Corns

One of the most common problems that I come across in my clinics are corns, so this month I thought I would talk about what they are and more importantly how to deal with them.

Corns are painful lesions on the feet caused by mechanical stress to that particular area. This increased mechanical stress can be due to pressure from foot ware or changes in the foot or the way we walk.

There are several types of corns or Helomata which comes from Greek helos, meaning stone wedge. Hard corns, heloma dura usually occur underneath the foot or on the tops or ends of the toes and may even occur under the nails or in the sides of the nails. Soft corns or heloma molle only appear between the toes and are soft due to perspiration between the toes. Vascular and neurovascular, heloma vasculare and heloma neurovasculare tend to be long standing lesions where blood vessels and nerves have become involved. Finally seed corns or helomata miliare which are not really corns at all. They are not caused by increased stress or pressure on the skin but are simply plugs or beads of cholesterol often in non weight bearing areas.

Differential diagnosis, most commonly confused with verruca which are generally not painful on direct pressure which corns are. Veruca also always have a vascular and neurological element.

Complications, neglected corns are can be prone to infections particularly due to foots close confinement in a warm humid environment and the proximity to the ground. Ulceration may also occur where there is sever mechanical stress or due to loss of sensitivity as in the case of diabetic neuropathy.

Treatment is roughly divided into two parts removal of the corn, sharp debridement where the corn is removed by a podiatrist/chiropodist with a scalpel. This should be a painless procedure and give instant relief from the ongoing discomfort.

Occasionally the use of local anaesthetic is required in the case of neurovascular corns. Once the corn is out the aim of the treatment is to prevent it returning. Here eliminating the original causes is the priority, reducing the pressure from foot ware and mechanical stress.

This may be padding to the foot in the short term. Changing footwear, insoles, orthotics or silicone guards to redistribute pressure where there have been changes in the shape and function of the foot longer term to mitigate the underlying problems.

There are of course over the counter remedies, usually in the form of corn plasters and these come in two basic types.
Foam rings, these aim to reduce the pressure on the lesion. Medicated corn plasters which contain an acid (usually salicylic acid) which aims to soften and dissolve the corn. The danger here is that if great care is not taken medicated corn plasters and liquids can dissolve healthy skin. This may not only be painful but in the case of diabetics and those with poor circulation can also be very dangerous and should be avoided.

As usual my advice is if in doubt see a podiatrist who will be able to treat the presenting problem and also work towards a longer term resolution.
Philip Mann 686912307

Dermatology and Feet

One of the many facets of podiatry is dermatology and if you think about it, feet are covered in skin and nails are just an adaption of skin.

There is now a podiatric speciality known as Podiatric dermatology which has grown out of the fact, that as a podiatrist much of what you do crosses over into dermatology and therefore many podiatrists want to know even more and specialise in this area.

When I go to conferences dermatology lectures are always packed. Many of the routine treatments I am involved in are dermatological in nature, Hyperkeratosis (callous), Heloma durum (corns), Human papiloma virus (verrucas) Onycomycosis (nail fungus) are all dermatological complaints which podiatrists treat every day. There are also the more serious skin conditions that often present in clinic.

Skin cancer is very common in feet as after to hands and faces feet are exposed to the sun probably more than any part of the body. From solar Keratosis sometimes known as sun spots, Squamous cell carcinoma, Basal cell carcinoma and even malignant Melanoma are all commonly seen on feet.

I think I have mentioned before that one of the differential diagnosis for ingrown toenails particularly if they are persistent, is malignant Melanoma. Obviously with skin cancers it is not a podiatrist’s role to treat them and swift referral especially in the case of suspected Melanoma to a Dermatologist is essential.

But malignancy aside, there are still many skin conditions of the feet that podiatrists treat very well. Cracked heels are very treatable with debridement and advice on the correct emollients. Often cracked or split heels are a symptom of psoriasis and psoriasis has other manifestations in the feet one of which is psoriatic nails. These often look just like fungal nails and although the psoriasis in nails cannot be eliminated it can be managed very well by reducing the nail bulk and improving appearance.

Athlete’s foot which is really a fungal infection is a very common presentation in clinic in its many forms. Even bacterial infections like Pitted Keratolysis where white holes are seen in the bottom of the feet especially when wet are very treatable in clinic.

There are too many skin conditions seen in feet to mention them all, but the above are a few which are commonly seen.

Role of a podiatrist

The term Podiatrist means foot specialist, someone who will manage all areas of foot care from simple nail cutting and treatment of corns and callous to assessment and treatment of Diabetic foot problems, minor surgery under local anaesthetic and sports injuries.

One of one of the questions that podiatrists get asked most is “how can you do this job looking at smelly feet all day?” well there is a great deal of variation; during the course of a clinical session they may find them self treating sports injuries, ingrown toe nails, corns and callous, Painful bunions, Heel pain and plantar fasciitis, diabetic ulcers , infections of the skin and nails, Verrucas (planter warts), children’s foot problems, or doing gait analysis, biomechanical assessment and prescribing orthotics. Generally speaking patients arrive in pain or discomfort and go home feeling better so there is a lot of satisfaction although maybe not much glamour.

Most first time consultations will start with a medical history as the feet cannot be treated in isolation and many systemic illnesses can affect the feet and vice versa. This is usually followed by examination and then diagnosis. Diagnosis is crucial; if this is wrong the treatment is bound to fail. Once a diagnosis is made this is carefully explained to the patient and or their guardian and treatment options discussed. A treatment plan can then be made based on informed choices from patient and practitioner.

Many of the problems encountered in the foot have an underlying biomechanical problem. This means that the problem is due to the way the feet and legs function, feet may “flatten out “or the arch may be too high. In turn this may cause increased pressure or stress on a particular part of the foot or leg leading to pain and dysfunction. A podiatrist can assess the alignment problem and prescribe the appropriate orthotic foot support to go into the shoe, as well as address any problems with muscle weakness or imbalance.

Podiatrists play a crucial role in diabetic foot care. Diabetes can have significant impact on the health of the feet and sadly diabetics represent the largest group of lower limb amputees. Diabetes can damage blood vessels and nerves in the feet and affect healing in the feet. But complications are avoidable with good education, diabetic control and assessment of diabetic patient’s feet. This usually involves looking at blood flow using Doppler ultrasound and assessment of any nerve damage in the foot. Advice on foot ware and care will be given. Prevention is definitely the key here and diabetic feet should not be ignored.

In our journey through life it is the feet that do the hard work but are often sadly neglected, so look after them make that appointment to see the podiatrist today.

Heel Pain

Heel pain is one of the most common problems that I see in the clinic and can be a very debilitating condition

Probably the most common type of heel pain is Plantar Fasciitis or as it is sometimes known as Calcaneal heel spur syndrome. Although heel spurs are often visible on X-ray this is not always diagnostic as they are also often seen on the non symptomatic foot too, and diagnosis is usually on history and symptoms. This condition is characterized by increased pain with the first steps in the morning or when standing after a prolonged period of sitting. It can be in one or both feet. There are many treatments available for this condition depending on the severity of the condition the length of time the individual has had the problem and level of activity, and can vary from stretching and strapping to orthotics and even night splints.

Achilles tendonitis is usually a sports injury or can be caused by over use or even foot ware. Pain is often worse on rising in the morning and exacerbated by activity. Treatment, laser treatment is very effective here and stretching is important also altering foot ware can also help.

Hagland’s deformity or Pump bumps as they are sometimes known are boney lumps at the back of the heel on the outside. Caused by the foot rubbing on foot ware the body attempts to protect the area laying down more bone. Sometimes there is an associated fluid filled sac called a bursa associated with this condition. The area can become inflamed and very sore in shoes. Treatment, controlling the motion of the foot, padding and laser work well, although surgical intervention is sometimes called for.

Bursa can also be a problem behind the Achilles tendon and in the fat pad of the heel. If these bursa become inflamed they can be painful on activity. Once again laser can be very good here as can padding or an accommodating insole.

Sever’s disease is a heel condition only seen in children and adolescents, eight to about 16 years old and is quite common. Usually seen in very sporty individuals, pain is exacerbated by exercise and often is only present when running or jumping. Often Sever’s coincides with a grown spurt as the leg bone grows and the Achilles tendon pulls on the heel bone pulling the growth plate of the bone away and causing localized avascular necrosis with resultant pain on exercise. Orthotics and stretching work very well here enabling the child recover fully and return to the sports they enjoy.

There are many conditions which cause heel pain from tumors, fractures to simple splits. I have just covered a few examples here.

Diabetic foot care

Why Diabetic foot care is important

With the incidence of diabetes on the increase in the western world, the importance of foot care for diabetics has never been more important. Sadly diabetics represent the biggest group of lower limb amputees even greater than that of road traffic accidents. But it is not all bad news diabetic amputations are avoidable and in this article we will look at the causes and how to avoid problems leading to amputation.

Diabetes is an increase in circulating blood sugar levels; there are two types of Diabetes, Type I and Type II. Type I often known as juvenile diabetes the onset is in childhood and young adults Type II diabetes, usually known as mature onset diabetes, as the name suggests mainly starts later in life. Both diseases are controlled differently, Type I requiring injections of insulin and Type II may be controlled by reducing sugar intake (diet) or drugs which help the body to use insulin better. Type II may eventually require the use or insulin too. Ultimately the disease causes the same problems to the body, especially if uncontrolled or poorly controlled. There is damage to small blood vessels particularly in feet, hands, eyes, kidneys and heart and damage to nerves.

Manifestations in the foot are largely three fold, poor circulation, nerve damage and poor healing following injury. But just because you are diabetic it does not mean that you will automatically have all of the following problems. If diabetes is well controlled it has a minimal effect on the body so controlling your blood sugar levels is very important.

Circulation can be effected by accelerating arthrosclerosis, the hardening of the arteries; this makes it more difficult for the blood to get to where it needs to go. If the blood can’t get down there in sufficient quantity or quality, when an injury occurs it may be slow to heal or even ulcerate. If the ulceration is not treated it can get infected and if that infection is not treated it can turn to gangrene which would mean amputation of the affected toe, foot or even leg. But as you can see there are many chances for intervention, from treating the original injury to treating the ulceration to treating the infection. Obviously it is better to treat the original injury early and avoid the complications of ulceration and infection.

Nerve damage or neuropathy can occur with diabetes. This can lead to loss of feeling particularly pain sensation in the feet. The problem here is the individual may not be aware that there is loss of feeling and if there is an injury may not seek care promptly. This increases the dangers of the above complications. Over the years my diabetic patients have been extremely inventive when it comes to damaging their feet without realizing it. From simple things like blisters and sun burn to scalding feet in a hot bath to the extreme cases of walking round with a nail through their shoe into the foot, all treatable but also all avoidable.

Poor healing in diabetic feet means that injuries are often slow to heal so wounds stay open longer increasing the chances of getting infected and infections love sugar. The higher the blood sugar the more rapidly the infection can take hold.

So what can we do to avoid these problems? Well, plenty. Good diabetic control means less damage and less problems. Inspect the feet daily make sure there are no injuries or changes in colour, inflammation or pain, if need be look at the bottom of the feet in a mirror if you have problems getting down there. Don’t walk bare foot it’s just asking for trouble. Wash the feet daily and dry carefully between toes and apply moisturiser to any dry areas, but not between the toes. Have feet measured when buying shoes and always check inside shoe before putting it on for stones or other foreign bodies. Visit a Podiatrist, well I would say that, but foot assessment by a podiatrist is important, circulation can be checked with Doppler and neuropathy measured then tailored advice given as well as routine care of nails corns and callous and even ulcers. If you have a foot problem don’t ignore it or try to self treat or self diagnose. Unfortunately there are too many amputees who put off seeking medical attention worried as they had heard about diabetics losing limbs, so that by the time they actually do seek care it is too late. Early intervention and treatment is the key to avoiding serious foot problems and having peace of mind.

Children’s Feet

Parents are often concerned about their offspring’s teeth and eyes but the developing feet are often forgotten. Although children’s feet usually encounter fewer problems than adult feet due to their flexibility and the resilience of the tissue, never the less they can be subject to some specific problems and many of the problems also seen in adult feet.

Firstly feet and children’s feet in particular are a remarkable piece of engineering. The foot is made up of 26 bones (28 if you include the Seasomoids, two small bones like sesame seeds in the tendons of the big toe) which when we are born are really cartilaginous molds of the bones. This means they are made of cartilage (that rubbery stuff on the end of chicken legs) with small centers of ossificication. As we mature the bones gradually ossify to become hard bone. Complete ossification doesn’t occur until we are in our late teens and even early twenties. So plenty of opportunities to damage this structure before it is fully formed. This is why good fitting shoes are so important. Children are prone to sudden growth spurts and it is important to check how the shoes fit at least every three months. There should be the width of the little finger’s space between the longest toe and the end of the shoe.

Verrucas are very common in children. These sometimes painful lesions are basically a wart on the foot and treatment may involve freezing the verruca or using an acid to get rid of them. Also commonly seen in children particularly in early teens are ingrown toe nails. Ingrown toenails are very common in this adolescent period when the feet are often a bit sweaty due to hormonal changes, making it easy for the nail to penetrate the skin. Sometimes it is simply a question of cutting out the bit that’s sticking in and advising about nail cutting but if the problem persists surgical removal of part of the nail under local anesthetic may be required. Fungal infections are very common in children and teenagers due to those damp feet again. Once diagnosed are relatively easy to treat with the appropriate antifungal medication.

Developmental problems in children’s feet include in toeing and flat feet both of which can be treated with orthotics and foot ware adjustments or occasionally casting.

Then there are some conditions which only happen in children. Avascular necrosis sometimes known as oseteochondrosis is a condition specific to children. There are four conditions here that all involve inflammation and necrosis at the growth plate of the bone. This results in pain which is exacerbated by weight bearing exercise, particularly running and jumping. The child will limp when running and experience pain especially during sporting activities. The area will be tender to touch and there may or may not be swelling there. Sever’s disease affects the heel, most commonly seen in children between eight and fifteen years. Kohler’s disease affects the navicular (top of the arch) and is generally seen between the ages of three and nine. Freiberg’s disease is found in the metatarsals usually the second and usually between the ages of thirteen and fifteen. Finally Osgood Schlatters disease, this actually affects the knee rather than the foot and is seen in children between the ages of eight and fifteen. Treatment for all of these conditions involves stopping all sporting activity provision of orthotics to support the foot. Laser treatment often speeds the process getting children back to normal activity more quickly.

It is worth remembering that there is no such thing as “growing pain” feet and legs especially in children should not be painful and pain requires the correct diagnosis.

Foot Pain

As the interface between the body and the ground the foot is subject to enormous stresses and loads during normal walking and running. With the hard unyielding ground and the rotations of the leg and trunk acting on it this complex structure it’s not surprising that occasionally we have problems. Sports men and women are more prone to problems as they demand more from their feet and legs.

When, we walk the first part of the foot to hit the ground is the outside of our heel (this is why we wear this part of our shoe first); as the rest of the foot comes in contact with the ground we start to move our body weight over the foot. At this point the foot starts to pronate (the rolling and flattening of the arch) this is a normal part of the gait cycle and allows the foot to adapt to uneven surfaces and absorb shock. As the body continues to move over the foot the foot starts to supernate, the arch starts to rise and the foot becomes more of a rigid lever enabling us to pivot over the foot (or push off) so we can take our next step, and so the cycle continues. We take an average of 2500 steps a day which means we walk about 3000 miles a year. It is not difficult to imagine that small changes in the gait cycle could have a significant impact on the whole system. If for example there is excessive pronation or flattening of the arch during the gait cycle, then we may be trying to pivot (push off) a foot that is a mobile adaptor rather than a rigid lever. Not only would this be less effective at moving us forward and therefore require more effort, but it may also have an impact on the structure doing the moving, i.e. the feet and legs. Excessive pronation can lead to many foot and leg conditions including, plantar fasciitis, tendonitis, shin splints, patello femoral problems and capsulitus to name a few. There may well be more remote symptoms including back pain and even tempro mandibular joint problems (jaw pain). Equally if there is excessive supernation and the foot is a rigid lever when it should be a mobile adaptor then the feet will be poor shock absorbers and this may also lead to problems like ankle sprains, Morton’s neuroma, stress fractures and knee problems, once again to name a few. Even callous and corns can often be traced back to underlying biomechanical problems causing increased pressure and or friction on a certain part of the foot.

Part of the role of a podiatrist is to assess the patient’s biomechanical problems when appropriate. This usually takes the form of a biomechanical assessment. The patient is examined to see how everything lines up, feet, legs, knees, and the rest of the body, lines may be drawn on the legs and feet and ranges of joint motion measured. Weakness or tightness of associated muscles will be noted. The gait may be observed and foot ware examined. From this the podiatrist can then make a diagnosis and prescribe the appropriate care often in the form of a custom made orthotic which fits in the shoe, this reduces excessive pronation or supernation and helps to align the legs and feet. Muscle stretching or strengthening may also be required. Often direct treatment to the injury or problem could be needed in the form of manipulation, strapping or laser treatment to the area. This type of treatment can not only resolve the presenting problem but also improve the way an individual walks or runs helping them to go faster or longer and preventing further injuries. Over the years I have treated many sports men and women from ramblers and power walkers, junior tri athletes, to professional footballers and marathon runners..

The Ageing Foot

We are all familiar with the ageing process, the changes that our body goes through as we go through life.

In my case the most obvious sign is that I have increasingly more face to wash and less hair to brush. Although age affects each individual differently generally we see the same sort of changes. There are various theories have been postulated as to why we age and although wear and tear may play a role this is not sufficient explanation for the whole process.

Programmed ageing this theory suggests that predetermined, presumably genetic, age related alteration in cellular function that leads to susceptibility to disease and death.

The Genomic Instability theory of ageing suggests errors in genetic transcription and translation resulting in impaired protein synthesis and determination of cell function as age increases.

The free radical theory of ageing suggests that these highly reactive molecules are no longer metabolized rapidly, so that accumulation occurs leading to irreversible cell damage.

Random genetic errors have also been implicated and an accumulation of errors over time is said to result in impaired protein synthesis.

At the time of writing there may well be more theories and of course it may not be one theory that is responsible but a combination which leads to the manifestations we see in our self and more easily others as we get older. To list a few in no particular order these are susceptibility to gain weight, greying and loss of hair, changes in skin texture and elasticity, bony and arthritic changes and alterations in circulation.

As usual the foot is often not considered when we think about ageing so this month I thought I would discuss some of the changes that occur in the foot.

Feet become more sensitive as we get older. The skin becomes thinner, dryer and the fatty padding that gives us protection and a degree of shock absorption may atrophy. If you think about young children’s feet they are very pudgy with lots of fatty padding, my children seem to be able to run bare foot over gravel with impunity, something that I am no longer able to do. We not only loose this padding but often it also moves leaving bones more exposed increasing susceptibility to corns and callous.

There is often an increase in size of feet this may be in length, width or both. Feet can get longer as we get older as the arch of the foot gradually collapses, if you fold a piece of paper in half and stand it on the table so it makes a triangle then push the top down you will see the ends get further away like the foot lengthening as the arch comes down. This may be exacerbated by increase in weight and arthritic changes. The foot may become wider due to swelling known as oedema often due to changes in the circulation. There are two possible changes we may see in circulation in the foot.

There may be a reduction in arterial circulation, the blood coming down to the foot due to hardening of the arteries known as arthrosclerosis which can increase with age. This can cause sensitivity, reduction in healing and in extreme cases pain. Problems with blood returning from the foot to circulate around the rest of the body are due to varicose veins this can cause pooling of blood and particularly tissue fluid leading to swelling as the day goes on. Arthritic changes in the foot can cause reduction of joint movement and bony swelling known as exostosis in the joints of the feet with in turn can cause problems with corns and callous. Often there are changes in the toe nails which although are not a direct result of the ageing process are more common as we age. The toe nails are there to protect the ends of our toes and if they get damaged, by trauma in the form of injury, knocking them or from tight shoes the nails will thicken to better protect the toes.

Of course the longer we live the more chances we have of damaging our nails and therefore the more chance that the nails will become thickened. With damage to nails there likelihood of getting fungal nail infections as fungus gets in between the damaged nail and the skin this may cause changes in colour of the nail as well as further thickening.

All these things to look forward to, but they are not inevitable I of course tend to see feet with problems simply by being a podiatrist, the good ones tend not to come and see me. There are many things we can do to mitigate these problems. Appropriate foot ware and that means having the feet measured as they may well have got longer or wider. When buying shoes it is best to do it late in the day when the feet are at their most swollen and sensitive. Look after the feet more put that cream on the heels put the feet up when the swell and that means level with the back side. Of course a trip to the podiatrist /chiropodist for diagnosis and treatment of any of the foot changes that age may bring us is always a good idea.