Minor foot conditions such as blisters, calluses, and cuts are often ignored as a result of the inability to feel and sense pain. Thereby, this loss of sensation can develop into foot infections, ulcers, and possibly result in amputation. The loss of sensation takes away the natural ability for the foot to feel irritation. As a result of unchecked glucose levels, the nerves in the foot are unable to warn the diabetic patient to sense minor injuries leading to infection.

It is imperative that the feet be inspected daily. If a problem is found it should be addressed by your podiatrist immediately to prevent any complications. Diabetic leg and foot problems are the leading reason for diabetes related hospitalizations and diabetes is the leading cause for amputation of the leg and foot.

One of the more serious foot problems associated with diabetic neuropathy is Charcot foot. This progressive degenerative condition results in the joints of the feet being subjected to continual trauma and injury. A minor trauma may initiate the process, and the loss of feeling in the foot allows for repeated injury to the joint, ligaments, and cartilage. Symptoms may include insensitivity in the foot, and increased warmth relative to the other foot. Signs may include change in the shape of the foot, redness, and swelling. As a result of the nerve damage caused by diabetic neuropathy, the muscles of the foot and ankle are weakened allowing for instability and dislocation. Advanced Charcot foot causes deformities which can result in calluses and ulcers as bony protrusions increase pressure with walking and standing leading to possible infection.

If you have diabetes it is imperative for you to have a comprehensive foot examination by a podiatrist. Diabetic neuropathy can rob you of any and all feeling in your lower extremities resulting in life altering complications. The only way to prevent this is by monitoring the condition of your feet daily and utilizing the expertise and experience of your podiatric doctor.

Plantar Fasciitis

What is it?

Plantar fasciitis is an inflammatory condition that occurs where the plantar fascia attaches to the medial tuberosity of the calcaneus.

What causes it?

Over-pronation results in a constant tugging of the aforementioned attachment site. Inflammation then results from this constant insult to the local tissues. When the patient is off-weight bearing, scar tissue begins to repair the site of injury. When the patient resumes weight-bearing, the scar tissue is torn resulting in acute pain. This explains why patients with this disorder typically experience the most pain when they get out of bed, or stand after a period of sitting.

What is the treatment?

Firstly, one must control the acute phase with ice or modalities that aid in the reduction of inflammation. Next, the biomechanical fault (over-pronation) needs to be corrected to take the chronic strain of the fascia. This may be accomplished with a properly designed custom orthotic.

Morton’s Neuroma

What is it?

Morton’s Neuroma is a thickening of the tissue that surrounds the intermetatarsal nerve leading to the toes.  When the nerve becomes squeezed and irritated, it causes painful symptoms.  Neuroma patients occasionally complain of a “pins and needles” sensation that spreads through their fourth and fifth toes, or of a feeling akin to hitting their “funny bone.”

What Causes It?

A neuroma can occur in response to the irritation of a nerve by one or more factors:

. Abnormal foot function or foot mechanics: primarily excessive pronation that causes strain on the nerve.

. Improper footwear: constricting, narrow, poor-fitting shoes with a tight or pointed toe box tend to compress the end of the foot, leading to excessive pressure in the area of the nerve. High-heeled shoes are a particular culprit here.

. Previous trauma to the foot: Those who engage in high-impact activities that bring repetitive trauma to the foot (running, aerobics, etc.) have a greater chance of developing a neuroma.

What is the treatment?

Once a diagnosis is obtained, it is essential to begin treatment immediately. If caught early enough, shoes that fit properly, and orthoses with metatarsal support may eliminate the need for any further intervention. There are orthoses and corrective shoes that can effectively alleviate the disturbances to the foot mechanics that are causing nerve inflammation.

Metatarsalgia

What is it?

Metatarsalgia is not an injury; it’s actually a symptom or a group of symptoms.  These may include pain in the ball of the foot, with or without bruising, and inflammation.  It is often localized in the metatarsal heads or it may be more isolated, in the area near the big toe.  One of the hallmarks of this disorder is pain in the ball of the foot during weight-bearing activities. Sharp or shooting pains in the toes also may be present, and pain in the toes and/or ball of the foot may increase when the toes are flexed. Accompanying symptoms may include tingling or numbness in the toes. It is common to experience acute, recurrent or chronic pain as a result of this problem.

What causes it?

Metatarsalgia develops when something changes or threatens the normal mechanics of the foot. Ultimately, this creates excessive pressure in the ball of the foot, and that leads to metatarsalgia. Some of the causes of metatarsalgia include:

. Being overweight: the more weight is brought to bear on the foot, the greater the pressure is on the forefoot when taking a step. As men and women age, the fat pad in the foot tends to thin out, creating less cushioning and making them more susceptible to pain in the ball of the foot.

. Wearing shoes that do not fit properly: Shoes with a narrow, tight toe box, or shoes that cause a great deal of pressure to be put on the ball of the foot (high heels, for example) are often the cause of metatarsalgia. Because such footwear inhibits the walking process and forces the wearer to alter his or her step to adjust to the shoe, the mechanics of the foot are compromised.

. Certain foot shapes contribute to metatarsalgia. A high-arched foot, or a foot with an extra-long metatarsal bone can cause pressure on the forefoot region and contribute to pain and inflammation there.

. Claw toes or hammertoes can press the metatarsals toward the ground and cause stress on the ball of the foot.

. Arthritis, gout or other inflammatory joint disorders can produce pain in the ball of the foot.

What is the treatment?

Some of the best treatments come from being proactive. Having the patient keep their body weight at a healthy level and wear shoes that fit properly, particularly in the toe area. Patients should avoid high heels whenever possible.

For patients with metatarsalgia one or more of the following measures should be taken:

. Orthotics help feet function more normally inside the shoe.  Metatarsal support should be considered in the design of the orthotics.

. Wearing appropriate footwear: clinicians should take a look at the footwear of their patients.

. Advise the patient to keep the body weight in a healthy range.

. Rest and ice.

Achilles Tendonitis

What is it?

Achilles Tendonitis is an inflammation of the common tendon of the gastrocnemius and soleus muscles of the posterior compartment of the leg.

What causes it?

Patients that have equinis deformity and/or run up-hill are candidates for this disorder. As the tibia moves over the foot, the ankle joint needs to be able to dorsiflex at least 10 degrees. If this is not possible, due to tightness of the aforementioned musculature, the tissues of the tendon can be damaged. In addition it is thought that over-pronation may reduce the blood supply to the area by “wringing out” the arterial blood supply to the tendon. This is due to the twisting movement of the tendon associated with over-pronation of the foot.

What is the treatment?

Firstly measures to reduce the inflammation such as ice and various electrical modalities should be employed. In addition all shoes should have a heel lift in them to reduce the strain on the tendon. In fact the patient should not even stand barefoot during this phase. After the acute phase, the patient may undergo a stretching program and foot orthotics should be prescribed to reduce the over-pronation. It is also advisable to have heel lifts added to the orthotics and to avoid up-hill running in the future.

Shin Splints

What is it?

The condition known as Shin Splints involves a muscular over-use scenario. There are Anterior Shin Splints and Posterior Shin Splints. Anterior Shin Splints involve the Tibialis anterior muscle of the anterior compartment of the leg, and Posterior Shin Splints involve the Tibialis posterior muscle of the posterior compartment of the leg.

What causes it?

Both of these muscles are involved in slowing down pronation during the stance phase of gait. Tibialis anterior functions early in the stance phase while Tibialis posterior functions a little later. If the patient over-pronates or pronates too rapidly, either or both of these muscles may be called upon to work harder than normal. As a result, fatigue sets in, leading to inefficient force production which leads to micro-tearing of the soft tissue and therefore an inflammatory reaction. Since the muscle is wrapped in a fascial covering, the swelling that occurs from the aforementioned problem is restricted by this covering. Beyond the fact that much pain results from the entire process, the pressure within the fascial covering can be sufficient to “choke-off” the blood supply to the involved musculature, further added to the insult on the tissue. In severe circumstances the swelling can be severe enough to damage the deep peroneal nerve resulting in a permanent “foot drop”, as this nerve supplies the dorsiflexors of the foot.

The scenario that typically brings on “shin splints” is a sedentary individual that suddenly starts running or walking long distances. When that individual is also an over-pronator, the combination of having weak muscles from lack of activity and having this biomechanical fault increases the likelihood of injury. Even changing the type of shoe worn during walking or running can be sufficient to increase the pronation of the subtalar and transverse tarsal joints and lead to tissue injury.

What is the treatment?

The first step in the recovery process is to stop the activity that initiated the tissue damage. At this point measures to control inflammation such as ice, anti-infammatory medication and electrical modilities such as ultrasound and interferential therapy may be indicated. The patient is then started on a stretching program followed by a program aimed at strengthening the involved musculature. The next step is to begin walking distances that do not aggravate the condition. The mileage is gradually increased until the patient can complete the activity without pain. This is probably a good point in the recovery protocol to introduce foot orthotics to reduce the over-pronation. Without the orthotics, it is quite possible that the conditions will re-occur even with the proper conditioning. The orthotics will help take the load of the muscles that will be over-worked if the pronation is not controlled. Once the patient has adapted to the biomechanical devices, the patient may start running short distances. The mileage is gradually increased until the desired level is reached.

Iliotibial Band Syndrome

What is it?

The iliotibial band which is a thick extension of the tensor fascia latae muscle slides over the lateral epicondyle. Iliotibial Band Syndrome is an inflammatory reaction at the side where this sliding occurs.

What causes it?

If the foot over-pronates, this is accompanied by internal rotation of the entire lower limb, producing a constant friction between the band and the bony prominence of the femur. It is therefore very common among runners especially if they run on a banked track or downhill.

What is the treatment?

First the patient must rest from the causative activity. During this time anti-inflammatory measures should be employed (ice, various modalities). Finally the biomechanical fault (over-pronation) should be corrected reduce the tendency for the lower limb to rotate excessively. An orthotic designed to reduce pronation should accomplish this task.

Runners Knee

What is it?

Runner’s Knee is a general term referring to pain around the front of a runner’s knee.

What causes it?

If the pain is anteromedial in location, the source of the problem may be over-pronation. The internal rotation of the tibia associated with over-pronation, may cause the knee to fall into a functional valgus orientation during the stance phase of gait. This in turn will compromise the ligaments on the medial aspect of the knee. Furthermore the abnormal motion will result in abnormal pressures behind the patella, leading to a more specific knee malady referred to as chondromalacia patella.

What is the treatment?

If over-pronation is the biomechanical fault in question, then orthotics designed to normalize the movements of the subtalar and transverse tarsal joints will solve the problem rather quickly.

Sacroiliac Syndrome

What is it?

Sacroiliac syndrome is a painful inflammatory condition of the sacroiliac joints. The patient generally experiences pain in the buttock and thigh regions. It is typically aggravated by sitting for long periods.

What causes it?

Quite frequently is is caused by an injury such as would be sustained by a fall on the buttocks or during a lifting activity. However there is some evidence to suggest that a chronic irritation from abnormal foot mechanics is also a possible cause. When a foot over-pronates, it creates a tendancy towards internal rotation of the lower limb. Due to the anatomy of the hip joint, this internal rotation translates into an extension of the pelvis (PSIS’s rotate upward while ASIS’s rotate downward). If the mechanics of the feet are not symmetrical, then conflicting rotations may occur at the two sacroiliac joints. This appears to set up a chronic irritation of these joints leading to the inflammation.

What is the treatment?

Spinal manipulation will be effective if the cause was traumatic in nature. However if the cause is poor foot mechanics, manipulation will only resolve the symptoms temporarily. To address the issue at hand, correction of the abnormal foot mechanics may be accomplished with orthotic prescription. Once the offending pathomechanics are dealt with, spinal manipulation should show long lasting effects.

At Foot and Ankle Alliance we will give you a comprehensive Gait analysis.  This includes the computerized gait scan that determines any abnormalities in your gait pattern.  This will also give us information of how to construct the best Orthotic device that is perfect for your feet. This will take the guess work out of the equation.

Aside from humor i wanted to talk about his injury.   I have tried to read about what exactlly caused the injury to his foot and i have not found much. Rockets team doctor “Clanton” said that he has sustained a hairline fracture in his foot.  He recommended surgery at first but they thought that this fracture can heal on its own.  The team and the dcotor did not discuss what bone in the foot they are talking about so i am going to shet some light on this subject.

A stress fracture is one kind of partial fracture in bones. It results due to unusual or constant stress. This is different to other kinds of fracture which are generally regarded as lone, serious effect. It could be explained as a quite small silver or fracture in the bone this is the reason at times it is called as hairline fracture.

Since they mentioned stress fracture and the said it was a hair line fracture I can tell that this fracture is non-displaced. What does this mean? What this means is that one of the bone in the foot  probably the  mid foot ( see pic area #3) is fractured but the two pieces are not separeted. This is good news because if they were separated he would have needed surgery.  Whenever there is a fracture , in order for this fracture to heal you need 1. bone to bone contact 2. no or minimal movement between the pieces.

Treatment for Yao is immobilization and rest.  He is wearing a Cam walker ( ski boot type of shoe).  This type of shoe has a very rigid rocker bottom which lets him walk without putting any stress on  his foot.  This boot does not let him bend his foot when taking a step and therefore minimizing the movement in his foot.  In the old days we used to cast people but these boots have allowed us to pretty much do the same thing without the hassle of putting the cast on and changing it every week.  Patients like this device better as well since they can take it off when showring etc…..  We still use cast for pediatric patients since they are more likely to be non compliant.

Healing time for bone is about 8-12 weeks that is if everything goes well.  So Yao is out for 8-12 weeks .  His doctor probably will use a bone stimulator to speed up the bone healing.  Bone stimulators have been popular in the last decade. There are few different companies that make these devices and they provide electormagnatic field that stimulates bone healing by varies physiological process ( I am not an expert in this field).

Yao needs to stay off of his foot in order for this fracture to heal.  If and when this does not happen , then he definatly needs surgery.  His doctor will take periodic x-rays /MRI/CT Scans to monitor the bone healing.  When a fracture does not heal it will turn in to what we call non-union.  I hope this does not happen but if it does , he need an operation .  This operation invovles the bones to be separated and cleaned up and put together with some kind of fixation.  Various bone substances are available to make the bones sick together better.

The well-equipped Walker

Let me ask you a question. What do you need to go on the walk? You probably say, a pair of shoes, a shirt and shorts. But if you’re going to do it right, you need to know that the right gear is very important. Your shoes should be comfortable and help you in staying injury free. Don’t focus on the price of the shoe and how it looks on you. The equipment has to be practical, durable, and comfortable.
Running/walking shoes
in my opinion running shoes should meet particular biomechanical needs. A good running shoe is designed to minimize injury and maximize form and function.
Factors to consider:
- foot type (high arch, flatfoot, normal arch)
- foot strike (heel striker, forefoot striker, mid- foot striker)
- stride pattern (pronator, supinator, neutral)

Buying the right shoe:
Purchase your shoes at a specialty running store rather than a wholesale sporting goods store. Pick a store that caters to the needs of runners, often have a professional and knowledgeable individuals who understand the needs of runners and are familiar with the latest models and brands of shoes. The experts at the stores are trained to match you with a particular shoe that would best for your biomechanical needs. One thing I suggest is that you shop for your shoes later in the day when you feet have swelled to their maximum size. There are many brands of running shoes and they are all equally good. The most important thing is to get the shoe that meets your biomechanical needs and feels comfortable to you.
Try the shoes on with the sock that you will be wearing when walking/running. Stand in the shoes, you need to have one thumb with between your longest toe and the end of the shoe ( have in mind that your longest toe could me your 2nd toe). This will prevent black toenails or toenails that fall off ( toes hitting the end of the shoe). Also, the heels should not slip out of the back of the shoe when walking. Try to take a walk in the shoe store, maybe off the carpet and on to a hard surface ( in the store if the store allows it).

Types of running shoes

Most important factors in choosing shoes are; support, cushioning and shock absorption. Training shoes that are very light weight are designed for experienced runners. However due to their lightweight these shoes don’t offer much protection compared to normal running shoes.

Shoe terminology

The Toe box :

Self explanatory (the toe section of the shoe), there should be about half an inch room between your toes and end of the shoe and top of the shoe.

Shoelaces:

Shoelaces should not be too long or too slippery. This is what pulls the uppers together and keeps your foot secure.

Uppers:

Material that holds the foot. This material should be breathable fabrics; this will prevent your feet from overheating during exercise/running/Walking. This Material should also be a sturdy material to help stabilize your foot in the shoe.

The tongue:

This should be thick enough to protect the top of the foot from the pressure of the laces but not too long that runs against your ankle.

Heel notch:

Most running shoes nowadays have a slight depression type into the shoe heel collar to reduce heel cord irritation and also to provide a more secure heel fit.

Heel counter:

This is a place where you heel fit securely in the shoe. This part of shoe is very important since an ill fitting heel can cause blisters on your heels. When buying shoes make sure you walk around and see if your heel is not coming in an out of the heel counter.

The sole:

Majority of the shock absorption and cushioning in the shoe is provided by the midsole. This part of the shoe you can not see. There are usually two kinds of midsole foams;

- Polyurethane : denser, heavier and more durable. Mostly heavier runners/walkers do well with polyurethane.

- Eva: softer, more cushion material . This is what most runners use

a good running shoe contains stabilizing technology, devices that reduce overpronation (rolling inward)

Wear and Tear

One of the most important aspects when you are running is how you lace them up. This might sound childish but I have seen many runners/runners with foot pain related to this.

- Heel slippage and top of foot irritation/falling asleep are due to improper lacing. If the top of your foot falls asleep or get irritated, your shoelaces are too tight.

** If your heel slips in and out of the shoe, while the laces are as tight as they can be, you might have a abnormally narrow foot. You might consider shopping for shoes from manufacturers that offer a variety of widths.

Consider Adding Orthotics

Every foot is unique and if you really think about it shoes that fit well and support your biomechanical needs are being mass-produced. Statistics have shown that only 1 out of 4 people have normal walking/running pattern. The other three-fourths have feet that either turn in too much (Overpronators) or not enough (Supinators). These runners are more prone to injury.

Types of orthotics:

- Over-the-counter orthotics: These orthotics are also again mass-produced. These devices come in various sizes ( S,M,L,XL etc..). This may help to some degree, but then again not everyone’s foot is the same. Also consider the fact that the materials used to make these devices are not durable ( might have to change them every few months)

- Custom-made functional orthotics: these devices are usually made by professional foot and ankle specialists. The way I do might functional orthotics for my patients is as follows:

o gait analysis by a digitized gait plate connected to a computer (this data is recorded and gives detail information about different parts of gait cycle)

o Full range of motion analysis of the feet ( this information provides the physician with any limitation of the joints in the foot). Limb length discrepancy is also major factor that I consider.

o Orthotics selection is also very important. We have a variety of orthotics to choose from which will make a difference in comfort and support. Just to name a few component;

§ thickness of the orthotics

§ top cover of the orthotics

§ external/internal heel and Forefoot post

Running Socks

Running socks are also very important, especially when you’re running or walking for more than half an hour. A good sock will prevent you from developing blisters on your feet. Stay away from cotton socks, these socks keep moisture in and promotes higher friction. There are numerous synthetic fabrics being used today. A good sock should fit well (snug) and Wick away moisture. My favorite sock for running or long distance walking is

“Wright Running Socks”, (Wrightsock)

Have had many people wearing the stock and there are all very happy. The sock will prevent enough cushioning and has an excellent fit. This is a double layered fabric that prevents blisters in most cases. They come in various size and style.

Treatment
The treatment for brachymetatarsia is very limited. Conservative treatment includes shoe modification ( more room in the toe box area) . Padding of the shoe to relieve pain in the high pressure area . Orthosis may be used to distribute the weigh to other bones.
Surgical treatment is performed to lengthen the bone to its ideal length. This is done by surgically cutting the bone and either 1. Grafting a bone between the two ends 2.Putting a device on the bone to lengthen the bone gradually ( my preferred method).
I like the lengthening method because it give the surgeon more control of how much he/she can lengthen the bone. I usually have the patient lengthen the bone 1/2 mm a day which is done by turning a screw at home ( this process is totally pain free).
Problem with method #1: If the bone needs significant lengthening and the surgeon tries to graft a bone that is too long ,the tendons, arteries and veins might not cooperate. This will result in lost of blood supply to the bone and eventually loosing the toe.

What is a high ankle sprain?

The best way i can explain this injury is to describe the anatomy of the ankle. The lower leg has two bones which starts below the knee. The bone on the outside is called the Fibula and the bone on the inside is called the Tibia. These two bones are connected together at the ankle by a ligament called the ” Syndesmotic ligament”. This ligament can be injured by various abnormal/extreme ankle movements. The bone that sits right under these two bones at the ankle is called ” Talus”. How you sustain a high ankle injury is when your foot is externally (outward) rotated to an extreme. In McGrady’s case his foot was probably planted against the floor and when Yao Ming landed on his ankle that caused his foot to rotate outward. If you want to demonstrate what happens at the ankle, just get a pencil and put it between your index and middle finger and rotate the pencil inward . You will see that your fingers pull apart and that is exactly how the tibia and fibula are pulled apart in these types of injuries. The outcome is an injury of the ligament that holds these bones together ( syndesmosis injury, i.e. high ankle sprain). There are various levels of high ankle sprains. I am not sure how severe McGrady’s high ankle injury is but the MRI and X-rays ( stressed view) will determine that.

How bad is this?

It all depends on how severe the injury is. If it is not a sever injury , it can be treated by means of immobilization ( cast, Boot) for at least 6-8 weeks. If it is severe, sometimes surgery is necessary . The surgeon will put a screw above the ankle from one bone to another to keep the ankle together and therefore allow the ligament to heal . The screw has to be removed before full weigh bearing, as it will not allow the normal range of motion at the ankle.

I myself like to use a fairly new device called “ankletightrope”. this devise is fabulous and you almost never have to remove it since it is flexible and will allow the ankle to have its normal movement. You can read more about this device at www.ankletightrope.com.