Common Symptoms

WHAT IS THE ACHILLES TENDON?

The Achilles tendon is the large tendon that connects your calf muscles to your heel bone. Actually three individual tendons, it serves two muscles in your leg, and is the largest tendon in your body. ?What is Achilles tendonitis? ?Inflammation of a tendon is called tendonitis, a condition linked to over- use and degeneration. But to understand this better, you need to know how tendons function. All tendons are elastic bands of tissue that attach muscle to bone. When a muscle contracts, the tendon pulls the bone towards the contracting muscle. Even though tendons are held in place by connective tissue bands, there is some latitude for slipping. A good example of this is the popping sound you hear when you crack your knuckles. The tendons are covered by a smooth tendon sheath, which allows the gliding motion over bone. Tendons have a poor blood supply and therefore heal very slowly when they are injured.

This condition is usually caused by some kind of significant, repetitive stress placed upon an inflexible lower leg. For this reason, I often see dancers and regular runners as well as novice marathoners and others who try to push themselves too far too fast. Dancers almost always rupture their Achilles tendons just above the site where the muscle attaches to the ten- don just below the calf. ?Among those more prone to this injury are women who wear high heels all the time and suddenly switch to flat shoes. The muscles in the back of their lower legs have been shortened from wearing high heels too often so that great force is put on the tendons when flats are worn. Simply keeping your lower leg muscles properly stretched can prevent this.

WHAT ARE THE SYMPTOMS OF ACHILLES TENDONITIS?

The number one symptom is pain. There may also be a slight swelling and the base of your heel may be painful to touch. Stair climbing can also cause pain. The tissue around the Achilles tendon where it inserts into the heel may appear reddish, and you may also hear the sound of two surfaces rubbing against each other when you move your ankle. Other symptoms include stiffness in this area, especially in the morning, thickening of the tendon, and a bone spur.

As in ligamentous injuries, there are varying degrees of damage. If you feel sharp pain in your calf, you may have a defect somewhere above your ankle area. If the tendon is mildly damaged a first degree case, you will find it difficult to rise up on your toes or walk on your heels. A second-degree case involves partial tearing of the tendon away from the heel bone. In a third-degree injury, the tendon is completely torn away from the bone, and some muscles may be ruptures. Only surgery will correct such third-degree injuries. In second-and-third degree cases, the ability to walk from place to place in significantly impaired.

WHAT CAN YOU DO ABOUT ACHILLES TENDONITIS?

What you do in the first 24 hours after your injury or when you first feel pain is crucial. Typically, this condition can be treated at home with rest, ice, compression and elevation. Rest your leg and take a break from any workouts or other activi- ties that cause more pain. You may need to wear a walking boot in order to reduce the pressure on the heel. Ice the tendon with an ice pack or bag of frozen peas or other vegetables. Apply ice for 20 minutes on and then 20 minutes off every few hours to reduce swelling. Compression with an ACE bandage or an elastic bandage for the first 24 hours is important. This will help minimize swelling. Elevate your foot above your heart. Your heel can also be elevated in your shoe with an insert or "lift" of felt or foam to reduce stress on the back of the leg and the Achilles tendon. Non-steroidal anti-inflammatory medications like ibuprofen and naproxen can alleviate pain and swelling in the short term, as can something as simple as a heel lift.

HOW TO AVOID ACHILLES TENDONITIS?

The best way to avoid this injury is to keep your body limber, and to do a regular stretching program for this and other parts of the body. This will increase the flexibility of muscles, ligaments, and tendons and help to prevent future injuries. When you exercise, especially if doing a new activity, begin gradually. If you have stopped exercising for a few weeks or more, resume gradually. Avoid being a weekend warrior. It’s a good idea to cross-train as part of your regular exercise routine, so that you're not con- stantly putting pressure on the same area of the foot. For example, if you like to walk, try swimming for some of your workouts. If you like to run, try cycling for a few of your workouts. Cross training benefits also include better conditioning of more muscle groups as well as decreasing the likelihood of repetitive stress injury.

WHAT DOES “PRONATION” MEAN?

Normally, your foot strikes the ground heel first, rolling forward toward your toes and inward at the arch. But your arch should only be dipping a little in this process. If it dips down too much, you've got what podiatrists call "excess pronation:' Your foot should spring back from each step with- out letting the whole arch touch the ground in a collapsing effect. If your arch falls on you, pain is inevitable. If you look at your shoes and are wearing out the outer border of your heel, this is an indication that you might be over pronating.

WHAT CAUSES EXCESS PRONATION?

Genetics play a role in how pronated your feet are. Other causes are obesity, standing for long periods of time, which stresses your arches, arthritic changes in your bones, old age, and wear and tear. Simply having flat feet won't take the spring out of your step, but troublesome muscle, bone, and ligament alignment, in which nothing fits together quite right, can make the arch of your foot take the brunt of your weight when you walk. Unfortunately, that inner side of your sole wasn't designed to bear the complete burden.

ARE THERE ANY OTHER REASONS FOR ACHING ARCHES?

If you suddenly change your routine; for example, you a very sedentary life to having to stand, walk, or climb a lot, you can also end up with arching aches. In this situation, you’ve simply overstretched underused muscles. Being unprepared for basketball, running, and tennis have been found to be arch enemies too. One of the most common causes of arch pain is plantar fasciitis, which simply means that you have overstretched a band of tissue, called the plan- tar fascia, running along the bottom of your foot from your heel to the ball of the foot. This band can become inflamed and very painful when walking. Standing on the rungs of a ladder or step stool too long isa typical way to hurt your plantar fascia. An inflammation of the small tendons that attach the muscles in your feet to their bones, may also be the cause of your arch pain. Long- distance runners have the worst tendon problems of all my patients.

HOW DO YOU TREAT ARCH PAIN?

Whether you've got tendinitis, plantar fasciitis, or simply aching arches, rest and ice packs, and later heat, may be applied to your foot. This should quickly reduce inflammation. An elastic bandage wrapping may help support the area, and new shoes with extra arch support can also ease your agony. You can try over-the-counter shoe inserts, which come in styles for your stilettos, flats, and sneakers, to help reduce arch pain. If you’re a runner, take a break from your regular running schedule for at least a week to see if the pain goes away. A wedge raising the inner border of your foot by 1/8- to 1/4-inch may be the best solution in the long run, but seek professional advice for this problem first. Pain relievers like ibuprofen (Advil or Motrin) can help temporarily. *G you are still in pain after trying home remedies, a visit toa doctor's office is in order. In certain cases, bones have been known to shift dangerously, and if this is the case, you ought to know. A good podiatrist or orthopedist won't just rely on your own description of your symptoms. He or she will ask you to walk and watch your footfall and your gait as you do so. Then he or she will ascertain your foot's range of motion by rotating it at the ankle and checking it for other kinds of flexible motion. Your doctor may also your feet. suggest X-rays, which use a small amount of radiation to show the joints in This can help rule out arthritis. Other tests include diagnostic ultrasound to show soft tissue tears along the arch, computerized tomography to show more detail than simply X-rays and an MRI, which will show details of the foot and ankle.

WHAT IS OVERPRONATION?

Overpronation is a biomechanical problem that occurs when your foot rolls in too much. Yes, a certain amount of rolling inward -pronation - is normal when you walk. The problem is if it's excessive and your foot rolls in too much and starts to collapse. This condition can be hereditary but can also be caused by obesity, pregnancy, and running, among other factors One way to tell if you overpronate is to check your shoes. If you're wearing out the outer border of the back of the heel, you're overpronating. Another way to tell is to look at the back of your leg. (You may need to have a friend take a photo to do this.) In a foot that doesn't overpronate, the back of the leg and the heel should be lined up. But if you draw a line from the back of the heel to the back of the leg and it curves out like a "C' shape, chances are that you're overpronating. As you'll see throughout this book, overpronating can cause an array of problems. Not only are you exerting much more energy to get your foot off the ground, but also you can get shin splints, heel problems, Achilles tendonitis, back problems, and more. Many people think overpronating means that you have flat feet, but that's not accurate. You can have flat feet and not overpronate.

WHAT DOES A FOOT ALLERGY LOOK LIKE?

They may not be able to sniffle, sneeze, or wheeze, but your feet, just like any other part of your body, can be affected by allergies. Your feet usually react to an offending allergen with an instant case of contact dermatitis. Signs of this are red to brown, bumpy, swollen blotches or spots that are ugly and itchy. Skin can also appear thickened, cracked, or scaly with blisters and it may be raw and sensitive. Not only can these symptoms crop up on your feet, but on your ankles, too. "Contact" is the key word, and the edges of your outbreak will be clear-cut. Sometimes the rash stops exactly where your shoes end; at other times you can see the outline of your offending socks after you've removed them. Foot allergies can be bad. When a 27-year-old chef came to see me still wearing his rubber-soled shoes, my heart went out to him. Red, swollen, oozing feet indicated the most severe case of contact dermatitis I had ever seen. What he didn’t realize was that his comfortable work shoes with the rippled soles were the reason his feet were on fire.

WHAT CAUSES FOOT ALLERGIES?

Some causes of foot allergies include sweating, hot humid weather, stress, dry skin and allergies to foods such as eggs, milk, fish, soy, and wheat. Some allergies can be genetic. New pairs of shoes, stockings, or socks can also cause a foot allergy. For example, if you are allergic to nickel, you will also react to substances called "chromates" used in the shoe-dying and leather-curing process, and various leather dyes also can lead to an eruption of blisters and bumps. Or, you may be allergic to the main ingredient in rubber cement, mercaptobenzothiazole, which is used to join pieces of leather. Moisturizing creams containing neomycin, lanolin, penicillin, perfumes, preservatives (such as sulfates), antihistamines, and parabens may also be a problem, too. Parabens are chemicals that are used as preservatives in cosmetics and skincare products that can also cause foot allergies. Always look for "para-ben-free" products. Read product labels and stay away from the ingredients in a product if your feet break out after applying it even once.

You can have an allergic reaction that starts slowly and builds up to a painful pitch all over your skin's surface. Or you can have an allergic rash all over your feet (or even your body) after wearing a new pair of shoes or socks and walking or sitting in a warm environment for a while. If trial and error or guesswork hasn't given you a clue about what the awful allergen is, go for a patch test at the doctor's office. This may pinpoint the offending chemical. One of my patients, a 26-six-year-old woman with parched, cracking heels, had applied a lanolin cream to her soles to soothe the dryness. Little did she realize that she was allergic to the lanolin, which wreaked havoc on her feet, literally inflaming the problem. What are some complications that can result from an allergic reaction? Allergic reactions aren't just uncomfortable; they can lead to serious skin infections like staph, discoloration, and thickening of the skin due to scratching. Prolonged itching and scratching may also lead to increases sensitivity of foot skin. Occasionally even permanent scars can results.

HOW DOES ARTHRITIS AFFECT YOUR FEET?

Your feet contain cartilage in many important joints and are susceptible to arthritis and consequent pain - arthritis' number one symptom. Your joints are lined with something called "synovial cells." When the number of these cells increases for some reason, the joint can become enlarged and thickened. The cells produce too much fluid, and it accumulates in the tissues, causing the joint to swell. Your joints may feel swollen, spongy, soft, hard, or tender. The pain will vary depending on the type of arthritis. The expanding of the synovium (layer of synovial cells) can be the cause of and the result of inflammation. It can also damage the cartilage lining the joint. Again, the degree of pain and inflammation depends on the type of arthritis that is present. Some people have chronic arthritis that lasts for years, while others have short, mild episodes. It's important to know what the cause of the arthritis is, because without proper treatment, inflammation can damage both cartilage and bone. Once the damage is done, it is irreversible. It becomes much harder to move your joints, and pain can increase, which is why treatment aimed at preventing the progression of your arthritis and destruction of the joint is essential and should be immediate.

The joint cartilage and synovial lining is a marvel of engineering. When undamaged the opposing joint surfaces, in conjunction with the synovial lining and fluid, glide over each other with literally-zero resistance. When lost or damaged, bone can grind against bone. If this happens, you can he, it, feel it, and your mobility can be severely restricted.

WHY IS ARTHRITIS SO PAINFUL?

Chemicals in the joint that control inflammation cause arthritis pain. The cells of the synovia and certain white blood cells release these chemical mediators. The white blood cells are responsible for the acute and chronic inflammation of arthritis. Certain chemicals that are released from the white blood cells, called "prostaglandins," are very powerful and can cause pain. Other chemicals make blood vessels expand and cause you even more pain and swelling. Still other chemicals, called "enzymes," may damage the joint tissue if they are allowed to remain in the joint for too long. In the later stages of the disease, the damage that has been done to the cartilage and bone causes more chronic pain because the abnormal cartilage and exposed bone are constantly rubbing against each other. Of course, pain is subjective, and it is always difficult for a physician to judge how much you are experiencing. A rheumatologist is trained to evaluate your personal condition, recognize your pain, and tailor the treatment depending on the severity and the cause.

WHAT ARE SOME OF THE TREATMENTS FOR OESTEOARTHRITIS?

At home: Resting the inflamed or painful joint can help as can avoiding activities that aggravate it. That said, exercise is a good way to build up the muscles around a joint to give it more support- the key is moderation. With acute pain, rest--for a few days; then gradually build an exercise program. If you are overweight, slimming down can reduce the stress on joints and the pain this pressure is causing. You can also try ice packs (or a sealed bag of frozen vegetables) to reduce pain and a heating pad to alleviate stiffness. You can try over-the-counter non-steroidal anti-inflammatory agents (like Advil and Motrin), and acetaminophen, (like Tylenol) and/or topical pain creams.

WHAT IS ATHLETE’S FOOT?

Athlete's foot is a scaly, itchy, smelly fungal infection that develops between your toes and on the soles of your feet. The medical term for athletes foot is tinea pedis (tinea, meaning grub, larva, or worm in Latin) and can refer to many different kinds of fungal infections of the skin; pedis lets you know that you are talking about the feet. The four common fungal culprits in athletes foot are Trichophyton rubrum, Trichophyton mentagrophytes, Epidermophyton floccosum, and Candida albicans. But even if you can't pronounce their names, any of these fungi can cause Athletes foot, as can an infection caused by any combination of them. Symptoms of his condition, the most common fungal infection, include dry, red, itchy, cracking- peeling, or stinging skin on your feet. In severe cases, you have dozing or crusty blisters. If your toenails get infected with fungi (a cont. lion called onychomycosis), the nail will pull away from the skin. See the Nail Disorders" chapter) Athlete's foot is a form of ringworm or jock itch, which is a fungal infection of the skin. It is has nothing to do with worms. Its actually a mold but it is usually called that only on skin surfaces other than the feet. Athlete's foot and fungal nails can be confused with psoriasis, but psoriasis is less likely io involve the toes and is characterized by silvery, gray, dry, and parchy lesions.

WHAT CAUSES ATHLETE’S FOOT?

Despite its name, you don't have to play sports or spend endless hours at the gym to get athletes foot. In fact, the microscopic organisms that cause this condition are one of the least prejudicial I know. You can easily get Athletes foot even if you've never put on a pair of sneakers! These contagious fungi attack the skin of your feet and the area between your toes and are easily picked up in moist, warm environments like locker rooms, public swimming pools and showers where people walk around barefoot. You can also get them from bathmats, towels, and shoes that have come in contact with infected feet. Be careful when renting shoes, such as when bowling.

You're more likely to develop this condition if you are overweight, or suffering from poor circulation in your feet (because you have peripheral vascular disease, congestive heart failure, or varicose veins or you're a smoker). Other risk factors include being over the age of 65 years old, male, and wearing tight shoes and/or sweaty socks, which create a warm, moist, airtight environment for your feet. The surface of your skin also makes you more or less susceptible. For example, the more alkaline your skin, as opposed to acidic, the more likely you are to get fungal infections. A weakened immune system is another risk factor.

HOW TO GET RID OF ATHLETE’S FOOT?

If you assume that athlete's foot will go away on its own, you're in for a not. so-pleasant surprise. It won't. It can also lead to complications. Sometimes people develop an allergic response to the fungus causing their athletes foot and this breaks down the skin and goes into the bloodstream. The result can be blisters on your hands or feet. Also, if a fungal infection like this one goes unchecked, cracks in the skin may develop that can allow bacteria to enter, leading to a secondary bacterial "superinfection" One of my patients, a young woman in her early 20s, had a fungal infection between her fourth and fifth toes. She ignored it and didn't even keep it dry, powdered or out of locker rooms. After two weeks, it turned into a much more severe infection of bacterial cellulitis that landed her in the hospital and on intravenous antibiotics. This could easily have been avoided if promptly treated.

HOW DO YOU TELL YOU IF YOU HAVE ATHELTE’S FOOT?

When I see a patient with a foot condition resembling athlete's foot, I first scrape off some of the scaly skin and then put it through a laboratory culture test. A solution of potassium hydroxide is combined with the scraping. If one of the fungi I mentioned earlier is present, the culture will grow. Under a microscope I can tell exactly what is present. The Wood's Lamp procedure helps distinguish a bacterial infection called erythrasma from athlete's foot. Under this light the scales of the skin will fluoresce a coral red if erythrasma is present.

HOW IS YOUR BACK CONNECTED TO YOUR FOOT PAIN?

Your back is a very complex structure. Bones, joints, ligaments, and nerves all converge there and are incredibly sensitive to the shocks and bumps of simple movement. The disks that make up your backbone bear the brunt. If your spine is continually out of alignment -from things like the way you walk or stand - its muscular support has probably been compromised. Poor posture can change the length of your muscles, and when they're over- stretched and you lack abdominal strength. These muscles can't support you, which results in dull muscle backaches. Other symptoms include an inability to stand up straight, limited flexibility, shooting or stabbing pain that may radiate down your leg, cramping, and muscle weakness. This leads to numbness in your foot.

HOW DO HIGH-ARCHED (CAVUS) FEET CAUSE AN ACHING BACK?

The name for a foot with an extremely high arch is cavus foot, referring to a cave-shaped instep. If your arch is too high, it will send painful signals up to your lower back. People with high arches have very heavy heel strikes. Their ability to absorb shock is often compromised. In a cavus foot all the forces generated by the ground with each step you take is sent straight up your leg and then to your spine. What adds to the high-arched foot problem is the lack of extra padding on the ball of the foot and the heel. Obviously such a heel hasn't had much time to build support with all the shock it absorbs on a regular basis. I've known patients who believed that their high-arched foot meant they had a good foot, but this isn't quite true, as we discussed in the "Aching Arches" chapter. The reality is that shock of your step is unnaturally distributed to your heel and the ball of your foot and both these areas can end up painful. The pain can go all the way up to your lower back, and wearing high heels can make matters worse since it puts more pressure on your back.

HOW TO TREAT THIS PROBLEM?

If your high-arched foot causes you pain, a podiatrist can treat the symptoms as they arise. Sometimes an orthotic placed under your arch works very well. Sometimes heel cups or padding across the metatarsal area of your foot redistributes the pressure, therefore eliminating the shock.

HOW DO OVERLY PRONATED OR UNCOMFORTABLY FLAT FEET CONTRIBUTE TO LOWER BACK PAIN?

Excessive pronation of your feet can also cause lower back pain. A simple flat foot isn't the problem, as I've explained; it is the pronation, or the degree to which your arch sags each time you take a step that causes the difficulties. When you have an overly pronated arch, your forefoot moves too much when you walk. Normally, your foot strikes the ground heel first, cling forward toward your toes and inward at the arch. But your arch should only be dipping a little in this process. If it dips down too much, you’ve got what podiatrists call excess pronation. When this happens and the lower leg rolls inward, the pelvis tilts forward increasing the curvature of your lower back and this can cause pain.

You can also be unbalanced, which puts extra pressure and shock absorption on the muscles and joints of your hips and knees, as well as your lower back High heels can be killers in this case. Your normal heel-to-toe movement is excessively increased causing your pelvis will tilt forward. If you wear high heels constantly, the pelvic muscles will lose their tone.

HOW DO YOU TREAT THIS PROBLEM?

Using over-the-counter shoe inserts that support your arch can help with alignment. In some cases, you may need to see a podiatrist for custom made orthotics.

Many golf players suffer from back problems which can be attributed to their feet as well as their swing. Because I've seen so many golfers with this problem, I created "Pillows for Your Feet° Soft Foot Gels Golf" (for men and women). This product helps to diminish back pain by supporting the foot arch. A supported arch keeps the pelvis from tilting forward and increasing the curvature of the back.

What if your legs are slightly different lengths?

If the difference is more than ¼ inch because of heredity or injury, your hips will tilt slightly and your spine may curve to one side or the other trying to correct for the difference. Your center of gravity will be thrown off just below your navel and so will the muscles of your lower back. Since any imbalance in your body will be corrected at the bottom somewhere, you will end up with pain in your feet as well as your back. Usually the side of your body with more pain is the side that is shorter.

To help even out the difference, you can put a little heel pad in your shoe. Make sure the pad is half the size of the difference in your leg lengths. For example, if you have an inch difference then the pad should be half an inch Determining if you have a difference in leg length isn't something you can measure yourself. You need to lie down and have someone else measure your body from the top of your hipbone to the inner portion of your leg at the start of anklebone.

HOW CAN A BUNION, PAINFUL CALLUS OR SIMPLE INGROWN TOENAIL GIVE YOU BACK PAIN?

If you try to take the pressure off the painful area of your foot and throw your weight in the opposite direction, you can end up changing your gait. When you do this, you will be pushing muscles out of alignment. This will make them tire faster and hurt.

WHAT DOES A BATTERED LIGAMENT FEEL LIKE?

By battered I mean strained, stretched, or impaired in some way. When these fibrous connecting bands are injured, it can be difficult to walk without pain or to move an area without feeling as though something has become disconnected or disjointed. Your ankle is especially predisposed to such problems. At the ankle joint, which bears the brunt of much of vour weight, where three bones come together - the talus, the tibia, and the fibula. (The tibia is the bone in the front and inside of your leg and ankle. The fibula is the long thin bone on the outside of your leg and ankle. They both surround and rest on the dome of the talus, which connects to the rest of your foot.) You can thank two groups of ligaments for keeping this joint stable. These groups, called the medial and the lateral ligaments allow your foot to move up and down. You need them in order to walk. High heels can wreak havoc with these ligaments. In a high-heeled shoe, your foot is in plantar flexion (heel up, toes down), your ability to flex your foot up and down is impaired and the higher the heel, the more vulnerable you are to injury. Falling off high heels or platform shoes, and twisting you foot inwards or outwards can cause significant injury.

WHAT ARE THE MOST COMMON ANKLE LIGAMENT INJURIES?

When you turn, twist or roll your ankle into an abnormal position or your ankle is positioned beyond its normal range of motion, you can stretch or tear the ligaments on the outer border of the ankle from their attachment points. Sometimes this sudden twisting can injure the medial or inside, ligaments as well. Either way, the result is a sprained ankle. Sprains are different from strains, which are caused by overstretching a muscle, tendon, or ligament without any gross tearing. Strains typically occur in your lower back or hamstring and are considered to be minor injuries with quick recovery.

You're more likely to sprain your ankle1f you are double jointed: meaning you have excess motion in your joints, if you are pregnant, or if you play sports like tennis or racquetball that involve quick side-to-side movement Falling awkwardly when wearing high heels or after jumping, walking or exercising on uneven terrain can also hurt your ankle ligaments. Another risk factor is a previous ankle injury. Your ankle may never heal properly, thus increasing your chances of future injuries. If you're overweight, you also put increased stress on all your weight bearing joints, especially your ankles. Knees and hips are also prone to ligamentous injuries.

WHAT ARE THE SYMPTOMS OF A SPRAINED ANKLE?

Symptoms include pain, tenderness, swelling, and even bruising. You may also notice that you can't move your foot and/or ankle normally. If you can't walk after a few minutes of rest, if you can't resume normal activities without pain, or if you hear a distinct "pop" when you hurt yourself you may have torn tissue. Prolonged pain, swelling, and a bruise in the region of pain (focal bleeding into the tissues) require medical evaluation because leaving a battered ligament untreated or resuming normal activities or wearing high heels before your ankle is healed can cause chronic pain, osteoarthritis, and permanent ankle issues.

HOW SHOULD YOU TREAT A SPRAINED ANKLE?

At home:

The first thing to think of is the acronym RICE, which stands for rest, ice, elevation, and compression. Put ice on the injured area for the first 24 to 48 hours. Keep your leg or foot elevated and try using an elastic bandage to compress the swelling. The ice will help constrict the blood flow and decrease bleeding and swelling. Raising the ankle above the level of your heart enlists the help of gravity in keeping blood away, also decreasing swelling and bleeding. The pain can be alleviated with ibuprofen (like Advil or Motrin), acetaminophen (like Tylenol) or naproxen (such as Aleve). It is best to use these non- steroidals after 48 hours so they don't delay healing.

After several days of this, I advise my patients to soak their ankles in warm water (96 to 100 F) for 20 minutes before beginning simple stretch in exercises aimed at increasing the range of motion. Ice should be used immediately and intermittently, five or 10 minutes per hour (we must permit blood flow in all areas of the body) for up to two days to decrease bleeding and swelling. The warmth is used to increase the blood flow so that the body can heal itself. After the swelling is gone, you may want to see a physical therapist who can show you exercises to increase your range of motion and strengthen and stabilize the ankle.

At the doctor's office:

Your doctor can take an X-ray, which uses a small amount of radiation to reveal any tiny cracks or fractures in the bones, a bone scan, which can reveal any damaged bones, a CT scan, which takes X-rays from various vantage points, or an MRI, which uses radio waves and a magnetic field to reveal damage to soft tissues.

One of the latest treatments for ankle sprains is prolotherapy. As my colleague, Joy Hamilton, M.D., MBA, describes it, "Prolotherapy is a controlled type of injury that induces healing? Here, an irritating solution, usually glucose, but sometimes saline or an anesthetic, is injected into the ligament or tendon exactly where it is torn, triggering a healing response in that specific area. Often three to six treatments are necessary. In severe cases, surgery may be necessary.

HOW LONG DOES IT TAKE FOR AN ANKLE SPRAIN TO HEAL?

It may take six to eight weeks for a simple sprain to heal, and even longer if you don't treat the ankle properly and rest it. I've seen patients who resume their normal activities or begin to wear high heel shoes too soon. But if the ankle isn't healed, you can make matters worse, risk further sprains, and create a chronic condition. Not only is this painful but it can lead to soft tissue damage. It can also cause a cankle - and no one wants that! Wearing a restrictive ankle strap may help. I have treated cases that were severe enough to require a cast and up to 12 weeks of immobilization.

WHAT DOES YOUR CENTER OF GRAVITY HAVE TO DO WITH YOUR LIGAMENTS?

Try to imagine an invisible line extending up through the middle of your body, past your belly button and out through the top of your head. This is often called the “line of your center of gravity” and for complete stability, it should be straight. If you’ve got a permanently slouched shape, or if you are pregnant, your center of gravity is thrown off. You are constantly off balance. You are stressing those ligaments that support your bones and general shape. You are out of alignment. In other words, your ligaments are struggling to compensate for this misshaping. They take a beating when this happens, and if you push them too far, you sprain them.

Pregnancy puts extra stress on ligaments because there are two factors working against them: the excess weight all in one spot and the increased amounts of hormones circulating throughout your body during these nine months. These hormones create ligamentous laxity in your body. Ligaments need to relax so you'll have room to accommodate your growing baby and get through labor and delivery, but, at the same time the ligaments across your stomach are stretching appropriately, causing the other ligaments in your body to be weakened. You may find yourself twisting an ankle or being able to flip your wrist in a way you never could before. The good news? This is not a permanent condition.

HOW CAN YOU AVOID LIGAMENT SPRAINS?

Wear good, supportive sneakers when you exercise. Poorly constructed shoes can do terrible things to your ankles and feet. If you can't get shoes to fit right and feel comfortable, opt for some over-the-counter orthotics in addition to high top sneakers to support your ankle. Always warm up before exercising. Don't run on uneven ground, and if you have inherently weak joints or other ligament problems, be careful when you run, jog, dance, or play racquet sports. Avoid platform heels, which are one of the worst types of shoes to wear, because you have no contact with the ground and all the shearing forces are placed on the ankle. Change your heel height regularly and do balance and stability exercises to strengthen muscles around the ankle as well as increase flexibility.

WHAT CAUSES A BLISTER?

A blister is actually the body's defense against the shearing forces of the friction between a shoe, sock and your skin. Blisters can develop from shoes or socks that don't fit right or from sweaty feet, and can be large or small, depending on how much friction is placed against the foot. These pus-filled sacs usually develop on the ball of the foot, the back of the heel or the tops of the toes. Most blisters start off with redness, swelling and a burning sensation. Sometimes your entire foot feels hot. Sometimes the friction is so great that a blood blister, also known as a hematoma forms.

HOW DO YOU PREVENT A BLISTER?

The key is to find shoes that fit well. If you get frequent blisters on the sides of your toes - particularly the big and little toes - your shoes may be too narrow. If the blisters seem to form most often on the tops of the toes, your shoes may be too short.

Properly fitting socks will prevent friction between your skin and shoes. If your feet tend to sweat, look for those made of cotton or synthetic materials that wick sweat away from the skin. If you exercise, opt for athletic socks, which tend to have extra protection in the areas that cover blister-prone parts of the foot. If you have bony toes or hammertoes, you can try covering sensitive areas and those that tend to blister with a bandage, over-the-counter blister cushions or moleskin to keep your shoes from rubbing the against the shoes. To prevent heel blisters, look for strap liners, blister roll on products or place a Band-Aid on the blister-prone area.

>You can also apply blister cream, petroleum jelly or any kind of emollient cream to areas you might suspect might blister to reduce friction.

Many athletes find that wrapping a very small amount of lamb's wool around the toes helps prevent blisters.

Foot powders also help by decreasing the frictional force against the foot and reducing the amount that your feet sweat. Rolling deodorant on the soles of your feet can reduce friction and sweating, which can help prevent blisters.

Botox injection is a new innovative treatment to diminish perspiration, friction and blister formation.

Dry your feet very well if they tend to sweat.

In some situations, something as simple as an insert in your shoe can help avoid the increased shearing forces on the foot, preventing blisters once and for all. You can try over-the-counter versions or see a podiatrist to have custom orthotics made.

HOW CAN YOU GET RID OF BLISTER?

At home:

Sometimes the best solution is simple to leave the blister alone, particularly when it develops ona weight-bearing area like the bottom of the foot. The unbroken skin over a blister protects it from bacteria and infection. Simply cover the blister with a Band-Aid and leave it alone. If the blister breaks on its own: wash the foot with mild soap (with no perfume or moisturizer if possible, such as Ivory soap). Rinse thoroughly and gently pat dry. Apply a topical antibiotic such as Neosporin, Bacitracin, or Polysporin. Cover with a sterile piece of gauze or a Band-Aid. For blisters that are painful, however, follow the steps below (unless you have diabetes or circulation issues, in which case see your doctor.)

You'll need:

-Rubbing alcohol or iodine

-A sharp, sterile needle

-Topical antibiotic cream like Neosporin, Bacitracin or Polysporin

-A Band-Aid or a sterile piece of gauze and tape

>Now Proceed:

>-Wash your hands thoroughly with soap and water before beginning.

-Gently wash the foot around the blister with mild soap and water.

-Rinse and dry gently.

-Clean the blister and surrounding area with rubbing alcohol or iodine.

-Clean your needle with rubbing alcohol or iodine.

-Using your needle, puncture the blister near the edge. Let the liquid drain out, but make sure that you leave the skin over the blister in place. This helps avoid infection and severe pain in the raw and sensitive underlying skin.

-Apply your topical antibiotic cream.

-Cover the blister with a Band-Aid or sterile gauze and tape.

-See a doctor ASAP if this area becomes red, pus-filled, painful, or warm to the touch, as these are signs of an infection.

WHAT IS THROMBOPHLEBITIS?

Small clots can form in small veins close to the skin (superficial thrombophlebitis) or deep in the large veins of the leg (deep venous thrombosis). If you have varicose veins, you may be subject to superficial thrombophlebitis, which is characterized by painful, localized, red, hot, and swollen veins, due to small clots. Sometimes you can even feel a tender lump. Your best bet is to place heat on the swollen vein, and take aspirin for the pain. Within 10-15 days, all symptoms should be gone.

Deep vein thrombosis is serious. Not only does the clot cause pain and, great deal of swelling, it can also break oft and travel through the veins to the lungs, called a pulmonary embolism. This can be life threatening and is why diagnosis and treatment are very important and require help from an experienced vascular specialist. These emboli are treated with bed rest and anticoagulant drugs.

A rare but serious problem that can occur is "venous gangrene? This is more common in patients with cancer. In venous gangrene, there is normal arterial flow to the extremity, venous blockage, and focal skin necrosis (skin death). Without proper treatment, the lower leg and foot may have to be amputated.

WHAT ARE SPIDER VEINS?

Varicose veins trouble many people, particularly women, and are caused by hormones, pregnancy, hereditary factors, and trauma, all of which lead to valve malfunctions. When the valves do not work right, blood cannot circulate properly and therefore the veins can become distended and twisted. The result is a varicose vein. For most people, the problem is only cosmetic, and there are no symptoms. In a few cases, varicose veins can produce significant discomfort, cause superficial phlebitis, and bleed profusely if ruptured. Support hose, exercise, and elevating your legs above your heart may help.

WHAT IS A BUNION?

A bunion is a bony bump either on the outside edge or on top of your big toe. It's actually a form of arthritis indicating that there are degenerative and takes place in the joint and bones at the base of your big toe. In fact, if you were able to look inside your toe under a microscope, the cartilage that lines the surface of the bones at the articulation would look pock-marked and yellow (rather than glistening and white like healthy cartilage) and you'd see an equally distressing picture of the accompanying bone. Bunions often come in pairs. So unfortunately, if your right foot has one, your left foot is probably not far behind.

WHY DOES A BUNION HURT SO MUCH?

Besides the fact that bunions can keep you from wearing fabulous shoes, they can be really painful and here's why. Beneath and next to the bone is something called a bursa, a fluid-filled sac that cushions bones, tendons and muscles around a joint. Wear and tear, friction, tight shoes, and heels put constant stress on the bunion and, as a result, can cause inflammation of the bursal sac, a condition called bursitis.

Patients often say, "My bunion is killing me." Yes, a bunion can be painful, but it's most likely the inflamed bursal sac around the bunion that's killing them. In fact, you can have a bunion for 10 years and not notice it because it is pain free. Then one day, perhaps because of unusual stress on your feet and your bunion, bursitis develops and the inflammation creates the pain. Bursas that swell in response to trauma, like friction or too tight shoes, are referred to as “adventitious”, a word that carries the sense of “not inherent” and “in an usual place.” Typically, a bursa becomes red and swollen as the bunion gets larger and interferes with the movement of the bone beneath.

WHAT IS THE BURSITIS TEST?

If you answer "yes" to some of the following questions, you may have bursitis:

-Does a whitish area appear when you press down on your bunion?

-Does the area turn red when you release your finger?

-Is the skin warm to the touch?

-Does the skin look like it's worn away, thinning in appearance, and unlike the skin elsewhere?

-Is the skin a little whitish in appearance?

-Is the area swollen?

-Is the area tender and painful?

HOW DO YOU REDUCE THE PAIN ASSOCIATED WITH A BUNION?

You don't have to live in pain and, though you can't get rid of the bunion on your own, you can reduce the pain. Here are a few tips on how to prevent the bunion pain from getting worse. Apply ice for 20 minutes on and 20 minutes off for a total of up to two hours. This can help reduce the acute inflammation. You can also put your foot in a tub of ice to cool it down. Use caution if you have Raynaud's or any cause of poor circulation. Soak your foot in lukewarm water with Epsom salt (available at drugstores) to reduce swelling. For more chronic inflammation, soak the area for 15 minutes in water and vinegar (one cup of vinegar to a gallon of warm water.) The vinegar can help alleviate the pain and inflammation.

Put some padding around your bunion. You can buy bunion pads, cut moleskin into a doughnut shape or try an over-the-counter product made for this purpose. Wear wider shoes that don't rub the bunion so you give the inflammation a chance to heal. Or reduce the pressure by wearing a sandal or a sneaker with a hole cut out to accommodate the bunion - not the most fashionable look, but it helps.

Give your arches some support. Available at most drug stores, shoe inserts can help reposition your foot so there is less pressure on the bunion and lift up on the arch giving it more support. I also developed a product just for this purpose called Pillows For Your Feet. Choose those that don't take up a lot of room so they can fit into your more stylish shoes. In fact, today they make them for various types of shoes from flats to high heels that offer support without sacrificing style. If store-bought inserts don't work, you can see a podiatrist to have custom-made orthotics made. Take a non-steroidal anti-inflammatory like Advil, aspirin or acetaminophen like Tylenol.

You can also try wrapping the area with a CoBand Cohesive Bandage. The compression this applies to the area may help reduce swelling. Change your shoes. You may have a bunion that bothers you only in certain shoes. These tips help you deal with the superficial pain. But deeper pain can actually be a change in the joint called arthritis, and often the big toe is dis- placed resulting in deformity. The word "arthritis" may conjure up images of little old ladies, but anyone can get this condition; arthritis is an inflammation of one or more joints and a breakdown of the articular cartilage Young people are just as apt to get arthritis, and I've seen plenty of them as patients, especially those who play kickball, soccer, and football and end up with traumatic arthritis.

WHEN IS IT TIME TO SEE A FOOT DOCTOR?

If the at-home treatments don't work please see a foot specialist who can diagnose a bunion and its cause by examining your foot and taking X-rays. Keep a log of when you experience the pain, including time of day, what you were doing when it came on, and what it feels like, in order to help your doctor figure out what's going on. You can track it on your iPhone calendar.

A foot specialist can tell if you have any biomechanical issues. For example, you may have a shortened Achilles tendon or you may be over-pronating, which could be causing some of the problems. A podiatrist can also drain any excess fluid, recommend physical therapy, stimulate healing using ultrasound or electro-galvanic stimulation, and create custom orthotics for you. Orthotics can change the way you walk and take pressure off your sore big toe.

HOW DO YOU PERMANENTLY GET RID OF A BUNION?

Surgery is the only way to get rid of a bunion permanently. There have been Many advances in bunion procedures in recent years making the results more effective than before. Also, many of them are covered by your medical insurance if you experience pain.

There are a variety of procedures, and which one you get depends on several factors, such as foot type, the quality of the bone, the stage of the deformity, medical history, and age. With all these factors in mind, your doctor will suggest the best procedure for you. Most surgeries are in-office, ambulatory procedures. Make sure that your doctor has an ambulatory surgical suite that is certified,or performs his or her surgeries in a hospital ambulatory suite. This means that your surgery is performed under local and intravenous (IV) sedation. It also means that you don't stay overnight, but go home the same day. (The exceptions: If you are deemed at higher risk due to a systemic condition, such as diabetes, your doctor might decide to do the surgery in the hospital, and you might have to stay overnight. This is unusual)

WHAT ARE THE RISKS OF SURGERY?

All surgeries come with risk and bunion surgery is no exception. Potential risks include infection, under or over correction, delayed healing, the bone not healing as well as it should, nerve entrapment, irritation, joint stiffness, scar tissue, limited range of motion, looseness of toe, delayed healing, infection, bleeding, recurrence of deformity, shortened toe and scarring. Though not all risks can be avoided, it does help to find the right doctor. It is important to follow doctor's orders post-surgery.

After most surgeries, you have sutures for two weeks; so you have to avoid getting your foot wet. I once told a patient not to get her foot wet, so she put a plastic bag on her foot and went swimming! Sometimes I'll tell patients they've got to be off their feet for 24 hours and then I see them in Bloomingdale's shopping that afternoon. I remember a patient coming in wondering why she had a post operative infection. After removing the bandage I found sand between her toes (well it's obvious she went to the beach.) I'll tell patients not to walk around and they'll swear they haven't, but one look at the worn-down heel of their surgical shoes and I know the truth. Clearly this is not following doctors' orders.

The reason you don't want to get your foot wet soon after surgery is to avoid infection. Walking around the ely and standing at the counter at Bloomingdales is had idea. Follow your doctor’s orders, and in a few months you will ft inte The chie new shoes your former bunion prevented you from wearing one innovation that helps speed up the healing from some bunionectomies is a bone stimulator As the name implies, this machine stimulates tha cells that make bones (osteoblasts) to heal a fracture site, When I use this in my practice, the patient goes home with a cold pack that's easy to apply and then the company that makes the bone stimulator machine comes to their home, gives them a machine, and shows them how to tune in. Surgery also requires that you have realistic expectations, If you have a very wide foot, but want one that's very narrow foot, It's not happening, We use the foot to walk on and we can't slim it down when structurally you're meant to have a wider foot. In the future, injections of stem cells and growth factors may help reduce inflammation, speed up the healing process, and reduce the formation of scar tissue in bunion procedures.

WILL BUNION SURGERY HURT MORE THAN MY BUNION ITSELF?

No, my patients don't feel any pain during the procedure and I almost always prescribe non-steroidal anti-inflammatory medications to alleviate minor discomfort that one might experience after the surgery. Occasionally, in patients with low pain thresholds, stronger analgesics may be given post operative for a few days.

WHAT IS METATARSALGIA?

The metatarsal bones end at the ball of the foot. Pain and inflammation in this area is called metatarsalgia. It typically flares up when you are active or walk barefoot and it subsides when you rest. You may also experience numbness or tingling. To treat metatarsalgia apply ice and remain non weight bearing (in other words take a break from physical activity.) You can relieve the pain with over-the-counter, non-steroidal medications like ibuprofen, naproxen or aspirin. To prevent metatarsalgia, you may need shoe inserts to absorb shock, by supporting your arches and the ball of the foot. Having other foot conditions, such as bunions, hammertoes, and being overweight can increase your risk of metatarsalgia.

WHAT MAKES THE BOTTOMS OF YOUR FEET FEEL LIKE THEY ARE ON FIRE?

There are several things that can make your soles burn and sting, including your shoes. Non-porous, typically man-made, inner soles can be one cause of burning feet while leather, suede, or plain, old cotton canvas usually don't cause this sort of problem. However, wearing shoes of any kind without socks increases the risk of burning soles because cotton socks or others made of absorbent material provide a barrier that soaks up perspiration and decreases friction; alternatively, the burning may result from poorly fitting shoes because friction abrades the outer layers of skin, even causing blistering. Poorly fitting shoes can be either too small or too large. Shoes that are too large permit your foot to move around, which increases friction. (They can also make you less stable on your feet, which increase your risk of an injury like a twisted ankle.) If your shoes are too large, replace them, but in the meantime try wearing one or two pairs of thicker socks. Shoe that are too small confine your foot in an unnatural position. They decrease circulation, constrict the foot, and decrease your foots normal flexibility, taking the bounce out of your step. There is a lot of truth to the adage that few things feel better than taking off your too tight shoes.

WHAT CAUSES DAMAGED NERVES IN YOUR FEET?

Alcoholism, pernicious anemia (vitamin B12 deficiency), and diabetes, are just three of the more serious diseases that can affect your feet. Alcoholism is frequently associated with malnutrition and vitamin deficiency, in particular, but a loss of vitamin B and thiamine in your body for other reasons can also damage the nerves of your feet.

If vitamin B12 deficiency is causing your problem, a doctor can tell by using a simple tuning fork on a bony point on your foot to look for your nerve reaction to the feel of the fork. If you have this condition, you won't feel anything. Pernicious anemia, which is typically seen in older people, is more than a low blood count. It involves an intrinsic change in your blood and also can produce neurological changes in many parts of your body, no just the soles of your feet. The burning sensation is undoubtedly just on in a cluster of symptoms. To be certain of a diagnosis, your doctor will also order blood tests. Vitamin B12 deficiency can be the result of decrease intake of this vitamin, but also be due to a problem with your body's ability to absorb this vitamin due to several factors, including intrinsic problem with your stomach or due to surgery such as gastric bypass for weight loss.

Anyone with lifelong diabetes has a much higher chance of developing foot problems. The nerve damage this serious disease brings about is quite insidious, but the first sign of it is a burning sensation in your feet. Proper control of your diabetes can reduce the possibility of this dreaded complication.

Other causes of this painful condition include rheumatoid arthritis, lupus, chronic kidney disease, HIV, hypothyroidism, bacterial or viral infections, and poisoning due to heavy metals such as lead, arsenic, or mercury. In addition medications can have an impact such as drugs for cancer, infections, seizure disorders or hypertension (for more information see chapter on "Chemo & Feet"). In fact, I had one patient who developed this burning, itching sensation the day after he had been treated with a drug used to decrease blood clotting.

Decreased circulation can also cause peripheral neuropathy and a major cause of this is smoking. Nerve damage can also be the result of prolonged pressure on a nerve from carpal tunnel, tarsal tunnel syndrome and/or from ill-fitting casts, braces, splints, or crutches, as well as prolonged exposure to cold temperatures.

HOW CAN YOU STOP THE PAIN?

If diabetes is the cause, then it's important to see a doctor about AlC levels.

When it comes to alcohol, there is no set amount or one type that has been associated with P. It hasn't been clearly identified whether it's the alcohol itself or the malnourishment associated with alcoholism that causes PN. All alcohol consumption should be stopped. Then, talk to your doctor about taking a vitamin B complex to help with the alcohol-associated vitamin deficiency. If you know that your shoes are the culprit, make sure that the shoe-repair shop replaces a nonabsorbent lining with a natural one. If it doesn't, then it means you need to get rid of the shoes that are the problem.

If your feet are burning because you were walking and standing more than usual, wash them in cold water and then rest and elevate them. You can also, try orthotics. The feet carry the entire weight of our bodies and that weight must be distributed properly. Custom-made orthotics, over-the-counter inserts, and padding can be very helpful.

If you suspect medication to be the cause, talk to your doctor about changing or discontinuing it.

If you can't find the root of your problem in anything obvious. You may have come in contact with a heavy metal. Many of the fish you eat regularly may contain a lot of mercury like tuna or swordfish. Certain blood tests, an analysis of your urine, and a thorough physical examination by a doctor are in order. (Unless the fish you eat is highly contaminated, once or twice a week tuna or swordfish should not be a problem.)

TO MANAGE THE PAIN IN YOUR FEET, YOU CAN TRY:

Vitamin supplements. For example, alpha-lipoic acid supplements are used in Europe to help reduce pain. Other vitamins that may help are B1, B6, B12, E, and niacin. Oral medications such as opiates, anticonvulsants, antidepressants and steroids. Assistive devices such as walkers and wheelchairs.

Orthotics like splints or braces to improve utilization of an arm/hand or leg/foot that has nerve damage.

Topical pain relief creams or patches. These can get you the most bang for your buck because you put the relief where it is needed. While a small amount goes into the body, it is less likely to cause side effects than oral medications. Active ingredients of topical pain relievers include a topical anesthetic, an anti-inflammatory agent (steroidal and non-steroidal), pain depressant and a counter irritant. I have found considerable success with a commercially available prescription, compounded product called NuSoothe. It includes a non-steroidal anti-inflammatory (NSAID), nerve pain depressant, muscle relaxant, topical anesthetic, antihistamine, and one product contains a local anesthetic/pain suppressant.

WHAT IS A NERUOMA?

A neuroma is a benign inflammation of an inter-metatarsal plantar nerve in the ball of the foot. It usually occurs between the third and fourth meta. Tarsals causing burning between toes. This is known as a Morton's neuroma, it is a benign focal expansion of the nerve. It is most likely caused by the repeated mild trauma of your normal foot motion over many years. Injury, irritation, or pressure that develops in your foot in your late 30s or 40s can exacerbate and also cause a neuroma. However, neuroma pain is also common in menopausal women due to hormonal changes in the body. The pain caused by a neuroma is usually a burning, tingling sensation, stabbing or searing. When a patient has a neuroma, they often come in with one of the following complaints: pain in the ball of the foot, a sharp pain in the toes that radiates like an electric shock; or pain that comes and goes and gets worse when they wear narrow or pointy shoes. Some people feel better in shoes as going barefoot can exacerbate the condition. You may feel an audible "click" when you manipulate the neuroma above and below the metatarsal bones.

HOW DO YOU TREAT NEUROMAS?

Treatments for neuromas have advanced considerably over the past 10 years. In the old days, podiatrists would typically give steroid injections, sclerosing injections, or simply perform a neurectomy (a surgical removal of nerve or part of a nerve). The effectiveness of these treatment methods was only mediocre as you can only give steroid injections occasionally. Sclerosing injections can be dangerous if the sclerosing agent is delivered to anyplace other than the nerve tissue. Surgery was only successful some of the time, with some patients developing a stump neuroma or recurrence of the neuroma. Some even experienced "phantom pain» (pain in the region where the suppling nerve is no longer present.)

So how do you know if you have a neuroma? Here are some clues:

-You have a tingling sensation in your foot.

-You feel an electric shock-like feeling in your foot that comes and goes.

-You have an occasional burning pain in the sole of your foot.

-The pain is worse when your wear tight shoes.

-You have to remove your shoes during the day to get relief.

WHAT IS A CALLUS?

A callus is an abnormal amount of dead, thickened skin that builds up on an area like the bottom of your feet. They can be yellowish-red in color and they don't feel like the rest of the skin on your soles. Primary locations include the ball of the foot (usually under the second metatarsal) and the end of your heel. Calluses don't look pretty or feel soft to the touch, but they're actually there to help. Your body produces them as protection to cushion underlying bone from pressure at points where there is little fat or natural padding. This may happen more as you age since the fat pads on your feet tend to lose their plumpness.

WHAT CAUSES CALLUSES?

Calluses can crop up anywhere on your body wherever stress from excess pressure and friction occurs. Gardeners usually have calluses on their hands due to the constant handling of garden tools. Professional chauffeurs often develop unusually thick calluses on the bottoms of their feet from hitting the brake pedal and pushing down on the accelerator for long hours. Having a bunion increases your chances of developing a callus because it may change your gait and put pressure on one part of your foot as a result. This is usually under the second metatarsal.)

People who weigh more will have more calluses, as will a rapid weight gain in a short period of time, as, for example, women who are pregnant or going through menopause. Menopause also makes you susceptible to these rough spots because hormonal changes cause drier skin. You're also more callus-prone if you have a higher arched foot because you're putting more weight on the ball of the foot.

As long as a callus doesn't hurt or turn red, you don't have to do anything about it. The challenge is when you have pain. Then you have a problem.

CAN CALLUSES BE MISTAKEN FOR SOMETHING ELSE?

Yes. Sometimes calluses will form around plantar warts or foreign bodies like splinters. One patient came to see me shortly after she had finished putling new hardwood floors into her home. After weeks of scraping, sanding, and staining, she noticed a strange-looking bumpy callus on the bottom of her heel. After trying to remove it herself with a razor blade - never a good idea because you increase your risk of infection - she came to see me. Tasked her about any changes in her routine and that's when she told me about her newly sanded floors. After carefully cutting away the callused tissue, I found and removed a small wooden splinter. She was shocked. I wasn't. Her callus never came back.

If calluses aren't a problem, why are they sometimes painful? Calluses are an indication that you have a biomechanical problem that is causing extra pressure in one area of your foot. For instance, if you aren't standing or walking properly, your feet may build up calluses in the weight-bearing areas, which can be quite painful. Sometimes a painful callus is caused by a misaligned bone or crooked toe. When one metatarsal is lower than its neighbors, more weight is placed on the region where the bone is lower.

HOW DOES A PAIN-FREE CALLUS SUDDENLY BECOME PAINFUL?

When the dry, inelastic skin of a callus thickens too much, it can cause constant irritation to the softer surrounding tissues. The nerve endings in this area react by sending pain signals. The area soon becomes red and puffy and hurts even more. You may also feel a burning sensation, especially if you're been walking on hard pavements. Specifically where you have a callus determines whether or not you'll have pain. For example, if the callus is in an area that bears a lot of weight, like the ball of your foot, it will continue to thicken and may hurt if you ignore it. But since your entire foot is a weight-baring extremity, it's not a good idea ignore any calluses. You are simply asking for more calluses, and more problems, which can be a vicious cycle.

HOW DO YOU BREAK THE BAD CALLUS CYCLE?

Start with your shoes. Women who are high-heel fanatics are constantly shifting more of their weight onto the metatarsal bones, causing increased stress on the ball of their feet and, therefore, excess callus formation. If this sounds like you, you can ease the situation by switching back and forth between high- and low heeled shoes. You should also look for high-heeled shoes with extra cushioning in the forefoot or have a shoe repair shop put extra foam cushioning in this area in new shoes. Other options are over-the-counter shoe inserts that offer extra cushioning. Also, in my practice at the Institute Beauté, we have developed a technique for restoring the lost padding on the bottom of the foot called, "Pillows For Your Feet."

Don't go backless. Calluses located on your heels that are caused by too much motion or rubbing, are important to keep under control because they can easily become dried out and cracked. This is especially the case in menopausal women who have put on extra weight. Avoid wearing open-backed shoes for a while since they just make calluses worse. Alternate with shoes that provide better support.

Wear comfortable socks. Sometimes your socks can irritate your feet causing calluses. Opt for those made of polyester or cotton, which are better at wicking away moisture, and make sure that they fit properly so they don't cause friction Use over-the-counter pads. If your callus isn't making your life absolutely miserable, you can redistribute your weight on the area by using non-medicated callus pads that you can find at the drugstore. These pads help cushion the area around the callus and diminish pressure on the callus. You can also try covering the area with lamb's wool.

Exfoliate with salicylic acid. You can get 20-40 percent salicylic acid over-the-counter and put that on your calluses to help slough off the thick, dead skin. Apply it carefully only to the callus, not the surrounding area or you risk damaging that skin. Soak your feet. If the callus isn't very thick and is causing only minimal discomfort, try soaking your feet in a tub with about two gallons of warm/not-too-hot water with a half a cup of Epson salts, and use an abrasive brush or foot file on the area every day, followed by a cream to soften the callus - both good habits to adopt. Most moisturizing creams will help. For even more benefit, try a cream containing an organic acid such as alpha hydroxy acid (from sugar cane) or beta hydroxy acid (salicylic acid).

Don't try to avoid callus pain by walking lopsided. This is a normal body defense mechanism in response to pain--but it can cause damage in other parts of the body including the knees, hips, spine, and even the neck. Treat the underlying cause of the pain soon and avoid the problems in the first place. Usually you will have to see your podiatrist to discover the underlying foot problem.

Aeryn was a 42-year-old American woman who loved to ski. She and her family would drive four to five hours every weekend to various ski resorts on the East Coast and spend the majority of Saturday and Sunday on the slopes. She came to see me in the middle of a ski season because her toes were always blue and somewhat numb when she went skiing, no matter how many layers of warm socks she wore or what she did. This put her at a serious risk for frostbite.

It got to the point where she could no longer ski. It wasn't until I took a full medical history that she sheepishly admitted that she was a smoker and had been for years. That was a huge problem for her because the nicotine in cigarettes causes your blood vessels to constrict, thus reducing blood circulation to your feet. In fact, smoking just one cigarette can decrease blood flow to your feet by up to 50 percent, and it can stay that way for an hour. The problem with Aeryn's smoking, which she claimed helped het to warm up when she went into the lodge between ski sessions, was that put her at risk for Raynaud's phenomenon.

WHAT CAUSES COLD FEET?

Most likely, you've heard the expression having "cold feet? Usually it’s in relation to getting married or other major decisions or events like having a baby or starting a new job. It means that you have a case of the nervous litters, and a literal case of cold feet is also linked to your nerves. Your feet get cold because your warm blood isn't circulating properly through the veins and arteries into your legs and out to your toes. Normally, the skin temperature down there should range between 75°F and 900F. If it drops below 65°E you've got a problem with your vascular or circulatory system. Your arteries, the smaller-sized blood vessels called "arterioles" and your veins aren't letting enough blood through.

Your nervous system plays a significant part in determining how much blood gets through. If you are upset about something or under a great deal of stress, nerves can constrict the smaller arterioles in your feet and lessen their ability to carry blood, giving you cold feet. At the other emotional extreme is the person whose nervous system sends excess blood through his or her body when the pressure is on. This is called vasodilation of the blood vessels and it can make you hot all over (hence the expression "hot under the collar").

To avoid cold feet, never wear constricting undergarments, like stockings or underpants that are too tight or that cut into the top of your legs and try not to cross your legs when you are sitting down. Exercise can definitely improve your circulation and warm your feet. So, get out there and start walking.

HOW IS SMOKING LINKED TO COLD FEET?

Most of us now know that smoking cigarettes puts your heart and lungs at risk, but you may not know that it is a major cause of cold feet. (Yet another reason to quit smoking) When you smoke, the nicotine makes your blood vessels tighten up, or constrict, and since it works on your entire nervous system, it affects the arterioles in your feet as well as other areas. You may wonder, "How bad can this really be?" or think that being a light smoker can't be a problem. Wrong! As noted above, after inhaling just one cigarette, the blood flow to your feet may be reduced by as much as 50 percent!

Sometimes the circulation doesn't pick up again for an hour, so imagine what happens if you're smoking two or more packs a day. The more you smoke, the colder you get. Ironically, many smokers who feel cold pick up another cigarette to try and warm up. Amphetamines and some other medications work the same way. If you have cold feet, look at what medications you take--this includes over the counter drugs. Sometimes the local anesthetic you receive in the dentist's chair contains epinephrine, which constricts blood flow, and some over-the-counter allergy remedies for nasal congestion or sniffles include ephedrine, which also contributes to constricted blood flow and cold feet.

WHAT IS A CORN?

A corn is a round, hard, thickened area of skin on the top of, the tip of, or between your toes. It looks very different from your normal skin and, as the name implies, is round and yellow like a corn kernel. With a central core that you can't see, it descends into your toe to a cone-shaped point, putting pressure on the normal cells in its way. Though most corns are yellow, those that are inflamed can have a reddish hue. Others can take on the color of your skin. In some cases, especially for women of color, you can get hypo-discoloration, which is diminished color on the corns so that they appear lighter than the skin around them. In others, the pressure on your toes can cause darker discoloration around or on a corn- called hyper-pigmentation. This happened to one of my patients.

WHAT CAUSES CORNS?

Let’s say you came to my office complaining about a painful corn, the first question I’d ask is, "When did it start to hurt?" Most of the time, you’d have lone something different-bought a new pair of shoes (hat were probably too tight), tried a new exercise such as taken a long walk, started a new job or undertaken some other activity that exposed your toes to extra friction and pressure. Like calluses, corns are your body's response to friction am pressure, and they grow to try to protect both your skin and the bone beneath it from bruises and injuries. When this happens, there's an increase of blood circulation to the area that speeds up the growth of com cells. The bigger your corns get, the more painful they become. Though tight shoes can exacerbate this condition, footwear can't take all the blame. Corns are hereditary. Need some proof? Mother Teresa had corns and she certainly didn’t wear stylish shoes (See photo in "Bunion chapter). If you have contracted toes (also known as hammertoes), mis. sharpen toes, or bony abnormalities between the toes, you're prone to painful corns. (Learn more in the "Hammertoes" chapter.) This is because your toes can't lie flat within the confines of a shoe so they constantly rul against its inside, causing the pressure and friction that encourage corns to grow.

HOW DO YOU STOP A CORN FROM HURTING?

Though only a doctor can get rid of an existing, corn there are a few things, you can do to reduce the inflammation and pain and keep a corn from getting worse.

At home:

-"Alleviate the pressure. Wear sandals that are open in the toe are, so they won't put pressure on your corn of, if you're willing, cut open an old pair of shoes to expose the corn, In colder weather, shoes and boots like Uggs are roomy and usually don't irritate à corn.

-Wear shoes that fit properly. To make this happen, you can use over-the-counter products made to protect corns or take your shoes to a shoemaker to get them stretched. However, if these things don't work and your shoes don't fit, don't wear them. Ill- fitting shoes will just aggravate your corn. You may have to buy a larger size or a different style than you're used to. Look for shoes with good arch support, that are wider at the top part of the shoe (known as the "toe box") and long enough so that there's no extra pressure on your toes. Slip in shoe inserts. You want to prevent too much motion at the forefoot - called over-pronating. Over-the-counter inserts may help do this. Or you can see a podiatrist to have custom orthotics made.

-Cover up. Wrapping a small amount of lamb's wool around the corn can help protect it.

-Soak in Epsom salts. A bursa is a fluid-filled sac that protects your joint. However, if it becomes inflamed and swollen at the site between the bone and corn (a condition called "bursitis"), it can be painful. Soaking your feet in a solution of warm water and pressure off the nearby sensory nerves. But the results aren't permanent so if you put on the same shoes that cramped your feet in the first place, the bursa will soon swell back to its painful size. I remember one young woman who came to see me on a Thursday because of a large painful corn and its accompanying swollen bursa. I sent her home to soak her toes. After two hours with her feet in a tub, she was pain free. Then she went dancing in high heels on Friday night. Can you guess who called me screaming in pain on Saturday morning?

-Apply an over-the-counter antibiotic cream. This can help alleviate some of the pain.

WHAT IS A HAMMERTOE?

A hammertoe is a permanent deformity of the second, third, fourth, or fifth toes where the middle joint has become twisted into a claw-like or clenched position. Because the bent toe juts up the air, it resembles the small hammer inside of a piano. If the curled-up toe joint is the one near the tip as opposed to the middles i's called a "mallet toe: A hammertoe can be difficult to move and to straighten, and can cause pain ana pressure when you’re wearing shoes. To make matters worse, hammertoes often develop corns because the top and tip of the toes are pushed upward, and rub against the inside of your shoes, as well as calluses between two toes or on the ball of the foot. If you have what's considered a flexible hammertoe, you can still move your toe at the joint. If you have a rigid hammertoe, you're not that lucky and as its name implies, the toe is stiff and inflexible. Typically, a hammertoe starts out as a flexible one. In fact, it may lie flat once you've slipped off those too-short, too high heels. However, without treatment, the tendons of a flexible hammertoe can tighten causing the toe to become rigid over time. This is one reason why early treatment can be the answer to your painful hammertoe prayers.

WHAT CAUSES HAMMERTOE?

Most hammertoes are the result of heredity; so if your mother, father or grandparents have these bent, clenched toes, you may, too. Structural issues also play a role. For example, people with larger feet and/or longer toes are more prone to hammertoes, as are people with high-arches, because a lot of weight is being put on the front of the foot and the toes are pulling back. If your second toe is exceptionally long it may get forced into the permanently bent, hammer-toed position in your shoes - especially if you like to wear pointy-toed high heels or cowboy boots. Several other foot shapes can increase your risk for hammertoes. A pronated foot means that you have a sagging or low arch. This can cause excessive motion in the front of your foot, encouraging your big toe to turn out toward the second toe; this can bend the second toe into a hammertoe.

Hammertoes may also come from injuries - such as a fractured toe or if you damage or dislocate any of the five bones in the middle part of the foot called the "metatarsal bones.? This can set up a dangerous cycle for your ligaments because loose or altered ligaments can cramp your toes into permanent bends and twists.

Though shoes aren't the only cause of hammertoes, the wrong pair certainly doesn't help. For example, if you continually wear footwear that's too short for your toes then they are going to curl up to fit the space they're allotted. Years of squeezing and scrunching up your toes like this can leave the muscles unable to straighten and the result is one (or more) permanently bent or twisted toes.

Some patients tell me their hammertoes suddenly appeared out of nowhere, which can happen typically after the age of 45, and women tend to get them more than men. As if they weren't ugly enough, a bunion can cause your big toe to lean over putting a lot of force on any of the neighboring toes, usually the second. Over time, this pressure traumatizes the plantar plate, a ligament on the bottom of your foot that lies between the base of the toe and the metatarsal. The plantar plate's job is to help keep the toe in the joint and on the ground.

DO HAMMERTOES HURT?

Not necessarily. A hammertoe itself is painless. When your hammertoe hurts, it is usually because it has been rubbing against something - such as the inside of your shoes. This can cause painful corns and calluses. It can also aggravate the fluid-filled sac that cushions your toe's bones, tendons and muscles around a joint, which is called a "bursal sac. "Inflammation of this bursal sac is a condition called "bursitis" and this can be excruciatingly painful. To temporarily soothe your hammertoe pain on your own, you can try the following.

At home:

-Cover up your corns. Sometimes it's the corn on top of your hammertoe that's causing your pain, so covering it with an over-the-counter pad, such as a corn or blister pad (available at most drugstores) or a Band-Aid can help alleviate the pressure. However, avoid corn products that contain acids. These are made to remove the corn, but can be extremely irritating to skin and, in the worst case, cause skin ulcers that can lead to infections. And of course, you should never try to trim or cut corns on your own because this also ups your risk of an infection.

-If you have diabetes, talk to your doctor before trying any over-the-counter product in order to avoid complications arising. Wear shoes that fit properly. Avoid those that rub against your bent and curled toe and find those that are long enough. Ideally, there should be 1/2 inch between your longest toe and the front of the shoe. The toe box - the area around your toes - should be wide enough, which usually means no narrow or pointy shoes. Also, look for those with good arch support and low heels since a high heel can force your toes forward toward the front of the shoe and very tightly together. Lace up shoes or boots are the best choice because you can usually control how tight the front of the shoe is. Also, check your size when shopping because many people try to stuff their feet into too-small shoes.

-If an inflamed bursal sac is causing your pain, soak your foot in Epsom salts (available at the drugstores or mass merchandisers). You'll know if your bursal sac is inflamed if it turns white when you press down on it or if you're in a lot of pain at night. Soaking in Epsom salts can provide temporary relief, as can over the counter pain relievers such as non-steroidal anti-inflammatory drugs like ibuprofen (NSAIDS, for example, Advil) or acetaminophen (for example, Tylenol). Also, using a little ice on your toe can help alleviate swelling and pain.

-Orthotics (inserts that you put into your shoes) can help by providing support for your arch and repositioning your toes to alleviate pressure. You can find over-the-counter shoe inserts or you can have custom orthotics made at a podiatrist's office to eliminate biomechanical issues.

WHAT CAN I DO TO FIX A HAMMERTOE PERMANENTLY?

Unfortunately, a hammertoe won't go away on its own. If the above treatments don't help reduce your pain, your hammertoe limits your activity or you can't move your toe, the next option is surgery - especially if you don’t want to change your lifestyle because of chronic pain. When you see a podiatrist, the first thing he or she will probably do is take an X-ray to see how severely the toe is deformed. Sometimes a joint has become fused, or permanently stuck.

As I mentioned, there are two types of hammertoes: flexible and rigid. For a flexible hammertoe, where you can lift up on the toe and move it, surgically correcting it requires a procedure known as soft tissue release or phalangeal set. Here, the doctor makes a small incision in the skin that releases the tendon capsule on the top of the toe, called the extensor tendon. He or she may also make a similar incision on the bottom of the toe to stretch out the flexor tendon. Releasing the tendons helps the toe lie flat but the incisions are so small that you don't even need stitches.

When the hammertoe is rigid, it's a more severe situation so you may need a procedure called an "arthroplasty," also known as a phalangeal head resection. Here, with a linear incision, part of the head of the bone nearest to the base of the toe (called the proximal phalanx) is removed. This gets rid of the area that is causing the greatest amount of pressure. 'Then, tendons are cut and realigned to fit the toe's flat position. Sometimes, especially on the fifth toe, a portion of the bone at the base of the distal phalanx at the tip of the toe may be removed. Often something called a "* wire" is used to hold the toe in place temporarily and is removed after about three to six weeks One of the latest advances in surgery for a rigid hammertoe is an implant arthroplasty procedure. Some of the bone is removed and then an implant, made of synthetic materials like silicone, is attached with a very thin screw to replace the bone around the joint. (The implant that I use is called the proToeVio Hammertoe Fixation System.) As the foot heals, the implant expands and then helps keep the toe straight. An implant minimizes shortening of the toe and increases flexibility while keeping the toe straight. However, we don't have long-term studies to let us know what happens after someone has an implant for, say, 30 years.

Another procedure is the joint fusion or arthrodesis. Here, your surgeon removes part of the joint and fuses the bone so that the toe straightens out. Often this is done if you have another foot issue such as a bunion. In some cases with a fusion, you can end up with a shortened toe and a scar, but your pain will be eliminated. Like you do in an arthroplasty, you may have a wire in your toe for about three to six weeks to hold it in its new, straighter position until it heals. You may also have to avoid putting weight on your toes until the bones fuse together. Surgery, on both flexible and rigid hammertoes, are outpatient procedures done with local anesthetic. How long it takes to heal is dependent on the patient.

HOW LONG IS THE RECOVERY PERIOD AFTER HAMMERTOE SURGERY?

After either type of surgery, you can have swelling, stiffness and redness. In my office we suggest that patients take it easy for 24 hours and apply ice. With a phalangeal set, you will be back on your feet the day of surgery and may even be back in your own shoes. With the other surgeries, you will probably be wearing a surgical shoe or sandal for about four weeks. How quickly you recover depends your bodies healing abilities, your general health- and how closely you follow doctors’ orders. For example, my patient Sherry not only had her hammertoes fixed, but also had bunion surgery for the bony protrusion on the side of her foot. And even then, only two and a half months after her surgery, she ran the New York City Marathon in under four hours. This may be an extreme example, but it indicates how patient-specific recovery is. Risks of surgery include: a toe or toe joint that doesn't completely straighten, that you don't regain all your toe flexibility, and that the hammertoe reoccurs. There's also a small risk of infection, pain, slow healing and numbness. As always, following doctor's orders carefully helps increase your chances for the best outcome.

WHAT SKIN CONDITIONS CAN CONTRIBUTE TO DRY FEET AND HEELS?

The dermatological conditions that can contribute to dry heels include:

Psoriasis

The dry rash associated with psoriasis is inherited. You can blame your genes for the red and pink pimples and the white scales they produce. This chronic skin condition usually strikes the elbows, knees, arms, legs, and, of course, the feet. It loves the heel area (and can be a primary cause of cracked heels) and the soles of your feet, and may even invade the spaces between your toes, where the cracks can make walking painful.

Eczema

Eczema, a word that describes a variety of skin rashes, is an inflammatory disease of the skin. If you've got it, you'll notice lesions, occasional watery discharge from your skin cells, and crusty scabs, and you may be restless, itchy, and running a low-grade fever. Sometimes eczema is caused by an allergy or some other disease you may or may not know you have. For instance, poor leg circulation could cause eczema on your legs and feet, and the poor circulation would tell you that you had a more serious vascular problem that needed to be evaluated and properly.

Atopic Dermatitis

This is a condition that shows up in very young people and often in those who suffer from asthma. Hay fever and other allergies seem to be associated with this type of dermatitis. If you've got it, red, scaly, itchy patches on your hands and feet will be bothering you. It may seem strange that they’re connected to your wheezing, but they are. No matter how itchy your skin is, don't scratch because this just makes the skin thicker and rougher in these areas.

Xeroderma

This is the mildest kind of dry skin, and I see it often in older people during the winter months. The lower indoor humidity wreaks havoc on those moisture-starved skin cells, and frequent and meticulous bathing aggravates the problem. Since xeroderma is a condition that disappears when the seasons change, the cure is not complicated. I recommend the use of moisturizers on a regular basis to alleviate dryness. Also adding oil to your bath will help.

Athlete's Foot

You may not have considered it, but the fungus between your toes that makes those warm, moist areas so painfully cracked could also be causing the general outbreak of dryness all over.

Too much keratinization

Sometimes dry skin is due to a process called "keratinization". Keratin is one of the principal proteins in the cells that make up the surface of your body: It's in your hair, your nails, the enamel of your teeth, and, especially your skin. Because it doesn't easily absorb water, too much keratin can cause problems for your skin even if you moisturize regularly. The excess keratin keeps water out of the cells; hence you get dry skin. Why excess keratin develops is a biochemical mystery. It may be a hereditary disorder. But it's not a hopeless situation. There are products called keratolytic agents that contain a small concentration of salicylic acid. These agents will help prevent over-keratinization and allow your cells to accept more moisture.

WHAT IS THE BEST WAY TO TREAT CRACKED HEELS?

At home:

Avoid long, hot baths or showers. Hot water can strip skin of its natural oils leaving it dry. Some days, try skipping your bath or shower altogether because you lose water from your surface skin cells by cleaning them too often. When you do take a bath, use bath oil.

Avoid soap. The detergents in soap are harsh on skin and strip it of its natural oils, too. Look for a soap-free cleanser or bubble bath. Use a humidifier in your home during winter months. It puts moisture into the air your skin is breathing.

Apply rich creams to feet two to three times a day. Urea and lactic acid are excellent moisturizers. These ingredients are called "humectants" because they prevent water from leaving the skin and help attract it into the skin to keep it hydrated. Also, products with high concentrations of these ingredients help exfoliate thick, dry skin.

Topical retinoids can be used, too. Best known for their wrinkle-smoothing abilities, retinoids help speed up the skin's natural exfoliation process. This removes the dead, dry cells. Retinoids are derivatives of vitamin A and are available over-the-counter as retinols and prescriptions like Renova, Retin-A, tretinoin.

Dermabrasion is a sanding down of the skin's surface, allowing for a new layer of skin to grow in its place. This must only be per. formed by a doctor.

Microdermabrasion is similar to dermabrasion but just the surface skin is removed. It uses vacuum suction and aluminum oxide crystals to remove the layer of dead skin cells. There may be slight redness afterwards, but this is temporary. Dermabrasion goes much deeper that microdermabrasion, which can be done at a spa. Which one is used depends on the thickness of the skin that must be removed.

Get greasy. Occlusive products are thicker and greasier and help your body retain the hydration that's already in your skin. Examples include Vaseline and Aquaphor. Because they're greasy, they're best used at night. Slather your feet with an occlusive product, wrap them in plastic wrap (which makes the occlusive product work better), and slip on cotton socks. While you sleep the heat generated by your body helps the occlusive product penetrate and alleviate dryness, irritation, and itchiness.

Moisturizing socks hydrate your skin overnight without the mess of applying an occlusive product. You just slip them on, go to sleep, and wake up with baby soft skin. Use a pumice stone or foot file regularly. This keeps dry, rough areas from building up.

Shoe inserts can help reposition your foot so that your heel doesn't rub as much when you walk.

Krazy Glue your cracks. A little Krazy Glue or Super Glue carefully applied to a heal crack can help bring the edges together and speed healing. It's similar to a liquid bandage, but is something you probably already have at home. Use sparingly and, of course,make sure the glue is completely dry before letting the treated area touch anything else, including your fingers.

Avoid backless shoes. In these open shoes, there's a lot of movement and friction which can cause dry skin. Backless shoes also expose your skin to the elements.

WHAT IS THE MOST COMMON CAUSE OF HEEL PAIN?

There are many different causes of heel pain. Some of these include: stress fracture, bursitis, Achilles tendonitis, gout, a pinched nerve, tarsal tunnel syndrome, tendonitis, or a bone tumor. However, one of the most common causes of heel pain is a condition called "plantar fasciitis". This affects over one million people a year. Here, the thick piece of tissue that extends from your heel to the ball of your foot, called the "plantar fascia" develops tiny tears and becomes inflamed. This condition is usually the result of excess stress on the foot from repeated trauma or overuse from things like exercising. This is why it's common in active people, both those who exercise regularly and weekend warriors. Being obese and gaining weight in a short amount of time (as during a pregnancy) increases your risk, as does being a woman, or having a job where you're standing for long periods of time. Most people who develop this condition are over the age of 40. Shoes that are worn out or too flat in the arch area can also cause strain to the tissues of the heel.

Plantar fasciitis typically occurs in only one foot and develops gradually. Symptoms include pain (like someone is cutting into your foot), inflammation, numbness, and swelling. The pain tends to get worse when you're standing for long periods of time or when putting your heel down on the ground after sitting causing chronic stress, the plantar fascia can develop calcifications or, in severe cases, turn into bone at the part of the foot where it attaches to the eel bone. This is called a "heel spur."

WHAT CAUSES A HEEL SPUR?

A heel spur is a sharp, bony protrusion on the bottom of your foot caused by a growth of calcium that has begun to project downward and is touching the plantar fascia. The pain from a heel spur can feel like a bruise on the bottom of your foot sending sharp, shooting pain into your arch from your heel. The heel spur can make the plantar fascia feel even worse. A heel spur is your body's reaction to stress and strain, but it doesn't always use pain. In fact, I have often unexpectedly discovered a heel spur when raying a patient's foot to diagnose another problem. When you do begin feel pain, the plantar fascia is tearing where it is attached to your heel. cause of the bony protrusion your arch is being stretched beyond its normal length and the foot muscles at your heel and along the bottom of your foot are also being strained. There may even be bleeding and further calcification, which can be seen on an X-ray. A calcification means that calcium deposits are building up around the bony point, making it hurt in more.

Any amount of weight gain in a short period of time, even ten pounds, can produce greater stress on your arch and lead to the development of a heel spur. Sometimes a sagging arch adds to the stress, as can shoes with too little room in the arch area. Any activity that puts excess pressure on your heels, such as running or tennis, can cause a heel spur. This is especially true if you are the proverbial "weekend warrior" If you go from sedentary to active--a good idea- do so gradually.

If you've got a heel spur, you probably noticed that it actually hurts more after you rest it, than it does if you've been walking on it. For example, a heel spur usually hurts more when you wake up in the morning and set your foot on the ground than it does after you walk around for a few minutes. This is because it had been at rest and relaxed while you slept. Then, when you put your foot on the floor, you strain your plantar fascia and the heel spur stresses it anew. If your heel spur is inflamed because of a fluid- filled bursal sac next to the bone, it may make your whole leg ache. Some of the complications of heel spurs and plantar fasciitis are hip, back, and knee problems because you're changing the way you walk to avoid the pain, and weight gain if you become inactive.

HOW CAN YOU EASE THE PAIN OF PLANTAR FASCITIS AND A HEEL SPUR?

To relieve your immediate pain, you can try the following

At home:

Take over-the-counter pain relievers like ibuprofen (such as Advil or Motrin) or naproxen (like Aleve). Rest. This is crucial because it helps reduce any inflammation. Elevate your foot and apply ice to the heel for twenty minutes at a time.

Do the frozen can roll. This can help stretch the plantar fascia and provides cold therapy to the injured area. Roll your bare injured foot back and forth from the tip of the toes to the heel over a frozen juice can. You can also freeze a bottle of water and do the same thing.

A foam or felt heel pad cut into the shape of a "U" to match your heel shape can take some of the pressure off. An over-the-counter shoe insert can also help.

Shoes with good arch support may help alleviate some pain. Also, replace your sneakers regularly. Your sneakers loose their protective cushioning effect with time and use. Stretch. Gentle stretches for the foot can help increase the flexibility of the plantar fascia and reduce pain.

The Calf/Achilles stretch: Stand facing a wall and put your hands on the wall Move the injured foot back as far as you can while still keeping the foot flat on the floor. Move the other leg forward and slowly lean toward the wall until you feel a stretch through the calf. Hold for 10-15 seconds, rest and then repeat 5-10 times.

Stair stretch: Stand on a step with both feet. Holding the rail or wall for balance, position the injured foot so that the ball of the foot is on the stairs and the heel is hanging off. Slowly lower the heel of the injured foot to stretch the arch of your foot. Hold for 10-15 seconds. Repeat 5-10 times.

Towel stretch: Sit on the floor with your legs stretched out in front of you. Loop a towel around the ball of the injured foot. Slowly pull the towel towards you while keeping your upper body straight. Hold for 10-15 seconds. Repeat 5-10 times.

WHAT IS HAGLUND DEFORMITY?

Sometimes an abnormal clump of tissue at the back of your heel, just over the bone; known as a Haglund deformity, can cause heel pain. Also referred to as a pump bump, I see it in two types of feet. those with very high arches and those with very low arches. What happens is that the back of the shoe is continually rubbing against the back of the heel, irritating the area and an inflamed, fluid-filled bursal sac may result.

Here, are some ways to alleviate and ease this situation:

Several times a day, apply warmth, such as a wet towel or a heating pad, to the back of your heel.

Be careful when you buy shoes. Look for those with soft edges because hard ones can rub and irritate a Haglund deformity, causing pain. Placing heel pads in your shoes can lift your foot almost out of the shoe, which helps avoid this irritation.

WHAT IS TARSAL TUNNEL SYNDROME?

On rare occasions, your heel may hurt because of the pressure of one of your nerves. If a podiatrist can't find a heel spur, he or she may consider a diagnosis of Tarsal Tunnel Syndrome, in which the nerve passes through the ankle near a ligament that leads to your heel. When something is pressing on this nerve - perhaps because of a biomechanical shift - it will send pain right down to your heel.

You can develop Tarsal Tunnel Syndrome in both heels and you may also have Carpal Tunnel Syndrome in your hand(s). Symptoms include pain, tingling and/or electrical shock-like sensations around the heel, ankle, and sometimes the toes, as well as burning on the bottom of the feet that radiates up toward the knee and hot and cold sensations. It can be caused by an injury, biomechanical issues (for example, flat feet are more prone), hormonal changes, or conditions like diabetes or arthritis.

To properly diagnose this condition a nerve conduction test is performed to see if the posterior tibial nerve is damaged and to what extent. When the nerve is damaged there is delayed and/or decreased conduction through the damaged portion of the nerve.

WHAT CAN YOU DO FOR TARSAL TUNNEL SYNDROME?

It's important to rest the foot.The treatment of choice is to put the foot in a biomechanically correct position with orthotics and to use physical therapy to help the body heal itself. Pain relief can be obtained with the injection of lidocaine and steroids, and in some cases PRP (platelet rich plasma). (For more on PRP, see "Achilles Tendonitis" chapter.) Other options are lidocaine patches or topical, prescription creams like NuSoothe. If nothing else works, your doctor can do surgical release of the posterior tibial nerve. Sometimes scar tissue in the area is causing the pain so surgery can help with this. (However, you can also wind up with more scar tissue from any procedure.) Surgery often requires that you are on crutches for about eight weeks. To prevent Tarsal Tunnel Syndrome, try to strengthen the muscles around the ankle and stretch the arch.

WHAT IS AN INGROWN TOENAIL?

When the sides or corners of your toenail cut into the skin around it, the area can become very sensitive, swollen, red, and inflamed. This is because the soft tissue surrounding your nail is reacting to the ingrown nail as if it were a foreign body. Formally known as onychocryptosis, an ingrown toenail is one of the most common nail issues. It typically occurs on the big toe, but all toes are at risk. In severe situations, an ingrown toenail can make it painful to walk and if you suffer from any condition that causes circulation problems, such as diabetes, an ingrown toenail can turn into a more serious situation and therefore you must consult your doctor.

HAT CAUSES AN INGROWN TOENAIL?

Sometimes simply cutting your nail improperly can start the problem. Nails should always be cut straight across. If they're curved or you keep your nails too short, you can create an ingrown toenail. Shoes that are not long enough or too tight can cause pressure and push the nail into the skin, Faulty foot mechanics may be another culprit. For example, if you have flat feet, your big toe and forefoot are more likely to roll inward when you walk, which will increase the pressure on the nails and create ideal circumstances for an incurvated toenail. The shape of your nail plate can also increase your risk of an ingrown nail. For example, if your toenails do not naturally lie flat in their beds, but appear more convex or curve down or are abnormally thick, you are more likely to develop an ingrown toenail. Excessive sweating can also put you at risk for ingrown toenails as can repeated injury to the same toe.

HOW DO YOU TREAT AN INGROWN TOENAIL?

A simple ingrown toenail is not a big problem. Often, if you cut it properly, straight across, it will correct itself. Also, avoid constant pressure on your poor inflamed toe. Depending on the weather you can wear open sandals or boots like Uggs that tend to be roomy in the toe area. Another option, if you're willing, is to cut out the portion of your shoe that presses on the toe. (If you have diabetes or circulation issues, see your doctor at the first sign of your ingrown toenail or you risk more serious complications.

If this isn't enough, soak your foot in a solution of ½ cup iodine and 1 gallon of warm water for 15 to 20 minutes twice a day, or in warm water, sea salt, and a few drops of tea-tree oil. Next, cut or trim your nails and gently clean the nail grooves with a cotton swab. Apply an antibiotic cream to reduce any inflammation, and cover with a bandage.

If this doesn't help and your toe is still painful, excessively red, and swollen with pus, you may have an infection, which is something you don't want to ignore because it can become a serious infection. Several patients have come to me only after they let their toe become red and swollen with pus. As I said earlier, if your circulation is poor or you have diabetes or any kind of infection you run the risk of gangrene, which is very serious, and therefore you must see your doctor immediately. Sometimes a bloody growth, called "proud flesh" builds on the side of the nail. This inflamed soft tissue can be quite sensitive when it extends into the nail groove. Never try and remove the offending piece of nail on your own.

In the past doctors, would cut a "v" into the center of the nail to alleviate the pressure, but this can be unsightly. Today, there are other options. Your doctor can numb the nail with a local anesthetic at the base of your toe. Once you're numb, your doctor can remove the offending portion of the nail causing your pain and the matrix may be cauterized with phenol. You may also be placed on antibiotics. If your ingrown toenail becomes a recurring condition, the matrix and part of the nail that keeps growing into the surrounding skin may be removed using lasers or phenol. Since this is more complicated, it might require a stitch or two. If the ingrown toenail is infected, you may be prescribed an antibiotic.

WHAT CAUSES NAIL FUNGUS?

A fungal infection causes nail fungus, a condition called "onychomycosis." The nail thickens and becomes brittle with ragged edges, distorted, dull, and discolored. Sometimes the nail lifts up off the nail bed (a condition called "onycholysis"). Infected nails can be painful and make it difficult to stand and walk in closed shoes. Fungal infections usually begin at the tip of the nail - also called the "distal end" - with a white or yellow spot. As they progress, the nail will appear yellow, black or brown and become thin and flaky-looking. At this point many people are embarrassed by the unsightly appearance of their toe.

The fungi that cause these infections favor dark, warm, moist areas like sweaty socks and shoes as well as shower floors, locker room floors and the areas around public swimming pools. It is crucial to wear shower shoes or flip-flops in public places like locker rooms, showers, and pools. Fungal spores enter your body through small cuts and cracks in your skin and even the slightest separation of your nail from the nail bed. (The latter often happens after minor trauma such as your toe hitting the front of an ill-fitting shoe or sneaker during exercise).

Risk of fungal nail infections increases as you age, and if you have diabetes, diminished circulation, psoriasis, athlete's foot, or damage to the nail. Other risk factors include family history, sweaty feet, participating in a lot of sports, poor health, and a compromised immune system (from things like HIV or chemotherapy). To test if you have a fungal infection, your doctor can do a biopsy of the fungal nail, which is then sent to a lab.

HOW DO YOU TREAT FUNGAL INFECTIONS?

Fungal infections account for up to 51 percent of the nail problems that doctors see. They might be common but they are very hard to treat. In fact, they may take one to two years to get under control. Yes, you read that correctly: years! That said, it's important to get them under control - especially if you have a weakened immune system or diabetes - so that they don't become more serious or spread to other nails. Fungal infections also make you more susceptible to getting a bacterial superinfection.

HOW CAN I PREVENT A FUNGAL INFECTION?

Prevent fungal infections by never going barefoot in damp, public places, and never ever wearing other people's shoes. Also, cut your nails straight across and even with the ends of your toes. (If nails are too long, they're more likely to be traumatized by hitting the front of you shoes; too short and you are in danger of an ingrown toenail.) Keep your feet, especially between toes, as dry as possible. Topical powders can help with wetness. If your feet tend to get sweaty, change your socks often and wear those made of synthetic materials that wick sweat away from skin. Moisture is the villain in some of these fungal nail infections so if you have very sweaty feet, you can get Botox injections to keep sweating under control. (Make sure to see a dermatologist or podiatrist who has experience with Botox for hyperhidrosis.) If you go for a salon pedicure, make sure the manicurist uses sterilized instruments or bring your own tools and never submerge your feet in whirlpool baths. (Some salons use disposable plastic liners in the footbath, which is a plus. Bring a small vial of Clorox bleach and add it to the water in the bath for a few minutes, then have them replace with fresh water.)

HOW CAN YOU TREAT PARONYCHIA?

The best home remedy is to soak your feet in a solution of one-quart warm water with half a cup of Epsom salts for about fifteen minutes twice a day. Then, apply a topical antibiotic cream, like Neosporin or Bacitracin, to the affected nail.

If the pain or redness persists after a few days of home treatment or if there is pus, severe pain, or fever, it is time to see a podiatrist. Usually your doctor will cleanse the area, inject a local anesthetic, and then cut into the paronychia and drain it. Then she/he will make a linear incision paralleling the infected nail fold. A culture is usually taken and sent to a lab for analysis so that your doctor can see exactly what the infecting organism was Finally, the infected area is coated with an iodine solution or topical antibiotic and covered with sterile gauze. Back home after the treatment, you soak your foot for 15 minutes, and apply a topical antibiotic and a bandage once a day until it is healed. Then go back to your doctor, just to make sure that the infection has subsided. For more severe cases, your doctor can also prescribe oral antibiotics like Keflex or dicloxacillin.

WHAT CAUSES BLACK-AND-BLUE NAILS?

A black-and-blue nail can be the result of an injury or trauma to the nail such as too tight shoes, dropping something on your toe, stubbing your toe, or banging your nail against the front of your shoe. This can happen if your nails are too long or your shoes are too small, especially if you do sports or workouts that involve running. In this case, you may need new exercise shoes. A podiatrist can sometimes remove the blood collected under the nail by drilling a small hole in the nail. The blood is drained from under the nail and the excess pressure relieved.

A bruise from something like your toenail hitting the front of your shoe or stubbing your toe will grow out as your nail grows. However, a dark blue/black/brown area that does not grow out may be skin cancer. It's hard to tell on your own so see a podiatrist or dermatologist as soon as you notice it. Jamaican singer Bob Marley died of a malignant melanoma on his toe that he had mistaken for a soccer injury. By the time he learned it was cancer, the disease had metastasized to other parts of his body and eventually killed him. (See below, "Signs of Skin Cancer" for more information). Consult a podiatrist or dermatologist for any lesion on your nail, especially one that doesn't heal or that changes in appearance. If more than one nail is blue/black it may be a sign of anemia, asthma, or emphysema. It can also be a sign of a vitamin C or B12 deficiency, which you can improve by eating foods rich in these vitamins. Oranges, red peppers, strawberries, and grapefruits are bursting with vitamin C while sardines, salmon, lean beef, and eggs contain B12.

Signs of Skin Cancer

Skin cancer is the most common form of cancer and affects over two million Americans annually, according to the Skin Cancer Foundation. See a dermatologist for a skin exam each year - and make sure to remove your nail polish. Also, regularly give your skin a self-exam that includes your toes. The ABCDE's of melanoma are warning signals that a mole, spot, or mark may be cancerous. Features include: Asymmetrical for (i.e., not symmetrical.) Uneven, scalloped, or ragged edges.

WHAT CAUSES THICKENED NAILS?

More formally called onychauxis, this condition is particularly common in older people. The nail may form a "ram's horn" shape, which is very hard to treat. The thickened nail can be caused by chronic dermatitis or some systemic disorders like diabetes or impaired circulation.

A physician can help this by filing down the nail with a rotary burr drill. Lasers are the latest way to reduce the thickness of a nail. When the condition is very severe, the nail can be removed under local anesthesia.

WHAT CAUSES THE NAIL TO SEPARATE FROM THE NAIL BED?

As I mentioned above, fungal infections and yeast can cause the nail to lift off the toe (a condition called onycholysis), as can immersion in harsh chemicals, contact dermatitis, eczema, tetracyeline (a prescription antibiotic), thyroid disease, psoriasis, and blistering sun exposure. Another cause is repeated injury, which I see in many athletes, particularly runners, who wear shoes that are too small, have toenails that are too long, or purchase new running shoes. 'The inflexibility of the new shoes causes them to abrade the toenails; in reflect, rubbing them off. In a few cases, a bony growth under the nail can force the nail up off the bed. When the nail separates from the nail bed, beginning at the bottom of the toenail, trauma is the culprit and it's a condition called onychomadesis. Often, the old nail flakes off and a new one grows in, something that may take as long as six months.

WHAT IS A PLANTAR WART?

Warts are abnormal skin growths that can appear anywhere on your skin or mucous membranes and can often be painful on surfaces such as the soles of your feet, which bear your weight. A wart on the bottom of your foot is called a plantar wart because "plantar" refers to the sole of your foot. They are more common on the weight-bearing areas of the foot, like the ball and the heel and the pressure on these spots can cause a plantar wart to be flat or grow into your foot.

These bumpy, spongy, sometimes thickened scaly lesions are actually benign tumors. The scientific name for warts is "verruca." Though some plantar warts are painless, others can make it feel like you have a small rock in your shoe and hurt when you're standing or walking.

Sometimes overlying corns and calluses can disguise a plantar wart. To see if you've got a plantar wart, squeeze the lesion, putting a side-to-side pressure on it. If it's a plantar wart, this will hurt; if it's a corn or a callus, the pressure won't be as painful. Another simple test for identifying a wart is to scrape the topmost layer of the lesion carefully and superficially. If you see tiny, dark spots resembling dried up blood, you are probably looking at tiny blood vessels and/or tiny areas of recent bleeding, a typical characteristic of warts. Plantar warts can bleed profusely because of the presence of these tiny vessels, so be careful when you scrape yours. Important Caveat: Warts and skin cancer can be confused on physical examination and if your doctor is uncertain, a biopsy may be needed for a definitive diagnosis.

HOW DO YOU GET RID OF PLANTAR WARTS?

Although plantar warts don't pose any health risk, you will want to get rid of them if they cause pain or tenderness, become annoying, interrupt your daily activities or multiply; or if you have diabetes. Plantar warts can be very recalcitrant and very challenging to treat. There are numerous treatment methods and none is 100 percent successful. Here are some treatments worth trying:

At home:

-Duct tape applied for two weeks. Yes, this good-for-everything tape of MacGyver fame has another purpose: erasing your plantar wart. It's believed that the chemicals it contains help suffocate the plantar wart, eventually killing it. In fact, this sometimes works better than cryotherapy, which is when you freeze the plantar wart with liquid nitrogen. Here, you apply a piece of duct tape that's just a tiny bit bigger than your wart, leaving it on for six days without removing it. When you take it off, you immerse your foot in warm water and then use a pumice stone to gently remove the top layer of dead skin. You repeat this until the wart is gone - which can take months, or not work at all, as with most plantar wart treatments.

-Salicylic acid pads. These are available over-the-counter and typically contain 40-60 % salicylic acid. After removing the pad, take a pumice stone or nail file and scrape the deadened tissue off before applying a new pad. Just make sure to throw out the pumice or nail file after each use or you can spread the virus.) Make sure the salicylic acid only goes on the plantar wart or you risk damaging the surrounding skin.

-Products that freeze plantar warts. These over-the-counter products aim to freeze off your wart with a very cold applicator. Apple cider vinegar. Soak your wart in apple cider vinegar for 20 minutes. Then, gently rub the wart with a pumice or nail file. Repeat daily until the wart falls off. Just make sure to throw out the pumice or nail file after each use or you can spread the virus that caused the plantar wart.)

HOW DOES PREGNANCY AFFECT YOUR FEET?

Some women sail through pregnancy with basketball-sized bellies, barely gain weight anywhere else, deliver their babies with ease, and shed any extra pounds just weeks post-partum. But for most women it doesn't work that way. Pregnancy brings many changes to our bodies that affect us literally from head-to-toe. Yes, you expect that your stomach is going swell, but your feet and lower legs can change, too. In fact, a study in the American Journal of Physical Medicine & Rehabilitation reports that pregnancy may permanently increase the length and width of women's feet. The researchers from the University of Iowa suggest this may be the result of the weight gained during those nine months and the fact that joints become looser at this time, too. Here are some of the things that can happen to your soles when you're a mom-to-be.

Bunions: Though it's not clear exactly why women get bunions more often tan men do, hormones definitely play a role and you're more at risk when you're pregnant. During those nine months, a hormone called "relaxing" makes your ligaments looser so that the ones surrounding your pelvis can relax in order to allow your baby to journey through the birth canal. But ligaments all over your body also relax and that includes the ligaments in your feet. This means that the bones of your feet can spread too, especially under all that extra weight, and this may contribute to bunions. It is also why many women go up a shoe size once their babies are born. The truth is, your feet aren't actually getting larger - after all the bones aren't growing; it's the looser ligaments allowing for spreading that can increase your shoe size. Also, pregnancy is a time when you gain a lot of weight in a short period of time, which predisposes you to bunions.

What can a mom-to-be do?Wear orthotics even if you've never worn them before. This may be a good time to invest in them to ward off foot pain and future problems that may last even after your bundle of joy arrives. Either over-the-counter or custom orthotics will help lift your arch to provide support, limit over pronation, and reduce the pressure on an existing bunion or prevent one from forming, These shoe inserts can also help decrease pregnancy-related leg and lower back pain. Choose supportive shoes. That means no flimsy flip-flops, which permit the foot to widen because they offer no arch support, and have no backs (see backless shoes in shoe section.) If you're concerned about your feet or have bunions or corns, it may be a good time to see a podiatrist. For more information see the "Bunions" chapter.

CAN YOU BE PREGNANT IN HEELS?

Many celebrities strut through their nine months of pregnancy in sky high heels, but it's not the best option for most women. And there is also the unexpected. In Kate Middleton's sixth month of pregnancy, for example, the Duchess of Cambridge got her high heel stuck in a street grate and that could have led to a fall. Though this could happen to any woman, pregnant or not, it is not something you want even to think about when you're a mom-to-be. Although you don't have to kick the high heel habit altogether, choose properly. When you're pregnant your center of gravity changes increasing your risk of falling, and sustaining ankle sprains, and strains and stress fractures in your feet, and putting more pressure on your lower back.

WHAT IS A STRESS FRACTURE?

Foot and ankle stress fractures are overuse injuries where you have a tiny crack or incipient fracture in the bone (The crack is usually hairline thin). Activities like running, tennis, dancing, basketball, and other high-impact sports are often the cause of these injuries especially when you do them often, for long periods of time, and/or at a high intensity because they put repetitive stress on your bones. This stress causes cracks, which eventually become stress fractures, especially if the bones don't have enough time to recover from the force placed upon them. Stress fractures are also more common in sedentary people who suddenly take part in an intense workout.

You are more prone to stress fractures if your bones are weak from osteopenia or osteoporosis, have flat feet or high arches, and are a woman with an abnormal menstrual cycle. The foot's second and third metatarsals, the heel, the outer bone of the lower leg, the shin bone, and the bone on top of the midfoot are the most common spots for stress fractures because these areas bear a lot of weight, especially during high-impact activities. Symptoms include pain that's barely noticeable at first and then all of a sudden gets worse, pain that gets worse during activity but gets better after rest, swelling of the foot or ankle, bruising, and sensitivity/tenderness to touch.

HOW DO YOU TREAT STRESS FRACTURES?

Most stress fractures heal with rest and refraining from engaging in the sport that caused the injury for about six to eight weeks. If you think you may have a stress fracture, rest your foot/ankle, ice it, and avoid putting weight on it. Avoid the type of activity that caused it for about three weeks and then resume the activity very gradually. Continuing to exercise with a stress fracture can cause a complete fracture with displacement of the broken bone. And a stress fracture that doesn't heal properly increases your risk of chronic pain and similar injuries in the future. However, being totally sedentary is not a good idea as this can worsen osteoporosis in the unused extremity. Try a low-impact form of exercise instead and resume other activities gradually. Some studies have found that ibuprofen and naproxen can delay bone healing, but this is a controversial subject. Still tombe safe, I suggest sticking to Tylenol.

HOW CAN YOU PREVENT A STRESS FRACTURE?

Wear good sneakers that are made for the activity you’re doing and replace them when they get worn out (this is usually about every six months, but sooner if you exercise more often or intensely). Also, vary the type of exercise you do (so the same muscles and bones aren't constantly being stressed), mix in low impact activities, strength train, and begin any new activity slowly rather than rushing into it, doing it too often, too intensely, or for too long. Custom orthotics can also help. It's also important to keep your bones strong by getting enough vitamin D (D3, cholecalciferol) and calcium in your diet and/or through supplements. But talk to your doctor before taking any supplement or medication.

WHAT IS A SHIN SPLIT?

In some cases, you may not have a stress fracture, but instead be suffering from a less serious condition called a shin splint. My experience with shin splints goes beyond the professional; it's personal. After years of a somewhat sedentary life, I started a jogging program, and a doctor who didn't follow her own good advice ended up having to doctor herself. In other words: I got shin splints!

A shin splint is when the two muscles that are attached to the front of your lower leg your shin, are pulling away from the bone. The connective tissue covering that bone becomes inflamed. Symptoms include tenderness and pain along the inner part of your tibia; pain when you walk, and swelling. If your shin splint gets worse, the soft tissue in the area can become inflamed and hot, which can cause a small lump to develop.

WHAT CAUSES SHIN SPLINTS?

Shin splints usually happen because of overuse during exercise, especially if your feet are excessively pronated because the arch starts to collapse and that stresses the lower leg muscles. This makes your muscles strain to keep your foot straight as you do things like run or race across a tennis court and when those muscles pull away from the bone, you've got a shin splint. Flat or rigid arches also make you more shin-splint prone. Running on extra hard surfaces, even when you have good foot balance, can put the same kind of pressure on these muscles as can running downhill, running too hard or fast, or exercising in worn-out sneakers. If your heel cords are too tight and you start a new exercise program, you can also send the strain up your leg.

Anyone who is starting an exercise program and hasn't been building up slowly and who overdoes it (a.k.a. the weekend warrior) can end up with shin splints. Also, sports that have sudden stops and starts, like soccer, tennis, or basketball, up your risk of shin splints as does running. Abnormal stress on these muscles will tighten them and make them pull away from the bone. Being overweight also increases your risk of this condition.

HOW DO YOU TREAT SHIN SPLITS?

-Use ice packs on the tender, sore muscles in order to reduce any inflammation. Do so for 15 to 20 minutes, four times a day. You can also wrap the area with an ACE bandage that has been dipped in water and frozen in the freezer.

-Rest is important. Don't rush to resume your usual activities, especially those that cause increased pain. Instead, try low-impact activities such as swimming, water running, using the elliptical, or bicycling. Start slowly and gradually increase your time and intensity.

-Stretch these muscles before and after doing any vigorous activity. It's a good idea to flex your feet slowly up and down several times. You can also work them by pretending your foot is stepping on a gas pedal. This will reduce the likelihood of shin splints in the future.

-Wrapping your leg in an elastic bandage to absorb some of the shock you get each time your heel hits the ground may also help. What you want to do is immobilize the joints and bones in your feet.

-Pain Relief. If your shin splint is very painful, try an over-the-counter pain reliever like ibuprofen, naproxen, or acetaminophen. If these at-home remedies don't alleviate your pain, see a doctor. And seek immediate medical attention if your shin is hot and inflamed, the swelling appears to be getting worse, you have severe pain after a fall or accident, or the pain is still there even when you're resting.

HOW DO I PREVENT SHIN SPLITS?

Wear the correct footwear for the sport you're doing. For example, you can't wear cross trainers if you're going to run; don't wear running shoes if you're playing tennis. Get new sneakers every six to nine months depending how often and how intensely you exercise.

Do mild stretches before and after your exercise and build up to any exercise program gradually.

Mix up your workouts by doing different activities instead of doing one form of high-impact exercise over and over again. Cross-training is important to avoid over-use injuries. Strength training, especially doing exercises that strengthen the calf muscles and front of the leg can help. (Some of these include toe raises and leg presses.) It may be worth investing in a personal trainer, at least for a few sessions, to learn proper technique for all planned exercises.

WHAT IS SWEAT?

Sweat is that salty, clear liquid with your own personal odor. It is the body's remarkable way of maintaining an even temperature. If it weren't for the act of sweating, you skin would always be colliding with the hot and cold of the outside world. Like Goldilocks trying to eat the three bears' porridge, you would always be saying, "Too hot" or "Too cold!" Your ability to sweat helps make your body just right. But where, when, and how much you sweat is controlled by your nervous system. And sometimes there is an upheaval in this chain of command. Signals get crossed.

The sweat glands found on the soles of your feet and the palms of your hands normally produce perspiration in small amounts. (You have 250,000of them in each foot!) Perspiration is composed of water, sodium chloride, potassium chloride, minerals, and lactic acid (which mosquitos’ home in on), urea, and trace amounts of organic material (that can also have odors from food you ate). If you were barefoot, the sweat would evaporate and your feet wouldn't smell, but they stay wet when you sweat while wearing shoes and socks. When bacteria, which thrive in the damp, dark environments, act upon these sweaty secretions, the result is foot odor.

Emotional problems can increase the amount of that you perspire. (Just think of how much more you can sweat when you're stressed.) Your body temperature can also trigger an outpouring of sweat. This is the reason why you sweat more in order to cool off when you are exercising. Closed shoes aggravate sweaty feet and set up a perfect environment for bacteria to grow, leading to more odors and more sweat.

ARE SMELLY FEET ACTUALLY A MEDICAL CONDITION?

Yes. "Bromhidrosis" is the term used to describe the excessive secretion of smelly sweat. The word comes from the Greek "bromos," meaning stench, and "hidrosis," meaning sweat. In relation to your feet, the less formal name for it is "dirty sock syndrome." Bromhidrosis is a quasi-medical problem, because it's not serious medically speaking but, nonetheless, it can cause social agony. However, if the sweating problem is severe and blisters develop on your feet as a result of the sogginess, it is called "dyshidrosis; which is a more serious, medical condition.

WHO GETS SMELLY, SWEATY FEET?

Almost all of my patients have at some time or another worried about foot odor. They often apologize to me before they peel off their socks or stockings. "I really did wash my feet today, but I think they smell.'Sweating disorders are common in all age groups. Sometimes there is an abnormality in the way the nerves supply the sweat glands with information. Any damage to, or destruction of, nerve endings can cause an increase in perspiration. I've known of severe cases in which an individual produced a full pint of perspiration each week. Normally, the amount is tiny and barely measurable.

CAN FOOD MAKE YOUR FEET SMELL FUNNY?

When you eat spicy or pungent foods, such as onions, peppers, garlic, or scallions, the essence of these odors can be excreted through the exocrine glands in your feet. Spicy food can also make you sweat more. So yes, your feet can end up smelling like what you have eating.

HOW CAN YOU CONTROL SWEATING AND ITS ODOR?

At home:

-Use an antiperspirant or a deodorant (the kind made for your underarms) right on your feet. Deodorants contain antibacterial agents that can kill the bacteria, thus eliminate the odor, but won't stop the perspiration. Antiperspirants, by contrast, will both stop the flood and kill the smell.

-Odor-prevention products. The good ones contain aluminum chloride hexahydrate, so check the label for this ingredient. You might also be interested in trying a menthol antibacterial spray. These have a very cooling effect. Sometimes cornstarch helps. Do-It-Yourself treatments include soaking your feet in a basin of warm water and vinegar, or warm water and ginger tea, to help get rid of the odor-causing bacteria.

-Go barefoot whenever you can. This way your feet can breathe and sweat, and bacteria aren't trapped in sweaty socks. Choose shoes made of natural materials, such as leather, which allow your feet to breathe and therefore sweat less. Avoid rubber-soled shoes, which don't allow your feet to breathe easily. Change shoes regularly. Not wearing the same shoes everyday gives them time to dry out.

-Spray inside your shoes in order to kill the bacteria and fungi that can cause your shoes to stink (and re-contaminate your clean feet more quickly). Europeans have been known to sprinkle sage, a leafy herb, in their shoes. Perhaps a dash of these dry, crumbled leaves will do the trick for you.

Change socks often. Wear light-colored or white socks or stockings made of all-natural fibers (like cotton and wool) or those that wick sweat away from the feet. Or wear pantyhose with cotton soles.

-Wash feet daily with antibacterial soap and dry meticulously. Then sprinkle them with foot powder, which can absorb wetness.

-Avoid spicy foods since they can cause you to sweat. Learn relaxation techniques, like yoga or meditation, if nerve wracking situations make you sweat.

WHAT IS HYPERHIDROSIS?

Sweating is normal when it's in response to exercise, hot weather humidity, and other external stimuli. Hyperhidrosis is excessive sweating primarily the hands, feet, face, and underarms that affects an estimated 2,8 percent of Americans. This degree of sweating is well beyond the amount you sweat if you were hot or exercising. It is frequent and can occur without any apparent cause. However, it can get worse if you're stressed or anxious. Genetics play a role in excessive sweating of the feet and hands Hyperhidrosis can make you more susceptible to conditions like fungal and bacterial infections, eczema, rashes, fungal nails, and warts. It can also affect your quality of life negatively and, as some patients say, it can make you feel like you're "swimming" in your shoes. (Shoes that can be ruined from the excess sweat).

HOW DO YOU TREAT HYPERHIDROSIS?

At home, you can try all of the suggestions mentioned earlier this chapter in the section "How can you control sweating and its odor?" If they don't work, it's time to see a doctor. Although this condition is usually obvious, your doctor can tell if you have hyperhidrosis by doing a few tests. One entail putting your feet on a piece of paper and seeing if the paper is wet. For another, skin is coated with powder that changes color when it gets wet. Your doctor may also try to rule out other conditions that cause sweat glands to go into overdrive, such as thyroid problems or low blood sugar.

WHAT ARE THE MOST COMMON NAIL PROBLEMS IN OLDER FEET?

Thickened and ingrown toenails are most commonly seen in older feet. Gradual thickening of the nail (onychauxis) is caused by repeated trauma, poor nutrition, and a change in circulation. Sometimes, after a long period of small but repeated injuries, such as those from ill-fitting shoes, your nail becomes thickened and discolored. Fungal infections can turn nails brown or yellowish. I've seen nails so brittle and cracked that they could be peeled off. (For more on fungal infections and how to treat them see the 'Nail Disorders" chapter.)

Ingrown toenails can become a problem when the nail grows down into the flesh and the flesh becomes irritated and infected (paronychia). Sometimes an abscess occurs. Incision, drainage, and removal of a piece of the nail, along with soaking, and if necessary, antibiotics, are the best treatments for neglected abscesses. Sometimes something called "proud flesh." or red, sore tissue accompanies repeated paronychia.

The most common cause of ingrown toenails is the improper cutting of the nails. Some people cut the sides of the nail too much and removed the part of the nail that meets the flesh. If your shoes are too narrow, they may squeeze the toes, causing the nail to grow into the flesh over tinder.

HOW DO I AVOID NAIL PROBLEMS?

Avoid trauma to your toenails by not wear ill-fitting shoes, keeping your nails short, and cutting them straight across. Don't cut into the corners and don't cut close to the flesh. It's helpful to keep your nails clean with warm, soapy water and a nailbrush used daily to remove dirt from under nails. if your feet sweat heavily; change your socks and shoes often, and use a dusting of cornstarch to eliminate excess perspiration (an excellent breeding environment for fungal infections).

If you can't cut your own toenails easily or correctly, go to a physician Don't allow a nail to separate from its bed because this forms a perfect setting for a bacterial or fungal infection, and it could be more dangerous than you think.

If these steps don't work, a podiatrist can remove a troublesome nail using a local anesthetic injected into the base of your toe. If you don't have circulation problems, the base of the nail can be surgically removed or chemically cauterized so that a deformed nail won't grow back again.

WHY DOES TRAUMA CAUSE NAIL PROBLEMS?

Tripping and the striking the toe, which injures the nail plate, happens often, and is usually a direct result of an unsteady gait resulting from aging and certain systemic problems. If this happens to you, applying ice during the first 24 hours after the injury helps stop the pain. If you are concerned about continuing pain, you should have your toe x-rayed to see if it has been fractured. If blood and fluid accumulate under the nail (which is a subungual hematoma) a hole can be drilled in the toenail to release the pressure and fluid. The nail plate may be permanently damaged or deformed by the injury.

HOW DO CALLUSES CAUSE FOOT PAIN IN OLDER PEOPLE?

Calluses, which are nothing more than a buildup of hard, thickened skin that develops due to abnormal friction and pressures on the foot, are the second most common condition (after nail problems) that I see in older patients. Most calluses form around a bony abnormality in a mechanically unsound foot, and even gaining as little as 10 pounds can increase callus formation. Usually, they strike the areas under the tips of the toes, particularly the big toe and the little toe, sometimes on the side of the big toe, and the outer and inner borders of the heel. Painful fissures caused by the dry, thickened callus may also appear on the heels.

HOW DO YOU TREAT CALLUSES IN OLDER PEOPLE?

The most conservative approach is to have a podiatrist remove the hard skin by shaving down the callus tissue every four to six weeks. (Don't try this at home or you put yourself at risk for injury and infection.) Removing excess pressure on the foot by using orthotics will change the abnormal forces on your foot. Often a measure as simple as wearing rubber-soled shoes can alleviate some of the callus symptoms.

There are also at-home remedies. With each passing birthday, our skin loses some of its elasticity and moisture, which is why it is important to try to restore this lost hydration. Before going to bed, soak your feet in lukewarm, sudsy water for about 15 minutes. Then towel-dry feet and apply a rich, moisturizing cream. Apply it all over your foot, concentrating on the callused areas. Then, cover your foot in plastic wrap, and slip on a clean sock. In the morning, remove the sock and plastic wrap and thoroughly wash your foot. Next, use callus file with a gentle sawing motion to remove some of the callus. Make sure you only do this to thickened skin. One caution: if you have impaired circulation, diabetes, or nerve problems, avoid this treatment and consult a podiatrist because the combination of slow healing and too-vigorous scrubbing can lead to infection.

Self-Help for Older Feet

Exercise, of every conceivable kind, is important for aging feet, including going up and down stairs, cleaning, and bending. Regular exercise will help prevent injuries and accidents because weaker muscles often mean less resistance to injury. One of the easiest forms of exercise is walking. If possible, do so for at least 30minutes a day (for more on walking see "Exercise & Your Feet" chapter). Here are a few guidelines: Don't go barefoot if you have any neurological problems. The neurological system is not as intact as it was at age 25, so a cut that you may not even feel is susceptible to infection.