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Adult Foot and Ankle Problems:
Aching Heels an unwanted Rite of Spring: Popular Flip-flop Sandles Linked to Rising Youth Heel Pain
At last, spring is here. After months wearing boots and thick-soled shoes, many are welcoming the warmer weather sporting flip-flop sandals, however, their popularity among teens and young adults is responsible for a growing epidemic of heel pain in this population.
We’re seeing more heel pain than ever in patients 15 to 25 years old, a group that usually doesn’t have this problem. A major contributor is wearing flip-flop sandals with paper-thin soles everyday to school. Flip-flops have no arch support and can accentuate any abnormal biomechanics in foot motion, and this eventually brings pain and inflammation.
With warm weather on the horizon for most of the country, people should wear sandals with reasonably strong soles and arch support. Especially for girls and young women, thicker soled sandals with supportive arches might not be considered stylish, but if you want to wear sandals most of the time, you’ll avoid heel pain if you choose sturdier, perhaps less fashionable styles.
Heel pain also is becoming more prevalent in younger people who become overweight and lead sedentary lifestyles in winter and dramatically increase their physical activity when the temperatures rise. Obesity in younger people has become a major health problem and heel pain is a consequence of it.
It is estimated that 15 percent of all adult foot complaints involve plantar fasciitis, the type of heel pain caused by chronic inflammation of the connective tissue extending from the heel bone to the toes. Being overweight and wearing inappropriate footwear are common contributing factors.
The pain is most noticeable after getting out of bed in the morning, and it tends to decrease after a few minutes and returns during the day as time on the feet increases. Not all heel pain, however, is caused by plantar fasciitis. It also can occur from inflammation of the Achilles tendon, bursitis, arthritis, gout, stress fractures, or irritation of one or more of the nerves in the region. Sometimes in such cases, heel pain could be a symptom of a serious medical condition that should be diagnosed and treated separately.
Clinical guidelines published by the American College of Foot and Ankle Surgeons are helping physicians diagnose and manage all types of heel pain and distinguish cases that should be treated conservatively from those that require more specialized care. The guidelines state that initial treatment options for heel pain caused by plantar fasciitis should include anti-inflammatory medications, padding and strapping of the foot and physical therapy. Patients also should stretch their calf muscles regularly, avoid wearing flat shoes and walking barefoot, use over-the-counter arch supports and heel cushions, and limit the frequency of extended physical activities.
Most patients with plantar fasciitis respond to conservative treatment within six weeks. However, surgery is sometimes necessary to relieve severe, persistent pain.
Arthritis and the Feet
Arthritis, characterized by inflammation and swelling of the soft tissues and lining of the joints, afflicts almost 40 million Americans. Although every joint in the body is susceptible to arthritis, the foot and its composition of 33 joints is a common target. Arthritic feet can interfere with active lifestyles, limiting mobility and independence,
The disabling effects of arthritis can often be avoided through early diagnosis and appropriate medical care.
Early diagnosis as key to effective treatment of arthritis. If the inflammation of arthritic disease isn’t treated, both soft tissue and cartilage can be damaged and destruction of the cartilage may be irreversible.
Arthritic symptoms generally include swelling and pain or tenderness in one or more joints for more than two weeks, redness or heat in a joint, limitation of motion of a joint, early morning stiffness, and skin changes, including rashes.
Symptoms do vary according to the form of arthritis and there are more than 100 different forms. Each form affects the body differently. Among the most recognized forms are:
- Osteoarthritis or degenerative joint disease (wear and tear), the most common form
- Rheumatoid arthritis, a complex, chronic inflammatory disease that can be crippling
- Gouty arthritis, a condition caused by elevation of uric acid levels – sometimes a by-product of diet – in the joints
- Septic arthritis or infectious arthritis, caused when bacteria spread from an infection through the bloodstream to a joint
- Psoriatic arthritis, an inflammatory arthritis associated with psoriasis.
Most forms of arthritis cannot be cured, but can be controlled and brought into remission. Arthritis treatment involves controlling inflammation and preserving joint function (or restoring it). Surgery is indicated in end-stage arthritic condition.
Traditional treatment methods include anti-inflammatories, pain medication, shoe inserts called orthoses that help with off-loading the joints affected, and physical therapy and exercise.
In addition to the traditional treatments there are new advancements in treatment for arthritis. A whole new class of anti-inflammatories are being introduced that are as effective as those currently available, but they have less side effects such as gastrointestinal distress. There has also been preliminary success with different types of injections into the joints to repair the cartilage and joint structures.
Another critical aspect to the treatment of arthritis is patient education and involvement. Recognizing the symptoms and following the prescribed treatment regimen including appropriate medication, modifications in diet and appropriate professional follow-up are of equal importance.
Avoid Winter Foot and Ankle Woes
Falls on Icy Sidewalks and Frostbite Are Major Causes
The season for ice, snow and sub-zero cold is here and with it comes the risk for serious foot and ankle problems for anyone who spends time outdoors.
Ankle sprains and Achilles tendon problems are very common in winter due to slips on icy sidewalks and from injuries that often occur when playing basketball and other indoor court sports. Very often ankle sprains are not taken seriously and may not heal properly. This can result in long-term ankle instability and increases the risk for joint damage and eventual arthritis.
Initial treatment for ankle sprains should include rest, ice, compression and elevation to decrease pain and reduce swelling. Compression with an elastic bandage, splint or brace may be used for stability and to optimize healing. The ability to walk or put weight on the joint depends on the severity of the sprain, as determined by the podiatric surgeon when assessing ligament damage caused by the injury.
Even minor sprains should be protected by bracing for several days. In most cases, it takes at least three weeks for an ankle sprain to heal and up to eight weeks for severe sprains.
Another winter malady, frostbite in the toes, is best treated by rapidly re-warming the affected extremities at the first sign of severe cold and numbness. Nearly half of all frostbite cases involve the foot or ankle and, in my experience, rapid re-warming is effective in preventing tissue damage. Therefore, at the first sign of possible frostbite it’s imperative to seek prompt treatment and apply controlled heat right away with warm towels and warm water.
Cold weather impairs circulation, especially in women who smoke and drink caffeinated beverages. Blood vessels can shut down in the feet, causing the toes to turn white and blister. Just as with frostbite, it’s critical to keep the extremities warn and insulated to avoid exposure to the cold.
Winter is a good time to think about corrective foot surgery if you’re not as active as during warm-weather months. For those who would benefit from surgery to correct bunions, hammertoes or persistent heel pain, scheduling the procedure now allows enough time for post-operative rest and to resume normal activities when spring arrives.
Lawnmower Accidents Needn’t Be a Rite of Spring
Thousands of Foot Injuries Can Be Prevented Each Year
Weekend gardeners should be aware that their yards could become toe-away zones if they’re not careful when operating rotary-blade lawn mowers.
Each year, some 25,000 Americans sustain injuries from power mowers, according to the U.S. Consumer Products Safety Commission. Although the number of accidents has steadily declined since the 1982 adoption of federal safety standards, we still see too many foot injuries from power lawnmowers. The blades whirl at 3000 revolutions per minute and produce three times the kinetic energy of a .357 handgun. Many patients have been hurt while operating a mower barefoot! Foot injuries range from dirty, infection-prone lacerations to severed tendons to amputated toes.
If a mower accident occurs – with just a minor injury – immediate treatment is necessary to flush the wound thoroughly and apply antibiotics to prevent infection. Superficial wounds can be treated on an outpatient basis, but more serious injuries usually require surgical intervention to repair tendon damage, deep clean the wound and suture it. Tendons severed in lawnmower accidents generally can be re-attached surgically unless toes have been amputated.
Children under the age of 14 and adults over age 44 are more likely to be injured from mowers than others. Anyone who operates a power mower to take a few simple precautions:
Don’t mow a wet lawn. Losing control from slipping on rain-soaked grass is the leading cause of foot injuries caused by power mowers.
- Wear heavy shoes or work boots when mowing – no sneakers or sandals.
- Mow slowly across slopes, never go up and down.
- Never pull a running mower backward.
- Keep the clip bag attached when operating a power mower to prevent projectile injuries.
- Use a mower with a release mechanism on the handle that automatically shuts it off when the hands let go.
- Always keep children away from the lawn when m
- owing it.
Minor Foot Fractures Can Warn of Osteoporosis
Foot doctors and their patients are learning an important new lesson in preventive medicine: Those who experience unexplained minor foot fractures appear to be at special risk for the porous bone disease, osteoporosis; and these types of foot fractures are often the first outward sign of bone loss.
Researchers have identified an important tool for early detection of osteoporosis, a problem suffered by an estimated 10 million Americans.
Being able to identify osteoporosis in its earliest stages should give patients and doctors hope, because there are ways, including changes in nutrition and exercise, to head it off or minimize its effects. At present, many diagnoses of osteoporosis are not made until after a hip is broken and that is usually too late to stop or reverse the deterioration, which is progressive.
Another useful aspect of the new research is the finding that osteoporosis is less discriminatory than medical experts have thought. According to lead researcher, Dr. Rodney L. Tomczak, DPM, FACFAS, this is not a disease that strikes only the frail and elderly.
Our study results did not see any correlation between a person’s size or bone density and the incidence of osteoporosis. The participants were 21 men and women ranging in age from 19 to 72 and of all body types. All had suffered fractures of the metatarsals, the long foot bones. None of these was known to be caused by injury or repetitive movement that might have overstressed the foot. Some patients reported feeling a sudden painful snap while walking. Others described only an unexplained nagging pain in their foot bones.
A clear majority (90 percent) of those in our study with fractures who were tested for osteoporosis had early or clinical signs of the disease, said Tomczak, whose study team is based at the Ohio State University Department of Orthopaedics.
Also significant was the fact that six of the eight men in the study were diagnosed with significant bone loss or worse – significant because men are thought to represent only about 20 percent of osteoporosis cases, and so are often not included in osteoporosis screening and research programs.
These new findings really support the view that patients who ignore foot discomfort are risking more than painful feet. In a given year, there are about 1.5 million osteoporosis-related fractures. With what we know now, it appears that many of these could be avoided. It is important to have even seemingly minor foot problems evaluated by a podiatric surgeon; one who is specially trained to identify larger health issues through careful foot inspection.
The American College of Foot and Ankle Surgeons (ACFAS) was founded in 1942. Headquartered in Park Ridge, IL, its membership includes 5,000 podiatric medical specialists. Its mission includes research, development of standards and promotion of proper foot and ankle care.
New Advice on Toe-Joint Disorders
Whether or not to consider foot surgery for conditions affecting the joint at the base of the big toe, including bunions and arthritis is a difficult decision.
However new clinical practice guidelines developed by a panel of leading experts on forefoot conditions from the American College of Foot and Ankle Surgeons offer some help. They provide options for physicians and patients to consider when assessing the benefits and risks of various treatments and also for determining the type of surgical procedure that is most appropriate based on age, lifestyle and severity of the condition.
A comprehensive examination by a podiatric foot and ankle surgeon is advised for anyone with symptomatic swelling around the foot and ankle.
At the base of the big toe is the first metatarsophalangeal joint (1st MTP). It is the most complex joint of the foot, where bones, tendons and ligaments work together to transmit and distribute the body’s weight, especially during movement.
If the joint is painful and interferes with walking, physical activities and regular exercise, non-operative treatments should be considered first.
Bunions are the 1st MTP joint disorder most frequently treated by podiatric foot and ankle surgeons and that first-line treatment involves educating patients about the condition and evaluating their footwear. At first, we recommend that patients to wear wider, low-heeled shoes, use bunion pads, apply ice and take over-the-counter analgesic medications. These options are designed to relieve pain and make it easier to walk and engage in physical activities, but they do not address the underlying cause of bunions.
Contrary to popular belief, bunions are aggravated, not caused, by shoes. Bunions usually occur from inherited faulty biomechanics that put abnormal stress on the 1st MTP joint.
Various non-surgical approaches can help prevent aggravation of bunions and other MTP-related problems, and for many patients that might be enough to keep them active and on their feet,. Bunions, however, are progressive, so if non-operative treatments bring little or no symptomatic improvement, surgical intervention should be considered. If the initial evaluation and treatment were performed by a primary care physician, the patient should be referred to a podiatric foot and ankle surgeon, he added.
Surgical options depend on severity and lifestyle
Different surgical techniques are used at the discretion of the surgeon to achieve the desired correction. Determining which procedure is most appropriate for specific patients involves consideration of several factors, such as bunion severity, age, possible onset of arthritis and the desired level of physical activity a patient wants to achieve following surgery.
Patients with a moderate to severe bunion should discuss the anticipated outcomes of various procedures with the surgeon to make sure they select the most appropriate option. For example, the lifestyle of someone involved in competitive sports differs from an elderly patient who simply wants to walk without pain.
Less severe or Stage 1 bunions may not show significant protrusion, and surgery is performed to repair tendons and other soft tissue and remove a small amount of bone. Procedures to correct more severe bunions (Stage 2) involve removal of the bump or minor realignment of the big toe joint. Stage 3 bunions usually are very severe and disabling. Surgery in these cases consists of extensive joint realignment, reconstruction, implants or joint replacement.
Other 1st MTP joint disorders
First MTP-related problems also occur from repetitive trauma to the area and from the ravages of arthritis, over time, avid tennis players and golfers put continuous stress on the 1st MTP joint that eventually can wear out the cartilage and lead to the onset of arthritis. This condition, known as hallux rigidus, causes loss of movement and pain in the joint.
Those who experience pain in the joint without evidence of protrusion symptomatic of a bunion should consider it a warning sign that the joint has been traumatized and they are advised to have it evaluated and treated before arthritis sets in most situations, non-operative treatments can be prescribed to provide relief, but others with advanced cases might need surgery, especially when the protective covering of cartilage deteriorates, leaving the joint damaged and with decreased range of motion.
New Guidelines Help Doctors Diagnose, Treat Heel Pain
Heel pain is one of the most common and persistent foot problems affecting men and women of all ages, but new clinical guidelines, recently announced by the American College of Foot and Ankle Surgeons (ACFAS), will help physicians more readily diagnose and treat the disorder.
Appearing in a recent issue of the Journal of Foot & Ankle Surgery, the ACFAS guidelines were developed by a committee of prominent heel pain specialists. They are the outcome of an extensive evaluation of current treatment methods and success rates and a thorough review of the medical literature.
The new guidelines are designed to help physicians diagnose and manage all types of heel pain and distinguish cases that should be treated conservatively from those requiring more specialized care. Further, the guidelines will assure consumers that medical evidence presented to their physicians strongly favors non-surgical treatments for the large majority of heel pain cases.
It is estimated that 15 percent of all adult foot complaints involve plantar fasciitis, heel pain caused by chronic inflammation of the connective tissue extending from the heel bone to the toes. The condition can lead to heel spurs and occurs most frequently in adults 40 years and older, especially women. Being overweight and wearing inappropriate footwear are also contributing factors. In most cases, this form of heel pain can be treated with anti-inflammatory medications, stretching exercises and orthotics. Unresponsive cases, however, may require surgical intervention. Other types of heel pain are caused by nerve and circulation problems, arthritis, and stress fractures and other trauma.
According to the new guidelines, initial treatment options for plantar fasciitis include anti-inflammatory medications, padding and strapping of the foot and injections of corticosterioids. Patients also should stretch their calf muscles regularly, avoid wearing flat shoes and walking barefoot, use over-the-counter arch supports and heel cushions, and limit the frequency of extended physical activities.
Most patients with plantar fasciitis respond to conservative treatment within six weeks. If improvement occurs, the guidelines specify that initial therapy should be continued until the heel pain is resolved. But if no improvement is evident, more specialized treatments, such as custom orthotics, shock-wave therapy or surgery, would be appropriate.
Old Ankle Sprains Increase Injury Risk for Newly Active Baby Boomers
Ankle injuries may end the careers of pro basketball star Grant Hill and tennis champion Martina Hingis, but their plight could be a valuable lesson for Baby Boomers now getting back into fitness and sports: Get your ankles checked for chronic instability caused by sprains and other injuries that might not have healed properly years ago.
Many who have suffered ankle sprains in the past could be at risk for more serious damage as they age and try to stay in good physical condition. It is estimated that one in four sports injuries involves the foot or ankle, and a majority of them occur from incomplete rehabilitation of earlier injuries.
Many older adult athletes who have had a previous injury that wasn’t fully rehabilitated may experience swelling and pain as they increase their physical activity, but pain isn’t normal in the ankle area, even if you’re starting to get back in shape.
Both serious athletes and weekend sports participants often misunderstand how serious a sprain can be, and they rush back into action without taking time to rehabilitate the injury properly. A sprain that happened years ago can leave residual weakness that isn’t noticed in normal daily activity, but subjecting the ankle to rigorous physical activity can further damage improperly healed ligaments, and cause persistent pain and swelling. For anyone hoping to regain past athletic fitness, it’s recommended that you have that old ankle injury checked out before becoming active again.
Some sprains are severe enough to strain or tear the tendons on the outside of the ankle, called the peroneal tendons. New research, however, shows that more than 85 percent of athletes who had surgery to repair a torn peroneal tendon were able to return to full sporting activity within three months after the procedure.
Peroneal tendon tears are an overlooked cause of lateral ankle pain. Although surgery for athletically active patients shouldn’t be taken lightly, surgical repair of the peroneal tendons is proving to be very successful in helping athletes with serious ankle problems return to full activity.
Persistent pain and tenderness after a sprain, especially if the individual felt a ‘pop’ on the outside of the ankle and couldn’t stand tiptoe, might be a warning sign that the tendon is torn or split. The injury is best diagnosed with an MRI exam. Patients who need surgery spend six to eight weeks in a cast followed by physical therapy.
Sandal Season Ahead; Time to Fix Your Feet!
Unsightly Deformities Can Be Repaired with Routine Surgery
If unsightly foot problems, such as bunions, hammertoes and nail fungus, prevent you from exposing your feet on the beach or in stylish sandals this summer, there are remedies available that will have your feet looking and feeling better before the warm weather comes.
Many women with common structural foot problems are embarrassed about exposing their feet, as a result, they are deprived of a comfortable pleasure of summer.
Bunions are the most common deformity for which women seek surgical treatment, both for improved mobility and comfort while wearing shoes and for a better appearance when barefoot or wearing sandals. A bunion can be repaired with a short post-operative recovery period, depending on the extent of the problem. A deformity of the big toe joint that usually is inherited, bunions tend to worsen over time.
Women are more frequently affected from wearing tight and pointed shoes that aggravate the condition. Seniors also are vulnerable because of their higher incidence of arthritis affecting the big toe joint.
Surgery may be performed at a hospital, surgical center or properly equipped office operating room, often using local anesthesia. The majority of bunions are corrected by realigning the bones of the joint and repositioning the surrounding muscles, tendons and ligaments.
Unsightly hammertoes also can be a source of embarrassment, but they can be corrected. Hammertoes are flexible or rigid, and may occur on any of the lesser toes. Ligaments and tendons that have tightened cause joints to buckle and cock the toe upward, he said. Depending on the number of toes involved, the recovery time from hammertoe surgery might be several weeks.
Nail fungus is another common problem that can make feet unattractive. The dark, moist surroundings created by shoes and stockings make the feet susceptible to fungal infection.
A fungus may cause the nail to thicken and become yellow or brownish. Oral and topical medications sometimes eliminate a fungus, but it can return if the medication is discontinued. Curing a fungal infection sometimes requires permanent removal of the nail. After surgery to permanently remove the nail plate, the body generates a hardened skin covering over the sensitive nail bed. When this covering has developed, normal activities can be resumed and women can use nail polish on the area.
Study Shows Surgery for Tailor’s Bunion is 96 Percent Successful
New Research Reported in Journal of Foot and Ankle Surgery
Surgical treatment for tailor’s bunion, a painful bony protrusion behind the little toe, has proven to be 96 percent successful in correcting the deformity, citing research reported recently in the Journal of Foot & Ankle Surgery (JFAS), a publication of the American College of Foot and Ankle Surgeons.
Also known as bunionettes, tailor’s bunions develop from an enlargement of the joint behind the little toe and they occur mainly in women. The enlarged joint can worsen from pre-existing arthritic joint inflammation, bone structure abnormalities that cause joint instability, and wearing high heels or other narrow-fitting shoes.
Common symptoms are pain and inflammation in the little-toe area, gait abnormalities, discomfort from wearing dress shoes, lesions on the little toe, ulceration and infection. Those with persistent symptoms that can’t be relieved by taking anti-inflammatory drugs or wearing wider shoes are best treated with surgery.
The surgery is very effective, and it’s a simple outpatient procedure using local anesthesia with a short recuperative time in a surgical shoe. Given the outstanding success of surgical treatment, there’s no reason anyone should endure persistent pain from a tailor’s bunion.
There are several surgical procedures to correct tailor’s bunion, which include shaving excess bone to remove the bunionette and procedures to realign the joint behind the little toe. The most appropriate surgical technique is determined by the patient’s foot type, activity level, age and other factors.
Taking a Vacation? Make It Easy on Your Feet!
Although rest and relaxation are the goals for most vacations, vacations usually involve a lot of walking and a lot of walking usually involves sore feet.
Walking is great exercise and one of the most reliable forms of transportation. But if your feet aren’t in the best shape or you don’t have the right shoes, too much walking can cause foot problems.
Good foot care is essential if you plan to subject your feet to long periods of walking. Some simple foot care tips include:
- Wear thick, absorbent socks (acrylic instead of cotton)
- Dry feet thoroughly after bathing, making sure to dry between toes. Use powder before putting on shoes
- Nails should be cut regularly, straight across the toe
- Bunions, hammertoes or any other serious foot problems should be evaluated by a foot care specialist.
The right shoe is also important to healthy walking. The ideal walking shoe should be stable from side to side, and well-cushioned, and it should enable you to walk smoothly. Many running shoes will fit the bill.
There are also shoes made specially for walking. Walking shoes tend to be slightly less cushioned, yet not as bulky, and lighter than running shoes. Whether a walking or running shoe, the shoes need to feel stable and comfortable.
Warming up exercises to help alleviate any muscle stiffness or pulled muscles is also advised before walking. Loosening up the heel cords (Achilles and calf) and thigh muscles before a walk is especially effective.
If you’re not accustomed to long walks, start slowly and rest if your feet start hurting.
Treating Flat Feet Early Avoids Complications Later
For many adults, years of wear and tear on the feet can lead to a gradual and potentially debilitating collapse of the arch. However, a new treatment approach based on early surgical intervention is achieving a high rate of long-term success, according to research presented recently at the American College of Foot and Ankle Surgeons (ACFAS) annual meeting.
Results of clinical studies of adults with flat feet have caused podiatric foot and ankle surgeons to believe that reconstructive surgery in the early stages of the condition can prevent complications later on. Left untreated, the arch eventually will collapse, causing debilitating arthritis in the foot and ankle. At this end stage, surgical fusions are often required to stabilize the foot.
We now know that surgical intervention for adult acquired flatfoot is appropriate when there is pain and swelling, and the patient notices that one foot looks different than the other because the arch is collapsing. As many as three in four adults with flat feet eventually need surgery, and it’s better to have the joint preservation procedure done before your arch totally collapses, he explained. In most cases, early and appropriate surgical treatment is successful in stabilizing the condition.
Collapsed arches occur in 5 percent of adults 40 years and older, especially those who are overweight or maintain sedentary lifestyles. The condition is caused by progressive lengthening of the tendon in the muscle that runs from the back of the knee to the arch. The tendon is responsible for maintaining the arch in the foot while the muscle lifts the heel when walking. When inflamed or stretched, the tendon loses its ability to support or hold up the arch, and this results in pain from the inside of the ankle to the arch area. At the onset of the condition, adult acquired flatfoot can be controlled with anti-inflammatory medications, physical therapy, taping and bracing, and orthotics, but surgery is now recommended as the problem worsens.
While most cases of adult-onset flatfoot require surgery, congenital flatfoot is an entirely different condition that is best treated with orthotics in children. Ninety percent of children born with flat feet will be fine with conservative treatment.
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