What Can You Do For Relief?
• Apply a commercial, nonmedicated bunion pad around the bony prominence.
• Wear shoes with a wide and deep toe box.
• If your bunion becomes inflamed and painful, apply ice packs several times a day to reduce swelling.
• Avoid high-heeled shoes over two inches tall.
• See your podiatric physician if pain persists.

Conservative Treatment For Bunion Pain
Treatment options vary with the type and severity of each bunion, although identifying the deformity early in its development is important in avoiding surgery. Podiatric medical attention should be sought at the first indication of pain or discomfort because, left untreated, bunions tend to get larger and more painful, making nonsurgical treatment less of an option.

The primary goal of most early treatment options is to relieve pressure on the bunion and halt the progression of the joint deformity. A podiatric physician may recommend these treatments:

Padding & Taping
Often the first step in a treatment plan, padding the bunion minimizes pain and allows the patient to continue a normal, active life. Taping helps keep the foot in a normal position, thus reducing stress and pain.

Medication
Anti-inflammatory drugs and cortisone injections are often prescribed to ease the acute pain and inflammations caused by joint deformities.

Physical Therapy
Often used to provide relief of the inflammation and from bunion pain. Ultrasound therapy is a popular technique for treating bunions and their associated soft tissue involvement.

Orthotics
Shoe inserts may be useful in controlling foot function and may reduce symptoms and prevent worsening of the deformity.

Surgical Options
When early treatments fail or the bunion progresses past the threshold for such options, podiatric surgery may become necessary to relieve pressure and repair the toe joint. Several surgical procedures are available to the podiatric physician. The surgery will remove the bony enlargement, restore the normal alignment of the toe joint, and relieve pain. A simple bunionectomy, in which only the bony prominence is removed, may be used for the less severe deformity. Severe bunions may require a more involved procedure, which includes cutting the bone and realigning the joint. Recuperation takes time, and swelling and some discomfort are common for several weeks following surgery. Pain, however, is easily managed with medications prescribed by your podiatric physician.

Bunion Tips
• Wear comfortable shoes that conform to the shape of your foot.
• Wear shoes with a wide and deep toe box.
• Always fit the larger foot and have your feet sized each time you purchase shoes.
• Apply a commercial, nonmedicated bunion pad around the bony prominence.
• If your bunion becomes inflamed and painful, apply ice packs several times a day to reduce swelling.
• Avoid high-heeled shoes over two inches tall.
• Seek professional podiatric evaluation and assistance with uncomfortable or noticeable bunions.

Your podiatric physician/surgeon has been trained specifically and extensively in the diagnosis and treatment of all manner of foot conditions. This training encompasses all of the intricately related systems and structures of the foot and lower leg including neurological, circulatory, skin, and the musculoskeletal system, which includes bones, joints, ligaments, tendons, muscles, and nerves.



Diabetic Wound Care
What is a Diabetic Foot Ulcer?
A diabetic foot ulcer is an open sore or wound that most commonly occurs on the bottom of the foot in approximately 15 percent of patients with diabetes. Of those who develop a foot ulcer, six percent will be hospitalized due to infection or other ulcer-related complication. Diabetes is the leading cause of nontraumatic lower extremity amputations in the United States, and approximately 14 to 24 percent of patients with diabetes who develop a foot ulcer have an amputation. Research, however, has shown that the development of a foot ulcer is preventable.

Who Can Get a Diabetic Foot Ulcer?
Anyone who has diabetes can develop a foot ulcer. Native Americans, African Americans, Hispanics and older men are more likely to develop ulcers. People who use insulin are at a higher risk of developing a foot ulcer, as are patients with diabetes-related kidney, eye, and heart disease. Being overweight and using alcohol and tobacco also play a role in the development of foot ulcers.

How do Diabetic Foot Ulcers Form?
Ulcers form due to a combination of factors, such as lack of feeling in the foot, poor circulation, foot deformities, irritation (such as friction or pressure), and trauma, as well as duration of diabetes. Patients who have diabetes for many years can develop neuropathy, a reduced or complete lack of feeling in the feet due to nerve damage caused by elevated blood glucose levels over time. The nerve damage often can occur without pain and one may not even be aware of the problem. Your podiatric physician can test feet for neuropathy with a simple and painless tool called a monofilament. Vascular disease can complicate a foot ulcer, reducing the body’s ability to heal and increasing the risk for an infection. Elevations in blood glucose can reduce the body’s ability to fight off a potential infection and also retard healing.

What is the Value of Treating a Diabetic Foot Ulcer?
Once an ulcer is noticed, seek podiatric medical care immediately. Foot ulcers in patients with diabetes should be treated for several reasons such as, reducing the risk of infection and amputation, improving function and quality of life, and reducing health care costs.

How Should a Diabetic Foot Ulcer be Treated?
The primary goal in the treatment of foot ulcers is to obtain healing as soon as possible. The faster the healing, the less chance for an infection.

There are several key factors in the appropriate treatment of a diabetic foot ulcer:
• Prevention of infection.
• Taking the pressure off the area, called “off-loading.”
• Removing dead skin and tissue, called “debridement.”
• Applying medication or dressings to the ulcer.
• Managing blood glucose and other health problems.

Not all ulcers are infected; however if your podiatric physician diagnoses an infection, a treatment program of antibiotics, wound care, and possibly hospitalization will be necessary.

There are several important factors to keep an ulcer from becoming infected:
• Keep blood glucose levels under tight control.
• Keep the ulcer clean and bandaged.
• Cleanse the wound daily, using a wound dressing or bandage.
• Do not walk barefoot.

For optimum healing, ulcers, especially those on the bottom of the foot, must be “off-loaded.” Patients may be asked to wear special footgear, or a brace, specialized castings, or use a wheelchair or crutches. These devices will reduce the pressure and irritation to the ulcer area and help to speed the healing process.

The science of wound care has advanced significantly over the past ten years. The old thought of “let the air get at it” is now known to be harmful to healing. We know that wounds and ulcers heal faster, with a lower risk of infection, if they are kept covered and moist. The use of full strength betadine, peroxide, whirlpools and soaking are not recommended, as this could lead to further complications.

Appropriate wound management includes the use of dressings and topically-applied medications. These range from normal saline to advanced products, such as growth factors, ulcer dressings, and skin substitutes that have been shown to be highly effective in healing foot ulcers.

For a wound to heal there must be adequate circulation to the ulcerated area. Your podiatrist can determine circulation levels with noninvasive tests.

Controlling Blood Glucose
Tightly controlling blood glucose is of the utmost importance during the treatment of a diabetic foot ulcer. Working closely with a medical doctor or endocrinologist to accomplish this will enhance healing and reduce the risk of complications.

Surgical Options
A majority of noninfected foot ulcers are treated without surgery; however, when this fails, surgical management may be appropriate. Examples of surgical care to remove pressure on the affected area include shaving or excision of bone(s) and the correction of various deformities, such as hammertoes, bunions, or bony “bumps.”

Healing Factors
Healing time depends on a variety of factors, such as wound size and location, pressure on the wound from walking or standing, swelling, circulation, blood glucose levels, wound care, and what is being applied to the wound. Healing may occur within weeks or require several months.

How Can a Foot Ulcer be Prevented?
The best way to treat a diabetic foot ulcer is to prevent its development in the first place. Recommended guidelines include seeing a podiatrist on a regular basis. He or she can determine if you are at high risk for developing a foot ulcer and implement strategies for prevention.

You are at high risk if you:
• have neuropathy,
• have poor circulation,
• have a foot deformity (i.e. bunion, hammer toe),
• wear inappropriate shoes,
• have uncontrolled blood sugar.

Reducing additional risk factors, such as smoking, drinking alcohol, high cholesterol, and elevated blood glucose are important in the prevention and treatment of a diabetic foot ulcer. Wearing the appropriate shoes and socks will go a long way in reducing risks. Your podiatric physician can provide guidance in selecting the proper shoes.

Learning how to check your feet is crucial in noticing a potential problem as early as possible. Inspect your feet every day—especially between the toes and the sole—for cuts, bruises, cracks, blisters, redness, ulcers, and any sign of abnormality. Each time you visit a health care provider, remove your shoes and socks so your feet can be examined. Any problems that are discovered should be reported to your podiatrist as soon as possible, no matter how “simple” it may seem to you.

The key to successful wound healing is regular podiatric medical care to ensure the following “gold standard” of care:
• lowering blood sugar
• appropriate debridement of wounds
• treating any infection
• reducing friction and pressure
• restoring adequate blood flow

The old saying, “an ounce of prevention is worth a pound of cure” was never as true as it is when preventing a diabetic foot ulcer.



Foot and Ankle Injuries
Immediate Treatment
Foot and ankle emergencies happen every day. Broken bones, dislocations, sprains, contusions, infections, and other serious injuries can occur at any time. Early attention is vitally important. Whenever you sustain a foot or ankle injury, you should seek immediate treatment from a podiatric physician.

This advice is universal, even though there are lots of myths about foot and ankle injuries. Some of them follow:

Myths
• "It can't be broken, because I can move it." False; this widespread idea has kept many fractures from receiving proper treatment. The truth is that often you can walk with certain kinds of fractures. Some common examples: Breaks in the smaller, outer bone of the lower leg, small chip fractures of either the foot or ankle bones, and the often neglected fracture of the toe.

• "If you break a toe, immediate care isn't necessary." False; a toe fracture needs prompt attention. If X-rays reveal it to be a simple, displaced fracture, care by your podiatric physician usually can produce rapid relief. However, X-rays might identify a displaced or angulated break. In such cases, prompt realignment of the fracture by your podiatric physician will help prevent improper or incomplete healing. Often, fractures do not show up in the initial X-ray. It may be necessary to X-ray the foot a second time, seven to ten days later. Many patients develop post-fracture deformity of a toe, which in turn results in a deformed toe with a painful corn. A good general rule is: Seek prompt treatment for injury to foot bones.

• "If you have a foot or ankle injury, soak it in hot water immediately." False; don’t use heat or hot water on an area suspect for fracture, sprain, or dislocation. Heat promotes blood flow, causing greater swelling. More swelling means greater pressure on the nerves, which causes more pain. An ice bag wrapped in a towel has a contracting effect on blood vessels, produces a numbing sensation, and prevents swelling and pain. Your podiatric physician may make additional recommendations upon examination.

• "Applying an elastic bandage to a severely sprained ankle is adequate treatment." False; ankle sprains often mean torn or severely overstretched ligaments, and they should receive immediate care. X-ray examination, immobilization by casting or splinting, and physiotherapy to ensure a normal recovery all may be indicated. Surgery may even be necessary.

• "The terms 'fracture,' 'break,' and 'crack' are all different." False; all of those words are proper in describing a broken bone.

Before Seeing the Podiatrist
If an injury or accident does occur, the steps you can take to help yourself until you can reach your podiatric physician are easy to remember if you can recall the word “rice.”

• Rest. Restrict your activity and get off your foot/ankle.
• Ice. Gently place a plastic bag of ice wrapped in a towel on the injured area in a 20-minute-on, 40-minute-off cycle.
• Compression. Lightly wrap an Ace bandage around the area, taking care not to pull it too tight.
• Elevation. To reduce swelling and pain, sit in a position that allows you to elevate the foot/ankle higher than your waist.
• For bleeding cuts, cleanse well, apply pressure with gauze or a towel, and cover with a clean dressing. See your podiatrist as soon as possible. It’s best not to use any medication on the cut before you see the doctor.
• Leave blisters unopened if they are not painful or in a weight-bearing area of the foot. A compression bandage placed over a blister can provide relief.
• Foreign materials in the skin—such as slivers, splinters, and sand—can be removed carefully, but a deep foreign object, such as broken glass or a needle, must be removed professionally.
• Treatment for an abrasion is similar to that of a burn, since raw skin is exposed to the air and can easily become infected. It is important to remove all foreign particles with thorough cleaning. Sterile bandages should be applied, along with an antibiotic cream or ointment.

Prevention
• Wear the correct shoes for your particular activity.
• Wear hiking shoes or boots in rough terrain.
• Don't continue to wear any sports shoe if it is worn unevenly.
• The toe box in “steel-toe” shoes should be deep enough to accommodate your toes comfortably.
• Always wear hard-top shoes when operating a lawn mower or other grass-cutting equipment.
• Don’t walk barefoot on paved streets or sidewalks.
• Watch out for slippery floors at home and at work. Clean up obviously dangerous spills immediately.
• If you get up during the night, turn on a light. Many fractured toes and other foot injuries occur while attempting to find one’s way in the dark.



Forefoot Surgery
When is Foot Surgery Necessary?
Many foot problems do not respond to “conservative” management. Your podiatric physician can determine when surgical intervention may be helpful. Often when pain or deformity persists, surgery may be appropriate to alleviate discomfort or to restore the function of your foot.

Bunions
A common deformity of the foot, a bunion is an enlargement of the bone and tissue around the joint of the big toe. Heredity frequently plays a role in the occurrence of bunions, as it does in other foot conditions. When symptomatic, the area may become red, swollen, and inflamed, making shoe gear and walking uncomfortable and difficult. If conservative care fails to reduce these symptoms, surgical intervention may be warranted. Your podiatric physician will determine the type of surgical procedure best suited for your deformity, based on a variety of information which may include X-rays and gait examination.

Hammertoes
A hammertoe deformity is a contracture of the toe(s), frequently caused by an imbalance in the tendon or joints of the toes. Due to the “buckling” effect of the toe(s), hammertoes may become painful secondary to footwear irritation and pressure. Corn and callus formation may occur as a hammertoe becomes more rigid over time, making it difficult to wear shoes. Your podiatric physician may suggest correction of this deformity through a surgical procedure to realign the toe(s).

Neuroma
An irritation of a nerve may produce a neuroma, which is a benign enlargement of a nerve segment, commonly found between the third and fourth toes. Several factors may contribute to the formation of a neuroma. Trauma, arthritis, high-heeled shoes, or an abnormal bone structure are just some of the conditions that may cause a neuroma. Symptoms such as burning or tingling in the ball of the foot or in the adjacent toes and even numbness are commonly seen with this condition. Other symptoms include swelling between the toes and pain in the ball of the foot when weight is placed on it.

Those suffering from the condition often find relief by stopping their walk, taking off their shoe, and rubbing the affected area. At times, the patient will describe the pain as similar to having a stone in his or her shoe. Your podiatric physician will suggest a treatment plan. If conservative treatment does not relieve the symptoms, then your podiatric physician will decide, on the basis of your symptoms, whether surgical treatment is appropriate.

Bunionette (Tailor’s Bunion)
A protuberance of bone at the outside of the foot behind the fifth (small) toe, the bunionette or “small bunion” is caused by a variety of conditions including heredity, faulty biomechanics (the way one walks) or trauma, to name a few. Pain is often associated with this deformity, making shoes very uncomfortable and at times even walking becomes difficult. If severe and conservative treatments fail to improve the symptoms of this condition, surgical repair may be suggested. Your podiatric physician will develop a surgical plan specific to the condition present.

Bone spurs
A bone spur is an overgrowth of bone as a result of pressure, trauma, or reactive stress of a ligament or tendon. This growth can cause pain and even restrict motion of a joint, depending on its location and size. Spurs may also be located under the toenail plate, causing nail deformity and pain. Surgical treatment and procedure is based on the size, location, and symptoms of the bone spur. Your podiatric physician will determine the surgical method best suited for your condition.

Preoperative Testing and Care
As with anyone facing any surgical procedure, those undergoing foot and ankle surgery require specific tests or examinations before surgery to improve a successful surgical outcome. Prior to surgery, the podiatric physician will review your medical history and medical conditions. Specific diseases, illnesses, allergies, and current medications need to be evaluated. Other tests that help evaluate your health status may be ordered by the podiatric physician, such as blood studies, urinalysis, EKG, X-rays, a blood flow study (to better evaluate the circulatory status of the foot/legs), and a biomechanical examination. A consultation with another medical specialist may be advised by a podiatric physician, depending on your test results or a specific medical condition.

Postoperative Care
The type of foot surgery performed determines the length and kind of aftercare required to assure that your recovery from surgery is rapid and uneventful. The basics of all postoperative care involve to some degree each of the following: rest, ice, compression, and elevation. Bandages, splints, surgical shoes, casts, crutches, or canes may be necessary to improve and ensure a safe recovery after foot surgery. A satisfactory recovery can be hastened by carefully following instructions from your podiatric physician.

Your Feet Aren’t Supposed to Hurt
Remember that foot pain is not normal. Healthy, pain-free feet are a key to your independence. At the first sign of pain, or any noticeable changes in your feet, seek professional podiatric medical care. Your feet must last a lifetime, and most Americans log an amazing 75,000 miles on their feet by the time they reach age 50. Regular foot care can make sure your feet are up to the task. With proper detection, intervention, and care, most foot and ankle problems can be lessened or prevented. Remember that the advice provided in this pamphlet should not be used as a substitute for a consultation or evaluation by a podiatric physician.



Hammertoes
What is a Hammertoe?
A hammertoe is a contracture—or bending—of the toe at the first joint of the digit, called the proximal interphalangeal joint. This bending causes the toe to appear like an upside-down V when looked at from the side. Any toe can be involved, but the condition usually affects the second through fifth toes, known as the lesser digits. Hammertoes are more common to females than males.

There are two different types:

Flexible Hammertoes:
These are less serious because they can be diagnosed and treated while still in the developmental stage. They are called flexible hammertoes because they are still moveable at the joint.

Rigid Hammertoes:
This variety is more developed and more serious than the flexible condition. Rigid hammertoes can be seen in patients with severe arthritis, for example, or in patients who wait too long to seek professional treatment. The tendons in a rigid hammertoe have become tight, and the joint misaligned and immobile, making surgery the usual course of treatment.

Symptoms:
• Pain upon pressure at the top of the bent toe from footwear.
• The formation of corns on the top of the joint.
• Redness and swelling at the joint contracture.
• Restricted or painful motion of the toe joint.
• Pain in the ball of the foot at the base of the affected toe.

How Do You Get a Hammertoe?
A hammertoe is formed due an abnormal balance of the muscles in the toes. This abnormal balance causes increased pressures on the tendons and joints of the toe, leading to its contracture. Heredity and trauma can also lead to the formation of a hammertoe. Arthritis is another factor, because the balance around the toe in people with arthritis is so disrupted that a hammertoe may develop. Wearing shoes that are too tight and cause the toes to squeeze can also be a cause for a hammertoe to form.

What Can You Do for Relief?
• Apply a commercial, nonmedicated hammertoe pad around the bony prominence of the hammertoe. This will decrease pressure on the area.
• Wear a shoe with a deep toe box.
• If the hammertoe becomes inflamed and painful, apply ice packs several times a day to reduce swelling.
• Avoid heels more than two inches tall.
• A loose-fitting pair of shoes can also help protect the foot while reducing pressure on the affected toe, making walking a little easier until a visit to your podiatrist can be arranged. It is important to remember that, while this treatment will make the hammertoe feel better, it does not cure the condition. A trip to the podiatric physician’s office will be necessary to repair the toe to allow for normal foot function.
• Avoid wearing shoes that are too tight or narrow. Children should have their shoes properly fitted on a regular basis, as their feet can often outgrow their shoes rapidly.
• See your podiatric physician if pain persists.

What Will Your Podiatrist Do to Treat a Hammertoe?
The treatment options vary with the type and severity of each hammertoe, although identifying the deformity early in its development is important to avoid surgery. Podiatric medical attention should be sought at the first indication of pain and discomfort because, if left untreated, hammertoes tend to become rigid, making a nonsurgical treatment less of an option. Your podiatric physician will examine and X-ray the affected area and recommend a treatment plan specific to your condition.

Padding and Taping:
Often this is the first step in a treatment plan. Padding the hammertoe prominence minimizes pain and allows the patient to continue a normal, active life. Taping may change the imbalance around the toes and thus relieve the stress and pain.

Medication:
Anti-inflammatory drugs and cortisone injections can be prescribed to ease acute pain and inflammation caused by the joint deformity.

Orthotic Devices:
Custom shoe inserts made by your podiatrist may be useful in controlling foot function. An orthotic device may reduce symptoms and prevent the worsening of the hammertoe deformity.

Surgical Options:
Several surgical procedures are available to the podiatric physician. For less severe deformities, the surgery will remove the bony prominence and restore normal alignment of the toe joint, thus relieving pain.

Severe hammertoes, which are not fully reducible, may require more complex surgical procedures. Recuperation takes time, and some swelling and discomfort are common for several weeks following surgery. Any pain, however, is easily managed with medications prescribed by your podiatric physician.

Your Feet Aren’t Supposed to Hurt
Remember that foot pain is not normal. Healthy, pain-free feet are a key to your independence. At the first sign of pain, or any noticeable changes in your feet, seek professional podiatric medical care. Your feet must last a lifetime, and most Americans log an amazing 75,000 miles on their feet by the time they reach age 50. Regular foot care can make sure your feet are up to the task. With proper detection, intervention, and care, most foot and ankle problems can be lessened or prevented. Remember that the advice provided in this pamphlet should not be used as a substitute for a consultation or evaluation by a podiatric physician.

Hammertoe Tips
• Apply a commercial, nonmedicated hammertoe pad around the bony prominence of the hammertoe. This will decrease pressure on the area.
• Wear a shoe with a deep toe box.
• If the hammertoe becomes inflamed and painful, apply ice packs several times a day to reduce swelling.
•Avoid heels more than two inches tall.
• A loose-fitting pair of shoes can also help protect the foot while reducing pressure on the affected toe, making walking a little easier until a visit to your podiatrist can be arranged. It is important to remember that, while this treatment will make the hammertoe feel better, it does not cure the condition. A trip to the podiatric physician’s office will be necessary to repair the toe to allow for normal foot function.
• Avoid wearing shoes that are too tight or narrow. Children should have their shoes properly fitted on a regular basis, as their feet can often outgrow their shoes rapidly.
• See your podiatric physician if pain persists.

Your podiatric physician/surgeon has been trained specifically and extensively in the diagnosis and treatment of all manner of foot conditions. This training encompasses all of the intricately related systems and structures of the foot and lower leg including neurological, circulatory, skin, and the musculoskeletal system, which includes bones, joints, ligaments, tendons, muscles, and nerves.



Heel Pain
Heel Pain Has Many Causes
In our pursuit of healthy bodies, pain can be an enemy. In some instances, however, it is of biological benefit. Pain that occurs right after an injury or early in an illness may play a protective role, often warning us about the damage we've suffered. When we sprain an ankle, for example, the pain warns us that the ligament and soft tissues may be frayed and bruised, and that further activity may cause additional injury. Pain, such as may occur in our heels, also alerts us to seek medical attention. This alert is of utmost importance because of the many afflictions that contribute to heel pain.

Heel Pain
Heel pain is generally the result of faulty biomechanics (walking gait abnormalities) that place too much stress on the heel bone and the soft tissues that attach to it. The stress may also result from injury, or a bruise incurred while walking, running, or jumping on hard surfaces; wearing poorly constructed footwear; or being overweight.

The heel bone is the largest of the 26 bones in the human foot, which also has 33 joints and a network of more than 100 tendons, muscles, and ligaments. Like all bones, it is subject to outside influences that can affect its integrity and its ability to keep us on our feet. Heel pain, sometimes disabling, can occur in the front, back, or bottom of the heel.

Heel Spurs
A common cause of heel pain is the heel spur, a bony growth on the underside of the heel bone. The spur, visible by X-ray, appears as a protrusion that can extend forward as much as half an inch. When there is no indication of bone enlargement, the condition is sometimes referred to as "heel spur syndrome."

Heel spurs result from strain on the muscles and ligaments of the foot, by stretching of the long band of tissue that connects the heel and the ball of the foot, and by repeated tearing away of the lining or membrane that covers the heel bone. These conditions may result from biomechanical imbalance, running or jogging, improperly fitted or excessively worn shoes, or obesity.

Plantar Fasciitis
Both heel pain and heel spurs are frequently associated with an inflammation of the band of fibrous connective tissue (fascia) running along the bottom (plantar surface) of the foot, from the heel to the ball of the foot. The inflammation is called plantar fasciitis. It is common among athletes who run and jump a lot, and it can be quite painful.

The condition occurs when the plantar fascia is strained over time beyond its normal extension, causing the soft tissue fibers of the fascia to tear or stretch at points along its length; this leads to inflammation, pain, and possibly the growth of a bone spur where it attaches to the heel bone. The inflammation may be aggravated by shoes that lack appropriate support, especially in the arch area, and by the chronic irritation that sometimes accompanies an athletic lifestyle.

Resting provides only temporary relief. When you resume walking, particularly after a night's sleep, you may experience a sudden elongation of the fascia band, which stretches and pulls on the heel. As you walk, the heel pain may lessen or even disappear, but that may be just a false sense of relief. The pain often returns after prolonged rest or extensive walking.

Excessive Pronation
Heel pain sometimes results from excessive pronation. Pronation is the normal flexible motion and flattening of the arch of the foot that allows it to adapt to ground surfaces and absorb shock in the normal walking pattern. As you walk, the heel contacts the ground first; the weight shifts first to the outside of the foot, then moves toward the big toe. The arch rises, the foot generally rolls upward and outward, becoming rigid and stable in order to lift the body and move it forward. Excessive pronation—excessive inward motion—can create an abnormal amount of stretching and pulling on the ligaments and tendons attaching to the bottom back of the heel bone. Excessive pronation may also contribute to injury to the hip, knee, and lower back.

Disease and Heel Pain
Some general health conditions can also bring about heel pain.

• Rheumatoid arthritis and other forms of arthritis, including gout, which usually manifests itself in the big toe joint, can cause heel discomfort in some cases.

• Heel pain may also be the result of an inflamed bursa (bursitis), a small, irritated sack of fluid; a neuroma (a nerve growth); or other soft-tissue growth. Such heel pain may be associated with a heel spur or may mimic the pain of a heel spur.

• Haglund's deformity ("pump bump") is a bone enlargement at the back of the heel bone, in the area where the achilles tendon attaches to the bone. This sometimes painful deformity generally is the result of bursitis caused by pressure against the shoe and can be aggravated by the height or stitching of a heel counter of a particular shoe.

• Pain at the back of the heel is associated with inflammation of the achilles tendon as it runs behind the ankle and inserts on the back surface of the heel bone. The inflammation is called achilles tendinitis. It is common among people who run and walk a lot and have tight tendons. The condition occurs when the tendon is strained over time, causing the fibers to tear or stretch along its length, or at its insertion on to the heel bone. This leads to inflammation, pain, and the possible growth of a bone spur on the back of the heel bone. The inflammation is aggravated by the chronic irritation that sometimes accompanies an active lifestyle and certain activities that strain an already tight tendon.

• Bone bruises are common heel injuries. A bone bruise or contusion is an inflammation of the tissues that cover the heel bone. A bone bruise is a sharply painful injury caused by the direct impact of a hard object or surface on the foot.

Stress fractures of the heel bone also can occur, although infrequently.

Children’s Heel Pain
Heel pain can also occur in children, most commonly between ages 8 and 13, as they become increasingly active in sports activity in and out of school. This physical activity, particularly jumping, inflames the growth centers of the heels; the more active the child, the more likely the condition will occur. When the bones mature, the problems disappear and are not likely to recur. If heel pain occurs in this age group, podiatric care is necessary to protect the growing bone and to provide pain relief. Other good news is that heel spurs do not often develop in children.

Prevention
A variety of steps can be taken to avoid heel pain and accompanying afflictions:
• Wear shoes that fit well—front, back, and sides—and have shock-absorbent soles, rigid shanks, and supportive heel counters.
• Wear the proper shoes for each activity.
• Do not wear shoes with excessive wear on heels or soles.
• Prepare properly before exercising. Warm up and do stretching exercises before and after running.
• Pace yourself when you participate in athletic activities.
• Don’t underestimate your body's need for rest and good nutrition.
• If obese, lose weight.

Podiatric Medical Care
If pain and other symptoms of inflammation—redness, swelling, heat—persist, you should limit normal daily activities and contact a doctor of podiatric medicine. The podiatric physician will examine the area and may perform diagnostic X-rays to rule out problems of the bone. Early treatment might involve oral or injectable anti-inflammatory medication, exercise and shoe recommendations, taping or strapping, or use of shoe inserts or orthotic devices. Taping or strapping supports the foot, placing stressed muscles and tendons in a physiologically restful state. Physical therapy may be used in conjunction with such treatments.

A functional orthotic device may be prescribed for correcting biomechanical imbalance, controlling excessive pronation, and supporting of the ligaments and tendons attaching to the heel bone. It will effectively treat the majority of heel and arch pain without the need for surgery. Only a relatively few cases of heel pain require more advanced treatments or surgery. If surgery is necessary, it may involve the release of the plantar fascia, removal of a spur, removal of a bursa, or removal of a neuroma or other soft-tissue growth.

Heel Pain Tips
• If you have experienced painful heels try wearing your shoes around your house in the evening. Don't wear slippers or socks or go barefoot. You may also try gentle calf stretches for 20 to 30 seconds on each leg. This is best done barefoot, leaning forward towards a wall with one foot forward and one foot back.
• If the pain persists longer than one month, you should visit a podiatrist for evaluation and treatment. Your feet should not hurt, and professional podiatric care may be required to help relieve your discomfort.
• If you have not exercised in a long time, consult your podiatric physician before starting a new exercise program.
• Begin an exercise program slowly. Don't go too far or too fast.
• Purchase and maintain good shoes and replace them regularly.
• Stretch each foot and achilles tendon before and after exercise.
• Avoid uneven walking surfaces or stepping on rocks as much as possible.
• Avoid going barefoot on hard surfaces.
• Vary the incline on a treadmill during exercise. Nobody walks uphill all the time.
• If it hurts, stop. Don't try to "work through the pain."

Your podiatric physician/surgeon has been trained specifically and extensively in the diagnosis and treatment of all manner of foot conditions. This training encompasses all of the intricately related systems and structures of the foot and lower leg including neurological, circulatory, skin, and the musculoskeletal system, which includes bones, joints, ligaments, tendons, muscles, and nerves.



Nail Problems
Barometers of Health
Toenails often serve as barometers of our health; they are diagnostic tools providing the initial signal of the presence or onset of systemic diseases. For example, the pitting of nails and increased nail thickness can be manifestations of psoriasis. Concavity—nails that are rounded inward instead of outward—can foretell iron deficiency anemia. Some nail problems can be conservatively treated with topical or oral medications while others require partial or total removal of the nail. Any discoloration or infection on or about the nail should be evaluated by a podiatric physician.

Nail Ailments

Ingrown Toenails
Ingrown nails, the most common nail impairment, are nails whose corners or sides dig painfully into the soft tissue of nail grooves, often leading to irritation, redness, and swelling. Usually, toenails grow straight out. Sometimes, however, one or both corners or sides curve and grow into the flesh. The big toe is usually the victim of this condition but other toes can also become affected.

Ingrown toenails may be caused by:
• Improperly trimmed nails (Trim them straight across, not longer than the tip of the toes. Do not round off corners. Use toenail clippers.)
• Heredity
• Shoe pressure; crowding of toes
• Repeated trauma to the feet from normal activities

If you suspect an infection due to an ingrown toenail, immerse the foot in a warm salt water soak, or a basin of soapy water, then apply an antiseptic and bandage the area.

People with diabetes, peripheral vascular disease, or other circulatory disorders must avoid any form of self treatment and seek podiatric medical care as soon as possible.

Other "do-it-yourself" treatments, including any attempt to remove any part of an infected nail or the use of over-the-counter medications, should be avoided. Nail problems should be evaluated and treated by your podiatrist, who can diagnose the ailment, and then prescribe medication or another appropriate treatment.

A podiatrist will resect the ingrown portion of the nail and may prescribe a topical or oral medication to treat the infection. If ingrown nails are a chronic problem, your podiatrist can perform a procedure to permanently prevent ingrown nails. The corner of the nail that ingrows, along with the matrix or root of that piece of nail, are removed by use of a chemical, a laser, or by other methods.

Fungal Nails
Fungal infection of the nail, or onychomycosis, is often ignored because the infection can be present for years without causing any pain. The disease is characterized by a progressive change in a toenail's quality and color, which is often ugly and embarrassing. In reality, the condition is an infection underneath the surface of the nail caused by fungi. When the tiny organisms take hold, the nail often becomes darker in color and foul smelling. 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 the fingernails. If ignored, the infection can spread and possibly impair one's ability to work or even walk. This happens because the resulting thicker nails are difficult to trim and make walking painful when wearing shoes. Onychomycosis can also be accompanied by a secondary bacterial or yeast infection in or about the nail plate.

Because it is difficult to avoid contact with microscopic organisms like fungi, the toenails are especially vulnerable around damp areas where people are likely to be walking barefoot, such as swimming pools, locker rooms, and showers, for example. Injury to the nail bed may make it more susceptible to all types of infection, including fungal infection. Those who suffer from chronic diseases, such as diabetes, circulatory problems, or immune-deficiency conditions, are especially prone to fungal nails. Other contributing factors may be a history of athlete's foot and excessive perspiration.

Prevention
• Proper hygiene and regular inspection of the feet and toes are the first lines of defense against fungal nails.
• Clean and dry feet resist disease.
• Washing the feet with soap and water, remembering to dry thoroughly, is the best way to prevent an infection.
• Shower shoes should be worn when possible in public areas.
• Shoes, socks, or hosiery should be changed more than once daily.
• Toenails should be clipped straight across so that the nail does not extend beyond the tip of the toe.
• Wear shoes that fit well and are made of materials that breathe.
• Avoid wearing excessively tight hosiery, which promote moisture.
• Socks made of synthetic fiber tend to "wick" away moisture faster than cotton or wool socks.
• Disinfect instruments used to cut nails.
• Disinfect home pedicure tools.
• Don't apply polish to nails suspected of infection—those that are red, discolored, or swollen, for example.

Treatment of Fungal Nails
Treatments may vary, depending on the nature and severity of the infection. A daily routine of cleansing over a period of many months may temporarily suppress mild infections. White markings that appear on the surface of the nail can be filed off, followed by the application of an over-the-counter liquid antifungal agent. However, even the best over-the-counter treatments may not prevent a fungal infection from coming back.

A podiatric physician can detect a fungal infection early, culture the nail, determine the cause, and form a suitable treatment plan, which may include prescribing topical or oral medication, and debridement (removal of diseased nail matter and debris) of an infected nail.

Newer oral antifungals, approved by the Food and Drug Administration, may be the most effective treatment. They offer a shorter treatment regimen of approximately three months and improved effectiveness. Podiatrists may also prescribe a topical treatment for onychomycosis, which can be an effective treatment modality for fungal nails.

In some cases, surgical treatment may be required. Temporary removal of the infected nail can be performed to permit direct application of a topical antifungal. Permanent removal of a chronically painful nail that has not responded to any other treatment permits the fungal infection to be cured and prevents the return of a deformed nail.

Trying to solve the infection without the qualified help of a podiatric physician can lead to more problems. With new technical advances in combination with simple preventive measures, the treatment of this lightly regarded health problem can often be successful.

Nail Care Tips
• Proper hygiene and regular inspection of the feet and toes are the first lines of defense against fungal nails.
• Clean and dry feet resist disease.
• Washing the feet with soap and water, remembering to dry thoroughly, is the best way to prevent an infection.
• Shower shoes should be worn when possible in public areas.
• Shoes, socks, or hosiery should be changed more than once daily.
• Toenails should be clipped straight across so that the nail does not extend beyond the tip of the toe.
• Wear shoes that fit well and are made of materials that breathe.
• Avoid wearing excessively tight hosiery, which promote moisture.
• Socks made of synthetic fiber tend to "wick" away moisture faster than cotton or wool socks.
• Disinfect instruments used to cut nails.
• Disinfect home pedicure tools.
• Don't apply polish to nails suspected of infection—those that are red, discolored, or swollen, for example.

Your podiatric physician/surgeon has been trained specifically and extensively in the diagnosis and treatment of all manner of foot conditions. This training encompasses all of the intricately related systems and structures of the foot and lower leg including neurological, circulatory, skin, and the musculoskeletal system, which includes bones, joints, ligaments, tendons, muscles, and nerves.



Neuromas
What is a Neuroma?
A neuroma is a painful condition, also referred to as a “pinched nerve” or a nerve tumor. It is a benign growth of nerve tissue frequently found between the third and fourth toes that brings on pain, a burning sensation, tingling, or numbness between the toes and in the ball of the foot. The principal symptom associated with a neuroma is pain between the toes while walking. Those suffering from the condition often find relief by stopping their walk, taking off their shoe, and rubbing the affected area. At times, the patient will describe the pain as similar to having a stone in his or her shoe. The vast majority of people who develop neuromas are women.

Symptoms
• Pain in the forefoot and between the toes.
• Tingling and numbness in the ball of the foot.
• Swelling between the toes.
• Pain in the ball of the foot when weight is placed on it.

How Do You Get a Neuroma?
Although the exact cause for this condition is unclear, a number of factors can contribute to the formation of a neuroma. Biomechanical deformities, such as a high-arched foot or a flat foot, can lead to the formation of a neuroma. These foot types bring on instability around the toe joints, leading to the development of the condition. Trauma can cause damage to the nerve, resulting in inflammation or swelling of the nerve. Improper footwear that causes the toes to be squeezed together is problematic. Avoid high-heeled shoes higher than two inches. Shoes at this height can increase pressure on the forefoot area. Repeated stress, common to many occupations, can create or aggravate a neuroma.

What Can You Do for Relief?
Wear shoes with plenty of room for the toes to move, low heels, and laces or buckles that allow for width adjustment. Wear shoes with thick, shock-absorbent soles and proper insoles that are designed to keep excessive pressure off of the foot. High heels should be avoided whenever possible because they place undue strain on the forefoot and can contribute to a number of foot problems. Resting the foot and massaging the affected area can temporarily alleviate neuroma pain. Use an ice pack to help to dull the pain and improve comfort. For simple, undeveloped neuromas, a pair of thick-soled shoes with a wide toe box is often adequate treatment to relieve symptoms, allowing the condition to diminish on its own. For more severe conditions, however, podiatric medical treatment or surgery may be necessary to remove the tumor. Use over-the-counter shoe pads. These pads can relieve pressure around the affected area.

Treatment by Your Podiatric Physician
Treatment options vary with the severity of each neuroma, and identifying the neuroma early in its development is important to avoid surgical correction. Podiatric medical care should be sought at the first sign of pain or discomfort; if left untreated, neuromas tend to get worse. The primary goal of most early treatment regimens is to relieve pressure on areas where a neuroma develops. Your podiatric physician will examine and likely X-ray the affected area and suggest a treatment plan that best suits your individual case.

Padding and Taping: Special padding at the ball of the foot may change the abnormal foot function and relieve the symptoms caused by the neuroma.

Medication: Anti-inflammatory drugs and cortisone injections can be prescribed to ease acute pain and inflammation caused by the neuroma.

Orthotic Devices: Custom shoe inserts made by your podiatrist may be useful in controlling foot function. An orthotic device may reduce symptoms and prevent the worsening of the condition.

Surgical Options: When early treatments fail and the neuroma progresses past the threshold for such options, podiatric surgery may become necessary. The procedure, which removes the inflamed and enlarged nerve, can usually be conducted on an outpatient basis, with a recovery time that is often just a few weeks. Your podiatric physician will thoroughly describe the surgical procedures to be used and the results you can expect. Any pain following surgery is easily managed with medications prescribed by your podiatrist.

Your Feet Aren’t Supposed to Hurt
Remember that foot pain is not normal, and any disruption in foot function limits your freedom and mobility. It is important to schedule an appointment with your podiatrist at the first sign of pain or discomfort in your feet, and follow proper maintenance guidelines to ensure their proper health for the rest of your life. The advice in this pamphlet should not be used as a substitute for a consultation or evaluation by a podiatric physician.

Neuroma Tips
• Wear shoes with plenty of room for the toes to move, low heels, and laces or buckles that allow for width adjustment.
• Wear shoes with thick, shock-absorbent soles and proper insoles that are designed to keep excessive pressure off of the foot.
• High heels should be avoided whenever possible because they place undue strain on the forefoot and can contribute to a number of foot problems.
• Resting the foot and massaging the affected area can temporarily alleviate neuroma pain. Use an ice pack to help to dull the pain and improve comfort.
• For simple, undeveloped neuromas, a pair of thick-soled shoes with a wide toe box is often adequate treatment to relieve symptoms, allowing the condition to diminish on its own. For more severe conditions, however, podiatric medical treatment or surgery may be necessary to remove the tumor.
• Use over-the-counter shoe pads. These pads can relieve pressure around the affected area.



Orthotics
What are Orthotics?
Orthotics are shoe inserts that are intended to correct an abnormal, or irregular, walking pattern. Orthotics are not truly or solely “arch supports,” although some people use those words to describe them, and they perhaps can best be understood with those words in mind. They perform functions that make standing, walking, and running more comfortable and efficient by altering slightly the angles at which the foot strikes a walking or running surface.

Doctors of podiatric medicine prescribe orthotics as a conservative approach to many foot problems or as a method of control after certain types of foot surgery; their use is a highly successful, practical treatment form. Orthotics take various forms and are constructed of various materials. All are concerned with improving foot function and minimizing stress forces that could ultimately cause foot deformity and pain. Foot orthotics fall into three broad categories: those that primarily attempt to change foot function, those that are primarily protective in nature, and those that combine functional control and protection.

Rigid Orthotics
The so-called rigid orthotic device, designed to control function, may be made of a firm material such as plastic or carbon fiber and is used primarily for walking or dress shoes. It is generally fabricated from a plaster of paris mold of the individual foot. The finished device normally extends along the sole of the heel to the ball or toes of the foot. It is worn mostly in closed shoes with a heel height under two inches. Because of the nature of the materials involved, very little alteration in shoe size is necessary.

Rigid orthotics are chiefly designed to control motion in two major foot joints, which lie directly below the ankle joint. These devices are long lasting, do not change shape, and are usually difficult to break. Strains, aches, and pains in the legs, thighs, and lower back may be due to abnormal function of the foot, or a slight difference in the length of the legs. In such cases, orthotics may improve or eliminate these symptoms, which may seem only remotely connected to foot function.

Soft Orthotics
The second, or soft, orthotic device helps to absorb shock, increase balance, and take pressure off uncomfortable or sore spots. It is usually constructed of soft, compressible materials, and may be molded by the action of the foot in walking or fashioned over a plaster impression of the foot. Also worn against the sole of the foot, it usually extends from the heel past the ball of the foot to include the toes.

The advantage of any soft orthotic device is that it may be easily adjusted to changing weight-bearing forces. The disadvantage is that it must be periodically replaced or refurbished. It is particularly effective for arthritic and grossly deformed feet where there is a loss of protective fatty tissue on the side of the foot. It is also widely used in the care of the diabetic foot. Because it is compressible, the soft orthotic is usually bulkier and may well require extra room in shoes or prescription footwear.

Semirigid Orthotics
The third type of orthotic device (semirigid) provides for dynamic balance of the foot while walking or participating in sports. This orthotic is not a crutch, but an aid to the athlete. Each sport has its own demands and each sport orthotic needs to be constructed appropriately with the sport and the athlete taken into consideration. This functional dynamic orthotic helps guide the foot through proper functions, allowing the muscles and tendons to perform more efficiently. The classic, semirigid orthotic is constructed of layers of soft material, reinforced with more rigid materials.

Orthotics for Children
Orthotic devices are effective in the treatment of children with foot deformities. Most podiatric physicians recommend that children with such deformities be placed in orthotics soon after they start walking, to stabilize the foot. The devices can be placed directly into a standard shoe or an athletic shoe. Usually, the orthotics need to be replaced when the child’s foot has grown two sizes. Different types of orthotics may be needed as the child’s foot develops and changes shape. The length of time a child needs orthotics varies considerably, depending on the seriousness of the deformity and how soon correction is addressed.

Other Types of Orthotics
Various other orthotics may be used for multidirectional sports or edge-control sports by casting the foot within the ski boot, ice skate boot, or inline skate boot. Combinations of semiflexible material and soft material to accommodate painful areas are utilized for specific problems. Research has shown that back problems frequently can be traced to a foot imbalance. It’s important for your podiatric physician to evaluate the lower extremity as a whole to provide for appropriate orthotic control for foot problems.

Orthotic Tips
• Wear shoes that work well with your orthotics.
• Bring your orthotics with you whenever you purchase a new pair of shoes.
• Wear socks or stockings similar to those that you plan on wearing when you shop for new shoes.
• Return as directed for follow-up evaluation of the functioning of your orthotics. This is important for making certain that your feet and orthotics are functioning properly together.

Your podiatric physician/surgeon has been trained specifically and extensively in the diagnosis and treatment of all manner of foot conditions. This training encompasses all of the intricately related systems and structures of the foot and lower leg including neurological, circulatory, skin, and the musculoskeletal system, which includes bones, joints, ligaments, tendons, muscles, and nerves.



Rearfoot Surgery
Many Conditions Affect the Rearfoot
Many conditions can affect the back portion of the foot and ankle. Fortunately, many of these problems can be resolved through conservative treatments. However when pain persists or deformity occurs, surgical intervention can often help alleviate pain, reduce deformity, and/or restore the function of your foot or ankle.

Heel Surgery
Two common conditions that can cause pain to the bottom of the heel are plantar fasciitis and heel spur(s). Although there are many causes of heel pain in both children and adults, most can be effectively treated without surgery. When chronic heel pain fails to respond to conservative treatment, surgical care may be warranted.

Plantar Fasciitis is an inflammation of a fibrous band of tissue in the bottom of the foot that extends from the heel bone to the toes. This tissue can become inflamed for many reasons, most commonly from irritation by placing too much stress (such as excess running and jumping) on the bottom of the foot.

Heel Spur(s) or heel spur syndrome are most often the result of stress on the muscles and fascia of the foot. This stress may form a spur on the bottom of the heel. While many spurs are painless, others may produce chronic pain.

Based on the condition and the chronic nature of the disease, heel surgery can provide relief of pain and restore mobility in many cases. The type of procedure is based on examination and usually consists of plantar fascia release, with or without heel spur excision. There have been various modifications and surgical enhancements regarding surgery of the heel. Your podiatric physician will determine which method is best suited for you.

There are many other causes of heel pain, which has become one of the most common foot problems reported by patients of podiatric physicians. Many of them have a basis in heredity, as do a lot of other foot conditions. Among the causes are stress fractures and stress-fracture syndrome, entrapped nerves, bruises, bursitis, arthritis (including gout), deterioration of the fat pad on the heel, improper shoes, and obesity, just to name some. Most of these conditions will be treated nonsurgically, though surgery may be recommended in some instances.

Haglund's Deformity (pump bump)
This deformity is characterized by a bony enlargement on the back of the heel. Although not always painful, it may become so if bursitis develops near the Achilles tendon secondary to footwear irritation. If attempts at shoe modification and other medical treatments fail to improve this condition, surgical correction may be beneficial. Based on X-ray evaluation and other tests or examinations, your podiatric surgeon will select an operative treatment to alleviate the condition.

Insertional Achilles Clarification/Spur
This deformity differs from Haglund's deformity, in that spur formation or calcification at the insertion of the achilles tendon is the cause of pain. Often associated with achilles tendinitis, this deformity can often be difficult to treat medically and therefore surgical treatment may be necessary in chronic cases. There are many causes of this condition, including arthritis, but the most common appears to be overuse syndrome, where trauma occurs where the achilles tendon attaches to the heel bone. Surgical treatment includes removal of the bone spur and/or calcification, along with repair of the achilles tendon.

Reconstructive Surgery
Reconstructive surgery of the foot and ankle consists of complex surgical repair(s) that may be necessary to regain function or stability, reduce pain, and/or prevent further deformity or disease. Unfortunately, there are many conditions or diseases that range from trauma to congenital defects that necessitate surgery of the foot and/or ankle. Reconstructive surgery in many of these cases may require any of the following: tendon repair/transfer, fusion of bone, joint implantation, bone grafting, skin or soft tissue repair, tumor excision, amputation and/or the osteotomy of bone (cutting of bones in a precise fashion). Bone screws, pins, wires, staples, and other fixation devices (both internal and external), and casts may be utilized to stabilize and repair bone in reconstructive procedures.

Preoperative Testing and Care
As with anyone facing any surgical procedure, those undergoing foot and ankle surgery require specific tests or examinations before surgery to obtain a successful surgical outcome. Prior to surgery, the podiatric surgeon will review your medical history and medical conditions. Specific diseases, illnesses, allergies, and current medications need to be evaluated. Other tests that help evaluate your health status that may be ordered by the podiatric physician include blood studies, urinalysis, EKG, X-rays, blood flow studies (to better evaluate the circulatory status of the foot/legs), and biomechanical examination. A consultation with another medical specialist is sometimes advised by a podiatric physician, depending on your test results or a specific medical condition.

Postoperative Care
Surgery of the rearfoot requires close care following surgery. To assure a rapid and uneventful recovery, it is important to follow your podiatric surgeon's advice and postoperative instructions carefully. Rest, ice, compression and elevation of your foot/ankle postoperatively is often advised. The usage of bandages, splints, casts, surgical shoes, crutches, or canes may be necessary after surgery. Your podiatric surgeon will also determine if and when you can bear weight on an operated foot.



Warts
What are Plantar Warts?
Warts are one of several soft tissue conditions of the foot that can be quite painful. They are caused by a virus, which generally invades the skin through small or invisible cuts and abrasions. They can appear anywhere on the skin, but technically only those on the sole are properly called plantar warts. Children, especially teenagers, tend to be more susceptible to warts than adults; some people seem to be immune.

Identification Problems
Most warts are harmless, even though they may be painful. They are often mistaken for corns or calluses—which are layers of dead skin that build up to protect an area which is being continuously irritated. The wart, however, is a viral infection. It is also possible for a variety of more serious lesions to appear on the foot, including malignant lesions such as carcinomas and melanomas. Although rare, these conditions can sometimes be misidentified as a wart. It is wise to consult a podiatric physician when any suspicious growth or eruption is detected on the skin of the foot in order to ensure a correct diagnosis.

Plantar warts tend to be hard and flat, with a rough surface and well-defined boundaries; warts are generally raised and fleshier when they appear on the top of the foot or on the toes. Plantar warts are often gray or brown (but the color may vary), with a center that appears as one or more pinpoints of black. It is important to note that warts can be very resistant to treatment and have a tendency to reoccur.

Source of the Virus
The plantar wart is often contracted by walking barefoot on dirty surfaces or littered ground where the virus is lurking. The causative virus thrives in warm, moist environments, making infection a common occurrence in communal bathing facilities. If left untreated, warts can grow to an inch or more in circumference and can spread into clusters of several warts; these are often called mosaic warts. Like any other infectious lesion, plantar warts are spread by touching, scratching, or even by contact with skin shed from another wart. The wart may also bleed, another route for spreading. Occasionally, warts can spontaneously disappear after a short time, and, just as frequently, they can recur in the same location.

When plantar warts develop on the weight-bearing areas of the foot—the ball of the foot, or the heel, for example—they can be the source of sharp, burning pain. Pain occurs when weight is brought to bear directly on the wart, although pressure on the side of a wart can create equally intense pain.

Tips for Prevention
• Avoid walking barefoot, except on sandy beaches.
• Change shoes and socks daily.
• Keep feet clean and dry.
• Check children's feet periodically.
• Avoid direct contact with warts—from other persons or from other parts of the body.
• Do not ignore growths on, or changes in, your skin.
• Visit your podiatric physician as part of your annual health checkup.

Self Treatment
Self treatment is generally not advisable. Over-the-counter preparations contain acids or chemicals that destroy skin cells, and it takes an expert to destroy abnormal skin cells (warts) without also destroying surrounding healthy tissue. Self treatment with such medications especially should be avoided by people with diabetes and those with cardiovascular or circulatory disorders. Never use them in the presence of an active infection.

Professional Treatment
It is possible that your podiatric physician will prescribe and supervise your use of a wart-removal preparation. More likely, however, removal of warts by a simple surgical procedure, performed under local anesthetic, may be indicated. Lasers have become a common and effective treatment. A procedure known as CO2 laser cautery is performed under local anesthesia either in your podiatrist’s office surgical setting or an outpatient surgery facility. The laser reduces post-treatment scarring and is a safe form for eliminating wart lesions.

Self treatment is generally not advisable. Over-the-counter preparations contain acids or chemicals that destroy skin cells, and it takes an expert to destroy abnormal skin cells (warts) without also destroying surrounding healthy tissue. Self treatment with such medications especially should be avoided by people with diabetes and those with cardiovascular or circulatory disorders. Never use them in the presence of an active infection.

Tips for Individuals with Warts
• Avoid self treatment with over-the-counter preparations.
• Seek professional podiatric evaluation and assistance with the treament of your warts.
• Diabetics and other patients with circulatory, immunological, or neurological problems should be especially careful with the treament of their warts.
• Warts may spread and are catching. Make sure you have your warts evaluated to protect yourself and those close to you.