What is it?

More than 15% of women in the UK suffer from bunions, but what is a bunion? A bunion, also known as ‘hallux valgus’ is a deformity of the big toe in which the big toe excessively angles towards the second toe and leads to a bony lump on the side of the foot. This can also form a large sac of fluid, known as a bursa, which can then become inflamed and sore.

What causes the problem?

There is no one cause of having a bunion and contrary to popular opinion, bunions are not generally caused by shoes. They are most often caused by a defective mechanical structure of the foot which is genetic and these certain foot types make a person prone to development of a bunion.

Bunions can also be caused from the big toe pushing over on to the second toe which can lead to problems. Commonly, it can end up lying on top of the second toe causing crossover of the toes making it difficult to walk due to pressure on the toes from footwear. Once the big toe leans toward the second toe, the tendons no longer pull the toe in a straight line, so the problem tends to get progressively worse. This condition can also lead to corns and calluses being developed.

Poorly fitting footwear tend to aggravate the problem as they can squeeze the forefoot, crowding the toes together and exacerbate the underlying condition, causing pain and deformity of the joint (hallux valgus).

Bunions can also be caused by age, arthritis or playing sport. 

Is it serious?

Some people have large bunions that cause no pain but do cause difficulties with footwear, while others have relatively small bunions that can be very painful. Although some treatments can ease the pain of bunions, only surgery can correct the defect.

In some cases, pressure from the big toe joint can lead to a deformity in the joint of the second toe, pushing it toward the third toe and so on. However, just because you have a bunion, does not mean you’ll get a bursa as well.

Who gets it?

Although anyone can get a bunion, they tend to be more common in women, possibly due to some of the more restrictive footwear typically worn. Women also tend to have looser ligaments. If your parents or grandparents have them, you may also be more prone to developing them.

How do I prevent it?

Wearing sensible shoes that fit well is a good preventative measure. If you notice a bump developing where your big toe joins the foot, it may be time to switch your footwear. Try to opt for wider shoes that provide your toes with room to move and keep your heel height to no more than 4cm for maximum comfort.  The following also serves as a useful guide:

• Wear backless, high-heeled shoes in moderation.Backless shoes force your toes to claw as you walk, straining the muscles if worn over a long period.
• Vary your heel heights from day to day, one day wearing low heels and the next day slightly higher heels.
• If you want to wear a heel every day, keep heel heights to 4cm or less.
• Wearing a shoe with a strap or lace over the instep holds the foot secure and acts a bit like a seatbelt in a car and helps stop your foot sliding forward.
• Calf stretches to counteract the shortening of the calf can help to keep feet supple.

What are the treatments?

Your podiatrist may recommend the following:

• Exercises
• Orthoses (special devices inserted into shoes)
• Shoe alterations or night splints which hold toes straight during sleep (helps to slow the progression of bunions in children)
  

However, these are conservative measures and although they may help relieve symptoms, there is no evidence they can correct the underlying deformity. Your podiatrist will be able to identify any significant deformity and/or defect and will refer you for surgery which can involve a combination of removing, realigning and pinning of the bone.

Once referred, your podiatric surgeon will evaluate the extent of the deformity. They can remove the bunion and realign the toe joint in a common operation known as a 1st Metatarsal Osteotomy (‘bunionectomy’).  However, there are more than 130 different types of operation that fall under this title, so each individual surgery is different.

The aim of surgery is to address the underlying deformity to prevent recurrence. As with all surgery, there are risks and complications, so it is not usually advised unless your bunions are causing pain – or if it is starting to deform your other toes.

When should I see a podiatrist about it?

If you experience any foot care issues which do not resolve themselves naturally or through routine foot care within three weeks, it is recommended to seek the help of a healthcare professional such as your GP to refer you to your local NHS trust for free treatment but if you do not qualify for this, or need urgent attention, you should contact a private podiatrist.

Heel Pain (Plantar Fasciitis)

Heel pain is most often caused by plantar fasciitis, a condition that is sometimes also called heel spur syndrome when a spur is present. Heel pain may also be due to other causes, such as a stress fracture, tendonitis, arthritis, nerve irritation or, rarely, a cyst.

Because there are several potential causes, it is important to have heel pain properly diagnosed. A foot and ankle surgeon is able to distinguish between all the possibilities and to determine the underlying source of your heel pain.

What Is Plantar Fasciitis?

Plantar fasciitis is an inflammation of the band of tissue (the plantar fascia) that extends from the heel to the toes. In this condition, the fascia first becomes irritated and then inflamed, resulting in heel pain.

Causes

The most common cause of plantar fasciitis relates to faulty structure of the foot. For example, people who have problems with their arches, either overly flat feet or high-arched feet, are more prone to developing plantar fasciitis.

Wearing nonsupportive footwear on hard, flat surfaces puts abnormal strain on the plantar fascia and can also lead to plantar fasciitis. This is particularly evident when one’s job requires long hours on the feet. Obesity and overuse may also contribute to plantar fasciitis.

Symptoms

The symptoms of plantar fasciitis are:

• Pain on the bottom of the heel
• Pain in the arch of the foot
• Pain that is usually worse upon arising
• Pain that increases over a period of months
• Swelling on the bottom of the heel
   

People with plantar fasciitis often describe the pain as worse when they get up in the morning or after they have been sitting for long periods of time. After a few minutes of walking, the pain decreases because walking stretches the fascia. For some people, the pain subsides but returns after spending long periods of time on their feet.

Diagnosis

To arrive at a diagnosis, the foot and ankle surgeon will obtain your medical history and examine your foot. Throughout this process, the surgeon rules out all possible causes for your heel pain other than plantar fasciitis.

In addition, diagnostic imaging studies, such as x-rays or other imaging modalities, may be used to distinguish the different types of heel pain. Sometimes heel spurs are found in patients with plantar fasciitis, but these are rarely a source of pain. When they are present, the condition may be diagnosed as plantar fasciitis/heel spur syndrome.

Nonsurgical Treatment

Treatment of plantar fasciitis begins with first-line strategies, which you can begin at home:

• Stretching exercises. Exercises that stretch out the calf muscles help ease pain and assist with recovery.
• Avoid going barefoot. When you walk without shoes, you put undue strain and stress on your plantar fascia.
• Ice. Putting an ice pack on your heel for 20 minutes several times a day helps reduce inflammation. Place a thin towel between the ice and your heel; do not apply ice directly to the skin.
• Limit activities. Cut down on extended physical activities to give your heel a rest.
• Shoe modifications. Wearing supportive shoes that have good arch support and a slightly raised heel reduces stress on the plantar fascia.
• Medications. Oral nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen, may be recommended to reduce pain and inflammation.
   

If you still have pain after several weeks, see your foot and ankle surgeon, who may add one or more of these treatment approaches:

• Padding, taping and strapping. Placing pads in the shoe softens the impact of walking. Taping and strapping help support the foot and reduce strain on the fascia.
• Orthotic devices. Custom orthotic devices that fit into your shoe help correct the underlying structural abnormalities causing the plantar fasciitis.
• Injection therapy. In some cases, corticosteroid injections are used to help reduce the inflammation and relieve pain.
• Removable walking cast. A removable walking cast may be used to keep your foot immobile for a few weeks to allow it to rest and heal.
• Night splint. Wearing a night splint allows you to maintain an extended stretch of the plantar fascia while sleeping. This may help reduce the morning pain experienced by some patients.
• Physical therapy. Exercises and other physical therapy measures may be used to help provide relief.
   

When Is Surgery Needed?

Although most patients with plantar fasciitis respond to nonsurgical treatment, a small percentage of patients may require surgery. If, after several months of nonsurgical treatment, you continue to have heel pain, surgery will be considered. Your foot and ankle surgeon will discuss the surgical options with you and determine which approach would be most beneficial for you.

Long-Term Care

No matter what kind of treatment you undergo for plantar fasciitis, the underlying causes that led to this condition may remain. Therefore, you will need to continue with preventive measures. Wearing supportive shoes, stretching and using custom orthotic devices are the mainstay of long-term treatment for plantar fasciitis.

What is it?

An ingrowing toenail is one that pierces the flesh of the toe. It can feel as if you have a splinter, be extremely painful and inflamed or infected. In more severe cases, it can cause pus and bleeding. Ingrowing toenails most commonly affect the big toenail, but can affect the other toes too. Whereas a nail that is curling (involuted or convoluted) into the flesh, but isn’t actually piercing the skin, isn't an ingrowing toenail but can feel very painful and also appear red and inflamed as well.

What causes it?

There are many genetic factors that can make you prone to ingrowing toenails including your posture (the way you stand), your gait (the way you walk) and any foot deformity such as a bunion, hammer toes or excessive pronation of the feet (when your foot rolls inward excessively). Your nails may also have a natural tendency to splay or curl out instead of growing straight, encouraging your nail to grow outwards or inwards into the flesh.

Tight footwear, hosiery and socks can also push your toe flesh onto the nail so that it pierces the skin. Also, if you sweat excessively or don’t rotate your footwear, this makes the skin moist and weak so that it is easily penetrated by the nail. If you have brittle nails with sharp edges or are in the habit of breaking off bits of nail that are sticking out, you are also more likely to get an ingrowing toenail. In addition, the wearing of support hose that is ill-fitting and squeezes the toes or likewise, the wearing of shoes with tight toe boxes.

However, one of the most common causes is not cutting your toenails properly such as cutting nails too low in order to relieve the pressure and discomfort of an involuted nail.

Less common is a fungal infection or in some cases particular types of medication, eg. isotretinoin.

Is it serious?

If left untreated, the infection can spread to the rest of the toe and foot and could lead to surgery. The quicker you treat it, the less painful the treatment.

Who gets it?

Active, sporty people are particularly prone, because they sweat more. Younger people are more likely to get it (as they pick their nails more, compared to older people who may not reach their toes!).

How do I know I have it?

The most common symptom is pain followed by some form of inflammation in the surrounding nail area.

However, not everyone identifies an ingrowing toenail correctly.  Sometimes, they have a curly nail which has a lot of debris (dirt or fluff) underneath it or a corn or callus down the side of the nail, which can be nearly as painful. However, if it’s a corn, the pain tends to be throbbing as opposed to the sharp pain you get with an ingrowing toenail. If this is the case, your podiatrist will remove the debris, and if necessary, thin the nail.

How do I prevent it?

Firstly, learn to cut your nails properly. Nail cutters aren’t a good idea because the curved cutting edge can cut the flesh and nail scissors can slip. It’s best to use nail nippers (available from chemists) because they have a smaller cutting blade but a longer handle. Cut your nails straight across and don’t cut too low at the edge or down the side. The corner of the nail should be visible above the skin. Also, cut them after a bath or shower when the nail is much softer.

Good hygiene can go a long way to preventing ingrowing toenails. Avoid moist, soggy feet by letting rotating your footwear so each pair has a chance to dry out thoroughly. Avoid man-made materials (synthetics) and choose socks and shoes of natural fibre and which fit properly. Keep your feet clean and dry and in the summer and wear open-toed sandals to let air get to your toes as much as possible.

If you have diabetes, are taking steroids or are on anti-coagulants, don’t attempt to cut your nails or remove the ingrowing spike of nail yourself.

When should I see a podiatrist about it?

Visit a podiatrist if you experience any:

• Persistent pain in your toe from the ingrowing nail
• Symptoms of infection, especially if you have Diabetes or a poor immune system
• Condition which affects the nerves and/or feeling in your foot.

If you experience any foot care issues which do not resolve themselves naturally or through routine foot care within three weeks, it is recommended to seek the help of a healthcare professional such as your GP to refer you to your local NHS trust for free treatment but if you do not qualify for this, or need urgent attention, you should contact a private podiatrist.

How can we help?

You may want to see a Foot Health Professional for advice and treatment if you have painful feet, thickened or discoloured toenails, cracks or cuts in the skin, growths such as warts, heel pain, plantar fasciitis, ingrowing toenails, scaling or peeling on the soles or any other foot-related problem.

Our clinicians can also supply orthotics, which are tailor-made insoles, padding and arch supports to relieve arch or heel pain. You put the orthotic device into your shoe to re-align your foot, take pressure off vulnerable areas of your foot or simply to make your shoes more comfortable.

Even if your feet are generally in good condition, you might consider having a single session of podiatry to have the hard skin on your feet removed, toenails clipped, to find out if you’re wearing the right shoes (take your shoes with you for specific advice on footwear) or just to check that you’re looking after your feet properly.

The Foot Clinic Northampton

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