Solutions to Four Common Foot Problems

One surprise of aging: Your tootsies can feel the worse for wear. Here's how to deal with bunions, heel inflammation, hardening skin and nail fungus

by Emily Listfield
feet image
Photograph: Illustrated by Thomas Fuchs

At a recent wedding reception north of New York City, Laura R. began sharing war stories about her recent bunion surgery to remove the unsightly (and painful) bone that was bulging from the side of her foot. Whipping out her iPhone, she proudly showed off an “after” photo. As every woman at the table peppered her with questions, her husband of 21 years just laughed. “This is what it’s come to. You used to show pictures of your kids; now it’s your feet,” he said.

Almost every woman I know feels bad about her feet. Correction: Every woman I know has feet that feel bad. Really bad. I’m no exception: I have things wrong with my feet that I’d never heard of before. I haunt the foot section of the drugstore like a junkie looking for relief. I scout plus-size shoe stores even though the rest of me is not plus size. In all of this, I am rather typical. In a 2010 study by the American Podiatric Medical Association, 77 percent of adults said they had experienced a foot ailment.

The number may be even higher for women, especially as they get older. “Before 40, many women’s foot problems stem from overuse injuries or high-heel accidents,” says New York City podiatrist Johanna Youner. But after you hit 40, your feet start to pay the price for years of holding up your body. “As you age, the tendons and ligaments in your feet lose some of their elasticity, which makes your arches flatten and your feet and ankles stiffen. At the same time, your toenails tend to thicken and curl,” Youner notes. In some women, the fat pads that cushion the bottom of the feet start to thin, so walking becomes painful. (To relieve those symptoms, Youner sometimes injects the foot pads with JuvĂ©derm, often used for filling out facial lines.)
Pregnancy can also change women’s feet. “There is some evidence that the hormones that allow the muscles to expand in the belly also relax the muscles in the feet, causing them to expand,” says Bob Baravarian, DPM, chief of podiatric foot and ankle surgery at Santa Monica/UCLA Medical Center and Orthopedic Hospital. Put everything together, and your feet can gain a half size every 10 years.

For a variety of reasons, women are more prone to foot issues than men are. There’s the pregnancy factor, as well as the greater innate laxity of women’s tendons and ligaments. But men are also much more likely to opt for, well, sensible shoes. “The more rigid the sole, the less strain on the foot, and men tend to wear flat shoes that have a lot of support built into them,” explains Baravarian. “Women who wear higher heels with pointier toes and thinner soles set themselves up for trouble.” Men also have genes on their side: Some foot issues are passed down disproportionately to women.

So are we destined to hobble into the golden years? Not necessarily. You can forestall trouble by choosing shoes that are easy on your feet for everyday use and saving the stilettos for special events. Another tack is to switch your workouts from activities that involve heavy pounding (such as running or jumping rope) to those that have little impact on your feet (such as swimming). But even if it’s too late for prevention, you still have options, because there have been significant advances in the treatment of problem feet. Here, four of the conditions that women suffer from most and the new fixes that can help.

Condition 1: Bunion
What it is: A protuberance caused by shifting of the first metatarsal (the big toe bone) toward the second toe.

Symptoms: A large bump on the big-toe side of your foot, reddened skin, swelling, pain while walking.

Causes: Bunions often result from a genetic predisposition, but you boost your chances of developing that big bump if you usually wear shoes that have a narrow toe box, says Baravarian. This kind of shoe creates pressure that can cause the first metatarsal to shift place.

What you can do at home: If you have bunions, opt for soft, supple leather shoes with a thick sole to decrease pressure on the bone. “Stick to a shoe with a heel no higher than two inches and a wide toe box,” recommends Naomi Shields, MD, an orthopedic surgeon in Wichita, Kansas, and a member of the board of directors of the American Academy of Orthopedic Surgeons. An orthotic that supports the arch can also reduce stress on your big toe and slow the progression of the bunion. (See “How to Choose an Orthotic”) You might also try using a bunion pad (available in drugstores) to make your shoes more comfortable.

What a surgeon can do: If you experience so much pain that it interferes with your daily activities, surgery may be your best option. There have been significant improvements in bunion surgery, and while no one would call it a walk in the park, it is not as brutal as it once was: Newer techniques considerably reduce both the recovery time and the risk of recurrence.

“In the old days, doctors would shave the protruding bone, and the bunion would often grow back because the bone wasn’t realigned with the toe joint,” Baravarian explains. “Now doctors cut the bone and line it up with the joint, holding it in place with special screws. There is less postoperative swelling because there is no motion between the bone and the joint and therefore very little pain.” You wear a boot for four to six weeks and sneakers for a couple of weeks after that. You won’t need crutches, but you’re not going to be training for a marathon either. Many activities can be resumed about two months after the operation, and in most cases the bunion does not regrow.

You may hear about a less invasive but more controversial surgical technique called a mini tightrope, which has been developed in the past five years. In this operation, a doctor subcutaneously ties together the first and second metatarsals (the bones leading up to the first and second toes) to realign them without cutting any bone. “In the right circumstances, mini tightrope can be a very good procedure,” says Baravarian.“The problem is that in very active patients, the FiberWire can break, or it can pull through bone. We use it in older patients who are less active.” But with the advent of new kinds of screws, the trend in the general population is toward more aggressive surgery to prevent the bunion from returning, says Mark Berkowitz, MD, an orthopedic surgeon at the Cleveland Clinic.

Condition 2: Plantar Fasciitis
What it is: An inflammation of the tissue on the bottom of the foot (plantar fascia) that connects the heel to the toes.

Symptoms: Pain in the heel, especially when you first get up in the morning.

Causes: Plantar fasciitis (PF) is among the most common foot problems, one in which genetics doesn’t seem to play a role. “In patients who have tight calf muscles, flat feet or a tendency to put a lot of strain on their arches, the tissue begins to tear at the bottom of the heel, causing pain,” Baravarian explains. “The pain is usually worst first thing in the morning, because the plantar fascia gets tight while you sleep. It stretches out during the day and feels a little bit better, but over time scar tissue forms and causes increasing amounts of pain.” You can exacerbate plantar fasciitis if you wear shoes that don’t offer ade-quate support or overdo a new work-outroutine without a proper buildup.

What you can do at home: “Most cases of plantar fasciitis will improve if you wear proper shoes and do certain stretches, but recovery is a slow process and can take from three months to a year,” says orthopedic surgeon Jonathan Deland, MD, chief of foot and ankle service at the Hospital for Special Surgery in New York City. The best footwear: shoes with one-and-a-half-inch heels. “Flats put too much pressure on the ball of the foot, which pulls at the heel,” Shields explains.

Deland recommends doing the following two stretches for five minutes in the morning and at night: “Put your affected foot on your opposite knee and gently pull the toes toward the shin and also let the ankle bend. Hold for 15 seconds, relax and then repeat.” Then do a classic runner’s stretch: Press your hands against a wall, standing two to three feet away so you’re leaning into the wall. Let your elbows bend so that your body goes forward. Adjust your distance from the wall to maximize the stretch in the back of your calves. You can also buy boots that stretch your plantar fascia while you sleep (one source: Amazon.com).

If you are overweight, you have one more reason to drop the pounds. “Walking is the equivalent of putting three times your body weight on your foot with each step. If you take some weight off, you lessen the strain,” says Youner.

Cortisone shots can help with the pain, though they won’t remedy the underlying cause of your problem, according to Baravarian.

What a doctor can do: “Ninety percent of people with PF get better with traditional treatments, but there are 10 percent of patients, mostly over 40, for whom the condition doesn’t improve,” says Raymond Rocco Monto, MD, an orthopedic surgeon on Martha’s Vineyard and Nantucket, Massachusetts. One problem: “Microtears to the connective tissue accumulate over the years.”
A number of therapies are available for these stubborn cases. Among the newest is platelet-rich plasma (PRP) therapy, recently in vogue among elite athletes to treat injuries such as tendinitis and tennis elbow. In this procedure, a patient’s blood is drawn, then spun in a centrifuge to concentrate the platelets, which release growth factors. The plasma is then injected into the affected area. In a study involving patients with severe plantar fasciitis, “we found the group treated with PRP did much better right away than those who received traditional nonoperative treatments,” says Monto. “The PRP people also maintained those good results over the year of follow-up.” Insurance coverage for platelet-rich plasma varies, and many doctors still have a wait-and-see attitude about the procedure, but it is becoming more accepted.
One treatment that is not gaining widespread support is the use of Botox to treat PF. While some doctors have touted the nerve paralyzer as a way to lessen heel pain, most in the medical community are dubious. “Your muscles can atrophy so that you might have trouble even walking,” Baravarian says.

Condition 3: Neuroma
What it is: An inflammation and thickening of nerve tissue in the ball of the foot, usually between the third and fourth toes.

Symptoms: The feeling that there is a pebble in your shoe; pain that is lessened when a shoe is removed.

Causes: If your feet tend to roll inward when you walk, that motion over time
can irritate the nerve tissue between the third and fourth toes, producing a neuroma. Another possible contributor: wearing tight shoes that put pressure on nerves in the ball of your foot. Because a variety of factors can cause a similar pain, a neuroma can be difficult to diagnose. Many doctors use a sonogram to see if nerve tissue is inflamed; others press the ball of the foot to listen for a clicking sound that indicates thickened nerves. To be absolutely certain, some inject the nerve tissue with Novocain. If the pain is alleviated, it is a good bet that a neuroma was the cause.

What you can do at home: “If you have a neuroma, deal with it early because it’s much easier to make an improvement then,” Baravarian says. Make sure your shoes are wide enough to avoid squeezing; orthotics and an over-the-counter insole pad to cushion the ball of the foot can also help. “You are better off in rigid-soled shoes that give more support. If you’re going to wear high heels, choose a platform or a wedge—or try to wear a bulkier heel so you don’t teeter on it,” says Baravarian.

Take a break from activities that irritate the nerve, such as anything that entails pounding the balls of your feet. For instance, if you are a gym-goer, use an elliptical trainer rather than a treadmill; replace a step class with Pilates. If pain continues, a cortisone injection can offer temporary relief by calming the nerve. It is not a cure, though, and repeated injections are not recommended because they can lead to nerve atrophy.

What a surgeon can do: The last resort for neuromas is surgery that removes the irritated nerve tissue, which entails up to three weeks of recovery. There is a risk of scarring, which can be painful, and full recovery can take up to three months. “I recommend trying more conservative treatments for six months first,” Deland says.

Condition 4: Nail Fungus
What it is: An infection that develops beneath your toenails.

Symptoms: Thick toenails that are chipping and yellowed.

Causes: Some 10 percent of American adults (more men than women) have this condition, which is sky-high in the yuckiness factor. You inherit a susceptibility to the fungal infection, which can enter in a spot where the nail is split or at an opening on the edge of the nail bed. Older, thicker nails are more at risk, according to the Mayo Clinic.

What you can do at home: Drugstore aisles are rife with OTC topical antifungal products, and they can work, though treatment may take up to a year as the damaged nail grows out. Baravarian offers this tip: “To help medication penetrate, file the top of your nail to remove the shiny coating.”

The most efficacious treatment is the prescription drug Lamisil (terbinafine), taken orally for three (or more) months. “About 75 to 88 percent of cases get cleared up, but the drug has serious side effects,” says Youner. “Three percent of patients experience an elevation in liver enzymes.” To monitor your levels, Baravarian recommends you get a blood test before you start treatment with Lamisil and another a month later.

Fungi breed in moist environments, so to speed recovery and avoid re-infection (always a possibility), choose shoes made of natural, breathable fibers (as opposed to, say, rubber), with enough room for your toes to spread. Also, wear cotton socks and change them if they become damp. Youner recommends going without polish on your toes as much as possible. “Let your nails breathe,” she says.

What a laser can do: In 2010 the Food and Drug Administration approved the Pinpointe Laser to treat toenail fungus. Youner is among those who have incorporated the Pinpointe into her practice. “We do it in a surgical center, no general anesthesia required. The laser goes through the nail and vaporizes the fungal material beneath it. In my experience, most people need a boost about six months later,” she says. A small, independent study published in the Journal of American Podiatric Medicine found that 85 percent of patients who received laser treatment experienced mild to moderate improvement after 180 days. The cost can be up to $1,200 per treatment and is generally not covered by insurance.

Next: The Most Foot-Friendly Shoewear

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First Published Fri, 2012-08-03 08:18

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