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Common Foot Problems

Heel Pain

Plantar Fasciitis

Plantar Fasciitis is the most common cause of heel pain. The typical description given is pain at the bottom of the heel which is often worst first thing in the morning. Onset of pain is usually gradual and insidious, the condition can become chronic and at times can be very painful. The term plantar simply means the bottom or sole of the foot. Fasciia is a type of strong connective tissue; Ėitis indicates 'inflammation of'.

The plantar fasciia is a band of very strong connective tissue extending from the ball of the foot back to the heel. If you pull your toes up and back, the plantar fasciia can be felt as a taut band across the sole of the foot. The insertional attachment of this tissue at the bottom of the heel is the weak point Plantar fasciitis is simply a local sprain of this tissue at the bottom of the heel.

Hyper-pronation is usually the cause. Pronation is a normal process by which the foot absorbs the impact of walking and other activity and adapts to terrain change. During hyper-pronation, however, the arch collapses excessively which actually lengthens the sole of the foot and places excessive stress and strain along the plantar fasciia. This can cause eventual injury of the tissue - plantar fasciitis.

Effective treatment must provide both relief of current pain and long term prevention of recurrence. Immediate rest of the foot is essential for healing, activity level must be reduced for a short time. Specialized taping, local icing with massage, and light stretching can all help to reduce current pain. Over the counter or prescription anti-inflammatory medications (Rx NSAIDs) can be helpful when safe for the individual patient; a direct local steroid injection will usually provide rapid and dramatic relief of pain and avoids the potential complications associated with NSAIDs.

However, these treatment options do not relieve the underlying strain on the tissue and can prove to be temporary. Long term pain relief and prevention of recurrence is the role of an orthotic. A foot orthotic is a supportive insole device that fits in the shoe. Many patients begin with a simple over-the-counter arch support.

A custom orthotic is directly made from a mold taken of the individual patientís foot. Custom orthotics provide superior support to the foot compared with an inexpensive off-the-shelf device and are almost always the long term cure for heel pain. Experience and proper casting technique are essential for fabrication of a custom orthotic. Glacier Foot and Ankle provides exceptional custom orthotics for long term pain relief. Our custom graphite orthotics are very thin, strong and supportive yet flexible, will fit into almost all shoes and will last for many years.

For the most resistant cases of heel pain, surgery can be performed. However, in our experience, surgery is rarely required for the relief of plantar fasciitis.

Posterior Heel Pain / Insertional Achilles Tendonitis

Insertional Achilles Tendonitis is pain at the back of the heel, the posterior heel. Often due to overuse, the attachment site of the Achilles tendon at the posterior heel is injured which leads to local pain and inflammation. With long duration of inflammation, calcification can develop in damaged tendon fibers and a posterior heel spur can then be seen on x-ray. Heel spurs and tendon calcifications can often develop micro-fractures causing increased inflammation and chronic pain.

A tight Achilles tendon can be a contributing factor. Patients with an underlying systemic arthritic condition may have weakened collagen tissue fibers and are often at increased risk for this Achilles tendon injury. The patient may recall a distant past history of injury, and a more recent increase of activity then sets off the current condition. Many patients however, due not recall the exact moment of onset. Posterior heel pain can often become chronic and, in some cases may last for years.

Activity reduction, rest, local icing, stretching and use of appropriate shoes are essential. Anti-inflammatory medications (NSAIDs) may be used to relieve pain as necessary. Steroid injections are not recommended vs. posterior heel pain due to the possible risk of Achilles tendon rupture. Physical therapy can prove beneficial for those with a tight, contracted tendon or other associated muscle weakness. A short period of cast immobilization for several weeks is often required to reduce the chronic inflammation and provide local pain relief. This is usually a walking cast, crutches rarely prove necessary. Immobilizing the foot and ankle at 90 degrees takes the repetitive daily propulsive strain off the Achilles tendon and allows the insertional attachment site to heal.

For the most difficult and recurrent cases, surgical lengthening of the Achilles tendon with removal of posterior heel spur can be necessary. Dr. Ploot at Glacier Foot and Ankle has extensive experience with both conservative care and surgical repair of this condition and can help provide relief of posterior heel pain.

Juvenile Calcaneal Apophysitis (Severís Disease)

Juvenile Calcaneal Apophysitis, also called Severís disease is an inflammation of the growth plate in the heel of growing children, typically adolescents. The typical patient is an athlete from 8-14 years old. This condition tends to be seen in more physically active children and is often aggravated upon beginning a new season in sports such as soccer, basketball, lacrosse. Upon the end of a season or with decreased participation, the intensity of the condition decreases and may resolve until beginning the next sport.

For most children, intensity of pain is dependent upon activity level with the most strenuous sporting games proving difficult to play. Some players can be in tears at the end of a game, as much from frustration as the pain, these kids want to play. The Achilles tendon attaches one of the bodyís strongest muscle groups to the back of the heel. In children, there is a cartilaginous growth plate between the main body of the heel and the much smaller attachment site of the Achilles tendon. In active children, this growth plate can become irritated by repetitive activity.

Rest, icing, stretching and appropriate shoes are all necessary to reduce inflammation and pain. Athletes must be counseled to warm up prior to vigorous exercise and stretching and should have rest days between practices and actual games. Many children athletes can continue to participate in their favorite sports and simply need to decrease the intensity of running and practice. The decision to actually discontinue a sport is not usually necessary and can bring on more tears than the heel pain itself. All kids wish to continue to play but require guidance as far as level of intensity of participation.

For stubborn, recurrent cases a short course of cast immobilization in a walking cast is by far the most effective treatment option. As the child ages, the growth plate will eventually close and the condition will then no longer recur.


Ingrown toenail

A painful ingrown toenail may be caused by an injury or improper cutting technique, but most often is simply due a hereditary characteristic of an in-curved toenail border. This problem often runs in the family. A curved in toenail can cut through the skin and then grows into the tissue around the nail. Due to the warm, moist environment inside a shoe, a secondary bacterial infection may then develop and leads to significant local redness, swelling and pain. Trimming back the toenail, local application of hydrogen peroxide, epsom salt soaks and topical antibiotic ointments can help reduce the local infection. Only in the most severe cases are oral antibiotic medications actually necessary. The nail border must be trimmed back or removed. Antibiotics and soaks alone will provide only partial and temporary relief, the border must be removed out of the irritated tissue.

Permanent toenail removal will resolve the current problem and prevent recurrence. Usually only the border or edge of the toenail is removed; the procedure provides immediate relief. Once healed the site is not even noticeable, it looks just fine afterwards. The procedure is quick and post-op care is simple, requiring just a small dab of wound cream covered with a band-aid, changed twice daily for a couple weeks. Pain is minimal to non-existent. As far as recovery, just a day or two of slight decrease in activity is needed; no loss of work or absence from school required. Glacier Foot and Ankle performs permanent toenail removal daily. A patient with an infected ingrown toenail can generally be worked into the schedule the same day if needed. Dr. Ploot has 15 years of experience perfecting the technique.

Toenail Fungus

Toenail fungus (onychomycosis) is a stubborn, chronic infection that leads to increased thickening, color change and destruction of the toenail. Fungal toenails can be unsightly, embarrassing and are often painful due to the increased build-up of fungal debris under the toenail. The infection has been notoriously difficult to eradicate; there is no simple cure. The condition is very common, eventually affecting most adults: onychomycosis is estimated to affect up to 35 million Americans. The most common infecting fungal organism is trichophyton rubrum, a dermatophyte.

Treatment options:

  • Periodic toenail debridement (nail reduction / trimming / grinding)
  • Daily topical antifungal nail lacquer application
  • Oral antifungal medication (Rx Lamisil -Terbinafine)
  • Pinpointe toenail fungus laser treatment
  • Permanent toenail removal

During treatment of any chronic infection involving the skin and nails of the feet, shoes must be periodically sanitized, as shoes will harbor the infection. The Steri-Shoe is an Ultraviolet shoe sanitizer, simple and effective this kills most germs within the shoe. Topical antifungals require prolonged continuous daily application to effect any change in appearance of the toenail, used alone they have a low success rate. Oral systemic antifungal medications are more effective. Prescription medications such as Rx Lamisil (terbinafine) achieve greater success and may result in clearing of the nail fungal infection approximately 50 - 70% of the time. Although quite rare, cases of liver failure, some leading to liver transplant or death, have occured with the use of Lamisil tablets in individuals with and without pre-existing liver disease. A baseline liver panel test is required.

The Pinpointe Laser treatment can also result in clearing of the toenails up to 70% of the time. The Pinpointe Laser treatment is safe with no history of burns or injury, the technology and procedure is FDA approved.

Any and all treatment options can give inconsistent results depending upon the duration and extent of infection. Mono-therapy utilizing a single treatment option alone will often fail.

A comprehensive program utilizing a combination approach including Pinpointe Laser treatment, a course of oral Rx Lamisil, daily application of topical antifungal lacquer to the toenails and antifungal cream to the skin, and regularly sanitizing shoewear will have the greatest chance for success and clearing of stubborn toenail fungus.

Corn / Callus

A corn or callus is a localized thickening (hypertrophy) of the skin in response to pressure. A corn or callus can become very painful in shoes and with activity. Although most are non-threatening, for some patients such as Diabetics or older patients with decreased circulation, these skin lesions can be the precursor for an open wound and infection.

When subjected to constant pressure and friction, skin will either gradually grow tougher and thicker or blister and breakdown. The medical term for thickened skin is hyperkeratosis. The causative pressure on the area is usually due to poorly fitting shoes or a digital deformity such as a hammertoe. Heel calluses form and thicken due to friction inside a shoe while walking. Increased activity leads to thicker and more painful hyperkeratosis.

A callus is a more generalized and spread out hyperkeratosis such as under the ball of the foot. One particular lesion, a porokeratosis, can feel just like a little rock imbedded in callused skin under the forefoot, they can be very painful to walk on. A corn is a harder, more localized lesion such as directly over the knuckle or the tip of a hammertoe deformity.

All of these painful lesions can be relieved with debridement, trimming the skin with a sterile scalpel blade. This must be performed with care on Diabetics or elderly patients. These patients in particular must avoid the use of medicated corn remover pads; the salicylic acid contained in the medication can cause an injury, eroding through delicate skin and forming an open wound.

Most painful corns and calluses will recur unless the inciting pressure is relieved. Avoiding constrictive shoes, use of cushioned insoles or soft digital pads can help to prevent or slow recurrence. Urea containing moisturizing creams (Kerasal) or lotions can help soften and ease forefoot and heel calluses. Regular use of an emery board or pumice stone can reduce the gradual thickening of the skin. Most patients simply need to return to the office on an as-needed basis for debridement of a painful callus.

Many painful hammertoe deformities and inter-digital corns can be permanently relieved by a simple in-office surgery. Usually this involves either removing a small portion of prominent bone or releasing a tightly contracted tendon. The procedure is performed under a local anesthetic block of the toe. The post op care regimen generally involves daily dry band aid change, buddy taping to the adjacent toe and use of a protective walking shoe for a couple weeks. Pain is usually minimal. Dr. Ploot has performed these procedure since 1999 and can individualize a conservative care or surgical repair plan for each individual patient.

Wart

A wart (verruca) is a painful thickened growth in the skin caused by a viral infection. The lesion typically has a roughened cauliflower type appearance. Warts vary in size, may be single or multiple, and can grow larger. The infecting virus is HPV, the human papilloma virus. The virus is contagious and can spread, although the type that causes a wart on the foot generally prefers the plantar surface (sole) of the foot. The virus can enter through areas of dry damaged skin. The visual appearance is quite different from that of a corn or callus, although a wart is often confused with these other skin lesions and vice-versa. The lesion may spontaneously disappear although many can last for years. Any wart can recur.

There are a number of treatment options, none of which are always effective. Salicylic acid drops or impregnated pads, blistering agents, cryotherapy (freezing), Rx Aldara and surgical excision are all potential options. Salicylic acid and over-the-counter cryotherapy units can be effective versus small new lesions. The skin on the sole of the foot is very thick, so longstanding lesions are much more difficult to eradicate with these simpler treatments. Surgical excision, cutting out the lesion, is usually effective and is the recommended treatment in most instances. Just the outer epidermal layer of the skin is removed, the dermal layer is not infected and is left intact. Since the dermal layer is not disturbed the risk for infection or scarring is very low. Some warts are simply too large or numerous to excise. Rx Aldara (imiquimod) is a topical cream which helps the bodyís immune system fight the virus.

The prescription can be quite expensive, make take several months of application to be effective and has been associated with some side effects. Prescription Aldara has proved quite effective in select cases. Size and number of warts, duration of infection, patient age and treatment experience are all considerations when choosing the appropriate treatment course for a patient.

Forefoot pain

Bunion deformity

Hammertoe deformity

Tendonitis

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Glacier Foot and Ankle Associates
95 Indian Trail Road Kalispell, MT 59901
406-755-1300

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