Foot Pain

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Foot Pain

WHAT IS FOOT PAIN?

About the Foot

The foot is a complex structure of 26 bones and 33 joints, layered with an intertwining web of 126 muscles, ligaments, and nerves. It serves the following functions:

Supports weight.
Acts as a shock absorber.
Serves as a lever to propel the leg forward.
Helps to maintain balance by adjusting the body to uneven surfaces.

Since the feet are very small relative to the rest of the body, the impact of each step exerts tremendous force upon them. This force is about 50% greater than the person's body weight. During a typical day, the average person spends about four hours on their feet and takes between 8,000 and 10,000 steps. This means that the feet support a combined force equivalent to several hundred tons every day.

About Foot Pain

Foot pain is generally defined by one of three sites of origin:

The toes. Toe problems most often occur because of the pressure imposed by ill-fitting shoes.
The front of the foot (forefoot). Pain originating in the front of the foot usually involves one of the following bone groups: the metatarsal bones (five long bones that extend from the front of the arch to the bones in the toe); or the sesamoid bones (two small bones imbedded at the top of the first metatarsal bone, which connects to the big toe).
The back of the foot (hind foot). Pain originating in the back of the foot can affect parts of the foot extending from the heel, across the sole (known as the plantar) to the ball of the foot.

Given what the foot must endure, it is not surprising that about 75% of Americans experience foot pain at some point in their lives. According to one study, chronic and severe foot pain is a serious burden for one in seven older disabled women. To compound problems, the lower back is often affected by injuries or abnormalities in the feet.

Foot Problems
Condition	Location of Symptoms	Symptoms	Recommended Footwear and Orthotics or Padding
Corns and calluses	Around toes, usually little toe, bottom of feet or areas exposed to friction.	Hard, dead, yellowish skin.	Wide (box-toe) shoes; soft cushions under heel or ball of foot or customized or gel insoles for calluses. Doughnut-shaped pads for corns.
Ingrown toenails	Toenails.	Nail curling into skin causes pain, swelling, and, in extreme cases, infection.	Sandals, open-toed shoes.
Bunions and bunionettes (tailor's bunion)	Big toe (bunions) or little toe (bunionettes).	Toes point inward. Area next to bony bump is red, tender, occasionally filled with fluid. Toe joint may be inflamed.	Soft, wide toed shoes or sandals. Bunion shields or splints. Thick doughnut-shaped moleskin pads, custom-made orthotics or foot slings if necessary.
Morton's neuroma	Third and fourth toes and bottom of foot near these toes.	Cramping and burning pain around the third and fourth toe. The neuroma may be detected by pressing top to bottom using one hand and with the other hand pressing on the top of the foot and moving it side to side. Aggravated by prolonged standing and relieved by the removal of the shoes and forefoot massage.	Wide (box-toe) shoes. Orthotic or insole with pad that reduces stress on the painful area.
Hammertoe	Usually second toe but may develop in any or all of the three middle toes.	Toes form hammer or claw shape. No pain at first, increasing as tendon becomes tighter and toes stiffen.	Wide (box-toe) shoes. Toe pads or specially designed shields, splints, caps, or slings. (Splints or slings not for people with diabetes.)
Metatarsalgia	Ball of the foot.	Acute, recurrent, or chronic pain.	Wide (box-toe) shoes. Orthotic with pad that reduces metatarsal pressure. Gel cushions. Metatarsal bandage.
Metatarsal stress fracture	Area beneath the second or third toe.	Sudden pain when injury occurs.	Low-heeled shoes with stiff soles.
Sesamoiditis	Ball of foot beneath big toe.	Pain and swelling.	Low-heeled shoe with stiff sole and soft padding inside.
Plantar fasciitis	Back of the arch right in front of heel.	At onset, some people report a tearing or popping sound. Pain, most severe with first steps after getting out of bed, decreasing after stretching, returning after inactivity.	Over-the-counter foot insole (cut quarter-size hole surrounding painful area). Possible night splints. Orthotics if necessary.
Bursitis of the heel	Center of the heel.	Pain, with warmth and swelling. Increases during the day.	Heel cup.
Haglund's deformity (pump bump)	Fleshy area on the back of the heel.	Tender swelling aggravated by shoes with stiff backs.	Soft shoes. Heel pads. Possible orthotic to support heel.
Stress fracture or heel spurs	Bottom of heel.	Sharp stabbing pain.	Heel cradles or cups.
Tarsal tunnel syndrome	Anywhere along the bottom of the foot.	Numbness, tingling, or burning sensations, pain, most commonly felt at night.	Specially designed orthotics to relieve pressure.
Flat feet or posterior tibial tendon dysfunction (PTTD)	The arch.	No arch. Often no pain or discomfort. Three stages in PTTD: Pain and weakness in the tendon. The arch flattens but is still flexible. The foot becomes rigid and possibly painful at the ankle. Sometimes people report fatigue, pain, or stiffness in the feet, legs, and lower back.	For children, possible custom-made insoles.
High arches (hollow feet)	The arch.	High arches. Lower back pain, possible tendency to lower limb injuries.
Achilles tendinitis	Achilles tendon: area along the back between calf muscles and heel.	Pain worsens during physical activities (particularly running) after which the tendon usually swells and stiffens. If it ruptures, popping sound may occur followed by acute pain similar to a blow at the back of the leg.	Insoles, tendon strap, heel cups.

WHAT ARE THE GENERAL CAUSES OF FOOT PAIN?

Nearly all causes of foot pain can be categorized under one or more of the following conditions.

Shoes. The causes of most foot pain are poorly fitting shoes. High-heeled shoes concentrate pressure on the toes and are major culprits for aggravating, if not causing, problems with the toes.
Temporary Changes in Foot Size and Shape. Temperature, and therefore weather, affects the feet: they contract with cold and expand with heat. Feet can change shape and increase in size by as much as 5% depending on whether a person is walking, sitting, or standing.
Poor Posture. Improper walking due to poor posture can cause foot pain.
Medical Conditions. Any medical condition that causes imbalance or poor circulation can contribute to foot pain.
Inherited Conditions . Inherited abnormalities in the back, legs, or feet can cause pain. For example, commonly one leg is shorter than the other, causing an imbalance.
High-Impact Exercising. High-impact exercising, such as jogging or strenuous aerobics, can injure the feet. Common injuries include corns, calluses, blisters, muscle cramps, acute knee and ankle injuries, plantar fasciitis, and metatarsalgia.
Industrial Cumulative Stress. Because of the effects of work-related repetitive stress on the hand, there has been considerable interest in the effect of work-stress on foot pain. According to one 2000 analysis, there is very little evidence for any significant impact of work on various foot disorders, including hallux valgus, neuroma, tarsal tunnel syndrome, toe deformity, heel pain, adult acquired flatfoot, or foot and ankle osteoarthritis. In general, the foot is designed for repetitive stress and few jobs pose the same stress on the feet as many do on the hands. Nevertheless, certain professions, such as police work, are associated with significant foot pain. More research is needed.

Medical Conditions Causing Foot Pain

Arthritic Conditions. Arthritic conditions, particularly osteoarthritis and gout, can cause foot pain. Although rheumatoid arthritis almost always develops in the hand, the ball of the foot can also be affected.

Diabetes. Diabetes is an important cause of serious foot disorders. It is discussed in a separate section. [See Box Diabetes and Foot Pain.]

Diseases That Affect Muscle and Motor Control. Diseases that affect muscle and motor control, such as Parkinson's disease, can cause foot problems.

High Blood Pressure. High blood pressure can cause fluid build-up and swollen feet. The effects of high blood pressure on the nervous and circulatory systems can cause pain, loss of sensation, and tingling in the feet, and can increase the susceptibility for infection and foot ulcers.

Osteoporosis. Osteoporosis, in which bone loss occurs, can cause foot pain.

Pregnancy. Pregnancy can cause fluid build-up and swollen feet. The increased weight and imbalance of pregnancy contributes to foot stress.

Other Diseases. Diseases that affect the nervous and circulatory systems, such as anorexia, can cause pain, loss of sensation, and tingling in the feet, as well as increase the susceptibility for infection and foot ulcers. A number of conditions, including heart failure, kidney disease, and hypothyroidism, can cause fluid build-up and swollen feet.

Medications. Some medications, such as calcitonin and drugs used for high blood pressure, can cause foot swelling.

Diabetes and Foot Problems

An estimated 15% of diabetics experience serious foot problems. They are the leading cause of hospitalizations for these patients. Research has demonstrated that following a strict preventive program can significantly reduce serious complications, including amputations.

Infections and Ulcers. People with diabetes are at risk for problems, particularly infections, resulting from blood vessel injury, which may be severe enough to cause ulcers in the legs and feet. Numbness from nerve damage, which is common in diabetes, makes this a significant problem, since the patient may not be aware of injuries. Even minor infections can develop into severe complications. In study of patients with type 2 diabetes, those at highest risk for foot ulcers were those who were less sensitive to sensation in the foot, who had a higher intake of alcohol, and who put more pressure on their feet.

Amputations. Extensive surgery may be required, and, in extreme cases, amputation may be necessary. Diabetes is responsible for more than half of all the lower limb amputations performed in the US each year and every year there are over 86,000 foot amputations due to this disease. According to a 2002 study, about one quarter of these amputations are performed on the toe, nearly 6% are mid-foot, 38% below the knee, and 21.4% above the knee. The remaining 10% of amputations are performed on the hip, pelvis, knee, and other sites.

Charcot Foot. Charcot foot or Charcot joint (medically referred to as neuropathic arthropathy) is of particular note. Between 1% and 2.5% of people with diabetes suffer from this condition, which is caused by abnormalities in the nerves in the feet. This condition can numb the feet so that the sufferer does not feel pain at first and is not aware of injury. Instead of resting an injured foot or seeking medical help, the patient often continues to walk, causing further damage. Early changes appear like an infection, with the foot becoming swollen, red, and warm. A seriously affected foot can become deformed. The bones may crack, splinter, and erode, and the joints may shift, change shape, and become unstable.

Prevention of Foot Disorders in Diabetes

Preventive foot care could reduce the risk of amputation in people with diabetes by 44% to 85%. Some tips for preventing problems include the following:

Patients should inspect their feet daily and watch for changes in color or texture, odor, and firm or hardened areas, which may indicate infection and potential ulcers.
When washing the feet, the water should be warm (not hot) and the feet and areas between the toes should be thoroughly dried afterward. Check water temperature with the hand or a thermometer before stepping in.
Moisturizers should be applied, but not between the toes.
Corns and calluses should be gently pumiced and toenails trimmed short and the edges filed to avoid cutting adjacent toes.
Patients should not use medicated pads or try to shave the corns or calluses themselves.
Well-fitting footwear is very important. In a 2001 study, 30% of diabetic patients wore shoes that were too narrow. Patients should also avoid high heels, sandals, thongs, and going barefoot.
Shoes should be changed often during the day.
Wear socks, particularly with extra padding (which can be purchased).
Seek footwear that reduces foot pressure. For example, custom-molded boots (e.g., Conformer Diabetic Boot) are designed to increase the surface area over which foot pressure is distributed. This reduces stress on the ulcers and allows them to heal. Researchers report pressure loads that are about a third lower than with standard casting technology. Special insoles (e.g., the Rocker insole) have also been designed to reduce pressure on the front of the foot, in one study by 48%.
Patients should avoid tight stockings or any clothing that constricts the legs and feet.
Foot pain, numbness, or tingling is worse at night; diphenhydramine (Benadryl) may help.

A specialist in foot care should be consulted for any problems.

Treating Foot Disorders in Diabetes

About one-third of foot ulcers will heal within 20 weeks with good wound care treatments. Some treatments are as follows:

In virtually all cases, wound care requires debridement, which is the removal of injured tissue until only healthy tissue remains. Debridement may be accomplished using chemical (enzymes), surgical, or mechanical (e.g. irrigation) means. Hospitalization and intravenous antibiotics for up to 28 days may be needed for severe foot ulcers.
Charcot foot is initially treated with strict immobilization of the foot and ankle; some centers use a cast that allows the patient to move and still protects the foot. A 2001 study in the UK concluded that a single dose of pamidronate, a bisphosphonate, reduces bone turnover, symptoms, and disease activity. When the acute phase has passed, patients usually need lifelong protection of the foot using a brace initially and custom footwear.
A number of recent investigative measures include the following:
A number of treatments that use human skin equivalent or HSE (Dermagraft, Apligraf, Regranex) are now available that stimulate new cell growth and help heal skin ulcers or use cultures of human skin cells. Studies are showing that HSE promotes healing and the risk for rejection of such grafts is low. Adverse effects include infections at other sites.
Administering hyperbaric oxygen (oxygen given at high pressure) is showing promise in promoting healing and preventing amputation.
Granulocyte-colony stimulating factor, or G-CSF (filgrastim, Neupogen, Amgen) is showing promise as an effective alternative to antibiotics. Studies are reporting that G-CSF accelerates healing and significantly reduces the need for surgery.
Total-contact casting (TCC). This approach uses a cast that is designed to contact the exact contour of the foot and distribute weight along the entire length of the foot. It is usually changed weekly. In one trial, it healed ulcers in nearly 90% of selected patients. It is also useful for Charcot foot.
A device that compresses the foot (NuPulse) appears to increase the circulation, reduces edema (swelling), and improves wound healing.

WHO EXPERIENCES FOOT PAIN?

Age

Nearly everyone who wears shoes has foot problems at some point in their lives.

The Elderly. Elderly people are at very high risk for foot problems. In one study 87% of older people reported at least one foot problem. Feet widen and flatten, and the fat padding on the sole of the foot wears down as people age. Older people's skin is also dryer. Foot pain, in fact, can be the first sign of trouble in many illnesses related to aging, such as arthritis, diabetes, and circulatory disease. Foot problems can also impair balance and function in this age group.

Children. Foot pain is fairly common even in children. Heel pain is common in very active children between the ages of eight and 13, when high-impact exercise can irritate growth centers of the heel.

Gender

Women are at higher risk than men for severe foot pain, probably because of high-heeled shoes.

Older Women . Severe foot pain appears to be a major cause of general disability in older women. In one study, 14% of older disabled women reported chronic, severe foot pain, which played a major role in requiring assistance in walking and in daily activities.

Pregnant Women. Pregnant women have special foot problems from weight gain, swelling in their feet and ankles, and the release of certain hormones that cause ligaments to relax. These hormones help when bearing the child but can weaken feet.

Occupational Risk Factors

An estimated 120,000 job-related foot injuries occur every year, about a third of them involving the toes. A number of foot problems, including arthritis of the foot and ankle, toe deformities, pinched nerves between the toes, plantar fasciitis, adult acquired flat foot and tarsal tunnel syndrome, have been attributed to repetitive use at work. For example, in a study of New York police who walked an average of three miles a day, 20% experienced foot pain at the end of their work-day. (Insoles can relieve much of this pain.) No studies, however, have yet scientifically distinguished between injuries due to work versus those due to regular use. This is an important issue because of its potential impact on disability claims.

Sports and Dancing

People who engage in regular high-impact aerobic exercise are at risk for plantar fasciitis, heel spurs, sesamoiditis, shin splints, Achilles tendon, and stress fractures. In one study of aerobic dance instructors, for example, nearly one third reported injuries in the feet and ankles.

Medical and Physical Conditions

Excess Weight . Anyone who is overweight puts increased stress on the feet and is at risk for foot or ankle injuries.

Diabetes. People with diabetes are at particular risk for severe foot infections and must take special precautions. [ See Box Diabetes and Foot Problems in section What Causes Foot Pain?]

Other Medical Conditions. Many other medical conditions, such as osteoarthritis, rheumatoid arthritis, and gout, predispose people to foot problems, as do inherited abnormalities.

Smokers

A 2000 study reported that smokers are at higher risk for blisters, bruises, sprains, and fractures, most likely because they tend to be less fit than nonsmokers. They also may heal less quickly, which, some evidence suggests, affects some foot surgeries.

WHAT ARE THE GENERAL PREVENTATIVE MEASURES FOR FOOT PAIN?

General Guidelines

The following tips from the American Podiatric Medical Association are very useful as general guidelines for preventing foot pain:

Don't ignore foot pain, it's not normal. If the pain persists, see a podiatric physician.
Inspect feet regularly. Pay attention to changes in color and temperature of the feet. Look for thick or discolored nails (a sign of developing fungus), and check for cracks or cuts in the skin. Peeling or scaling on the soles of feet could indicate athlete's foot. Any growth on the foot is not considered normal.
Wash feet regularly, especially between the toes, and be sure to dry them completely.
Trim toenails straight across, but not too short. (Cutting nails in corners or on the sides increase the risk for ingrown toenails.)
Make sure that shoes fit properly. Purchase new shoes later in the day when feet tend to be at their largest and replace worn out shoes as soon as possible.
Select and wear the right shoe for specific activities (i.e., running shoes for running). [See What Are the Best Shoes for Preventing Foot Pain?]
Alternate shoes. Don't wear the same pair of shoes every day.
Avoid walking barefoot, which increases the risk for injury and infection. At the beach or when wearing sandals always use sunblock on the feet, as one would on the rest of your body.
Be cautious when using home remedies for foot ailments; self-treatment can often turn a minor problem into a major one.
It is critical that people with diabetes see a podiatric physician at least once a year for a check-up. Persons with diabetes, poor circulation, or heart problems should not treat their own feet, including toenails, because they are more prone to infection.

Skin Creams and Foot Baths

Skin creams can help maintain skin softness and pliability. Taking a warm footbath for 10 minutes two or three times a week will keep the feet relaxed and help prevent mild foot pain caused by fatigue. Adding 1/2 cup of Epsom salts increases circulation and adds other benefits. Taking footbaths only when feet are painful is not as helpful. A pumice stone or loofah sponge can help get rid of dead skin.

Massage Therapy

Reflexology is an Eastern massage therapy that manipulates hands and feet. A pleasant exercise using this method can be done while taking a bath. Use the thumb, index, and middle finger to rotate each toe in a circular motion. Then, make a fist and rotate it slowly around the bottom of the foot. Finally, gently twist each foot as if wringing wet clothes, moving the top and bottom in opposite directions.

Preventing Blisters from Hiking or Strenuous Walking

Hiking or strenuous walking can cause blisters. To prevent them, one study reported that treating feet with antiperspirants before setting out may be helpful.

Caring for Toenails

Toenails should be trimmed short and straight across. Filing should be straight across as well using a single movement, lifting the file before the next stroke. The file should not saw back and forth. A cuticle stick can be used to clean under the nail.

Preventing Foot Problems in Childhood

Early Development. The first year in a person's life is important for foot development. Parents should cover their babies' feet loosely, allowing plenty of opportunity for kicking and exercise. The child's position should be changed frequently. Staying too long on the stomach can strain the feet. Children generally walk between 10 and 18 months; they should not be forced to start walking early. Wearing just socks or going barefoot indoors helps the foot develop normally and strongly and allows the toes to grasp. Going barefoot outside, however, increases the risk for injury and other conditions, such as plantar warts.

Shoes. Children should wear shoes that are light and flexible, and since their feet perspire greatly, their shoes should be made of materials that breathe. Footwear should be changed every few months as the child's feet grow. Footwear should never be handed down.

Sports. High-impact sports can injure growing feet, and parents should be sure that their children's feet are protected if they engage in intensive athletics.

WHAT ARE THE BEST SHOES FOR PREVENTING FOOT PAIN?

In general, the best shoes are well cushioned and have a leather upper, stiff heel counter, and flexible area at the ball of the foot. The heel area should be strong and supportive, but not too stiff, and the front of the shoe should be flexible. New shoes should feel comfortable right away, without a breaking in period.

Getting the Correct Fit

Well-fitted shoes with a firm sole and soft upper are the best way to prevent nearly all problems with the feet. They should be purchased in the afternoon or after a long walk, when the feet have swelled. There should be 1/2 inch of space between the largest toe and the tip of the shoe, and the toes should be able to wiggle upward. A person should stand when being measured, and both feet should be sized, with shoes bought for the larger-sized foot. It is important to wear the same socks as you would regularly wear with the new shoes. Women who are used to wearing pointed-toe shoes may prefer the feel of tight-fitting shoes, but with wear their tastes will adjust to shoes that are less confining and properly fitted.

The Sole

Ideally, the shoe should have a removable insole [ see Insoles below]. Thin hard soles may be the best choice for older people. Elderly people wearing shoes with thick inflexible soles may be unable to sense the position of their feet relative to the ground, significantly increasing the risk for falling. Some research suggests that thick soles may even be responsible for foot injury in younger adults who engage in high-impact exercise.

The Heel

High heels are the major cause of foot problems in women. Although people believe that foot binding is a problem limited to Chinese women of the past, many fashionable high heels are designed to constrict the foot by up to an inch. One study suggests that wearing high heels may even lead to arthritis of the knee. Women who insist on high heels should at least look for shoes with wide toe room, reinforced heels that are relatively wide, and cushioned insoles. They should also keep the amount of time they spend wearing high heels to a minimum.

Laces

The way shoes are laced can be important for preventing specific problems. Laces should always be loosened before putting shoes on. People with narrow feet should buy shoes with eyelets farther away from the tongue than people with wider feet. This makes for a tighter fit for narrower feet and looser for wider. If, after tying the shoe, less than an inch of tongue shows, then the shoes are probably too wide. Tightness should be adjusted both at the top of the shoe and at the bottom. Where high arches cause pain, eyelets should be skipped to relieve pressure.

Breaking in and Wearing the Shoes

If shoes do require breaking in, moleskin pads should be placed next to areas on the skin where friction is likely to occur. Once a blister occurs, moleskin is not effective. Shoes should be changed during the day and rotated in their use. As soon as the heels show noticeable wear, the shoes or heels should be replaced.

Special-Purpose Footwear

People should avoid extreme variations between their exercise, street, and dress shoes.

Exercise and Sports. Shoes purchased for exercise should be specifically designed for a person's preferred sport. For instance, a running shoe should especially cushion the forefoot, while tennis shoes should emphasize ankle support. [ See Shoes for Sports below.] Athletic socks are almost as important as shoes. Experts often recommend padded acrylic socks.

Occupational Footwear. Because a number of occupations put the feet in danger, workers in high-risk jobs should be sure their footwear is protective. For example, non-electric workers at risk for falling or rolling objects or punctures should wear shoes with steel toes and possibly other metal foot guards. Electric workers should wear footgear with no metal parts (or insulated steel toes) and rubber soles and heels. Chemical workers should wear shoes made of synthetics or rubber, not leather.

Shoes for Sports

Aerobic Dancing	Sufficient cushioning to absorb shock and pressure, which should be many times greater than shock from walking. Arches that maintain side-to-side stability. Thick upper leather support. Box-toe. Orthotics may be required for people with ankles that over-turn inward or outward. Soles should allow for twisting and turning.
Cycling	Rigid support across the arch to prevent collapse during pedaling. Heel lift. Cross-training or combo hiking/cycling shoes may be sufficient for the casual biker. Toe clips or specially designed shoe cleats for serious cyclers. In some cases, orthotics may be needed to control arch and heel and balance forefoot.
Running	Sufficient cushioning to absorb shock and pressure. Fully bendable at the ball of the foot. Sufficient traction on sole to prevent slipping. Consider insole or orthotic with arch support for problem feet.
Tennis	Allows side-to-side sliding. Low-traction sole. Snug fitting heel with cushioning. Padded toe box with adequate depth. Soft-support arch.
Walking	Lightweight. Breathable upper material (leather or mesh). Wide enough to accommodate ball of the foot. Firm padded heel counter that does not bite into heel or touch anklebone. Low heel close to ground for stability. Good arch support. Front provides support and flexibility.

Correct Walking and Exercise

In addition to wearing proper shoes and socks, a person should also walk often and correctly to prevent foot injury and pain. The head should be erect, the back straight, and the arms relaxed and swinging freely at the side. A person should step out on the heel, move forward with the weight on the outside of the foot, and complete the step by pushing off the big toe.

Stretching. Gentle stretching and heel lifts after warm-up and before running can help prevent Achilles tendinitis and heel pain.

Hiking. A person should prepare for long hikes by putting moleskin pads on the heel and other parts of the foot that might be rubbed by the shoe. At the end of a hike, the foot should be checked for irritation and redness.

WHAT ARE INSOLES AND ORTHOTICS?

Insoles

An insole is a flat cushioned insert that is placed inside the shoe. They are designed to reduce shock, provide support for heels and arches, and absorb moisture and odor. In general, they can be very helpful for many people. For example, in a study of foot pain in New York police officers, over 60% of them reported more comfort and less foot pain after using insoles. People respond very differently to specific insoles and what may work for one person may not for another. The thickness of socks must be considered when purchasing insoles to be sure they do not squeeze the toes up against the shoes.

Purchasing Insoles . Insoles can be purchased in athletic and drug stores. Shoe stores that specialize in foot problems often sell customized, but more expensive, insoles. In general, over-the-counter insoles offer enough support for most people's foot problems. Most well-known brands of athletic shoes have built-in insoles.

Brands and Materials. Dr. Scholl's is the most popular insole, but many others are available. They are composed of various materials, such as cork, leather, plastic foams, and rubber materials. Very beneficial insoles are now made from viscoelastic polymers (e.g., Sorbothane, Airplus, Spenco, Dr. Scholl's Massaging Gel, and others), which are gel-like materials that act both as liquids and solids. In a 1999 military study comparing Sorbothane with foam insoles, Sorbothane offered the best protection against heel strikes while marching and running.

Heel Cushions for Shortened Achilles Tendons . People who have developed short, tightened Achilles tendons, usually women who have worn high heels for prolonged periods, should consider using heel cushions. Like insoles, heel cushions are inserted inside the shoes. They should be at least 1/8 inch thick, but not more than 1/4 inch thick.

Orthotics

For severe conditions, such as fallen arches or structural problems that cause imbalance, podiatrists or physicians may need to fit and prescribe orthotics, or orthoses, which are insoles molded from a plaster cast of the patient's foot. Orthotics are usually categorized as rigid, soft, or semi-rigid.

Rigid Orthotics. Rigid orthotics are used to control motion in two major foot joints that lie directly below the ankle. They are often used to prevent excessive pronation (the turning in of the foot) and are useful for people who are very overweight or have uneven leg lengths. Some experts warn that rigid orthotics may cause sesamoiditis or benign tumors that form from pinched nerves.

Soft Orthotics. Soft orthotics are designed to absorb shock, improve balance, and remove pressure from painful areas. They are made from a lightweight material and are often beneficial for people with diabetes or arthritis. They need to be replaced periodically, and because they are bulkier than rigid orthotics, they may require larger shoes.

Semi-Rigid Orthotics. Semi-rigid orthotics are designed to provide balance, often for a specific sport. They are typically made of layers of leather and cork reinforced by silastic.

Orthotics vs. Insoles. Before seeking prescription orthotics, people with less severe problems should consider testing the lower-priced over-the-counter insoles. One study found that 72% of people reported less foot pain from store-purchased insoles compared to 68% of those who had them custom made.

WHAT ARE THE IMMEDIATE TREATMENTS FOR FOOT INJURY?

If a patient suspects that bones in a toe or foot have been broken or fractured, he should call a physician, who will probably order x-rays. It should be noted that a person is often able to walk even if a foot bone has been fractured, particularly if it is a chipped bone or a toe fracture.

Over-the-Counter Pain Relievers

Over-the-counter nonsteroidal anti-inflammatory drugs (NSAIDs) are commonly used to treat mild pain caused by muscle inflammation. Aspirin is the most common NSAID. Others include ibuprofen (Motrin, Advil, Nuprin, Rufen), ketoprofen (Actron, Orudis KT), naproxen (Aleve, Naprelan), and tolmetin (Tolectin). A gel containing ibuprofen can be applied to sore joints. Acetaminophen (Tylenol) is not an NSAID, and although it is a mild pain reliever, it will not reduce inflammation. It is important to note that high doses or long-term use of any NSAID can cause gastrointestinal disturbances, with sometimes serious consequences, including dangerous bleeding. No one should take NSAIDs for prolonged periods without consulting a physician.

RICE (Rest, Ice, Compression, and Elevation)

The acronym RICE stands for rest, ice, compression, and elevation, the four basic elements of immediate treatment for an injured foot.

Rest. Patients should get off injured feet as soon as possible.
Ice. Ice is particularly important to reduce swelling and promote recovery during the first forty-eight hours. A bag or towel containing ice should be wrapped around the injured area on a repetitive cycle of 20 minutes on, 40 minutes off.
Compression. An Ace bandage should be lightly wrapped around the area.
Elevation. The foot should be elevated on several pillows.

WHAT ARE SOME CAUSES AND TREATMENTS FOR TOE PAIN?

Corns

A corn is a form of callus, a protective layer of dead skin cells formed due to repeated friction. It is cone-shaped and has a knobby core that points inward. This core can put pressure on a nerve and cause sharp pain. They can develop on the top or between toes. If a corn develops between the toes, it is may be called a soft corn if it is kept pliable by the moisture from perspiration.

Corns develop as a result of friction from the toes rubbing together or against the shoe; they often occur from the following:

Shoes, socks, or stockings that fit too tightly around the toes.
Pressure on the toes from high-heeled shoes.
Shoes that are too loose can also cause corns due to the friction of the foot sliding within the shoe.
Deformed and crooked toes.

Preventing Corns and Calluses and Relieving Discomfort. To prevent corns and calluses and relieve discomfort if they develop:

Do not wear shoes that are too tight or too loose. Wear well-padded shoes with open toes or a deep toe box (the part of the shoe that surrounds the toes). If necessary, have a cobbler stretch the shoes in the area where the corn or callus is located.
Wear thick socks to absorb pressure, but do not wear tight socks or stockings.
Apply petroleum jelly or lanolin hand cream to corns or calluses to soften them.
Use doughnut-shaped pads that fit over a corn and decrease pressure and friction, they are available at most drug stores.
Place cotton, lamb's wool, or mole skin between the toes to cushion any corns in these areas.

Removing Corns and Calluses. To remove a corn or callus, soak it in very warm water for five minutes or more to soften the hardened tissue, then gently sand it with a pumice stone. Several such treatments may be necessary. Do not trim corns or calluses with a razor blade or other sharp tool. If the cutting instrument is not sterile, infection can result, and it is easy to slip and cut too deep, causing excessive bleeding or injury to the toe or foot.

Medicated Solutions and Pads. There are a number of over-the-counter pads, plasters, and medications for removing corns and calluses. These treatments commonly contain salicylic acid, which may cause irritations, burns, or infections that are more serious than the corn or callus. Use caution with these medications. The following patients should not use them:

Diabetics.
Patients with reduced feeling in the feet due to circulation problems or neurological damage.
Patients, such as the elderly, who do not have the flexibility or eyesight to use them properly.

Bursitis of the Toe

Bursitis is an inflammation of the fluid filled sacs that protect the toe joints.

Ingrown Toenails

Ingrown toenails can occur on any toe but are most common on the big toes. They usually develop when tight fitting or narrow shoes put too much pressure on the toenail and force the nail to grow into the flesh of the toe. Incorrect toenail trimming can also contribute to the risk of developing an ingrown toenail. [ See Caring for Toenails below.] Fungal infections, injuries, abnormalities in the structure of the foot, and repeated impact on the toenail from high-impact aerobic exercise can also produce ingrown toenails.

Treatments. To relieve pain from ingrown toenails, try wearing sandals or open-toed shoes. Soaking the toe for five minutes twice a day in a warm water solution of Domeboro or Betadine can help. People who are at increased risk for infections, such as diabetics, should have professional treatment.

Antibiotic ointments can be used to treat ingrown toenails that are infected. Apply the ointment by working a wisp of cotton under the nail, especially the corners, to lift the nail up and drain the infection. The cotton will also help force the toenail to grow out correctly. Change the cotton daily and use the antibiotic consistently.

In severe cases, more intensive treatments are needed. Surgery involves simply cutting away the sharp portion of ingrown nail, removal of the nail bed, or removal of a wedge of the affected tissue. Three nonsurgical methods involve using chemicals (usually phenol), cauterization (heating), or lasers to remove the skin. A major review of studies reported that the use of phenol along with simple separation of the nail was more effect than surgery alone in preventing recurrence, although infections were more common after the chemical procedure.

Bunions

A bunion is a deformity that usually occurs at the head of the one of the five long bones (the metatarsal bones) that extend from the arch and connect to the toes. A bunion typically develops in the following way:

Most often it occurs in the first metatarsal bone is the one that attaches to the big toe. A bunion may also develop in the bone that joins the little toe to the foot (the fifth metatarsal bone), in which case it is known as a bunionette or tailor's bunion.
A bunion begins to form when the big or little toe is forced in toward the rest of the toes, causing the head of the metatarsal bone to jut out and rub against the side of the shoe.
The underlying tissue becomes inflamed, and a painful bump forms.
As this bony growth develops, the bunion is formed as the big toe is forced to grow at an increasing angle towards the rest of the toes. One important bunion deformity, hallux valgus , causes the bone and joint of the big toe to shift and grow inward, so that the second toe crosses over it.

Bunions can be caused by a number of conditions:

Narrow high-heeled shoes with pointed toes can put enormous pressure on the front of the foot.
Injury in the joint may cause a bunion to develop over time.
Genetics play a role in 10% to 15% of all bunions.
Other causes are flat feet, gout, arthritis, and occupations (such as ballet) that place undue stress on the feet increase the risk for bunions.

Shoes and Protective Pads. Pressure and pain from bunions and bunionettes can be relieved by wearing appropriate shoes, such as the following:

Soft, wide, low-heeled leather shoes that lace up.
Athletic shoes with soft toe boxes.
Open shoes or sandals with straps that don't touch the irritated area.

A thick doughnut-shaped, moleskin pad can protect the protrusion. In some cases, an orthotic can help redistribute weight and take pressure off the bunion. Nonsteroidal anti-inflammatory drugs (NSAIDs) or corticosteroid injections may offer some pain relief.

Surgery. If discomfort persists, surgery may be necessary particularly for more serious conditions, such as hallux valgu s. Over 130 surgical variations have been described for this problem, and patients must discuss options carefully with their surgeon.

Bunionectomy. The most common surgery is an office procedure known as bunionectomy involves shaving down the bone of the big toe joint. In one procedure the surgeon uses a very small incision, through which the bone-shaving drill is inserted. The physician shaves off the bone, guided by feel or x-ray. It is not a cure, but patient satisfaction is high and results are long-lasting.
Surgeries to Realign the Toe Joint. In some cases surgery involves realigning the big toe joint and bone as well as tendons and ligaments. The extent of the surgery depends on the severity of the condition. Such surgeries may be known as osteotomies, arthroplasties, or arthrodeses. Surgery may include release of the tendon between the toes, fusion of the toes, or lengthening of the toe bone. Recovery may take six to eight weeks. In some of the procedures a patient may need to wear a cast or use crutches. Patients are generally satisfied with the results. In one study of an osteotomy for moderate to severe hallux valgus, after 12 years more than 90% of patients were still satisfied with the extent of pain relief and motion, and greater than 80% of them were pleased with the appearance of the foot.

Complications can include shortening of the metatarsal, which may be prevented or reduced using a procedure called fixation osteotomy, which uses a plate and screw device to hold the bone in place. In severe cases, surgeons are testing bone grafts to restore bone length in patients who have had previous bunion surgeries or when damage from osteoarthritis has occurred.

Hammertoes

A hammertoe is a permanent deformity of the toe joint in which the toe bends up slightly and then curls downward, resting on its tip. When forced into this position long enough, the tendons of the toe contract and it stiffens into a hammer- or claw-like shape.

Hammertoe is most common in the second toe but may develop in any or all of the three middle toes if they are pushed forward and do not have enough room to lie flat in the shoe. The risk is increased when the toes are already crowded by the pressure of a bunion. Lying down for long periods, diabetes, and various diseases that affect the nerves and muscles put people at risk.

Treatment for Hammertoe. At first, a hammertoe is flexible, and any pain it causes can usually be relieved by putting a toe pad, which are sold in drug stores, into the shoe. To help prevent and ease existing discomfort from hammertoes, shoes should have a deep, wide toe area. As the tendon becomes tighter and the toe stiffens, other treatments, including exercises, splints, and custom-made shoe inserts (orthotics) may help redistribute weight and ease the position of the toe.

Surgery. Surgery may be needed in some severe cases. If the toe is still flexible, only a simple procedure that releases the tendon may be involved. Such procedures sometimes only require a single stitch and a Band-Aid. If the toe has become rigid, surgery on the bone is necessary, but it can still be performed in the doctor's office. A procedure called PIP arthroplasty involves releasing the ligaments at the joint and removing a small piece of toe bone, which restores the toe to its normal position. The toe is held in this position with a pin for about three weeks, then the pin is removed. A 2000 study reported that after five years, 92% of patients who had arthroscopy were still pain free.

WHAT ARE SOME CAUSES AND TREATMENTS FOR PAIN IN THE FRONT OF THE FOOT?

The incidence of forefoot pain and deformity increases with age. With early diagnosis, conservative therapy is often successful in treating common disorders of the forefoot.

Calluses

Calluses are composed of the same material as corns [ see above ], hardened patches of dead skin cells. Calluses, however, develop on the ball or heel of the foot. The skin on the sole of the foot is ordinarily about 40 times thicker than skin anywhere else on the body, but a callus can be double even this thickness. A protective callus layer naturally develops to guard against excessive pressure and chafing as people get older and the padding of fat on the bottom of the foot thins out. If calluses get too big or too hard, they may pull and tear the underlying skin.

Risk factors for calluses include the following:

Poorly-fitting shoes.
Walking regularly on hard surfaces.
Flat feet.

Of note, in people with diabetes, the presence of calluses is a strong predictor of ulceration, particularly in those who have a history of foot ulcers.

Neuromas

Neuromas occur when the tissue surrounding a nerve becomes enlarged and inflamed causing a burning or tingling sensation and cramping in the front of the foot. Tight, poorly-fitting shoes, injury, arthritis, or abnormal bone structure may also cause this condition. Morton's neuroma is the most common neuroma of the foot and develops when the third and fourth metatarsal bones to pinch together compressing an underlying nerve. Neuromas can also occur in other locations.

Treatment for Neuromas. Pain from Morton's neuroma can be reduced by massaging the affected area. Roomier shoes (box-toe shoes), pads of various sorts, and cortisone injections in the painful area are also helpful.

If these treatments are not effective, the enlarged area may need to be surgically removed. In one long-term study of one surgeon's experience, 85% of patients reported satisfaction as being good to excellent nearly six years after surgery. About 65% were pain free. Some numbness is common afterward but it rarely bothers patients. Occasionally, the nerve tissue may re-grow and form another neuroma.

Stress Fracture

A stress fracture in the foot, also called fatigue or march fracture, usually results from a break or rupture in any of the five metatarsal bones (mostly the second or third). These fractures are caused by overuse during strenuous exercise, particularly jogging and high-impact aerobics.

A fracture in the first metatarsal bone, which leads to the big toe, is uncommon because of the thickness of this bone. If it occurs, however, it is more serious than a fracture in any of the other metatarsal bones because it dramatically changes the pattern of normal walking and weight bearing.

Treatment for Stress Fractures. In most cases, stress fractures heal by themselves if rigorous activities are avoided. It is best to wear low-heeled shoes with stiff soles. Some physicians recommend moderate exercise, particularly swimming and walking. Occasionally, a physician may recommend wearing a special wooden shoe and a compressive wrap to make walking more comfortable.

Sesamoiditis

Sesamoiditis is an inflammation of the tendons around the small, round bones that are imbedded in the head of the first metatarsal bone, which leads to the big toe. Sesamoid bones bear much stress under ordinary circumstances; excessive stress can strain the surrounding tendons. Often there is no clear-cut cause, but sesamoid injuries are common among people who participate in jarring, high-impact activities, such as ballet dancing, jogging, and aerobic exercise.

Treatment for Sesamoiditis. Rest and reducing stress on the ball of the foot are the first lines of treatment for sesamoiditis. A low-heeled shoe with a stiff sole and soft padding inside is all that is usually required. In severe cases, surgery may be necessary.

Metatarsalgia

When a cause cannot be determined, any pain on the ball of the foot is generally referred to as metatarsalgia. It is most likely caused by improper footwear, particularly high heels, or by high-impact activities.

WHAT ARE THE CAUSES AND TREATMENTS FOR PAIN IN THE HEEL AND BACK OF THE FOOT?

The heel is the largest bone in the foot. Heel pain is the most common foot problem and affects two million Americans every year. It can occur in the front, back, or bottom of the heel.

General treatment guidelines are follows:

The American Orthopaedic Foot and Ankle Society (AOFAS) suggests shoe inserts, medications, and stretching as a first line of therapy for heel pain. One study found that 95% of women who used an insert and did simple stretching exercises for the Achilles tendon and plantar fascia experienced improvement after eight weeks.
If these treatments fail, the patient may need prescription heel orthotics and extended physical therapy.
Heel surgery to relieve pain may be performed for heel spurs, plantar fasciitis, bursitis, or neuroma.
Surgery is not recommended until nonsurgical methods have failed for at least six months and preferably up to 12 months. Nonsurgical treatments for heel pain are effective in 90% of patients.

Plantar Fasciitis

Plantar fasciitis occurs from small tears and inflammation in the wide band of tendons and ligaments that stretches from the heel to the ball of the foot. This band, much like the tensed string in a bow, forms the arch of the foot and helps to serve as a shock absorber for the body. The term plantar means the sole of the foot, and fascia refers to any fibrous connective tissue in the body.

Plantar fasciitis is usually a result of overuse during high-impact exercise and sports. It accounts for up to 9% of all running injuries. Because the condition often occurs in only one foot, factors other than overuse may be responsible in some cases. Other causes of this injury include poorly-fitting shoes or an uneven stride that causes an abnormal and stressful impact on the foot.

Pain often occurs suddenly and mainly in the heel, although it often spreads to the arch. The condition can be temporary or may become chronic if the problem is ignored. In such cases, resting provides relief, but only temporarily.

The three major treatment goals for plantar fasciitis are:

Reducing inflammation and pain.
Reducing pressure on the heel.
Restoring strength and flexibility.

Embarking on an exercise program as soon as possible and using NSAIDs, splints, or heel pads as needed reduces the risk for future surgery. Pain that is not relieved by NSAIDs may require more intensive treatments, including leg supports and even surgery [ see below ].

Exercises to Restore Strength and Flexibility . Stretching the plantar fascia is the mainstay therapy for restoring strength and flexibility. One exercise involves the following:

Put the hands on a wall and lean against them.
Place the uninjured foot on the floor in front of the injured foot. The injured foot in back should have the heel off the floor.
Stretch the back leg and foot gently.

With stretching treatments, the plantar fascia nearly always heals by itself but it may take as long as a year, with pain occurring intermittently. A moderate amount of low-impact exercise (such as walking, swimming, or cycling) also seems to be beneficial.

Medications to Relieve Pain and Reduce Inflammation.

NSAIDs. Inflammation and pain is most commonly treated with ice and over-the-counter nonsteroidal anti-inflammatory drugs (NSAIDs) such as aspirin or ibuprofen (Advil).
Corticosteroids. Corticosteroids, or steroids, are powerful anti-inflammatory agents. An injection of a steroid plus a local anesthetic (such as xylocaine) may provide relieve in severe cases. For athletes or performers who need immediate relief, an effective method is to administer the steroid dexamethasone using a procedure called iontophoresis, which introduces the drug into the foot's tissue using an electrical current.

Reducing Pressure on the Heel.

Comfortable Shoes and Insoles. Wearing comfortable shoes that have thick soles and rubber heels and wearing a sole insole relieves pressure. (An insole with an arch support might also be helpful.) Cutting a round hole about the size of a quarter in the sole cushion under the painful area may help support to the rest of the heel while relieving pressure on the painful spot itself. Heel cups are not very useful. When combined with exercises that stretch the arch and heel cord, over-the-counter insoles may offer the same relief as prescribed orthotics. A 2001 study indicated, however, that patients may comply better with the custom-made orthotics.
Night Splints. There is some evidence that splints worn at night may be helpful for some people. One device uses an Ace bandage and an L-shaped fiberglass splint, which the patient wears while sleeping; it keeps the foot stretched, allowing the muscle to heal. One study reported that nearly any splint, regardless of cost, is equally effective in about three-quarters of patients. A 2001 comparison study reported, however, that patient compliance was better with custom-made prescribed orthotics than with tension night splints and that there was no difference between the two in pain improvement.
Elevated Heels. Some people report that mild symptoms may be relieved with the use of shoes or cowboy boots that have elevated heels. This approach, however, may not work in some people and is not recommended for anyone with a moderate to severe condition. (Heel cups have not been proven to be very useful.)

Extracorporeal Shock Wave Therapy. Some patients may benefit from extracorporeal shock wave therapy (ESWT). The therapy uses low-dose sound waves to injure the surrounding tissues in the heel, which triggers healing of the tissues that are causing the pain. A 2002 study suggested that three applications of 1,000 impulses of low-energy shock waves reduced pain and might help patients avoid later surgery. (A group who received 10 impulses achieved no significant benefits.) Some experts believe it may be a useful and safe alternative to steroid injections.

Surgery. Surgery is appropriate in about 5% of patients, typically those who have disabling heel pain for at least a year that does not respond to other treatments. The procedure is a release surgery, instep plantar fasciotomy. It relieves pressure on the nerves that are causing pain by removing part of the plantar fascia.

The standard procedure uses a large incision and takes about two months to resume complete normal activity. A less invasive variant uses a procedure called endoscopy that employs small incisions and may prove to be effective.

For either approach, studies report good to excellent pain relief in 80% to 90% of patients. In one study, however, half of the patients were dissatisfied because the procedure didn't work or because recovery took too long. In another 2000 study, about 15% of the patients reported long-lasting complications, including pain from scar tissue and continued heel pain.

Wearing a below-the-knee walking cast after the operation for two weeks may reduce the need for pain relief and speed recovery time compared to use of crutches.

Bursitis of the Heel

Bursitis of the heel is an inflammation of the bursa, a small sack of fluid, beneath the heel bone. Nonsteroidal anti-inflammatory drugs (NSAIDs) such as aspirin or ibuprofen (Advil) and steroid injections will help relieve pain from bursitis. Applying ice and massaging the heel are also beneficial. A heel cup or soft padding in the heel of the shoe reduces direct impact when walking.

Haglund's Deformity (Pump Bump)

Haglund's deformity is a bony growth surrounded by tender tissue on the back of the heel bone. It is commonly called pump bump and known medically as posterior calcaneal exostosis. It develops when the back of the shoe, almost always one with a high heel, repeatedly rubs against the back of the heel, aggravating the tissue and the underlying bone.

Treatment for Haglund's Deformity. Applying ice followed by moist heat will help ease discomfort from a pump bump. Nonsteroidal anti-inflammatory drugs (NSAIDs) such as aspirin or ibuprofen (Advil) will also reduce pain. Physicians may recommend an orthotic device to control heel motion. Corticosteroid injections are not recommended because they can weaken the Achilles tendon.

In severe cases, surgery may be necessary to remove or reduce the bony growth. According to one study, however, surgery was not effective for over 30% of patients and, in fact, 14% experienced a worse condition afterward. A more recent study reported that surgery cured 90% of cases, but full recovery required six months to two years. Experts advise patients to try all conservative measures before choosing surgery.

Tarsal Tunnel Syndrome

Tarsal tunnel syndrome results from compression of a nerve that runs through a narrow passage behind the inner ankle bone down to the heel. It is caused by injury to the ankle, such as a sprain or fracture, or by a growth that presses against the nerve. Magnetic resonance (MR) imaging and the dorsiflexion-eversion test are being used to diagnose this syndrome.

Treatment for Tarsal Tunnel Syndrome. Pain from tarsal tunnel syndrome may be relieved by treatment with orthotics, specially designed shoe inserts, to help redistribute weight and take pressure off the nerve. Corticosteroid injections may also help. Surgery is sometimes performed to relieve pressure on the nerve, but studies are mixed on its effectiveness. Tarsal tunnel syndrome caused by known conditions, such as tumors or cysts, may respond better to surgery than when the cause is not known.

Achilles Tendinitis

Achilles tendinitis is an inflammation of the tendon that connects the calf muscles to the heel bone. It is caused by small tears in the tendon from overuse or injury and is most common in people who engage in high-impact exercise, particularly jogging, racquetball, and tennis.

People at highest risk for this disorder from these activities are those with a shortened Achilles tendon. Such people tend to roll their feet too far inward when walking, and tend to bounce when they walk. A shortened tendon can be due to an inborn structural abnormality or acquired after wearing high heels regularly.

Evidence is uncertain about the best way to treat either acute or chronic Achilles tendinitis. Some approaches are discussed.

Treatments to Relieve Pain and Reduce Inflammation. Nonsteroidal anti-inflammatory drugs (NSAIDs) such as aspirin or ibuprofen (Advil) may help to ease pain and reduce inflammation. It is also helpful to apply ice four or five times a day for 20 to 30 minutes. (Note: Corticosteroid injections are sometimes used, although evidence suggests they don't help very much and they pose a risk for rupture of the tendon.)

Gentle Stretching. Gentle stretches may also help reduce the pain and spasms. If the calf is swollen, elevating the leg is recommended. Exercise is safe when the heel is no longer swollen or tender, even if pain is still present. If pain increases with exercise, stop immediately.

Laser Therapy. Low-level laser therapy that emits energy directed at pain trigger points has helped some patients. No strong evidence supports its use to date, however.

Surgery vs. Nonsurgical Treatment. If pain continues, the ruptured tendon will require a cast and perhaps surgery. Although some experts believe a cast is sufficient in many cases, without an operation, the tendon has a 38% chance of rupturing again. Some experts suggest surgery for active persons and nonsurgical treatment for older people.

Surgery requires a long incision with a postoperative period of immobilization that can average six weeks. Complications can include a significant surgical scar, infection, and muscle atrophy. Less invasive techniques are being tested. In one study, selected patients with ruptured tendons were hospitalized for about five days and fitted with special footgear (Variostabil that continuously raised the back of the foot). The footgear was effective for most patients and the tendon ruptured again in only 5% of these cases.

Heel Spurs

Heel spurs are calcium deposits that develop into sharp bony growths under the heel bone. As a spur develops, the soft tissue in the heel becomes irritated and swells, putting pressure on the nerves and causing pain. Pain may increase with age as the fatty tissue on the bottom of the foot wears away.

They often result from improper foot movement during running or walking, poorly-fitting shoes, and excessive body weight. It should be noted that spurs are less common causes of heel pain than many other conditions, particularly plantar fascia, bursitis, stress fractures, and tarsal tunnel syndrome.

Treatment for Heel Spurs. Most heel spurs do not cause pain. If they do, insoles and nonsteroidal anti-inflammatory drugs (NSAIDs) such as aspirin or ibuprofen (Advil) may be sufficient.

If the pain persists, surgery that involves cutting and releasing the plantar fascia and removing the spurs may be recommended. The surgery can be risky and leave scarring that may be more painful than the original problem. Recovery usually requires immobilization of the foot and use of crutches for about two weeks. Surgery should be a last resort.

Extracorporeal shock wave therapy is showing promise for being a safe and effective alternative for heel spurs. [ See Plantar Fasciitis above for a description.]

Excessive Pronation

Pronation is the normal motion that allows the foot to adapt to uneven walking surfaces and to absorb shock. Excessive pronation occurs when the foot has a tendency to turn inward and stretch and pull the fascia. It can cause not only heel pain, but also hip, knee, and lower back problems.

Stress Fracture

Stress fractures, also called fatigue or march fracture, can occur in the heel and are caused by overuse during strenuous exercise, particularly jogging and high-impact aerobics. Most stress fractures in the foot heal with rest and gradual reintroduction of activity. Note, however, that fractures in the fifth metatarsal (the bone connecting to the little toe) have a high risk for complications and may require intensive treatments.

WHAT ARE CAUSES AND SPECIFIC TREATMENTS FOR ARCH AND BOTTOM-OF-THE-FOOT PAIN?

Flat Foot

Flat foot, or pes planus, is a defect of the foot that eliminates the arch. The condition is most often inherited. Arches, however, can also fall in adulthood, in which case the condition is sometimes referred to as posterior tibial tendon dysfunction (PTTD). This occurs most often in women over 50 but it can occur in anyone. The following are risk factors for PTTD:

Wearing high heels for long periods of time is a particular risk for flat feet. In such cases, over the years, the Achilles tendon in the back of the calf shortens and tightens, so the ankle does not bend properly. The tendons and ligaments running through the arch then try to compensate. Sometimes they break down and the arch falls.
Some studies have indicated that the earlier one starts wearing shoes, particularly for long periods of the day, the higher the risk for flat feet later on.
Other conditions that can lead to PTTD include obesity, diabetes, surgery, injury, rheumatoid arthritis, or use of corticosteroids.

Some research suggests that flat feet in adults can, over time, actually exert abnormal pressure on the ankle joint that can cause damage. One indirect complication of flat arches may be urinary incontinence or leakage during exercise. The less flexible the arch, the more force reaches the pelvic floor, jarring the muscles that affect urinary continence.

Treatment for Flat Feet. Children with flat feet often outgrow them, particularly tall, slender children with flexible joints. One expert suggests that if an arch forms when the child stands on tip-toes, then the child will probably outgrow the condition.

In general, conservative treatment for flat feet acquired in adulthood (posterior tibial tendon dysfunction) involves pain relief and insoles or custom-made orthotics to support the foot and prevent progression. In severe cases, surgery may be required to correct the foot posture, usually with procedures called osteotomies or arthrodesis, which typically lengthen the Achilles tendon and adjusting tendons in the foot. These procedures have potential complications and conservative methods should be tried first.

Abnormally High Arches

An overly-high arch (hollow foot) can cause problems. Army studies have found that recruits with the highest arches have the most lower-limb injuries and that flat-footed recruits have the least. Contrary to the general impression, the hollow foot is much more common than the flat foot.

Clawfoot, or pes cavus, is a deformity of the foot marked by very high arches and very long toes. Clawfoot is a hereditary condition, but can also occur when muscles in the foot contract or become unbalanced due to nerve or muscle disorders.

WHERE ELSE CAN HELP BE OBTAINED FOR FOOT PAIN?

American Podiatric Medical Association, 9312 Old Georgetown Rd., Bethesda, MD 20814. Call (800-ASK-APMA) or on the Internet (http://www.apma.org)

Web site has excellent information and provides names of podiatrists in local areas. It also provides Seals of Approval to manufacturers of products that help protect feet. They publish this list on their website (http://www.apma.org/seal2.html).

American Orthopedic Foot and Ankle Society, Inc., 2517 Eastlake Ave. E., Suite 200, Seattle, WA 98102. Call (206 223-1120) or fax (206-223-1178) or on the Internet (http://www.aofas.org)

Shoe Service Institute of America, c/o Quabaug Corporation, 18 School Street, North Brookfield, MA 01535. Call (508·867·7731) or on the Internet (http://www.shoesmarts.com)

Information on Foot Problems in Diabetes

American Diabetes Association, 1701 North Beauregard Street, Alexandria, VA 22311. Call (800-DIABETES or (http://www.diabetes.org/). This is the primary source for information on diabetes.

Foot Product Web Sites

The following are a few web sites sponsored by manufacturers of insoles and other foot products that have the Seal of Approval from the American Podiatric Medical Association. These sites also provide interesting information.

Dr. Scholl's Foot Health Guide (http://www.drscholls.com)

Implus Footcare, LLC. (http://www.sofsole.com/)

Spenco Medical Corp. (http://www.spenco.com/)

See the following for a complete list of all the manufacturers approved by the APMA (http://www.apma.org/seal2.html)

Other Useful Websites

http://podiatrychannel.com/

http://www.podiatrynetwork.com/

http://www.foothealthnetwork.com ( sponsored by Apex Foot Health Industries, Inc.)

http://www.footexpress.com/ (Sells a number of products, including night splints)