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What is a Podiatrist?
A Podiatrist, Doctor of Podiatric Medicine (DPM), is the only health care professional whose total training focuses on the foot, ankle and related body systems. After obtaining an undergraduate degree, the podiatric doctor spends four years in a college of podiatric medicine to obtain a doctorate degree. Many podiatrists further their education by participating in a post-graduate residency program at an approved hospital or university. Following their doctorate degree, each podiatrist must pass national and state examinations in order to be licensed by the state in which he or she will practice.
The podiatric physician cares for people of all ages. Common disorders of feet include bunions, heel pain/spurs, hammertoes, neuromas, ingrown toenails, warts, corns, calluses, sprains, fractures, infections, and injuries. If your podiatric surgeon is certified by the American Board of Podiatric Surgery, he or she has successfully completed a credentialing and examination process and has demonstrated knowledge of podiatric surgery. This includes the diagnosis of general medical problems and surgical management of foot diseases, deformities, and trauma of the foot, ankle and related structures..
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Athlete's Foot (Tenia Pedis)
Description
Athlete's foot is caused by a fungal infection of the skin on the foot and is by far the most common fungal infection of the skin. The infection can be either acute or chronic. The chronic form of the disease is often associated with fungal-infected toenails. The acute form of the infection most often presents with scaling between the toes with occasional small blisters and/or fissures. As the blistering breaks, the infection spreads and can involve large areas of the skin on the foot. The burning and itching that accompany the blisters may cause great discomfort that can be relieved by opening and draining the blisters or applying cool water compresses. The infection can also occur as isolated circular lesions on the bottom or top of the foot. As the skin breaks down from the fungal infection, a secondary bacterial infection can ensue.
Diagnosis
The diagnosis of tinea pedis is generally made based upon the clinical presentation. A definitive diagnosis is made by taking a scraping of the skin and culturing it. It may take up to three weeks for the culture to grow the fungus. In some instances the culture may present a false negative result because the skin scraping was inadequate. Some doctors may perform a KOH prep of a skin scraping. This is examined under a microscope and may reveal elements that can make the diagnosis.
Treatment
Treatment should be directed at controlling the fungal infection and treating any secondary bacterial infection with oral antibiotics. Soaking the feet in Epsom salts and warm water is helpful. Wearing sandals to reduce moisture accumulation and heat generated by closed shoes will also help in the control and spread of the infection. Other conditions that mimic acute athlete's foot are contact dermatitis and pustular psoriasis.
The chronic form of athletes foot is a relatively noninflamatory type of infection. It is characterized by a dull redness to the skin and pronounced scaling. It may involve the entire bottom of the foot giving a "moccasin" appearance. It generally does not itch or result in the formation of blisters. This form of the disease frequently has an associated fungal infection of the toenails. There are good topical and oral medications available for the treatment of this condition.
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Bunions
Description of the Condition
One of the more common conditions treated by podiatric surgeons is the painful bunion. Patients with this condition will usually complain of pain when wearing certain shoes, especially snug fitting dress shoes. Treatment may involve shoe gear modification, padding and orthoses. When this fails to provide adequate relief, surgery is often recommended. There are several surgical procedures to correct bunions. Selection of the most appropriate procedure for each patient requires knowledge of the level of deformity, review of the x-rays and an open discussion of the goals of the surgical procedure. Almost all surgical procedures require cutting and repositioning the first metatarsal. In the case of mild to moderate bunion deformities the bone cut is most often performed at the neck of the metatarsal (near the joint).
Cause of Bunion Deformity
The classic bunion, medically known as hallux abductovalgus or HAV, is a bump on the side of the great toe joint. This bump represents an actual deviation of the 1st metatarsal and often an overgrowth of bone on the metatarsal head. In addition, there is also deviation of the great toe toward the second toe. Shoes are often blamed for creating these problems. This is inaccurate. It has been noted that primitive tribes, where going barefoot is the norm, will develop bunions. Bunions develop from abnormal foot structure and mechanics which place an undue load on the 1st metatarsal. This leads to stretching of supporting soft tissue structures such as joint capsules and ligaments with the end result being gradual deviation of the 1st metatarsal. As the deformity increases, there is an abnormal pull of certain tendons, which leads to the drifting of the great toe toward the 2nd toe. At this stage, there is also adaptation of the joint.
Symptoms Related to Bunion Deformity
The most common symptoms associated with this condition are pain on the side of the foot. Shoes will typically aggravate bunions. Stiff leather shoes or shoes with a tapered toe box are the prime offenders. This is why bunion pain is most common in women whose shoes have a pointed toe box. The bunion site will often be slightly swollen and red from the constant rubbing and irritation of a shoe. Occasionally, corns can develop between the 1st and 2nd toe from the pressure the toes rubbing against each other. On rare occasions, the joint itself can be acutely inflamed from the development of a sac of fluid over the bunion called a bursa. This is designed to protect and cushion the bone. However, it can become acutely inflamed, a condition referred to as bursitis.
Treatment of Bunion Deformity
Early treatment of bunions is centered on providing symptomatic relief. The use of pads and cushions to reduce the pressure over the bone can be helpful for mild bunion deformities. Functional foot orthotics, by controlling abnormal pronation, reduces the deforming forces leading to bunions in the first place. These may help reduce pain in mild bunion deformities and slow the progression of the deformity. When these conservative measures fail to provided adequate relief, surgical correction is indicated. The choice of surgical procedures (bunionectomy) is based on a biomechanical and radiographic examination of the foot. Because there is actual bone displacement and joint adaptation, most successful bunionectomies require cutting and realigning the 1st metatarsal (an osteotomy). Simply "shaving the bump" is often inadequate in providing long-term relief of symptoms and in some cases can actually cause the bunion to progress faster. The most common procedure performed for the correction of bunions is the 1st metatarsal neck osteotomy, near the level of the joint. This refers to the anatomical site on the 1st metatarsal where the actual bone cut is made. Other procedures are preformed in the shaft of the metatarsal bone or are selected by the surgeon.
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Foot Orthotics
Prescription Foot Orthoses
A prescription foot orthosis is an in-shoe brace which is designed to correct for abnormal foot and lower extremity function. In correcting abnormal foot and lower extremity function, the prescription foot orthosis reduces the strain on injured structures in the foot and lower extremity, allowing them to heal and become non-painful. In addition, prescription foot orthoses help prevent future problems from occurring in the foot and lower extremity by reducing abnormal or pathological forces acting on the foot and lower extremity. A prescription foot orthosis is more commonly known by the public as a "foot orthotic".
Podiatrists prescribe two main types of prescription foot orthoses for their patients, accommodative orthoses and functional foot orthoses. Both types of prescription foot orthoses are used to correct the foot plant of the patient so that the pain in their foot or lower extremity will improve. However, accommodative and functional foot orthoses are generally made using different materials and may not look or feel the same. Both types of prescription foot orthoses are nearly always prescribed as a pair to allow more normal function of both feet.
Accommodative Foot Orthoses
Accommodative foot orthoses are used to cushion, pad or relieve pressure from a painful or injured area on the bottom of the foot. They may also be designed to try to control abnormal function of the foot. Accommodative orthoses may be made of a wide range of materials such as cork, leather, plastic foams, and rubber materials. They are generally more flexible and soft than functional foot orthoses.
Accommodative orthoses are useful in the treatment of painful callouses on the bottom of the foot, diabetic foot ulcerations, sore bones on the bottom of the foot and other types of foot pathology. The advantages of accommodative orthoses are that they are relatively soft and forgiving and are generally easy to adjust in shape after they are dispensed to the patient to improve comfort. The disadvantages of accommodative orthoses are that they are relatively bulky, have relatively poor durability, and often need frequent adjustments to allow them to continue working properly.
Functional Foot Orthoses
Functional foot orthoses are used to correct abnormal foot function and also correct for abnormal lower extremity function. Some types of functional foot orthoses may also be designed to accommodate painful areas on the bottoms of the foot. Functional foot orthoses may be made of flexible, semi-rigid or rigid plastic or graphite materials. They are relatively thin and easily fit into most types of shoes.
Functional foot orthoses are useful in the treatment of a very wide range of painful conditions of the foot and lower extremities. Big toe joint and lesser toe joint pain, arch and instep pain, ankle pain and heel pain are commonly treated with functional foot orthoses. Since abnormal foot function causes abnormal leg, knee and hip function, functional foot orthoses are commonly also used to treat painful tendinitis and bursitis conditions in the ankle, knee and hip. The advantages of functional foot orthoses are that they are relatively durable, infrequently require adjustments and more likely to fit into standard shoes. The disadvantages are that they are relatively difficult to adjust and relatively firm.
The Process of Prescribing Foot Orthoses
In order to design and fabricate a prescription foot orthosis, the podiatrist must perform a biomechanical examination of the foot and lower extremities. Angular measurements are taken of the toes, foot, ankle, knees and hip to determine the amount and level of any structural or functional deformities. This examination is done while the patient is on an examining table and also while standing. The podiatrist will also do a walking gait analysis of the patient to determine how their foot and lower extremity functions during these activities. Abnormalities from the biomechanical examination and gait examination are noted in the patient's chart for future consideration in the design and fabrication of the prescription foot orthosis.
The podiatrist then next must make a three dimensional model of the patient's feet in order to make a prescription foot orthosis. This is done by applying plaster splints to the patient's foot. The resultant three-dimensional model of the foot is then used along with a detailed orthosis prescription from the podiatrist to have the prescription foot orthoses made for the patient. Most podiatrists have a specialty podiatric orthosis laboratory make their orthoses.
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Heel Pain, Heel Spurs
Description
The most common form of heel pain, is pain on the bottom of the heel. It tends to occur for no apparent reason and is often worse when first placing weight on the foot. Patients often complain of pain the first thing in the morning or after getting up to stand after sitting. The pain can be a sharp, searing pain or present as a tearing feeling in the bottom of the heel. As the condition progresses there may be a throbbing pain after getting off your feet or there may be soreness that radiates up the back of the leg. Pain may also radiate into the arch of the foot.
To understand the cause of the pain one must understand the anatomy of the foot and some basic mechanics in the function of the foot. A thick ligament, called the plantar fascia, is attached into the bottom of the heel and fans out into the ball of the foot, attaching into the base of the toes. The plantar fascia is made of dense, fibrous connective tissue that will stretch very little. It acts something like a shock absorber. As the foot impacts the ground with each step, it flattens out lengthening the foot. This action pulls on the plantar fascia, which stretches slightly. When the heel comes off the ground the tension on the ligament is released. Anything that causes the foot to flatten excessively will cause the plantar fascia to stretch greater that it is accustom to doing. One consequence of this is the development of small tears where the ligament attaches into the heel bone. When these small tears occur, a very small amount of bleeding occurs and the tension of the plantar fascia on the heel bone produces a spur on the bottom of the heel to form. Pain experienced in the bottom of the heel is not produced by the presence of the spur. The pain is due to excessive tension of the plantar fascia as it tears from its attachment into the heel bone. Heel spur formation is secondary to the excessive pull of the plantar fascia where it attaches to the heel bone. Many people have heel spurs at the attachment of the plantar fascia without having any symptoms or pain. There are some less common causes of heel pain but they are relatively uncommon.
There are several factors that cause the foot to flatten and excessively stretching the plantar fascia. The primary factor is the structure of a joint complex below the ankle joint, called the subtalar joint. The movement of this joint complex causes the arch of the foot to flatten and to heighten. Flattening of the arch of the foot is termed pronation and heightening of the arch is called supination. If there is excessive pronation of the foot during walking and standing, the plantar fascia is strained. Over time, this will cause a weakening of the ligament where it attaches into the heel bone. When a person is at rest and off of their feet, the plantar fascia attempts to mend itself. Then, with the first few steps the fascia re-tears causing pain. Generally after the first few steps, the pain diminishes. This is why the heel pain tends to be worse the first few steps in the morning or after rest.
Diagnosis
The diagnosis of heel pain and heel spurs is made by a through history of the course of the condition and by physical exam. Weight bearing x-rays are useful in determining if a heel spur is present and to rule out rare causes of heel pain such as a stress fracture of the heel bone or the presence of bone tumors.
Treatment
Taping and oral anti-inflammatory agents can sometimes be helpful. Functional foot orthotics might be considered. A functional orthotic is a device that is prescribed and fitted by your foot doctor which fits in normal shoes like an arch support. Unlike an arch support, the orthotic corrects abnormal pronation of the subtalar joint. Thus orthotics address the cause of the heel pain; abnormal pronation of the foot. Surgery to correct heel pain is generally only recommended if all other treatment has failed. There are some exceptions to this course of treatment and it is up to you and your doctor to determine the most appropriate course of treatment. Following surgical treatment to correct heel pain the patient will generally have to continue the use of orthotics. The surgery does not correct the cause of the heel pain. The surgery may eliminate the pain but the process that caused the pain will continue without the use of orthotics. If orthotics have been prescribed prior to surgery they generally do not have to be remade.
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Ingrown Toenails
Description
Ingrown toenails are due to the penetration of the edges of the nail plate into the soft tissue of the toe. It begins with a painful irritation that often becomes infected. With bacterial invasion, the nail margin becomes red and swollen often demonstrating drainage or pus. In people who have diabetes or poor circulation this relatively minor problem can be become quite severe. In this instance a simple ingrown toenail can result in gangrene of the toe. These patients should seek medical attention at the earliest sign of an ingrown toenail. There are several causes of ingrown toenails: a hereditary tendency to form ingrown toenails, improperly cutting the toenails either too short or cutting into the side of the nail and ill-fitting shoes can cause them. Children will often develop ingrown toenails as a result of pealing or tearing their toenails off instead of trimming them with a nail clipper. Once an ingrown toenail starts, they will often reoccur. Many people perform "bathroom" surgery to cut the nail margin out only to have it reoccur months later as the nail grows out.
Treatment
Treatment for ingrown toenails is relatively painless. The injection to numb the toe may hurt some, but a skilled doctor has techniques to minimize this discomfort. Once the toe is numb, the nail margin is removed and the nail root in this area is destroyed. The doctor may use an acid to kill the root of the nail, but other techniques are also available. It may take a few weeks for the nail margin to completely heal, but there are generally no restrictions in activity, bathing or wearing shoes. Once the numbness wears off, there may be some very mild discomfort. A resumption of sports activities and exercise is generally permitted. There are very few complications associated with this procedure. Reoccurrence of the ingrown toenail can occur a small percentage of the time. Continuation of the infection is possible which can be controlled easily with oral antibiotics. On occasion, the remaining nail may become loose from the nail bed and fall off. A new nail will grow out to replace it over several months. With removal of the nail margin, the nail will be narrower and this should be expected.
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Neuroma
Description
Neuromas are the swelling of nerves that are the result of compression or trauma. They are often described as nerve tumors. However, they are not in the purest sense a tumor. They are a swelling within the nerve that may result in permanent nerve damage. The most common site for a neuroma is on the ball of the foot. The most common cause of neuroma in ball of the foot is the abnormal movement of the long bones behind the toes called metatarsal bones. A small nerve passes between the spaces of the metatarsals. At the base of the toes, the nerves split forming a "Y" and enter the toes. It is in this area the nerve gets pinched and swells, forming the neuroma. Burning pain, tingling, and numbness in one or two of the toes is a common symptom. Sometimes this pain can become so severe it can bring tears to a patient's eyes. Removing the shoe and rubbing the ball of the foot helps to ease the pain. As the nerve swells, it can be felt as a popping sensation when walking. Pain is intermittent and is aggravated by anything that results in further pinching of the nerve. When the neuroma is present in the space between the third and fourth toes, it is called a Morton's Neuroma. This is the most common area for a neuroma to form. Another common area is between the second and third toes. Neuromas can occur in one or both of these areas and in one or both feet at the same time. Neuromas are very rare in the spaces between the big toe and second toe, and between the fourth and fifth toes.
A puncture wound or laceration that injures a nerve can cause a neuroma. These are called traumatic Neuromas. Neuromas can also result following a surgery that may result in the cutting of a nerve.
Diagnosis
The diagnosis of Neuromas is made by a physical exam and a thorough history of the patient's complaint. Conditions that mimic the pain associated with Neuromas are stress fracture of the metatarsals, inflammation of the tendons in the bottom of the toes, and arthritis of the joint between the metatarsal bone and the toe. Because nerve tissue is not seen on an x-ray, the x-ray will not show the neuroma. A skilled foot specialist will be able to actually feel the neuroma on his exam of the foot. Special studies such as MRI, CT Scan, and nerve conduction studies have little value in the diagnosis of a neuroma. Additionally, these studies can be very expensive and generally the results do not alter the doctor's treatment plan. If the doctor on his exam cannot feel the neuroma, and if the patient's symptoms are not what is commonly seen, then nerve compression at another level should be suspected.
Treatment
Treatment for the neuroma consists of cortisone injections, orthotics, chemical destruction of the nerve, or surgery. Cortisone injections are generally used as an initial form of treatment. Cortisone is useful when injected around the nerve, because it can shrink the swelling of the nerve. This relieves the pressure on the nerve. Cortisone may provide relief for many months, but is often not a cure for the condition. The abnormal movements of the metatarsal bones continue to aggravate the condition over a period of time.
To address the abnormal movement of the metatarsal bones, a functional foot orthotic can be used. These devices are custom-made inserts for the shoes that correct abnormal function of the foot. The combination treatment of cortisone injections and orthotics can be a very successful form of treatment. If there is significant damage to the nerve, failure to this treatment can occur. When there is permanent nerve damage, the patient is left with three choices: live with the pain, chemical destruction of the nerve, or surgical removal of the nerve.
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