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Psoriatic Arthritis In The Feet and Ankles: Symptoms and Treatment

25 Feb

Psoriatic arthritis, sometimes misdiagnosed as osteoarthritis, gout, or rheumatoid arthritis, is a form of arthritis accompanied by psoriasis, a condition which causes scaly red and white patches on your skin. This form of arthritis can cause swelling in your toes, frequently described as making them look like sausages.

Psoriatic arthritis feet and toes

Psoriatic arthritis causes toes to swell like sausages, a condition called dactylitis. In this patient, the toenails have been affected by the psoriasis, which is often misdiagnosed as a fungal infection.

Psoriasis is a condition in which the body’s immune system goes into overdrive and attacks healthy tissue in the skin, creating an overproduction of skin cells. In psoriatic arthritis, the immune system also attacks your joints, causing persistent, painful inflammation, in addition to the skin condition. It typically affects the larger joints in your feet or ankles, but may affect the smallest joints in the toes as well. Swelling of the joints in the toes can be quite extreme, taking on the appearance of sausages, a condition called dactylitis.

Psoriatic arthritis can also cause discoloration and “pitting” in your toenails – depressions or separation from the nail bed. As these symptoms appear similar to a fungal infection, it’s often misdiagnosed. In later stages, toenails may crumble or suffer other damage.

Why the immune system turns on healthy tissue is still somewhat of a mystery, but it appears that genetic and environmental factors are at play. Many patients who suffer with psoriatic arthritis have a family history of the disease, or a family history of psoriasis. In others, physical trauma, or a viral or bacterial infection may trigger psoriatic arthritis.

One of the characteristics of psoriatic arthritis is Enthesitis – pain in the heel or the sole, where ligaments and tendons join the bone. In some cases, this is the cause of plantar fasciitis or Achilles tendinitis. Research suggests that the continual inflammation from psoriatic arthritis causes significant joint damage, so early diagnosis and treatment is important.

If you’re experiencing heel pain, arch pain, or joint pain in your ankles or feet, and you suffer from psoriasis, please inform your podiatrist, as your treatment plan may vary.

Just as with rheumatoid arthritis, the pain and stiffness in joints affected by psoriatic arthritis is progressive, which means it will worsen over time. The pain and stiffness may at times subside and vary in intensity. Additionally, some patients also experience mood changes, fatigue, muscle weakness, and anemia.

Osteoarthritis may accompany psoriatic arthritis, and bones in the feet, ankle, or toes may deteriorate. Your podiatrist can use ultrasound imaging to determine this even before other symptoms occur.

Unfortunately, psoriatic arthritis becomes extremely painful as the condition progresses. Toes and feet may become swollen and tender, and they may no longer fit into your shoes. Your podiatrist may recommend special footwear in this case.

Symptoms of psoriatic arthritis in the foot and ankle

  • Joint pain. Joints may also be swollen or warm to the touch
  • Joints in the toes may develop dactylitis, a unique type of swelling. Dactylitis sometimes develops before pain or stiffness occurs.
  • Toes may become deformed and nails become discolored or pitted
  • Achilles tendinitis or plantar fasciitis may develop
  • Unlike other forms of arthritis, psoriatic arthritis is more likely to cause pain in the tendons of your feet

Who is most likely to develop psoriatic arthritis?

  • People with a family history of the disease. Men and women are equally affected.
  • People with psoriasis, especially those who have psoriasis lesions on their toenails
  • Those between the ages of 30-50, but it may also occur in children

Treatment for psoriatic arthritis

  • Mild exercise like walking, biking, or swimming keeps joints flexible and reduces pain
  • Stretching exercises
  • Custom orthotics (shoe inserts) to relieve pressure on painful areas
  • Wear comfortable footwear like athletic shoes,or if severe, diabetic shoes
  • Over the counter anti-inflammatory pain relievers like ibuprofen (Motrin, Advil), or naproxen (Aleve)
  • Cortocisteroid injections from your podiatrist to reduce joint swelling
  • Prescription medicines used to treat Rheumatoid arthritis
  • Podiatric surgery to replace or repair damaged joints

Diabetic Nerve Pain Treatment Options and Symptoms

23 Jan
Diabetic Nerve Pain, also known as neuropathy or Diabetic Peripheral Neuropathy, is a nerve disorder common in those who have diabetes. Some people with this nerve damage show no symptoms, while others may feel pain, tingling, or numbness in the hands, arms, feet, toes, or legs.
peripheral neuropathy diabetic nerve pain

Courtesy of NIH

Diabetes is not the only cause of neuropathies – they may also result from vitamin deficiencies (B-12 and Folate), chemical exposures, pressure on nerves, or certain medications, especially those used in AIDS therapies and chemotherapy.

Roughly 70% of people with diabetes will develop some form of neuropathy, including Diabetic Nerve Pain. It can appear at any time during the progression of the disease, but the risk increases with age and the duration of the illness. According to the U.S. Department of Health and Human Services,  The highest rates of neuropathy are among people who have had diabetes for at least 25 years. Diabetic neuropathies also appear to be more common in people who have problems controlling their blood glucose, also called blood sugar, as well as those with high levels of blood fat and blood pressure and those who are overweight.

The early symptoms of diabetic nerve pain are a slight tingling or numbness in the extremities. As the disease progresses, and nerves are further damaged, the tingling or numbness becomes painful and may be quite severe. When these symptoms appear in the feet, hands, or legs, it’s known as Peripheral Neuropathy, and when caused by diabetes, Diabetic Peripheral Neuropathy.

Symptoms of Diabetic Peripheral Neuropathy include

  • Numbness or insensitivity to pain or temperature
  • A tingling or burning sensation
  • Pains or cramping
  • Extreme sensitivity to touch
  • Loss of balance or coordination

How are nerves damaged by diabetes?

Vascular and neural diseases are closely related. Blood vessels depend on nerves, and nerves depend on blood vessels. Scientists know that prolonged exposure to high blood sugar damages nerve fibers, but exactly how that happens is still a matter of debate. What they know for sure is that high blood glucose interferes with the ability of nerves to transmit signals, and weakens the walls of capillaries (tiny blood vessels) that supply nerves with nutrients. When nerves don’t receive enough oxygen and nutrients from blood vessels, cells begin to die, and nerves don’t function properly. Other risk factors for nerve damage of this type are smoking, alcohol abuse, and certain genetic factors unrelated to diabetes.

What you can do to avoid DPN

The best way to avoid DPN or to minimize nerve damage once it begins, is to keep your blood sugar under control, exercise regularly, and see your physician on a regular basis to test you for symptoms. According to John Hare, MD, Medical Director of Joslin Diabetes Center’s Affiliated Centers program, “people who keep their blood sugars consistently in [a] healthful range can decrease their risk of nerve damage by more than 50%. Getting diabetes under better control also may help limit the amount of damage caused by neuropathy once it’s developed.” 

In addition to a diabetes specialist, a podiatrist should also be a member of your diabetes health team. Early symptoms of DPN typically appear first in the feet, and may go unnoticed by the patient. Podiatrists are experts at detecting these symptoms, and early intervention can avoid further damage to the blood vessels and nerves.

Treatments for Diabetic Peripheral Neuropathy

Early in its development, the pain and tingling of DPN can be managed with over the counter pain medicine like acetaminophen (tylenol), aspirin, or ibuprofen (advil, motrin). Some also find relief with over the counter pain creams which contain capsaicin, an extract of hot peppers like cayenne and tabasco peppers. It’s believed that these creams block pain signals, but they’re not effective for everyone. As the disease progresses and pain intensifies, your physician may prescribe narcotic pain killers, medicines such as Lyrica, or anti-depressants such as Cymbalta, which are also approved to relieve some types of severe pain.

A highly effective treatment used by the podiatrists at PA Foot and Ankle Associates is MicroVas, originally developed by the U.S. military to treat hypothermia in Navy SEALS. This non-invasive, pain-free therapy uses electronic impulses to cause muscle contraction and relaxation cycles which stimulate circulation. The increased blood flow raises the oxygen level in the tissues, which promotes healing in the nerves and muscles which have been damaged. MicroVas is successful in over 85% of the patients treated, who report reduced pain and improved sensation.


What is Plantar Fasciitis?

4 Dec
plantar fasciitis

Kobe Bryant famously suffered with Plantar Fasciitis

Plantar Fasciitis is the leading cause of heel pain. In medicine, the suffix itis refers to irritation or inflammation of an organ, and in this case, to the plantar fascia, a band of tissue which connects your heel bone (calcaneus) to the ball of your foot. Pain can be felt anywhere along this path.

The classic sign of plantar fasciitis comes in the morning, when you step out of bed – a sharp pain in your heel. Gradually, as the tissue warms up and becomes flexible, the pain fades – maybe not completely, but substantially. It may then return if you stand on your feet all day or exercise, especially if you run or exercise strenuously.

What causes the heel pain of plantar fasciitis? When the plantar fascia is constantly stressed, small tears occur in the tissue. The tears make the plantar fascia weaker, less able to do its job of support and shock absorption. This offloading of the work causes stress on the surrounding tissues, which is the actual cause of the pain.

Plantar fasciitis also makes itself known to those who are carrying more body weight than normal, like pregnant women or obese individuals. You might also develop plantar fasciitis if you made a poor choice in shoes and wear a style which doesn’t support your feet correctly. People with flat feet also frequently suffer from plantar fasciitis, as do long distance runners .

Symptoms of Plantar Fasciitis
  • A sharp pain at the back of your heel, sometimes described as “knife-like”
  • Pain is most common with your first few steps in the morning, but may also occur after physical activity, or climbing stairs
  • In most cases, pain increases gradually
  • Usually appears in one foot, but occasionally both
  • Foot may be stiff and difficult to bend
heel pain plantar fasciitis

Click for larger view

The Plantar Fascia acts like a shock absorber for your foot, and also supports your arch. If the plantar fascia receives repetitive stress, such as from exercising on hard surfaces, unsupportive footwear, or too much pressure from weight, small tears form in the tissue. These tears cause irritation in the surrounding tissue, which triggers pain.

If plantar fasciitis is left untreated, the condition may get substantially worse. Knee pain is also frequently reported in patients with plantar fasciitis, due to their change in gait to compensate for the heel pain.

Treatment for Plantar Fasciitis
  • Custom orthotics (not off the shelf) prescribed by your podiatrist
  • Physical therapy
  • Rest, elevate, and ice the heel
  • Over the counter anti inflammatory pain medicine such as Ibuprofen (Advil) or Naproxen (Aleve)
  • Athletic shoes which provide excellent arch support and padding at the heel
  • If exercising, train on soft surfaces instead of hard surfaces
  • If overweight, start a weight management program

If these methods aren’t successful in relieving your pain, your podiatrist may recommend steroid injections, PRP injections, EPAT (shockwave) therapy, Radiofrequency Ablation (RFA), or in extreme cases, surgery.

What Is Sever’s Disease?

10 Oct

Sever’s disease, known as calcaneal apophysitis, is the most common cause of heel pain in children.  It’s a painful bone disorder created by inflammation of the growth plate in the heel, usually from muscle strain and repetitive stress. Sever’s Disease is very common in obese children and those who play lots of sports, and most commonly occurs during growth spurts in adolescence.  For girls, this is usually between 8 and 13 years of age, and for boys, between 10 and 15.

heel pain children

The heel is especially susceptible to injury in children. The foot is one of the first parts of the body to grow to full size and the heel area is not very flexible. The growth plate is a soft area at the end of the heel bone where cartilage cells change into bone cells, and it eventually fuses with the heel bone.

During the early part of puberty, the heel bone sometimes grows faster than the leg muscles and the Achilles tendon, which attaches the calf to the heel bone. When this unequal growth occurs, the muscles and tendons become very tight, which makes the heel less flexible, placing a lot of stress on the growth plate. The Achilles tendon, when stretched too tightly, becomes swollen, tender, and painful where it attaches to the growth plate. This injury, a result of repetitive stress on the Achilles tendon, is Sever’s Disease.

If  a child is active, doing a lot of running, jumping, and playing on hard surfaces, they can put a lot of stress on those too-short muscles and Achilles tendon, resulting in heel pain. Other factors which can contribute are:

Severs-Disease heel pain children

  • Long periods of standing which put constant pressure on the heel
  • Pronated foot (a foot that rolls inward when walking). Pronation tightens and twists the Achilles tendon and pulls on the growth plate
  • Flat feet or a high arch. This again cause the Achilles to be overstretched
  • Short leg syndrome, in which one leg is shorter than the other. This causes the foot on the short leg to bend downward, putting stress on the Achilles
  • Obesity  – weight puts pressure on the growth plate

Symptoms of Sever’s Disease

  • Pain or tenderness in one or both heels. Pain is usually felt at the back of the heel, but may also be felt along the sides and bottom of the heel, all the way to the arch.
  • Swelling and redness in the heel
  • Feet are stiff upon waking
  • Difficulty walking or running
  • Child may walk on tiptoes or with a limp to avoid putting pressure on the heel
  • Pain may increase with activity

To relieve symptoms

  • Rest to relieve pain
  • Curtail athletic activities
  • Wear athletic shoes that fit properly and provide cushioning
  • Ice and elevate the sore foot to reduce swelling
  • Stretching exercises for the heel and hamstring
  • No high heeled shoes
  • Over the counter pain medicine (check with your doctor first)
  • If symptoms are caused by obesity, a weight management plan

Sever’s Disease fortunately is a temporary condition. With proper care and treatment, symptoms will usually go away within 2-8 weeks, and it will have no long term consequences. If the condition recurs due to the child having a pronated foot, or a flat or high arch, your podiatrist may recommend custom orthotics to position the foot correctly inside the shoe and reduce stress on the heel.

The risk of recurrence of Sever’s Disease diminishes with age, and as a rule won’t occur after the age of 15. By that time, foot growth is complete and the growth plate has fused to the rest of the heel bone.

Buying Athletic Shoes For Kids: Avoid Hand-Me-Downs

22 Aug

athletic shoes kidsIt’s true that every parent with young children wants to save a buck wherever possible. You might be tempted to hand down your 12 year old’s outgrown shoes to your 10 year old, but you might want to think twice before doing that, especially when it comes to athletic shoes.

Sneakers, cleats, and any shoes made for athletic training need to fit every foot correctly. Considering the heavy beating a foot takes when they’re in these shoes, this is not an area to skimp. Your child will be running, jumping, and kicking, and their feet require padding and comfort to not only perform as well as possible, but to protect their feet from injury. Athletic shoes that are too tight will create blisters, corns, calluses, redness, sores, or ingrown toenails. Those that are too loose will allow the foot to slide, putting undue stress on the toes.

Hand-me-downs also may provide less support for the arch and heel than what’s needed. “Shoes lose their shock absorption over time, and wear and tear around the edges of the sole usually indicates it’s worn out and should be replaced.”, notes Dr Teichman at PA Foot and Ankle Associates. “If a child keeps wearing worn-out or non-supportive dress or athletic shoes, it elevates the risk for developing heel pain, Achilles tendonitis and even ankle sprains and stress fractures.”

When you’re buying new shoes for your child, make sure they’re not too tight, and resist the urge to buy a pair that are slightly large, believing that your child will “grow into them”. And with the innovations in shoe design and construction, modern materials don’t need to “break-in”, like they did years ago.

How to know if the shoe is right for your child:

  • Make sure there’s a finger’s width distance in the shoe box between the longest toe and the front of the shoe
  • No redness should appear on the child’s feet after taking the shoes off. Redness is a sign of the shoe rubbing or pinching
  • The shoe should not bend in the middle of the sole, it should bend at the ball of the foot
  • The toe box should flex easily
  • The back of the shoe should meet your child’s foot, but not be tight
  • Shoes should be made of quality materials which will cushion the foot
  • The toe box should be roomy enough that your child can wiggle their toes

Your child’s shoes not only protect their feet from injury this year, but also protect them from developing foot problems which may follow them into adulthood. Take the time and choose wisely.

Help! The Arches In My Feet Are Falling!

6 Aug
adult aquired flat foot

In a normal foot, only the smallest toe is visible when viewed from behind.

A common problem among the elderly and increasingly middle aged patients is collapsing arches, medically known as Adult Acquired Flat Foot Syndrome (AAF), or Posterior Tibial Tendon Dysfunction (PTTD). This is a progressive condition in which the arch of the foot collapses and the bones of the ankle and foot fall out of proper alignment.

A magnitude of foot problems develop as we age and many of these complaints begin about the age of 60. Among the most serious from a biomechanical standpoint is Adult Acquired Flat Foot Syndrome (AAF).  Treated early enough, symptoms can be arrested or at least slowed. Untreated however, AAF becomes an extremely painful condition which ultimately affects the entire body and the patient’s lifestyle, as gait is significantly altered by the out-of-line foot and ankle. This malalignment can create pain, fatigue, and discomfort throughout the entire body.

As we age, many of our muscles, tendons, and ligaments lose their ability to stretch and support our bones.  If you’ve ever discovered an old rubber band in the bottom of a drawer, you’ll get the idea – it’s more likely to snap than stretch. The Posterior Tibial Tendon, which attaches the calf muscle to the bones in the foot, is largely responsible for the support of your foot when walking, and to hold up the arch. With aging, overuse, or trauma, this tendon degenerates and loses its function, along with associated ligaments and joints on the inner side of the ankle and foot. Ligaments are responsible for holding bones in place, and when they fail, bones shift and deformity is the result. The deformity causes malalignment, which leads to more stress and failure of the ligaments, and a slow collapse of the arch which becomes debilitating in its later stages.

AAF is most frequently seen in women, especially those who start out with somewhat flat feet or a pronated (rolls inward) foot. These attributes place extra stress on the soft tissue structures, along with the posterior tibial tendon and the ligaments on the inner side of the foot. Other contributing factors are diabetes, obesity, rheumatoid arthritis, and hypertension. People who play high impact sports may also develop tears in the posterior tibial tendon, eventually leading to AAF.

pttd out of alignment foot ankle

The foot and ankle become malaligned as AAF progresses

Symptoms of PTTD/AAF

The symptoms of posterior tibial tendon deformity change considerably as the condition progresses. Initially, pain may be felt along the tendon’s path on the inside of the foot and ankle. This area may also be red, warm, and swollen. As the arch starts to flatten, in addition to pain, the foot and toes turn outward and the ankle rolls inward. As the arch flattens even more, the pain shifts to the outside of the foot, just below the ankle. Arthritis develops in the foot, and later may develop in the ankle, sometimes causing the ankle joint to lock.

Treatment of PTTD/AAF

Treatment of adult acquired flatfoot depends on the stage of the condition and its severity. Mild cases may only warrant rest, ice, and custom orthotics. Advanced cases may require immobilization, bracing, or even surgery. Early intervention by a podiatric surgeon is key to slowing the progression of PTTD.

At the onset of PTTD, a boot or brace is used to support the arch and relieve strain on the soft tissues, including the tendon. When pain has subsided, custom orthotics are used to reduce the stress on these tissues. However, as the arch has already fallen, the deformity may progress. If pain persists after these conservative measures, surgery to correct the deformity may be recommended.

Angels’ Albert Pujols Out With Plantar Fascia Tear

29 Jul

pujolsLos Angeles Angels slugger Albert Pujols, who has been struggling with plantar fasciitis in his left foot for seven years (that’s right, 7 years!), is most likely out for the rest of the season after tearing his plantar fascia in Friday night’s game against Oakland. Angels’ Manager Mike Scioscia said that Pujols, who hit .258 with 17 home runs and 64 RBI’s despite being hobbled all season by the troublesome foot, will be out “for a significant amount of time.”

Back in April Pujols, 33, said of his plantar fasciitis, “I’m dying. It’s hurting real bad.”  He was considering off season surgery, and he sort of got his wish Friday night when he tore the ligament, achieving a similar result. In plantar fascia surgery, a podiatric surgeon cuts part of the plantar fascia ligament to release tension and relieve inflammation. The surrounding soft tissue attaches to the plantar fascia and helps it heal. Unfortunately for Pujols, he didn’t suffer a complete tear, so off-season surgery may still be an option.

The minimum recovery period for a plantar fascia tear is six weeks, but with the Angels all but out of playoff contention and a season-high 13 games behind Oakland in the American League West, there is no need to bring Pujols back for the final two weeks of the season. Instead of having surgery in October and spending most of the winter rehabbing, Pujols  can spend the rest of the summer recovering and come back healthy in 2014.

plantar-fasciitis diagramJust goes to show what we always say – don’t play through the pain, because it will always get worse, sometimes seriously.  It’s remarkable that even with the Angels’ state of the art sports medicine, highly paid trainers, and months to rest in every off season, Pujols’ plantar fasciitis never sufficiently healed. It’s a particularly difficult injury to treat in some cases.

Even if you’re an amateur athlete – especially you marathon runners – you may easily be exposing your feet to the same pounding an MLB player like Pujols does.  Any sign of pain – toes, heel, arch, or ankle – needs to be addressed immediately and given time to properly heal. Being out of the game temporarily, even for a full season, is much better than aggravating a minor condition into a serious injury which can sideline you for much longer.

Why Does My Heel Hurt?

2 Jul

Heel pain affects nearly everyone at one time or another. Sedentary or active, man or woman, overweight or desired weight, heel pain is not discriminating.

If you’re not an athlete subjecting your feet to extraordinary stress, then your heel pain is most likely due to one or a combination of factors: carrying too many pounds on your frame; having a job which requires long periods on your feet; faulty biomechanics of your foot; flat feet; high arches; dress shoes or athletic shoes which don’t support and cushion your feet correctly; or overuse, such as doing too much too soon in a new exercise program, or not warming up your legs before exercising.

The most common reasons for heel pain are:

Plantar Fasciitis

The tissue that connects your heel bone to your arch is called the plantar fascia, and in the majority of heel pain cases, this is the culprit. The plantar fascia connects at the bottom of the heel bone and wearing shoes which don’t support your arch correctly, playing sports repeatedly on hard surfaces, or carrying extra weight, puts unusual stress on the plantar fascia, and it becomes irritated at this juncture. The irritation is called plantar fasciitis. Read more about plantar fasciitis

Achilles Tendinitis or rupture

The Achilles tendon is the largest tendon in our body, connecting the heel to the calf. Whenever you jump, walk, or run, your Achilles is hard at work. Because it’s used constantly, it’s also the tendon in your body most likely to be injured. The pain from achilles tendinitis or a rupture of the tendon is felt anywhere in the area behind your ankle. Read more about achilles tendon injuries.

Haglund’s Deformity

Also known as “pump bump”, this form of heel pain is fairly obvious, as a small bump becomes red and sore on the back of your heel, right about where the hard backs of shoes rub, hence it’s nickname. Read more about Haglund’s deformity.

Heel spurs

A bone spur is a bony growth that forms along the edge of a bone in response to wear and tear. When it appears in the heel, it causes heel pain by rubbing on the achilles tendon or other soft tissues. Read more about heel spurs here.

Other, less frequent causes of heel pain are bursitis, stress fractures, and tarsal tunnel syndrome.

To learn more about heel pain, order our free download, The End Of Heel Pain.

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