Osteoarthritis (OA) is a degenerative disease of the joints. It causes cartilage in the joints, a type of connective tissue that covers and protects the ends of the bones at a joint, to break down. As cartilage deteriorates the bones no longer have the proper cushioning that help the joint to move smoothly. Thus, the bones in the joint are now rubbing together directly causing friction, pain, stiffness, decreased range of motion, and inflammation. In certain cases osteophytes are created.

Osteophytes are spurs or lumps of bone that appear close to osteoarthritic joints making the joint appear deformed. Another issue is fluid that accumulates in the joints. A third issue is pain, which is sometimes severe. It is caused by deformation of the bones, fluid accumulation in the joints and, often, footwear that no longer fits properly. The pain gets better with rest and grows more severe when weight-bearing and moving.

The causes of OA are classified into primary: OA caused by hereditary factors; and secondary: OA that is the result of trauma, injury, and surgery.

An early sign of OA is early morning stiffness and soreness. As the disease progresses, the pain becomes worse and inflammation develops. Pain is now present even during rest and joint mobility decreases permanently. Unfortunately, this can lead to stress, anxiety, depression, anger, feelings of helplessness, and decreased ability to work.

Radiography, health history, and physical examination are used as means of diagnosing osteoarthritis. During physical examination, affected joints may exhibit the symptoms of warmth, rigidity, enlarged size, loss of agility, and decreased flexibility. The client will have difficulty finding footwear that fits. From the client’s perspective the foot pain is dull, throbbing, aching, grinding, is more severe after use at the end of the day, different every day, and totally debilitating.

To treat OA the client can use professional orthotics, use special footwear with wide heels, and/or wear shoes modified by a certified pedorthist. The use of mobility devices such as canes, as well as gait modification devices, including ankle braces and gait plates, are recommended.

In case of mild OA, the first medication of choice is Paracetamol. Topical medications (used on the skin called nonste)roidal anti-inflammatories (NSAIDs) can also be used in conjunction with Paracetamol. Corticosteroid injections are often done to the joint for short-term pain relief. A newer treatment that involves injection of Hyaluronan into the joint, to bring back viscosity and elasticity of synovial fluid (natural fluid in the joint), is very beneficial.

If OA is advanced and the previous treatments mentioned do not help, it’s useful to make an appointment with an orthopedic surgeon.

Rheumatoid Arthritis

This is a condition that can affect any joint in the body and is progressive and autoimmune in origin. RA is more common in women than men and begins between the ages of 25 and 60. It occurs when the immune system attacks the joints and the surrounding tissues causing pain, inflammation, and eventually, disability in the joints. During “flares”, an active phase of RA, the joints become inflamed, red, hot, and painful.  Since joints in the feet are often affected when RA is present, it has a major effect on gait, balance, ability to walk, and may cause restrictions in activities of daily living. Joints in the neck, jaw, ankles, knees, hips, shoulders, and elbows can also be affected.

     Following the trigger for the autoimmune reaction, which is unknown, inflammatory cells penetrate the joint filling it. In addition, inflammatory chemicals erode cartilage, bone, ligaments, and articular capsule. This is followed by synovial fluid build-up in the joint resulting in pain and swelling. Then, the following sequence of events occurs: synovium becomes thick and changes into a tissue called “pannus”, it releases inflammatory mediators that damage cartilage and bone under it, thick scar tissue develops that, eventually, causes the bone ends to fuse together. Bone fusion does not occur in all cases of RA.

     RA causes symptoms inside and outside the joints. Inside the joints, it affects synovium, a thin layer of tissue that lines the joints throughout the body. Other symptoms of RA include fatigue, joint pain, morning stiffness, and swelling in the joints furthest away from the body, such as the wrists and the feet in a symmetrical pattern. Outside the joint, the symptoms include muscle weakness, decrease in muscular strength and mass, anemia, myalgia, malaise, swollen glands, loss of appetite, weight loss, and low grade fever.

     In order to protect the joints and prevent the disease from getting worse, it is important to treat RA early. To this end, medications and lifestyle changes are used. Drug therapy for RA includes disease-modifying antirheumatic drugs (DMARDs), non-steroidal anti-inflammatories (NSAIDs), and steroids. Other treatment options are foot orthotics, specialty footwear, analgesics, occupational and physical therapy, splinting, and alternative therapies. If advanced disease is present, orthopedic surgery may be indicated.

Peripheral Vascular Disease (PVD)

This condition is characterized by the arteries in the feet and legs becoming narrow
and hard, which restricts blood supply. As the circulation becomes impaired, oxygen
and other nutrients cannot be replenished in the cells of the legs and feet, contributing
to slowed wound healing, dry skin, reduced skin and nail health, feeling cold in the
extremities, and is more common in people who have diabetes.
The cause of PVD is atherosclerosis, the technical name for hardening of the
arteries. Peripheral arterial disease (PAD) is a type of peripheral vascular disease that
affects the arteries of the extremities, such as posterior and anterior tibial arteries
(arteries behind and in front of tibia, the major bone of the lower leg). The classic
symptoms of PAD are: intermittent claudication and pain in the legs when resting.
Intermittent claudication (IC) is characterized by pain upon movement, due to lack of
blood supply that is relieved by rest. IC is caused by build-up of plaque in blood vessels.
Clients with diabetes and PAD may not have these symptoms if severe peripheral
neuropathy is present. Neuropathy may mask the symptoms of intermittent claudication
in this population, which can lead to worse health outcomes in clients who have diabetic
vs. those without it. As a result, both neuropathy and lack of oxygenation in the tissues,
also called ischemia, leads to formation of foot ulcers in clients with diabetes.
Recommended footwear modifications include: orthopedic footwear with a rocker
sole feature, good mid-foot stability, firm heel counter, and it has to only flex in the
forefoot. Custom orthotics are also greatly beneficial. As to surgery, arterial
reconstruction is an option. Revascularization procedures used are: stenting,
angioplasty, bypass grafts to blood vessels of the feet, and atherectomy.

Lesser Toe Deformities: Hammer, Claw and Mallet Toes

     These types of deformities are most common in the elderly population and most often in women. Claw toe deformity appears as a toe that is bent in the joint closest to the leg. Mallet toe deformity is when a toe is bent in the joint furthest from the leg. Claw toe deformity affects both joints: the closest to the leg (proximal) and furthest from the leg (distal). The cause of these deformities is usually badly fitted shoes or muscle imbalance. The most common cause of hammer toes is the imbalance between intrinsic flexors and extensors of the toes.

    Other causes of these deformities include: diabetes, inflammatory arthritis, peripheral neuropathy, acute injuries, neuromuscular disorders, and congenital malformations. One of the most common issues that cause hammer toes is a bunion. This happens when the big toe pushes on the second toe so that the second toe becomes bent or “hammered”. If the length of the second toe is the longest, shoes that have a small toe box will cause this toe become deformed. Toe box of the shoes that is too narrow can cause deformity in the fifth toe. When wearing narrow short footwear the lesser toes are forced into a flexed position for a long period of time. Then, the muscles adapt and become permanently fixed in this position.

     It is important to determine whether the deformity is flexible or fixed. If the deformity is flexible that means that the toe is bent at the joint but can be manually straightened. The deformity can be passively corrected while avoiding pressure points and fixation in deformed position. A fixed deformity needs to be accommodated for, with orthotics, footwear accommodations, and/or surgery, to decrease high pressure areas and avoid further deformation.

     To lessen discomfort common treatments include: orthotics, footwear modifications, surgery, physiotherapy, and commercial accommodative devices. Orthotic intervention can include a metatarsal bar, toe crest, cushioning, metatarsal pad, and/or a pair of orthotics. Make sure there is a ½ inch is left beyond the longest toe, the toe-box material is soft, and that there is no stitching that can irritate toes and prevent stretching. Footwear can be stretched manually by a pedorthist, chiropodist, or podiatrist to accommodate a deformity. Also, do not to wear shoes with a narrow and shallow toe-box. It will only cause more injury and pain in the problem area.

     The most extreme treatment is surgical intervention. It is done only if the deformity is severe and/or disabling. The type of surgery will only depend on the type of deformity and does not require the client to be non-weight-bearing for too long afterwards. For example, a rigid deformity needs correction and fixation of the bone.

Peripheral Neuropathy

It is characterized by a gradual loss of protective sensation in the feet, legs and, sometimes, arms and hands. Perception of touch, pressure, temperature, and pain are affected. It’s important because it is the most significant predictor of foot ulceration and other complications in the diabetic population. The lack of painful feedback makes it easy for unnoticed repetitive trauma to occur to the feet. Now, let’s look at the three main types of neuropathy: sensory, motor, and autonomic.

Sensory neuropathy is the loss of sensation, specifically, inability to feel pressure and pain caused by outside forces, as well as altered proprioception: inability to know the position of the feet. Since sensory nerves send messages from the muscles to the spinal cord and the brain, when these nerves cease to function, the message or impulse about sensation does not get sent. The result is extreme sensitivity to touch, numbness, tingling, and pain. Loss of protective sensation can lead to repeated injuries, including burns and abrasions, as well as mechanical stress.

Motor neuropathy often leads to foot deformities which further predispose a diabetic foot to ulceration. Some common deformities include: contracted toes, hammer and claw toes, limited joint mobility, prominent metatarsal heads, as well as weakness and deformity of the small muscles of the foot. It’s the function of the motor nerves to send impulses from the brain and spinal cord to all the muscles in the body. When these nerves are damaged the result is muscles spasms, cramps and weakness, as well as difficulty moving and walking.

Autonomic neuropathy leads to no oil or sweat being produced by the skin due to autonomic system dysfunction. Autonomic system is involuntary. It presides over such bodily functions as blood pressure, heart rate, sweating, and digestion. When the skin can no longer produce sweat or oil it becomes dry, non-elastic, and hot to touch, which can lead to cracking, wound formation, and, possibly, infection.

All clients with diabetes but without neuropathy are considered to be at high risk of developing neuropathy. It is essential for them to examine their feet every day looking for abnormalities, sores, and abrasions, check footwear for foreign objects, avoid going barefoot, check water temperature before getting into shower or bath, wear wide shoes with good insoles and big toe box, and tell their doctor if they have any issues with their feet.

Crossover Toe Deformity

Dislocation of the second toe usually happens slowly, where the toe drifts and, eventually, overlaps the big toe. It often occurs concurrently to a bunion. The cause is a tear in the Plantar Plate, the tough fibrocartilagenous thickening which attaches the toes to the pad that covers the joint at the base of the toes. Its main function is to resist the force of toe off.

This deformity can happen due to chronic inflammation or acute trauma to the second metatarsophalangeal joint (the area of attachment of the bones of the toes to the base of the toes called metatarsal heads). Progressive inflammation in the MTP joint leads to rupture of the plantar plate and collateral ligaments. In fact, any structural of functional deformity that results in inflammation of the plantar plate can result in joint instability.

Localized inflammation and pain of the 2nd MTP joint are early signs of strain of the plantar plate. When weight-bearing the toe may not shift sideways and may not touch the ground, which will cause more pressure on the bottom part of the metatarsal heads leading to bone bruise, callusing, and pain. Eventually, the pressure on the misaligned joint may cause arthritis. The biomechanics and functionality will also be altered.

Swelling around the base of the toe is a common symptom, as well as the distinct change in the position of the toe during the previous weeks or months. An X-ray as well as a physical examination will confirm the diagnosis. Common treatments include pain relief with NSAID medications, orthotics, and accommodative padding, as well as avoidance of high-heeled shoes. Taping is effective if the toe is deviated but not if it is dislocated. However, prolonged taping may cause swelling and/or an ulcer to form.

Corticosteroid injection in the joint is usually not recommended because it may weaken an already compromised plantar plate. Surgical removal of the toe will cause the 3rd toe to drift to the place of the missing toe so it’s not often recommended.

Varicose Veins: Causes and Remedies.

Varicose Veins are veins usually in your lower legs that are blue or purple, twisted, and bulging out. Veins bring blood back to the heart. In order to bring the blood back to the heart the muscles in the vein walls must push against gravity. As the blood is pushed up, valves that close prevent it from coming down again. People with varicose veins have valves that no longer close so the blood does not get pumped back to the heart effectively. It pools and causes distension in the veins of the lower legs, which are most effected by gravity. Pressure around the abdomen, such as during constipation or pregnancy, will also make it difficult for the blood to be pumped to the heart.

For some people who have no other symptoms the concern is that they look awful. But others can experience pain that gets worse after sitting or standing, swelling in the lower legs, muscle cramps, burning or throbbing, heavy feeling in the legs, itchiness, dry skin, and skin discoloration.

Varicose veins can be caused by heredity, female gender, age 50 or older, being overweight (high body-mass index), pregnancy, and standing for long periods of time. Weight lifting can make varicose veins worse.

Whether varicose veins are a cosmetic concern or a serious discomfort, there are some things you can do about them. The same things that prevent varicose veins also help treat them. They are: weight reduction, a diet high in fiber and low in salt, exercise, compression stockings, reducing constipation, elevation of the legs, avoidance of crossing the legs, avoidance of high heels and tight hosiery, and changing the standing and sitting position often. Also, there are procedures where a doctor can remove and close veins.

Flat Feet

Flat feet or Pes Planus is when the arches of your feet become flat as soon as you stand up from a sitting position. Having flat feet is very common. In fact, up to 22% of Canadians have flat feet. One in ten of these people will have foot pain or soreness. This condition is usually hereditary but can also be caused by pregnancy, aging, arthritis, obesity, injury, or another disease, such as muscular dystrophy, cerebral palsy, or spina bifida.

     Since all of your weight-bearing joints are connected, that means your back, hips, knees, ankles, and feet, a deformity of the feet affects all the rest of these joints. Pain and imbalance in your feet will lead to pain in other joints as well as gait and postural changes. Working to correct flat feet will bring your body into alignment and help correct other problems caused by having flat feet.

     It is normal for infants to have flat feet. Children 2-3 years old usually develop non-flattening arches as the tendons and ligaments in the feet tighten. Common categories of flat feet are: posterior tibial tendon dysfunction, tight Achilles tendon, and flexible flat foot.

     Flexible Flat Foot is the least problematic and most common of the three. It begins in childhood and is characterized by an arch present only when feet are lifted above the ground, when on the ground the arch falls flat. A tendon connects muscle to a bone. Achilles tendon connects gastrocnemeus (your calf muscle) to calcaneus (your heel bone) directly behind your heel. Having flat feet leads to tightness in this tendon, which in turn leads to soreness and pain when walking and running. To compensate and prevent further pain, the heel can lift prematurely when weight bearing.

     Posterior tibial tendon connects tibialis posterior muscle in the back of your leg and navicular (a bone in the arch of the foot). It supports the arch of the foot and helps to turn the foot in. Posterior Tibial Tendon Dysfunction can occur once there is an injury, tear, or swelling in the posterior tibial tendon. It is characterized by pain on the inside of the foot and ankle and on the outside of the ankle. This can happen in one or both feet. Diagnosis is made through obtaining family history, foot examination, and MRI.

     Common symptoms associated with flat feet are aching when walking or standing for a long time, pain in the ankles and lower legs, callouses, numbness, and stiffness. If you don’t experience any discomfort but you have flat feet, treatment may not be necessary. If you’re experiencing any of the above symptoms, see a pedorthist, chiropodist, or podiatrist. You will need orthoses, proper footwear, and footwear modifications. Non-steroidal anti-inflammatory medications for pain and inflammation and/or physiotherapy may be prescribed by a foot care professional. In extreme cases surgery may be indicated.

Hallux Valgus (Bunion)

Hallux Valgus also called a Bunion, is a deformity of the first metatarsophalangeal joint (the joint at the base of the big toe). “Hallux” is the big toe and “valgus” means the deformity of the big toe. It is more common in women. Family history of hallux valgus is the main cause of this deformity, more so than ill-fitting shoes. In feet with bunions, there is an imbalance between the following muscles of the feet: flexor halluces brevis, and adductor and abductor halluces muscles. The severity of the bunion is determined by the degree of the following angles: the hallux valgus angle (HVA) and intermetatarsal angle (IMA). As the metatarsophalangeal joint is compressed and widened during repeated impact when walking, additional bone is added to the first metatarsal head at the site of the bunion. This joint also becomes dorsiflexed and inverted, hence it’s shape.

     Many people with bunions will only experience pain at the site of the bunion when wearing tight narrow shoes with a small toe box. Some will complain of redness, tenderness, swelling, and pain with plantar flexion. If the bunion is severe, the second toe may become “hammered”: the two joints of the second toe become permanently flexed. The second toe may overlap the big toe.

     Proper fitting foot orthotics with a rocker sole, no seams over the bunion, and a deep vamp are the best treatment option. A pedorthist, podiatrist, or chiropodist may place a metatarsal pad under the top cover of the orthotic just underneath metatarsal heads (the joints at the base of the toes) will help unload the pressure off the forefoot. Surgery may be considered if pain in the bunion is extreme or for aesthetic reasons. It is not covered by OHIP and tends to be expensive. Complications of a surgical procedure include long-term pain in metatarsal heads, recurrence of bunions, and necrosis of the first metatarsal.

Who Is a Foot Care Nurse and What Does a Foot Care Nurse Do?

A foot care nurse can be a Registered Nurse or a Registered Practical Nurse. She will assess the skin condition, hair distribution, and structure of your feet as well as your pulses and feeling with a monofilament to test the dermatomes. This confirms presence of adequate or inadequate circulation. The monofilament is used to check for neuropathy, a lack of feeling in the feet that could be an advanced sign of Diabetes. The nurse will also check what medications you are on and for what health conditions. History of surgery or injury to the feet, ankles, hips, and back is especially important because foot care must be tailored to support the feet as they are with all their health history. Of course, nails are cut, callouses are reduced, and corns are removed. However, a foot care nurse is not just there for the one-time visit, but someone who oversees the state of your feet and provides ongoing care, health teaching, and recommendations about self-care. If nail fungus or Athlete’s foot is present, the foot care nurse will let you know and explain which over-the-counter or home remedies can be used as long as it does not interact with what is prescribed by your healthcare practitioner. In summary, a foot care nurse knows what your feet have been through and how to optimize their health.

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