being driven into the flesh, causing pain. In an attempt to trim the offending edge, often one has simply either missed or been unable to get the entire nail edge, leaving a spicule (nail spike), which causes further pain and, often, infection. Antibiotics are sometimes needed, but usually the problem is dealt with by temporary removal of the nail spicule. This approach is similar to the body's reaction to any foreign body: the offending matter needs to be removed for resolution of the pain/infection. Onychocryptosis often becomes a chronic state, where the simple incurvated shape of the nail causes incredible pressure and thus pain. This is often the result of years of rounding the incurvated edges of the nail plate in an attempt to reduce symptoms. This perpetual habit allows nearby skin to be pushed into a void where the nail pain exists and to "train" nail re-growth to become slightly more curved. This problem can be eliminated or corrected with a small surgical procedure involving local anesthesia and removal of the portion of the nail and nail root (matrix).

Fungal Nails

Fungal infections of nail plates are usually caused by either dermatophytes (athlete's foot organisms) or saprophytes (molds). Initially, nail plate thickening can be marginally uncomfortable; more often it is simply unsightly, but it can eventually lead to considerable thickening and pain. Treatment varies but usually involves some shoe considerations, including toe box room and periodic shoe disinfection. This can easily be done with a mixture of bleach and water (50:50 ratio), finely misted inside shoes once a month and allowed to air dry in direct sunshine. Additionally, various topical versus oral medications can be implemented. Manual reduction by either a podiatrist/health care provider, or by oneself trimming the nail after a shower or bath, can aid in reducing pain. A note on oral anti-fungal medications: despite considerable pharmaceutical advertisement, risks do exist and recurrence is as great or greater than 50% at two years after treatment. This is largely due to the existence of fungi in our environment and the failure of the immune system to recognize and fight repeat infections.

In summary, a variety of insults occur on a regular recurring basis to our feet. It is only when they bother a fair number of us that we stop to think about the punishment that we give our feet and the need for simple periodic maintenance. Many of the developmental problems seen in feet can be prevented with daily hygiene, rotation of good supportive shoes, especially if one is engaged in considerable ambulating, either walking, standing or hiking, and by regular stretching of gastrocnemius/Achilles tendon. Foot pain is a common aspect of getting older as we place more miles on our wheels. However, much can be done to prevent foot pain.