PODIATRIST

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 excessive, some areas of the skin thicken, in the form of corns and callus, as a protective response.

A callus, or callosity, is an extended area of thickened skin on the soles of the feet, and occurs on areas of pressure. It is the body's reaction to pressure or friction, and can appear anywhere the skin rubs against a bone, a shoe, or the ground.

Walking on stones?

Most calluses are symptoms of an underlying problem like a bony deformity, a particular style of walking, or inappropriate footwear. Some people have a natural tendency to form callus because of their skin type. Elderly people have less fatty tissue in their skin and this can lead to callus forming on the ball of the foot.

What to do

You can control a small amount of hard skin by gently rubbing with a pumice stone, or chiropody sponge occasionally when you are in the bath. Use a moisturising cream daily. If this does not appear to be working, seek advice from a registered chiropodist (also known as podiatrist) or pharmacist.

If the callus is painful and feels as if you are "walking on stones", consult a registered chiropodist/podiatrist who will be able to advise you why this has occurred and, where possible, how to prevent it happening again. Your chiropodist/podiatrist can also remove hard skin, relieve pain, and redistribute pressure with soft padding, strapping, or corrective appliances which fit easily into your shoes. The skin should then return to its normal state.

The elderly can benefit from padding to the ball of the foot, to compensate for any loss of natural padding. Emollient creams delay callus building up, and help improve the skin's natural elasticity. Your chiropodist/podiatrist will be able to advise you on the most appropriate skin preparations for your needs

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

Who gets it? 
Active, sporty people are particularly prone, because they sweat more. Younger people are more likely to get it (as they pick their nails more, compared to older people who may not reach their toes!) Women often develop them as a result of cutting nails too low in order to relieve the pressure and discomfort of an involuted nail.

Is it serious? 
If left untreated, the infection can spread to the rest of the toe. The quicker you treat it, the less painful the treatment.

What causes it? 
There are many genetic factors that can make you prone to ingrowing toenails, explains registered podiatrist Shuja Qureshi, such as your posture (the way you stand), your gait (the way you walk), a foot deformity such as a bunion, hammer toes or excessive pronation of the feet (when your foot rolls in excessively). Your nails may also naturally splay or curl out instead of growing straight, encouraging your nail to grow outwards or inwards into the flesh.

“Tight footwear, tight hosiery and tight socks can also push your toe flesh onto the nail so that it pierces the skin,” says Shuja. “And if you sweat excessively or don’t rotate your footwear, this makes the skin moist, so that it welcomes the nail like a soft sponge. If you have brittle nails with sharp edges or are in the habit of breaking off bits of nails that are sticking out, you’re more likely to get an ingrowing toenail.” However, one of the most common causes is not cutting your toenails properly.

What can I do? 
Firstly, learn to cut your nails properly. “Nail cutters aren’t a good idea because the curved cutting edge can cut the flesh and nail scissors can slip,” says Shuja. “It’s best to use nail nippers (available from chemists) because they have a smaller cutting blade but a longer handle.” Cut your nails straight across and don’t cut too low at the edge or down the side. The corner of the nail should be visible above the skin. Also, cut them after a bath or shower when they’re soft.

Good hygiene can go a long way to preventing ingrowing toenails. Avoid moist, soggy feet by rotating your footwear so each pair has a chance to dry out thoroughly. Avoid man-made materials and choose socks and shoes of natural fibre. In the summer, wear open-toed sandals where possible.

If you’ve booked an appointment with a podiatrist, relieve the discomfort in the meantime by bathing your foot in a salty footbath. This prevents infection and reduces inflammation. Then apply a clean sterile dressing, especially if you have a discharge. Rest your foot as much as possible.

If you have diabetes, are taking steroids or are on anti-coagulants, don’t attempt to cut your nails or remove the ingrowing spike of nail yourself.

What can a podiatrist do? 
It depends on the severity of your condition. For the most basic painful and irritable ingrowing toenail, your podiatrist will remove the offending spike of nail and cover with an antiseptic dressing.

If your toe is too painful to touch, your podiatrist may inject a local anaesthetic before removing the offending portion of nail.

If you have involuted nails, your podiatrist may remove the bit that’s curling into the flesh and file the edges of the nail to a smooth surface.

If you have bleeding or discharge from an infection, or even excessive healing flesh (hypergranulation tissue) around the nail, you’ll need antibiotics to beat the infection as well as having the offending spike removed.

Shuja explains that not everyone coming to him with an ingrowing toenail actually has an ingrowing toenail. “Sometimes they have a curly nail which has a lot of debris (dirt or fluff) underneath it or a corn or callus down the side of the nail, which can be nearly as painful. However, if it’s a corn, the pain tends to be throbbing as opposed to the sharp pain you get with an ingrowing toenail.” If this is the case, your podiatrist will remove the debris, and if necessary, thin the nail.

If you are particularly prone to ingrowing toenails from underlying problems such as poor gait, your podiatrist may recommend correction of the underlying problem as well as a more permanent solution to the nail itself, such as partial nail avulsion (PNA). This is done under a local anaesthetic, where 8-10% of the nail is removed (including the root) so that the nail permanently becomes slightly narrower. The chemical phenol cauterises the nail and prevents it regrowing in the corners. This is 97-98% successful. You will, however, have to go back to your podiatrist for a number of re-dressings.

After surgery, the overall appearance of the nail looks normal – to the extent that some people even forget which nail they’ve had done!

Diabetes may affect your feet in a number of ways. One of the early changes can be loss of sensation in your feet, often starting at the toes. This is known as peripheral neuropathy.
Professional advice is to always wear shoes that fit properly. When buying new shoes, get your feet measured.

One of the first ways in which diabetes may affect your feet is through the loss of sensation within your feet, often starting at the toes. You may experience a cotton wool like feeling or numbness in your feet, this is called neuropathy. Your chances of losing feeling in your feet increases with the number of years that you have diabetes and research suggests that up to one in three people with diabetes have some loss of sensation (called neuropathy). The onset of neuropathy is gradual and often people who develop this complication are unaware of it in the beginning. Often it occurs between 7 and 10 years of having diabetes, although in some cases it can occur sooner where blood sugar levels have not been so well controlled.

If you have lost feeling in your feet then it is possible that you may unknowingly damage your feet. You may stand on sharp objects like a nail, piercing the skin even down to the bone without realising. If unnoticed and not treated appropriately this can have potentially serious consequences and could lead to an amputation. Such an outcome is less likely if you seek expert advice from your multi-disciplinary foot team.

This explains why your podiatrist checks your ability to feel pressures on the soles of your feet and toes every year. If you are forewarned that you have lost or are losing feeling then you will be able to reduce the risk of problems occurring by undertaking daily inspections of your feet and taking precautions such as not walking bare footed or sitting too close to fires.

 Occasionally people with loss of feeling can sense a burning pain in their feet. This can be severe and worse at night, they can find contact from socks and shoes can cause discomfort. This is called painful peripheral neuropathy. If you experience these symptoms it is advisable to consult your Diabetic Clinic or Podiatrist, since it is possible in many cases to alleviate the symptoms. Diabetes can also affect blood supply to and within your feet, this can delay healing and increase your risks of infection. Because the implications of poor blood supply can have serious consequences for your feet, your podiatrist will routinely screen your feet for signs of poor blood flow. If necessary you may be referred on to a Vascular Surgeon.

If you have been diagnosed with diabetes then it is possible that you could develop complications in your feet. For example, you are at 15 times increased risk of having a limb amputated.

The risks of complications can be greatly reduced if you are able to bring your blood sugar levels under control. They are also reduced if blood pressure and cholesterol levels are monitored and controlled with medication if needed.

Smoking is also not a good idea as it has adverse effect upon blood supply to your feet.

What does the Podiatrist look for?

If you are presently at low risk of an ulcer you can expect your Practice Nurse or GP to check your feet once a year. However if you are at increased risk of an ulcer, these inspections may be more frequent and by a Podiatrist. The Podiatrist will normally check both the blood supply to your feet and look for evidence of loss of sensation in your feet.

Blood supply will be checked by looking at the colour of the skin, checking the pulses in the feet and by asking questions about certain kinds of pains in your feet and legs. Normally people have two pulses in their feet, one of the top (dorsalis pedis) and one on the inside of the ankle (posterior tibial), most often the podiatrist will check these pulses by feeling the pulse with their fingers. Sometimes they will use a small hand held scanner (called a doplar) to listen to the pulse.

Sensation will most commonly be checked with a monofilament and tuning fork. The monofilament is a plastic probe that is designed to buckle at a given pressure, and is a good indicator for loss of feeling.

The podiatrist will also be looking for any foot deformity or signs of excessive loading that may warrant either footwear advice or in some cases an insole.

Warning signs 

Check your feet, hosiery and shoes daily. If there are signs of redness in any part of the foot or leg, or if the foot feels warmer than usual, this might indicate infection of inflammation, which needs prompt professional attention. Awareness of pain and injury may be diminished, so inspect the inside of your shoes daily for objects like nails or torn linings, which might cut the skin.

You should urgently consult your podiatrist or seek medical attention, if you see any of the following in your feet:

·         A breaks in the skin or a discharge

·         The skin changes colour, becoming redder, bluer, paler, blacker over part or all of foot

·         New swelling in your feet

You should also seek an urgent appointment, if you normally have little or no feeling in your feet, but suddenly experience an unexplained pain or discomfort, especially if the surrounding skin is a little warmer to touch, when compared to the same spot on the other foot.

If you see a red or black spot within callus or at a site of a corn, you should see a podiatrist as soon as possible for this to be looked at, regardless of whether it is painful or painless. This is often a sign of excessive pressure that has resulted in localised bleeding under the skin. If left such an area is likely to develop into an ulcer, that may require prolonged treatment. Until you see your podiatrist you should keep off your feet as much as possible.

If your eyesight is impaired, or you have difficulty bending down to check, use a mirror or ask a friend to look for you. 

The foot is roughly divided into three sections: the hindfoot or heel, the midfoot and the forefoot & toes.

The function of the toes, especially the big toe, is to help us balance, and to propel us forward during walking or running. The 14 bones of the toes are among the smallest in the body, and, not surprisingly, things can and often do go wrong. Some problems begin in childhood and may go unnoticed. Others begin later on in life, perhaps as the result of injury or the added pressure of incorrect footwear.

What are bunions? 

What most people call a bunion is actually known as "Hallux valgus". Hallux valgus refers to the condition in which the big toe is angled excessively towards the second toe – and a bunion is a symptom of the deformity.

“In a normal foot, the big toe and the long bone that leads up to it (the first metatarsal) are in a straight line,” explains podiatric surgeon Trevor Prior. “However, Hallux valgus occurs when the long foot bone veers towards your other foot and your big toes drifts towards your second toe.”

A bunion actually refers to the bony prominence on the side of the big toe. This can also form a large sac of fluid, known as a bursa, which can then become inflamed and sore.

Is it serious?

“Some people have massive bunions that aren’t that painful but cause difficulties with shoes, while others have relatively small bunions that are very painful,” says Trevor. However, just because you have Hallux valgus doesn’t mean you’ll get the bursa.

Pressure from the big toe joint can lead to a deformity in the joint of the second toe, pushing it toward the third toe and so on. Likewise, if the second toe and big toe cross over, it can be difficult to walk.

“Once the big toe leans toward the second toe, the tendons no longer pull the toe in a straight line, so the problem tends to get progressively worse,” explains Trevor.

This condition can also encourage corns and calluses to develop.

Who gets them?

“Women tend to get bunions more than men,” says Trevor. “This could be due to the more restrictive footwear they wear, (such as high heels or narrow toe boxes which force the big toe towards the little toes) but women also tend to have looser ligaments, making them slightly more prone.” You’re also more likely to get bunions if your parents or grandparents have them.

What causes bunions? 

“No one single cause has been proven,” explains Trevor. “There are a number of causes, and though shoes can exacerbate the problem, bunions do occur in societies that don’t wear them.”

Michael Ratcliffe, a registered podiatrist who specialises in podiatric clinical biomechanics, explains that we walk on the same type of ground all the time, whereas the human foot was actually designed to adapt to varying terrains. In a sense, a bunion is a type of repetitive strain injury. And like repetitive strain injury, some people are more prone to it than others. One theory - though it remains unproven - is that bunions are caused by one or both of the following:

1) Because the foot wasn’t designed to constantly walk on a level surface, the ball of the big toe is slightly lower than the ball of the rest of your foot. When your foot meets the ground, the ball of the big toe is pushed up, and the big toe joint can’t bend as well as it was designed to. In order for the big toe joint to bend fully as you walk, your foot rolls slightly over to the side (this is also why people with hallux valgus often get hard skin).

2) Also, if your midtarsal joint tends to move from side to side more than it does up and down, the arch in your foot collapses as your foot rolls in. This also makes you more prone to developing bunions.

Such problems can be exacerbated by tight footwear. “Slip-on shoes can make matters worse,” says Trevor. “Because they have to be tighter to stay on your feet, you automatically have less room for your toes. And with nothing to hold your foot in place, your toes often slide to the end where they’re exposed to lots of pressure. Likewise, high heels throw more weight onto the ball of the foot, putting your toes under further pressure.”

If you haven’t got a bunion by adulthood and you later develop one, there could be some underlying arthritis.

What can I do? 

One of the best things you can do is to go for wider, deeper shoes. Trevor Prior says there should be a centimeter between the end of your longest toe and end of shoe. You should also choose shoes with an adjustable strap or lace.

Podiatrists often recommend exercises to strengthen your muscles and tendons around the big toe. Here’s one you can try yourself. Put your feet side by side, and try to move your big toes towards each other. Do this three or four times a day, while you’re in the bath or in bed.

What can a podiatrist do? 

Your podiatrist can recommend exercises, orthoses (special devices inserted into shoes), shoe alterations or night splints (which hold toes straight over night) which may slow the progression of bunions in children. According to Trevor Prior, ‘conservative’ measures such as these may help relieve symptoms, though there is no evidence they can correct the underlying deformity.

“Orthoses are designed to prevent the problem getting worse by decreasing any biomechanical causes of bunions,” says Michael. In other words, if the biomechanical theory is correct (i.e. if your bunions are caused by the way you walk), orthoses may help you walk in a way that doesn’t exacerbate the problem.

“But it won’t change the already established shape of your foot,” explains Michael. For that, you need surgery.

What can a podiatric surgeon do? 

Your podiatrist can refer you to a podiatric surgeon who will evaluate the extent of the deformity. A podiatric surgeon can remove the bunion and realign the toe joint in an operation generally referred to as a bunionectomy. However, there are actually around 130 different operations that fall under this title - so don’t presume you’ll need the same type of surgery as that friend of a friend who couldn’t walk for 3 months!

The aim of surgery is to correct the cause of the bunion and prevent it growing back. Which type of surgery your podiatric surgeon recommends will depend on the severity of your bunion. Because there are risks and complications with any type of surgery, it’s not usually advised unless your bunions are causing pain – or if it is starting to deform your other toes.

Silvers procedure – this is the simplest procedure that involves removing the prominent bump on the inside of the foot. But because it doesn’t cure the underlying deformity, it will only be used in people with mild deformities or in older people. This is a short procedure and recovery is quick.

Austin (Chevron)/Reverdin - green osteotomies – these involve cutting the bone toward the end of the first metatarsal (the long bone leading up to the big toe), before fixing it back into a straighter position. You’ll need to rest the foot for two to four days. You’ll be able to do limited walking and on average, be able to get back into shoe 2-6 weeks after the operation. You’ll walk normally around three months after the operation

Scarf osteotomy – This is similar to the above technique but because more bone is cut, it allows for slightly more correction. Recovery is the same as for the above procedure.

Base wedge osteotomy – This is for more serious deformities. A small wedge of bone can be removed from the base of the metatarsal. Recovery is longer. You’ll need to wear a non-weight bearing cast for 4-6 weeks (ie you can’t walk on it) and possibly a weight-bearing cast for 2-4 weeks.

Lapidus – This is very good for people that have a mobile metatarsal. By removing the bone in a wedge shape from either side of the joint at the base of the metatarsal, this allows the surgeon to correct the position of the metatarsal while fusing the joint, making it more stable. Recovery is similar to that of the base wedge.

Akin osteotomy - In many deformities, you need to straighten the big toe as well as the position of the first metatarsal. A small wedge of bone can be removed from the base of the big toe. This is usually done in conjunction with one of the above procedures and doesn’t lengthen the recovery period.

Keller arthoplasty – this involves removing the bone at the base of the big toe and essentially removing half of the big toe joint. However, this can leave the big toe a little bit unstable and is mainly used for older people with arthritis. Recovery is slightly quicker to that of the Austin procedure.

“Although the vast majority of patients have an excellent outcome,” says Trevor, “surgery cannot guarantee a pain-free toe or that deformity won’t recur again.”

Other Big Toe deformities

A complaint which is more common among men then women is "Hallux rigidus", where, instead of bending normally, the big toe stiffens and forms a bump at the top of the joint, making the 'pushing-off' motion in walking difficult. This often results from stubbing or injury to the toe, perhaps during sport. Women often suffer from "Hallux rigidus" as a result of persistent trauma to the joints from slip-on or shoes that are too tight.

Wearing shoes with low heels and firm soles will act as a supporting splint. Registered podiatrists will be able to provide pads or strapping to stabilise the joint, or appliances (orthotics) to modify the way you walk. In severe cases, footwear may be modified or surgery may be indicated.

Smaller Toes

Another common complaint is "Hammer Toes". The toe most usually affected is the second, which becomes bent up in an inverted "V" shape and can't straighten out during walking. Corns develop where it rubs against the shoe. Some people are born with clawing of the lesser toes, which might be due to muscle imbalance, and can lead to hammer toes. Too-tight shoes and socks make the condition worse.

You can help by investing in shoes that are "foot shaped" - with a straight inside edge, rounded toe and a toe box deep enough to remove pressure on the joints. Registered podiatrists will be able to prescribe treatment, appliances which straighten the toes, or, when necessary, may advise surgery to provide permanent correction.

Curly Orretracted Toes

Many babies are born with toes that don't lie flat, or are retracted. The problem generally clears up, especially if the toes are not too restricted in the early stages by tight shoes and socks. If the problem continues, muscle strengthening exercises may help, or silicone orthoses may be needed to correct the complaint. Take a look at our section on children's feet for more details.

The human foot is a highly complex structure, composed of 26 bones working together to enable us to walk and run, providing mobility and quality of life. In the newborn, the foot is made up of relatively soft and flexible cartilage that gradually converts to bone over time. During this period of development great care should be taken with your child’s feet as they can be at risk from injury and deformity due to ill-fitting footwear and abnormal activity. 

Oh look, he's got your feet 

At around the age of two the foot shape your child has inherited becomes clear. There are three main foot shapes. Which are you?

Tapered: Big toe is definitely big here

Rounded (or Grecian): The 2nd or 3rd toe is actually longer than the big toe!

Square: Well not quite square but all toes of roughly equal length.

Older Kids' Feet 

Feet continue to grow and develop well into the teens but by the age of 5, kids’ feet are starting to look more like grown-up versions. But they’re still vulnerable even at this stage.

Still growing strong: By the age of 5 the foot has its full count of 26 bones now the navicular bone has developed. However, even at the age of 8 the bones in the foot are still not fully formed, as the “secondary centres of ossification” are still not complete. However feet will start to grow less quickly (good news for parents) but still by a whole size per year. The arch is also properly developed, which means your child’s footprint will now start to look much more like your own.

Walk like a man (woman): Only now does the foot develop the adult walking motion. The foot touches the ground first on the outside of the heel. The weight is then transferred down the foot’s outer border and the front part of the foot touches down. Finally, weight moves to the inside of the foot and the toes push off towards the next step.

Fit still first concern: Even now when your child’s foot looks more like an adult’s, it’s still almost as vulnerable as it’s ever been. The new heel to toe walking style means the shape of the foot changes inside the shoe with every step, so having shoes that are the correct shape and fitting is as vital as ever.

Right fit, right look: Even very young children quickly develop a strong sense of what they like. For girls especially, having the right look is very important. Some retailers now produce good-looking shoes which also care for your child's feet.