Common Foot Problems

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Dry Skin … If it’s wintertime … it’s time for dry skin

As people age there appears those predictable but otherwise disappointing changes we note in the way our body appears and how it functions. Related to skin condition, there are some general observations that can be easily made. They don’t apply to everyone at the same time. Some folks develop these conditions earlier in life, others later.

Especially in the winter, I hear many complaints of dry skin affecting the lower legs and feet. Sometimes this includes the fissures or cuts that spontaneously open up along the rim of the heel. Heel fissures are especially painful and are usually caused when heavy callous builds up around the rim of the heel. This callous needs to be reduced. When a thick covering of callous dries out and cracks with the pressure of weight-bearing, it causes the living skin beneath to tear with it. This is similar to what we experience on the tips of fingers in the wintertime. These problems are much less likely to arise in humid summer months.

In the earlier decades of life the specialized oil producing cells in our skin provided for a natural 24 hour a day VAPOR BARRIER, keeping the outer layer
of skin from drying out. As we age, these specialized cells no longer protect the skin so efficiently.  I believe this has a lot to do with regional changes in the amount of circulation and therefore nutrition supplied to these oil glands and other specialized skin cells. Note as well, that the amount of hair present on the lower legs feet and toes diminishes with age or more specifically with diminished conditions that allow for the full functioning of these specialized cells in the skin.

So … Your Body Isn’t Doing it. … So … You Need To …

When your body no longer supplies an efficient 24 hour a day vapor barrier and the relative humidity in your warm house in the wintertime is around 25 to 30% your skin dries out, causing flaking and cracking. So the treatment is to provide your own externally applied vapor barrier. There are an abundance of safe skin products that do this. I believe the amount that you pay for these products has little to do with how well they work. What is more important is that the product be applied frequently. Putting it on every other day, or once every few days is not going to work well. Your self-applied vapor barrier needs to be maintained 24/7. Skin creams rub off and wash off. For more detailed information contact your dermatologist… or a qualified skin care specialist.

Cold Feet. .. More Wintertime Challenges … No Wonder Everybody Leaves!

Another wintertime problem. This is worse for some folks than others. Having cold and discolored feet indicates a more concerning problem related to circulation. Blood leaving the heart is at the normal core temperature. Our circulation regulates the temperature at our skin. When blood is not supplied well to regions far from the heart, to include the fingers and toes, they may appear discolored and feel painfully cold. The bottom line is that heat is not being sufficiently supplied to these areas. To help control this problem external heat should be made available and the small amount of heat produced by the feet and legs should be trapped with insulating boots and socks.  PLEASE NOTE…the recommendation for slipper boots below.

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How To Keep Your Feet Warm?

Be aware of the air temperature near your feet. Your house thermostat may be 72° at eye level but possibly 20° cooler on the floor. And when you’re driving your car the heat blasting out of the vents might be 80° but the floorboards can be very much colder.

Dead Air Space … Insulation

The key to warmth is to provide dead air space to Trap Heat; just like an insulated window or with a batt of fiberglass insulation. You need to trap heat near your feet. This can be done with socks that are designed and woven to keep the feet warm. Also consider an insulated boot slipper. I usually recommend calf high boots such as Uggs or similar. Higher insulated boots will TRAP MORE HEAT coming from the skin of the leg and the foot inside the boot.

Polar Fleece Boots

NEW! Well, NEW to me …again…..Check out this online store…POLAR FEET ….Google… Polar Feet…They sell a Level 3 Polarfleece indoor boot slipper for $50.00…..definitely worth it ….I have an example at the office. Among other products, Polar Feet sells a ladies boot liner….which I see as a really warm just below the knee…slipper sock. If you have poor circulation of Raynaud’s Disease, etc…. in your feet and / or legs, I especially recommend these products. The combination of the boot liner with the slipper over the liner would be the “hot setup” for sure. Unfortunately, the boot liners come in only womens sizes. You might want to go up a boot size if wearing both…REMEMBER! NOTHING…tight…..maintain dead space….don’t crush the insulation.

Socks And Boots: Better A Little Big Than TOO Small.

Wearing insulated boots that are too small or stuffed with socks just serves to crush the dead air space, totally defeating the purpose by eliminating the heat collecting quality of the insulated footgear. It’s all about maintaining dead air pace.

Purple Toes
When people have cold and discolored feet, meaning purplish or red purplish, they should be examining them daily or … have someone help them do that. Having very poor circulation predisposes to developing ulcerations on the toes or on the bottoms of the forefoot. Be Aware! Be Vigilant!

Swollen Legs And Feet.. .. Are You Still Watching TV With Your Feet Not Up?

Swelling of the lower extremities, that is, edema is a problem concerning the circulatory system. Its origins are either in the condition of physical anatomy and / or its physiology. These problems are addressed by your primary care doctor or your cardiologist.

Really SIMPLE things that you can do to make life easier for your heart and lungs …. and your feet and legs … are among the following:

When you are reading or watching TV …. YOUR FEET AND LEGS SHOULD BE ELEVATED …. 100% of the time … I think that an ottoman is too low. Standing for long periods is not healthy either. And … sitting at a computer … it’s either time for an iPad, a tablet PC, MacBook or similar device to take into the recliner with you …. Remember. …. It’s just EASIER on your heart and lungs if fluids do not have to be pushed back ‘up hill’ from a dependent position where the legs are down. I recommend the use of a reclining chair which is easy to get in and out of. Dave Barbo’s place in Dennis Port has an abundance of this type of chair.

Support Hose …. A Sometimes Necessary Pain In The ….

The other ‘easy’ thing to do is to wear SUPPORT HOSE. Your primary care or your cardiologist may have already suggested this. I know, some support
hosiery is almost impossible to get on. If that’s the case, discuss this with the person who prescribed them. Wearing something less compressive …. that you can actually get on …. is probably better than nothing. Also, avoid the top elastic edges of regular socks from cutting into your ankle and calf … choose socks designed to fit just of below the knee. Otherwise consider socks, especially in warmer months, that only come to the area below your ankle.

Poor Sensation or Lack of Sensation … Oh, NO!… This Is Not Good… At All!… Neuropathy

This is potentially a very serious condition. It may be accompanied with poor circulation. My experience has demonstrated that people with profoundly poor sensation can be unaware of injuries developing in their feet. It is essential that the feet be protected. This means carefully providing for appropriate foot gear which will fit correctly and provide for shock absorption. People who do not have, adequate sensation in their feet impact the ground with forces higher than those  with full sensation. Therefore, footgear that cushions effectively is essential.

Protective Shoes And Protective Shoe Inserts

Is my opinion that the modern running shoe (fabric toe box athletic shoe} if well designed and constructed is usually the best ‘diabetic’ shoe available. After all, this type  of athletic shoe..is designed specifically to protect the foot. They are designed to absorb shock. They are designed to support the foot where need be. They are designed to be flexible where necessary. They are designed to be light. They are designed to allow air to circulate inside the shoe. They are washable. Well designed shoes have removable inserts. However, inserts that come as original equipment are frequently of relatively poor quality.  Factory inserts should be evaluated at time of purchase and replaced with better ones if necessary.

Note that the shoes described above may not be appropriate for everyone needing a protective shoe. Specialty shoes are available. I can help make that decision.

Specialized And Modified Inner Soles

I frequently modify appropriate inner soles to further protect particularly vulnerable areas of the foot. Quality inner soles provide a convenient platform to
design into the shoe additional protection for trouble areas of the foot. Modifications can be made to relieve pressure from specific areas of concern as
necessary.

I regularly refer my patients to Hanlon’s shoe store in Hyannis where I know that my patients will get both quality attention and superior equipment. Buy power tools at Sears… not shoes.

Plantar Warts. Apparently, You Just Can’t Go Through Life Without One Of These

Plantar warts are caused by infection with the human papilloma virus. The virus attacks compromised skin through direct contact. This means entering by a microscopic cut or abrasion in the stratum corneum, which is the outermost layer of the skin. Plantar warts are benign skin tumors … but. … Warts do not penetrate the entire skin. On non weight bearing surfaces they form a raised lump. On the bottom of the feet they are usually found on weight-bearing regions and through the process of weight-bearing are pushed into the skin topographically, not histologically, …. causing a depression.

Plantar warts are similar in appearance to calluses and corns. Typically the fingerprint-like lines on the feet go around warts but pass-through areas of
corns/callous. Warts are typically painful when pressure is applied side to side rather than directly on the warts. Calluses tend to be more painful when pressed upon directly. Generally, warts are not a serious health concern but they do become painful sometimes.

It’s a good idea to get treatment when warts are painful or interfering with regular weight-bearing activities or whenever any lesion is changing its appearance, size or color. People who have compromised sensation in the feet should be particularly mindful of any visual skin changes.

In my hands the best way to eradicate warts is to physically remove them. All methods of treating warts are called ‘treatments of destruction’ whether that be with the extreme cold of liquid nitrogen, methods that cause local heat such as laser or cauterization, or a chemical applications such as salicylic acid. I prefer to carefully provide local anesthesia to the area of a wart and physically peel it from the underlying skin. Plantar warts are discrete lesions that readily peel from the dermis … the second layer of skin. Unlike other methods of wart destruction, this process normally avoids the possible formation of scars.

How About A Little Help From The Immune System …. .Please?

The wart viruses are not particularly contagious. However in some environments they thrive. For example warm moist environments such as the inside of shoes, shower floors locker rooms and public swim areas. There will probably be more virus particles in these environments available for penetration of the skin. There appears to be no practical way to keep plantar or other types of warts, for that matter, from occurring again. Removal of warts, especially single lesions, is usually successful on the first attempt. However, the greater the number of lesions the greater the chance there is of at least some recurrence.

Morton’s Neuroma …. A Specific Pain Between Toes

This is another common problem described by patients as pain experienced between either the second and third toes or the third and fourth toes. The
discomfort emanates from the bottom of the foot. Patient’s frequently grab the area near the ball of the foot at the base of the toes. Classical descriptions of this problem include; splaying of the toes, numbness into one or both of the involved toes, localized shooting pains, the strange sensation of a wrinkle in a sock although no socks are being worn at the time. Characteristically, the pain is often relieved by removing the shoe.

I Keep Needing To Quote … Spike Lee .. Old Nike Commercials ….. ‘It’s The Shoes, Man’

Once again, properly fitting footgear make all the difference. Many times just avoiding footgear that squishes the forefoot side to side and top to bottom makes a big difference. Women have this more difficult since their dress shoes tend to squish stuff … And high heels just accentuates the matter. Boat shoes and slip-on loafers are no prizes either. If there are also angular deformities present, such as a bunion or hammertoes, which take up more room in the shoe, this situation makes shoe fitting even more difficult.

A.K.A. Perineural Fibroma

The Morton’s neuroma is not actually a true neuroma but rather the deposition of fibrous tissue in the vicinity of or surrounding the sensory nerve that supplies sensation only to the skin surfaces between the toes. This is known as a perineural fibroma. The involved nerve branches at the ball of the foot and this bifurcation is particularly exposed to micro trauma as the heel comes off the ground as we walk. I think this is why it is discovered in the second and third inter-digital spaces. In addition to poorly fitting shoes, trauma or angular deformities of the toes …. hammer toes .. may contribute to symptoms in these areas. Injuries to soft tissues and the joints surrounding the nerve may actually be the primary problem. Inflammation of these tissues may bring secondary pressure to· bear on the nerve and cause ‘neuroma’ symptoms as well.

Treatment: Let’s Think About Changing The Shoes For A While

The success of treatment of this problem is greatly influenced by the duration of the symptoms. With specific symptoms that have been occurring for days or a couple of weeks, just getting into a loose fitting shoe, or rather, and appropriately fitting shoe will usually take care the problem. When symptoms have been present for many weeks or months, in addition to shoe changes, I usually recommend a one time injection of cortisone. This can be done, in my hands, almost painlessly. Most of the time, the injections are very helpful. Even in cases where symptoms have been long-standing, an injection of cortisone may last many weeks or months; sometimes longer.

Biomechanics.

Sometimes the use of an orthotic, or a modified over-the-counter insert will help with the symptoms and prevent their return.

Surgical Considerations

When there is no response to changes in foot gear or cortisone injection, surgical correction is an excellent choice. Surgical correction involves the removal of a section of the involved nerve. Remember, this is a purely sensory nerve which provides sensation to the skin between the toes. It does not operate muscles. When a section of this nerve is removed, the patient experiences, but rarely mentions to me, some residual and partial numbness in the area between the toes. The procedure is scheduled as a day surgery in the hospital with sedation and local anesthesia. There is no pain involved in the procedure and patients usually report very little pain during the postoperative course.