Common Conditions

Heel Pain

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Heel pain is a common occurrence and in most cases the pain is caused by some form of mechanical injury caused by small repetitive injuries that occur at a rate faster than the body can heal them.

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What is it?

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The heel is a specialised part of the body designed to absorb the impact of your body weight when walking, running or undertaking any other form of physical exertion or weight bearing exercise. When pain does develop, it can be very disabling, making every step a problem which in turn affects your overall posture

There are various types of heel pain and the more common ones include:

• Heel spurs (plantar fasciitis)

• Heel bursitis (subcalcaneal bursitis)

• Heel bumps

 

What causes the problem?

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Heel pain is a common occurrence and in most cases the pain is caused by some form of mechanical injury caused by small repetitive injuries that occur at a rate faster than the body can heal them. Heel pain can also be caused by lower back problems or inflammatory joint conditions. The following types of heel pain are not exhaustive but may help you appreciate the complexity of heel pain and why specialist advice can be helpful.

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Heel spurs (plantar fasciitis or fasciosis):

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This is the most common caused by inflammation to the fascia ‘band’ (similar to a ligament) which connects the heel bone to the base of the toes. This condition can be caused in various ways including extensive running/walking/standing for long periods of time, especially when you are not used to it as well as a sedentary lifestyle. In particular, a change of surface (eg. road to track), poor shoe support, being overweight, overuse or sudden stretching of your sole as well as a tight Achilles tendon can lead to this condition.

 

Heel bursitis (subcalcaneal bursitis):

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This is an inflammation of a bursa (a fluid filled fibrous sac) under the heel bone where the pain is typically more in the centre of the heel than that experienced with plantar fasciitis (heel spur) and significantly worsens during the day. This condition can be caused following a fall from a height on to the heel

 

Heel bumps:

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These are firm bumps on the back of the heel

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Tarsal tunnel syndrome:

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This can feel like a burning or tingling sensation under the heel within the arch of the foot with occasional loss of sensation on the bottom of the foot. This is caused by compression of the tibial nerve as it passes the inside of the ankle and tapping of the nerve will stimulate the symptoms known as Tinel’s sign.

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Chronic inflammation of the heel pad:

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This is caused by a heavy heel strike or sometimes a reduction in the thickness of the heel pad which can give rise to a dull ache in the heel which increases during the day.

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Stress fracture:

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Often caused following injuries such as falling from a height or landing on an uneven surface.

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Severs disease (calcaneal apophysitis, and osteochondrosis):

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This condition affects young children, usually between the ages of 8-12 and occurs when part of the heel bone suffers a temporary loss of blood supply. The bone dies only to reform when the blood supply is later restored and is also known as osteochondrosis where this condition occurs in active growing bones.

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Achilles Tendonosis:

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This condition occurs when the Achilles tendon is placed under more pressure than it can cope with and small tears develop along with inflammation and in some cases can lead to tendon rupture. These tears become a source of further injury which can lead to swelling within the tendon, hence the name ‘tendonosis’ (sometimes referred to in error as ‘tendonitis’).

 

Is it serious?

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Heel pain is a common condition and in most cases will diminish following some routine self-care measures but if the pain persists longer than three weeks, it is best to seek professional advice from someone who specialises in heel pain, such as a podiatrist or chiropodist. This is necessary as there are many types of heel pain, each with their own different causes and separate forms of treatment.

 

Who gets it?

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Heel pain can affect everyone, whatever your age, but those more commonly affected include those in middle age (over 40’s age group) as well as athletes.

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How do I know I have it?

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With heel spurs, there are no visible features on the heel but a deep localised painful spot found in or around the middle of the sole of the heel and is usually worse on standing after long periods of rest, particularly first thing in the morning. Although the name implies a spur of bone sticking out of the heel bone (heel spur syndrome), around 10% of the population have heel spurs without any pain whatsoever. With bursitis, pain can be felt at the back of the heel when the ankle joint is moved and there may be a swelling on both sides of the Achilles tendon. Or you may feel pain deep inside the heel when it makes contact with the ground. With heel bumps, these are usually caused by excessive shoe rubbing in the heel area.

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How do I prevent it?

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Follow the self-care measures below in the first instance.

What are the treatments?

If you experience heel pain, some simple self-care measures include:

• Avoid wearing ill-fitting or uncomfortable shoes

• Wear shoes with good heel cushioning and effective arch support

• Avoid walking or exercising on hard ground

• Rest regularly and try not to walk or run too fast

• Wear a raised heel (no more than 6-10 mm higher than normal)

• Losing weight if you are overweight

 

More specialist treatments include: Heel spurs (plantar fasciitis or fasciosis):

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Treatment can take many forms from resting your foot as much as possible, stretching exercises and deep heat therapy to steroid injections and even medication or surgery to release the tight tissue ‘band’. In some cases, padding and strapping is applied to alter the direction of stretch of the ligament to alleviate symptoms in the short-term. However, for the long-term, special insoles (orthoses) are prescribed to help the feet to function more effectively and help to make any possible recurrence less likely.

 

Heel bursitis (calcaneal bursitis):

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Medication and ultrasound can give relief but for the long-term, a shoe insert may be necessary. In addition, attention to the cause of any rubbing and appropriate padding and strapping will allow inflammation to settle.

 

Heel bumps:

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Adjustments to footwear is usually enough to make them comfortable, although a leather heel counter and wearing boots may help. In more serious, recurring cases, surgery may be necessary.

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Tarsal tunnel syndrome:

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Special shoe inserts can reduce the pressures on the nerve and may be appropriate for certain foot types whereas, on other occasions, local injections of medication to the area where the tibial nerve is inflamed may be necessary.

 

Chronic inflammation of the heel pad:

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A soft heel cushion can help this condition.

 

Stress fracture:

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If this is suspected, an X-ray is required to confirm final diagnosis and to determine the extent of the injury and a follow-on treatment plan.

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Severs disease (osteochondrosis):

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This condition is temporary and self-limiting but can be painful at the time.

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Achilles Tendonosis:

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Treatment involves special exercises that strengthen the tendon and increasing the height of the heel with an insole on a temporary basis.

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When should I see a podiatrist about it?

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If you experience any foot care issues which do not resolve themselves naturally or through routine foot care within three weeks, it is recommended to seek the help of a healthcare professional.

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Ingrowing Toenail

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An ingrowing toenail is one that pierces the flesh of the toe. It can feel as if you have a splinter, be extremely painful and inflamed or infected.

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What is it?

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An ingrowing toenail is one that pierces the flesh of the toe. It can feel as if you have a splinter, be extremely painful and inflamed or infected. In more severe cases, it can cause pus and bleeding. Ingrowing toenails most commonly affect the big toenail, but can affect the other toes too. Whereas a nail that is curling (involuted or convoluted) into the flesh, but isn’t actually piercing the skin, isn't an ingrowing toenail but can feel very painful and also appear red and inflamed as well.

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What causes it?

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There are many genetic factors that can make you prone to ingrowing toenails including your posture (the way you stand), your gait (the way you walk) and any foot deformity such as a bunion, hammer toes or excessive pronation of the feet (when your foot rolls inward excessively). Your nails may also have a natural tendency to splay or curl out instead of growing straight, encouraging your nail to grow outwards or inwards into the flesh. Tight footwear, hosiery and socks can also push your toe flesh onto the nail so that it pierces the skin. Also, if you sweat excessively or don’t rotate your footwear, this makes the skin moist and weak so that it is easily penetrated by the nail. If you have brittle nails with sharp edges or are in the habit of breaking off bits of nail that are sticking out, you are also more likely to get an ingrowing toenail. In addition, the wearing of support hose that is ill-fitting and squeezes the toes or likewise, the wearing of shoes with tight toe boxes. However, one of the most common causes is not cutting your toenails properly such as cutting nails too low in order to relieve the pressure and discomfort of an involuted nail. Less common is a fungal infection or in some cases particular types of medication, eg. isotretinoin.

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Is it serious?

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If left untreated, the infection can spread to the rest of the toe and foot and could lead to surgery. The quicker you treat it, the less painful the treatment.

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Who gets it?

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Active, sporty people are particularly prone, because they sweat more. Younger people are more likely to get it (as they pick their nails more, compared to older people who may not reach their toes!).

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How do I know I have it?

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The most common symptom is pain followed by some form of inflammation in the surrounding nail area. However, not everyone identifies an ingrowing toenail correctly. Sometimes, they have a curly nail which has a lot of debris (dirt or fluff) underneath it or a corn or callus down the side of the nail, which can be nearly as painful. However, if it’s a corn, the pain tends to be throbbing as opposed to the sharp pain you get with an ingrowing toenail. If this is the case, your podiatrist will remove the debris, and if necessary, thin the nail.

 

How do I prevent it?

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Firstly, learn to cut your nails properly. Nail cutters aren’t a good idea because the curved cutting edge can cut the flesh and nail scissors can slip. It’s best to use nail nippers (available from chemists) because they have a smaller cutting blade but a longer handle. Cut your nails following the shape of the toe and don’t cut too low at the edge or down the side. The corner of the nail should be visible above the skin. Also, cut them after a bath or shower when the nail is much softer. Good hygiene can go a long way to preventing ingrowing toenails. Avoid moist, soggy feet by letting rotating your footwear so each pair has a chance to dry out thoroughly. Avoid man-made materials (synthetics) and choose socks and shoes of natural fibre and which fit properly. Keep your feet clean and dry and in the summer and wear open-toed sandals to let air get to your toes as much as possible. If you have diabetes, are taking steroids or are on anti-coagulants, don’t attempt to cut your nails or remove the ingrowing spike of nail yourself.

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When should I see a podiatrist about it?

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Visit a podiatrist if you experience any:

• Persistent pain in your toe from the ingrowing nail

• Symptoms of infection, especially if you have Diabetes or a poor immune system

• Condition which affects the nerves and/or feeling in your foot.

If you experience any foot care issues which do not resolve themselves naturally or through routine foot care within three weeks, it is recommended to seek the help of a healthcare professional, always ensure that any practitioners you visit are registered with the Health Professionals Council (HCPC) and describe themselves as a podiatrist (or chiropodist).

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What are the treatments?

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Before you are seen by a podiatrist, you can relieve the discomfort by bathing your foot in a salty footbath which helps to prevent infection and reduces inflammation. Then apply a clean sterile dressing, especially if you have a discharge and rest your foot as much as possible.

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How a podiatrist will treat you will depend largely on the severity of your condition:

• For the most basic painful and irritable ingrowing toenail, the offending spike of nail will be removed and covered with an antiseptic dressing.

• For toes too painful to touch, a local anaesthetic will be injected before removing the offending portion of nail.

• For involuted nails, part of the nail that is curling into the flesh is removed and then the edges of the nail are filed to a smooth surface.

• For any bleeding or discharge from an infection, or even excessive healing flesh (hypergranulation tissue) around the nail, antibiotics will be prescribed to beat the infection as well as having the offending spike removed.

• For those particularly prone to ingrowing toenails from underlying problems such as poor gait, partial nail avulsion (PNA) may be recommended along with finding a more permanent solution to the underlying condition. This procedure is done under a local anaesthetic where 8-10% of the nail is removed (including the root) so that the nail permanently becomes slightly narrower. The chemical phenol cauterises the nail and prevents it regrowing in the corners. This is over 95% successful. You will, however, have to go back to your podiatrist for a number of re-dressings. After surgery, the overall appearance of the nail looks normal – to the extent that some people even forget which nail they’ve had done!

 

Verrucae

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Verrucae are plantar warts that commonly occur on the soles of the feet or around the toe area.

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What is it?

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Verrucae are plantar warts that commonly occur on the soles of the feet or around the toe area. They are caused by the Human Papilloma Virus (HPV) which is highly contagious through direct person to person contact. There are various forms of HPV which all relate to various parts of the human body.

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What causes the problem?

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The virus is thought to thrive in moist, damp environments such as swimming pools, changing room floors and communal shower areas. It is possible to contract verrucae simply by walking across the same floor area as someone with a verruca, especially if you have any small or invisible cuts or abrasions that make it easier for the virus to penetrate.

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Is it serious?

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Verrucae are harmless but can be uncomfortable and painful if they develop on a weight bearing part of the foot. In addition, callus can form over the top of the verruca increasing the discomfort in this area. There are also some strains of the virus that spread very quickly and can look unsightly.

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Who gets it?

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Verrucae are most commonly seen in children, teenagers and young adults, largely those who use communal changing rooms. It is possible to develop an immunity against the virus over time but most people remain susceptible, although some more than others.

 

How do I know I have it?

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The most common appearance is that of a small cauliflower type growth on the soles of your feet with tiny black dots. If when you pinch the area (like when you squeeze a spot) it is painful, you are likely to have a verruca. They can grow to half an inch in diameter and may spread into a cluster of small warts. If you are unsure, seek advice from your local pharmacist or visit a podiatrist.

 

How do I prevent it?

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To avoid catching verrucae, keep your feel in a regular healthy condition. Always dry them thoroughly after washing and if your feet are sweaty, treat them with surgical spirit; if they are dry, moisturise them with suitable creams and lotions. Other tips include wearing flip-flops in communal areas, not sharing towels, shoes and socks, and treating conditions such as Athlete’s Foot with specialist treatment from a pharmacist. If you do have a verruca and want to go swimming, special verrucae socks should be worn to avoid passing on the virus and can also be worn generally as a preventative measure

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What are the treatments?

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In the first instance, avoid touching or scratching it as it may spread into a cluster of warts. Instead, cover it up with a plaster and this may cure it. In many cases, evidence suggests that verrucae will disappear of their own accord within six months for children but longer for adults (up to two years). This is because the body’s immune system recognises the presence of the virus and fights the infection naturally but it can take many months for this to happen. If it is painless, no treatment may be required as some treatments can be painful especially for children and can cause side-effects. For painful and/or unsightly verrucae or ones which are spreading, you can self-treat using ointments and gels from your local pharmacist following the instructions carefully. Evidence suggests the most effective ones contain salicylic acid which when applied to the wart, helps to disintegrate the viral cells. Sometimes, merely by rubbing away the dry skin over a verrucae and applying a plaster helps to stimulate the body’s immune system to fight the infection. However, if your verruca becomes unusually painful or the surrounding skin area goes red, stop treatment immediately and see a podiatrist. This is because if the healthy tissue around a verruca is damaged, you could hamper further treatment Treatments provided by a podiatrist involve an assessment of your general well-being and foot health before deciding on a treatment plan. These may include:

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• Acid based treatments which are stronger than regular ‘over the counter’ (OTC) treatments from your local pharmacy

• Cryotherapy which involves freezing the verruca with liquid nitrogen or nitrous oxide gas.

• Electrosurgery which requires a local anaesthetic to be given

• Excisional surgery which is similar to the above

• Laser surgery, particularly for larger areas of verrucae

 

When should I see a podiatrist about it?

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If you are worried about your verrucae and/or self-treatment is not working and/or the verrucae appears to be getting larger or more painful, you should seek the help of a HCPC registered podiatrist. Additionally, if you have diabetes, poor circulation, are pregnant or any other condition affecting your feet (or your immune system), it is important never to treat verrucae yourself and visit a podiatrist instead.

 

FLAT FEET

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Having flat feet, or 'fallen arches', means that your feet have low or no arches and press almost completely flat against the ground.

The arch, or instep, is the middle part of the foot that's usually raised off the ground when you stand, while the rest of the foot remains flat on the ground. In young children, this arch isn't always visible because of the baby fat and soft tissue in their feet. It usually develops and appears as they get older. However, some people never really develop this arch. Sometimes, this is because they inherited flat feet from their parents.

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Are flat feet a problem?

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Flat feet are usually nothing to worry about. Many people with flat feet don't have any associated problems, so treatment isn't necessary.

However, flat feet can sometimes be associated with:

• pain in the feet, ankles, lower legs, knees, hips or lower back

• the feet rolling inwards too much (overpronation) – this can cause shoes to wear out quickly and lead to injuries

• an underlying problem with the bones, muscles or connective tissues in and around the feet (see below)

Treatment may be recommended if you have any of these problems.

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When to seek medical advice

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Consider seeing your GP/Podiatrist if you have flat feet and your:

• feet are painful, even when wearing supportive, well-fitting shoes

• shoes wear out very quickly

• feet appear to be getting flatter

• feet are weak, numb or stiff

 

Your GP will examine your foot and may be able to advise you about treatments that can help. If necessary, they may be able to refer you to a podiatrist (a specialist in foot problems) to discuss possible treatments.

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What causes flat feet?

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Many people simply inherit flat feet from their parents.

Occasionally, flat feet can be the result of:

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• the feet bones not forming properly in the womb

• loose connective tissue throughout the body, such as in Ehlers-Danlos syndrome or joint hypermobility syndrome

• a condition affecting the muscles and nerves, such as cerebral palsy, spina bifida or muscular dystrophy

• the connective tissue in the foot becoming stretched and inflamed – possibly as a result of overuse, unsupportive footwear, an injury, increasing age, obesity or rheumatoid arthritis

 

Treatments for flat feet

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Flat feet only need to be treated if you have an associated problem, such as pain, overpronation or an underlying health condition. Non-surgical treatments are often recommended first, although surgery may be needed in some cases.

 

Non-surgical treatments

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Your GP or podiatrist may recommend:

• wearing supportive shoes that fit well

• wearing specially made insoles (orthotics) inside your shoes to support your feet and stop them rolling inwards

• taking painkillers if you have any discomfort

• losing weight if you're overweight

• stretching the muscles and connective tissues in your lower legs to help stop your foot rolling over – you may be referred to a physio who can recommend some exercises to try

These treatments won't change the shape of the feet, but may help relieve some of the problems associated with flat feet. If these measures don't help, you may be referred to an orthopaedic surgeon to discuss whether surgery is an option.

 

Surgery

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Surgery is normally only considered if the treatments above haven't helped or you have an underlying problem that can be corrected with an operation, such as abnormally developed bones in the feet. The surgical procedure recommended for you will depend on the cause of your flat feet. For example, bones that are abnormally shaped or joined together may need to be straightened or separated, while flat feet caused by a problem with your connective tissues may be treated by lengthening or repairing the affected tissues. Your surgeon will talk to you about the operation you may need and what this involves

 

Prescription Orthoses

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What are Foot Orthotics?

Foot orthotics are shoe inserts designed to support, align or improve the function of the foot. There are many different types of orthotics, those recommended by podiatrists are prescription devices, custom made to suit your individual needs and biomechanics (the way your body moves)

Who Wears Orthotics?

People of all ages with a variety of foot and lower leg problems wear orthotics. Sports people are often prescribed orthotics by their podiatrists to help maximise their performance, as well as to address biomechanical problems. Anyone suffering from a chronic foot or lower limb condition that is limiting their mobility or independence may benefit from wearing orthotics.

When are Orthotics Used?

Your podiatrist may prescribe orthotics for your particular foot problem after a comprehensive assessment, taking into account your own biomechanics, footwear, occupational and lifestyle factors. Orthotics provide valuable long term solutions in the treatment and prevention of corns, calluses and ulceration by redistributing the pressure of the bodies weight on the feet. Orthotics can also help rehabilitation of acute and chronic foot conditions such as tendonitis, recurrent ankle sprains and stress fractures by providing consistent postural control.

 

A Personalised Approach

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If orthotics are recommended, your podiatrist will design a care plan. This plan will outline your diagnosis, the type of orthotic you have been prescribed, proposed footwear options, lifestyle changes that may be needed and additional treatment that may be required.

 

What Type of Orthotic

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Cushioning orthotics provide cushioning and padding under foot with shock absorption during walking. Pressure relief orthotics provide additional relief by redistributing the pressure of problem areas of the foot. Moulded cast or non cast orthotics offer similar features with a superior fit, whilst prefabricated orthotics provide relief can and are customised by your podiatrist. Functional foot (customised kinetic) orthotics offer all of those features, plus the benefit of postural realignment.

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