Every now and then I am reminded of the difficulties that come with diabetes. Most of my patients, that have been diagnosed with diabetes, get up every morning and take on their day with the additional difficulties that diabetes provides. Whether it be finger sticks, feeling poorly or simply the frustrations of a modified diet my patients handle the burden placed on them by diabetes with grace and vigor. I am fortunate to get to know them better and hopefully I make their lives a bit better. That is the great part of what I do and I want to thank my diabetic patients who manage their diabetes well. I plan on creating a series of blogs with tips concerning diabetes, some of which come from my patients. I hope you enjoy them.
A plantar fibroma is a fibrous knot (nodule) in the arch of the foot. It is embedded within the plantar fascia, a band of tissue that extends from the heel to the toes on the bottom of the foot. A plantar fibroma can develop in one or both feet, is benign (non-malignant), and usually will not go away or get smaller without treatment. Definitive causes for this condition have not been clearly identified. The characteristic sign of a plantar fibroma is a noticeable lump in the arch that feels firm to the touch. This mass can remain the same size or get larger over time, or additional fibromas may develop.
People who have a plantar fibroma may or may not have pain. When pain does occur, it is often caused by shoes pushing against the lump in the arch, although it can also arise when walking or standing barefoot. To diagnose a plantar fibroma, Dr. Sowell will examine the foot and press on the affected area. Sometimes this can produce pain that extends down to the toes. An MRI or biopsy may be performed to further evaluate the lump and aid in diagnosis.
Non-surgical treatment may help relieve the pain of a plantar fibroma, although it will not make the mass disappear. The foot and ankle surgeon may select one or more of the following non-surgical options:
- Steroid injections. Injecting corticosteroid medication into the mass may help shrink it and thereby relieve the pain that occurs when walking.
- Orthotic devices. If the fibroma is stable, meaning it is not changing in size, custom orthotic devices (shoe inserts) may relieve the pain by distributing the patient’s weight away from the fibroma.
- Physical therapy. The pain is sometimes treated through physical therapy methods that deliver anti-inflammatory medication into the fibroma without the need for injection.
Surgical treatment to remove the fibroma is considered if the patient continues to experience pain following non-surgical approaches. Orthotic devices may be prescribed to provide support to the foot. Due to the high incidence of recurrence with this condition, continued follow-up with Dr. Sowell is recommended.
A very common description of foot pain from my patients at Sowell Podiatry is the complaint that “my feet hurt when I get out of bed in the morning”. Now this can be caused by many things, but I would like to explain the phenomenon of post-static dyskinesia that my patients often experience. The spaces for swelling in the deeper tissues of the foot are very tight. Very small amounts of swelling can often lead to discomfort in some areas. When the foot is in motion, particularly when weight bearing, the muscles and motion of the foot squeeze any swelling in these places away and the swelling will move up into the lower leg. This “natural pump” is very efficient as long as it keeps running.
When we get off of our feet for an extended time, such as driving home from work, sitting to rest or sleeping at night the “pump” is turned off and the swelling collects. When we engage this “pump” by getting up on our feet and walking there is a build up swelling that must be moved quickly and it is painful until a few steps are taken and we begin to get the swelling moving. So often, patients think it is the first few steps that are the problem but actually it is the activity before resting that led to the swelling build up.
Most likely, the foot is not being properly supported while walking or working and this leads to continual swelling throughout the day. If you are suffering with pain upon rising, you might try icing your feet at the end of your day. Rolling a frozen water bottle on the floor underneath your foot from your heel to the ball of your foot can be very helpful. As a podiatrist I can assess the foot for lack of support and swelling and often can relieve this pain upon rising with simple shoe, insole or lifestyle modifications
A few quick misconceptions about heel spurs:
- That they have to be cut out for the pain to go away.
- That they are digging into your flesh.
- That they are due to a “stone bruise”.
In fact, if we took one hundred people off the street and took x-rays ten would have heels spurs with no pain. This should tell us that heel spurs are fairly common and are not always painful. At Sowell, Podiatry we are very good at ending your heel pain without surgery.
The band that runs along the bottom of the foot from your heel to the ball of the foot is called the plantar fascia. To find your plantar fascia, simply lift your big toe and the plantar fascia will typically “pooch” out along the arch on the bottom of your foot. The swelling of this band is our focus in this article and is called plantar fasciitis. Patients with plantar fasciitis often have pain upon rising from a chair, getting out of the car or during the first few steps of the day.
Plantar fasciitis is often caused by poor foot mechanics. If your foot flattens out too much the fascia may overstretch and swell and if your foot is very high arched the fascia may be too tight and ache. Additionally, many activities can injure your plantar fascia leading to irritation along it. Chronic pulling of the plantar fascia with concurrent swelling can lead to the condition commonly known as a heel spur.
Physical examination of the foot can reveal if plantar fasciitis and a good understanding of foot mechanics will often lead to a determination as to why it is present. X-rays are required to diagnose a heel spur. The presence of a heel spur is a good indicator that the plantar fascia has been under increased tension for an extended period.
Reducing the symptoms of plantar fasciitis and heel spurs can include many things:
- Ice. We recommend rolling a frozen water bottle under the bottom of the foot.
- Anti-inflammatory medications.
- Controlling foot motion with insoles and shoes.
- Starting a stretching program to reduce tension on the area.
Occasionally plantar fasciitis and heel spurs require surgery but typically they can be addressed with conservative measures. We are very successful in treating this condition and we can often return patients back to a pain free active lifestyle in just a few visits.
The term Hallux Rigidus describes a limited motion of the big toe joint. The hallux, or big toe, becomes rigid and will no longer move up and down freely. Also known as a dorsal bunion or Hallux Limitius, the condition is most commonly caused by every day wear and tear of the joint and is characterized by an extensive dorsal spurs and arthritic changes in the top half of the joint. As hallux limitus continues to worsen the joint will move less and less. Eventually, we might call it hallux rigidus. Hallux rigidus can be very painful and will often cause patients to change how they walk, leading to more difficulties. Patients with limited motion of their big toes will often have a callus on their big toe as well.
A thorough biomechanical exam will reveal the severity of joint changes and will consider the motion of the first ray of the foot. The first ray includes the metatarsal (see anatomy page) and its motion plays a large role in the motion of the big toe joint. Also, xrays are typically taken to determine the location and severity of the bone spurs on top of the joint and arthritic changes within the joint.
Conservative treatment of hallux limitus might include physical therapy, shoe modifications and often custom made orthotics. With orthotics we can change how the joint and first ray move and possibly avoid surgery. However, if surgery is required the procedure can remove the spurs around the joint that are limiting its motion and may allow a patient to regain much of the range of motion that has been lost.
“Flat feet” or pes planus is a term we hear thrown around quite a bit. Many patients plop down in my podiatry chair each day and proclaim “I have flat feet”. What they are describing is a foot that has no arch and sometimes the whole bottom of the foot touches the floor when walking. Well, “flat feet” by itself is not much of a diagnosis, it is more of a description of the foot’s position. Additionally, a foot that is flattened has often been considered a foot that is prone to problems and this is likely why many years ago the military avoided recruits with flat feet. It should be noted that people with overly high arches are more prone to problems as well.
A foot that appears flat when standing and walking may actually have an arch when the foot is at rest and off of the ground. This is called a functionally flat foot and this simply describes how the foot moves when walking. Many children appear to have flat feet because they have not developed their bone structure enough to have an arch and for a few children this can lead to pain. (If your child is having arch or heel pain, please see a podiatrist for evaluation.)
Some great athletes have flat feet and it is possible to get through life with flat feet and little problems. However, there are some common complications that occur when walking in this foot position:
- Heel pain
It is my recommendation, as a podiatrist, that if you have flat feet you should at least get an assessment of your feet before you have problems.