Conditions of the Foot & Ankle

 

ARTHRITIS

Arthritis
Arthritis is a frequent component of complex disease processes that may involve more than 100 identifiable disorders. It is characterized by inflammation of the cartilage and lining of the body's joints. If the feet seem more susceptible to arthritis than other parts of the body, it is because each foot has 33 joints which can be afflicted, and there is no way to avoid the pain of the tremendous weight-bearing load on the feet. Arthritis may be a disabling and occasionally crippling disease; it afflicts almost 40 million Americans. In some forms, it appears to have hereditary tendencies. While the prevalence of arthritis increases with age, all people from infancy to middle age are potential victims. People over 50 are the primary targets. Arthritic feet can result in loss of mobility and independence. But that may be avoided with early diagnosis and proper medical care.


What is Arthritis?
Arthritis, in general terms, is inflammation and swelling of the cartilage and lining of the joints, generally accompanied by an increase in the fluid in the joints. Arthritis has multiple causes; just as a sore throat may have its origin in a variety of diseases, so joint inflammation and arthritis are associated with many different illnesses.

Some Causes
Besides heredity, arthritic symptoms may have their source in a number of phenomena:

  • They can be traumatic, having their origins in injuries, notably in athletes and industrial workers, especially if the injuries have been ignored (which injuries of the feet tend to be).

  • Bacterial and viral infections can strike the joints. The same organisms that are present in pneumonia, gonorrhea, staph infections, and Lyme disease cause the inflammations.

  • Arthritis can develop in conjunction with bowel disorders such as colitis and ileitis, frequently in the joints of the ankles and toes. Such inflammatory bowel diseases seem distant from arthritis, but their control can relieve arthritic pain.

  • Drugs, both prescription drugs and illegal street drugs, can induce arthritis.

  • Arthritis can be part of a congenital autoimmune disease syndrome, of undetermined origin. Recent research has suggested, for instance, that a defective gene may play a role in osteoarthritis.

Symptoms
Because arthritis can affect the structure and function of the feet it is important to see Dr. Bruscia if any of the following symptoms occur in the feet:

  • Swelling in one or more joints

  • Recurring pain or tenderness in any joint 

  • Redness or heat in a joint

  • Limitation in motion of a joint

  • Early morning stiffness

  • Skin changes, including rashes and growths

Some Forms of Arthritis
Osteoarthritis is the most common form of arthritis. It is frequently called degenerative joint disease or "wear and tear" arthritis. Although it an be brought on suddenly by an injury, its onset is generally gradual; aging brings on a breakdown in cartilage, and pain gets progressively more severe, although it can be relieved with rest. Dull, throbbing nighttime pain is characteristic, and it may be accompanied by muscle weakness or deterioration. Gait patterns – normal walking – may grow erratic. It is a particular problem for the feet when people are overweight, simply because there are so many joints in each foot. The additional weight contributes to the deterioration of cartilage and the development of bone spurs. Rheumatoid arthritis (RA) is a major crippling disorder, and perhaps the most serious form of arthritis. It is a complex, chronic inflammatory system of diseases, often affecting more than a dozen smaller joints during the course of the disease, frequently in a symmetrical pattern – both ankles, or the index fingers of both hands, for example. It is often accompanied by constitutional signs and symptoms – lengthy morning stiffness, fatigue, and weight loss – and it may affect various systems of the body, such as the eyes, lungs, heart, and nervous system. Women are three or four times more likely than men to suffer RA, indicating a linkage to heredity. RA has a much more acute onset than osteoarthritis. It is characterized by alternating periods of remission, during which symptoms disappear, and exacerbation, marked by the return of inflammation, stiffness, and pain. Serious joint deformity, and loss of motion, frequently result from acute rheumatoid arthritis. However, the disease system has been known to be active for months, or years, then abate, sometimes permanently. Gout (gouty arthritis) is a condition caused by a build-up of the salts of uric acid – a normal byproduct of the diet – in the joints. A single big toe joint is commonly the locus, possibly because it is subject to so much pressure in walking; attacks of gouty arthritis are extremely painful, perhaps more so than any other form of arthritis. Men are much more likely to be afflicted than premenstrual women, an indication that heredity may play a role in the disease. While a rich diet that contains lots of red meat, rich sauces, and brandy is popularly associated with gout, there are other protein compounds in such foods as lentils and beans which may play a role.

Diagnosis
Different forms of arthritis affect the body in different ways; many have distinct systemic affects that are not common to other forms. Early diagnosis is important to effective treatment of any form. Destruction of cartilage is not reversible, and if the inflammation of arthritic disease isn't treated, both cartilage and bone can be damaged, which makes the joints increasingly difficult to move. Most forms of arthritis cannot be cured, but can be controlled or brought into remission; perhaps only five percent of the most serious cases, usually of rheumatoid arthritis, result in such severe crippling that walking aids or wheelchairs are required.

Treatment
The objectives in the treatment of arthritis are controlling inflammation, preserving joint function (or restoring it if it has been lost), and curing the disease if that is possible.

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ATHLETE'S FOOT

Athlete's Foot
Athlete’s foot is a skin disease caused by a fungus, usually occurring between the toes. The fungus most commonly attacks the feet because shoes create a warm, dark, and  humid environment which encourages fungus growth. The warmth and dampness of  areas around swimming pools, showers, and locker rooms, are also breeding grounds for fungi. Because the infection was common among athletes who used these facilities frequently, the term "athlete's foot” became popular. Not all fungus conditions are athlete’s foot. Other conditions, such as disturbances of the sweat mechanism, reaction to dyes or adhesives in shoes, eczema, and psoriasis, also may mimic athlete's foot.

Symptoms
The signs of athlete's foot, singly or combined, are drying skin, itching, scaling, inflammation, and blisters. Blisters often lead to cracking of the skin. When blisters break, small raw areas of tissue are exposed, causing pain and swelling. Itching and burning may increase as the infection spreads. Athlete's foot may spread to the soles of the feet and to the toenails. It can be spread to other parts of the body, notably the groin and underarms, by those who scratch the infection and then touch themselves elsewhere. The organisms causing athlete's foot may persist for long periods. Consequently, the infection may be spread by contaminated bed sheets or clothing to other parts of the body.

Prevention
It is not easy to prevent athlete's foot because it is usually contracted in dressing rooms, showers, and swimming pool locker rooms where bare feet come in contact with the fungus. However, you can do much to prevent infection by practicing good foot hygiene. Daily washing of the feet with soap and water; drying carefully, especially between the toes; and changing shoes and hose regularly to decrease moisture, help prevent the fungus from infecting the feet. Also helpful is daily use of a quality foot powder.

Tips

  • Avoid walking barefoot; use shower shoes.

  • Reduce perspiration by using talcum powder.

  • Wear light and airy shoes.

  • Wear socks that keep your feet dry, and change them frequently if you perspire heavily.

Treatment
Fungicidal and fungistatic chemicals, used for athlete's foot treatment, frequently fail to contact the fungi in the horny layers of the skin. Topical or oral antifungal drugs are prescribed with growing frequency.  In mild cases of the infection it is important to keep the feet dry by dusting foot powder in shoes and hose. The feet should be bathed frequently and all areas around the toes dried thoroughly.

Consult Dr. Bruscia
If an apparent fungus condition does not respond to proper foot hygiene and self care, and there is no improvement within two weeks, consult Dr. Bruscia. He will determine if a fungus is the cause of the problem. If it is, a specific treatment plan, including the prescription of antifungal medication, applied topically or taken by mouth, will usually be suggested. Such a treatment appears to provide better resolution of the problem when the patient observes the course of treatment prescribed by the podiatrist; if it’s shortened, failure of the treatment is common. If the infection is caused by bacteria, antibiotics, such as penicillin, that are effective against a broad spectrum of bacteria may be prescribed.

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CHILDREN'S FEET
     

Children's Feet
You worry about your children’s teeth, eyes, and other parts of the body. You teach washing, brushing, and grooming, but what do you do about your child's feet-those still-developing feet which have to carry the entire weight of the body through a lifetime? Many adult foot ailments, like other bodily ills, have their origins in childhood and are present at birth. Periodic professional attention and regular foot care can minimize these problems in later life. Neglecting foot health invites problems in other parts of the body, such as the legs and back. There can also be undesirable personality effects. The youngster with troublesome feet walks awkwardly and usually has poor general posture. As a result, the growing child may become shy, introverted, and avoid athletics and social functions. Consultation between Dr. Brusica, your pediatrician, and other medical specialists helps to resolve these related problems.
Your Baby's Feet
The human foot – one of the most complicated parts of the body -has 26 bones, and is laced with ligaments, muscles, blood vessels, and nerves. Because the feet of young children are soft and pliable, abnormal pressure can easily cause deformities. A child's feet grow rapidly during the first year, reaching almost half their adult foot size. This is why Dr. Bruscia considers the first year to be the most important in the development of the feet. Here are some suggestions to help you assure that this development proceeds normally:

  • Look carefully at your baby’s feet. If you notice something that does not look normal to you, seek professional care immediately. Deformities will not be outgrown by themselves.

  • Cover baby's feet loosely. Tight covers restrict movement and can retard normal development.

  • Provide an opportunity for exercising the feet. Lying uncovered enables the baby to kick and perform other related motions which prepare the feet for weight-bearing.

  • Change the baby's position several times a day. Lying too long in one spot, especially on the stomach, can put excessive strain on the feet and legs.

Starting to Walk
It is unwise to force a child to walk. When physically and emotionally ready, the child will walk. Comparisons with other children are misleading, since the age for independent walking ranges from 10 to 18 months. When the child first begins to walk, shoes are not necessary indoors. Allowing the youngster to go barefoot or to wear just socks helps the foot to grow normally and to develop its musculature and strength, as well as the grasping action of toes. Of course, when walking outside or on rough surfaces, babies' feet should be protected in lightweight, flexible footwear made of natural materials.
Growing Up
As a child's feet continue to develop, it may be necessary to change shoe and sock size every few months to allow room for the feet to grow. Although foot problems result mainly from injury, deformity, illness, or hereditary factors, improper footwear can aggravate preexisting conditions. Shoes or other footwear should never be handed down. The feet of young children are often unstable because of muscle problems which make walking difficult or uncomfortable. A thorough examination by Dr. Bruscia  may detect an underlying defect or condition which may require immediate treatment or consultation with another specialist. The American Podiatric Medical Association has long known of the high incidence of foot defects among the young, and recommends foot health examinations for school children on a regular basis. 
Sports Activities
 Millions of American children participate in team and individual sports, many of them outside the school system, where advice on conditioning and equipment is not always available, Parents should be concerned about children’s involvement in sports that require a substantial amount of running and turning, or involve contact. Protective taping of the ankles is often necessary to prevent sprains or fractures. Parents should consider discussing these matters with their family podiatrist if they have children participating in active sports. Sports-related foot and ankle injuries are on the rise as more children actively participate in sports.

Advice for Parents
 Problems noticed at birth will not disappear by themselves. You should not wait until the child begins walking to take care of a problem you've noticed earlier. Remember that lack of complaint by a youngster is not a reliable sign. The bones of growing feet are so flexible that they can be twisted and distorted without the child being aware of it.  Walking is the best of all foot exercises, according to podiatrists. They also recommend that walking patterns be carefully observed. Does the child toe in or out, have knock knees, or other gait abnormalities' These problems can be corrected if they are detected early. Going barefoot is a healthy activity for children under the right conditions. However, walking barefoot on dirty pavements exposes children’s feet to the dangers of infection through accidental cuts and to severe contusions, sprains or fractures. Another potential problem is plantar warts, a condition caused by a virus which invades the sole of the foot through cuts and breaks in the skin. They require protracted treatment and can keep children from school and other activities. Be careful about applying home remedies to children's feet. Preparations strong enough to kill certain types of fungus can harm the skin.   Whenever you have questions about your child’s foot health, contact Dr. Bruscia.

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DIABETES
     

Diabetes
 Diabetes mellitus is a chronic disease which afflicts about 16 million people in the United States, half of whom are unaware they have the disease. It is a metabolic disease characterized by elevated glucose (blood sugar), resulting from defects in secretion of the hormone insulin, defects which cause tissue to resist absorption of insulin, or both. Chronic elevation of blood sugar (hyperglycemia) is associated with long-term damage to the eyes, heart, kidneys, feet, nerves, and blood vessels. Symptoms of hyperglycemia may include frequent urination, excessive thirst, extreme hunger, unexplained weight loss, tingling or numbness of the feet or hands, blurred vision, slow-to-heal wounds, and susceptibility to certain infections. Those who have any of these symptoms and have not been tested for the disease should see a physician without delay. Individuals with diabetes are prone to many complications, both acute and chronic. About 15 percent of those with diabetes will develop an open wound (ulceration) on a foot during their lifetimes, and 20 percent of these ulcerations will lead to amputations. The annual incidence of nontraumatic lower extremity amputations among people with diabetes is about 54,000, according to the American Diabetes Association. Among African-Americans, the amputation rate is 1 1/2 to 2 1/2 times that of whites, and Native Americans have even higher rates, three or four times that of whites.

An Unwelcome Lifetime Companion
Diabetes, once diagnosed, is present for life. Considerable research is focused on finding a cure, and much progress has been made in treatment and control of the disease. The majority of people with diabetes have type II diabetes. Type I, insulin-dependent diabetes mellitus, once referred to as juvenile, or juvenile-onset diabetes, afflicts five to 10 percent of people with diabetes. Type II, non-insulin-dependent diabetes mellitus, once known as adult-onset diabetes, afflicts the other 90-95 percent, many of whom use oral medication or injectable insulin. The vast majority of those people (80 percent or more) are overweight, many of them obese. Obesity itself can cause insulin resistance. The socioeconomic costs of diabetes are enormous. The dollar costs have been estimated at 592 billion annually, about equally split between direct medical costs and indirect costs. Diabetes is the fourth leading cause of death by disease in the United States. Individuals with diabetes are two to four times as likely to experience heart disease and stroke. It is the leading cause of end-stage kidney disease and new cases of blindness among adults under 75. The trauma of amputation is particularly debilitating. It often ends working careers, and restricts social life and the independence which mobility affords. For more than 50 percent of those who experience an amputation of one limb, the loss of another will occur within three to five years. The key to amputation prevention is early recognition and foot screening, at least annually, of at-risk individuals. Those individuals considered to be at high risk are those who exhibit one or more of six characteristics: (1) peripheral neuropathy, a nerve disorder generally characterized by loss of protective sensation and/or tingling and numbness in the feet; (2) vascular insufficiency, a circulatory disorder which inhibits blood flow to the extremities; (3) foot deformities, such as hammertoes; (4) stiff joints; (5} calluses on the soles of the feet; and (6) a history of open sores on the feet (ulcerations) or a previous lower extremity amputation.

The Role of Dr. Bruscia
Dr. Bruscia is a foot care specialist with skills in recognition and treatment of diabetic foot conditions. Because diabetes is a systemic disease, affecting many organs of the body, ideal case management requires a team approach, involving Dr. Bruscia as well as the family physician, several medical specialists, and a dietitian. Dr. Bruscia, as an integral part of the treatment team, has documented success in the prevention of amputations. It is one of the most serious conditions treated by Dr. Bruscia, whose training stresses salvage of the foot rather than amputation. A comprehensive approach to prevention of complications must include good glucose control, adherence to diet, an exercise program, proper medication and hygiene, and regular foot care. Those who follow the medical team's advice have a good chance of preventing or delaying the complications of the disease, and living normal lives. Furthermore, with such a regimen as groundwork, it is estimated that more than half of the lower extremity amputations among people with diabetes could be prevented. 

Warning Signs
For the person with diabetes who has not yet developed foot complications, there are warning signs which should be recognized and called to the attention of the family physician or Dr. Bruscia.

They include:

  • color changes of the skin

  • elevation of skin temperature

  • swelling of the foot or ankle

  • pain in the legs, either at rest or while walking

  • open sores, with or without drainage, that are slow to heal

  • ingrown and fungus-infected toenails

  • corns or calluses with bleeding within the skin

  • dry fissures (cracks) in the skin, especially around the heel

  • Ulceration is a common occurrence of the diabetic foot. Poorly fitted shoes, or something as seemingly trivial as a stocking seam, can create a wound that cannot be felt and may not immediately be seen by someone whose level of skin sensation has been minimized. Left unattended, such an ulcer can quickly become infected and lead to serious consequences.

Visit Dr. Bruscia Regularly
For the person with diabetes a number of practices and precautions should be employed. Regular visits to Dr. Bruscia for foot inspections, no less than annually and preferably more often, are recommended. The doctor may conduct specific diagnostic tests to assess the presence or progression of diabetes complications. Such tests may include assessments of circulation, using an instrument known as the Doppler for measurement of blood flow; vibration sense, using a tuning fork; sensation (light touch and deep pressure), using a plastic monofilament slightly thicker than a toothbrush bristle in what is called the Semmes-Weinstein test; and foot structure, using X-rays. Dr. Bruscia will probably also reinforce self foot care, reminding patients of previously dispensed advice. There is a sizable list of “do's and don’ts.” Shoes are at the top of the list Poorly fitted shoes are involved in as many as half of the problems that lead to amputations. Foot shape and size may change over the years; peripheral neuropathy contributes to change. Everyone, particularly those with diabetes, should be fitted by experienced shoe fitters for every new pair of shoes. New shoes should be comfortable at the time they're purchased – they should not require a break-in period – but it is a good idea to wear them for only short periods of time at first. Shoes should have leather or canvas uppers, fit both the length and width of the foot, leaving room for the toes to wiggle freely, and be cushioned and sturdy. Athletic footwear may fit the bill nicely. It’s a good idea to change shoes during the day, to relieve pressure areas. Avoid high heels and shoes with pointed toes. Never wear shoes with open toes or heels, including sandals, especially those with straps between the first two toes. Shake shoes out and feel inside them for rough stitching or foreign objects, such as small pebbles. Never go without socks. Diabetics who have difficulty finding shoes that fit should ask Dr. Bruscia to prescribe corrective shoes, or refer them to a shoe specialist, the pedorthist. For those eligible, Medicare provides coverage for extra depth shoes or specially molded shoes, and inserts, for those with advanced cases of diabetes. The medical or osteopathic doctor treating an individual for diabetes can certify the need for therapeutic shoes which Dr. Bruscia can prescribe.

Other cautions:

  • Wash feet daily, using mild soap and lukewarm water. Those with diabetes should always test bath water temperature with a thermometer or the elbow, since the feet may be unable to detect scalding temperatures.

  • Dry feet carefully with a soft towel, especially between the toes, and dust them with talcum powder. If the skin is dry, use a good moisturizing cream daily, but avoid getting it between the toes.

  • Feet and toes should be inspected daily for cuts, bruises, and sores, or other changes that are less obvious. If self-inspection is hampered by age or other factors, use a mirror or get the assistance of another person.

  • Wear thick, soft socks; avoid mended socks or those with seams, which could cause blisters or other skin injuries. Never go barefoot, even inside your own home, and especially out of doors on unfamiliar terrain such as the beach or grassy areas.

  • Smokers should give up the habit The consumption of alcohol should be moderated. Tobacco can contribute to circulatory problems, and alcohol to neuropathy.

  • Smokers should give up the habit The consumption of alcohol should be moderated. Tobacco can contribute to circulatory problems, and alcohol to neuropathy.

  • Exercise is important Walk as frequently as possible; it’s the best overall conditioner for the feet.

  • People with diabetes are commonly overweight. That approximately doubles the risk of complications; close observance of good dietary habits is important.

  •  For cold feet at night, wear loose socks (don’t use heating pads or hot water bottles, or other external heat sources).

  • Don't use garters or elastics to hold up stockings, and don't use panty girdles that are too tight around the legs.

  • Cut toenails straight across, then use an emery board to gently file away sharp corners. Don’t cut into the corners.

  • Never try to cut calluses with a razor blade, or anything else, without professional guidance, and never use commercial preparations to remove corns or warts; they contain chemicals that can burn the skin.

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FOOT & ANKLE INJURIES
  

Foot & Ankle Injuries
 Foot and ankle emergencies happen every day. Broken bones, dislocations, sprains, contusions, infections, and other serious injuries can occur at any time. Early attention is vitally important. Whenever you sustain a foot or ankle injury, you should seek immediate treatment from Dr. Bruscia. That advice is universal, even though there are lots of myths about foot and ankle injuries. Some of them follow:

Myths
1. "It can't be broken, because I can move it" False; this widespread idea has kept many fractures from receiving proper treatment. The truth is that often you can walk with certain kinds of fractures. Some common examples: breaks of the thinner of the two leg bones; small "chip" fractures of either foot or ankle bones; and the frequently neglected fracture of a toe.

2. "If you break a toe, immediate care isn't necessary." False; a toe fracture needs prompt attention. If X-rays reveal it to be a simple, displaced fracture, care by your podiatrist usually can produce rapid relief. However, X-rays might identify a displaced or angulated break. In such cases, prompt realignment of the fracture by your podiatric physician will help prevent improper or incomplete healing. Many patients develop post-fracture deformity of a toe, which in turn results in formation of a painfully deformed toe with a most painful corn. A good general rule is: Seek prompt treatment for injury to foot bones. 

3. "If you have a foot or ankle injury, soak it in hot water immediately." False; don’t use heat or hot water if you suspect a fracture, sprain, or dislocation. Heat promotes blood flow, causing greater swelling. More swelling means greater pressure on the nerves, which causes more pain. An ice bag wrapped in a towel has a contracting effect on blood vessels, produces a numbing effect, and prevents swelling and pain, After seeing Dr. Bruscia, warm compresses and soaks may be used.

4. "Applying an elastic bandage to a severely sprained ankle is adequate treatment” False; ankle sprains often mean torn or severely overstretched ligaments, and they should receive immediate care. X-ray examination, immobilization by casting or splinting, and physiotherapy to insure a normal recovery all may be indicated, Surgery may even be necessary. 

5. "The terms 'fracture, ‘break,' and 'crack' are all different" False; all of those words are proper in describing a broken bone. 

Before Seeing Dr. Bruscia
If an injury or accident does occur, the steps you can take to help yourself until you can reach Dr. Bruscia are easy to remember if you can recall the word “RICE." 

1. Rest. Cut back on your activity, and get off your feet if you can.

2. Ice. Gently place a plastic bag of ice, or ice wrapped in a towel, on the injured area in a 20-minute-on, 40-minute-off cycle.

3. Compression. Lightly wrap an Ace bandage around the area, taking care not to pull it too tight.

4. Elevation. Sit in a position that you can elevate the foot higher than the waist, to reduce swelling and pain.

5. Switch to a soft shoe or slipper, preferably one that Dr. Bruscia can cut up in the office if it needs to be altered to accommodate a bulky dressing.

6. For bleeding cuts, cleanse well, apply pressure with gauze or a towel, and cover with a clean dressing. It’s best not to use any medication on the cut before you see Dr. Bruscia. 

7. Leave blisters unopened if they are not painful or swollen.

8. Foreign materials in the skin, such as slivers, splinters, and sand, can be removed carefully with a sterile instrument. A deep foreign object, such as broken glass or a needle, must be removed professionally. 

9. Treatment for an abrasion is similar to that of a burn, since raw skin is exposed to the air and can easily become infected. Cleansing is important to remove all foreign particles. Sterile bandages should be applied, along with an antibiotic cream or ointment.

Prevention
1. Wear the correct shoes for any event. Good walking shoes provide more comfort and better balance. 

2. Wear hiking shoes or boots in rough terrain.

3. Different sports activities call for specific footwear to protect feet and ankles. Use the correct shoes for each sport Don't wear any sports shoe beyond its useful life.

4. Wear safety shoes if you're in an occupation which threatens foot safety. There are specific safety shoes for a variety of on-the-job conditions. Be certain they are fitted properly.

5. Always wear hard-top shoes when operating a lawn mower or other grass-cutting equipment. 

6. Don't walk barefoot on paved streets or sidewalks.

7. Watch out for slippery floors at home and at work. Clean up obviously dangerous spills immediately.

8. If you get up during the night, turn on a light. Many fractured toes and other foot injuries occur while attempting to find your way in the dark.

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FOOT HEALTH

Foot Health
The human foot is a biological masterpiece. Its strong, flexible, and functional design enables it to do its job well and without complaint – if' you take care of it and don’t take it for granted. The foot can be compared to a finely tuned race car, or a space shuttle, vehicles whose function dictates their design and structure. And like them, the human foot is complex, containing within its  relatively small size 26 bones (the two feet contain a quarter of all the bones in the body), 33 joints, and a network of more than 100 tendons, muscles, and ligaments, to say nothing of blood vessels and nerves. 

Tons of Pressure
The components of your feet work together, sharing the tremendous pressures of daily living. An average day of walking, for example, brings a force equal to several hundred tons to bear on the feet and lower legs.
Specialized Care
Your feet, like other specialized structures, require specialized care. A doctor of podiatric medicine can make an important contribution to your total health, whether it is regular preventive care or surgery to correct a deformity. In order to keep your feet healthy, you should be familiar with the most common ills that affect them. Remember, though, that self-treatment can often turn a minor problem into a major one, and is generally not advisable. You should see Dr. Bruscia when any of the following conditions occur or persist. Athlete’s foot is a skin disease, usually starting between the toes or on the bottom of the feet, which can spread to other parts of the body. It is caused by a fungus that commonly attacks the feet, because the wearing of shoes and hosiery fosters fungus growth. The signs of athlete’s foot are dry scaly skin, itching, inflammation, and blisters. You can help prevent infection by washing your feet daily with soap and warm water; drying carefully, especially between the toes; and changing shoes and hose regularly to decrease moisture. Athlete’s foot is not the only infection, fungal and otherwise, which afflicts the foot, and other dry skin/dermatitis conditions can be good reasons to see Dr. Bruscia if a suspicious condition persists. Blisters are caused by skin friction. Don’t pop them. Apply moleskin or an adhesive bandage over a blister, and leave it on until it falls off naturally in the bath or shower. Keep your feet dry and always wear socks as a cushion between your feet and shoes. If a blister breaks on its own, wash the area, apply an antiseptic, and cover with a sterile bandage. Bunions are misaligned big toe joints which can become swollen and tender. The deformity causes the first joint of the big toe to slant outward, and the big toe to angle toward the other toes. Bunions tend to run in families, but the tendency can be aggravated by shoes that are too narrow in the forefoot and toe. There are conservative and preventive steps that can minimize the discomfort of a bunion, but surgery is frequently recommended to correct the problem. Corns and calluses are protective layers of compacted, dead skin cells. They are caused by repeated friction and pressure from skin rubbing against bony areas or against an irregularity in a shoe. Corns ordinarily form on the toes and calluses on the soles of the feet. The friction and pressure can burn or otherwise be painful and may be relieved by moleskin or padding on the affected areas. Never cut corns or calluses with any instrument, and never apply home remedies. Foot odor results from excessive perspiration from the more than 250,000 sweat glands in the foot. Daily hygiene is essential. Change your shoes daily to let each pair air out, and change your socks, perhaps even more frequently than daily. Foot powders and antiperspirants, and soaking in vinegar and water, can help lessen odor. Hammertoe is a condition in which any of the toes are bent in a claw-like position. It occurs most frequently with the second toe, often when a bunion slants the big toe toward and under it, but any of the other three smaller toes can be affected. Although the condition usually stems from muscle imbalance, it is often aggravated by ill-fitting shoes or socks that cramp the toes. Avoid pressure on the toes as much as possible. Surgery may be necessary to realign the toes to their proper position. Heel pain can generally be traced to faulty biomechanics which place too much stress on the heel bone, ligaments, or nerves in the area. Stress could result while walking or jumping on hard surfaces, or from poorly made footwear. Overweight is also a major contributing factor. Some general health conditions – arthritis, gout, and circulatory problems, for example – also cause heel pain. Heel spurs are growths of bone on the underside of the heel bone. They can occur without pain; pain may result when inflammation develops at the point where the spur forms. Both heel pain and heel spurs are often associated with plantar fasciitis, an inflammation of the long band of connective tissue running from the heel to the ball of the foot. Treatments may range from exercise and custom-made orthotics to anti-inflammatory medication or cortisone injections. Ingrown nails are nails whose corners or sides dig painfully into the skin, often causing infection. They are frequently caused by improper nail trimming, but also by shoe pressure, injury, fungus infection, heredity, and poor foot structure. Toenails should be trimmed straight across, slightly longer than the end of the toe, with toenail clippers. If painful or infected, Dr. Bruscia may remove the ingrown portion of the nail; if the condition reoccurs frequently, Dr. Bruscia may permanently remove the nail. Neuromas are enlarged, benign growths of nerves, most commonly between the third and fourth toes. They are caused by bones and other tissue rubbing against and irritating the nerves. Abnormal bone structure or pressure from ill-fitting shoes also can create the condition, which can result in pain, burning, tingling, or numbness between the toes and in the ball of the foot. Conservative treatment can include padding, taping, orthotic devices and cortisone injections, but surgical removal of the growth is sometimes necessary. Warts are caused by a virus, which enters the skin through small cuts and infects the skin. Children, especially teenagers, tend to be more susceptible to warts than adults. Most warts are harmless and benign, even though painful and unsightly. Warts often come from walking barefooted on dirty surfaces or littered ground. There are several simple procedures which Dr. Bruscia might use to remove warts.

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FOREFOOT SURGERY
        

Forefoot Surgery
Many foot problems do not respond to "conservative" management; Dr. Bruscia can determine when surgical intervention may be helpful. Often when pain or deformity persists, surgery may be appropriate to help alleviate them, or to restore the function of your foot.

Bunions
A common deformity of the foot, a bunion is an enlargement of the bone and tissue around the joint of the big toe. Heredity frequently plays a role in the occurrence of bunions (especially among women), as it does in other foot conditions. When symptomatic, the tissue may become red, swollen, and inflamed, making shoe gear and walking uncomfortable and difficult. If conservative care fails to reduce these symptoms, surgical intervention may be warranted. Dr. Bruscia will determine the type of surgical procedure best suited for your deformity, based on a variety of information which may include X-rays and gait examination. 

Hammertoe
A hammertoe deformity is a contracture of the toe(s), frequently caused by an imbalance in the tendon or joints of the toes; due to the "budding" effect of the toe(s), hammertoes may become painful secondary to footwear irritation and pressure. Corn and callus formation may occur as a hammertoe becomes more rigid over time, making if. difficult to wear shoes. Dr. Bruscia may suggest correction of this deformity through a surgical procedure to realign the toe(s).

Neuroma
An irritation of a nerve may produce a neuroma, which is a benign enlargement of a nerve segment, commonly found between the third and fourth toes. Several factors may contribute to the formation of a neuroma. Trauma, arthritis, high-heeled shoes, or an abnormal bone structure are just some of the conditions that may cause a neuroma. Symptoms such as burning or tingling to adjacent toes and even numbness are commonly seen with this condition. If conservative treatment does not relieve the symptoms, then Dr. Bruscia will decide based on your symptoms whether surgical treatment is appropriate.

Bunionette (tailor's bunion)
A protuberance of bone at the outside of the foot behind the fifth (small) toe, the bunionette or "small bunion” is caused by a variety of conditions including heredity, faulty biomechanics (the way you walk) or trauma, to name a few, Pain is often associated with this deformity, making shoes very uncomfortable and at times even walking becomes difficult If severe and conservative treatments fail to improve the symptoms of this condition, surgical repair may be suggested. Dr. Bruscia will develop a surgical plan specific to the condition present.

Toenail Deformities
Ingrown or deformed toenail tissue may be severe enough to warrant surgical treatment. Removal of part or all the nail may be necessary, depending on the deformity. Sometimes soft tissue near or at the nail plate must be removed to adequately treat specific conditions of the toenail, Dr. Bruscia will decide the surgical procedure best suited to treat your nail condition. 

Bone Spurs
A bone spur is an overgrowth of bone as a result of trauma or reactive stress of a ligament or tendon. This growth can cause pain and even restrict motion of a joint, depending on its location and size. Spurs may also be located under the toenail plate, causing nail deformity and pain. Surgical treatment and procedure is based on the size, location, and symptoms of the bone spur. Dr. Bruscia will determine the surgical method best suited for your condition.

Preoperative Testing and Care
As with anyone facing any surgical procedure, those undergoing foot and ankle surgery require specific tests or examinations before surgery to improve a successful surgical outcome. Prior to surgery, the podiatric surgeon will review your medical history and medical conditions. Specific diseases, illnesses, allergies, and current medications need to be evaluated. Other tests that help evaluate your health status may be ordered by the podiatric physician, such as blood studies, urinalysis, EKG, X-rays, blood flow studies (to better evaluate the circulatory status of the foot/legs), and biomechanical examination. A consultation with another medical specialist is sometimes advised by Dr. Bruscia, depending on your test results or a specific medical condition.

Postoperative Care
The type of foot surgery performed determines the length and kind of aftercare required to assure that your recovery from surgery is rapid and uneventful. The basics of all postoperative care involve to some degree each of the following: rest, ice, compression and elevation. Bandages, splints, surgical shoes, casts, crutches, or canes may be necessary to improve and insure a safe recovery after foot surgery. A satisfactory recovery can be hastened by carefully following instructions from Dr. Bruscia.

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HEEL PAIN
        

Heel Pain
In our pursuit of healthy bodies, pain can be an enemy. In some instances, however, it is of biological benefit. Pain that occurs right after an injury or early in an illness may play a protective role, often warning us about the damage we've suffered. When we sprain an ankle, for example, the pain warns us that the ligament and soft tissues may be frayed and bruised, and that further activity may cause additional injury. Pain, such as may occur in our heels, also alerts us to seek medical attention. This alert is of utmost importance because of the many afflictions that contribute to heel pain.

Heel Pain 
Heel pain is generally the result of faulty biomechanics (walking gait abnormalities) which place too much stress on the heel bone and the soft tissues that attach to it. The stress may also result from injury, or a bruise incurred while walking, running, or jumping on hard surfaces; wearing poorly constructed footwear; or being overweight. The heel bone is the largest of 26 bones in the human foot, which also has 33 joints and a network of more than 100 tendons, muscles, and ligaments. Like all bones, it is subject to outside influences that can affect its integrity and its ability to keep us on our feet. Heel pain, sometimes disabling, can occur in the front, back, or bottom of the heel.

Heel Spurs
A common cause of heel pain is the heel spur, a bony growth on the underside, forepart of the heel bone. The spur, visible by X-ray, appears as a protrusion that can extend forward as much as half an inch. When there is no indication of bone enlargement, the condition is sometimes referred to as “heel spur syndrome." Heel spurs result from strain on the muscles of the foot, by stretching of the long band of tissue that connects the heel and the ball of the foot, and by repeated tearing away of the lining or membrane that covers the heel bone. These conditions may result from biomechanical imbalance, running or jogging, improperly fitted or excessively worn shoes, or obesity. 

Plantar Fasciitis
Both heel pain and heel spurs are frequently associated with an inflammation of the band of fibrous connective tissue (fascia} running along the bottom (plantar surface) of the foot, from the heel to the ball of the foot. The inflammation is called plantar fasciitis. It is common among athletes who run and jump a lot, and can be quite painful. The condition occurs when the plantar fascia flattens out and elongates over time beyond its normal extension, causing the soft tissue fibers of the fascia to tear or stretch at various points along its length, including at the heel bone A gap occurs, which between the fascia and the heel bone may be filled in with the growth of new bone. The inflammation may be aggravated by shoes that lack appropriate support, especially in the arch area, and by the chronic irritation that sometimes accompanies an athletic lifestyle. Resting provides only temporary relief. When you resume walking, particularly after a night's sleep, you may experience a sudden elongation of the fascia band which stretches and pulls on the heel. As you walk, the heel pain may lessen or even disappear, but that may be just a false sense of relief. The pain often returns after prolonged rest.

Excessive Pronation
Heel pain sometimes results from excessive pronation. Pronation is the normal flexible  motion of the foot that allows it to adapt to ground surfaces and absorb shock in the normal walking pattern. As you walk, the heel contacts the ground first; the weight shifts first to the outside of the foot, then moves toward the big toe. The arch rises, the foot generally rolls upward and outward, becoming rigid and stable in order to lift the body and move it forward. Excessive pronation – excessive inward motion – can create an abnormal amount of stretching and pulling on the fascia while jogging or running, for example. Excessive pronation may also contribute to injury to the hip, knee, and lower back.

Disease and Heel Pain
Some general health conditions can also bring about heel pain. Rheumatoid arthritis and other forms of arthritis, including gout, which usually manifests itself in the big toe joint, can cause heel discomfort in some cases. Heel pain may also be the result of an inflamed bursa (bursitis), a small, irritated sack of fluid; a neuroma (a nerve growth); or another soft-tissue growth. Such heel pain may be associated with a heel spur, or may mimic the pain of a heel spur. Haglund's deformity ("pump bump"} is a bone enlargement at the back of the heel bone, in the area where the Achilles tendon attaches to the bone. This sometimes painful deformity generally is the result of bursitis caused by pressure against the shoe, and can be aggravated by the height or stitching of a heel counter of a particular shoe, Bone bruises, and stone bruises, are common heel injuries. A bone bruise or contusion is an inflammation of the skin that covers the heel bone. A stone bruise is a sharply painful injury caused by the direct impact of a hard object or surface on the foot. Stress fractures can occur, but these are less frequent. 

Children's Heel Pain
Heel pain can also occur in children, most commonly between ages 8 and 13, as they become increasingly active in sports activity in and out of school. This physical activity, particularly jumping, irritates the growth centers of the heels; the more active the child, the more likely the condition will occur. When the bones mature, the problems disappear and are not likely to recur. If pain is disabling, professional care may be indicated to provide relief. Other good news is that heel spurs do not often develop in children.

Prevention
A variety of steps can be taken to avoid heel pain and accompanying afflictions:

  •  Wear shoes that fit well – front, back, and sides – and have shock-absorbent soles, rigid shanks, and supportive heel counters.

  •  Wear the proper shoes for each activity.

  •  Do not wear shoes with excessive wear on heels or soles.

  •  Prepare properly before exercising. Warm up before running or walking, and do some stretching exercises afterward.

  •  Pace yourself when you participate in athletic activities.

  •  Don't underestimate your body's need for rest and good nutrition.

  •  If obese, lose weight.

Podiatric Medical Care
If pain and other symptoms of inflammation – redness, swelling, heat – persist, you should limit normal daily activities and contact Dr. Bruscia. He may perform various diagnostic X-rays, to rule out heel spurs or fractures. Early treatment might involve oral or injectable anti-inflammatory medication, exercise and shoe recommendations, taping or strapping, or use of various shoe inserts – orthotic devices. Taping or strapping supports the foot, placing stressed muscles in a physiologically restful state and preventing stretching of the plantar fascia. Physical therapy may be used in conjunction with such treatments. A functional orthotic device may be prescribed for correcting biomechanical imbalance, supporting the heel, controlling excessive pronation and stretching of the plantar fascia. It will effectively treat the majority of heel and arch pain without the need for surgery. Only a relatively few cases of heel pain require surgery. If surgery is necessary, it is usually for the removal of a spur, but also may involve release of the plantar fascia, removal of a bursa, or removal of a neuroma or other soft-tissue growth.

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HIGH BLOOD PRESSURE
 

As a member of the health care team, Dr. Bruscia is vitally concerned about hypertension (high blood pressure) and vascular disease (heart and circulatory problems). There are several reasons for this concern. First, because you are a patient, Dr. Bruscia is interested in all aspects of your health and your treatment program. Second, he supports the goals of high blood pressure detection, treatment, and control. Dr. Bruscia should know if you have any of the following cardiovascular or related conditions: 

  • Hypertension and/or cardiovascular disease-Hypertension sometimes causes decreased circulation. A careful examination is required to determine if there is lower than normal temperature in any of the extremities, or absence of normal skin coloration, or diminished pulse in the feet. The concern here is that these are signs of arterial insufficiency (reduced blood flow). Increased or periodic swelling in the lower extremities is important because it may mean that hypertension has contributed to heart disease. 

  • Rheumatic heart disease – Persons who have had rheumatic heart disease must be protected with prophylactic antibiotics prior to any surgical intervention. If you take medication for this condition, tell your podiatrist. Any medication you may be taking for high blood pressure, a heart condition, or any other reason should he reported to the podiatrist to ensure that it does not conflict with medications that may be prescribed in the treatment of your feet. 

  • Diabetes- This condition frequently affects the smaller arteries, resulting in diminished circulation and decreased sensation in the extremities. Let Dr. Bruscia know if you have ever been told that you have diabetes, particularly if you are taking medication or insulin for this condition.

  • Ulceration-Open sores that do not heal or heal very slowly may be symptoms of certain anemias, including sickle cell disease. Or they may be due to hypertension or certain inflammatory conditions of the blood vessels. Dr. Bruscia is on the alert for such conditions, but be sure to mention if you have ever had this problem.

  • Swollen Feet – Persistent swelling of one or both feet may be due to kidney, heart, or circulatory problems.

  • Burning Feet-Although it can have a number of causes, a burning sensation of the feet is frequently caused by diminished circulation.

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NAIL PROBLEMS
     

Nail Problems
Most people don't give much thought to the value of their toenails. They have to be trimmed occasionally, often considered more of a nuisance than anything else, but that may be the limit of attention from many. In reality, because they are at the far point of our circulatory system, they often serve as barometers of our health, diagnostic tools providing the initial signal of the presence or onset of systemic diseases. Pitting of nails and increased nail thickness, as examples, can be manifestations of psoriasis. Concavity – nails that are rounded inward, instead of outward – can foretell iron deficiency anemia; red discoloration beneath the rear of the nail could be a sign of impending heart failure.

Outside Influences
Toenails grow constantly. Some conditions make them grow faster than usual, such as an excess of thyroid hormone, and the injury recovery process. A lot of energy is required for toenail growth relative to the small amount of tissue involved. This high level of metabolic activitymakes them sensitive to outside influences, resulting in abnormalities – deformity, discoloration, and related infection. Some nail problems can be conservatively treated, others require partial or total removal of the nail. The major parts of the toenail are the nail itself (nail plate), its root, or nail bed {matrix), rear area (lunula) or cuticle, underside of the nail (nail bed) and nail side or groove (sulcus). Healthy nails are pink, free of dirt and impairment, and grow into the grooves normally.

Nail Ailments
Because of their association with health-related diseases, toenails of persons of all ages can undergo an array of changes, some of which are relatively common. They can become brittle, curved, discolored, infected, clubbed, pitted, and grooved. In some cases, the nail falls off and a new one grows in. These conditions may be caused by injury, warts, tumors under the nail, infection, poor circulation, poor foot hygiene, and congenital problems with parts of the nail that normally grow into the skin. Older persons with poor circulation are prone to having their nails become discolored or darkened, thick, or brittle. Another disorder of aging is the formation of narrow ridges running from the nail matrix to the sides. Many older persons do not have the strength, skill, eyesight, or tools to trim their nails, especially if the nails are deformed, and should seek podiatric medical care for those services.

Ingrown Toenails
Ingrown nails, the most common toenail impairment, are nails whose corners or sides dig painfully into the soft tissue of nail grooves, often leading to irritation, redness, and swelling. Usually toenails grow straight out. Sometimes, however, one or both corners or sides curve and grow into the flesh, Ingrown nails are varied in shape; some appear flat, others are C-shaped, a problem more commonly of older persons. It's usually the big toe that’s the victim, but other toes can be affected. Ingrown toenails may be caused by:

  •  Improperly trimmed nails

  •  Shoe pressure; crowding of toes

  •  Repeated trauma to the feet from normal activities associated with work, sports, and other leisure-time and fitness pursuits, such as aerobics

  •  Heredity

Fungal And Other Infections
Toenails are hiding places for dirt, and can serve as breeding ground for infection-causing bacterial and fungal organisms. Fungal infections are among the most troublesome of nail conditions to treat. They are often characterized by thickening, discoloration, and separation of the front of the nail from the nail bed. In some cases, the nail crumbles. If treatment with medication is unsuccessful, the nail may have to be removed. However, removal does not necessarily prevent the nail from growing back, or fungal infection from recurring. In older persons with impaired circulation, such as diabetics, medical treatment is generally preferable to surgery. Some other infections cause inflammation of the matrix (onychia) and inflammation of the tissue adjacent to the nail (paronychia), which often lead to serious complications, including more widespread infection extending up the leg. When ignored or treated without medical attention,  infections of these types may result in loss of toes, a foot, or even a leg.

Podiatric Medical Care
If you suspect an infected toenail, you can immerse the foot in a warm salt water soak, or a basin of soapy water, then apply an antiseptic and bandage the area. These are only temporary measures, for relief of discomfort before you consult with Dr. Bruscia. Other "do-it-yourself’ treatment – including any attempt to remove any part of an infected nail – and use of over-the-counter medications should be avoided. Sudden changes in color or shape, or any drainage from infection, should be discussed with Dr. Bruscia. He can diagnose the ailment, and then prescribe medication and/or another appropriate treatment. An injury can cause bleeding under the nail plate, for example, and the podiatrist might need to create a hole or holes in the nail to remove the blood. For nail injuries or conditions that cannot be permanently cured by medication or removal of part of the nail, as in the case of ingrown nails, Dr. Bruscia may have to surgically remove the nail plate and/or its matrix. As part of the surgery, the nail bed can be treated in a variety of ways, including electric cauterization, application of chemicals, or use of a laser.

To Avoid The Woes Of Toes

  • Trim toenails straight across, slightly longer than the end of the toes. Do not round off corners; this can be the cause of ingrown nails.

  • Clip nails with toenail clippers.

  • After clipping, smooth nails with a file or emery board. Wear only properly fitted shoes, not short or narrow ones.

  • Wash feet regularly, especially between toes, and dry thoroughly,

  • Wear hosiery that is not constrictive.

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ON-THE-JOB FOOT HEALTH
     

On-the-Job Foot Health
Your ability to use your feet safely, with ease and comfort, is vital if you are to remain a valuable and productive worker. When your job requires you to walk significant distances, stand on your feet for long periods, work in potentially hazardous areas or with potentially hazardous materials, you have some risk of foot injury. However, you can do a lot to prevent injuries by keeping your feet healthy and following safe work practices. In 1994, there were about 140,000 job-related foot injuries, 40,000 of them toe injuries, according to the National Safety Council. And those were only the reported incidents; experts say many injuries go unreported. You can't take your feet for granted. And your concern for them cannot be divided; it should continue off the job, as well as at work.

Off-the-Job
There are a few simple things you should do:

  • Bathe your feet daily; dry them thoroughly.

  • Check your feet frequently for any changes – redness, swelling, growths, skin changes (e.g., corns, calluses, cracks).

  • Keep your feet warm in winter, cool in summer.

  • Trim your toenails straight across, slightly longer than the end of the toe.

  • Prevent foot problems by visiting your podiatrist as part of your annual health check-up 

  • Wear protective footwear when using lawnmowers or chain-saws, moving heavy objects, working around chemicals, or in extreme temperatures.

On-the-Job
It is important for you to develop safe work habits and attitudes. Some things to remember: 

  • Be aware of the hazards of your job and the proper protective measures to take.

  • Don't take chances or unnecessary risks. Take time to do your job right.

  • Be alert. Watch for hidden hazards.

  • Be considerate. Watch out for other workers' safety.

  • Follow the rules. Don't cut corners. Use your equipment as specified.

  • Concentrate on the job. Inattention can lead to accidents.

  • Pace yourself. Work steadily at a comfortable speed.

  • Keep your work area clean and your tools in their place.

Protective Footwear is Essential
Safety shoes and boots protect your feet, help prevent injuries to them, and reduce the severity of injuries that do occur in the workplace. Only one out of four victims of job-related foot injury wear any type of safety shoe or boot, according to the National Safety Council. The remaining three either are unaware of the benefits of protective footwear or complain about it. Safety footwear can be comfortable, flexible, stylish, and still provide protection from injury. The foot is a most valuable part of your body subjected to injury in industry. Because of the many potential work hazards, it is important that you discuss  with your supervisor the safety shoe, boot, or other protective equipment that you need for your protection.

  • HAZARD: falling and rolling objects, cuts and punctures
    PROTECTION: steel-toe safety shoes; add-on devices: metatarsal guards, metal foot guards, puncture-proof inserts, shin guards
     

  • HAZARD: chemicals, solvents
    PROTECTION: footwear with synthetic stitching, and made of rubber, vinyl or plastic
     

  • HAZARD: electric current
    PROTECTION: shoes or boots with rubber soles, and heels, no metal parts and insulated steel toes 
     

  • HAZARD: extreme cold
    PROTECTlON: shoes or boots with moisture- or oil-resistant insulation, and that can repel water (if this is a problem); insulated socks
     

  • HAZARD: extreme heat and direct flame 
    PROTECTION: overshoes or boots of fire-resistant materials with wooden soles
     

  • HAZARD: high voltage
    PROTECTION: shoes with rubber or cork heels and soles, and no exposed metal parts
     

  • HAZARD: hot surfaces
    PROTECTION: safety shoes with wooden or other heat-resistant soles; wooden sandals over shoes 
     

  • HAZARD: sanitation contamination
    PROTECTION: special plastic booties or overshoes; paper or wood shower sandals 
     

  • HAZARD: slips and skids wet, oily surfaces) 
    PROTECTION: shoes with wooden soles or cleated, non-slip rubber or neoprene soles; non-skid sandals that slip over shoes; strap-on cleats for icy surfaces 
     

  • HAZARD sparking (from metal shoe parts) 
    PROTECTION: safety shoes with no metal parts and non-sparking material 
     

  • HAZARD: sparks, molten metal splashes (that get inside shoes)
    PROTECTION: foundry boots with elastic sides or quick-release buckles for speedy removal
     

  • HAZARD: static electricity
    PROTECTION: shoes or boots with heels and soles of cork or leather 
     

  • HAZARD: wetness
    PROTECTION: lined rubber shoes or boots; rubbers or shoes of silicone-treated leather

If Your Feet are Injured at Work
Report any injury to your foreman or supervisor promptly for necessary first aid. Then see Dr. Bruscia if further treatment is recommended. Foot pain is not normal, though many people try to bear up under it, under the mistaken notion that feet are supposed to hurt And proper foot are improves your efficiency and keeps you on the job. Dr. Bruscia is a specialist who diagnoses and treats foot disorders and injuries medically and surgically. By visiting him or her regularly, you an insure yourself a lifetime of pain-free feet.

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ORTHOSES
        

Orthoses
Orthoses, or orthotic devices, are shoe inserts that are intended to adjust an abnormal, or irregular, walking pattern. Orthoses are not truly or solely "arch supports,” though some people use those words to describe them, and they perhaps can best be understood with those words in mind. They perform functions that make standing, walking, and running more comfortable and efficient, by altering the angles at which the foot strikes a walking or running surface. Dr. Bruscia prescribes the use of orthoses as conservative approaches to many foot problems; their use is a highly successful, practical treatment form. Orthoses take various forms and are constructed of various materials. All are concerned with improving foot function and minimizing stress forces that could ultimately cause foot deformity and pain. Foot orthoses fall into three broad categories: those that primarily attempt to change foot function, those that are primarily protective in nature, and those that combine functional control and protection

Rigid Orthoses
The so-called rigid orthotic device, designed to control function, may be made of a firm material such as plastic, and is used primarily for walking or dress shoes. It is generally fabricated from a mold of the individual foot. The finished device normally extends along the sole of the heel to the ball or toes of the foot. It is worn mostly in closed shoes with a heel height under two inches. Because of the nature of the materials involved, very little alteration in shoe size is necessary. Rigid orthoses are chiefly designed to control motion in two major joint complexes of the foot, which lie directly below the ankle joint. These devices are long lasting, do not change shape, and are usually unbreakable. Strains, aches, and pains in the legs, thighs, and lower back may be due to abnormal function of the foot, or a slight difference in the length of the legs. In such cases, orthoses may improve or eliminate these symptoms, which may seem only remotely connected to foot function.

Soft Orthoses
The second, or soft, orthotic device helps to absorb shock, increase balance, and take pressure off uncomfortable or sore spots. It is usually constructed of soft, compressible materials, and may be molded by the action of the foot in walking or fashioned over a plaster impression of the foot. Also worn against the sole of the foot, it usually extends from the heel past the ball of the foot to include the toes. The advantage of any soft orthotic device is that it may be easily adjusted to changing weight-bearing forces. The disadvantage is that it must be periodically replaced. It is particularly effective for arthritic and grossly deformed feet where there is a loss of protective fatty tissue on the side of the foot. It is also widely used in the care of the diabetic foot. Because it is compressible, the soft orthosis is usually bulkier and may well require extra room in shoes.

Semi-rigid Orthoses
The third type of orthotic device (semirigid) provides for dynamic balance of the foot while walking or participating in sports. This orthosis is not a crutch, but an aid to the athlete. Each sport has its own demand and each sport orthosis needs to be constructed appropriately with the sport and the athlete taken into consideration. This functional dynamic orthosis helps guide the foot through proper functions, allowing the muscles and tendons to perform more efficiently. The classic, semirigid orthosis is constructed by using laminations of leather and cork, reinforced by a material called silastic.

Orthoses for Children
Orthotic devices are effective in the treatment of children with foot deformities, Dr. Bruscia recommend that children with such deformities be placed in Orthoses soon after they start walking, to stabilize the foot. The devices can be placed directly into a standard shoe, or an athletic shoe. Usually, the orthoses need to be replaced when the child's foot has grown two sizes. Different types of orthoses may be needed as the child's foot develops, and changes shape. The length of time a child needs orthoses varies considerably, depending on the seriousness of the deformity and how soon treatment is initiated.

Other Types
Various other orthoses may be used for multidirectional sports or edge-control sports by casting the foot within the ski boot or ice skate boot or roller skate boot, Combinations of semiflexible material and soft material to accommodate painful areas are utilized for specific problems. Research has shown that back problems frequently can be traced to a foot imbalance. It is just as likely that foot problems are brought about by a back imbalance. It's important for Dr. Bruscia to evaluate the lower extremity as a whole to provide for appropriate orthotic control for foot problems.

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PODIATRIC MEDICINE

Background
There are nearly 13,000 practicing doctors of podiatric medicine m the United States. The skills of these physicians are in increasing demand, because foot disorders are among the most widespread and neglected health problems affecting people in this country. The neglect may stem from a curious misconception on the part of many people that their feet are supposed to hurt That’s not the case, and it is estimated that more than 75 percent of Americans will experience foot problems of varying degrees of seriousness at one time in their lives. Among the more serious systemic diseases that can manifest themselves in the feet is diabetes, doctors of podiatric medicine play especially important team and individual roles in the prevention of foot and lower limb amputation attributable to diabetes. The increasing demand for services of podiatrists probably stems from two factors. First, as more Americans engage m exercise and fitness programs, more of them become aware of the limits foot pain places on full participation. Second, since foot problems are often the result of a lifetime of neglect, and the number of older Americans is increasing almost three times as fast as the population as a whole, they may account for a disproportionate share of the growing demand. Whatever the case, it’s known that there were nearly 40 million patient visits to podiatric physicians in 1983, and the 1995 figure is estimated to be more than 55 million.

The Organization
The American Podiatric Medical Association (APMA) was founded in 1912 to promote levels of understanding of the profession; it continues to work to improve the quality of foot care in the United States, to attract qualified young men and women to the field, and to increase awareness of the importance of foot health among the general public and other health professionals. PMA’s headquarters are Bethesda, Maryland, just outside Washington, DC, and it has component societies in every state, the District of Columbia, Puerto Rico, and the Federal Service. APMA also has more than 20 affiliated and related organizations, which focus attention on education, research, and specialty areas of interest, such as dermatology, pediatrics, radiology, surgery, sports Medicine, and others.

Education
There are seven colleges of podiatric medicine in the United States – the Barry University School of Podiatric Medicine in Miami, the California College of Podiatric Medicine in San Francisco, the New York College of Podiatric Medicine in New York City, the Ohio College of' Podiatric Medicine in Cleveland, the Pennsylvania College of Podiatric Medicine in Philadelphia, the Dr. William M. Scholl College of Podiatric Medicine in Chicago, and the College of Podiatric Medicine and Surgery at the University of Osteopathic Medicine and Health Sciences in Des Moines.  They all receive accreditation from the Council on Podiatric Medical Education of APMA, which is recognized by the US Secretary Education and the Commission on Recognition of Postsecondary Accreditation; they all grant the degree of doctor of podiatric medicine (DPM). Candidates for admission to all seven colleges are expected to complete baccalaureate degrees before admission. As with institutions granting MD (medical doctor) and DO (doctor of osteopathy) degrees, the colleges will consider candidates who show unusual promise and have completed a minimum of 90 Semester hours at accredited undergraduate colleges or universities. Applicants for admission are required to complete the Medical College Admission Test (SCAT) as a prerequisite.  Individuals may apply to any or all of the colleges by submitting a single application through the application service of the American Association of Colleges of Podiatric Medicine, an APMA-affiliated organization. The course of instruction leading to the DPM degree is four years in length first two years are devoted largely to classroom instruction and laboratory work in the basic medical sciences, such as anatomy, physiology, microbiology, biochemistry, pharmacology, and pathology. During the third and fourth years, students concentrate on courses in the clinical sciences, gaining experience in the college clinics, community clinics, accredited hospitals. Clinical courses include general diagnosis (history taking, physical examination, clinical laboratory procedures, and diagnostic radiology), therapeutics (pharmacology, physical medicine, orthotics, and prosthetics), surgery, anesthesia, and operative podiatric medicine. After completing the four-year course and receiving the DPM degree, the graduate is eligible to take a state board examination to obtain a license to practice in about one-third of the states; two-thirds require an additional year of postdoctoral work before licensure.

Postdoctoral and Continuing Education
As they near graduation, most prospective podiatric physicians seek postdoctoral residency programs. These programs, designed to strengthen and refine  the practitioner’s podiatric medica1 primary care, orthopedic, surgical, and/or public health skills, are based in hospitals accredited by the Joint Commission on the Accreditation of Healthcare organizations (JCAHO) and the American Osteopathic Association. The programs are at least one year in duration, and may extend to four years. There are continuing podiatric medical education requirements for state license renewal, and there is heavy attendance at many educational programs and seminars developed and presented each year by the colleges and local, state, and national podiatric medical associations.

Practice
Podiatric physicians are 1icensed in all 50 states, the District of Columbia, and Puerto Rico to diagnose and treat the foot and its related or governing structures by medical, surgical, or other means. In addition to private practices, they serve on the staffs of hospitals and long-term care facilities, on the faculties of schools of medicine and nursing, as commissioned Officers in the Armed Forces and US Public Health Service, Department of Veterans Affairs, municipal health departments Many podiatrists today are also accepting invitations to join group medical practices.

Special Areas of Practice
In its continuing efforts to protect and improve public health and welfare, APMA. has recognized and approved two specialty boards that certify in three areas – podiatric orthopedics, pediatric surgery, and primary podiatric medicine, These boards confer certification on a podiatric physician who has satisfactorily passed written and oral examinations and has demonstrated knowledge and experience in his or her chosen specialty. Those boards are the American Board of Podiatric Orthopedics and Primary Podiatric Medicine, in Chicago, and the American Board of Podiatric Surgery, in San Francisco.

Health Insurance Coverage
Nearly all private and public health insurance plans provide coverage for the services of doctors of podiatric medicine. Most Blue Shield plans, as well as those of commercia1 health insurance carriers, make provision in their contracts for the medical and surgical care of the feet, whether such care is rendered by doctors of medicine, osteopathy, or podiatric medicine. Even though third-party coverage of podiatrists’ services generally includes medical and surgical care of the foot, details of such coverage can and do vary among plans. The same applies to federal health insurance plans, including Medicare, federal employee heath benefits, and federal employee compensation programs. Medicaid, however, is an exception to this general rule; it is prescribed in federal law as an optional rather than a mandated service.

Community Podiatric Medicine
Consistent with the podiatrist’s education and licensure, Jcaho, the American Medical Association, and other organizations recognize the right of qualified podiatric physicians to serve on the staffs of hospitals and other health care facilities. In 1992, about 87 percent of practicing doctors of podiatric medicine an the United States had staff privileges at hospitals; in 1991, 84 percent of hospitals in the United States had doctors Of podiatric medicine on staff. There is a strong and growing role for podiatrists an public health. There has been a podiatric health section in the American Public Health Association (APHA) for nearly a quarter of a century, and APMA has a policy statement on professional standards for public health units which have foot health programs.

Federal Service
The growth in numbers among podiatrists in the federal service has been most impressive since two occurrences in the 1970s. First, the Veterans 0mnibus  Health Care Act of 1976 launched an expanded VA podiatric medical program. By granting VA podiatrists Department of Medicine and Surgery classification and compensation benefits, the new law strengthened the VA’s foot health services. There are now more than 200 doctors of podiatric medicine in the VA, and the VA sponsors a number of postdoctoral residency programs in podiatric medicine and surgery. In 1978, the US Public Health Service authorized the commissioning of podiatric medical officers, and they serve in the Indian Health Service and related federal health service programs. Since the early 1950s, podiatric physicians have been commissioned to serve in the various branches of the military services.  Officers are professionally assigned to the orthopedic service at most military medical installations, where they render invaluable service to military personnel and their dependents.

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REARFOOT SURGERY
  

Rearfoot Surgery
Many conditions can affect the back portion of the foot and ankle. Fortunately, many of these problems an be resolved through conservative treatments. However when pain persists or deformity occurs, surgical intervention can often help alleviate pain, reduce deformity, and/or restore the function of your foot or ankle.

Heel Surgery
Two common conditions that can cause pain to the bottom of the heel are plantar fasciitis and heel spur(s). Although there are many causes of heel pain in both children and adults, most an be effectively treated without surgery. When chronic heel pain fails to respond to conservative treatment, surgical care may be warranted. Plantar fasciitis is an inflammation of a fibrous band of tissue in the bottom of the foot that extends from the heel bone to the toes. This tissue an become inflamed for many reasons, most  commonly from irritation by placing too much stress (such as excess running and jumping) on the bottom of the foot. Heel Spur(s) or heel spur syndrome are most often the result of stress on the muscles and fascia of the foot. This stress may form a spur on the bottom of the heel. While many spurs are painless others may produce chronic pain. Based on the condition and the chronic nature of the disease, heel surgery can provide relief of pain and restore mobility in many cases. The type of procedure is based on examination and usually consists of plantar fascia release, with or without heel spur excision. There have been various modifications and surgical enhancements regarding surgery of the heel. Dr. Bruscia will determine which method is best suited for you. There are many other causes of heel pain, which has become one of the most common foot problems reported by patients of podiatric physicians. Many of them have a basis in heredity, as do a lot of other foot conditions. Among the causes are stress fractures and stress-fracture syndrome, entrapped nerves, bruises, bursitis, arthritis (including gout), deterioration of the fat pad on the heel, improper shoes, and obesity, just to name some. Most of these conditions will be treated  non-surgically, though surgery may be recommended in some instances.

Haglund’s Deformity (pump bump)
This deformity is characterized by a bony enlargement on the back of the heel. Although not always painful, it may become so if bursitis develops near the Achilles tendon secondary to footwear irritation. If attempts at shoe modification and other medical treatments fail to improve this condition, surgical correction may be beneficial. Based on X-ray evaluation and other tests or examinations your podiatric surgeon will select an operative treatment to alleviate the condition.

Insertional Achilles Calcification/Spur
This deformity differs from Haglund's deformity, in that spur formation or calcification at the insertion of the Achilles tendon Is the ause of pain. Often associated with Achilles tendinitis, this deformity can often be difficult to treat medically and therefore surgical treatment may be necessary in chronic cases. There are many causes of this condition, including arthritis, but the most common appears to be overuse syndrome, where trauma occurs where the Achilles tendon attaches to the heel bone. Surgical treatment includes removal of the bone spur and/or calcification, along with repair of the Achilles tendon.

Reconstructive Surgery
Reconstructive surgery of the foot and ankle consists of complex surgical repair(s) that may be necessary to regain function or stability, reduce pain, and/or prevent further deformity or disease. Unfortunately, there are many conditions or diseases that range from trauma to congenital defects that necessitate surgery of the foot and/or ankle. Reconstructive surgery in many of these cases may require any of the following: tendon repair/transfer, fusion of bone, joint implantation, bone grafting, skin or soft tissue repair, tumor excision, amputation and/or the osteotomy of bone (cutting of bones in a precise fashion). Bone screws, pins, wires, staples, and other fixation devices (both internal and external), and casts may be utilized to stabilize and repair bone in reconstructive procedures.

Preoperative Testing and Care
As with anyone facing any surgical procedure, those undergoing foot and ankle surgery require specific tests or examinations before surgery to obtain a successful surgical outcome. Prior to surgery, Dr. Bruscia will review your medical history and medial conditions. Specific diseases, illnesses, allergies, and current medications need to be evaluated. Other tests that help evaluate your health status that may be ordered by Dr. Bruscia include blood studies, urinalysis, EKG, X-rays, blood flow studies (to better evaluate the circulatory status of the foot/legs), and biomechanical examination. A consultation with another medial specialist is sometimes advised, depending on your test results or a specific medical condition.

Postoperative Care 
Surgery of the rearfoot requires close care following surgery. To assure a rapid and uneventful recovery, it is important to follow your podiatric surgeon's advice and postoperative instructions carefully. Rest,ice, compression and elevation of your foot/ankle postoperatively is often advised. The usage of bandages, splints, casts, surgical shoes, crutches, or canes may be necessary after surgery. Dr. Bruscia will also determine if and when you can bear weight on an operated foot.

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WALKING
        

Walking
For a healthier, happier lifestyle, try walking – the most popular form of exercise. It's easy, safe, and inexpensive. It’s also relaxing and at the same time invigorating, requires little athletic skill, and does not all for dub membership or special equipment other than sturdy, comfortable shoes. And it is fun and natural – good for your mind and self-esteem. The results of walking are physically rewarding – a trim, fit body better able to enhance general health and add enjoyable years to your life. Fundamental walking – also called health-walking – can be done almost anywhere and at any time, year around – to the store, in the mall or in your neighborhood; alone, with your dog, or with others; and at your own pace. It is simple, uncomplicated – physical fitness at your leisure. Walking benefits most everybody, regardless of age. About 67 million men and women are walking regularly. Convinced that it is good exercise, they're making it a part of their daily routine. And their numbers are increasing every year, according to the President's Council on Physical Fitness and Sports.

A Sure Way to Fitness
For those with a long history of inactivity, problems with obesity, or who just don’t like strenuous activity, walking is an excellent way to begin an exercise program. You can start slowly, then increase your speed and maintain a steady pace. A good conditioning program begins with moderation and dedication. Dr. Bruscia recommends walking to ease or ward off a number of physically related ills. Walking can help you:

  •  Strengthen your heart and lungs, and improve circulation.

  •  Prevent heart attacks and strokes.

  •  Red' obesity and high blood pressure.

  •  Boost your metabolic rate.

  •  Favorably alter your cholesterol.

  •  Improve muscle tone in your legs and abdomen.

  •  Reduce stress and tension.

  •  Reduce arthritis pain; stop bone tissue decay.

Walking: There's An Art to It
Before you start walking, some simple warmup exercises – but not strenuous, advanced stretching – can give your muscles added flexibility. Body twists at the waist, in a slow hula-hoop motion, and a few toe-touching or knee-bend exercises are appropriate. There’s an art to stretching the Achilles tendon, which is important. Keeping your feet flat on a surface, stand about three feet from a wall and put your hands out to lean against it, repeating the warmup several times. When you’re ready to begin walking, the best way to start is walking 20 uninterrupted minutes at least three times a week Walk at a comfortable pace, slowing down if you find yourself breathing heavily. Don‘t tire yourself. If 20 minutes is too much, cut back to 1O or 15 minutes. You can gradually increase your time and pace as your body adapts to the exercise. There are several ways to measure your pace. One is to walk on routes which you have pre-measured with your car's odometer. Perhaps the simplest is to use a wristwatch. Count the number of steps you take in a 15 second period; if you're taking 15 in that time, you’re walking about two miles an hour. At about 23, you’re probably going three miles an hour, and at 30, the pace is dose to four miles an hour. You may want to keep an activity log, in which you jot down the dates, times, and estimated distances of your walks, plus other notes, such as routes, milestones, and incidental experiences.

Some Walking Tips

  • Move at a steady pace, brisk enough to make your heart beat faster. Breathe more deeply.

  • Walk with your head erect, back slight, abdomen flat. Keep your legs out front and your knees slightly bent.

  • Swing your arms freely at your sides.

  • As you walk, land on the heel of your foot and roll forward to push off on the ball of your foot.

  • At least at the beginning, confine your walks to level stretches of flat surfaces, avoiding excessively steep hills and embanked roadways.

  • If you're walking in the evening, be sure to wear clothing with reflective material sewn in, or otherwise attached.

  • Cool down after a long, brisk walk to help pump blood back up from your legs to where it's needed. Here's where some stretching exercises an be helpful. A good one is standing about three feet from a wall, with your hands flat on the wall. Then take five or six small steps backward, maintaining your hand contact with the wall. Repeat the exercise five to ten times.

Racewalking
Racewalking is a very specific technique that's used by walkers for both fitness and competition. It has greater aerobic benefits than healthwalking, since it is faster and increases the heartbeat rate. If you get to the point where you think racewalking is for you, there are clubs which an be contacted in most places.

Walking footwear: Comfort and Fit
Choose a good quality, lightweight walking shoe with breathable upper materials, such as leather or nylon mesh. The heel counter should be very firm; the heel should have reduced cushioning to position the heel closer to the ground for walking stability. The front or forefoot area of the shoe should have adequate support and flexibility. Fit is very important. Go to a reputable store and have both shoes fitted for length and width with the socks you'll be using. (Do this late in the afternoon, since your feet do swell enough during the day to affect your shoe size.) Make sure the shoe is sag, but not too tight over the sock. The shoe should have plenty of room for the toes to move around. Several walking shoes have qualified to use the APMA Seal of Acceptance. Your choice of athletic socks is also important. Dr. Bruscia frequently recommends appropriately padded socks of acrylic fiber. Acrylic fibers tend to "wick" away excessive perspiration, which active feet an produce from 250,000 sweat glands at a rate of four to six ounces a day, better than cotton or wool, Again, there are popular brands of athletic socks which are authorized to use APMA's Seal of Acceptance.

Some Other Tips:

  • Check on the shoe width; it must comfortably accommodate the width of the ball of your foot.

  • Make sure you get good arch support.

  • See that the top of the heel counter of the shoe is properly cushioned and does not bite into the heel or touch the ankle bones.

Do You Need A Checkup?
If you are free of serious health problems, you can start walking with confidence.  Walking is not strenuous; it involves almost no risk to health. You should, of course, exercise good judgment, not exceed the limits of your condition, and not walk outdoors during extreme weather periods, until you have a good walking program established. You should, however, consult your family physician before you begin a walking regimen. A checkup is suggested, particularly if you are over 60, have a disease or disability, or are taking mediation. It is also recommended for those who are 35-60, substantially overweight, easily fatigued, excessive smokers, or have been physically inactive. One of your physicians will help you determine your proper walking heart rate. Heart rate is widely accepted as a good method for measuring intensity during walking and other physical activities. The formula says that subtracting your age from the number 220 yields your maximum heart rate (beats per minute), and that the proper walking rate is 60-70 percent of that number. For a 50-year-old, that’s 220 minus 50 equals 170; 60 percent of that is 102 and 70 percent is 119. Other factors should be considered, though; a physician’s advice is the best indicator of your correct rate. You are now ready to begin a walking program. It is prescription for a healthier, happier life.

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WARTS
        

Warts
Warts are one of several lesser afflictions of the foot, which nevertheless can be quite painful. They are caused by a virus, which typically invades the skin through small cuts and abrasions. They are frequently called plantar warts, because they appear most often on the plantar surface, or sole, of the foot. They can appear anywhere on the skin, however, and technically only those on the sole are properly called plantar warts. Children, especially teenagers, tend to be mare susceptible to warts than adults; some people seem to be immune, and never get them.

Identification Problems
Most warts are harmless and benign, even though painful. They are often mistaken for corns, which are layers of dead skin that build up to protect an area which is being continuously irritated, whereas a wart is a viral infection. It is also possible that a variety of other more serious lesions, including carcinomas and melanomas, although they are not overly common, can be mistakenly identified as warts. Because of those identification problems, and for pain relief, it’s wise to consult Dr. Bruscia about any suspicious growth or eruption on the skin of the feet. On the bottom of the feet, plantar warts tend to be hard and flat, rough-surfaced, with well-defined boundaries; they are generally fleshier when they’re on the top of the feet or the toes. They are often gray or brown (but the color may vary), with a center that appears as one or more pinpoints of black.

Source of the Virus
The plantar wart is often contracted by walking barefooted on dirty surfaces or littered ground where the virus is lurking. The virus is also sustained by warm, moist environments, so that warts are often associated with communal bathing facilities – more for the wet surfaces, however, rather than for transmission in water, which probably is rare. If left untreated, warts can grow to an inch or more in circumference, and they can spread into clusters of several warts. Like any other infectious lesion, they are spread by touching and scratching, and even by contact with skin shed from another wart. They may also bleed, another route for spreading. Warts can last for varying lengths of time, which may average about 18 months. Occasionally, they spontaneously disappear after a short time. Perhaps just as frequently, they can recur in the same location. When plantar warts develop on the weight-bearing areas of the feet – the ball of the foot, or the heel, for example – they an be the source of very sharp, burning pain. Pain occurs when weight is brought to bear directly on the wart, although pressure on the side of a wart can create pain just as intense.

Tips for Prevention

  • Avoid walking barefooted, except on sandy beaches

  • Change shoes daily

  • Keep feet clean and dry

  • Check children's feet periodically

  • Avoid direct contact with warts – from other persons, and from other parts of the body

  • Do not ignore skin growths or changes in your skin

  • Visit Dr. Bruscia as part of your annual health check-up

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WOMEN'S FEET
            

Women's Feet
Women are prominent in the US work force, and a lot of them are finding that their professional and white-collar employment brings job satisfaction, but that it's tempered by other realities. One is that the new responsibilities haven't replaced those of the woman's once-traditional role as homemaker and mother. Those roles remain, and many women find themselves not only holding down a full-time salaried position, but still doing the marketing, the child-rearing, the laundry. Their feet are taking even more punishment, and the footwear that some feel obliged to wear in the work place may be playing a role. All of this adds up to a need for women to pay more attention to foot care; to avoid subjecting themselves to unnecessary foot problems, particularly those that might be caused by improper footwear and hosiery.

High Heels: Use and Abuse
The wearing of high-heeled shoes is a prime example of women inviting foot problems, Doctors of podiatric medicine see no value in high heels (generally defined as pumps with heels of more than two inches). They believe them to be bio-mechanically and structurally unsound, citing medical, postural, and safety faults of such heels. They know, for example, that high heels may contribute to knee and back problems, disabling injuries in falls, shortened calf muscles, and an awkward, unnatural gait. In time, high heels may cause enough changes in the feet to impair their proper function. Most women admit high heels make their feet hurt, but they tolerate the discomfort in order to look taller, stylish, and more professional. In a Gallup Poll, 37 percent of the women surveyed said they would continue to wear high heels, even though they did not think them comfortable.

Toward Greater Comfort
If women persist in wearing high heels, there are ways to relieve some of the abusive effects; they can limit the time they wear them, for example, alternating with good-quality oxford-type shoes or flats for part of the day. High heels that are too tight compound the abuse; it's good advice to buy shoes in the afternoon, since feet tend to increase in size later in the day. Women have other heel-size choices, fortunately. They don't have to endure pain at the expense of their foot health. The key is wearing the right shoe for the right activity – and that means varying heel height, determining what heel is most suitable. For example, there are comfortable and attractive "walking" pumps (also called "comfort" or "performance" pumps) for women for work and social activities. The shoe manufacturers who have introduced them seek a marriage of fashion considerations and comfort, offering fashionable pumps with athletic shoe-derived construction, with reinforced heels and wider toe room. They are using space-age materials, like long-lasting memory cushioning that acts as a shock absorber. And the soles are more pliable. At least three lines of walking pumps have the use of the American Podiatric Medial Association’s Seal of Acceptance. Several companies have also designed footwear for certain athletic activities, including aerobics, specifically for women. Perhaps the best shoe for women, from an structural point of view, is a walking shoe with ties (not a slip-on), a Vibram type composition sole, and a relatively wider heel, no more than a half or three-quarters of an inch in height – even though such a shoe may not be widely acceptable in the work place.

What About Stockings?
Women who always wear nylon pantyhose are also inviting foot problems. Nylon is occlusive – it doesn’t breathe – and the heat that it generates and traps causes excessive perspiration. A warm, damp area is an ideal place for the encouragement of fungal infections such as athlete’s foot. (Pantyhose aren't the only apparel that cause excessive perspiration; the dress boots and shoe boots many women don in cold weather shouldn't be worn all day in an office.) Nylon, which tends to be abrasive, is even more so when it’s damp; in a tight shoe that’s already irritating, it offers little protection against blisters. Support hose, because they’re so much tighter, can be the worst culprits of all. Inexpensive nylon pantyhose can also cause forefoot problems, because the stretch mechanism constricts normal expansion of the foot when walking, and may pull the toes backward when the pantyhose ride up. The cramping and pressure of the hose can contribute to ingrown toenails and hammertoes. A better quality nylon will provide a better fit, and the better the fit, the less likely cramping will be. Women's feet have grown larger because of improved health care and nutrition. The one-size-fits-all stocking no longer is the universal answer, if it ever was. Attention to proper fit is essential.

Pregnancy
Pregnant women need to observe good foot health to prevent pain and discomfort. Since the body undergoes changes and acquires a new weight-bearing stance, women should wear shoes with broad-based heels that provide support and absorb shock, Additional body weight also calls for more support, to prevent foot "breakdown." The expectant mother often experiences more than ordinary swelling of her feet and ankles, which can aggravate existing foot conditions and promote inflammation or irritation. Pregnancy also triggers the release of hormones which enhance laxity in ligaments, which can contribute to toot strain. If problems develop, she should see Dr. Bruscia.

Women Over 65
Older women have more trouble with their feet than younger ones, for the simple reason that fat pads on the bottom of the feet tend to deteriorate in the aging process. They can alleviate some foot problems by wearing properly fitted, well-constructed shoes – shoes which provide cushioning and have a soft, flexible upper that will conform to the shape of their feet. They also need leather shoes which “breathe" and can reduce the possibility of skin irritation. Soles should be lightweight, with enough flexibility and shock-absorbing quality to provide solid footing and not be slippery. Low-heeled shoes provide greater stability, more protection for the feet, and greater comfort. Because older women often have circulatory problems, they have a special need to keep their feet warm in cold weather, to prevent frostbite or chilblains.

Women's Foot Afflictions
Whether the sources are congenital problems, foot abuse, high heels, poorly fitting shoes, or other maltreatment of the feet, women are subject to a number of afflictions involving the feet (most of which can also occur to men): Achilles tendinitis: inflammation of the Achilles tendon, the link between the calf muscle and heel bone. Those who wear high heels regularly can expect to acquire shortened tendons; switching to low heels for strenuous physical activity without appropriate warm-up exercises creates an ideal scenario for Achilles tendinitis. Bunions: misaligned big toe joints which become swollen and tender. Bunions tend to be familial, but the tendency can be aggravated by shoes that are too narrow in the forefoot and toe. Hammertoe: a condition in which the toe is contracted in a claw-like position. Although the condition usually stems from muscle imbalance, it is often aggravated by ill-fitting shoes, socks, or hosiery that cramp the  toes. Metatarsalgia: general pain in the ball of the foot; often caused by wearing high heels. Neuromas: enlarged, benign growths of nerves, most commonly between the third and fourth toes. They may stem, in part, from ill-fitting shoes, resulting in pain, burning, tingling or numbness between the toes and in the ball of the foot. Treatment includes orthotic devices and/or steroid injections, and sometimes surgery. Plantar fasciitis/heel pain: inflammation of the long band of connective tissue running from the heel to the ball of the foot, a main cause of rear-foot pain. This condition is sometimes caused by shoes that cramp the feet, especially in the arch area. Pump bump (Haglund’s deformity): a bone enlargement at the back of the heel bone, in the area where the Achilles tendon attaches to the bone. The deformity generally is the result of faulty biomechanics causing increased motion of the heel bone against the shoe counter.

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