Foot Care Carol L. Tran Duke, DPM When we consider the things in life that cause us discomfort or interfere with our usefulness and enjoyment of life, we discover that our feet are often the culprits. Corns and hammer-toes and plantar warts are just a few examples of the little things that often cause big problems. In this chapter, Carol L. Tran Duke, Doctor of Podiatric Medicine, discusses many of these problems. Dr. Duke suggests ways not only to avoid problems with the feet, but describes many things one can do at home to manage problems when they develop. Where appropriate, additional alternate treatment options are suggested by the editor. (Editorial comment) Chapter contents A) Tinea pedis (athlete s foot) B) Plantar warts C) Onychomycosis (fungi in nails) D) Ingrown toenails E) Subungual hematoma 1 / 17
F) Plantar fascitis G) Plantar fibromas H) Ganglion cysts I) Achilles tendonitis/rupture J) Mallet/hammer/claw toes K) Bunions L) Rigid toes M) Metatarsalgia N) Neuroma O) Charcot foot P) Diabetic foot care 2 / 17
A) Tinea pedis (athlete s foot) Tinea pedis is a fungal infection of the skin on the feet. It can occur through a break or cut in the skin. Warm, moist environments (shoes, socks, locker rooms, and public shower) encourage fungus to spread. The first line of treatment consists of attempting to keep the feet dry. Avoid shoes that cause the feet to sweat. Use clean, dry socks at least daily. Many natural agents are available for treating fungus infections (Section III, chapter 13, J). When secondary infection is present as manifest by pain, swelling, redness, etc., healing may be hastened by using drying soaks several times daily (Section VII, chapter 3, G). A number of products available over-the-counter are often very effective. B) Plantar warts (warts on the sole of the feet): Plantar warts are caused by a virus invading through tiny cuts or breaks in the skin. These lesions are benign and occur on the bottom of the foot. They can become very painful especially on weight bearing areas or on areas that come in direct contact with shoe gear. 3 / 17
1. Diagnosis Plantar warts are skin-colored and have tiny brown or black pinpoints. These are the blood supply to the warts. 2. Treatment (Section III, chapter 13, D) Note: It is necessary to shave any callous that is present overlying the wart before applying chemical agents or duct tape. C) Onychomycosis (thickened nails) Onychomycosis is an infection of the fingernails or toenails caused by a fungus, yeasts, and molds resulting in thickened, discolored, brittle, and disfigure nails. Nails will often split as well. When nails become too thick, any pressure from shoe gear will cause pain. To control or treat fungal nails with topical medication, you need to daily file nail and apply an antifungal topical solution (Section III, chapter 13, J) (Section VII, chapter 3, F). Filing the nail or scraping with the sharp edge of a piece of glass will allow the medication to be absorbed deeper. This route will take a number of months of daily attention, and may not always be effective since the fungal nails tend to be so thick that often time, the medication cannot be well absorbed. To prevent pain from shoe pressure, maintain nails short and file daily to prevent thickened nails. 4 / 17
To prevent recurrence once the condition is resolved, maintain good foot hygiene with changing socks daily, alternating shoes to allow drying of the inside of the shoes, drying between the toes, and using foot powder to absorb sweat. 2. Indications for professional help Fungal nails can also be treated with oral medication, such as lamisil or sporonox. A physician must prescribe these medications and monitor your liver enzymes. D) Ingrown toenails Ingrown toenail occurs when the nail grows into the skin or when the skin on the side of the nail grows over the edge of the nail. Ingrown toenail results from incorrect trimming of nails, narrow shoes, tight socks or stockings, and trauma (stubbing the toe). The condition may cause pain and redness of the skin on the side of the nail. If untreated, the nail may invade the skin and cause a bacterial infection of the skin. 1. Prevention To prevent ingrown toenail, trim nail straight across rather than rounding it to correspond to the shape of the toe. File the sharp or rough edges. It is very important that the whole nail be allowed to grow out past the end of the toe. Avoid narrow shoes and tight socks/stockings. 2. Treatment There are many over-the-counter preparations to prevent and treat ingrown nail. One way is to wash foot in warm soapy water. Pat foot dry. Then trim the ingrown nail edge, and smooth the new edge. Next, apply an antibiotic ointment and a gauze or band-aid. If there is drainage present, soak foot daily in warm water with or without Epson salt until resolution of discharge. 5 / 17
3. Indications for professional help Call your healthcare professional if the nail continues to be painful with red, swollen skin, and discharge. The toenail may be infected and a portion may need to be removed by performing a minor nail procedure. If ingrown toenail recurs often, you may need a permanent nail procedure, in which part of the nail and its matrix are removed with a chemical application or a surgical excision. Both are performed as minor procedures. E) Subungual hematoma (blood under the nail) Subungual hematoma is a collection of blood that occurs between the nail bed and nail plate due to trauma to the nail bed. The nail bed will appear red or blue beneath the nail plate when injury is acute. After 5 7 days, the discoloration will turn brownish-black. Pain can occur when there is pressure under the nail plate due to the hemorrhage. For simple subungual hematoma, regardless of size, leave the nail alone and observe for healing. In contrast, if subungual hematoma involves more than 50% of nail and throbbing pain persists, drainage of the hematoma may be necessary. This is easily accomplished by taking a metal paper clip or similar stiff metal wire, heating it red hot with a flame, and touching the center of the nail, melting a small hole through the nail and allowing the blood to escape. Pain relief should be prompt. 2. Indications for professional help 6 / 17
Subungual hematomas are often accompanied by a fracture of the toe bone. If this is suspected, professional consultation is in order, especially if one has diabetes or any circulatory problem. F) Plantar fascitis (painful heel) Plantar fascitis is inflammation of a band of connective tissue (plantar fascia) attached from the heel bone to the ball of the foot. Pain is usually present at the center aspect of the bottom of the heel bone. Pain can also be present along the plantar fascia (mid-arch of the foot). Pain is usually most pronounced with the first few steps in the morning. Over time, pain is aggravated with prolong walking or standing. A spur may form on the bottom of the heel as a result of chronic pulling of the plantar fascia away from the heel bone. Conservative treatment for plantar fascitis includes rest, ice, and supportive shoes. Over-the-counter inserts may be used to alleviate and control pain by providing support for the plantar arch. Custom-molded orthotics are highly recommended since they are specific for each person s foot. Stretching tight calf muscles will also alleviate pain and inflammation. Hot and cold soaks several times daily may hasten healing (Section VII, chapter 7, Q). Warm poultices may prove very helpful in relieving pain and helping healing (Section XI, chapter 1 U). 2. Indications for professional help If pain persists, heel injections with local anesthetics and corticosteroids may be necessary. 7 / 17
Wearing night splints to prevent muscles from tightening is another option. G) Plantar fibromas (lumps on bottom of feet) Plantar fibromas are seen as soft tissue bumps on the bottom of the foot along the plantar fascia. They feel thick and cord-like on palpation. These lesions are benign, but can be painful on weight-bearing areas. To treat these lesions conservatively, use accommodative padding or cut-outs to off-weight direct pressure on them. To do this, obtain a thick piece of felt cloth or similar soft, but substantial material and cut it to fit in the shoe. Then cut a hole in the padding at the site of the tender, painful nodule. Custom-molded orthotics with accommodative depressions are also recommended. Lastly, surgical excision can be performed to remove these lesions. However, recurrence is common. H) Ganglion cyst A ganglion cyst is a benign soft tissue mass, usually found on the top of the foot. It is round and non-mobile. They occur over tendons or joints in the foot. They are usually painless, but can at times cause pain and restrict joint motion. Treatment is aspiration of the lesion with a large, sterile needle, or surgical excision. However, recurrence is common. I) Achilles Tendonitis/Rupture The Achilles tendon is the tendon that connects the leg to the foot. It lies in the back of the leg 8 / 17
and attaches to the heel bone. Pain and swelling in the back of the heel can be caused either by inflammation, partial, or complete tear of the Achilles tendon. Inflammation usually occurs at the insertion of the tendon into the back of the heel. This is due to overstressing of the tendon. Over time, this can result in partial or complete tear of the tendon. Complete tear of the tendon can also be caused by trauma or direct injury to the tendon. Improper shoe wear (high-heels), improper training, or inadequate warm-up, and sports activity requiring sudden starts and stops can incite Achilles tendon injury. In the presence of an Achilles tendonitis or partial rupture, the tendon is completely or mostly intact. In contrast, in a complete rupture, there is a discontinuity of the tendon along the back of the leg. Furthermore, the injured leg is unable to move the foot down. To treat tendonitis, rest, ice, compression, and elevation is recommended. Limit or stop the inciting activity. Orthotics can provide stability and support to alleviate pain. Heel lifts can also decrease and control pain by decreasing stress on the tendon. If above therapy does not resolve pain and swelling of tendonitis, casting with complete non-weight bearing of the effected leg with use of crutches may be necessary. A partial tear and complete tear also require casting with non-weight bearing. Following the acute phase, alternating hot and cold soaks may hasten resolution of inflammation (Section VII, chapter 7, Q). 9 / 17
Poultices may be used in addition to the above measures to reduce inflammation (Section XI, chapter 1 U). 2. Indication for professional help Nonsteroidal anti-inflammatory medications can also reduce pain and swelling. Surgery may also be necessary and is often recommended in active individuals who have complete tear. J) Mallet/hammer/claw toes Mallet, hammer, and claw toes are curled toes caused by biomechanical dysfunction in the foot as well as improper shoes and stockings. Shoes that have high heels, narrow toe box, or short length cause toes to jam against the front of the shoes. This results in bending of one or more joints. There are three bones in each of the four smaller toes. Mallet toe is a deformity of the joint closest to the tip of the toe; hammertoe is a deformity at the joint in the middle of the toe; and claw toe is a deformity of the joint at the base of the toe. Other causes of these deformities are trauma, rheumatoid arthritis, and neuromuscular disorders. 1. Symptoms Pain is usually present at the tip or on top of the toe. Pain is also present on the ball of the foot. There also may be corns or calluses associated with these deformities. Corns are hard skin growths that form on top of the toes where the toe rubs against the top of the shoe. In contrast, calluses form under the tip of the toe or on the ball of the foot. 2. Treatment Conservative treatment of mallet, hammer, and claw toes consist of wearing shoes with wide toe boxes or extra-depth to prevent painful friction rub of shoe on toe. Also wear shoes with padding to prevent and reduce callus pain and formation. Lastly, avoid high- heeled shoes since 10 / 17
they jam the toes against the end of the shoes. Over-the-counter gel inserts, toe pads, splints, or tube foams can accommodate the area of tenderness and deformity on the toes. Corn and callus can be filed down by soaking the foot in warm water to soften the hard skin. Next, gently dry the foot and use a pumice stone or a nail file to rub on the hard skin. Afterwards, apply lotion to the areas. 3. Indications for professional help If the above conservative therapies do not relieve pain from the deformity, surgical correction may be necessary. Surgery may involve removing the prominent bone or fusing the joint to straighten the toe. K) Hallux abducto valgus (bunion) Bunion is a bony bump that occurs on the inner side of the foot at the base of the big toe as a result of the migration of the big toe toward the little toes. Bunions are a result of altered biomechanics of the foot, pronated foot type (flatfoot), trauma, arthritis, improper shoe gear (tight, pointy-toed shoes), and hereditary. Bunions can be mild, moderate, or severe. Bunions can be painful and aggravated by tight or narrow shoes. The skin at bunion site may become red, and swelling may occur in the big toe joint. Calluses may also occur due to chronic friction irritation. As the bunion progresses, it may cause displacement of the 2 nd toe resulting in 2 nd toe sitting on top or under the big toe. Chronic bunion deformity can also lead to arthritis of the big toe joint which is painful on range of motion of the big toe (hallux limitis/hallux rigidus). Conservative treatment of bunions consists of wearing wide shoes or using padding to 11 / 17
accommodate or cushion the bony prominence. Application of ice to bunion may also relieve some pain and swelling. Using custom-molded orthotics may also help prevent the progression of bunions. Gel inserts, pads, cushions, etc., may protect prominent points from friction and help relieve pain. 2. Indication for professional help If pain is not resolved with conservative therapy, patients may need evaluation for surgical treatment. Surgical treatment may involve only resection of the prominent bunion bump. For more severe deformities, additional surgical bone cut(s) into the metatarsal bone may be necessary to help realign the bone and joint. L) Hallux limitus/rigidus (rigid toes) Hallux limitis is a deformity in which there is a decreased range of motion of the big toe joint. This limitation may cause pain while walking. Normal range of motion of the big toe joint is normally between 65 75 degrees. One common cause of hallux limitus is trauma. A bony prominence can be seen on top of the foot at the base of the big toe where it articulates or moves with the first metatarsal bone. Conservative treatment for hallux limitus can be a rocker bottom shoe that aids the foot to roll without requiring the joint to move too much during walking. Another method is by using custom-molded orthotics with an extension to limit motion at the joint. 12 / 17
2. Indications for professional help If pain is not alleviated with conservative therapy, surgical treatment may be required. Surgical procedures such as cleaning the joint space, increasing the joint space, fusing the joint space, or replacing the joint with a spacer (joint implant) may be used depending on the patient. M) Metatarsalgia Metatarsalgia is pain on the bottom of the foot caused by prominent metatarsal head(s). Pain is aggravated on weight bearing. Prominent metatarsal heads may be due to an enlarged bone, an excessively long metatarsal bone, or a metatarsal bone that is lower than the remainder metatarsals. Other conditions causing metatarsalgia are hammertoes, rheumatoid arthritis, decreased fat pad, or a fracture of metatarsal bone that healed in an incorrect position. Treating metatarsalgia requires wearing well-cushioned shoes. Low-heeled shoes are recommended. Calluses may be gently trimmed with pumice stone. Over-the-counter metatarsal pads and inserts can also provide pain relief. Custom-molded orthotics with accommodation for the calluses are highly recommended. Surgery may be necessary when the above accommodative methods do not relieve pain. N) Neuroma A neuroma is a benign enlargement of a nerve between metatarsal bones on the bottom of the foot caused by compressive forces. If a neuroma is large enough, it may cause the toes to spread apart. 13 / 17
A neuroma will give a feeling of walking on a lump in the shoe or a wrinkle in the sock. Mild swelling may also be present in the area on the bottom of the foot. A neuroma may cause sharp, dull, or throbbing pain. The pain may also radiate to the toes causing numbness to the affected adjacent toes. Pain is aggravated by shoes (especially narrow shoes) and is relieved by taking shoes off, messaging the forefoot, and wiggling the toes. Neuroma pain can be alleviated and treated by wearing wider shoes. Metatarsal pads or inserts with metatarsal pads can spread out metatarsal bones to prevent irritation on the nerve. In addition, injection of local anesthetics and a corticosteroid can be performed between the metatarsal heads. Injection with dilute 4% alcohol solution may also be considered. Lastly, surgery may be necessary if the above conservative therapies do not resolve pain. O) Charcot foot Charcot foot is a complication of diabetic neuropathy in which there is a loss of sensation in the foot. As a result, minor trauma in the foot goes unnoticed and untreated. Over time, repeated trauma weakens the structure of the foot and can lead to foot deformity. Charcot foot is commonly seen as a red, hot, and swollen foot. There may also be a collapse of the arch causing the foot to become rocker bottom. As a result of the collapsed arch and misaligned bones, there may be callus formations over the abnormal bony prominences in the foot. Callus formations can lead to ulcerations in the foot. Treating Charcot foot requires strict non-weight bearing of the effected lower extremity in a 14 / 17
below knee cast. The cast may be necessary for several weeks to several months for the soft tissue swelling and bone changes to resolve and become stable. Once the foot becomes stable, then it should be fitted for custom-molded orthotics or shoes depending on the foot deformity. These special inserts and shoes can also help prevent recurrence by providing support and stability to the foot. Surgical treatment with resection of prominent bones or fusion of joints to reconstruct the foot may also be necessary depending on the foot deformity. P) Diabetic foot care Foot care is especially important for people with diabetes mellitus. Sometimes the slightest injury or irritation from a corn, callus, toenail, etc. can set up an infection that may result in the loss of all or a portion of the leg. Diabetics cannot afford to play with or neglect even slight foot problems. The American College of Foot and Ankle Surgeons recommend the following guidelines: 1. Perform daily foot inspection. Examine the entire foot and look for cuts, blisters, redness, swelling, calluses, or nail problems. If you are not able to do so, use a mirror or ask someone to help. 2. Wash feet daily. Keep feet clean by washing in lukewarm water and mild soap. Dry them gently with special attention to drying between the toes. Apply moisturizing lotion to the feet, but not between the toes since it could promote bacteria to grow. Using lotion daily will prevent dryness, crackling, and itching. 3. Trim nails with care. Cut toenails straight across, and file the nails to remove any rough or sharp edges. Do not cut nails too short since this can result in ingrown toenail. 15 / 17
4. Do not trim corns and calluses. Trimming corns and calluses with razor blades may lead to skin cuts and infection. 5. Change socks daily. Wear clean and dry socks. Change socks more often during the day if your feet sweat a lot. 6. Select socks and shoes with care. Choose socks that fit comfortably. Socks with tight elastic bands can decrease circulation while socks that are too loose or bulky can irritate the skin. Choose shoes that have good support and fit comfortably. When shopping for new shoes, try them on in the late afternoon when your feet tend to be larger. Slowly break in new shoes to prevent blisters. 7. Keep feet warm. Wear socks to bed if your feet get cold at night. Do not use a heating pad or hot water bottles to keep feet warm since they could cause burns on the feet. ( Note: Diabetics often lose sensation and do not feel burns!) 8. Inspect shoes before wear. Check the inside of shoes and shake shoes before you wear to remove any object, such as a pebble, inside your shoes. 9. Do not walk barefoot. You may step on something (a stone or pebble, insulin needles, glass, nails, etc) that could lead to a foot infection. Walking barefoot on pavement may also result in burns on the bottom of the foot. 10. Control your blood sugar. Chronic high blood sugar can decrease circulation and alter sensation in your feet. Poor circulation weakens the skin and impedes wound healing. Loss of sensation leads to inability to feel pain or pressure. Both of these conditions can result in foot complications. 11. See treatment of leg ulcers for further recommendations (Section III, chapter 11, T, U), 16 / 17
12. Optimum control of the diabetes is necessary for healing of diabetic foot problems (Section IV, chapter 4). 17 / 17