PODIATRIST

When walking, your heels repeatedly hit the ground with considerable force. They have to be able to absorb the impact and provide a firm support for the weight of the body.

When pain develops in the heel, it can be very disabling, making every step a problem, affecting your posture.

There are various types of heel pain. Some of the most common are: heel spurs (plantar fasciitis); heel bursitis and heel bumps.

Common symptoms:

Heel Spurs: the pain is usually worst on standing, particularly first thing in the morning when you get up. It is relatively common, though usually occurring in the over forty's age group. There are no visible features on the heel but a deep localised painful spot can be found in or around the middle of the sole of the heel. Although it is often associated with a spur of bone sticking out of the heel bone (heel spur syndrome), approximately ten per cent of the population have heel spurs without any pain.

Heel 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.

Heel Bumps: recognised as firm bumps on the back of the heel , they are often rubbed by shoes causing pain.

Recommended treatments 

Heel Spurs: cushioning for the heel is of little value. Your chiropodist/podiatrist may initially apply padding and strapping to alter the direction of stretch of the ligament. This is often successful at reducing the tenderness in the short term. Your chiropodist/podiatrist may suggest a course of deep heat therapy to stimulate the healing processes, allowing damage to respond and heal faster. In the long term, your chiropodist/podiatrist may prescribe special insoles (orthoses) to help the feet to function more effectively, thereby reducing strain on the ligaments and making any recurrence less likely.

If pain from heel spurs continues, you may be referred to your GP who can prescribe an oral non-steroidal anti-inflammatory. Alternatively, localised hydrocortisone injection treatment may be given by your GP or an appropriate chiropodist/podiatrist. If pain persists, surgery may be considered.

Heel Bursitis: in most cases, attention to the cause of any rubbing, and appropriate padding and strapping by your chiropodist/podiatrist will allow the inflammation to settle. If infection is present, your chiropodist/podiatrist will refer you to your GP for antibiotics.

Heel Bumps: adjustments to footwear is often enough to make them comfortable. A leather heel counter and wearing boots may help. However, if pain persists, surgery may be necessary.

Rheumatoid arthritis (RA) is a condition that causes inflammation in many joints of the body. Unlike osteoarthritis which is caused by wear and tear, rheumatoid arthritis is a chronic inflammatory disease where a faulty immune system attacks the tissue that lines and cushions the joints, leaving them swollen, painful and stiff.

This condition particularly affects the hands, feet, wrists, ankles and knees -and tends to occur symmetrically. That is, if your right big toe joint is swollen and painful, chances are, your left one is too. But RA can also affect other organs. As well as joint pain and stiffness, symptoms include muscle aches, anaemia (a low blood count, leaving you feeling tired) and fever. The stiffness tends to be worse in the morning and after rest.

Women are three times more likely than men to get it and it tends to affect people between the ages of 30 and 50.

The severity of the symptoms vary from person to person. According to the Arthritis Research Campaign. About 1 in every 20 will have RA that becomes progressively worse leading to severe damage in a lot of joints while around 1 in 5 will have mild RA that causes few problems, beyond a little pain and stiffness.

How does rheumatoid arthritis affect the feet? RA affects the smaller joints such as the fingers and toes first, so feet are often one of the first places to be affected. Symptoms usually strike the toes first and may then affect the back of the feet and the ankles. The joints may enlarge and even freeze in one position, so they can't extend fully.

Front of the foot The metatarsal-phalangeal joints are often affected (where the long bones of the feet meets the toes), and can result in Hallux valgus (a condition in which the big toe is angled excessively towards the second toe) and hammer toe deformities (where the toes curl up in a claw-like shape). Each of these deformities can cause further problems, for example, if you have hammer toes, you'll be more likely to develop corns on the tops of your toes.

Midfoot If the joints in the middle of the foot are affected, the arch can collapse leading to a flatfoot deformity and spreading of the forefoot (where the front section of the foot becomes wider). The fatty pads on the balls of the feet may slip forward, causing pain on the balls of the feet and backs of the toes. If this happens, it can feel as if you are walking on stones.

Back of the foot If the joint where the heel bone meets the ankle (the joint that lets you rotate your ankle) is affected, it can lead to a condition known as valgus hindfoot (where the heel bends outwards), making it difficult to walk.

Any kind of foot deformity will cause an uneven distribution of pressure as you walk, making you more likely to develop corns, calluses and ulcers.

You may also get rheumatoid nodules - fleshy lumps that usually occur below the elbows but can appear on the hands and feet too. They may form over bony areas such as the heels and occur in 30 to 40 percent of people with rheumatoid arthritis.

What can I do? There could be many other causes of your joint pain, but if it is arthritis, the sooner you are diagnosed, the more effective treatment will be. According to the Arthritis Research Campaign, many rheumatology departments have Early Arthritis Clinics which your GP can refer you to.

You can help yourself by understanding as much as possible about your disease and treatment. The best starting point is the website for the charity, Arthritis Research Campaign, which has numerous downloadable leaflets on all aspects of arhtritis. See www.arc.co.uk

What can other health professionals do? Your doctor can make a clinical diagnosis using blood tests (which may show changes in the blood caused by inflammation) and X-rays (which can show up damaged joints). It is likely your feet will be x-rayed because the changes caused by rheumatoid arthritis often appear in the feet before they appear in other joints.

Your GP will also decide the most appropriate treatment for you. What treatment you'll need depends on how advanced your Rheumatoid Arthritis is. Drugs available include analgesics, non-steroidal anti-inflammatory drugs (NSAIDs), which reduce pain and swelling, and disease-modifying anti-rheumatic drugs (DMARDs), which slow down the effects of the disease on the joints. If your arthritis is advanced, you may be prescribed corticosteroids. It may take a while to find the drug that's right for you, but it's worth persevering.

Managing arthritis involves a specialist team of rheumatologists, podiatrists, physiotherapists, and occupational therapists, along with specialist nurses.

What can a podiatrist do? There are many things a podiatrist can do to make walking less painful:

Orthoses These are a special type of insole that can be fitted into your shoes. They will help you walk in such a way to minimise the pressure on your affected joints.

Shoes As well as a moulded insole, your podiatrist will help you find shoes that are roomy enough to accommodate your foot - and orthoses - without adding unnecessary pressure. If your toes are beginning to stiffen or curl, for example, it's important for you to wear a shoe with an extra deep toe box. Your podiatrist may make a plaster of Paris copy of your foot, so a shoe can be tailored to your exact foot shape.

Protective shields They can also provide protective shields for your toes or padding to relieve pressure and reduce friction.

Surgery Surgery can correct any bunions and hammertoes caused by RA. If your joint cartilage has been completely destroyed and the joints in your foot have been dislocated to the extent that it's extremely painful to walk, they can be fused together (a process known as arthrodesis). This involves removing the joint cartilage (the substance that allows the bones to glide over each other). The bones are then held together with screws, plates or a rod. The bones eventually merge into one solid bone. Although this results in a loss of movement in that particular joint, it can reduce pain.

Secondary problems Any secondary problems such as ulcers or corns that have been caused by foot deformities can also be treated.

Osteoarthritis (OA) is often called the 'wear and tear' arthritis. It occurs when the cartilage of a joint (a thin layer of gristle that covers the end of the bones and allows them to glide over each other) becomes damaged. When the cartilage deteriorates, the bone underneath can thicken, causing pain, stiffness and swelling. The joints most affected are the knees, hips, hands and big toes.

OA is uncommon before the age of 40. Though the exact cause of OA is unknown, according to the Arthritis Research Campaign, it is probably due to the fact that as we age, we tend to put on weight thereby putting more pressure on our joints, our muscles become weaker and our body loses its ability to heal itself.

When OA occurs in younger people, it is usually because the joint cartilage has been damaged through injury (such as a sprain or fracture), a bacterial or viral infection or even through overuse of a particular joint as is common in farmers (hips), plumbers (knees) and footballers (knees and ankles). The Arthritis Research Campaign estimates that 8 million Britons are affected by Osteoarthritis, but only 1 million seek treatment.

It can be. In severe cases, the cartilage can deteriorate to the extent that the bones rub together, making it difficult to move the affected joint at all. But symptoms vary from person to person - and some people may have OA without experiencing many symptoms at all. Osteoarthritis does not always get worse.

OA can affect any of the 33 joints in the feet but mostly affects the joints at the base of the big toes. This joint is more prone to wear and tear from the pressures of walking, especially if you over-pronate (ie roll your foot in excessively as you walk). Wear and tear at the ends of the bone cause the cartilage to erode and the bone ends may begin to join together. Eventually your big toe may become rigid (a condition known as hallux rigidus) which makes walking difficult. Or your big toe may drift towards your other toes (hallux valgus) which can leads to bunions.

You may initially feel a toothache-type ache in the affected joint that gets worse when you're active, wearing high-heels or when it's cold and damp. It may progress to the stage where your feet ache at night. In severe cases, the range of movement in the joint may fall to the extent that you can't move it at all.

If you are worried that you have OA, you should see your GP or a podiatrist. The early you are diagnosed, the more effective any treatment will be. If you do have OA, there are many things you can do yourself to help ease the condition:

Footwear Minimise the stress on the joints by choosing well-cushioned shoes. Go for shoes with lace-up fastenings or an adjustable strap: they keep the heel in place and stop the toes being pushed to the front of the shoe. Your feet should keep their natural shape when in shoes. There should be a centimetre between the end of your longest toe and end of shoe. They should also be roomy enough to accommodate any swelling, so go for a wide, deep pair.

Exercise Toes aren't a part of the body we often think of exercising, but by exercising and stretching regularly, you can help nourish the joint cartilage and strengthen the muscles and tendons around the joint. Podiatrist Trevor Prior recommends you put your feet side by side (say, while you're in the bath), and try to move your big toes towards each other. Do this three or four times a day. You should ideally exercise your whole body to keep your joints flexible, your muscles strong and your bone and cartilage tissues healthy. Yoga is a great exercise for all your joints, including your toes. Swimming is also great, because it doesn't put any pressure on your joints.

What can other health professionals do? 

 Your GP may recommend painkillers or steroids to ease the pain. There are also creams and gels (such as Capsaicin cream) which can be absorbed into the bloodstream if rubbed on the affected joints when they are painful, such as after exercise or at the end of the day. Ideally, you should be seen by a team of rheumatologists, physiotherapists, occupational therapists and podiatrists.

What can a podiatrist do? 

Though there is no known cure for OA, there are many ways your podiatrist can help you ease the pressure on the affected joints, and therefore reduce the pain and inconvenience:

Orthoses Orthoses are special shoe inserts that help re-distribute the pressure as you walk. They'll help you walk in such a way that alleviates the pain in your joints.

Shoes Your podiatrist can advise you on the best type of footwear to wear for your exact problem. If you develop hallux valgus (where your big toe drifts towards your second toe), for example, your podiatrist may recommend a shoe with a stiff sole. This relieves pain by reducing the movement of the big toe. In some cases, a shoe with a slight heel raise may be more comfortable.

Strapping and padding Your podiatrist may strap the feet in the short-term to limit joint movement. They can also provide protective shields for your toes or padding to relieve pressure and friction.

Surgery If your problem doesn't improve with the above measures, you may be referred to a podiatric surgeon who will evaluate the extent of your problem and see if you are suitable for excisional arthroplasty (replacement of joint surfaces), interpositional arthroplasty (placing soft tissue, especially joint capsule, between the resected bone surfaces),.osteotomy (decompresses and realigning the joint surfaces), joint replacement (used for irreverisibly damaged joints) or arthrodesis (where the bones are fused together). However, surgery is only used a last resort.

Arthritis is a disease of the joints which causes them to become inflamed and stiffen. There are three types of arthritis - Rheumatoid, Osteo-arthritis and Gout.

Gout is the result of an imbalance of uric acid in the body, and affects more men than women.

The main symptom is waking up in the middle of the night with an acute throbbing pain in the big toe, which is swollen. Usually only one of the big toes is affected. The pain lasts for around three or four hours and will then subside and usually not return for a few months. It can be controlled by drugs, which your GP will be able to prescribe. The application of ice or cooling lotions will help during an acute phase.

All three forms of arthritis can benefit from chiropody care. Registered chiropodists (also known as podiatrists) work in the NHS and in private practice. They will be able to adapt your existing footwear with orthoses or other appliances, which fit easily into your shoes and help redistribute pressure away from the affected parts.

Made-to-measure shoes can also be prescribed, and registered chiropodists/podiatrists will also be able to advise you on the correct type of shoes to wear, and where to obtain them. Registered chiropodists/podiatrists can also provide protective shields for your toes, or padding to relieve pressure and reduce friction. Any secondary problems, like ulcers or corns, can also be treated. They will also refer you to a specialist for further treatment, if they consider it necessary.

Specialist teams of rheumatologists, chiropodists/podiatrists, physiotherapists and occupational therapists, along with specialist nurses, will provide the most effective care and treatment for arthritic patients, especially those with rheumatoid arthritis.

When we walk or stand, our body weight is carried first on the heel and then on the ball of the foot, where the skin is thicker, to withstand the pressure. When this pressure becomes intense, growths, in the form of corns and callus, may appear.

Corns always occur over a bony prominence, such as a joint.

There are five different types of corns. The two most common are hard and soft corns.

Hard corns

These are the most common and appears as small, concentrated areas of hard skin up to the size of a small pea, usually within a wider area of thickened skin or callous, and can be symptoms of feet or toes not functioning properly.

Soft corns

These develop in a similar way to hard corns. They are whitish and rubbery in texture, and appear between toes, where the skin is moist from sweat, or from inadequate drying. A registered podiatrist/chiropodist will be able to reduce the bulk of the corn, and apply astringents to cut down on sweat retention between the toes.

Seed corns

These are tiny corns that tend to occur either singly or in clusters on the bottom of the foot. They are usually painless.

Vascular corns

These corns will bleed profusely if they are cut and can be very painful.

Fibrous corns

These arise from corns that have been present for a long time. They appear to be more firmly attached to the deeper tissues than any other corn. They may also be painful.

Don't cut corns yourself, especially if you are elderly or diabetic, and don't use corn plasters or paints which can burn the healthy tissue around the corns. Home remedies, like lambswool around toes, are potentially dangerous. Commercially available 'cures' should be used only following professional advice.

You could use a pumice stone to remove the thickened skin a little at a time, or relieve pressure between the toes with a foam wedge, but if you are unsure of what to do, or need special attention, consult a registered podiatrist/chiropodist who will be able to remove corns painlessly, apply padding or insoles to relieve pressure, or fit corrective appliances for long-term relief.