Arthritis and the Feet

Arthritis is a frequent component of complex disease processes that may involve more than 100 identifiable disorders. It is characterized by inflammation of the cartilage and lining of the body's joints. If the feet seem more susceptible to arthritis than other parts of the body, it is because each foot has 33 joints which can be afflicted, and there is no way to avoid the pain of the tremendous weight-bearing load on the feet.

Arthritis may be a disabling and occasionally crippling disease; it afflicts almost 40 million Americans. In some forms, it appears to have hereditary tendencies. While the prevalence of arthritis increases with age, all people from infancy to middle age are potential victims. People over 50 are the primary targets.

Arthritic feet can result in loss of mobility and independence. But that may be avoided with early diagnosis and proper medical care.

What is Arthritis?

Arthritis, in general terms, is inflammation and swelling of the cartilage and lining of the joints, generally accompanied by an increase in the fluid in the joints. Arthritis has multiple causes; just as a sore throat may have its origin in a variety of diseases, so joint inflammation and arthritis are associated with many different illnesses.

Some Causes
Besides heredity, arthritic symptoms may have their source in a number of phenomena:

• They can be traumatic, having their origins in injuries, notably in athletes and industrial workers, especially if the injuries have been ignored (which injuries of the feet tend to be).
• Bacterial and viral infections can strike the joints. The same organisms that are present in pneumonia, gonorrhea, staph infections, and Lyme disease cause the inflammations.
• Arthritis can develop in conjunction with bowel disorders such as colitis and ileitis, frequently in the joints of the ankles and toes. Such inflammatory bowel diseases seem distant from arthritis, but their control can relieve arthritic pain.
• Drugs, both prescription drugs and illegal street drugs, can induce arthritis.
• Arthritis can be part of a congenital autoimmune disease syndrome, of undetermined origin. Recent research has suggested, for instance, that a defective gene may play a role in osteoarthritis.

Symptoms

Because arthritis can affect the structure and function of the feet it is important to see a doctor of podiatric medicine if any of the following symptoms occur in the feet:

• Swelling in one or more joints
• Recurring pain or tenderness in any joint
• Redness or heat in a joint
• Limitation in motion of a joint
• Early morning stiffness
• Skin changes, including rashes and growths

Some Forms of Arthritis

Osteoarthritisis the most common form of arthritis. It is frequently called degenerative joint disease or "wear and tear" arthritis. Although it can be brought on suddenly by an injury, its onset is generally gradual; aging brings on a breakdown in cartilage, and pain gets progressively more severe, although it can be relieved with rest. Dull, throbbing nighttime pain is characteristic, and it may be accompanied by muscle weakness or deterioration. Gait patterns -- normal walking -- may grow erratic.

It is a particular problem for the feet when people are overweight, simply because there are so many joints in each foot. The additional weight contributes to the deterioration of cartilage and the development of bone spurs.

Rheumatoid arthritis (RA) is a major crippling disorder, and perhaps the most serious form of arthritis. It is a complex, chronic inflammatory system of diseases, often affecting more than a dozen smaller joints during the course of the disease, frequently in a symmetrical pattern -- both ankles, or the index fingers of both hands, for example. It is often accompanied by constitutional signs and symptoms -- lengthy morning stiffness, fatigue, and weight loss -- and it may affect various systems of the body, such as the eyes, lungs, heart, and nervous system.

Women are three or four times more likely than men to suffer RA, indicating a linkage to heredity.

RA has a much more acute onset than osteoarthritis. It is characterized by alternating periods of remission, during which symptoms disappear, and exacerbation, marked by the return of inflammation, stiffness, and pain. Serious joint deformity, and loss of motion, frequently result from acute rheumatoid arthritis. However, the disease system has been known to be active for months, or years, then abate, sometimes permanently.

Gout (gouty arthritis) is a condition caused by a build-up of the salts of uric acid -- a normal byproduct of the diet -- in the joints. A single big toe joint is commonly the locus, possibly because it is subject to so much pressure in walking; attacks of gouty arthritis are extremely painful, perhaps more so than any other form of arthritis. Men are much more likely to be afflicted than premenstrual women, an indication that heredity may play a role in the disease.

While a rich diet that contains lots of red meat, rich sauces, and brandy is popularly associated with gout, there are other protein compounds in such foods as lentils and beans which may play a role.

Diagnosis

Different forms of arthritis affect the body in different ways; many have distinct systemic affects that are not common to other forms. Early diagnosis is important to effective treatment of any form. Destruction of cartilage is not reversible, and if the inflammation of arthritic disease isn't treated, both cartilage and bone can be damaged, which makes the joints increasingly difficult to move. Most forms of arthritis cannot be cured, but can be controlled or brought into remission; perhaps only five percent of the most serious cases, usually of rheumatoid arthritis, result in such severe crippling that walking aids or wheelchairs are required.

Treatment

The objectives in the treatment of arthritis are controlling inflammation, preserving joint function (or restoring it if it has been lost), and curing the disease if that is possible.

Because the foot is such a frequent target, the doctor of podiatric medicine is often the first physician to encounter some of the complaints -- inflammation, pain, stiffness, excessive warmth, injuries. Even bunions can be manifestations of arthritis.

Arthritis may be treated in many ways. Patient education is important. Physical therapy and exercise may be indicated, accompanied by medication. In such a complex disease system, it's no wonder that a wide variety of drugs have been used effectively to treat it; likewise, a given treatment may be very effective in one patient and almost no help at all to another. Aspirin is still the first-line drug of choice for most forms of arthritis, and the benchmark against which the efficacy of a host of therapies is measured.

The control of foot functions with shoe inserts called orthoses, or with braces or specially prescribed shoes, may be indicated. Surgical intervention is a last resort in arthritis, as it is with most disease conditions; the replacement of damaged joints with artificial joints is a possible surgical procedure.

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Athlete's Foot

Athlete's foot is a skin disease caused by a fungus, usually occurring between the toes.

The fungus most commonly attacks the feet because shoes create a warm, dark, and humid environment which encourages fungus growth.

The warmth and dampness of areas around swimming pools, showers, and locker rooms, are also breeding grounds for fungi. Because the infection was common among athletes who used these facilities frequently, the term ìathlete's footî became popular.

Not all fungus conditions are athlete's foot. Other conditions, such as disturbances of the sweat mechanism, reaction to dyes or adhesives in shoes, eczema, and psoriasis, also may mimic athlete's foot.

Symptoms
The signs of athlete's foot, singly or combined, are drying skin, itching scaling, inflammation, and blisters. Blisters often lead to cracking of the skin. When blisters break, small raw areas of tissue are exposed, causing pain and swelling. Itching and burning may increase as the infection spreads.

Athlete's foot may spread to the soles of the feet and to the toenails. It can be spread to other parts of the body, notably the groin and underarms, by those who scratch the infection and then touch themselves elsewhere.

The organisms causing athlete's foot may persist for long periods. Consequently, the infection may be spread by contaminated bed sheets or clothing to other parts of the body.

Prevention
It is not easy to prevent athlete's foot because it is usually contracted in dressing rooms, showers, and swimming pool locker rooms where bare feet come in contact with the fungus. However, you can do much to prevent infection by practicing good foot hygiene. Daily washing of the feet with soap and water; drying carefully, especially between the toes; and changing shoes and hose regularly to decrease moisture, help prevent the fungus from infecting the feet. Also helpful is daily use of a quality foot powder.

Tips

• Avoid walking barefoot; use shower shoes.
• Reduce perspiration by using talcum powder.
• Wear light and airy shoes.
• Wear socks that keep your feet dry, and change them frequently if you perspire heavily.

Treatment
Fungicidal and fungistatic chemicals, used for athlete's foot treatment, frequently fail to contact the fungi in the horny layers of the skin. Topical or oral antifungal drugs are prescribed with growing frequency.

In mild cases of the infection it is important to keep the feet dry by dusting foot powder in shoes and hose. The feet should be bathed frequently and all areas around the toes dried thoroughly.

Consult Your Podiatrist
If an apparent fungus condition does not respond to proper foot hygiene and self care, and there is no improvement within two weeks, consult your podiatrist. The podiatrist will determine if a fungus is the cause of the problem. If it is, a specific treatment plan, including the prescription of antifungal medication, applied topically or taken by mouth, will usually be suggested. Such a treatment appears to provide better resolution of the problem, when the patient observes the course of treatment prescribed by the podiatrist; if it's shortened, failure of the treatment is common.

If the infection is caused by bacteria, antibiotics, such as penicillin, that are effective against a broad spectrum of bacteria may be prescribed.

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Diabetes

Diabetes mellitus is a chronic disease that affects the lives of about 16 million people in the United States, 5.4 million of whom are unaware that they even have the disease. Every day, 2,200 new cases of diabetes are diagnosed, and an estimated 780,000 new cases are identified each year. The disease is marked by the inability to manufacture or properly use insulin, and impairs the body’s ability to convert sugars, starches, and other foods into energy. The long-term effects of elevated blood sugar (hyperglycemia) are damage to the eyes, heart, feet, kidneys, nerves, and blood vessels.

Symptoms of hyperglycemia may include frequent urination, excessive thirst, extreme hunger, unexplained weight loss, tingling or numbness of the feet or hands, blurred vision, fatigue, slow-to-heal wounds, and susceptibility to certain infections. People who have any of these symptoms and have not been tested for diabetes are putting themselves at considerable risk and should see a physician without delay.

Part of keeping your diabetes in control is testing your blood sugar often. Ask your doctor how often you should test, and what your blood sugar levels should be. Testing your blood and then treating high blood sugar early will help you to prevent complications.

The socioeconomic costs of diabetes are enormous. The dollar costs have been estimated at $98 billion annually, about $44 billion of which are direct costs from the disease with $54 billion indirectly related. Diabetes is the sixth leading cause of death by disease in the United States, and individuals with diabetes are two to four times as likely to experience heart disease and stroke.

The growth of the disease worldwide is especially alarming. The World Health Organization (WHO) expects the number of new diabetes cases to double in the next 25 years from 135 million to nearly 300 million. Much of this growth will occur in developing countries where aging, unhealthy diets, obesity, and sedentary lifestyles will contribute to the onset of the disease.

• According to a recent survey, about 86,000 lower limbs are amputated annually due to complications from diabetes.
• Diabetes is the leading cause of end-stage kidney disease, accounting for about 40 percent of new cases.
• Diabetes is the leading cause of new cases of blindness among adults, age 20 to 74.

While there is currently no cure for diabetes, there is hope. With a proper diet, exercise, medical care, and careful management at home, a person with diabetes can keep the most serious of the consequences at bay and enjoy a long, full life.

How do you get Diabetes?
No one knows why people develop diabetes, but once diagnosed, the disease is present for life. It is a hereditary disorder, and certain genetic indicators are known to increase the risk of developing diabetes. Type 1, previously known as insulin-dependent diabetes mellitus or juvenile-onset diabetes, afflicts five to ten percent of diagnosed cases of diabetes. This type occurs most frequently in children and adolescents, and is caused by the inability of the pancreas to produce the insulin needed for survival. Type 2, previously called noninsulin-dependent diabetes mellitus or adult-onset diabetes, affects the other 90-95 percent of all diagnosed cases of diabetes, many of which are controlled by oral medicine or insulin injections. The vast majority of those people (80 percent or more) are overweight; obesity itself can cause insulin resistance.

Certain characteristics put people at a higher risk for developing Type 2 diabetes. These include:

• A family history of the disease
• Obesity
• Prior history of developing diabetes while pregnant
• Being over the age of 40
• Being a member of one of the following ethnic groups:
• African American
• Native American
• Latino American
• Asian American
• Pacific Islander
• African Americans are 1.7 times more likely to have diabetes than the general population, with 25 percent of African Americans between the ages of 65 and 74 diagnosed with the disease.
• Hispanic Americans are almost twice as likely to develop type 2 diabetes, which affects 10.6 percent of that population group.
• Native Americans are at a significantly increased risk for developing diabetes, and 12.2 percent of the population suffers from the disease. In some tribes, as many as 50 percent of members have diabetes.
• Weight is the most important risk factor, with more than 80 percent of diabetes sufferers classified as overweight.

The Role of your Poditric Physician
Because diabetes is a systemic disease affecting many different parts of the body, ideal case management requires a team approach. The podiatric physician, as an integral part of the treatment team, has documented success in the prevention of amputations, one of the most serious conditions that they treat. The key to amputation prevention in diabetic patients is early recognition and regular foot screenings, at least annually, from a podiatric physician.
In addition to these check ups, there are warning signs that you should be aware of so that they may be identified and called to the attention of the family physician or podiatrist. They include:

• Skin color changes
• Elevation in skin temperature
• Swelling of the foot or ankle
• Pain in the legs
• Open sores on the feet that are slow to heal
• Ingrown and fungal toenails
• Bleeding corns and calluses
• Dry cracks in the skin, especially around the heel

Wound Healing
Ulceration is a common occurrence with the diabetic foot, and should be carefully treated and monitored by a podiatrist to avoid amputations. Poorly fitted shoes, or something as trivial as a stocking seam, can create a wound that may not be felt by someone whose level of skin sensation is diminished. Left unattended, such ulcers can quickly become infected and lead to more serious consequences. Your podiatric physician knows how to treat and prevent these wounds and can be an important factor in keeping your feet healthy and strong. New to the science of wound healing are remarkable products that have the appearance and handling characteristics of human skin. These living, skin-like products are applied to wounds that are properly prepared by the podiatric physician. Clinical trials indicate that when applied to wounds, even those that are hard to heal, such products achieve impressive success rates.

IF YOU HAVE DIABETES ALREADY . . .

DO:

Wash feet daily
Using mild soap and lukewarm water, wash your feet in the mornings or before bed each evening. Dry carefully with a soft towel, especially between the toes, and dust your feet with talcum powder to wick away moisture. If the skin is dry, use a good moisturizing cream daily, but avoid getting it between the toes.

Inspect feet and toes daily.
Check your feet every day for cuts, bruises, sores or other changes that may be less obvious. If age or other factors hamper self-inspection, ask someone to help you or use a mirror.

Lose weight.
People with diabetes are commonly overweight, which nearly doubles the risk of complications.

Wear thick, soft socks.
Socks made of an acrylic blend are well suited, but avoid mended socks or those with seams, which could rub to cause blisters or other skin injuries.

Give up smoking.
Tobacco can contribute to circulatory problems, which can be especially troublesome in patients with diabetes.

Cut toenails straight across.
Never cut into the corners, or taper, which could trigger an ingrown toenail. Use an emery board to gently file away sharp corners or snags.

Exercise.
As a means to keep weight down and improve circulation, walking is one of the best all-around exercises for the diabetic patient. Walking is also an excellent conditioner for your feet. Be sure to wear the appropriate athletic shoe when exercising. Ask your podiatric physician what’s best for you.

See your podiatric physician.
Regular checkups by your podiatric physician—at least annually—is the best way to ensure that your feet remain healthy.

Be properly measured and fitted every time you buy new shoes.
Shoes are of supreme importance to diabetes sufferers because poorly fitted shoes are involved in as many as half of the problems that lead to amputations. Because foot size and shape may change over time, everyone should have their feet measured by an experienced shoe fitter whenever they buy a new pair of shoes.

New shoes should be comfortable at the time they’re purchased and should not require a "break-in" period, though it’s a good idea to wear them for short periods of time at first. Shoes should have leather or canvas uppers, fit both the length and width of the foot, leave room for toes to wiggle freely, and be cushioned and sturdy.

DON'T:

Go barefoot.
Not even in your own home. Barefoot walking outside is particularly dangerous because of the possibility of cuts, falls, and other foot injuries on unfamiliar terrain. When at home, wear slippers. Never go barefoot.

Wear high heels, sandals, and shoes with pointed toes.
These types of footwear can put undue pressure on parts of the foot and contribute to bone and joint disorders, as well as diabetic ulcers. In addition, open toed shoes and sandals with straps between the first two toes should also be avoided.

Drink in excess.
Alcohol can contribute to neuropathy (nerve damage) which is one of the consequences of diabetes. Drinking can speed up the damage associated with the disease, deaden more nerves, and increase the possibility of overlooking a seemingly minor cut or injury.

Wear anything that is too tight around the legs.
Panty hose, panty girdles, thigh-highs or knee-highs can constrict circulation to your legs and feet. So can men’s dress socks if the elastic is too tight.

Never try to remove calluses, corns or warts by yourself.
Commercial, over-the-counter preparations that remove warts or corns should be avoided because they can burn the skin and cause irreplaceable damage to the foot of a diabetic sufferer. Never try to cut calluses with a razor blade or any other instrument because the risk of cutting yourself is too high, and such wounds can often lead to more serious ulcers and lacerations. See your podiatric physician for assistance in these cases.

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Foot/Ankle Injuries

Immediate Treatment
Foot and ankle emergencies happen every day. Broken bones, dislocations, sprains, contusions, infections, and other serious injuries can occur at any time. Early attention is vitally important. Whenever you sustain a foot or ankle injury, you should seek immediate treatment from a podiatric physician.

That advice is universal, even though there are lots of myths about foot and ankle injuries. Some of them follow.

Myths

1. "It can't be broken, because I can move it." False; this widespread idea has kept many fractures from receiving proper treatment. The truth is that often you can walk with certain kinds of fractures. Some common examples: breaks of the thinner of the two leg bones; small "chip" fractures of either foot or ankle bones; and the frequently neglected fracture of a toe.
2. "If you break a toe, immediate care isn't necessary." False; a toe fracture needs prompt attention. If X-rays reveal it to be a simple, displaced fracture, care by your podiatrist usually can produce rapid relief. However, X-rays might identify a displaced or angulated break. In such cases, prompt realignment of the fracture by your podiatric physician will help prevent improper or incomplete healing. Many patients develop post-fracture deformity of a toe, which in turn results in formation of a painfully deformed toe with a most painful corn. A good general rule is: Seek prompt treatment for injury to foot bones.
3. "If you have a foot or ankle injury, soak it in hot water immediately." False; don't use heat or hot water if you suspect a fracture, sprain, or dislocation. Heat promotes blood flow, causing greater swelling. More swelling means greater pressure on the nerves, which causes more pain. An ice bag wrapped in a towel has a contracting effect on blood vessels, produces a numbing effect, and prevents swelling and pain. After seeing a podiatric physician, warm compresses and soaks may be used.
4. "Applying an elastic bandage to a severely sprained ankle is adequate treatment." False; ankle sprains often mean torn or severely overstretched ligaments, and they should receive immediate care. X-ray examination, immobilization by casting or splinting, and physiotherapy to insure a normal recovery all may be indicated. Surgery may even be necessary.
5. "The terms 'fracture,' 'break,' and 'crack' are all different." False; all of those words are proper in describing a broken bone.

Before Seeing the Podiatrist
If an injury or accident does occur, the steps you can take to help yourself until you can reach your podiatric physician are easy to remember if you can recall the word "rice."

1. Rest. Cut back on your activity, and get off your feet if you can.
2. Ice. Gently place a plastic bag of ice, or ice wrapped in a towel, on the injured area in a 20-minute-on, 40-minute-off cycle.
3. Compression. Lightly wrap an Ace bandage around the area, taking care not to pull it too tight.
4. Elevation. Sit in a position that you can elevate the foot higher than the waist, to reduce swelling and pain.
5. Switch to a soft shoe or slipper, preferably one that your podiatrist can cut up in the office if it needs to be altered to accommodate a bulky dressing.
6. For bleeding cuts, cleanse well, apply pressure with gauze or a towel, and cover with a clean dressing. It's best not to use any medication on the cut before you see the doctor.
7. Leave blisters unopened if they are not painful or swollen.
8. Foreign materials in the skin, such as slivers, splinters, and sand, can be removed carefully with a sterile instrument. A deep foreign object, such as broken glass or a needle, must be removed professionally.
9. Treatment for an abrasion is similar to that of a burn, since raw skin is exposed to the air and can easily become infected. Cleansing is important to remove all foreign particles. Sterile bandages should be applied, along with an antibiotic cream or ointment.

Prevention

1. Wear the correct shoes for any event. Good walking shoes provide more comfort and better balance.
2. Wear hiking shoes or boots in rough terrain.
3. Different sports activities call for specific footwear to protect feet and ankles. Use the correct shoes for each sport. Don't wear any sports shoe beyond its useful life.
4. Wear safety shoes if you're in an occupation which threatens foot safety. There are specific safety shoes for a variety of on-the-job conditions. Be certain they are fitted properly.
5. Always wear hard-top shoes when operating a lawn mower or other grass-cutting equipment.
6. Don't walk barefoot on paved streets or sidewalks.
7. Watch out for slippery floors at home and at work. Clean up obviously dangerous spills immediately.
8. If you get up during the night, turn on a light. Many fractured toes and other foot injuries occur while attempting to find your way in the dark.

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What Is a Bunion?

A bunion is an enlargement of the joint at the base of the big toe—the metatarsophalangeal (MTP) joint—that forms when the bone or tissue at the big toe joint moves out of place. This forces the toe to bend toward the others, causing an often painful lump of bone on the foot. Since this joint carries a lot of the body’s weight while walking, bunions can cause extreme pain if left untreated. The MTP joint itself may become stiff and sore, making even the wearing of shoes difficult or impossible. Bunions– from the Latin "bunio," meaning enlargement–can also occur on the outside of the foot along the little toe, where it is called a "bunionette" or "tailor’s bunion."

Symptoms

• Development of a firm bump on the outside edge of the foot, at the base of the big toe.
• Redness, swelling, or pain at or near the MTP joint.
• Corns or other irritations caused by the overlap of the first and second toes.
• Restricted or painful motion of the big toe.

How Do You Get a Bunion?
Bunions form when the normal balance of forces that is exerted on the joints and tendons of the foot becomes disrupted. This can lead to instability in the joint and cause the deformity. They are brought about by years of abnormal motion and pressure over the MTP joint. They are, therefore, a symptom of faulty foot development and are usually caused by the way we walk, and our inherited foot type, our shoes, or other sources.

Although bunions tend to run in families, it is the foot type that is passed down—not the bunion. Parents who suffer from poor foot mechanics can pass their problematic foot type on to their children, who, in turn, are also prone to developing bunions. The abnormal functioning caused by this faulty foot development can lead to pressure being exerted on and within the foot, often resulting in bone and joint deformities such as bunions and hammertoes.

Other causes of bunions are foot injuries, neuromuscular disorders, or congenital deformities. People who suffer from flat feet or low arches are also prone to developing these problems, as are arthritic patients and those with inflammatory joint disease. Occupations that place undue stress on the feet are also a factor; ballet dancers, for instance, often develop the condition.

Wearing shoes that are too tight or cause the toes to be squeezed together is also a common factor, one that explains the high prevalence of the disorder among women.

What Can You Do For Relief?

• Apply a commercial, nonmedicated bunion pad around the bony prominence.
• Wear shoes with a wide and deep toe box.
• If your bunion becomes inflamed and painful, apply ice packs several times a day to reduce swelling.
• Avoid high-heeled shoes over two inches tall.
• See your podiatric physician if pain persists.

Conservative Treatment For Bunion Pain
Treatment options vary with the type and severity of each bunion, although identifying the deformity early in its development is important in avoiding surgery. Podiatric medical attention should be sought at the first indication of pain or discomfort because, left untreated, bunions tend to get larger and more painful, making nonsurgical treatment less of an option.

The primary goal of most early treatment options is to relieve pressure on the bunion and halt the progression of the joint deformity. A podiatric physician may recommend these treatments:

• Padding & Taping
  Often the first step in a treatment plan, padding the bunion minimizes pain and allows the patient to continue a normal, active life. Taping helps keep the foot in a normal position, thus reducing stress and pain.
• Medication
  Anti-inflammatory drugs and cortisone injections are often prescribed to ease the acute pain and inflammations caused by joint deformities.
• Physical Therapy
  Often used to provide relief of the inflammation and from bunion pain. Ultrasound therapy is a popular technique for treating bunions and their associated soft tissue involvement.
• Orthotics
  Shoe inserts may be useful in controlling foot function and may reduce symptoms and prevent worsening of the deformity.

When early treatments fail or the bunion progresses past the threshold for such options, podiatric surgery may become necessary to relieve pressure and repair the toe joint.

Surgical Options
Several surgical procedures are available to the podiatric physician The surgery will remove the bony enlargement, restore the normal alignment of the toe joint, and relieve pain.

A simple bunionectomy, in which only the bony prominence is removed, may be used for the less severe deformity. Severe bunions may require a more involved procedure, which includes cutting the bone and realigning the joint.

Recuperation takes time, and swelling and some discomfort are common for several weeks following surgery. Pain, however, is easily managed with medications prescribed by your podiatric physician.

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Children's Feet

You worry about your children's teeth, eyes, and other parts of the body. You teach washing, brushing, and grooming, but what do you do about your child's feet--those still-developing feet which have to carry the entire weight of the body through a lifetime?

Many adult foot ailments, like other bodily ills, have their origins in childhood and are present at birth. Periodic professional attention and regular foot care can minimize these problems in later life.

Neglecting foot health invites problems in other parts of the body, such as the legs and back. There can also be undesirable personality effects. The youngster with troublesome feet walks awkwardly and usually has poor general posture. As a result, the growing child may become shy, introverted, and avoid athletics and social functions. Consultation between the podiatrist, pediatrician, and other medical specialists helps to resolve these related problems.

Baby's Feet
The human foot - one of the most complicated parts of the body - has 26 bones, and is laced with ligaments, muscles, blood vessels, and nerves. Because the feet of young children are soft and pliable, abnormal pressure can easily cause deformities.

A child's feet grow rapidly during the first year, reaching almost half their adult foot size. This is why foot specialists consider the first year to be the most important in the development of the feet.

Here are some suggestions to help you assure that this development proceeds normally:

• Look carefully at your baby's feet. If you notice something that does not look normal to you, seek professional care immediately. Deformities will not be outgrown by themselves.
  
• Cover baby's feet loosely. Tight covers restrict movement and can retard normal development.
  
• Provide an opportunity for exercising the feet. Lying uncovered enables the baby to kick and perform other related motions which prepare the feet for weight bearing.
  
• Change the baby's position several times a day. Lying too long in one spot, especially on the stomach, can put excessive strain on the feet and legs.

Starting to Walk
It is unwise to force a child to walk. When physically and emotionally ready, the child will walk. Comparisons with other children are misleading, since the age for independent walking ranges from 10 to 18 months.

When the child first begins to walk, shoes are not necessary indoors. Allowing the youngster to go barefoot or to wear just socks helps the foot to grow normally and to develop its musculature and strength, as well as the grasping action of toes. Of course, when walking outside or on rough surfaces, babies' feet should be protected in lightweight, flexible footwear made of natural materials.

Growing Up
As a child's feet continue to develop, it may be necessary to change shoe and sock size every few months to allow room for the feet to grow. Although foot problems result mainly from injury, deformity, illness, or hereditary factors, improper footwear can aggravate preexisting conditions. Shoes or other footwear should never be handed down.

The feet of young children are often unstable because of muscle problems which make walking difficult or uncomfortable. A thorough examination by a podiatrist may detect an underlying defect or condition which may require immediate treatment or consultation with another specialist.

The American Podiatric Medical Association has long known of the high incidence of foot defects among the young, and recommends foot health examinations for school children on a regular basis.

Sports Activities
Millions of American children participate in team and individual sports, many of them outside the school system, where advice on conditioning and equipment is not always available. Parents should be concerned about children's involvement in sports that require a substantial amount of running and turning, or involve contact. Protective taping of the ankles is often necessary to prevent sprains or fractures. Parents should consider discussing these matters with their family podiatrist if they have children participating in active sports. Sports-related foot and ankle injuries are on the rise as more children actively participate in sports.

Advice for Parents
Problems noticed at birth will not disappear by themselves. You should not wait until the child begins walking to take care of a problem you've noticed earlier.

Remember that lack of complaint by a youngster is not a reliable sign. The bones of growing feet are so flexible that they can be twisted and distorted without the child being aware of it.

Walking is the best of all foot exercises, according to podiatrists. They also recommend that walking patterns be carefully observed. Does the child toe in or out, have knock knees, or other gait abnormalities? These problems can be corrected if they are detected early.

Going barefoot is a healthy activity for children under the right conditions. However, walking barefoot on dirty pavements exposes children's feet to the dangers of infection through accidental cuts and to severe contusions, sprains or fractures. Another potential problem is plantar warts, a condition caused by a virus which invades the sole of the foot through cuts and breaks in the skin. They require protracted treatment and can keep children from school and other activities.

Be careful about applying home remedies to children's feet. Preparations strong enough to kill certain types of fungus can harm the skin.

Whenever you have questions about your child's foot health, contact a podiatrist in your community.

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Forefoot Surgery

A Major Health Concern
Many foot problems do not respond to "conservative" management. Your podiatric surgeon can determine when surgical intervention may be helpful. Often when pain or deformity persists, surgery may be appropriate to help alleviate them, or to restore the function of your foot.

Bunions
A common deformity of the foot, a bunion is an enlargement of the bone and tissue around the joint of the big toe. Heredity frequently plays a role in the occurrence of bunions (especially among women), as it does in other foot conditions. When symptomatic, the tissue may become red, swollen, and inflamed, making shoe gear and walking uncomfortable and difficult. If conservative care fails to reduce these symptoms, surgical intervention may be warranted. Your podiatric surgeon will determine the type of surgical procedure best suited for your deformity, based on a variety of information which may include X-rays and gait examination.

Hammertoes
A hammertoe deformity is a contracture of the toe(s), frequently caused by an imbalance in the tendon or joints of the toes. Due to the "buckling" effect of the toe(s), hammertoes may become painful secondary to footwear irritation and pressure. Corn and callus formation may occur as a hammertoe becomes more rigid over time, making it difficult to wear shoes. Your podiatric surgeon may suggest correction of this deformity through a surgical procedure to realign the toe(s).

Neuroma
An irritation of a nerve may produce a neuroma, which is a benign enlargement of a nerve segment, commonly found between the third and fourth toes. Several factors may contribute to the formation of a neuroma. Trauma, arthritis, high-heeled shoes, or an abnormal bone structure are just some of the conditions that may cause a neuroma. Symptoms such as burning or tingling to adjacent toes and even numbness are commonly seen with this condition. If conservative treatment does not relieve the symptoms, then your podiatric physician will decide based on your symptoms whether surgical treatment is appropriate.

Bunionette (tailor's bunion)
A protuberance of bone at the outside of the foot behind the fifth (small) toe, the bunionette or "small bunion" is caused by a variety of conditions including heredity, faulty biomechanics (the way you walk) or trauma, to name a few. Pain is often associated with this deformity, making shoes very uncomfortable and at times even walking becomes difficult. If severe and conservative treatments fail to improve the symptoms of this condition, surgical repair may be suggested. Your podiatric surgeon will develop a surgical plan specific to the condition present.

Toenail Deformities
Ingrown or deformed toenail tissue may be severe enough to warrant surgical treatment. Removal of part or all the nail may be necessary, depending on the deformity. Sometimes soft tissue near or at the nail plate must be removed to adequately treat specific conditions of the toenail. Your podiatric physician will decide the surgical procedure best suited to treat your nail condition.

Bone Spurs
A bone spur is an overgrowth of bone as a result of trauma or reactive stress of a ligament or tendon. This growth can cause pain and even restrict motion of a joint, depending on its location and size. Spurs may also be located under the toenail plate, causing nail deformity and pain. Surgical treatment and procedure is based on the size, location, and symptoms of the bone spur. Your podiatric physician will determine the surgical method best suited for your condition.

Preoperative Testing and Care
As with anyone facing any surgical procedure, those undergoing foot and ankle surgery require specific tests or examinations before surgery to improve a successful surgical outcome. Prior to surgery, the podiatric surgeon will review your medical history and medical conditions. Specific diseases, illnesses, allergies, and current medications need to be evaluated. Other tests that help evaluate your health status may be ordered by the podiatric physician, such as blood studies, urinalysis, EKG, X-rays, blood flow studies (to better evaluate the circulatory status of the foot/legs), and biomechanical examination. A consultation with another medical specialist is sometimes advised by a podiatric physician, depending on your test results or a specific medical condition.

Postoperatice Care
The type of foot surgery performed determines the length and kind of aftercare required to assure that your recovery from surgery is rapid and uneventful. The basics of all postoperative care involves to some degree each of the following: rest, ice, compression and elevation. Bandages, splints, surgical shoes, casts, crutches, or canes may be necessary to improve and insure a safe recovery after foot surgery. A satisfactory recovery can be hastened by carefully following instructions from your podiatric surgeon.

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Nail Fungus

Fungal infection of toenails is a common foot health problem. A majority of victims don't seek treatment, maybe don't even recognize the existence of a problem. Studies estimate that it afflicts three to five percent of the population; however, doctors of podiatric medicine think that because so many cases go unreported, the incidence is much higher than that (they treat perhaps 2.5 million people annually, but that's less than a quarter of the cases estimated by the studies).

Probably one reason that so many people ignore the infection is that it can be present for years without ever causing pain. Its prevalence rises sharply among older adults (20 to 30 percent, the studies say, though podiatric physicians think it's much higher). Because the older adults may be experiencing much more serious medical problems, it is understandable that fungal nails can be passed over as very minor, though it is anything but that.

Whatever the case, the disease, characterized by a change in a toenail's color, is often considered nothing more than a mere blemish - ugly and embarrassing. It is apparently assumed that since white markings or a darkening of the nail are minor occurrences, the change represents something minor as well, even when the blemish spreads. It may be that cosmetologists see this condition as often as doctors. Nail polish is an easy solution for many women, rendering the problem "out of sight, out of mind."

In many cases, however, that change in color is the start of an aggravating disease that ultimately could take months to control. Fungal infection of the nails is known to podiatrists and other physicians as onychomycosis. It is an infection underneath the surface of the nail, which can also penetrate the nail. If it is ignored, its spread could impair one's ability to work or even walk. That happens because it is frequently accompanied by thickening of the nails, which then cannot easily be trimmed and may cause pain while wearing shoes. This disease can frequently be accompanied by a secondary bacterial and/or yeast infection in or about the nail plate.

What is a Fungal Nail?
Onychomycosis is an infection of the bed and plate underlying the surface of the nail, and is caused by various types of fungi, which are commonly found throughout the environment. Fungi are simple parasitic plant organisms, such as molds and mildew, that lack chlorophyll and therefore do not require sunlight for growth. A group of fungi called dermophytes easily attack the nail, thriving off keratin, the nail's protein substance.

When the tiny organisms take hold, the nail may become thicker, yellowish-brown or darker in color, and foul smelling. Debris may collect beneath the nail plate, white marks frequently appear on the nail plate, and the infection is capable of spreading to other toenails, the skin, or even the fingernails.

Because it is difficult to avoid contact with microscopic organisms like fungi, the toenails are especially vulnerable around damp areas where people are likely to be walking barefoot -- swimming pools, locker rooms, and showers, for example. Injury to the nail bed may make it more susceptible to all types of infection, including fungal infection. Those who suffer chronic diseases, such as diabetes, circulatory problems, or immune-deficiency conditions, are especially prone to fungal nails. Other contributory factors may be a history of athlete's foot and excessive perspiration.

Prevention
Because fungi are everywhere, including the skin, they can be present months before they find opportunities to strike, and before signs of infection appear. By following precautions, including proper hygiene and regular inspection of the feet and toes, chances of the problem occurring can be sharply reduced, or even put to a halt.

Clean, dry feet resist disease; a strict regimen of washing the feet with soap and water, remembering to dry thoroughly, is the best way to prevent an infection. Shower shoes should be worn when possible, in public areas. Shoes, socks, or hosiery should be changed daily. Toenails should be clipped straight across so that the nail does not extend beyond the tip of the toe. Use a quality foot powder -- talcum, not cornstarch -- in conjunction with shoes that fit well and are made of materials that breathe.

Avoid wearing excessively tight hosiery, which promotes moisture. Socks made of synthetic fiber tend to "wick" away moisture faster than cotton or wool socks, especially for those with more active life styles.

Artificial Nails and Polish
Moisture collecting underneath the surface of the toenail would ordinarily evaporate, passing through the porous structure of the nail. The presence of an artificial nail or a polish impedes that, and the water trapped below can become stagnant and unhealthy, ideal for fungi and similar organisms to thrive.

Always use preventive measures when applying polishes. Disinfect home pedicure tools and don't apply polish to nails suspected of infection ñ those on toes that are red, discolored, or swollen, for example.

Treatment
Depending on the nature of the infection and the severity of each case, treatment may vary. A daily routine of cleansing, over a period of many months, may temporarily suppress mild infections. White markings that appear on the surface of the nail can be filed off, followed by the application of an over-the-counter liquid antifungal agent.

However, even the best-over-the-counter treatments may not prevent a fungal infection from coming back. A fungus may work its way through the entire nail, penetrating both the nail plate and the nail bed. If an infection is not overcome, or continues to reappear, further medical attention is strongly recommended.

Podiatric Medical Care
A podiatric physician can detect a fungal infection early, culture the nail, determine the cause, and form a suitable treatment plan, which may include prescribing topical or oral medication, and debridement (removal of diseased nail matter and debris) of an infected nail. Indeed, debridement is one of the most common foot care procedures performed by DPMs.

Newer oral antifungals approved by the Food and Drug Administration may be the most effective treatment. They offer a shorter treatment outlook (three to four months) and improved effectiveness, though DPMs advise that lengthier treatments, up to 12 months, may still be required for some infections. Current studies show that, for a small percentage of the population, there are some unwanted side effects with any oral antifungal.

In some cases, surgical treatment may be required. Temporary removal of the infected nail can be performed to permit direct application of a topical antifungal. Permanent removal of a chronically painful nail, which has not responded to any other treatment, permits the fungal infection to be cured, and prevents the return of a deformed nail.

Trying to solve the infection without the qualified help of a podiatric physician can lead to more problems. With new technological advances in combination with simple preventive measures, the treatment of this lightly regarded health problem can often be successful.

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Heel Pain

Heel Pain Has Many Causes
In our pursuit of healthy bodies, pain can be an enemy. In some instances, however, it is of biological benefit. Pain that occurs right after an injury or early in an illness may play a protective role, often warning us about the damage we've suffered.

When we sprain an ankle, for example, the pain warns us that the ligament and soft tissues may be frayed and bruised, and that further activity may cause additional injury.

Pain, such as may occur in our heels, also alerts us to seek medical attention. This alert is of utmost importance because of the many afflictions that contribute to heel pain.

Heel Pain
Heel pain is generally the result of faulty biomechanics (walking gait abnormalities) that place too much stress on the heel bone and the soft tissues that attach to it. The stress may also result from injury, or a bruise incurred while walking, running, or jumping on hard surfaces; wearing poorly constructed footwear; or being overweight.

The heel bone is the largest of the 26 bones in the human foot, which also has 33 joints and a network of more than 100 tendons, muscles, and ligaments. Like all bones, it is subject to outside influences that can affect its integrity and its ability to keep us on our feet. Heel pain, sometimes disabling, can occur in the front, back, or bottom of the heel.

Heel Spurs
A common cause of heel pain is the heel spur, a bony growth on the underside of the heel bone. The spur, visible by X ray, appears as a protrusion that can extend forward as much as half an inch. When there is no indication of bone enlargement, the condition is sometimes referred to as "heel spur syndrome."

Heel spurs result from strain on the muscles and ligaments of the foot, by stretching of the long band of tissue that connects the heel and the ball of the foot, and by repeated tearing away of the lining or membrane that covers the heel bone. These conditions may result from biomechanical imbalance, running or jogging, improperly fitted or excessively worn shoes, or obesity.

Plantar Fasciitis
Both heel pain and heel spurs are frequently associated with an inflammation of the band of fibrous connective tissue (fascia) running along the bottom (plantar surface) of the foot, from the heel to the ball of the foot. The inflammation is called plantar fasciitis. It is common among athletes who run and jump a lot, and can be quite painful.

The condition occurs when the plantar fascia is strained over time beyond its normal extension, causing the soft tissue fibers of the fascia to tear or stretch at points along its length; this leads to inflammation, pain, and possibly the growth of a bone spur where it attaches to the heel bone.

The inflammation may be aggravated by shoes that lack appropriate support, especially in the arch area, and by the chronic irritation that sometimes accompanies an athletic lifestyle.

Resting provides only temporary relief. When you resume walking, particularly after a night's sleep, you may experience a sudden elongation of the fascia band, which stretches and pulls on the heel. As you walk, the heel pain may lessen or even disappear, but that may be just a false sense of relief. The pain often returns after prolonged rest or extensive walking.

Excessive Pronation
Heel pain sometimes results from excessive pronation. Pronation is the normal flexible motion and flattening of the arch of the foot that allows it to adapt to ground surfaces and absorb shock in the normal walking pattern.

As you walk, the heel contacts the ground first; the weight shifts first to the outside of the foot, then moves toward the big toe. The arch rises, the foot generally rolls upward and outward, becoming rigid and stable in order to lift the body and move it forward. Excessive pronation—excessive inward motion—can create an abnormal amount of stretching and pulling on the ligaments and tendons attaching to the bottom back of the heel bone. Excessive pronation may also contribute to injury to the hip, knee, and lower back.

Disease and Heel Pain
Some general health conditions can also bring about heel pain.

• Rheumatoid arthritis and other forms of arthritis, including gout, which usually manifests itself in the big toe joint, can cause heel discomfort in some cases.
• Heel pain may also be the result of an inflamed bursa (bursitis), a small, irritated sack of fluid; a neuroma (a nerve growth); or other soft-tissue growth. Such heel pain may be associated with a heel spur, or may mimic the pain of a heel spur.
• Haglund's deformity ("pump bump") is a bone enlargement at the back of the heel bone, in the area where the Achilles tendon attaches to the bone. This sometimes painful deformity generally is the result of bursitis caused by pressure against the shoe, and can be aggravated by the height or stitchng of a heel counter of a particular shoe.
• Pain at the back of the heel is associated with inflammation of the achilles tendon as it runs behind the ankle and inserts on the back surface of the heel bone. The inflammation is called achilles tendonitis. It is common among people who run and walk a lot and have tight tendons. The condition occurs when the tendon is strained over time, causing the fibers to tear or stretch along its length, or at its insertion on to the heel bone. This leads to inflammation, pain, and the possible growth of a bone spur on the back of the heel bone. The inflammation is aggravated by the chronic irritation that sometimes accompanies an active lifestyle and certain activities that strain an already tight tendon.
• Bone bruises are common heel injuries. A bone bruise or contusion is an inflammation of the tissues that cover the heel bone. A bone bruise is a sharply painful injury caused by the direct impact of a hard object or surface on the foot.
• Stress fractures of the heel bone also can occur, but these are less frequent.

Children’s Heel Pain (Calcaneal Apophysitis)
Heel pain can also occur in children, most commonly between ages 8 and 13, as they become increasingly active in sports activity in and out of school. This physical activity, particularly jumping, inflames the growth centers of the heels; the more active the child, the more likely the condition will occur. When the bones mature, the problems disappear and are not likely to recur. If heel pain occurs in this age group, podiatric care is necessary to protect the growing bone and to provide pain relief. Other good news is that heel spurs do not often develop in children.

Prevention
A variety of steps can be taken to avoid heel pain and accompanying afflictions:

• Wear shoes that fit well — front, back, and sides — and have shock-absorbent soles, rigid shanks, and supportive heel counters.
• Wear the proper shoes for each activity.
• Do not wear shoes with excessive wear on heels or soles.
• Prepare properly before exercising. Warm up and do stretching exercises before and after running.
• Pace yourself when you participate in athletic activities.
• Don’t underestimate your body's need for rest and good nutrition.
• If obese, lose weight.
  

Podiatric Medical Care
If pain and other symptoms of inflammation—redness, swelling, heat—persist, you should limit normal daily activities and contact a doctor of podiatric medicine.

The podiatric physician wiil examine the area and may perform diagnostic X rays to rule out problems of the bone.

Early treatment might involve oral or injectable anti-inflammatory medication, exercise and shoe recommendations, taping or strapping, or use of shoe inserts or orthotic devices. Taping or strapping supports the foot, placing stressed muscles and tendons in a physiologically restful state. Physical therapy may be used in conjunction with such treatments.

A functional orthotic device may be prescribed for correcting biomechanical imbalance, controlling excessive pronation, and supporting of the ligaments and tendons attaching to the heel bone. It will effectively treat the majority of heel and arch pain without the need for surgery.

Only a relatively few cases of heel pain require more advanced treatments or surgery. If surgery is necessary, it may involve the release of the plantar fascia, removal of a spur, removal of a bursa, or removal of a neuroma or other soft-tissue growth.

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The Podiatric Physician and Cardiovascular Ailments

As a member of the health care team Dr. More is vitally concerned about hypertension (high blood pressure) and vascular disease (heart and circulatory problems). There are several reasons for this concern. First, because you are a patient, your podiatric physician and surgeon is interested in all aspects of your health and your treatment program. Second, he or she supports the goals of high blood pressure detection, treatment, and control.

Dr More should know if you have any of the following cardiovascular or related conditions:

Hypertension and/or cardiovascular disease
Hypertension sometimes causes decreased circulation. A careful examination is required to determine if there is lower than normal temperature in any of the extremities, absence of normal skin color, or diminished pulse in the feet. The concern is that these are signs of arterial insufficiency (reduced blood flow). Increased or periodic swelling in the lower extremities is important because it may mean that hypertension has contributed to heart disease.

Rheumatic heart disease
Persons who have had rheumatic heart disease must be protected with prophylactic antibiotics prior to any surgical intervention. If you take medication for this condition, tell your podiatric physician. Any medication you may be taking for high blood pressure, a heart condition, or any other reason should be reported to the DPM to ensure that it does not conflict with medications that may be prescribed in the treatment of your feet.

Diabetes
This condition frequently affects the smaller arteries, resulting in diminished circulation and decreased sensation in the extremities. Let your podiatric physician know if you have ever been told that you have diabetes, particularly if you are talking medication or insulin for this condition.

Ulceration
Open sores that do not heal, or heal very slowly, may be symptoms of certain anemias, including sickle cell disease. Or they may be due to hypertension or certain inflammatory conditions of the blood vessels. Your DPM is on the alert for such conditions, but be sure to mention if you have ever had this problem.

Swollen feet
Persistent swelling of one or both feet may be due to kidney, heart, or circulatory problems.

Burning feet
Although it can have a number of causes, a burning sensation of the feet is frequently caused by diminished circulation.

Control of High Blood Pressure
High blood pressure is a major risk factor for cardiovascular disease. Uncontrolled high blood pressure can cause fatal strokes and heart disease. As a health care provider, your podiatric physician assists in controlling this public health problem. There are three major areas in which he or she provides this important public service:

Detection
Many podiatric physicians routinely take every patient's blood pressure and determine if it is elevated.

Treatment
After confirming that blood pressure is elevated and making this information part of each patient's record, the DPM refers all patients with elevated blood pressure to their primary care physicians for evaluation, diagnosis and treatment.

Long-Term Control
By encouraging patients in every visit to adhere to treatment, and by monitoring reductions in blood pressure, side effects of treatment, and referring for reevaluation as needed, the podiatric physician facilitates long-term control.

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Nail Problems

Barometers of Health
Toenails often serve as barometers of our health; they are diagnostic tools providing the initial signal of the presence or onset of systemic diseases. For example, the pitting of nails and increased nail thickness can be manifestations of psoriasis. Concavity—nails that are rounded inward instead of outward—can foretell iron deficiency anemia. Some nail problems can be conservatively treated with topical or oral medications while others require partial or total removal of the nail. Any discoloration or infection on or about the nail should be evaluated by a podiatric physician.

Nail Ailments

Ingrown Toenails
Ingrown nails, the most common nail impairment, are nails whose corners or sides dig painfully into the soft tissue of nail grooves, often leading to irritation, redness, and swelling. Usually, toenails grow straight out. Sometimes, however, one or both corners or sides curve and grow into the flesh. The big toe is usually the victim of this condition, but other toes can also become affected.

Ingrown toenail may be caused by:

• Improperly trimmed nails (Trim then straight across, not longer than the tip of the toes. Do not round off corners. Use toenail clippers.)
• Heredity
• Shoe pressure; crowding of toes
• Repeated trauma to the feet from normal activities

If you suspect an infection due to an ingrown toenail, immerse the foot in a warm salt water soak, or a basin of soapy water, then apply an antiseptic and bandage the area. People with diabetes, peripheral vascular disease, or other circulatory disorders must avoid any form of self treatment and seek podiatric medical care as soon as possible.

Other "do-it-yourself" treatments, including any attempt to remove any part of an infected nail or the use of over-the-counter medications, should be avoided. Nail problems should be evaluated and treated by your podiatrist, who can diagnose the ailment, and then prescribe medication or another appropriate treatment.

A podiatrist will resect the ingrown portion of the nail and may prescribe a topical or oral medication to treat the infection. If ingrown nails are a chronic problem, your podiatrist can perform a procedure to permanently prevent ingrown nails. The corner of the nail that ingrows, along with the matrix or root of that piece of nail, are removed by use of a chemical, a laser, or by other methods.

Fungal Nails
Fungal infection of the nail, or onychomycosis, is often ignored because the infection can be present for years without causing any pain. The disease is characterized by a progressive change in a toenail's quality and color, which is often ugly and embarrassing.

In reality, the condition is an infection underneath the surface of the nail caused by fungi. When the tiny organisms take hold, the nail often becomes darker in color and foul smelling. Debris may collect beneath the nail plate, white marks frequently appear on the nail plate, and the infection is capable of spreading to other toenails, the skin, or even the fingernails. If ignored, the infection can spread and possibly impair one's ability to work or even walk. This happens because the resulting thicker nails are difficult to trim and make walking painful when wearing shoes. Onychomycosis can also be accompanied by a secondary bacterial or yeast infection in or about the nail plate.

Because it is difficult to avoid contact with microscopic organisms like fungi, the toenails are especially vulnerable around damp areas where people are likely to be walking barefoot, such as swimming pools, locker rooms, and showers, for example. Injury to the nail bed may make it more susceptible to all types of infection, including fungal infection. Those who suffer from chronic diseases, such as diabetes, circulatory problems, or immune-deficiency conditions, are especially prone to fungal nails. Other contributing factors may be a history of athlete's foot and excessive perspiration.

Prevention

• Proper hygiene and regular inspection of the feet and toes are the first lines of defense against fungal nails.
• Clean and dry feet resist disease.
• Washing the feet with soap and water, remembering to dry thoroughly, is the best way to prevent an infection.
• Shower shoes should be worn when possible in public areas.
• Shoes, socks, or hosiery should be changed more than once daily.
• Toenails should be clipped straight across so that the nail does not extend beyond the tip of the toe.
• Wear shoes that fit well and are made of materials that breathe.
• Avoid wearing excessively tight hosiery, which promote moisture.
• Socks made of synthetic fiber tend to "wick" away moisture faster than cotton or wool socks.
• Disinfect instruments used to cut nails.
• Disinfect home pedicure tools.
• Don't apply polish to nails suspected of infection—those that are red, discolored, or swollen, for example.
  

Treatment of Fungal Nails
Treatments may vary, depending on the nature and severity of the infection. A daily routine of cleansing over a period of many months may temporarily suppress mild infections. White markings that appear on the surface of the nail can be filed off, followed by the application of an over-the-counter liquid antifungal agent. However, even the best over-the-counter treatments may not prevent a fungal infection from coming back.

A podiatric physician can detect a fungal infection early, culture the nail, determine the cause, and form a suitable treatment plan, which may include prescribing topical or oral medication, and debridement (removal of diseased nail matter and debris) of an infected nail.

Newer oral antifungals, approved by the Food and Drug Administration, may be the most effective treatment. They offer a shorter treatment regimen of approximately three months and improved effectiveness. Podiatrists may also prescribe a topical treatment for onychomycosis, which can be an effective treatment modality for fungal nails.

In some cases, surgical treatment may be required. Temporary removal of the infected nail can be performed to permit direct application of a topical antifungal. Permanent removal of a chronically painful nail, which has not responded to any other treatment, permits the fungal infection to be cured, and prevents the return of a deformed nail.

Trying to solve the infection without the qualified help of a podiatric physician can lead to more problems. With new technical advances in combination with simple preventive measures, the treatment of this lightly regarded health problems can often be successful.

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On-The-Job Foot Health

Protect Your Feet
Your ability to use your feet safely, with ease and comfort, is vital if you are to remain a valuable and productive worker.

When your job requires you to stand on your feet for long periods, work in potentially hazardous areas or with potentially hazardous materials, you have some risk of foot injury. However, you can do a lot to prevent injuries by keeping your feet healthy and following safe work practices.

In any given year, there are about 120,000 job-related foot injuries, one-third of them toe injuries, according to the National Safety Council. You can't take your feet for granted! And your concern for them cannot be divided; it should continue off the job, as well as at work.

Off-the-Job
There are a few simple things you should do:

• Bathe your feet daily; dry them thoroughly.
• Check your feet frequently for corns, calluses, cracks.
• Keep your feet warm.
• Trim your toenails straight across, slightly longer than the end of the toe.
• Prevent foot problems by visiting your podiatrist as part of your annual health check-up.
• Wear protective footwear when using lawnmowers, chain-saws, and moving heavy objects.

On-the-Job
It is important for you to develop safe work habits and attitudes. Some things to remember:

• Be aware of the hazards of your job and the proper protective measures to take.
• Don't take chances or unnecessary risks. Take time to do your job right.
• Be alert. Watch for hidden hazards.
• Be considerate. Watch out for other workers' safety.
• Follow the rules. Don't cut corners. Use your equipment as specified.
• Concentrate on the job. Inattention can lead to accidents.
• Pace yourself. Work steadily at a comfortable speed.
• Keep your work area clean and your tools in their place.

Protective Footwear Is Essential
Safety shoes and boots protect your feet, help prevent injuries to them, and reduce the severity of injuries that do occur in the workplace.

Only one out of four victims of job-related foot injury wear any type of safety shoe or boot, according to the National Safety Council. The remaining three either are unaware of the benefits of protective footwear or complain about it.

Safety footwear is comfortable, flexible, stylish, and still provides protection from injury.

The foot is the most valuable part of your body subjected to injury in industry. Because of the many potential work hazards, it is important that you discuss with your supervisor the safety shoe, boot, or other protective equipment that you need for your protection.

HAZARD: falling and rolling objects, cuts and punctures
PROTECTION: steel-toe safety shoes; add-on devices: metatarsal guards, metal foot guards, puncture-proof inserts,shin guards

HAZARD: chemicals, solvents
PROTECTION: footwear with synthetic stitching, and made of rubber, vinyl or plastic

HAZARD: electric current
PROTECTION: shoes or boots with rubber soles, and heels, no metal parts and insulated steel toes

HAZARD: extreme cold
PROTECTION: shoes or boots with moisture- or oil-resistant insulation, and that can repel water (if this is a problem); insulated socks

HAZARD: extreme heat and direct flame
PROTECTION: overshoes or boots of fire-resistant materials with wooden soles

HAZARD: high voltage
PROTECTION: shoes with rubber or cork heels and soles, and no exposed metal parts

HAZARD: hot surfaces
PROTECTION: safety shoes with wooden or other heat-resistant soles; wooden sandals overshoes

HAZARD: sanitation contamination
PROTECTION: special plastic booties or overshoes; paper or wood shower sandals

HAZARD: slips and skids (from wet, oily shoes with wooden soles or cleated, surfaces)
PROTECTION: non-slip rubber or neoprene soles; non-skid sandals that slip over shoes; strap-on cleats for icy surfaces

HAZARD: sparking (from metal shoe parts)
PROTECTION: safety shoes with no metal parts and non-sparking material

HAZARD: sparks, molten metal splashes
PROTECTION: foundry boots with elastic sides or (that get inside shoes) quick-release buckles for speedy removal

HAZARD: static electricity
PROTECTION: shoes or boots with heels and soles of cork or leather

HAZARD: wetness
PROTECTION: lined rubber shoes or boots; rubbers or shoes of silicone-treated leather

If Your Feet are Injured at Work
Report any injury to your foreman or supervisor promptly for necessary first aid. Then see your podiatrist if further treatment is recommended. Proper foot care improves your efficiency and keeps you on the job.

Your podiatrist is a specialist who diagnoses and treats foot disorders and injuries medically and surgically. By visiting your podiatrist regularly, you can insure for yourself a lifetime of pain-free feet.

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Rearfoot Surgery

Many Conditions Affect the Rearfoot
Many conditions can affect the back portion of the foot and ankle. Fortunately, many of these problems can be resolved through conservative treatments. However when pain persists or deformity occurs, surgical intervention can often help alleviate pain, reduce deformity, and/or restore the function of your foot or ankle.

Heel Surgery
Two common conditions that can cause pain to the bottom of the heel are plantar fasciitis and heel spur(s). Although there are many causes of heel pain in both children and adults, most can be effectively treated without surgery. When chronic heel pain fails to respond to conservative treatment, surgical care may be warranted.

Plantar fasciitis is an inflammation of a fibrous band of tissue in the bottom of the foot that extends from the heel bone to the toes. This tissue can become inflamed for many reasons, most commonly from irritation by placing too much stress (such as excess running and jumping) on the bottom of the foot.

Heel Spur(s) or heel spur syndrome are most often the result of stress on the muscles and fascia of the foot. This stress may form a spur on the bottom of the heel. While many spurs are painless others may produce chronic pain.

Based on the condition and the chronic nature of the disease, heel surgery can provide relief of pain and restore mobility in many cases. The type of procedure is based on examination and usually consists of plantar fascia release, with or without heel spur excision. There have been various modifications and surgical enhancements regarding surgery of the heel. Your podiatric physician will determine which method is best suited for you.

There are many other causes of heel pain, which has become one of the most common foot problems reported by patients of podiatric physicians. Many of them have a basis in heredity, as do a lot of other foot conditions. Among the causes are stress fractures and stress-fracture syndrome, entrapped nerves, bruises, bursitis, arthritis (including gout), deterioration of the fat pad on the heel, improper shoes, and obesity, just to name some. Most of these conditions will be treated nonsurgically, though surgery may be recommended in some instances.

Haglund's Deformity (pump bump)
This deformity is characterized by a bony enlargement on the back of the heel. Although not always painful, it may become so if bursitis develops near the Achilles tendon secondary to footwear irritation. If attempts at shoe modification and other medical treatments fail to improve this condition, surgical correction may be beneficial. Based on X-ray evaluation and other tests or examinations your podiatric surgeon will select an operative treatment to alleviate the condition.

Insertional Achilles Clarification/Spur
This deformity differs from Haglund's deformity, in that spur formation or calcification at the insertion of the Achilles tendon is the cause of pain. Often associated with Achilles tendinitis, this deformity can often be difficult to treat medically and therefore surgical treatment may be necessary in chronic cases. There are many causes of this condition, including arthritis, but the most common appears to be overuse syndrome, where trauma occurs where the Achilles tendon attaches to the heel bone. Surgical treatment includes removal of the bone spur and/or calcification, along with repair of the Achilles tendon.

Reconstructive Surgery
Reconstructive surgery of the foot and ankle consists of complex surgical repair(s) that may be necessary to regain function or stability, reduce pain, and/or prevent further deformity or disease. Unfortunately, there are many conditions or diseases that range from trauma to congenital defects that necessitate surgery of the foot and/or ankle. Reconstructive surgery in many of these cases may require any of the following: tendon repair/transfer, fusion of bone, joint implantation, bone grafting, skin or soft tissue repair, tumor excision, amputation and/or the osteotomy of bone (cutting of bones in a precise fashion). Bone screws, pins, wires, staples, and other fixation devices (both internal and external), and casts may be utilized to stabilize and repair bone in reconstructive procedures.

Preoperative Testing and Care
As with anyone facing any surgical procedure, those undergoing foot and ankle surgery require specific tests or examinations before surgery to obtain a successful surgical outcome. Prior to surgery, the podiatric surgeon will review your medical history and medical conditions. Specific diseases, illnesses, allergies, and current medications need to be evaluated. Other tests that help evaluate your health status that may be ordered by the podiatric physician include blood studies, urinalysis, EKG, X-rays, blood flow studies (to better evaluate the circulatory status of the foot/legs), and biomechanical examination.

A consultation with another medical specialist is sometimes advised by a podiatric physician, depending on your test results or a specific medical condition.

Postoperative Care
Surgery of the rearfoot requires close care following surgery. To assure a rapid and uneventful recovery, it is important to follow your podiatric surgeon's advice and postoperative instructions carefully. Rest, ice, compression and elevation of your foot/ankle postoperatively is often advised. The usage of bandages, splints, casts, surgical shoes, crutches, or canes may be necessary after surgery. Your podiatric surgeon will also determine if and when you can bear weight on an operated foot.

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Walking

For a healthier, happier lifestyle, try walking - the most popular form of exercise.

It's easy, safe, and inexpensive. It's also relaxing and at the same time invigorating, requires little athletic skill, and does not call for club membership or special equipment other than sturdy, comfortable shoes. And it is fun and natural - good for your mind and self-esteem.

The results of walking are physically rewarding - a trim, fit body better able to enhance general health and add enjoyable years to your life.

Fundamental walking - also called health walking - can be done almost anywhere and at any time, year around - to the store, in the mall or in your neighborhood; alone, with your dog, or with others; and at your own pace. It is simple, uncomplicated - physical fitness at your leisure.

Walking benefits most everybody, regardless of age. About 67 million men and women are walking regularly. Convinced that it is good exercise, they're making it a part of their daily routine. And their numbers are increasing every year, according to the President's Council on Physical Fitness and Sports.

A Sure Way To Fitness
For those with a long history of inactivity, problems with obesity, or who just don't like strenuous activity, walking is an excellent way to begin an exercise program. You can start slowly, then increase your speed and maintain a steady pace. A good conditioning program begins with moderation and dedication.

Podiatric and family physicians recommend walking to ease or ward off a number of physically related ills. Walking can help you:

• Strengthen your heart and lungs, and improve circulation.
• Prevent heart attacks and strokes.
• Reduce obesity and high blood pressure.
• Boost your metabolic rate.
• Favorably alter your cholesterol.
• Improve muscle tone in your legs and abdomen.
• Reduce stress and tension.
• Reduce arthritis pain; stop bone tissue decay.

Walking: There's An Art To It

Before you start walking, some simple warmup exercises - but not strenuous, advanced stretching - can give your muscles added flexibility. Body twists at the waist, in a slow hula-hoop motion, and a few toe-touching or knee-bend exercises are appropriate. When you're ready to begin, the best way to start is walking 20 uninterrupted minutes at least three times a week. Walk at a comfortable pace, slowing down if you find yourself breathing heavily. Don't tire yourself. If 20 minutes is too much, cut back to l0 or l5 minutes. You can gradually increase your time and pace as your body adapts to the exercise.

There are several ways to measure your pace. One is to walk on routes which you have pre-measured with your car's odometer. Perhaps the simplest is to use a wristwatch. Count the number of steps you take in a 15-second period; if you're taking 15 in that time, you're walking about two miles an hour. At about 23, you're probably going three miles an hour, and at 30, the pace is close to four miles an hour.

You may want to keep an activity log, in which you jot down the dates, times, and estimated distances of your walks, plus other notes, such as routes, milestones, and incidental experiences.

Some Walking Tips:

• Move at a steady pace, brisk enough to make your heart beat faster. Breathe more deeply.
• Walk with your head erect, back straight, abdomen flat. Keep your legs out front and your knees slightly bent.
• Swing your arms freely at your sides.
• As you walk, land on the heel of your foot and roll forward to push off on the ball of your foot.
• At least at the beginning, confine your walks to level stretches of flat surfaces, avoiding excessively steep hills and embanked roadways.
• If you're walking in the evening, be sure to wear clothing with reflective material sewn in, or otherwise attached.
• Cool down after a long, brisk walk to help pump blood back up from your legs to where it's needed. Here's where some stretching exercises can be helpful. A good one is standing about three feet from a wall, with your hands flat on the wall. Then take five or six small steps backward, maintaining your hand contact with the wall. Repeat the exercise five to ten times.

Race walking
Race walking is a very specific technique that's used by walkers for both fitness and competition. It has greater aerobic benefits than health walking, since it is faster and increases the heartbeat rate.

If you get to the point where you think race walking is for you, there are clubs which can be contacted in most places.

Walking Footwear: Comfort and Fit
Choose a good quality, lightweight walking shoe with breathable upper materials, such as leather or nylon mesh. The heel counter should be very firm; the heel should have reduced cushioning to position the heel closer to the ground for walking stability. The front or forefoot area of the shoe should have adequate support and flexibility.

Fit is very important. Go to a reputable store and have both shoes fitted for length and width with the socks you'll be using. (Do this late in the afternoon, since your feet do swell enough during the day to affect your shoe size.) Make sure the shoe is snug, but not too tight over the sock. The shoe should have plenty of room for the toes to move around. Several walking shoes have qualified to use the APMA Seal of Acceptance.

Your choice of athletic socks is also important. Sports podiatrists frequently recommend appropriately padded socks of acrylic fiber. Acrylic fibers tend to "wick" away excessive perspiration, which active feet can produce from 250,000 sweat glands at a rate of four to six ounces a day, or even more. Again, there are popular brands of athletic socks which are authorized to use APMA's Seal of Acceptance.

Some Other Tips:

• Check on the shoe width; it must comfortably accommodate the width of the ball of your foot.
• Make sure you get good arch support.
• See that the top of the heel counter of the shoe is properly cushioned and does not bite into the heel or touch the ankle bones.

Do You Need A Checkup?

If you are free of serious health problems, you can start walking with confidence. Walking is not strenuous; it involves almost no risk to health. You should, of course, exercise good judgment, not exceed the limits of your condition, and not walk outdoors during extreme weather periods, until you have a good walking program established.

You should, however, consult your family or podiatric physician before you begin a walking regimen. A checkup is suggested, particularly if you are over 60, have a disease or disability, or are taking medication. It is also recommended for those who are 35-60, substantially overweight, easily fatigued, excessive smokers, or have been physically inactive.

One of your physicians will help you determine your proper walking heart rate. Heart rate is widely accepted as a good method for measuring intensity during walking and other physical activities. The formula says that subtracting your age from the number 220 yields your maximum heart rate (beats per minute), and that the proper walking rate is 60-70 percent of that number. For a 50-year-old, that's 220 minus 50 equals 170; 60 percent of that is 102 and 70 percent is 119. Other factors should be considered, though; a physician's advice is the best indicator of your correct rate.

You are now ready to begin a walking program. It is a prescription for a healthier, happier life.

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What are plantar warts?

Warts are one of several soft tissue conditions of the foot that can be quite painful. They are caused by a virus, which generally invades the skin through small or invisible cuts and abrasions. They can appear anywhere on the skin, but, technically, only those on the sole are properly called plantar warts.

Children, especially teenagers, tend to be more susceptible to warts than adults; some people seem to be immune.

Identification Problems
Most warts are harmless, even though they may be painful. They are often mistaken for corns or calluses—which are layers of dead skin that build up to protect an area which is being continuously irritated. The wart, however, is a viral infection.

It is also possible for a variety of more serious lesions to appear on the foot, including malignant lesions such as carcinomas and melanomas. Although rare, these conditions can sometimes be misidentified as a wart. It is wise to consult a podiatric physician when any suspicious growth or eruption is detected on the skin of the foot in order to ensure a correct diagnosis.

Plantar warts tend to be hard and flat, with a rough surface and well-defined boundaries; warts are generally raised and fleshier when they appear on the top of the foot or on the toes. Plantar warts are often gray or brown (but the color may vary), with a center that appears as one or more pinpoints of black. It is important to note that warts can be very resistant to treatment and have a tendency to reoccur.

Source of the Virus
The plantar wart is often contracted by walking barefoot on dirty surfaces or littered ground where the virus is lurking. The causative virus thrives in warm, moist environments, making infection a common occurrence in communal bathing facilities.

If left untreated, warts can grow to an inch or more in circumference and can spread into clusters of several warts; these are often called mosaic warts. Like any other infectious lesion, plantar warts are spread by touching, scratching, or even by contact with skin shed from another wart. The wart may also bleed, another route for spreading.

Occasionally, warts can spontaneously disappear after a short time, and, just as frequently, they can recur in the same location.

When plantar warts develop on the weight-bearing areas of the foot—the ball of the foot, or the heel, for example—they can be the source of sharp, burning pain. Pain occurs when weight is brought to bear directly on the wart, although pressure on the side of a wart can create equally intense pain.

Tips for Prevention

• Avoid walking barefoot, except on sandy beaches.
• Change shoes and socks daily.
• Keep feet clean and dry.
• Check children's feet periodically.
• Avoid direct contact with warts—from other persons or from other parts of the body.
• Do not ignore growths on, or changes in, your skin.
• Visit your podiatric physician as part of your annual health checkup.

Self Treatment
Self treatment is generally not advisable. Over-the-counter preparations contain acids or chemicals that destroy skin cells, and it takes an expert to destroy abnormal skin cells (warts) without also destroying surrounding healthy tissue. Self treatment with such medications especially should be avoided by people with diabetes and those with cardiovascular or circulatory disorders. Never use them in the presence of an active infection.

Professional Treatment
It is possible that your podiatric physician will prescribe and supervise your use of a wart-removal preparation- ration. More likely, however, removal of warts by a simple surgical procedure, performed under local anesthetic, may be indicated.

Lasers have become a common and effective treatment. A procedure known as CO2 laser cautery is performed under local anesthesia either in your podiatrist’s office surgical setting or an outpatient surgery facility. The laser reduces post-treatment scarring and is a safe form for eliminating wart lesions.

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Women's Feet

Active Women
As women move into the US work force in greater numbers, a lot of them are finding that their professional and white-collar employment brings job satisfaction, but that it's tempered by other realities. One is that the new responsibilities probably haven't replaced those of the woman's once-traditional role as homemaker and mother.

Those roles remain, and many women find themselves not only holding down a full-time salaried position, but still doing the marketing, the child-rearing, the laundry. Women probably were on their feet a lot more than men before work outside the home beckoned, and their new situations certainly haven't alleviated that. Their feet are taking even more punishment, and the footwear that some feel obliged to wear in the work place may be playing a role.

All this adds up to a need for women to pay more attention to foot care, to avoid subjecting themselves to unnecessary foot problems, particularly those that might be caused by improper footwear and hosiery.

High Heels: Use and Abuse
The wearing of high-heeled shoes is a prime example of women inviting foot problems. Doctors of podiatric medicine see no value in high heels (generally defined as pumps with heels of more than two inches). They believe them to be biomechanically and orthopedically unsound, citing medical, postural, and safety faults of such heels.

They know, for example, that high heels may contribute to knee and back problems, disabling injuries in falls, shortened calf muscles, and an awkward, unnatural gait. In time, high heels may cause enough changes in the feet to impair their proper function. Most women admit high heels make their feet hurt, but they tolerate the discomfort in order to look taller, stylish, and more professional. In a Gallup Poll, 37 percent of the women surveyed said they would continue to wear high heels, even though they did not think them comfortable.

Toward Greater Comfort
If women persist in wearing high heels, there are ways to relieve some of the abusive effects; they can limit the time they wear them, for example, alternating with good-quality oxford-type shoes or flats for part of the day. High heels that are too tight compound the abuse; it's good advice to buy shoes in the afternoon, since feet tend to increase in size later in the day.

Women have other heel-size choices, fortunately. They don't have to endure pain at the expense of their foot health. The key is wearing the right shoe for the right activity - and that means varying heel height, determining what heel is most suitable.

For example, there are comfortable and attractive "walking" pumps (also called "comfort" or "performance" pumps) for women for work and social activities. The shoe manufacturers who have introduced them seek a marriage of fashion considerations and comfort, offering fashionable pumps with athletic shoe-derived construction, with reinforced heels and wider toe room. They are using space-age materials, like long-lasting memory cushioning that acts as a shock absorber. And the soles are more pliable.

Several companies have also designed footwear for certain athletic activities, including aerobics, specifically for women.

Perhaps the best shoe for women, from an orthopedic point of view, is a walking shoe with ties (not a slip-on), a Vibram type composition sole, and a relatively wider heel, no more than a half or three-quarters of an inch in height -- even though such a shoe may not be widely acceptable in the work place.

What About Stockings?
Women who always wear nylon pantyhose are also inviting foot problems. Nylon is occlusive - it doesn't breathe - and the heat that it generates and traps causes excessive perspiration. A warm, damp area is an ideal place for the encouragement of fungal infections such as athlete's foot. (Pantyhose aren't the only apparel that cause excessive perspiration; the dress boots and shoe boots many women don in cold weather shouldn't be worn all day in an office.) Nylon, which tends to be abrasive, is even more so when it's damp; in a tight shoe that's already irritating, it offers little protection against blisters. Support hose, because they're so much tighter, can be the worst culprits of all.

Inexpensive nylon pantyhose can also cause forefoot problems, because the stretch mechanism constricts normal expansion of the foot when walking, and may pull the toes backward when the pantyhose ride up. The cramping and pressure of the hose can contribute to ingrown toenails and hammertoes. A better quality nylon will provide a better fit, and the better the fit, the less likely it is that cramping will occur. Women's feet have grown larger because of improved health care and nutrition. The one-size-fits-all stocking no longer is the universal answer, if it ever was. Attention to proper fit is essential.

Pregnancy
Pregnant women need to observe good foot health to prevent pain and discomfort. Since the body undergoes changes and acquires a new weight-bearing stance, women should wear shoes with broad-based heels that provide support and absorb shock. Additional body weight also calls for more support, to prevent foot "breakdown."

The expectant mother often experiences more than ordinary swelling of her feet and ankles, which can aggravate existing foot conditions and promote inflammation or irritation. Pregnancy also triggers the release of hormones which enhance laxity in ligaments, which can contribute to foot strain. If problems develop, she should see a podiatric physician.

Women Over 65
Older women have more trouble with their feet than younger ones, for the simple reason that fat pads on the bottom of the feet tend to deteriorate in the aging process. They can alleviate some foot problems by wearing properly fitted, well-constructed shoes -- shoes which provide cushioning and have a soft, flexible upper that will conform to the shape of their feet. They also need leather shoes which "breathe" and can reduce the possibility of skin irritation. Soles should be lightweight, with enough flexibility and shock-absorbing quality to provide solid footing and not be slippery. Low-heeled shoes provide greater stability, more protection for the feet, and greater comfort. Because older women often have circulatory problems, they have a special need to keep their feet warm in cold weather, to prevent frostbite or chilblains.

Women's Foot Afflictions
Whether the sources are congenital problems, foot abuse, high heels, poorly fitting shoes, or other maltreatment of the feet, women are subject to a number of afflictions involving the feet (most of which can also occur to men):

Achilles tendinitis: inflammation of the Achilles tendon, the link between the calf muscle and heel bone. Those who wear high heels regularly can expect to acquire shortened tendons; switching to low heels for strenuous physical activity without appropriate warm-up exercises creates an ideal scenario for Achilles tendinitis.

Bunions: misaligned big toe joints which become swollen and tender. Bunions tend to be familial, but the tendency can be aggravated by shoes that are too narrow in the forefoot and toe.

Hammertoe: a condition in which the toe is contracted in a claw-like position. Although the condition usually stems from muscle imbalance, it is often aggravated by ill-fitting shoes, socks, or hosiery that cramp the toes.

Metatarsalgia: general pain in the ball of the foot; often caused by wearing high heels.

Neuromas: enlarged, benign growths of nerves, most commonly between the third and fourth toes. They may stem, in part, from ill-fitting shoes, resulting in pain, burning, tingling or numbness between the toes and in the ball of the foot. Treatment includes orthotic devices and/or steroid injections, and sometimes surgery.

Plantar fasciitis: inflammation of the long band of connective tissue running from the heel to the ball of the foot, a main cause of rear-foot pain. This condition is sometimes caused by shoes that cramp the feet, especially in the arch area.

Pump bump (Haglund's deformity): a bone enlargement at the back of the heel bone, in the area where the Achilles tendon attaches to the bone. The deformity generally is the result of faulty biomechanics causing increased motion of the heel bone against the shoe counter.

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