Doc, My Feet Hurt

Dear Dr. B: I have been walking a lot this summer. My feet hurt and that restricts my activities. What I can do about it?

Like back pain there is no perfect cure for all ailments of the feet. Most of us are on our feet longer than any other part of our body. So our feet receive the biggest brunt of all the damage we inflict on ourselves.

Feet problems present in different ways with pain, deformity and swelling.

About 10 per cent of the general population suffer from feet pain, and in the elderly it is much higher – ranges from 53 to 95 per cent. Proximal plantar fasciitis (inflammation of the fascia – a thick tissue which runs from the heel to the ball of each foot) is the most common cause of painful feet in clinical practice, and is twice as common among women as among men.

Metatarsalgia (pain in the forefoot in the region of the base of the toes) is probably the most common cause of foot pain among middle-aged women. Most women in this age-group have been exposed to high-heeled shoes over many years.

There are many other conditions which cause painful feet. Some of these are: plantar warts, corns, calluses, ingrown toe nails, hammer toes, flat feet, bunions, arthritis, gout, stress fractures and some others.

Treatment for most of these conditions remain the same: elevate and rest your feet as much as you can – but with the busy schedule we keep, not many of us have time to do that. Other management points are: lose weight, use pain killers, hot or cold compresses, arch support, good quality fitting shoes, foam cushions to relieve pressure on painful areas, and keep feet clean and dry.

Gout and other types of arthritis may require anti-inflammatory medications. Ingrown toe nail can be surgically fixed in a doctor’s office. Some conditions require injection of cortisone to relieve inflammation and pain. Physiotherapy can relieve many ailments of the feet.

One may have to try different combinations of therapy to find relief.

Foot is a complex structure and needs to be treated with respect. There are 26 bones in our foot and they are held together by ligaments. In addition to that, there are variable numbers of accessory bones called sesamoids.

Foot is divided into forefoot, midfoot and hindfoot. When one stands normally, the body weight is equally distributed between the heel and the ball of the foot. The weight distribution depends on muscle contraction.

“Studies have shown that relatively small changes in muscle balance and tone can result in significant changes in the load distribution of the foot,” says Dr. William Hamilton in the Surgical Anatomy of the Foot and Ankle. The normal function of the foot depends on the bones, ligaments, and muscles acting in concert.

A lot depends on how you stand, how you walk, how you run, what you wear, how much you weigh, and how much care you take of your feet. Foot pain and deformities are widespread. So, treat your feet with respect. Without them you cannot go too far comfortably!

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Toenail Problems

There are many people with toenail problems. I wonder if toenails are the most neglected part of our anatomy. I have written about ingrown toenails and fungus infection in the nails. I feel it is time to revisit the subject.

The nails are appendages of our most versatile organ – skin. Besides nails, the skin has three other appendages – hairs, sweat glands, and sebaceous glands.

Nails protect the tips of our fingers and toes. Hairs protect and provide warmth to the skin. Sweat glands help regulate body temperature and fluid and electrolyte balance. Sebaceous glands provide oil and odour to the skin.

The nail has a free end which we trim on regular basis. The two sides of the nail are under the skin folds. The root is at the base where the growth occurs. The average rate of growth of the nail is 0.1 mm a day or 3 mm per month. About 3.6 cm a year.

Fingernails grow faster than toenails. Both grow faster in the summer than in the winter. The nails grow rapidly in “nail biters” and slowly in people confined to bed. The growth is faster in males than females. Certain illnesses can arrest the growth.

The nail can be a window for physicians to suspect other illnesses. Normally, nails are flat and light pink. They are pale in anaemia. Nails in general and big toenail in particular can be sites of many problems. Ingrown big toenail with infection and pain is a very common condition. It can lead to gangrene and amputation in patients with diabetes and circulatory problems.

Ingrown toenail of the big toe usually occurs when sweaty feet are encased in tight shoes. The situation gets worse when the nail is trimmed short and the corners are curved down. The side of the nail curls inwards and grows to form outer spikes. This causes painful infection of the overhanging nail fold.

Ingrown toenails can be prevented by keeping feet nice and clean. Wear roomy shoes and clean cotton socks. Allow the outer corners of the nail to grow over the skin margins placing small piece of cotton soaked in an antiseptic just under the outer corners of the nail. Cut the nails straight. Antibiotics will help relieve acute infection but will not cure the primary problem.

If all this fails then surgical treatment becomes necessary. Simple whole nail avulsion or wedge removal of the nail can result in more than 50 percent recurrence rate. The best results are obtained by removing the root at the same time. This is done under local anaesthetic in a doctor’s office. About 10 days of tender loving care of the big toe after the surgery usually results in satisfactory outcome. There is about 10 percent or less recurrence rate.

Fungal infection of the nails is common as well. It affects toenails more than finger nails. The nail is thickened and discolored. It is usually yellowish. The nail may grow in a twisted manner. The infection is picked up in a public place where it is transmitted from person to person. Poor feet hygiene does not help.

Fungus infection is best treated with anti-fungal therapy orally and locally for three months. Cure rate is around 80 percent. Ongoing meticulous foot care is very important to prevent recurrence.

In my view, walking bare feet is the worst thing you can do for your feet. Wash your feet at least once a day (twice if your feet sweat a lot) with soap and water. Dry them well with a soft towel. Wear good quality clean socks and proper fitting comfortable shoes.

If you love your feet then take good care of them.

Thought for the week:

“War is the unfolding of miscalculations.” – Barbara Tuchman (1912-1989)

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Problems of Hands and Feet

There are numerous minor but common conditions of the hands and feet which bother people. Most people do not understand why they get them. The conditions are not life threatening but they are a nuisance. I will describe few conditions here and briefly discuss their cause and treatment.

Ganglion: A ganglion occurs mainly in the hand and foot and joint areas. It is a cyst containing jelly like substance. It may be soft or tense. It is usually smooth. It arises from the bursa within the substance of a joint capsule or the sheath covering a tendon. Some times this occurs after an injury. Sometimes it may cause pain.

Treatment: There are non-surgical methods to treat ganglion. But surgery usually provides satisfactory results. Occasionally it may recur at the same site.

Plantar warts: These are same as common warts. They grow on the soles of the feet. They grow into the skin because we walk on them. They can be painful on walking. The virus causing the wart is picked up from walking bare foot in locker rooms and swimming pools.

Treatment: They may spontaneously disappear if you wait long enough – months to years. They can be managed by freezing, scrapping or burning. They can recur.

Plantar fasciitis: Also known as “policeman’s heel”. It is common in men aged 40-60years. Exact cause of the condition is not known. There is pain beneath the heel. It is tender when pressure is applied.

Treatment: Pain can be minimized by padding and/or by cortisone injection. This may or may not work. Pain usually gets better in six to twelve months.

Callus and corns: These are thickened areas on the hands or feet caused by pressure or friction. This is usually related to work or sporting activities. Uneven pressure of body weight during walking or ill fitting shoes can cause calluses and corns on the feet.

Treatment: Wear proper fitting shoes and use corn pads to relieve pressure on the corns. Thick calluses can be sliced down to normal skin over a period of time. If the source of friction and pressure is removed then corns and calluses should not recur.

Toenail problems: Mainly involves the big toe. It may be ingrown or overgrown. Ingrown toe nails are commonly due to ill-fitting shoes pressing on an incorrectly cut nail. Poor foot hygiene encourages infection.

Treatment: In an acute stage antibiotic, painkillers and bathing the foot in warm salt water are necessary. Surgery is required in most cases. The problem can be prevented from recurring by keeping the feet clean and wear correctly fitting shoes. Cut the nail straight.

Fungus infection of the nails: Usually affects toenails. The nail is thickened and discolored. It is usually yellowish. The nail may grow in a twisted manner. The infection is picked up in a public place where it is transmitted from person to person. Poor feet hygiene does not help.

Treatment: Anti-fungal therapy is required – orally and locally for three months. Cure rate is around 80 percent. Ongoing meticulous foot care is very important to prevent recurrence.

Our feet are subjected to more wear and tear and hence they get more problems than our hands. Our natural tendency is to take care of our hands more than our feet. Many of these problems are preventable.

In my view, walking bare feet is the worst thing you can do for your feet. Wash your feet at least once a day (twice if your feet sweat a lot) with soap and water. Dry them well with a soft towel. Wear good quality clean socks and proper fitting comfortable shoes.

If you love your feet then take good care of them.

Start reading the preview of my book A Doctor's Journey for free on Amazon. Available on Kindle for $2.99!

Instructions For Toenail Surgery

INSTRUCTIONS FOR TOENAIL SURGERY

You have been booked for toenail surgery to be done in my office on ________________ at ________________. This will be done under local anesthetic.

If you fail to keep this appointment, then we reserve the right to bill you for not showing up. Please phone our office three days before your appointment to confirm that you will be coming for the procedure.

PRE & POST SURGERY INSTRUCTIONS

1. Make sure your feet are clean before you come for the procedure.

2. Have somebody bring you here and take you home as you will have a bulky dressing and will be
unable to wear your shoes and unable to drive.

3. After the surgery you should keep your feet elevated above your hip line for 48 hours. This helps
reduce the swelling and pain and help the healing process.

4. Watch the tip of the toe for adequate circulation. If it is pale white or dusky and turns blue then
loosen the dressing to improve circulation.

5. If there is bleeding or pain which is persistent then call my office or in the evenings or weekends
see the doctor on call at the hospital emergency.

6. For pain – take painkillers which you are familiar with at home or ask for a prescription before you
leave the office after the procedure.

7. Take antibiotics if you have been instructed to do so after surgery.

8. After 48 hours you should change the dressings. It will be stuck to the skin so you
should soak it well and peel it off gently.

9. Apply polysporin and gauze and light dressing once or twice a day until
the pain is gone.

10. If you have stitches then have them removed from you doctor in 10 days.

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