1. What Is Podiatry?
2. What is a Podiatrist?
3. What are Podiatry Practice Characteristics?
4. What does it take to be a Podiatrist?
5. What are the board specialties in Podiatry?
6. What are bone spurs?
7. What are bunions?
8. What are corns and calluses?
9. What are warts?
10. How can diabetes effect my feet?
11.What are hammertoes?
12. What is plantar fasciitis?
13. What are high arch and low arch feet?
14. What is metatarsalgia?

 

 

1. What is Podiatry?
Podiatry (US English), or chiropody (British English), is a field of healthcare devoted to the study and treatment of disorders of the foot and ankle (translated literally, chiropody refers to medicine of the "hand and foot", but the term no longer has this meaning).

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2. What is a Podiatrist?
A podiatrist (US English), or chiropodist (British English), is a podiatry professional, a person devoted to the study and treatment of disorders of the foot and ankle.

In the United States a licensed Doctor of Podiatric Medicine (D.P.M.) practices podiatry. Education consists of a doctoral level four-year program followed by a two or three year residency. Like regular Medical School this training follows their college degree. The first four years of Podiatric Medical School are similar to training that traditional, medical (MD) and osteopathic (DO), physicians receive, but with more emphasis on foot and ankle problems and slightly less emphasis on other topics such as pathology and neonatology. Some of the Podiatric Medical schools are integrating into MD and DO schools for the first year or two.

A residency follows the four-year Podiatric Medical School, which is the hands-on post-doctoral training. This training has varied extensively in the past; however, there are now two standard residencies named Podiatric Medicine and Surgery 2 or 3. These represent the two or three year residency training. Podiatric residents rotate through all main areas of medicine such as Emergency, Pediatric, Internal Medicine, Orthopedic and General Surgery and of course Podiatry - both clinic and surgery. During these rotations, attending physicians train the resident physicians in medicine and surgery. The surgical training varies from basic bunion and hammertoe surgery to more complex foot and ankle reconstruction and salvage as well as trauma.

Podiatrists may independently diagnose, treat and prescribe medicine and perform surgery for disorders of the foot and in some states the ankle and leg. There are three Board Certification possibilities for Podiatrists. First is the Board of Primary Care and Orthopedics, which is the nonsurgical Board Certification. The surgical Board Certification is divided into foot surgery and rearfoot/ankle reconstruction surgery. The rearfoot and ankle Board Certification requires at least a three-year residency to qualify. All of the Surgical Board Certifications require applicants to submit their surgical cases to the Board committee who heavily scrutinize them. The applicants then take written and oral exams prior to becoming Board Certified. The exams are rigorous and the pass rate reflects the difficulty.

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3. What are Podiatry Practice Characteristics?
Podiatrists in the main practice in solo practice. However, there has been a movement toward larger group practices as well as the use of podiatrists in multi-specialty groups treating diabetes or in multi-specialty surgical groups. Some podiatrists work within clinic practices such as the Indian Health System (IHS), the Rural Health Centers (RHC) and Community Health Center (FQHC) systems established by the Federal government to provide services to under insured and non-insured patients as well as within the United States Department of Veterans Affairs providing care to veterans of military service.

* Scope: State law determines the differences in podiatry practice. Each state allows or limits the practice of podiatry to the foot, ankle or and in many cases includes portions of the leg. This may include surgery above the ankle in several states. Many states require completion of a residency to practice. Many podiatrists work in hospital settings doing both medical and surgical treatments for patients. As in many other specialties some podiatrists work in nursing homes and some perform house calls for patients. Podiatry patients range from newborns and infants to the geriatric.

* Medical and orthopedic practice: Some podiatrists limit their practices to the non- (hospital) surgical treatment of patients. Because much work in podiatry involves cutting of some kind, many procedures are considered surgical by insurance companies including tasks such as  (cutting of nails, removing of corns or callus), which the general public would not ordinarily consider to be surgery. These podiatrists use their skills in handling arthritic, diabetic, and other medical problems associated with the feet and lower extremities. Some use devices fitted in shoes (orthotic devices) or modify the shoe itself to make walking better or easier. Some practices focus on sports medicine and treat many runners, dancers, soccer players and other athletes.

* Surgical Practice: Within the scope of practice, podiatrists are the experts at foot surgery. Podiatrists have specialized training and interest in the lower extremities as well as one to three year surgical residencies in the United States. Some podiatrists have solely surgical practices. Most podiatrists mix medical, orthopedic, biomechanics and surgical practices. Indeed surgical podiatric principles rest on a base of orthopedic and kinesthetic knowledge.

The majority of patients seen by the podiatrist are referred to the specialist specifically trained in the treatment of foot and ankle disorders. In addition to their surgical training, podiatrists have extensive training in the non-surgical treatment of foot and ankle problems.

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4. What does it take to be a Podiatrist?
The US Department of Labor, Bureau of Labor Statistics expects need for podiatrists to rise but slowly because podiatrists tend to have long practice lives, stopping practice when they retire. Podiatrists need a State license that requires the completion of at least 90 hours of undergraduate study, the completion of a four-year program at a college of podiatric medicine, and in most states, a postdoctoral residency program of at least one year. This has now changed to all 50 states requiring a residency and there are two-year and three-year residencies available as well a fellowship for advanced training. Podiatrists are commissioned officers in all the armed services and serve as department heads in the Veterans Affairs system. Practice income is relatively high for most podiatrists.

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5. What are the board specialties in Podiatry?
There are two recognized certifying boards for podiatry. The purpose of board certification is two-fold. Board certification primarily recognizes a level of achievement. For most examinations candidates must prepare cases, sit for written and then oral examinations to become a Diplomate of a board. In effect these are doctors who have chosen a sub-specialty. Although completion of a board does not guarantee competency, it does acknowledge that that candidate has been judged by peers to have a fund of knowledge and competence in a particular area of practice.

The second use for board certifications is so that organizations such as a hospital medical staff, surgery center, or HMO can make decisions about the skills of the applicant.

To allow doctors of podiatry time to qualify to become diplomates of a board, there is a holding status; board qualified which permits those doctors to practice while waiting to complete the boards. Doctors who have passed their boards may say they are diplomates of the board, are board certified or are certified by a certain board. Those who are waiting may only call themselves board qualified.

* Podiatric medicine: The certifying board for primary care in podiatry, now combined with the [podiatric orthopedic] board as the American Board of Podiatric Orthopedics and Primary Podiatric Medicine (ABPOPPM).

* Podiatric surgery: The certifying board for surgery in podiatry is the American Board of Podiatric Surgery. Until 2000 there was only a single certification; however now there is an additional certification for rearfoot and ankle surgery. Podiatrists must qualify for this board by completing a two-year surgical residency program (three or its equivalent for the ankle certification portion).

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6. What are bone spurs?
Bone spurs, also known as osteophytes, are bony projections that form along joints. Bone spurs form due to the body's increase of a damaged (usually due to arthritis) joint's surface area in a futile attempt to improve weight distribution. However, they usually limit joint movement and typically cause pain. Diagnosis of a bone spur can only be determined by x-ray. When seen on x-ray, the spur is usually imbedded in muscle, tendon or ligament. Since muscle, tendon and ligament are elastic, the spur causes the muscle, tendon or ligament to shorten. As the foot moves, the shortened muscle, tendon or ligament become overstretched. This causes pain. Common areas of bone spurs in the foot are the toes, heel, great toe joint, the top of the foot, and the ankle. The location of the spur and the amount of discomfort determines the appropriate treatment. This may be as simple as a pad or cushion or may require a cortisone injection. Sometimes surgery may be necessary to permanently solve the problem.

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7. What are bunions?
A bunion is a painful deformity of the bones and the joint between the foot and big toe.   A bunion is an enlargement of the bone on the inside of the foot just behind the great toe. The great toe gradually drifts and points toward the 2nd toe.  Bunions can occur on one or both feet. The tendency to develop a bunion is usually inherited, but can occur without a family history.  It is more common in women.  Bunions may also develop via long-term irritation (inflammation) from arthritis and poorly fitting shoes, any of which can cause this joint at the base of the big toe to thicken and enlarge. This causes the bones of the big toe to angle in toward the second toe, and leads to an often-painful lump of bone, which forms at the outside-edge base of the big toe. People with flat feet and laxity in their ligaments are prone to developing bunions, as well as those in professions, which place excessive stress on the feet, such as ballet dancers. The front part of the foot gradually widens as our feet flatten when standing. The deformity gradually gets worse with time, making all shoes painful and difficult to wear. Because the bunion deformity is progressive, it should be evaluated early.  Painful calluses, resulting from a changed foot balance, may follow bunions.

Treatment options depend on how painful the bunion are, the patient's lifestyle and the degree of the deformity. Most bunions are treatable without surgery, and foot specialists emphasize that prevention is always best. To minimize the chance of developing a bunion, choose shoes that accommodate the shape of your feet. Options include wearing sensible shoes with a round toe box.  Ill-fitting shoes, which may be short, tight, or sharply pointed, cause many bunions. As well, avoid high-heeled shoes, a major contributor to the development of bunions. If you are developing a bunion, wear shoes that are roomy enough not to put pressure on it, which should help with a large amount of the pain associated with a bunion. Shoes can be stretched professionally, and you can also try adding protective padding to cushion the area, such as a non-medicated bunion pad, which fits around the bony lump.  Also, inserts for your shoes called orthotics are custom fitted to control the abnormal foot movement.  If bunions are left untreated, they can lead to the risk of serious infection in some patients, such as those people with diabetes.

In many instances surgery is recommended.  The selection of the procedure to be used is based upon the degree of the deformity, the underlying biomechanical cause of the bunion and the procedure that will get the patient back to activity in the shortest period of time.  As the bunion worsens, it becomes more difficult to treat surgically and the healing time can increase significantly.  Over time, the joint in the big toe can become arthritic, lose its flexibility and become painful with nearly every step.   At this stage the surgical treatments are limited and a joint replacement may be required.  Surgery, while an effective intervention for the treatment of bunions, usually requires a 6- to 8-week recovery period during which crutches are usually required for aid in mobility.

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8. What are corns and calluses?
A callus is an especially toughened area of skin, which has become relatively thick and hard as a response to repeated contact or pressure. Since repeated contact is required, calluses are most often found on hands or feet. Calluses are generally not harmful, but may sometimes lead to other problems, such as infection. Shoes that fit tightly can often form calluses on the feet.

Corns are specially shaped calluses that usually occur on thin, hairless and smooth skin surfaces, especially on the top of toes or fingers. They can sometimes occur on the thicker palmar or plantar skin surfaces.  Corns form when the pressure point against the skin traces an elliptical or semi-elliptical path.  This forms a swirl of tissue, the center of which is at the point of pressure, gradually widening.  If there is constant stimulation of the tissues producing the corns, even after the corn is removed or the pressure surgically removed, the skin may continue to grow as a corn.  The name corn comes from its appearance under the microscope. The hard part at the center of the corn resembles a barley seed, that is, a funnel with a broad raised top and a pointed bottom. The scientific name is heloma.  Hard corns are called heloma durum, while soft corns are called heloma molle.  The place of occurrence differentiates between soft and hard corns. Hard corns occur on dry, flat surfaces of skin. Soft corns, frequently found between two toes, stay moist, keeping the surrounding skin soft.   The corn's center is not soft, however.People with bunions may find painful calluses behind the second or third toe.  These are caused by unequal pressure placed on the smaller toes. Such pressure-induced calluses can be very painful and often do not respond to trimming of the callus, soft materials, or orthotic devices. It is not the callus that causes pain, but rather the severe imbalance in the function of the foot that is taking its toll.  Shoes can produce corns by rubbing against the top of the toes or foot.  Continued irritation may cause pain. Stretching the rubbing area of the shoe may reduce the pressure and stop the pain, but the corn may remain. If a toenail or a fingernail rubs against the skin, pinching it between surfaces for a period of time, a corn can form at the edge of the nail. These are difficult to treat because frequently the nail is the primary cause. Sometimes a callus occurs where there is no rubbing or pressure. These hyperkeratoses can have a variety of causes. Some toxins, such as arsenic, can cause thick palms and soles. Some diseases, such as syphilis, can cause thickening of the palms and soles as well as pinpoint hyperkeratoses. There is a benign condition called keratosis palmaris et plantaris, which produces corns in the creases of the fingers and non-weight-bearing spaces of the feet. Some of this may be caused by actinic keratosis, which occurs due to overexposure to sun, or with age and hormonal shifts.

Treatment should be directed at stopping the pressure or friction on the toe.  You should typically avoid over the counter remedies, especially if they contain acids.  Home remedies for calluses can include soft shoe inserts or pads. If the corns are on top of or between the toes, lambs wool or foam pads might be used.  Warm water soaks and then buffing with a pumice stone may help.  Repeated soaking over a period of several days can often allow removal of even the core with nothing more than the friction of a cloth towel.  If this fails, sandpaper can also remove the skin.  Creams and lotions can give temporary relief. CAUTION: All of these remedies can be especially dangerous if the individual has diabetes or poor circulation. Home remedies should be avoided when the person is a diabetic or has poor circulation. All diabetics should be seen routinely for foot exams. When any evidence or signs of foot problems appear in the diabetic, professional care should be sought immediately.  A common method, often done by a podiatrist, is to shave the calluses down, and perhaps pad them. Most corns and calluses located under the foot are caused by the pressure of the foot's bones pressing against the skin, possibly preventing it from moving with the shoe or the ground. While well-fitting shoes will help some of these problems, occasionally some other degree of intervention is required to completely rid the foot of the problem. The most basic treatment is to put a friction-reducing insole or material into the shoe, or against the foot. In some cases, this will reduce the painfulness without actually making the callus go away. In many situations, a change in the function of the foot by use of an orthotic device is required. This reduces friction and pressure, allowing the skin to rest and to stop forming protective skin coverings. 

At other times, surgical correction of the pressure is needed.  On a corn the procedure would normally consist of a filing down/removal of the prominent spur causing the corn.  Now when it comes to calluses on the bottom or ball of the foot, this procedure is a bit more complicated and is usually caused by the "declination" of one or more of the long bones of the foot called metatarsal bones.  Due to one or more of these metatarsal bones being positioned lower than the others, the bone(s) bear more weight.  Calluses then form under the end of the metatarsal bone in an attempt to protect the bone form trauma. The types of surgeries vary when correcting this problem.  Most commonly used is the "V" osteotomy for the second, third and fourth metatarsal, and an oblique osteotomy for the fifth metatarsal.  Internal fixation, pins or screws, are sometimes used to help stabilize the bones. This type of surgery is usually done under a local block anesthesia, and the patient under normal circumstances is ambulatory with a post-operative cast walking boot almost immediately after the surgery.

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9. What are warts?
A wart is a generally small, rough, cauliflower-like growth, typically on hands and feet. Warts are common, and are caused by a viral infection, specifically by the Human Papilloma Virus (HPV).  They live within the upper layer of the skin. Because a virus causes them, they can spread. They are not highly contagious, but will often spread by contact to other areas of the foot.  Some scientists believe they are also caused by stress. They typically disappear after a few months but can last for years and can recur.  A few Papilloma viruses are known to cause cancer.

If you have plantar warts, do not pick at them and do not share your shoes with others. Treatments that may be prescribed by a medical professional include: Aldara™(Imiquimod) topical cream, that not only clears up the wart but helps the immune system fight the virus without the pain of having the wart burned, frozen or cut off. It is indicated for genital warts but has been prescribed effectively to clear up other kinds of warts as well; Cryosurgery, which involves freezing the wart, after which the wart and surrounding dead skin falls off by itself; Cryosurgery followed by surgically removing the infected spot; Treatment with chemical compounds, containing salicylic acid, blistering agents, immune system modifiers, or Formaldehyde;  Laser treatment.  None of these treatments are very effective on single uses.  The wart often returns after the skin has healed from the treatment, but repeated treatment should rid the wart permanently. As they disappear after a few months and maximally a few years, treatment is necessary only if the lesions are painful or are a cosmetic problem.

There are over-the-counter wart removers.  They generally do not work because the skin is so thick and it is difficult for the medicine, which is an acid, to penetrate to the depth necessary to kill the wart. The most common one involves salicylic acid.  These products are readily available at most drugstores and supermarkets.  There are typically two types of products: adhesive pads treated with salicylic acid, or a bottle of concentrated salicylic acid. Removing a wart with this method requires a strict regimen of cleaning the area, applying the salicylic acid, and removing the dead skin with a pumice stone or emery board. It may take up to 12 weeks to remove a stubborn wart.  Another over-the-counter product that can aid in wart removal is silver nitrate in the form of a Caustic Pencil, which is also available at drug stores. This method generally takes three to six daily treatments to be effective.  The instructions must be followed to minimize staining of skin and clothing.  Over-the-counter cryosurgery kits are also available.  Warts can be quite persistent; it is best to catch them early and get treatment before they become established.

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10. How can diabetes effect my feet?
Diabetics are particularly at risk for significant foot problems that can lead to the loss of their feet or legs. They are at higher risk for foot infections. This is the most common cause of hospitalizations for the diabetic patient.  These problems are responsible for significant time off of work because foot ulcerations can take weeks, months, or several years to heal.

Two primary conditions associated with diabetes put the diabetic patient at risk. The first is called neuropathy, a nerve condition that frequently affects the feet.  Neuropathy causes a gradual loss in the patient's ability to feel sharp touch or pain.  As the protective sensation is lost, the patient cannot feel the difference between hot and cold, sharp and dull, vibration or excessive pressure.  This loss of sensation can become quite profound.  Without feeling pain, patients can step on sharp objects or cut themselves. They may burn themselves with hot water and not be aware of it.  These can develop into pressure sores and eventual infections.As a result, diabetic patients must be constantly aware of their feet and inspect them daily. They should avoid walking barefoot and avoid hot showers or baths. The temperature of the shower or bath water must be checked, usually with the elbow rather than the hand, prior to immersing the feet. They should avoid soaking the feet since this dries the skin and may cause cracking, leading to infection.  Special care should be taken when trimming the toenails.  They should avoid sharp trimming of corns and calluses and over-the-counter corn removers. Shoe gear must be appropriately fitted to avoid areas of irritation. Frequently this condition causes a burning pain that makes sleeping difficult. Some patients may feel like their feet are ice cold and have difficulty warming them.  They should avoid using heating pads or hot water bottles to warm the feet since this can cause burns to the skin that may not heal and could lead to the loss of their foot or leg.

A second condition is a loss of or poor circulation that can cause a delay in healing of cuts or sores on the feet. In severe cases it can lead to gangrene and amputation. Poor circulation causes the skin to appear to be thin.  The growth of hair on the foot and leg slows down and eventually stops.  In Caucasians, the skin color turns reddish, orange or blue.  The feet are cool to the touch and can be very sensitive.  This makes it painful to walk, even short distances.

Over a period of time, the more common problems the diabetic may encounter are ingrown or fungal toenails, thick calluses on the bottom of the feet and corns on or between the toes.  Even these relatively simple problems can lead to serious complications and problems for the diabetic. It is recommended that the diabetic patient have their feet checked on a regular basis, by a podiatrist. This can then prevent skin irritation, sores and infections.  If the foot appears to change shape, the arches appear to be falling or sudden onset of swelling is seen, please consult your podiatrist. The best form of prevention against problems including infections and possible loss of feet or legs is to inspect the feet daily and have regular foot exams.  Keeping your blood sugar under control helps to minimize the development of problems and allows problems to heal faster when they occur.  Check your blood sugar daily and see your medical doctor or an endocrinologist routinely.  More information about diabetes you can be obtained by contacting the American Diabetes Association at 1-800-DIABETES (343-2383) or visiting their web site at http://www.diabetes.org.

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11. What are hammertoes?
A hammertoe is a term used to describe a toe that is abnormally bent at one or more joints.  Generally speaking, contracture only at the proximal interphalangeal joint is called a hammertoe; contracture at the distal interphalangeal joint is called a mallet toe, while contracture of both joints is called a claw toe.  Hammertoes can become very painful with a sharp constant or throbbing pain located in the joint space and corns form on the top of the toe or the front of the toe due to friction in the shoe that has become a pressure point. Hammertoes can result from a muscle imbalance, which causes the tendons and ligaments to unnaturally tighten and produce curling of the toes downward.  Trauma to the local area and arthritis can also cause this problem. Women have a greater risk of acquiring a hammer toe due to size, width and height of the shoes they wear which increase the chances of bunions which in turn can place external pressure on the 2nd, 3rd and 4th digit.  Athletes also have a higher occurrence due to trauma to the foot.  But over all, no one is safe from getting a hammertoe. You will see a claw like deformity, a corn formation on the top of the toe or a callus on the bottom of the foot.  Strong family/medical history and physical exam by your physician or podiatrist is necessary to properly diagnose a hammertoe.  Ruling out diseases such as gout and rheumatoid arthritis are a must.  A simple x-ray will confirm the diagnosis showing the joint swelling and bone displacement. The foot can become deformed to the point of inability to walk or run, the pain can become so unbearable that one is not able to put shoes on.  This can also impinge on one’s coordination and balance.

Conservative treatment is used prior to surgical intervention as long as the signs and symptoms are caught early.  The sooner one sees their podiatrist and begin treatment the greater one improves their chances of not having to have surgery.  Conservative treatment for hammertoes consists of trying to help improve the muscle balance in the foot by removing as much pressure as possible from the local area.  Hammertoe crests, splints, gel toe shields, and gel toe caps will help in the early stages of the problem.  The use of certain pads do help, especially a pad called a Buttress Pad that you can buy at the store or a custom pad can be made for you by a podiatrist.  Wearing shoes with wide and high toe box areas, limiting or not wearing high-heeled shoes, tight fitting socks/nylons is another measure for prevention. Orthotic devices or arch supports help realign the foot and can assist in correcting a hammertoe by placing the foot back into the proper position/alignment.

When the hammertoes become a constant problem in trying to use padding around the toes and nothing is working, surgical straightening of the toe or toes is indicated.  There a few different procedures that are used to correct hammertoe deformities. The two most common is the joint arthroplasty and joint fusion.  Joint arthroplasty is a procedure that removes the largest part of the middle joint in the toe to allow the toe to straighten out.  A joint fusion is where the middle joint is fused using various fusion techniques.  Depending on the amount of lifting that has resulted in the ball of the foot from the hammertoe deformity, both an arthroplasty and a fusion may require the additional procedure of a release of the joint contracture at the joint in the ball of the foot.  Ultimately, regardless of the method used to correct the hammertoe deformity, after surgery, the patient should expect a good result and should not experience any major pain from the toe surgery.  Usually if the second through fifth toes have a hammertoe deformity, the typical treatment is to fuse the second through fourth toes and to perform an arthroplasty on the fifth toe. After the surgery, there may be some stiffness, swelling and redness and the toe may be slightly longer or shorter than before.  You will be able to walk, but should not plan any long hikes while the toe heals, and should keep your foot elevated as much as possible.

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12. What is plantar fasciitis?
Plantar fasciitis is a painful inflammatory condition caused by excessive wear to the plantar fascia of the foot.  The plantar fascia is a strong band of fibers, which begins at the heel, and extends to the toes.  The pain usually begins as a mild pain to either the arch area or the underside of the heel.  When the pain is mainly in the heel, medically this condition is called heel spur syndrome.  The pain is often most intense with the first steps of the day and seems to improve after a period of “warming up” of the foot.  If left untreated, the pain can become intolerable. 

Plantar fasciitis is commonly associated with long periods of weight bearing.  Obesity, weight gain, jobs that require a lot of walking on hard surfaces, shoes with little or no arch support, going barefoot, and inactivity are also associated with the condition. This condition often results in a heel spur on the calcaneus. The heel spur is a ridge of bone, which forms to reinforce where the plantar fascia attaches to the heel.  It should be noted that in the underlying condition, and not the spur itself, which produces the pain.  The plantar fascia is the primary pathological anatomical structure that is causing pain to the patient.  If the pulling on the plantar fascia is corrected, it is important to understand that the heel spur that formed from the pulling is not important and does not need to be removed with surgery.  There are many doctors who get the heel spur confused and tell the patient that the heel spur is causing their pain, when in fact it is the injury to the plantar fascia that needs to be medically treated.Treatment is usually a slow and drawn out process.  Patients learn quickly that they must be an active force in the healing of the plantar fascia.  Treatment should address life style changes (increase in weight, prolong standing, excessive running, and even decrease in activity), which can be the culprit.  These changes must be decreased, removed or increased depending on the situation.  The mainstays of treatment are stretching the Achilles tendon and the plantar fascia 3 to 4 times a day, especially after long periods of inactivity (before getting out of bed, working at your desk for long periods) and reducing the stress on the arch by inserting a heel lift in the shoe. Rest and applying ice after activity can help reduce inflammation. To relieve pain and inflammation, the patient can take nonsteroidal anti-inflammatory drugs (NSAIDs) such as aspirin and ibuprofen. Strapping or taping the arch is helpful by limiting the stress or tension placed on the bottom of the foot. Arch supports (custom-molded orthotic shoe inserts) have the largest impact on improving plantar fasciitis.  In patients with unusually low or high-arched feet, insole arch supports may assist recovery.  Therapeutic ultrasound, with or without iontophoresis, and more recently, extracorporeal shockwave therapy (ESWT) have been used with a very high success rate in patients with symptoms lasting more than 6 months.  Another recent addition to the treatment options is the application of night splints to keep the foot in a dorsiflexed position during sleep.

When used properly, a local injection of cortisone may also be useful.  Cortisone is a naturally produced chemical in our bodies.  It is useful in treating inflammatory processes that result from injury or arthritis. It can, in many instances, halt the painful process permanently. In other instances, it is a useful addition to other treatments.  Cortisone does not dissolve bone spurs, but can decrease swelling and inflammation in soft tissues.  The steroid is usually combined with a local anesthetic to make the procedure less painful and to give immediate relief. Response usually occurs over the following week. While relief is often permanent, the condition may relapse after a few months.

When conservative treatment is unsuccessful a release of the plantar fascia is needed.  A podiatrist at his or her office or an outpatient clinic performs a plantar fasciotomy.  Local anesthesia is used and the procedure can take from 20 minutes to an hour depending on the patient, severity of the problem and unforeseen complications.  Small incisions are made on the bottom of the foot and a small portion of the fascia is cut near the heel then the incisions are closed and a dressing is applied.  Patients can usually walk almost immediately pain free, and can wear shoes in only 3 to 5 days.  Returning to normal activities is usually in less than 3 to 4 weeks.  Some surgeons use a procedure called an EPF (endoscopic plantar fasciotomy).  This procedure uses a scope and at times has shown a better recovery time and less associated pain compared to traditional procedures.  Because plantar fasciitis and heel spur syndrome is an inflammatory condition, early intervention is essential to stop the repeated scarring of the plantar fascia that can lead to irreversible shortening of the plantar fascia and nerve entrapment.  An arch support is normally required after this surgery.

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13. What are high arch and low arch feet?
The shape of your feet can be a good indicator for potential problems.  It's not uncommon to see a patient with a high arch foot complain about ankle sprains or back pain.  Individuals with low arch or flat feet often complain of fatigue in the feet and legs, especially after long periods of standing or walking.  More important than the shape of your foot is how your feet work or function.  Just like a car, the alignment of the foot is important to the overall function of the foot. If the car is out of alignment, the tires wear out fast.  If the foot is not well aligned, changes occur in the structure or shape of the foot.  Areas of irritation such as corns or calluses develop. More serious problems such as bunions and hammertoes can develop. The abnormal foot function can also cause conditions such as heel pain (plantar fasciitis or heel spur), metatarsalgia or pain in the ball of the foot (neuromas, stress fractures, or tendonitis). If there is a family history of foot problems, it's not unusual to see juvenile or pediatric foot problems.  These foot imbalances or biomechanical abnormalities, if identified early enough, are often treated very successfully with orthotic therapy

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14. What is metatarsalgia?
Metatarsalgia refers to pain in the ball of the foot.  It may represent a stress fracture, neuromas, or tendonitis.

A stress fracture is one type of an incomplete fracture in bones. It could be described as a very small sliver or crack in the bone. It typically occurs in weight-bearing bones, such as the tibia/fibula and metatarsals, which are all long bones of the lower extremity.  Stress fractures usually have a narrow list of symptoms.  It could present as a generalized area of pain, tenderness, and pain with weight-bearing.  A good indicator of a stress fracture is that the pain is present with any pressure on the foot and increases with increased standing and walking.  Usually when running, a stress fracture has severe pain in the beginning of the run, moderate pain in the middle of the run, and severe pain at the end and after the run.  The pain is usually accompanied by swelling.

Many metatarsal stress fractures are associated with a callous formation under the metatarsal head that is being heavily pressured.   A metatarsal stress fracture is a condition that occurs from repetitive pressure to the second metatarsal head.  The second metatarsal head is the most common of the lesser metatarsal heads to become injured.  The second metatarsal will take up most of the weight of the body if the foot is flattening or pronating during gait or standing.  The big toe joint is pushed out of the way from the rotation that occurs as the foot pronates during standing and gait and this exposes the second metatarsal to excessive pressure.  The pain is typically a deep aching type pain that increases with more weight bearing and decreases with rest.  

One of the historical findings that are helpful is that the foot hurts with squeezing the bones directed from top to bottom.  X-rays usually do not show any evidence of stress fractures, so a CT scan, MRI, or 3-phase bone scan may be more effective in unclear cases.  Histological examination of the bone is the most accurate test, but it obviously can only be performed on amputated limbs or during autopsy of patients who have died.  Besides the foot flattening out, another cause of stress fractures is the first metatarsal becoming too short from a bunion procedure.  If the first metatarsal becomes too short, the second metatarsal will take on too much weight and many times a stress fracture will result.  Rarely, poor bone density is the cause of stress fractures. 

Treatment is first aimed at making the diagnosis and then moving forward with a plan of treatment based on the severity of the stress fracture.  If a stress fracture occurs in a weight-bearing bone, healing will be delayed or prevented by continuing to put weight on that limb.  Rest is the only way to completely heal a stress fracture. The average time of complete rest from the activity that caused the stress fracture(s) is four to twelve weeks. During this time, it is advised that training errors be identified (for instance, too much, too soon) and avoided in the future.  One rule of thumb is to not increase the volume of training by more than 10% from one week to the next.  Rehabilitation usually consists of muscle strength training to help dissipate the excessive forces transmitted to the bones. 

Initial intervention for a mild to moderate stress fracture is to off load the second metatarsal head by changing the padding in the shoe or by wearing a padded post-operative shoe. Custom molded foot orthotics is also routinely prescribed, along with motion control athletic shoes.  Anti-inflammatory medication such as Celebrex will help with the pain; however, until the pressure is off the foot, the pain will continue.  The key is that the body is trying to stop further injury to the bone from further ground pressure.  As soon as the bone has no pressure on it from standing and walking, the pain and related disability will diminish quickly.  

A cast is required for moderate to severe stress fractures and the decision is on a case-by-case basis.  Bracing or casting the limb with a hard plastic boot or air cast may also prove beneficial by taking some stress off the stress fracture.  An air cast has pre-inflated cells that put light pressure on the bone, which promotes healing by increasing blood flow to the area and takes away a lot of the pain because of the pressure it applies to the bone. If the stress fracture is severe enough, crutches also help to take all stress off the bone.  With severe stress fractures, surgery may be needed for proper healing.  The procedure may involve pinning the fracture site, and rehabilitation takes an average of six months.

In certain sports injury situations, a bone growth stimulator is used to speed the time it takes for the body to lay down bone at the stress fracture site.  These devices send electrical impulses into the bone to promote healing.  Recent studies have shown that the bone heals naturally via electromagnetic stimulation.  Electromagnetically stimulating the bone causes the bone to lay out more bone cells that strengthen the bone.  Typically, a stress fracture heals in six weeks.  In using a bone growth stimulator, the stress fracture can be healed in about two to three weeks to allow the athlete to return to full activities.  The use of a bone growth stimulator is a decision between the patient and the doctor and usually the cost prohibits the use of the bone growth stimulator.

A neuroma is any tumor of cells of the nervous system. They can be either benign or malignant. Morton's Neuroma (or "Morton's metatarsalgia", or "Morton's neuralgia", "plantar neuroma" or "intermetatarsal neuroma") is a benign neuroma of the interdigital plantar nerve.  This problem is characterized by numbness and pain, relieved by removing footwear.  It represents a swollen nerve that has been repeatedly pinched between the metatarsal bones.  Although it is labeled a "neuroma", many sources do not consider it a true tumor, but rather a thickening of existing tissue. The nerve gradually thickens and scars secondary to chronic irritation.  The thickened nerve appears like a tumor, thus, the misnomer.  Neuromas can occur in all adult age groups, but more common in females.  Usually affects one foot, but can occur in both and is usually but not limited to the 3rd interdigital space between the 3rd and 4th toes.

A neuroma may feel as if it is stabbing, shooting, burning, radiating or a generally odd feeling in the area.  A classic sign of neuromas is seen when one lightly massages the area of pain, causing it to go away for a while.  The clinical examination elicits radiating pain when the nerve is pushed on from below and between the metatarsal heads.  Sometimes there is even a click (Mulder’s click) that occurs or a marble feeling to the bottom of the foot with walking as the nerve becomes enlarged with repeated injury.  With each injury to the nerve, the nerve enlarges with scar tissue that is a mixture of scar and nerve tissue.  It is the repeated scarring that is the cause of the pain, as the nerve tissue has nowhere to go when one is standing on their feet.  If left untreated, the neuromas can grow in size, increasing the pain level and consistency.  Inability to wear certain shoes or perform different tasks will occur.  This will lead to an eventual surgical removal of the neuroma.  Other tests are available (MRI and ultrasonography), but provide very limited useful information to confirm diagnosis.

Treatment for neuromas is aimed at changing the way in which one stands,  by changing shoes to a more support motion control athletic shoe and many times custom molded foot orthotics.  Cortisone injection therapy is used to try to reduce the amount of inflammation in the nerve and to relieve pain.  Without any other intervention, the cortisone shots have little long term use for curing the neuroma condition.  If treatment is quickly administered, by including anti-inflammatory medications such as Celebrex, the prognosis is excellent for resolving the nerve injury condition.  A more recent treatment consists of a series of weekly injections (minimum of three, maximum of seven) with an alcohol sclerosing agent.  The agent kills the nerve and shrinks it down to a normal size.

In patients who have a neuroma, more than half resolve the problem without surgery.  Surgery usually entails of removing the scarred nerve and placing the cut nerve end into a small muscle tissue next to the metatarsal.  If the nerve is not implanted into the interosseous muscle tissue adjacent to the shaft of the metatarsal, there is a high re-occurrence rate of having the neuroma return.  Extremity nerves that go to the skin will regenerate unless the nerve end is placed into a tissue that already has a nerve innervation such as a muscle belly.  For this reason, patients who have had neuroma surgery and not had the nerve implanted into muscle should expect a re-occurrence after surgery.  Although rare, if the nerve is implanted into muscle, the nerve can still develop a painful mushroom at the end of the nerve where the nerve was cut and implanted into muscle.  The recovery from neuroma surgery is usually minimally painful if tissues are respected and the surgeon closes the tissues in layers and lets down the tourniquet prior to closing the skin and not after the skin is closed.  The patient should not need to take more that a few pain pills in the first couple days and use anti-inflammatory medications for the next two weeks to control the amount of swelling in the area.

Tendonitis is an inflammation in the ball of the foot.  One of the most common areas for pain is just behind and under the base of the second toe.  The symptoms are similar to those associated with the neuroma.  Tendonitis is often seen in runners and in women who wear stylish shoes with high heels.

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