Flat Feet

WHAT ARE FLAT FEET?

The arch of your foot is its main supportive structure. If this arch loses strength, the bony framework begins to collapse, causing your foot to flatten. Like a sagging bridge, the weakness in the middle strains the joints at both ends of your foot.

Causes

There are many causes of flat feet. Some people are born with them. Others acquire flat feet as a result of arthritis, trauma, or musculoskeletal disease. Overuse or repeated pounding on hard surfaces can also weaken the foot’s arch.

Symptoms

Discomfort from flat feet often doesn’t appear for years. At some point, pain may be felt and walking may become awkward as increasing strain is put on your feet and calves.


Related Problems

The excess strain from flat feet can cause other foot problems, such as hammertoes, bunions, heel spurs, arch strain, corns, neuromas, and sagging joints. Flat feet can also affect other parts of the body, causing fatigue, pain, or stiffness in the ankles, knees, hips, and lower back.

Medical History and Physical Exam

To determine the best treatment for your problem, your podiatrist looks at your medical history, such as any medical problems you may have had in the past. He or she asks about the length and frequency of your symptoms, the types of activities you do, and any pain or problems you may have in other parts of your body. Your podiatrist does a complete examination of your foot, including a gait analysis to observe the movement and stability of your legs and feet as you walk.

Testing

If your problem is severe and your podiatrist suspects a bone problem, x-rays may be needed. If other problems are suspected, magnetic resonance imaging (MRI) or computerized tomography (CT) may be done, which reveals cross-sectional images of soft tissue and bone.

HOW DOES MY PODIATRIST TREAT FLAT FEET?

If flat feet are diagnosed at an early age, chances are good that nonsurgical treatment, such as strapping, custom shoe inserts (orthotics), or medication can help the problem.

Nonsurgical Care

  • Strapping: Taping your feet may help by temporarily maintaining the proper position of your feet.
  • Orthotics: Custom orthotics can readjust the weight-bearing position of your feet. Soft, semi-flexible, or rigid inserts may be used, depending on your weight and physical activity.
  • Medication: You may be given anti-inflammatory medication to temporarily relieve pain caused by flat feet.

WHAT CAN I DO ABOUT FLAT FEET?

To help ease the pain of flat feet, try the following as part of your daily routine. If you have continuing problems, be sure to see your podiatrist.

Stretching
To stretch your soles and tendons, try this: Lean on something stationary, with one leg in front of the other and both heels flat. Bend the front knee. Hold for 10 seconds. Bend your back knee, bringing the heel up. Hold for 10 seonds. Do this 5 times with each leg.

Shoes
Be sure your shoes are supportive and comfortable, with enough space in the toe box for toes to wiggle. Women should wear low-heeled shoes, not pumps.

Soaking and Massage
Warm-water soaks or ice massages can help relieve pain. But if you have diabetes or a circulation problem, talk with your podiatrist first.

EPAT

Plantar Fasciitis (PF) is the most common cause of foot pain of the approximate 2 million people who seek treatment annually (Surgeons, 2010). The specific etiology is most commonly unknown and pain occurs suddenly and without warning.

Treatment recommendations for PF as described along with the strength of evidence are provided in the JOSPT clinical guidelines. These include: anti-inflammatory agents (advising patients concerning NSAIDS and steroid injections), Iontophoresis, Manual Therapy, Stretching, Taping Techniques, Orthotic Devices, and Night Splints (McPoil, Martin, Cormwall, Wukich, Irrgang, & Godges, 2008). The limitation of this guideline is the absence of further recommendations after possible unsuccessful outcomes.

Treatment recommendations for PF are described using 3 tiers of a treatment ladder in the JT&AS clinical guidelines ((ACFAS), 2010). The 1st tier is the use of padding and strapping, stretching, OTC arch support, heel cups [if fat pad atrophy is present], shoe gear recommendations, oral anti-inflammatories, and/or corticosteroid injection. The 2nd tier consists of: corticosteroid injection, custom orthotics, night splints, immobilization, and/or Rx Physical Therapy.

Tier 3 consists of either Extracorporeal Shock Wave Therapy (ESWT) or Fasciotomy with or without nerve release. Tier 3 is considered chronic and conservative treatment has been tried for at least 6 months ((ACFAS), 2010). Both clinical guidelines agree that approximately 90% of the patients with PF will resolve with conservative interventions, but 10% remain chronically involved.  Extracorporeal Shock Wave Therapy (ESWT) is a relatively new device here in the United States and it is not a common topic of discussion in the health care field.

Extracorporeal Shock Wave Therapy has been used in Europe for over 20 years. In North America it has only been used since 1996. In 2005, the American Food and Drug Administration (FDA) accepted two new types of ESWT devices for the treatment of tennis elbow and PF (Gerdesmeyer & Weil, Extracorporea Shockwave Therapy, 2007). 

ESWT releases high intensity acoustic pressure waves into the target tissue (Iorio, Rode, & Hart). The exact mechanisms of physiological effects of ESWT are unknown. The two major principles of therapeutic effect are: alleviation of pain by increasing blood flow and decreasing the inflammation, and damage of the cell membranes which, this author states, interferes with the transmission of pain signals to the brain (Gerdesmeyer & Weil, Extracorporea Shockwave Therapy, 2007) (Iorio, Rode, & Hart).  Extracorporeal Pulse Activation Treatment (EPAT) is the name of the Low Energy device that we are currently using here at Foot & Ankle Specialists of West Michigan.

It is administered with a hand held applicator, requires 3 treatments and each treatment takes approximately 5-10 minutes, 1-2 weeks apart. EPAT is well tolerated and therefore does not usually require any use of anesthesia, nerve block, or sedation. You will be able to walk out of the procedure and resume normal weight bearing activities.

There is much evidence to support ESWT. Most of the research that is currently published demonstrates statistically significant improvements in patient reported heel pain in over 85% of the participants in the studies. The primary agreement among the articles that implemented ESWT was a reduction in heel pain.

The majority of the quality studies reported that these chronic plantar heel patients would have to either undergo a surgical procedure, which involves risks, or to continue to suffer with the condition and hope that it would eventually improve in time. ESWT interventions are demonstrating effective and long-term pain relief in PF and other chronic musculoskeletal conditions from these studies and many others.

References

(ACFAS), A. C. (2010). The Diagnosis And Treatment of Heel Pain. The Journal of Foot & Ankle Surgery , 49 (35), 51-57.
McPoil, T. G., Martin, R. L., Cormwall, M. W., Wukich, D. K., Irrgang, J. J., & Godges, J. J. (2008).
Heel Pain-Plantar Fasciitis: Clinical Practice Guidelines Linked to the International Classification of Function, Disability, and Health from the Orthopaedic Section of the American Physical Therapy Association. The Journal of Orthopaedic & Sports Physical Therapy , 38 (4), A1-A18.
Gerdesmeyer, L., & Weil, L. (2007). Extracorporea Shockwave Therapy. Towson, MD: Data Trace Publishing Company.
Iorio, A. R., Rode, K. W., & Hart, B. J. Extracorporeal Pulse Activation Technology (EPAT) in Acute and Chronic Musculoskeletal Pain of the Lower Extremity: A Case Report. New York College of Podiatric Medicine. New York: Storz Medical

Cracks & Fissures

WHAT ARE CRACKS AND FISSUES?

Cracks and fissures are breaks in your skin. They may be the result of skin that is too dry to too moist. When skin is too dry, it can become rough and flaky. A large fissure often forms at the base of the heel. When skin is too moist, you may get a bacterial or fungal infection. This can cause cracks between the toes. People who often walk barefoot or wear open shoes are at risk for dry skin. People who wear shoes without socks or shoes and socks that don’t breathe well are at risk for moist skin problems. Your doctor can treat your cracks and fissures. You can help prevent future problems by wearing proper shoes.

WHAT CAUSES CRACKS AND FISSURES

Your skin is a complex organ that requires the right amount of moisture to stay healthy. It can be hard to achieve the right balance of moisture in your feet. When skin is too dry or too moist, cracks or fissures may appear.

When Skin Is Too Dry
Walking barefoot can strip your skin of its natural oil. So can wearing sandals or open shoes. Natural oils form a protective layer on your skin. Without enough oils, skin may crack. Cracks may widen, becoming deep fissures. These fissures may not be able to heal on their own. Cracks and fissures leave your foot open to infection.

When Skin Is Too Moist
Moist skin can result from not drying feet after bathing, or from excess sweat. Wearing shoes without socks or shoes that don’t ventilate can trap sweat on your feet. Overly moist skin can encourage bacteria and fungus to grow. This weakens your skin, leading to cracks. Fungus can progress to athlete’s foot or thick fungal nails

Your Physical Exam

Your doctor will ask you questions about your medical history and current symptoms. He or she will also talk to you about the kinds of shoes you wear. Your doctor will then inspect your feet for breaks in the skin, growths, drainage, and redness. Your skin may also be tested for fungus.

Treatment

If moist skin is causing fungus or bacteria, your doctor may apply medication to your feet. You may be given an antifungal foot soak or lotion to take home. Oral medications may also be prescribed. If you have dry skin, your doctor may remove rough patches with a pumice or special lotion. Fissures may be taped to help them heal. An antibiotic ointment may be prescribed to soothe cracks and prevent infection.

CARING FOR YOUR FEET

Your doctor will treat cracks and fissures in the office. You can also try the tips below.

Caring for Dry Skin
- Use moisturizer on your feet after bathing and at bedtime
- Ask you doctor before using a pumice stone to reduce calluses.
- Never walk barefoot. Avoid sandals and other open shoes.

Caring for Moist Skin
- Always dry between your toes after bathing. Don’t apply moisturizer between toes.
- Ask your doctor about using antifungal powders and lotions or special foot
antiperspirants.
- Choose cotton socks instead of nylon.

Checking Feet Daily
Whether you have dry or moist skin, check your feet daily. Look at the top and bottom of your feet and between your toes. You may need to use a mirror. Call your doctor if you notice redness, swelling, or increased heat.

USING PROPER FOOTWEAR

Choose well-fitting canvas or leather shoes that allow skin to breathe. Avoid synthetic shoes that trap moisture. Disinfect or replace shoes as often as your doctor suggests. And always wear shoes with socks, even at home.