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Taking Care of Your Feet
The
human foot has 26 bones, 33 joints, and more than 100 tendons,
muscles, and ligaments. With such a complex structure, a lot can go
wrong. While some foot problems are inherited, many occur because of
years of wear and tear.
Signs of foot trouble include pain, excessively dry skin, thickened
or discolored nails, swelling, redness, and unusual sensations.
"Consumers should know that these symptoms are not normal," says
Joshua Kaye, D.P.M, a podiatrist in Los Angeles. "Whatever the
problem is, don't bury it in your shoe and hope it will go away."
Pain in the feet can trigger pain in the legs, hips, and back. Some
foot problems can even signal a larger disease, which is why the
American Podiatric Medical Association (APMA) suggests that people
take their socks off when they go to their primary care physician
for a regular checkup. In a recent APMA survey of more than 600
people, 73 percent said their feet were not routinely inspected at
doctor visits.
Toenails that are rounded inward instead of outward could signal
iron deficiency anemia. Kidney disease, heart disease, high blood
pressure, and circulatory problems can cause the feet to swell.
Tingling or numbness in the feet and slow-healing wounds could be
signs of diabetes or other serious diseases, according to the APMA.
Chronic stiffness in the toes could be a sign of arthritis.
"Changes in the structural appearance of the foot can also be signs
of abnormalities such as tendon rupture, rheumatoid or
osteoarthritis, or neuropathic disease," says Barbara Buch, M.D.,
acting clinical deputy director of the Food and Drug
Administration's Division of General, Neurological and Restorative
Devices.
Diabetes and the Feet
According to the American Diabetes Association, about 20 million
people in the United States have diabetes, a disease in which the
body does not produce or properly use insulin. But while nearly 15
million have been diagnosed with diabetes, another 6 million people
are unaware that they have it.
"A problem that seems minor for many people, like a fungal infection
or sores on the feet, can become catastrophic in someone with
diabetes or other circulatory problems," says Jonathan Wilkin, M.D.,
former director of the FDA's Division of Dermatologic and Dental
Drug Products. Diabetes is the leading cause of non-traumatic foot
amputations each year.
People with diabetes may experience neuropathy in the feet, a
condition that affects the nerves and the ability to feel pain and
heat or cold. "Someone without sensation in the feet can literally
step on a nail and not know it," says Amir Assili, D.P.M, a
podiatrist in Gaithersburg, Md. Assili says a 28-year-old man who
came in complaining of a loss of sensation in both feet was
diagnosed with diabetes soon after.
Another major foot problem linked to diabetes is poor blood
circulation. High levels of blood sugar damage the blood vessels,
making them less able to supply the skin and other parts of the body
with blood. Poor circulation interferes with the ability to heal and
raises the risk of infection. Minor cuts or even cracks from dry
skin can turn into ulcers, small red sores that can become deep and
infected. Foot amputations may be necessary when an infection
reaches bone and spreads beyond a manageable extent.Doctors normally
treat diabetic foot ulcers by cleaning them and applying wound
dressings, or with surgical debridement, which removes contaminated
tissue from a wound to prevent infection. In severe cases,
reconstructive procedures that reshape the foot may be needed to
prevent undue pressure on the foot.
During the past few years, the FDA has approved new products to
treat chronic foot ulcers that are not responding to standard
methods. Examples are Apligraf, made by Organogenesis Inc. of
Canton, Mass., and Dermagraft, made by Smith and Nephew in La Jolla,
Calif.
"The optimal approach," Assili says, "is to prevent ulcers from
occurring through tight blood sugar control and regular visits to an
endocrinologist." People with diabetes should also see a podiatric
physician at least once a year and practice the basics of good foot
care that apply to everyone--wearing comfortable socks and shoes and
maintaining foot hygiene. Those who have been diagnosed with
decreased circulation or neuropathy with loss of protective
sensation should be seen by their podiatric physician more
frequently.
Feet should also be checked daily by the patient or family members
for any cuts and sores. "Early detection is important because a
problem can quickly turn serious," Assili says. People with diabetes
and other circulatory problems should never try to treat their own
feet, because of the risk of infection.
Shoes Make a Difference
As stylish as they may be, high heels and shoes that squeeze the
feet are linked to a host of foot problems. Painful bunions, which
are misaligned toe joints, are much more common in women than men.
Poorly fitting shoes don't cause bunions, but can aggravate existing
ones.
Some people with bunions can eliminate pain with conservative
approaches such as wearing bunion pads, avoiding high heels, and
buying comfortable shoes that are shaped like their feet and that
provide more toe room.
Other common problems from tight shoes include nerve growths called
neuromas, corns, calluses, blisters, and hammertoes, a condition in
which the toes are bent like a claw.
"Shoes should be comfortable right when you buy them," says Jane
Andersen, D.P.M., a podiatrist in Chapel Hill, N.C. "You should be
able to wiggle your toes. And shoes should have a strong sole that
flexes at the ball of your foot."
Consumers also should make sure that they're wearing the right size.
"Most adults don't have their feet measured when they buy new
shoes," Andersen says, "but your shoe size can change as you get
older because the feet can spread and lengthen."
Buch says one way to ensure that you get the right shoe size is to
stand on a blank piece of paper and trace the outline of your feet
on the paper with a pen at home. "Your shoe choice should completely
cover the outline of your foot," Buch says, "with no lines showing
outside the shoe when the shoe is placed on top of the outline you
traced."
Foot Hygiene
The foot has more than 250,000 sweat glands. It's the mixture of
sweat and bacteria in our shoes and socks that makes feet smelly.
"Clean, dry feet can lower the risk of both foot odor and fungus
infections," says Kaye.
Feet should be washed every day with soap and lukewarm water,
especially between the toes, and then dried completely with a soft
towel. Any mild soap or antibacterial hand soap works fine.
"People spend a lot of time shampooing and conditioning their hair
and applying soaps and lotions to their body, but then probably
don't spend 10 seconds washing their feet," Kaye says. "Washing the
feet with a wash cloth or similarly abrasive product is important
because it helps remove the dead skin, bacteria, and fungus." For
patients who can't reach their feet during a shower because of
obesity, arthritis, or instability, Kaye recommends using a
long-handle brush like a shower back brush.
People who want to soak their feet should use warm, soapy water,
Kaye says. "Soaking feet in Epsom salt can cause excessive drying of
skin," he says. "This is an important consideration for diabetics or
with those who have existing dry or fragile skin. Consider soaking
feet in warm water with a small amount of liquid dishwashing
solution that has skin softeners. There is no benefit in soaking
feet in Epsom salt compared to regular table salt."
Some people tell Kaye they soaked their feet in very hot water
because they were trying to kill bacteria. He says, "Unfortunately,
that type of home treatment often results in skin burns. If someone
is diabetic or has poor circulation, hot water bottles or heating
pads also shouldn't be used on the feet."
Applying moisturizing lotion on the feet after bathing can alleviate
dry skin. "During dry winter months, apply a small amount of lotion
a few times per day," Kaye says. "Inexpensive generic creams are
usually equally effective as expensive brand-name products."
Kaye estimates that half of the ingrown toenails he treats are due
to improper nail clipping. "Toenails should be trimmed straight
across and not too short," he says. "Many people incorrectly cut the
corners, leaving a small point of nail that then grows into the skin
or they accidentally cut the skin."
People who pamper themselves with a salon pedicure also need to make
sure that proper cutting and safety measures are followed. In the
last few years, there have been reports of infections linked to nail
salon whirlpool footbaths that hadn't been properly cleaned or
disinfected.
Andersen suggests that people check to see that salons and their
employees are licensed. "You could ask how they clean their tubs and
instruments and how often," she says. "Some people bring their own
instruments." People with diabetes should exercise caution when
having salon treatments, and may be advised by their physicians to
avoid treatments by anyone other than a trained podiatric or medical
specialist.
Exercise Right
Wearing inadequate and worn-out shoes is a common mistake for
athletes, says James Losito, D.P.M., team podiatrist for the Miami
Heat basketball team and professor of podiatric biomechanics at
Barry University in Miami Shores, Fla.
"Running shoes should be discarded after 200 miles to 400 miles of
use and they should fit correctly," Losito says. "There should be a
thumb-width of length between the longest toe and the end of a shoe.
Failure to wear the correct shoe size can result in runner's toe,
calluses, ingrown nails, fungal nail infections, and hammertoe
deformities."
People also should purchase the right shoe for the sport. "Many
injuries occur because someone is wearing a running shoe while
playing basketball," Losito says.
Another common cause of athletic injuries is doing too much too
soon. "Both overuse training habits and worn-out shoes could result
in stress fractures, heel pain or heel spur (plantar fasciitis) or
shin splints," he says. "It is important to start out slowly and
increase distance, duration, and pace gradually. For runners, I
recommend no more than a 10 percent increase per week."
Walking or jumping on hard surfaces and failing to stretch and do
warm-ups may also cause shin splints, plantar fasciitis, and heel
spurs. Losito says, "There is no solid evidence to confirm that
stretching actually decreases the likelihood of injuries, but it
makes sense to maintain flexibility through gentle stretching,
especially following exercise."
According to the American Academy of Podiatric Sports Medicine, the
most common pain associated with jogging is runner's knee, which can
be caused by rolling in or down on the foot. With aerobics, rising
on the toes can cause an inflamed Achilles tendon. Stress fractures
can be caused by running and other repetitive strain. Sharp pain,
bruising, or swelling after a foot injury warrants medical
attention. Contrary to popular belief, it's possible to walk, even
if a foot bone is broken.
Orthotic Devices
Orthotic devices are intended to make the feet more comfortable,
minimize stress on the foot, or improve an abnormal or irregular
walking pattern. An orthotic device could be a conservative approach
to a foot problem, a preventive measure to avoid problems, or a
useful support after foot surgery.
According to the American Academy of Orthopaedic Surgeons, orthotic
devices commonly used include bunion shield pads, arch pads for
people with a flat foot, and heel inserts for people with plantar
fasciitis. These devices are sold over-the-counter (OTC) at
drugstores and sporting stores. They can be custom made and also
sold by podiatrists, physical therapists, or orthotic companies.
Consumers might do well to try a less expensive OTC orthotic device
first. "But if the problem doesn't go away after six weeks, you may
need to seek a professional consultation and a custom orthotic may
be indicated," says Eddy Gosschalk of Southern California Orthotics
and Prosthetics. "People who are at risk for developing wounds or
who have an unusual foot shape tend to need a custom orthotic." To
create a custom orthotic, a plaster cast is taken of your foot and
sent to a laboratory.
Most orthotic devices are considered "Class I exempt" by the FDA.
This category means they are exempt from pre-market notification
requirements. But they still must be manufactured under a quality
assurance program, be suitable for intended use, be adequately
packaged and properly labeled, and have establishment registration
and device-listing forms on file with the FDA. Legally marketed
Class I devices are subject to the least regulatory control because
they present minimal potential for harm to the user. But when
orthotic devices make a new health claim or a claim for certain
treatments, or use a fundamentally different technology, they must
go through FDA clearance.
Non-Prescription Drug Products
The types of OTC products for foot health include pain medicines
such as nonsteroidal anti-inflammatory drugs and products that treat
athlete's foot, corns, calluses, blisters, and warts.
Depending on the intended use, some OTC foot products, such as
lotions for moisturizing the skin, are considered cosmetics and not
drugs. There are medicated powders and creams to treat athlete's
foot. For corns and calluses, there are nonmedicated pads to improve
comfort when walking, as well as medicated pads and patches that
work to get rid of dead skin. Similar products are used to shrink
warts. These products are typically made of salicyclic acid. They
should be used with care so that healthy skin isn't harmed, and they
should never be used by people with diabetes or poor foot
circulation.
Matthew Holman, Ph.D., a scientist in the FDA's Office of
Nonprescription Products, says consumers need to pay close attention
to drug labels. "Consumers should read the indications, directions,
and warnings carefully," Holman says. "A product won't be effective
if you are trying to treat a condition that's not in the label. If
it says to only use the product on intact skin with no open sores,
that's important. If a product isn't working or the condition
becomes worse, you need to seek a doctor's advice." People with
heart disease, diabetes, and circulation problems should never
self-treat because of the risk of infection.
Prescription Drugs
Prescription drugs for treating the feet include pain medicine,
antibiotics for infections, and antifungal medicine. For instance,
an ingrown toenail may require antibiotic or antifungal treatment if
it becomes infected. For bunions and hammertoes, a cortisone
injection may be given to relieve inflammation and pain.
Fungal nails make toenails thick, brittle, and discolored to white,
yellow, or brown. The fungus grows deep in the nail bed, and it
won't go away on its own. It also can spread to other toenails.
"Discolored nails aren't always from fungus," says Andersen. "They
could also be from trauma due to exercise or psoriasis, so we take a
fungal culture to make a diagnosis."
Penlac (ciclopirox), made by Dermik Laboratories of Berwyn, Pa., is
an example of a topical antifungal. It is generally used daily for
several months for mild to moderate nail fungus. Side effects
include irritation and redness around the nails. Oral medications
for fungal infections, including fungal nails and athlete's foot,
are Lamisil (terbinafine) made by Novartis Pharmaceuticals of East
Hanover, N.J., and Sporanox (itraconazole), made by Janssen
Pharmaceuticals of Titusville, N.J. These medicines travel through
the bloodstream to attack the fungus. The tablets are taken daily
for about 12 weeks. It takes about nine months for a healthy nail to
grow in.
The most commonly reported side effects of the oral antifungals are
headaches and stomachaches. In 2001, the FDA put out a public health
advisory about both drugs and announced labeling changes. Both drugs
have been associated with serious liver problems resulting in liver
failure and death in rare cases. The FDA and the maker of Sporanox
also warned against using Sporanox for those who have a heart
condition, because of safety concerns.
Patients using these drugs should immediately report symptoms of
persistent nausea, anorexia, fatigue, or vomiting, upper right
abdominal pain or jaundice, dark urine, or pale stools. A simple
blood test is used to check liver function during treatment.
Foot Surgery and Other Procedures
Common types of foot surgery include surgery to correct bunions,
surgery for fungal nails when medications don't work, and surgery to
reduce arthritis pain. For people who have chronic ingrown toenails,
a procedure called matrixectomy may be used to prevent recurring
problems. Andersen says, "We numb the toe and remove the smallest
amount of the nail on the side, usually about one-eighth of an inch,
and then use a chemical to kill the root or remove the root of the
nail surgically."
Sometimes, bunions can be treated without surgery, but when bunions
limit or affect one's daily activities, bunion surgery may be
appropriate. Pain is the big factor here. Kaye says, "Bunion surgery
may also be warranted if there is chronic inflammation and the
person gets no relief from nonsteroidal anti-inflammatory drugs and
other conservative treatments."
Kaye says there are two main components to bunion problems. "One
problem is the pain associated with shoe pressure against the bony
enlargement," he says. "The second condition is a stiff toe joint
that causes internal joint pain during movement of the big toe. Both
or either of these problems can occur."
Advanced surgical techniques have improved outcomes for bunion
surgery. The type of surgery needed depends on the patient's age,
activity level, and degree of deformity. Kaye says he doesn't only
remove the "bump of bone," which won't usually produce lasting
results. "We realign the bone and use a surgical screw for stable
bone alignment," he says. Recovery time usually takes about four
weeks.
"The precision in which the bone is cut, shaped, and realigned is
critical," Kaye says. Though consumers may see lasers publicized to
treat bunions, lasers can't cut bone or correct bunions, he says.
Lasers are not cleared by the FDA for these indications.
According to the American College of Foot and Ankle Surgeons, there
have also been advances in less invasive foot and ankle surgery.
Newer surgical plates and screws let surgeons repair fractures with
less trauma. Smaller incisions mean less bleeding and tissue damage.
In ankle arthroscopy, surgeons look at the ankle joint with a fiber
optic camera system. This technique has been applied to knee surgery
for several years, but now it's being used for bones and joints in
the foot and ankle. This type of surgery can relieve inflammation
from arthritis and ligament damage, with reduced recovery time as
compared to open surgical procedures.
Before considering any surgery, people should always explore and
discuss the nonsurgical options with their doctor, and the benefits
and risks of surgery. It is also important to consider the doctor's
experience and results with the procedure.
The American Orthopaedic Foot & Ankle Society (AOFAS) has released
statements warning about trends in cosmetic surgery to improve the
appearance of the foot. "Some women are getting surgeries to shorten
toes and narrow their feet so they can fit into fashionable shoes,"
says Sharon Dreeben, M.D., chairwoman of the AOFAS Public Education
Committee and an orthopedic surgeon in La Jolla, Calif.
"A woman recently called asking if I would inject collagen into her
heel, and she will probably go doctor shopping to find someone who
will do it," Dreeben says. "Some people want more padding to have
cushion for high heels. But cosmetic foot surgery can result in
chronic pain, infection, and nerve injury."
Dreeben has had to fix problems from cosmetic foot surgery that went
wrong. "One woman had bunion surgery even though she hadn't been
experiencing pain," she says. "She ended up with more problems,
including nerve pain and difficulty walking."
The AOFAS defines cosmetic foot surgery as surgery that is aimed at
only improving appearance. Dreeben says, "Foot surgery should only
be used if the goal is to provide pain relief, improve function, or
enhance quality of life during normal activities of daily living."
"I tell people: One difference between cosmetic surgery on the face
and cosmetic surgery on the feet is that you don't walk around on
your face. When you readjust one piece in the foot, it can affect
everything."
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Shock Wave Therapy
The most common cause of heel and arch pain is painful stretching or
tearing of the plantar fascia, which runs along the bottom of the
foot and supports the arch of the foot. Extracorporeal shock wave
treatment is an outpatient procedure in which a medical device uses
shock waves to relieve chronic heel pain. A dome filled with water
is placed against the heel so shock waves pass through. The shock
waves increase blood flow to trigger the healing process so that
inflammation and pain subside.
FDA-approved devices for this procedure are the Ossatron, made by
SanuWave Inc. of Marietta, Ga.; The Epos Ultra, made by Dornier
MedTech, Kennesaw, Ga.; and the Orsabone Pain Relief System, made by
Orthometrix Inc., White Plains, N.Y. People who have bleeding
disorders, who are taking blood-thinning medication, or who are
pregnant, should not undergo shock wave therapy. Complications can
include mild neurological symptoms and tears in the tissue in the
bottom of the foot.
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Common Foot Ailments
Fungal Nails
Discolored toenails. Infection can spread to other nails. Fungal
infection can be picked up in damp areas like swimming pools and
locker rooms. Clean, dry feet help prevent it. Treatments are
topical and oral antifungal medications and, in severe cases,
surgery to remove the nail.
Ingrown Toenails
Nails whose corners or sides dig painfully into skin, often causing
infection. Can be caused by improper nail trimming, pressure from
shoes that are too small, injury, fungus infection, heredity, and
poor foot structure. Trim toenails straight across to prevent
problems. Soak the foot in soapy water, apply antiseptic, and
bandage. Wear well-fitting shoes. If a toenail is painful or
infected, the doctor may remove the ingrown portion.
Athlete's Foot
A skin disease that can spread from the feet to other parts of the
body and is caused by fungus. This disease doesn't typically spread
from person to person. Signs are dry, scaly skin; itching;
inflammation; and blisters. Athlete's foot can be prevented by daily
washing with soap and water, drying feet, changing sweaty shoes and
hose and socks regularly, and wearing shoes or sandals in public
environments like the locker room or pool.
Warts
Caused by a virus that enters the skin through small cuts and
infects the skin. Children tend to be more susceptible than adults.
Most warts are harmless, though they can be unsightly and painful.
They can be caused by walking barefoot on dirty ground. Treatments
include over-the-counter and prescription topical acids, and laser
or surgical removal.
Bunions
Misaligned big toe joints that can become swollen and tender. The
first joint of the big toe slants outward, angling the big toe
toward other toes. Bunions tend to run in families, but can be
aggravated by tight shoes. Conservative treatment includes padding,
choosing shoes with wide toe box, and orthotic devices. Pain
medicines and surgery to relieve pain may be needed in severe cases,
but should not be done for cosmetic purposes.
Hammertoes
The toes are bent like a claw. This condition occurs most frequently
with the second toe because of bunion slanting. It can be caused by
muscle imbalance or can be made worse by tight shoes or tight socks.
Pain medicine or orthotic devices may help. Surgery may be needed to
realign toes.
Blisters: Caused by skin friction, especially from poorly
fitting shoes. A band-aid should be worn until the blister heals,
and socks should be worn with shoes. If the blister breaks, it
should be washed, and an antiseptic and sterile bandage applied. It
shouldn't be popped. It should be drained only by a professional.
Corns and Calluses
Protective layers of dead skin cells. Calluses appear on the soles
of the feet, and corns appear on top of toes. They are caused by
friction from skin rubbing and shoes. Pain may be relieved by
moleskin or padding. They should never be cut with an instrument.
Plantar Fasciitis
Stretching or tearing of the plantar fascia, which runs along the
bottom of the foot and supports the arch of the foot. Heel pads,
pain medicines, or cortisone injections may help. Other conservative
care includes splinting, stretching, avoiding walking barefoot, and
physical therapy. Shock wave treatments use shock wave energy to
relieve inflammation and are an alternative to surgery.
Neuroma
Enlarged benign growths of nerves, most commonly between the third
and fourth toes. This nerve condition is caused by bones rubbing
against and irritating the nerves. It is also caused by abnormal
bone structure or pressure from poorly fitting shoes. It may cause
pain, burning, or numbness between toes and in the ball of the foot.
Treatment includes padding, taping, orthotic devices, and cortisone
injections. Sometimes, surgical removal is required.
Heel Spurs
Calcium growths on the underside of the foot bones often associated
with plantar fasciitis. Pain may occur if there is inflammation.
Treatments range from exercise and custom-made orthotics to
anti-inflammatory medication.
By
Michelle Meadows
from FDA consumer magazine, Mar-Apr 2006
All-in-One Foot Care
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