What is Sesamoiditis?

Under the big toe are two small bones called the sesamoid bone. These are embedded in tendon in the same way that the patella bone is in the from of the knee. The function of the sesamoid bones (and the patella) is to give the tendons are more efficient lever to move the joint. As these bones are under the big toe joint, they are subjected to a lot of force when walking and playing sport. Sports like tennis where you need to use the big toe joint to pivot on put an enormous amount of force on them. If these loads are too high, you can end up with a condition called sesamoiditis in which these small bones and the structures around them become inflamed. Wearing higher heels shoes also puts pressure on the sesamoid bone and so does having to stand all day at work, especially on hard floors.

The symptoms of sesamoiditis are gradually increasing levels of pain under the big toe joint. If you palpate where these bones are they can be quite painful. Sometime the bones are very prominent because there has been some atrophy of the fat pad. On occasion, especially if the onset of pain is acute there might be a fracture of one or both of the sesamoid bones. There are a number of conditions that can affect the big toe joint such as gout or osteoarthritis that also needs to be taken into account when assessing someone with pain in this area.

Once a sesamoiditis has been diagnosed then sesamoiditis treatment usually starts with some sort of reduction in activities or modifying them if that is possible. Getting into well padded and cushioned footwear is also a useful idea. There are adhesives felts that can be stuck on the foot to get pressure off the painful are. Pads an also be used on insoles in the shoes. Over the long term foot orthotics with pressure relieve are usually very helpful.

Medical Conditions Affecting the Foot

When you first come to us we will be asking questions about your medical history and what medicines that you might be taking. Periodically when you come to see us, we will update this information. Sometimes you may wonder why this information is relevant and what it might have to do with your foot and what we do. It is relevant and important as it might impact on what is the cause of your foot problem and it may impact on how and what we do to treat your foot problem.

The obvious one is diabetes. Diabetes increases the risk for a lot of foot problems due to its effect on the nerves and blood vessels. Not only does diabetes increase the risk for foot problem, it also affects how problems with the foot heal up. We really do need to know if you have diabetes and how things are going with it so we can assess how it affects your feet.

It may not seem relevant, but thyroid disease is another one. Over and under activity of the thyroid glad can cause issues with the feet. For example, under-activity can lead to dryer skin that can lead to painful cracks around the heel.n

Coeliac disease is another one that you might well wonder what it would have to do with the foot when the disease is a problem with gluten damaging the villi in the gastrointestinal tract. Coeliac disease does affect the foot. There have been a number of case reports of chilblains in those with celiac disease and it can also cause an enthesopathy in the foot and affect the nerves to the foot. This means that something that may seem to be so unrelated to the foot and problems with the foot may need to be considered when assessing a foot problem.

When you get asked about your medical history and symptoms and the drugs or medicines that you might be taking, then there is a good reason why we might need that information. It may not seem relevant to you, but it could well be a factor in your foot problem and may be a factor that needs to be taken into account when we recommend the best approach to treat your problem.

Arthritis of the midfoot

Pain in the midfoot, just in front of the ankle is a reasonably common problem. One of the more common causes of that pain is osteoarthritis, the so called ‘wear and tear’ arthritis. The symptoms typically start out with a mild ache in the midfoot. Often that can be helped with a some mild anti-inflammatory drugs and wearing more supportive footwear. Later as the osteoarthritis progresses the pain can become more constant and become a real problem. The pain is typically deep within the midfoot or arch area of the foot and is made worse after activity.

One of the biggest risk factors for osteoarthritis is obesity and that is true for midfoot osteoarthritis, so loosing weight is a good approach to dealing with the symptoms of osteoarthritis. You should raise this with your general medical practitioner about how to approach that.

The use of a cream like fisiocrem that give a deep heat feeling is often advised as well as mobilisation exercises. There are different exercises for both stretching and strengthening the muscles around the midfoot that can be helpful. Anti-inflammatory drugs are also more helpful as the pain gets worse.

Another approach can be to use the shoe stiffening inserts for midfoot osteoarthritis. These are thin and very rigid carbon fibre plates that help stiffen the footwear to make it more rigid. Some people find that wearing more rigid or less flexible shoes are more comfortable, so in these cases they will often benefit from these types of rigid plates.

Foot orthotics for midfoot osteoarthritis are most commonly used to give some support and stability to the midfoot and arch. This is usually very helpful at helping with the symptoms and increasing the ability to walk without any pain. Custom made foot orthotics are generally a better option for managing this.

If you have pain in your midfoot, then give us a call for an appointment and we can certainly help and discuss your options..

What chilblain cream do we use?

Chilblains are a relatively common vasospam of the small blood vessels in the toes that create a reddish or bluish lesion that can be itchy and painful. They typically occur in the cooler climates and that chilblain season is coming up. There are a number of things that can be done to prevent and treat chilblains. This include protecting the feet from the cold, not warming them too quickly after they become cold, and using creams that can help to stimulate and the circulation as well as sooth them when they occur.

There are a number of different creams, lotion, potions and ointments on the market that can be used for chilblains and every single one of them can probably produce some pretty convincing anecdotes and testimonials about how good they are. For us as clinicians it can be a bit of a problem to know which one to recommend in the context of them all claiming to be the best and each one of them having some support. There is no research that has been done to show which one is the best chilblain cream to use. We have some experience with some of them and that results of that experience is a bit mixed. The problem is that one cream that works for one person may not necessarily work for the next person. So any recommendation for a cream to use for chilblains is going to have to be for one that is more likely to affect a lot of people and be a good place to start. One thing I did notice is that when you see questions asked of a group of podiatrists, there will be a number of different recommendations given, but also the name “Akileine Akilwinter Chilblain Cream” does keep coming up and recommended more often than others, so that is now the one that we typically use first.

New foot orthotics or refurbish old foot orthotics?

Foot orthotics wear out over time as nothing lasts forever. The questions is that if you do need to continue wearing foot orthotics (and not everyone does) should we make a new pair for you or should we adjust and refurbish the old pair of foot orthotics. Every one is going to be different and the advice that we give here is going to be on a case-by-case basis as there is no generic answer if you should get new ones or refurbish the old ones.

We have seen our fair share of foot orthotics that look like these:

It is relatively easy to refurbish these with a new top cover and maybe some improved cushioning to get at least a few more years out of them. However, that is not always the best option. Your feet change over time and the shape of the foot orthotic changes over time. The best thing is that we will check the foot orthotic shape and check that against your feet to see if it still meets the needed requirements before we could advice you on if you probably really do need to get a new pair or if we can refurbish the old ones.

Either way, come in with your old orthotics for us to check how they are going and if they are still meeting your needs.

What are those tiny holes or craters under the ball of the foot?

They are most likely a condition called pitted keratolysis. It is an infection by a bacteria (a Corynebacterium) in feet that sweat a lot. As sweat accumulate and is not allowed to evaporate it creates an environment that the bacteria like to grow in. All the multiple tiny holes or pits or craters come about because of an enzyme that the bacteria release to eat away at the keratin in the outer skin layer. The skin also tends to have a whitish colour which is due to the accumulation of moisture in the skin. The feet also commonly have a foul odor as well due to the bacteria causing sulfur to be released.

There are two approaches to get rid of pitted keratolysis: first there is to use a topical antibiotic that can usually quickly and easily deal with the infection. The second and more important is to get rid of the environment that the bacteria likes to grow in, so the pitted keratolysis can no longer be a problem. This means good foot hygiene habits. The feet need to be washed, cleaned and thoroughly dried every day. Go barefoot as much as possible so that the sweat can evaporate and the feet dry out. Wear socks and shoes that can help absorb moisture or at least wick it away from the foot. Change the socks during the day so they can help keep the feet dry. An absorbent powder in the socks can also help. Odour eating insoles can also help absorb moisture.

If you have pitted keratolysis and none of these measures are helping, then please call us and come in for a consultation and we can advise more clearly on what needs to be done.

If your big toe hurts to move, then we need to find a way to stop it moving

Pain in the big toe that hurts when walking is most commonly due to osteoarthritis, a condition commonly known as hallux rigidus (if the joint is really stiff) or hallux limitus (if its not so stiff). If its really painful at rest, then it might more likely be gout than hallux rigidus. With the hallux rigidus, when we are walking and the heel starts to come off the ground, the big toe joint needs to move. If that movement is limited or there is osteoarthritis in the joint, then that is going to be painful to walk. It makes sense that if that joint hurts to walk, then a logical way to deal with it is to restrict how much the joint moves.

There are a number of ways to do this. One is felt padding that can be stuck on the foot under the big toe and ball of the foot or strapping could be used to tape the joint. Both of these are really good short term measures. If you need a foot orthotic for other reasons, there is an extension that can go on the front of the orthotic called a Morton’s extension that can be used to stiffen up the joint. Another way is to use a carbon fibre insole plate that usually are about 1-1.5mm thick and very rigid that fit inside the full length of your shoes. These carbon fibre plates are often used to treat hallux rigidus and other problems such as turf toe. The evidence is that they are pretty effective.

Another way to treat the pain from the hallux rigidus is to simply use shoes that are more rigid across the ball of the foot. The more flexible the sole of a shoe is, the more that the big toe joint is going to move and the more likely it is to be painful. The are some shoes, especially the Hoka running shoes, that have a rocker built into them. The effect of the rocker is that the big toe does not need to move as much. A pedorthist or shoe technician can add a rocker on the sole to many different types of shoes to achieve the same thing.

If you have pain in your big toe joint when you walk, come and see us and we can discuss what options may be the best for you.

The thyroid gland and the foot

When we see a patient we always collect an initial detailed history of medical conditions, and not for no good reason. There is a good reason that we need that information. The medical condition may cause symptoms in the foot. The medical condition may affect the choices that we have to deal with your foot problem. The drug you are on may have side affects that show up in the lower limb. There is a good reason for asking all that information and plenty of things that can affect the foot and the treatment choices of foot problems.

The thyroid gland is in our neck and secretes some hormones that help control our body’s metabolism. At first glance is probably is not hard to wonder what that might have to do with the foot! It has plenty to do with the foot.

For those who are lacking some of the thyroid hormone (hypothyroidism), the skin can be dry and make heel fissures more common. There may be some symptoms in some of the joints that might feel like a common form of arthritis, but are an effect of the lack of the thyroid hormone. The nails my become easily ‘looser’. Some of the tendon reflexes do not work as well and do not relax well after you hit the Achilles tendon (this is called Woltman’s sign). There could be some nerve damage that can cause the feet to get some pins and needles and even go numb. If you are on treatment for hypothyroidism with the drugs, then these problems are less likely to occur, but we need to look out for them and consider them when there is a foot problem.

This is just the affects of a low thyroid hormone, but serves as a good illustration as to why we need to know about your medical history.

What a load of …. Croc

Crocs are a somewhat maligned brand of footwear and the butt of jokes about peoples fashion sense. Crocs are a brand of footwear that were designed as a boating shoe and rapidly become a popular fashion item. They are a one piece molded type of footwear that is easy to get on and off and come in a lot of different colours and styles. They are comfortable, but probably not that good to wear on the feet all day, every day as they can make the feet sweat a lot and the toes do have to flex to help them stay on, which in some people can create problems long term.

There is no doubt about their popularity and there is also no doubt about the jokes and comments they get. They are a source of a lot of memes:

A few have even used Crocs as running shoes and done all right in them, but that is not recommended. However, those that do use them as running shoes do claim that they last much longer than a running shoe and cost a lot less than a good running shoe.

Like most footwear types, there is probably not a lot wrong with Crocs if you use them for what they are intended to be used for and use them in moderation.

Dealing With Thicker Toenails

As we get older the toe nails get thicker. It is a normal part of ageing. That is going to make the cutting of toenails all the more difficult as they are so thick. On top of that aging related thickness, trauma to a nail can also damage the growing area of the nail and cause the nail to become thicker. That trauma could be from years of wearing tighter shoes, a claw toe that puts pressure on the toenail or something like dropping a brick on the foot that damages the nail. Occasionally there is a skin condition associated with the thicker toenails.

Technically a thicker toenail that has no deformity is called onychauxis and if there is a deformity of the nail present, then it is called onychogryphosis. Onycho- means ‘nail’, so its a conditions of the nails.

Once the damage is done to the nail matrix or growing area of the nail in conditions like onychauxis, it is not possible to repair or fix that damage. The nail will always grow that way. If you can not manage to cut and look after the damaged toenail, that is where we come in. Using our tools and our skills we can reduce that problem nail or all of them if they are all affected. This is going to need to be done periodically as the nail will continue to grow back.

On occasion, especially of the toenail is causing a lot of problems it may be possible to remove the nail permanently and destroy the nail matrix so that it does not grow back.