Common foot problems
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Arthritis is a frequent component of complex disease processes that may involve more than 100 identifiable disorders. It is characterized by inflammation of the cartilage and lining of the body’s joints. If the feet seem more susceptible to arthritis than other parts of the body, it is because each foot has 33 joints that can be afflicted, and there is no way to avoid the pain of the tremendous weight-bearing load on the feet. Arthritis may be a disabling and occasionally crippling disease; it afflicts almost 40 million Americans. In some forms, it appears to have hereditary tendencies. While the prevalence of arthritis increases with age, all people—from infants to seniors—are potential victims. People over 50 are the primary targets. Arthritic feet can result in loss of mobility and independence, but with early diagnosis and proper medical care, this may be avoided.
What is arthritis?
Arthritis, in general terms, is inflammation and swelling of the cartilage and lining of the joints, generally accompanied by an increase in the fluid in the joints. There are multiple causes; just as a sore throat may have its origin in a variety of diseases, so joint inflammation and arthritis are associated with many different illnesses. Besides heredity, arthritic symptoms may have their source in a number of phenomena:
- They can be traumatic, having their origins in injuries—notably in athletes and industrial workers—especially if the injuries have been ignored (and injuries of the feet tend to be).
- Bacterial and viral infections can strike the joints. The same organisms that are present in pneumonia, gonorrhea, staph infections, and Lyme disease cause the inflammation.
- Arthritis can develop in conjunction with bowel disorders—such as colitis and ileitis—frequently in the joints of the ankles and toes. Such inflammatory bowel diseases seem distant from arthritis, but controlling them can relieve arthritic pain.
- Drugs—both prescription drugs and illegal street drugs—can induce arthritis.
- Arthritis can be part of a congenital autoimmune disease syndrome of undetermined origin. Recent research has suggested, for instance, that a defective gene may play a role in osteoarthritis.
Because arthritis can affect the structure and function of the feet, it is important to see a doctor of podiatric medicine if any of the following symptoms occur in the feet:
- Swelling in one or more joints
- Recurring pain or tenderness in any joint
- Redness or heat in a joint
- Limitation in motion of a joint
- Early morning stiffness
- Skin changes, including rashes and growths
Some forms of arthritis:
Osteoarthritis the most common form of arthritis. It is frequently called degenerative joint disease or “wear and tear” arthritis. Although it can be brought on suddenly by an injury, its onset is generally gradual; aging brings on a breakdown in cartilage, and pain becomes progressively more severe—although it can be relieved with rest. Dull, throbbing nighttime pain is characteristic, and it may be accompanied by muscle weakness or deterioration. Gait patterns (normal walking) may grow erratic. It is a particular problem for the feet when people are overweight, simply because there are so many joints in each foot. The additional weight contributes to the deterioration of cartilage and the development of bone spurs. Rheumatoid Arthritis (RA) is a major crippling disorder and perhaps the most serious form of arthritis. It is a complex, chronic inflammatory system of disease, often affecting more than a dozen smaller joints during the course of the disease, frequently in a symmetrical pattern—both ankles or the index fingers of both hands, for example. It is often accompanied by constitutional signs and symptoms—lengthy morning stiffness, fatigue, and weight loss—and it may affect various systems of the body—such as the eyes, lungs, heart, and nervous system. Women are three or four times more likely than men to suffer from RA, indicating a linkage to heredity. RA has a much more acute onset than osteoarthritis. It is characterized by alternating periods of remission—during which symptoms disappear—and exacerbation—marked by the return of inflammation, stiffness, and pain. Serious joint deformity and loss of motion frequently result from acute rheumatoid arthritis. However, the disease system has been known to be active for months or years, then to abate, sometimes permanently. Gout (gouty arthritis) is a condition caused by a build-up of the salts of uric acid—a normal byproduct of the diet—in the joints. A single big toe joint is commonly the locus, possibly because it is subject to so much pressure in walking. Attacks of gouty arthritis are extremely painful, perhaps more so than any other form of arthritis. Men are much more likely to be afflicted than premenopausal women, an indication that heredity may play a role. While a rich diet that contains red meat, rich sauces, and brandy is popularly associated with gout, there are other protein compounds in such foods as lentils and beans which may also play a role.
Different forms of arthritis affect the body in different ways; many have distinct systemic affects that are not common to other forms. Early diagnosis is important to effective treatment of any form. Destruction of cartilage is not reversible, and if the inflammation of arthritic disease isn’t treated, both cartilage and bone can be damaged, which makes the joints increasingly difficult to move. Most forms of arthritis cannot be cured, but they can be controlled or brought into remission; perhaps only five percent of the most serious cases—usually of rheumatoid arthritis—result in such severe crippling that walking aids or wheelchairs are required.
The objectives in the treatment of arthritis are controlling inflammation, preserving joint function (or restoring it if it has been lost) and curing the disease, if possible. Because the foot is a frequent early warning sign, the doctor of podiatric medicine is often the first physician to encounter some of the complaints—inflammation, pain, stiffness, excessive warmth, injuries. Even bunions can be manifestations of arthritis. Arthritis may be treated with several modalities. Patient education is important. Physical therapy and exercise may be indicated, accompanied by medication. In such a complex disease system, it’s no wonder that a wide variety of drugs have been used effectively to treat it; likewise, a given treatment may be very effective for one patient and almost no help at all to another. Aspirin is still the first-line drug of choice for most forms of arthritis and the benchmark against which the efficacy of a host of therapies is measured. The control of foot functions with shoe inserts—called orthoses—or with braces or specially prescribed shoes may be indicated. Surgical intervention is a last resort in arthritis, as it is with most disease conditions; the replacement of damaged joints with artificial joints is a possible surgical solution.
Bone spurs can develop almost anywhere on the foot. They are often a reaction to pressure or a result of an arthritic change near a joint. The term “bone spur” is often used to describe multiple types of foot problems. The term “calcium deposit” is sometimes used to describe a bone spur.
A heel spur is a horizontal projection of bone growth, extending forward from the bottom of the calcaneus (or heel bone). It can be quite painful and is often associated with plantar fasciitis. They can exist on one or both heels and take many years to develop. Even though this type of spur can be present for a long time, it may not be painful until it reaches a certain size. The diagnosis is made from a lateral view x-ray of the foot.
Bone spurs around the toes are often present around the bunion joint (1st metatarsophalangeal joint) or within the toes themselves. In the front part (the forefoot), spurs are often associated with a corn or callous. The medical terminology for a corn or callous is a hyperkeratosis. These types of spurs can often be felt through the skin and are also visible on x-ray. Toe bone spurs can be painful with shoe pressure. Treatment choices range from conservative to more aggressive surgical options. Initially, trimming the corn or callous on the skin can be effective. However, since the skin problem is actually caused by the underlying spur, bony smoothing of the spur usually cures this type of problem.
An irritation can develop on the top of the foot in the area of the arch. This area becomes painful when the shoe laces are tied or with pressure from a slip-on shoe. Examination of this area often shows redness of the skin and hardness beneath the skin. This is associated with a spur or overgrowth of bone in the midfoot area. The most common location is at the joint between the first metatarsal and the first cuneiform bones. The spur development is associated with arthritis in the area. The treatment of this problem often requires surgery. The excessive build-up of bone needs to be removed by smoothing or filing the enlargement.
More than half the women in America have bunions, a common deformity often blamed on wearing tight, narrow shoes. Bunions cause the base of your big toe (metatarsophalangeal joint) to enlarge and protrude. The skin over it may be red and tender. Wearing any type of shoe may be painful. This joint flexes with every step you take. The bigger your bunion gets, the more it hurts to walk. Bursitis may set in. Your big toe may angle toward your second toe or even move all the way under it. The skin on the bottom of your foot may become thicker and painful. Pressure from your big toe may force your second toe out of alignment, sometimes overlapping your third toe. If your bunion gets too severe, it may be difficult to walk. Your pain may become chronic, and you may develop arthritis. Most bunions can be treated without surgery by wearing protective pads to cushion the painful area—and of course, avoiding ill-fitting shoes in the first place. Bunion surgery (or bunionectomy) realigns the bone, ligaments, tendons, and nerves so your big toe can be brought back to its correct position. Many bunion surgeries are performed on a same-day basis (no hospital stay) using an ankle-block anesthesia. A long recovery is common and may include persistent swelling and stiffness.
Diabetes Mellitus is a chronic disease which afflicts about 16 million people in the United States, half of whom are unaware they have the disease. It is a metabolic disease characterized by elevated glucose (blood sugar), resulting from defects in secretion of the hormone insulin, defects which cause tissue to resist absorption of insulin, or both. Chronic elevation of blood sugar (hyperglycemia) is associated with long-term damage to the eyes, heart, kidneys, feet, nerves, and blood vessels. Symptoms of hyperglycemia may include frequent urination, excessive thirst, extreme hunger, unexplained weight loss, tingling or numbness of the feet or hands, blurred vision, slow-to-heal wounds, and susceptibility to certain infections. Those who have any of these symptoms and have not been tested for the disease should see a physician without delay. Individuals with diabetes are prone to many complications, both acute and chronic. About 15% of those with diabetes will develop an open wound (ulceration) on a foot during their lifetimes, and 20% of these ulcerations will lead to amputations. The annual incidence of non-traumatic lower extremity amputations among people with diabetes is about 54,000, according to the American Diabetes Association. Among African-Americans, the amputation rate is 1 1/2 to 2 1/2 times that of Caucasians, and Native Americans have even higher rates—three or four times that of Caucasians. Diabetes, once diagnosed, is present for life. Considerable research is focused on finding a cure, and much progress has been made in treatment and control of the disease. The majority of people with diabetes have type II diabetes. Type I (insulin-dependent diabetes mellitus), once referred to as juvenile (or juvenile-onset diabetes), afflicts 5-10% of people with diabetes. Type II (non-insulin-dependent diabetes mellitus), once known as adult-onset diabetes, afflicts the other 90-95%, many of whom use oral medication or injectable insulin. The vast majority of those people (80% or more) are overweight, many of them obese. Obesity itself can cause insulin resistance. The socioeconomic costs of diabetes are enormous. The dollar costs have been estimated at $92 billion annually, almost equally split between direct medical costs and indirect costs. Diabetes is the fourth leading cause of death by disease in the United States. Individuals with diabetes are two to four times as likely to experience heart disease and stroke. It is the leading cause of end-stage kidney disease and new cases of blindness among adults under 75. The trauma of amputation is particularly debilitating. It often ends working careers and restricts social life and the independence which mobility affords. For more than 50% of those who experience an amputation of one limb, the loss of another will occur within three to five years. The key to amputation prevention is early recognition and foot screening—at least annually—of at-risk individuals. Those individuals considered to be at high risk are those who exhibit one or more of six characteristics: (1) peripheral neuropathy, a nerve disorder generally characterized by loss of protective sensation and/or tingling and numbness in the feet; (2) vascular insufficiency, a circulatory disorder which inhibits blood flow to the extremities; (3) foot deformities, such as hammertoes; (4) stiff joints; (5) calluses on the soles of the feet; and (6) a history of open sores on the feet (ulcerations) or a previous lower extremity amputation.
The Role of the Podiatric Physician
The podiatrist is a foot care specialist with skills in recognition and treatment of diabetic foot conditions. Because diabetes is a systemic disease, affecting many organs of the body, ideal case management requires a team approach, involving the podiatrist as well as the family physician, several medical specialists, and a dietitian. Your podiatrist, as an integral part of the treatment team, has documented success in the prevention of amputations. It is one of the most serious conditions treated by podiatric physicians, whose training stresses salvage of the foot rather than amputation. A comprehensive approach to prevention of complications must include good glucose control, adherence to diet, an exercise program, proper medication and hygiene, and regular foot care. Those who follow the medical team’s advice have a good chance of preventing or delaying the complications of the disease and living normal lives. Furthermore, with such a regimen as groundwork, it is estimated that more than half of the lower extremity amputations among people with diabetes could be prevented.
For the person with diabetes who has not yet developed foot complications, there are warning signs which should be recognized and called to the attention of your podiatrist or your family physician. Warning signs include:
- Color changes of the skin
- Elevation of skin temperature
- Swelling of the foot or ankle
- Pain in the legs, either at rest or while walking
- Open sores, with or without drainage, that are slow to heal
- Ingrown and fungus-infected toenails
- Corns or calluses with bleeding within the skin
- Dry fissures (cracks) in the skin, especially around the heel
Ulceration is a common occurrence of the diabetic foot. Poorly fitted shoes, or something as seemingly trivial as a stocking seam, can create a wound that cannot be felt and may not immediately be seen by someone whose level of skin sensation has been minimized. Left unattended, such an ulcer can quickly become infected and lead to serious consequences.
Visit a Podiatric Physician Regularly
For the person with diabetes, a number of practices and precautions should be employed. Regular visits to one of our doctors for foot inspections—no less than annually and preferably more often—are recommended. The doctor may conduct specific diagnostic tests to assess the presence or progression of diabetes complications. Such tests may include assessments of circulation, using an instrument known as the Doppler for measurement of blood flow; vibration sense, using a tuning fork; sensation (light touch and deep pressure), using a plastic monofilament slightly thicker than a toothbrush bristle in what is called the Semmes-Weinstein test; and foot structure, using X-rays. Our doctors will reinforce self foot care, reminding patients of previously dispensed advice. There is a sizable list of “do’s and don’ts.” Shoes are at the top of the list. Poorly fitted shoes are involved in as many as half of the problems that lead to amputations. Foot shape and size may change over the years; peripheral neuropathy contributes to change. Everyone, particularly those with diabetes, should be fitted by experienced shoe fitters for every new pair of shoes. New shoes should be comfortable at the time they’re purchased—they should not require a break-in period—but it is a good idea to wear them for only short periods of time at first. Shoes should have leather or canvas uppers, fit both the length and width of the foot—leaving room for the toes to wiggle freely, and be cushioned and sturdy. Athletic footwear may fit the bill nicely. It’s a good idea to change shoes during the day to relieve pressure areas. Avoid high heels and shoes with pointed toes. Never wear shoes with open toes or heels, including sandals, especially those with straps between the first two toes. Shake shoes out and feel inside them for rough stitching or foreign objects, such as small pebbles. Never go without socks. Diabetics who have difficulty finding shoes that fit should ask their podiatrist to prescribe corrective shoes or refer them to a shoe specialist (a pedorthist.) For those eligible, Medicare provides coverage for extra-depth shoes (or specially molded shoes) and inserts for those with advanced cases of diabetes.
Wash feet daily, using mild soap and lukewarm water. Those with diabetes should always test bath water temperature with a thermometer or the elbow, since the feet may be unable to detect scalding temperatures. Dry feet carefully with a soft towel, especially between the toes, and dust them with talcum powder. If the skin is dry, use a small amount of moisturizing cream daily, but avoid getting it between the toes. Feet and toes should be inspected daily for cuts, bruises, sores, or other changes that are less obvious. If self-inspection is hampered by age or other factors, use a mirror or get the assistance of another person. Wear thick, soft socks; avoid mended socks or those with seams, which could cause blisters or other skin injuries. Never go barefoot, even inside your own home, and especially out of doors on unfamiliar terrain, such as the beach or grassy areas. Quit smoking. The consumption of alcohol should be moderated. Tobacco can contribute to circulatory problems and should be stopped. Exercise is important. Walk as frequently as possible; it’s the best overall conditioner for the feet. Observance of good dietary habits is important. People with diabetes are commonly overweight. This approximately doubles the risk of complications they may face. For cold feet at night, wear loose socks. Don’t use heating pads, hot water bottles, or other external heat sources. Don’t use garters or elastics to hold up stockings. Cut toenails straight across, or if in doubt, see a podiatrist. If you are diabetic and have Medicare, your Medicare benefits very often cover the treatment of your toenail problems. Never try to cut calluses with a razor blade—or anything else—without professional guidance, and never use commercial preparations to remove corns or warts, as they contain chemicals which can burn the skin.
Warts, which are caused by a virus, can be quite painful. They are frequently called plantar warts because they appear most often on the “plantar surface,” or sole of a foot. Children, especially teenagers, tend to be more susceptible to warts than adults; some people seem to be immune and never get them. Although adults also get plantar warts, it is relatively uncommon.
Identification of Problems
Most warts are harmless and benign, even though painful. They are often mistaken for corns, which are layers of dead skin that build up to protect an area which is being continuously irritated. Although they are not overly common, it is also possible that a variety of other more serious lesions, including carcinomas and melanomas, can be mistakenly identified as warts. Because of those identification problems, it is wise to consult a podiatrist about any suspicious growth or eruption on your feet. On the bottom of the feet, plantar warts tend to be hard and flat, rough-surfaced, with well-defined boundaries. They are generally fleshier when they are on the top of the feet or the toes. They are often gray or brown with a center that appears as one or more pinpoints of black.
Source of the Virus
The plantar wart is often contracted by walking barefooted on dirty surfaces or littered ground where the virus is lurking. The virus is sustained by warm, moist environments. If left untreated, warts can grow to an inch or more in diameter, and they can spread into clusters of several warts. Warts can last for varying lengths of time, which may average about 18 months. Occasionally, they spontaneously disappear after a short time. Perhaps just as frequently, they can recur in the same location.
Tips for Prevention
- Avoid walking barefooted, except on sandy beaches.
- Change shoes daily.
- Keep feet clean and dry.
- Check children’s feet periodically.
- Avoid direct contact with warts—from other people and from other parts of the body.
- Do not ignore skin growths or changes in your skin.
Self treatment is generally not advisable. Over-the-counter preparations contain chemicals, such as an acid, that destroy skin cells. It takes an expert to destroy abnormal wart cells without also destroying surrounding healthy tissue. Self treatment with such medications especially should be avoided by diabetics and those with circulation problems that cause insensitive feet. Never use them in the presence of an active infection.
A preferred treatment process is called electrocautery or hyfrecation. Using this method, the area of the foot is first numbed using a local anesthetic. When the area is completely numb, the wart is removed using an “electric needle.” The wart and the virus is treated. A small dressing is applied. There is very little pain after the treatment, and normal activities can usually begin within one day. The advantage of electrocautery is that it normally requires only one treatment. Topical skin treatments are also available in the office. Multiple office visits are required, and recurrence of the wart is more common.
What is a hammertoe?
Hammertoe is the name given to contracted, curly toes that have the shape of a hammer. These deformities can become quite uncomfortable. A hammertoe generally develops in one or two locations on a toe. A “corn” or redness can be located at the toe joint closest to the body of the foot or at the joint closest to the toenail. Sometimes the hammertoe that forms at the joint closest to the toenail is called a “mallet toe.” Treatment for a hammertoe at either location is similar. Frequently, the affected toe can be excessively long compared to the adjacent toe.
How do I get hammertoes?
Individuals get ‘hammering of digits’ mainly due to biomechanical abnormalities during walking. Although there is an increase in occurrence with those who have flat feet, contracted toes can show up in all types of feet. Hammertoes are also increasingly common with age. Poor shoes and genetics play a role in the development of these deformities.
How do I know if I have a hammertoe?
An early sign may be that you have more difficulty or pain wearing your shoes. The longer you have a hammertoe, the more rigid and contracted the deformity can become. Most people realize they have a problem when they develop painful calluses or blisters on the top of their toes. In severe cases, ulceration and infection can develop with hammertoes. Other signs of hammertoes include painful calluses under the balls of the feet, cramping, and weakness. Sometimes a painful area can develop between toes or on the side of the toe. This problem can be caused by a small bone spur.
How do I get rid of my hammertoes?
Most people start treating themselves because of painful corns on top of the toe. They try corn pads, corn removers, cushioning pads, pedicures, etc. The problem is a structural deformity within the toe, and thus, the above mentioned treatments are temporary and affect only the skin. The source of the problem is the contracture of the bone within the toe. In the drawing above, the toe on the left shows contracture of the toe bones with an overlying corn (or hyperkeratosis). The toe on the right shows a corrected hammertoe, with straight toe bones and no overlying corn. The use of larger shoes may initially help this problem, but this will not alter the underlying bone structure problem. Some milder forms of hammertoes can be improved with the use of foot orthotics. The most effective treatment is surgical correction.
What is surgery like?
The procedure can be done in the office or in an outpatient operating room using local anesthetic. The choice of the location of the surgery is dependent upon the length of time required for the surgery. Some patients prefer an outpatient operating room where sedation or anesthesia is available. If the procedure is done in the office, only local anesthesia is available. The surgery takes less than fifteen minutes per toe. Through a small incision, the bone deformity is reduced and the tendons are rebalanced around the contracted joint. About four sutures are required. The patient can walk immediately in a special post-operative shoe, using minimal or no pain medication.
What is it like after the surgery?
A moderate and gradually increasing amount of walking is allowed during the first two weeks. Minimal pain medication is usually required. The use of an ice pack and the elevation of the foot greatly decrease the swelling and discomfort. Two weeks after the surgery, the sutures are removed in the office, and usually wide or tennis shoes can be worn. Graphic, inter-operative photographs are available of a hammertoe surgery. Is surgery for you? If you’re tired of not fitting comfortably in your shoes, getting little relief from pads, and having corns that are sensitive and painful, you might consider a surgical option.
Heel pain is most often caused by Plantar Fasciitis, a condition that is sometimes also called heel spur syndrome when a spur is present. Heel pain may also be due to other causes, such as a stress fracture, tendonitis, arthritis, or nerve irritation. Because there are several potential causes, it is important to have heel pain properly diagnosed. The most common cause of heel or arch pain is caused by a painful stretching or micro-tearing of the plantar fascia. The plantar fascia is a fibrous or tendon-like structure that courses along the bottom of the foot, connecting the toes and calcaneus (or heel bone). During normal conditions, the fascia is flexible and strong. The fascia is partially responsible for the strength and flexibility of the arch and is required for normal walking. However, due to factors such as abnormal stress, excessive weight, age, or improper foot support, the fascia can become weakened, irritated, or inflamed. If the foot flattens excessively or becomes unstable at critical times during the gait cycle, the attachment of the plantar fascia onto the calcaneus may begin to stretch and pull away from the calcaneus. This painful condition is called plantar fasciitis. After many years, a heel spur may develop on the bottom of the calcaneus in addition to plantar fasciitis.
- Heel spurs are visible on a lateral view x-ray of the foot. X-rays sometimes reveal very large heel spurs that do not produce pain. It is not the bone, but rather the inflammation of the fascia attaching to the heel which causes discomfort.
- The onset can be gradual, yet many people report the pain during the first steps onto the floor in the morning for about ten minutes, or after extended resting periods during the day.
- You may experience plantar fasciitis after a sudden increase in activity, weight gain, or a recent change in footwear.
- The most common cause is abnormal or excessive internal motion of the foot.
- During resting or non-weight bearing periods, the plantar fascia shortens. When body weight is rapidly applied to the foot, the fascia must stretch and quickly lengthen, causing micro-tears in the fascia.
- Hypermobility (excessive internal motion) of the foot can induce future or coexisting problems involving the knee, hip, sacroiliac joint, or the low back region.
- Plantar fasciitis and calcaneal heel spurs usually can be controlled with conservative or non-surgical treatment when treated early.
- Although the development of plantar fasciitis takes a long time, we tend to pay attention to it when the pain has become significant. In general, the longer the pain has been present, the longer it will take to resolve.
- Although soft heel materials or soft arch supports appear to cushion the heel, they do not address the problem of foot support which initially caused the problem. Therefore, with soft heel cushions, the painful heel tends to return.
- An orthotic (a custom-made shoe insert) should be used to stabilize the foot.
- The role of the orthotic in these conditions is to prevent excess pronation and rapid excessive lengthening of the plantar fascia. The orthotic control limits the micro-tearing of the plantar fascia, thereby decreasing the pain.
- Wearing a night splint allows you to maintain an extended stretch of the plantar fascia while sleeping. This may help reduce the morning pain experienced by some patients.
- In addition to the use of foot orthotics, steroid (cortisone) injections, changing shoes, foot taping, and physical therapy are also helpful. Significant weight reduction is important.
- No matter what kind of treatment you undergo for plantar fasciitis, the underlying causes that led to this condition may remain. Therefore, you will need to continue with preventive measures. Wearing supportive shoes and using orthotic devices are the mainstay of long-term treatment for plantar fasciitis.
When the hard toenail presses excessively against the soft skin on the edges of the nail, there is usually pain. Typically, the nail presses on the skin for extended periods of time, and an infection (or paronychia) develops. This toenail infection is usually very painful, develops pus, and causes the end of the toe to become red and swollen. At least half of the ingrown toenails that we treat are caused by improper cutting of nails. Many people try to cut the corners of their toenails and either cut the skin or leave a small point of nail, which eventually grows into the flesh. This makes a simple problem more complicated. Nails should be cut flat across the top, and the corners should not be cut out. If you feel the need to cut the corners, it should be done only by a podiatrist. Most drug store topical “cures” for ingrown toenails are ineffective. They may soften the nail edge or decrease the soreness for a short period of time, but they do not cure the problem. The source of the problem is present under the cuticle at the nail root.
This photograph shows three degrees of severity of ingrown toenails. The big toe (hallux) has a severe ingrown toenail, where the nail is curved in almost a complete circle. The second toe has moderate severity. The third toe demonstrates a mild level of incurvation. Although it is very common for the skin around the nail to become infected (called a paronychia), here there is no infection present. The cure for an ingrown toenail usually involves numbing the toe with a local anesthetic, such as Lidocaine or Novocain. The toe will become completely numb, and there will be absolutely no pain during the procedure. An approximately 1/8-inch section of the nail plate will be removed from the painful corner. If an infection is present, it will be treated at the same time. The most important part of the procedure involves the removal of that 1/8-inch section of nail root, so the problem will not return. If the root is not treated, then the abnormally growing nail plate will grow back in the same place and cause a similar problem within a few months. After treatment, a small dressing is placed on the toe, and a regular shoe can be worn. Some people prefer to wear a wider shoe, tennis shoe, or an open sandal. The foot is soaked in warm water, and the dressing is changed at home the following day.
Fungal infection (or onychomycosis) is a common foot health problem. A majority of sufferers don’t seek treatment, perhaps not even recognizing the existence of a problem. One reason that people may ignore the infection is that it can be present for years without causing pain. Its prevalence rises sharply among older adults. People often consider the disease, characterized by a change in a toenail’s color, nothing more than a mere blemish—ugly and embarrassing. They apparently assume that since white markings or a darkening of the nail are minor occurrences, the change represents something minor as well, even when the blemish spreads. In many cases, however, that change in color is the start of an aggravating disease that ultimately could take many months to control. It is an infection underneath the surface of the nail, which can also penetrate the nail. This disease can frequently be accompanied by a secondary bacterial and/or yeast infection in or around the nail plate.
What is Nail Fungus?
Onychomycosis is an infection of the bed and plate underlying the surface of the nail caused by various types of fungi commonly found in the environment. Fungi are simple parasitic plant organisms—such as molds and mildew—that lack chlorophyll and therefore do not require sunlight for growth. A group of fungi called dermatophytes easily attack the nail, thriving on keratin, the nail’s protein substance. When the tiny organisms take hold, the nail may become thicker, yellowish-brown or darker in color, and have a foul smell. Debris may collect beneath the nail plate; white marks frequently appear on the nail plate, and the infection is capable of spreading to other toenails, the skin, or even fingernails. Other contributory factors may be a history of athlete’s foot, improper cleansing, anxiety, and excessive perspiration.
Because fungi are everywhere (including the skin), they can be present months before they find opportunities to strike—and before signs of infection appear. By following certain precautions, including proper hygiene and regular inspection of the feet and toes, chances of the problem occurring can be significantly reduced. Clean, dry feet resist disease. A strict regimen of washing the feet with soap and water is the best way to prevent an infection. Shoes, socks, or hosiery should be changed daily. Toenails should be clipped straight across so that the nail does not extend beyond the tip of the toe. It is very unlikely that a few exposures to an unclean environment will cause a fungal infection. Walking barefoot once or twice in a public shower will not generally spread the infection. Similarly, it is also unlikely that a single visit to a pedicurist will cause the infection. Lengthy exposure to a contaminated environment is often required in order to contract the fungal infection, although individuals may be more susceptible to fungal infections than others. Socks made of synthetic fiber tend to “wick” away moisture faster than cotton or wool socks, especially for those with more active lifestyles. This can be helpful in denying a hospitable environment for the fungi to grow in.
Artificial Nails and Polish
Moisture collecting underneath the surface of the toenail would ordinarily evaporate, passing through the porous structure of the nail. The presence of an artificial nail or polish impedes evaporation.
Depending on the nature and severity of your infection, treatment may vary. Most over-the-counter treatments are minimally effective at best, but almost none of them have produced a permanent treatment. The main reason for these poor results is that the fungal infection resides deep within the nail or nail bed, and the topical medications have great difficulty in penetrating to this depth. A fungus may work its way through the entire nail, penetrating both the nail plate and the nail bed.
Podiatric Medical Care
Your doctor can diagnose a fungal infection, culture the nail, and form a suitable treatment plan. Treatment may include topical or oral medication and debridement (removal of diseased nail matter and debris). Newer oral anti-fungal medications are the most effective treatment. The two most common oral medications are Lamisil and Sporanox. These medications are very similar in most respects and are about 75% effective. The medication is taken for three months. A total of approximately nine months is required for new, healthy nail growth. Current studies show that for a very small percentage of the population there are some unwanted side effects with an oral antifungal; however, these are usually reversible when medication is terminated. A topical medication is Penlac Lacquer. This prescription medication is generally less effective than the oral medications, and it is best used with a limited fungal infection. Penlac is applied approximately three times per week for several months. In some cases, surgical treatment may be required. Temporary removal of the infected nail can be performed. If there is no response to other treatment methods, permanent removal of a chronically painful nail may become necessary.