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Toe Woes - what goes wrong with feet

bySuzette Hill | May 1, 2003

Three out of every four Americans will have problems with their feet at least once in their lifetime. Combined with the fact that women experience four times as many foot health problems as men, it’s a sure bet that most clients will complain of one or more foot disorders at some time. And little wonder: With 26 bones, 33 joints, 107 ligaments, and 19 muscles, the foot is a complex structure that stands up to a lot of pressure.

According to the American Podiatric Medical Association (APMA), most Americans log 75,000 miles on their feet by the time they reach the age of 50.

Fortunately, APMA affirms that the foot and ankle are well designed to handle the stresses of living on the run. Even so, without early detection and intervention, disorders of the feet can sideline otherwise fit individuals. Not only do the conditions detailed below cause pain and discomfort in the feet, but also the adjustments people make to their gait can lead to pain in the knees, hip, and lower back.

Regular pedicures paired with an attentive home maintenance regimen serve as excellent preventive measures. Stay a step ahead of clients’ needs by learning to recognize the most common non-nail-related conditions that may cause pain and disfigurement to clients’ toes.While you can’t diagnose clients or recommend treatment, rate a 10 in customer service by alerting them to potential problems and referring them to a podiatrist or primary physician

Bunions: Bone Gone Beastly

According to The American Orthopaedic Foot & Ankle Society (AOFAS), more than half of American women suffer from a bunion (a misalignment of the joint where the big toe attaches to the forefoot).As the joint enlarges, the big toe tends to drift into — or even under — the second toe. This shift of the big toe combined with the enlargement of the metatarsophalangeal joint results in a bony protrusion that looks bad and feels even worse. The overlying skin can redden and swell in response to constant rubbing from shoes as well as from the simple act of walking.

This joint flexes with every step you take,”states AOFAS’ patient education materials. “The bigger the bunion gets, the more it hurts to walk.” Other symptoms may include restricted motion of the big toe and corns and other skin irritations between the first and second toes.

Don’t buy the story that bunions are hereditary: Foot specialists agree that while you can inherit the faulty foot mechanics that make some more prone to developing bunions, many bunions can be directly related to a history of wearing tight- or ill-fitting shoes.

“Nine out of 10 bunions happen to women,” states the AOFAS.“Nine out of 10 women wear shoes that are too

small.” Poor-fitting footwear, in fact, gets the blame for most foot disorders, making it critical to put shoe fit over fashion (see “10 Shopping Tips to Make the Shoe Fit” at end of this story).

Advise clients who suspect they may be developing a bunion to seek treatment from a podiatrist or orthopedist.

Doctors can recommend several options — such as pressure-relieving pads, arch supports, and orthotic devices — to ease pressure, alleviate pain, and perhaps slow or stop the disease progression.According to the APMA, other options to reduce stress and pain include bunion pads, anti-inflammatory medications, ice packs, and ultrasound therapy.

None of these options correct the joint misalignment behind the bunion, however, and many foot specialists say that some people find no relief from the sometimes debilitating pain without surgery.And while surgery is no walk in the park, doctors have innovated numerous new surgical techniques to correct bunions that allow many patients to walk almost immediately wearing a special shoe.

Clients with bunions can certainly enjoy pedicures, and absolutely will benefit from the skin and nail care — just take care to avoid putting pressure on the bunion or manipulating the deformed joint. Follow the client’s lead during the massage to determine her comfort zone. Doctors also recommend keeping soak water on the cool side because heat can magnify inflammation. Many women with bunions will develop corns on top of or between toes. Corns can cause significant discomfort in and of themselves, particularly when they thicken. Some doctors urge pedicurists to defer thinning the corn, while others say it’s safe to reduce them with a callus file or exfoliating cream. Use your best judgment, but take care not to thin the corn too much — and to never cut it.

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Smash Hammertoe Habits

The feel of sand between the toes, fresh grass under the feet — many tactile sensations can cause the toes to curl with pleasure. But when the curling is contracture of the toe response to illfitted shoes or a foot disorder and becomes a long-term habit, the condition is called hammertoe or claw toes (depending on which toe joint is involved and the direction of the contracture).

The contracture is typically a result of a muscle imbalance between the tendons on the top of the toe and the ones on the bottom.“Hammertoe is the general term used to describe an abnormal contraction or ‘buckling’ of the toe because of a partial or complete dislocation of one of the joints of the toe or the joint where the toe joins with the rest of the foot,” says Richard Allen, D.P.M., a podiatrist in Lewiston, Ohio. “As the toe becomes deformed, it rubs against the shoe and the irritation causes the body to build thicker skin to help protect the area.”

According to Dr. Allen, a deformity in the joint nearest the nail is called a mallet toe, while a deformity in the joint where the toe meets the foot is called a hammertoe.Deformities in both joints, on the other hand, result in what’s called a claw toe. Regardless of which joint is involved, the toe contracture results from muscle imbalances that cause the tendons and ligaments in the affected joint to tighten and shorten, which in turn bends the toe.

According to podiatrists at The Walking Clinic in Colorado Springs, Colo., the important distinction in toe contractures is whether the toe is flexible or rigid. Initially, contracted toes can be straightened (hence the term “flexible”), but over time tendons and muscles in the toe permanently shorten and the joint freezes, making the contraction permanent and the toe rigid.

While flexible contractures can be relatively painless — except when corns form in response to friction from shoes — rigid hammertoes can restrict foot movement and cause pain in the foot as well as potentially cause other imbalances that lead to additional disorders.

While the toe is still flexible, hammertoes are relatively easy to correct. For example, the doctors at The Walking Clinic regularly release the tendons from the bone, a fast surgery done via a tiny incision in just minutes. The patient has only a local anesthetic and walks out of the office with little more than a bandage to mark the operation. Rigid contractures, on the other hand, require a more invasive surgery to remove the joint or fuse the bones. While these procedures straighten the toe, podiatrists emphasize that the rigid toes can cause pain while walking and may even negatively affect the walking pattern.

To minimize the risk of forming hammertoes, Dr. Allen recommends women ensure their stockings don’t constrict their toes and cause them to contract. Avoid high heels, as well, which tend to jam toes into the front of the shoe and cause the tendons to contract. Treat the corns that are a common result of hammertoes the same as advised for bunions, and use a light hand around affected toes when massaging. Refer clients to a podiatrist for treatment, urging them to seek help before the joint freezes.

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Nix Numbing Neuromas

We all know the uncomfortable sensation of a small stone jabbing the bottom of your foot every time you step — but what do you do when there’s nothing there? People with Morton’s neuroma know there’s no choice but to grit their teeth and hobble on.

Morton’s neuroma results when the tissue surrounding the digital nerve leading to the toes thickens where the nerve passes under the ligament connecting to the toe bones. As with bunions, women account for nine out of 10 sufferers of Morton’s neuroma. Unlike a bunion, however,Morton’s neuroma typically leaves no visible sign. Instead, symptoms range from pain between the toes while walking, the sensation of having a stone in the bottom of the shoe, and a burning pain in the ball of the foot that may radiate into the toes. They may also experience numbness in the toes.

In diagnosing Morton’s neuroma, the American Academy of Orthopedic Surgeons recommends that doctors look for a mass or “click” between the bones of the third and fourth toes (where the tissue thickening typically occurs). The doctor also will rule out arthritis or joint inflammation by checking the range of motion in the toes. An X-ray offers the final proof by ruling out stress fractures or arthritis in nearby joints.

As with bunions and hammertoes, Morton’s neuroma can result from biomechanical deformities and tight and high-heeled shoes. APMA also cites repeated stresses and trauma to the nerve as factors contributing to the condition. AOFAS cites research that concluded roomier shoes, anti-inflammatory medications, custom foot orthotics, and local cortisone injections can provide symptomatic relief. APMA recommends choosing shoes with laces or buckles that allow for width adjustment, as well as footwear with thick, shock-absorbent soles and low heels.

“The primary goal of most early treatment regimens is to relieve pressure on areas where a neuroma develops,” APMA states. Other options include special padding at the ball of the foot and custom shoe inserts. The remaining 20% who get no relief from non-invasive options may opt for surgery to remove a small portion of the nerve or release the tissue around the nerve.

Without diagnosing the condition, advise clients who complain of the above symptoms to seek treatment from a podiatrist — but they can safely wait until after they’ve received their pedicure. Show the same considerations for patients with symptoms ofMorton’s neuroma as you would for patients with bunions and hammertoes, even if the problem isn’t as readily apparent.

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10 Shopping Tips to Make the Shoe Fit

According to the American Orthopaedic Foot and Ankle Society (AOFAS), most foot disorders can be tied to improperly fitted shoes. Women are the worst offenders, bowing to the dictates of fashion rather than comfort by donning constricting stockings and topping them with high-heeled shoes and styles with narrow toe boxes. So it should come as no surprise, says the organization, that more than 90% of foot surgeries to correct deformities such as hammertoes and bunions are performed on women.

Help your clients avoid becoming a statistic by following these 10 tips from the AOFAS and the American Podiatric Medicine Association (APMA) when shopping for stockings and shoes.

1. Invest in high-quality stockings that fit properly. APMA notes that the stretch mechanism of inexpensive nylon pantyhose constricts normal expansion of the foot while walking, which can contract the toes.

2. Nylon stockings also promote friction and perspiration, creating the ideal environment for a fungal infection. Whenever possible, wear socks made of cotton or newer synthetic materials that wick moisture away from feet.

3. Shop for shoes late in the day, when feet are largest. Bring the type of socks or stockings you’ll regularly wear with the shoe style you’re seeking.

4. Have both feet measured for length and width every time you shop. Understand, though, that sizes vary by brand and even style, so try on every pair of shoes.

5. Fit shoes to the largest foot, allowing 3/8- to 1/2-inch space between the tip of your longest toe (which isn’t always your big toe) and the end of the shoe.

6. Choose shoes that conform to the shape of your foot. The toe box (the area of the shoe where the toes reside) should allow space for you to freely wiggle all of your toes. The heel of the shoe should fit firmly, with minimal slippage. Finally, the ball of your foot should fit at the widest part of the shoe, which is where the shoe is designed to flex.

7. Flat shoes (no higher than a one-inch heel) are the best choice for optimum foot health. The best all-purpose shoe, says APMA, “is a walking shoe with ties, a Vibram type composition sole, and a relatively wide heel no more than a half or three-quarters of an inch in height.”

8. If you must buy heels, AOFAS recommends limiting the height to two inches or less, and wearing them no longer than three hours at a time. Alternate with good quality flats or athletic shoes.

9. Choose shoes for the intended activity. AOFAS, for example, has seven sub-categories for athletic shoes based on usage demands. For example, the association deems a soft upper, good shock absorption, smooth tread, and a rocker sole design as key qualities in a walking shoe. In contrast, AOFAS recommends judging a jogging shoe based on cushioning, flexibility, control and stability in the heel counter area, lightness, and good traction.

10. Walk around the store several times to make sure the shoes fit and feel good. Don’t purchase shoes that feel too tight, expecting them to stretch. Know the store’s return policy; if possible, “test-walk” the shoes in your home for a few hours.

 

 

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