From the article of the same title “Archives of Orthopaedic and Trauma Surgery” (05/12) Regab, Ehab Mohamed Selem; Othman, Ahmed Mohamed Ahmed

The nail weakens as fungi continue to grow through the nail tissue. Since fungus grows faster than the nail, damage increases and the nail becomes more and more unsightly, with the infection spreading to the root or base of the nail.

Yeast and molds are also suspected to cause toenail fungus. These types of fungi exist in warm and moist environments, like shower areas, locker rooms, swimming pools and even in your shoes (as toes are usually encased in shoes). People with circulatory problems, weak immune systems or diabetes are at greater risk of developing fungal infections, as well.

Nail fungus has been difficult to treat with success. The only options in the past have been topical or oral medications, which provide limited benefit. In addition, oral medications may cause liver damage. Now there is a safe, effective laser treatment for nail fungus. The laser destroys the fungus that causes onychomycosis with very little effect on the surrounding tissues. Treatment normally takes fewer than 20 minutes and there is no pain, although sometimes you may experience a warm or tingling sensation. There are no age or health restrictions for laser treatments. Laser toenail treatment is considered aesthetic (cosmetic). Therefore, most health insurance plans do not cover treatment. I recently have begun laser treatment for fungus toenails in my office. Go to the Common Foot Problems section of my website to learn more about my laser treatment for onychomycosis.

> Wear supportive shoes.

> Wear moisture wicking socks.

> Stretch muscles before and after you walk.

> If you’ve been inactive over the winter, don’t overdo it.  Gradually work into a walking program.

> Walkers can frequently experience heel pain, especially if you’ve been inactive during the winter months.  Often, ibuprofen and daily stretching exercises can provide relief.

> If you experience pain in your heels or ankles that does not disappear within two weeks, schedule an exam in my office.

Don’t let foot pain slow you down!

Aching heels can truly affect your lifestyle and disrupt essential activities and prevent you, to a large extent, from playing sports or simply going for a walk.  An accurate and speedy diagnosis of the cause of your symptoms will help you receive appropriate treatment.

There are several causes of heel pain.  The most common include:

* Plantar Fasciitis- 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.  Both heel pain and heel spurs are frequently associated with plantar fasciitis.

* Heel Spurs- 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.  Heel spurs can result from strain on the ball of the foot and repeated tearing away of the lining or membrane that covers the heel bone.  Contrary to popular belief, heel spurs are generally not the cause of heel pain–the pain you feel is from inflammation of the plantar fascia.

* Excessive Pronation- Excessive inward motion can create an abnormal amount of stretching and pulling on the ligaments and tendons that attach to the bottom back part of the heel bone.  Excessive pronation may also contribute to injury to the hip, knee and lower back.

* Achilles Tendonitis- Pain at the back of the heel is associated with Achilles tendonitis, which is inflammation of the Achilles tendon as it runs behind the ankle and inserts on the back surface of the heel bone.

Other possible causes of heel pain include rheumatoid arthritis and other forms of arthritis (e.g. gout); Haglund’s deformity (a bone enlargement at the back of the heel bone in the area where the Achilles tendon attaches to the bone); inflamed bursa (”bursitis”), a small, irritated sac of fluid; neuromas (nerve growths) or other soft-tissue growths; and bruises or contusions, which involve 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.

Some contributing factors associated with heel pain are age (with increasing age, often there is decreasing flexibility); any sudden changes in activity (particularly activities that increase weight bearing or pressure on the foot); flat, pronated feet or high-arched feet; a sudden increase in weight; pregnancy; stress from an injury; a bruise incurred while walking, running or jumping on hard surfaces; or medical conditions such as tarsal tunnel syndrome.

Seeking medical attention from your podiatric physician is the first line of defense in treating heel pain.  However, there are several steps you can take to avoid heel pain in the first place:

* Wear shoes that fit well and have shock-absorbent soles, rigid shanks (the part of the shoe that supports the foot and helps give the shoe its structure) and a supportive heel counter (the rear-most part of the shoe, at the back of the heel above the sole).

* Wear the proper shoes for each activity.

* Do not wear shoes with excessive wear on heels or soles.

* Begin exercises slowly.  Consult with your podiatric physician before beginning a new exercise program.

* Wear athletic shoes with good shock support in the heels.

* Purchase shoes that fit.

* Avoid activities that may put constant strain on the foot.

* Avoid going barefoot on all surfaces.

* If obese, lose weight.

A variety of treatment solutions are available to provide short and long-term pain relief.  Begin treating heel pain by avoiding all sorts of pressure or tension on the inflamed area, giving your feet ample rest.  Applying ice and heat packs in alternating fashion will greatly accelerate the process of healing.  Another option is the use of custom insoles created by your podiatric physician.  Custom insoles may assist with treating active conditions of heel pain and likewise reduce the risk of reoccurrence.  The custom insole will restore body balance and prevent the plantar fascia from experiencing strain while you walk.  If all non-invasive treatment solutions do not work, surgery is probably the best next option.

Regular exercise for calf muscles and the plantar fascia is necessary to alleviate pain and improve flexibility of the affected muscle.  These exercises are advised for both legs even if pain is in one heel only.  Some of the most beneficial exercises are:

* Towel stretches- This exercise should be done every morning before you leave your bed.  Make a loop with a towel and use it to pull your toes toward your body, while keeping the knee straight.  Stretch each foot three times and hold each stretch for 30 seconds, if possible.

* Stair stretches- Stand tall on a staircase with the balls of both feet on the edge of the step.  Place hands on the railing or the wall for balance and support.  Slowly lower heels toward the floor until you feel a stretch in your lower leg and heels.  Maintain the stretch for 10-15 seconds.  Repeat this exercise six times and perform the stretches twice every day.

* Wall-leaning stretch- Stand an arm’s length away from a wall, place both hands on the wall at shoulder height, the the feet slightly apart and one foot in front of the other.  Your front knee should be bent, but the back knee should be straight while you lean toward the wall.  Hold the position for 10 seconds at a time for up to 15 or 20 repetitions per leg.

If you are unsure of the cause of your symptoms, if pain is severe or if you have the following symptoms, call a podiatric physician immediately:

* Inability to bend your foot downward.

* Inability to rise on your toes.

* Inability to walk comfortably on the affected side.

* Swelling or discoloration of the back of the foot.

* Heel pain that occurs at night or while resting.

* Heel pain that persists beyond a few days.

Heel pain does not always subside quickly after medical attention is received.  Unfortunately, it may take several months before pain is actually gone.  In most cases, heel pain can be treated at home under a podiatric physician’s supervision.

* Appropriate stretching and warm up for all sports activities should be done to help prevent injury.

* If your child is overweight, help him or her to shed some pounds.  Extra weight puts additional stress on the feet.

* Limit wearing cleated shoes to the time actually spent on the field.  Cleated shoes do not provide adequate support and may cause increased pressure on the soles of the feet.

* Make sure shoes are well-constructed and support the foot adequately.  Have them professionally fitted.

If your children are involved in sports activities–especially those that are hard on their feet such as soccer, basketball, track and football–it’s important that you are on the lookout for “overuse injuries”.  Kids’ bones, ligaments and tendons in their feet and ankles are not fully developed yet and damage can occur when they are stressed from hours of sports activities.  Problems FROM OVERUSE that can occur when kids’ feet are involved in a lot of activities include:

> Calcaneal apophysitis- an inflammation of the heel’s growth plate due to muscle strain and repetitive stress.

> Achilles tendonitis- an inflammation of the tendon connecting the heel bone to the calf muscle.

> Stress Fractures- hairline breaks resulting from repeated stress on the bone.

> Sprains- ankles can turn in when ankle ligaments and muscles are weakened or fatigued.

> Shin Splints- inflammation of the muscle attachment along the bone of the shin occurs because of fatigue due to overuse, improper shoe wear and the change of playing fields from one sport to another.

Remember, pain is NEVER normal in a child’s foot or ankle.  Some kids may insist on playing their sport even when they’re in pain.  Parents should not allow this to happen.  Continuing to play with an injury can result in serious injuries that can follow your child into adulthood.

Best rule of thumb: If your child has any pain in their foot that lasts longer than a few days, or that is severe enough to limit the child’s walking or playing a sport, he or she should be evaluated in my office.

Frostbite is a condition that can occur when skin is exposed to extreme cold, resulting in tissue damage and possible tissue loss.  Your finger, toes and areas of commonly exposed skin like the nose and cheeks are at risk as well.  In the foot, frostbite typically develops in stages beginning with cold toes that turn bright red in color.  The color in the toes continues to change and darkens into purples and blues and eventually black, indicating severe frostbite.  If you have diabetic neuropathy, which causes loss of feeling in the foot, it is especially important you check your toes regularly for signs of frostbite.

Another symprom of frostbite is numbness in the toes; however, numb toes can also be a symptom of other conditions, such as tarsal tunnel syndrome, metatarsalgia and neuromas.  Wearing tight shoes can also cause numbness in the toes. 

If you are experiencing numbness in your toes, call my office to schedule an appointment.  If you suspect the numbness is due to frostbite, seek medical attention immediately.

Some common winter and snow sports injuries related to the foot and ankle include:

* Frostbite- The symptoms include skin-color changes, from blue to whitish, and a feeling of burning or numbness;

* Blisters- Friction in winter sports footwear often cause blisters;

*  Neuromas- Enlarged benign growths of nerves between the toes are caused by friction in tight footwear and can result in pain, burning, tingling and numbness.  Neuromas require professional treatment, including an evaluation of skates and boots, from a podiatric physician;

* Sprains and strains-  The stress of skiing and skating can result in sprains and strains of the foot and ankle.  They can be treated with rest, ice, compression and elevation (RICE).  If pain persists, seek medical attention from a podiatric physician; and

* Subungual hematoma- Pressure in the toebox of a ski or skate can cause bleeding under the toenail known as subungual hematoma.  This condition should be treated by a podiatric physician to prevent the loss of a toenail.

Podiatric physicians recommend properly fitted shoes or boots to prevent winter and snow injuries.  With adequate preparation and proper equipment, you can prevent most injuries common to winter and snow sports.

* Maintain an adequate fitness level all year round.  Being fit is the best way to avoid most sports-related injuries in winter.

* Find a buddy who enjoys your sport.  Never participate in winter sports alone.

* Warm up thoroughly before activity.  Cold muscles, tendons and ligaments are vulnerable to injury.  Make sure to cool down thoroughly afterwards, as well.

* Wear several layers of light, loose, water-and-wind-resistant clothing for warmth and protection.

* Wear proper footwear in good condition and keep feet warm and dry.  Footwear should provide ample ankle support, as well.

* Wear a blended sock that “wicks” sweat away from the skin.  Consult your podiatric physician for recommendations.

* Drink plenty of water before, during and after your sports activity.

* Move to a warm, dry environment if your feet get wet.  The skin tissues of wet, cold feet are in danger of freezing (frostbite).