An uncommon cause of small lumps in the Achilles tendon is an excessively high cholesterol level in the blood stream. This is a hereditary disorder that results in the deposition of cholesterol in the Achilles tendon. Frequently people will also have yellowish plagues on the lower eye lids, This is a serious condition and requires aggressive treatment by a physician to lower the cholesterol levels. Left untreated the high cholesterol levels can lead to premature heart attack and death.

Diagnosis

Diagnosis is made by clinical exam. Palpation of the Achilles tendon will reveal multiple small nodular masses. Noting excessively high blood cholesterol levels on routine lab tests provides conformation of the condition. A biopsy of the lesion will also make the diagnosis.

Treatment

The nodules in the Achilles tendon should be left alone. There is no value in removing them unless they are painful. Initial treatment should be directed at lowering the blood cholesterol levels.

Dry scaling skin on the feet is most commonly due to chronic athlete's foot. This is caused by a fungal infection of the skin and is often associated with a fungal infection of the toenails. Frequently, the skin has a dull, reddish appearance and is an "moccasin" like distribution on the bottom of the foot.

Psoriasis also causes dry scaling of the skin. It presents itself as small, white flaky patches. When these scales are scrapped off it will cause pinpoint bleeding. Psoriasis can also present as pustules or small blisters.

Neurodermatitis often presents itself as a solitary patch of dry, scaling skin that itches constantly. Commonly, it occurs on the ankle. Its cause is unknown. Treatment consists of using topical steroid compounds. Injecting the area with a cortisone compound will also often cure the condition. Allergic dermatitis and contact dermatitis also cause skin rashes but tend to be more acute.

Malignant Melanoma

Pigmented lesions should always be inspected and observed. Most pigmented areas are nothing but freckles and moles. However a potentially deadly pigmented lesion that can occur on the foot and lower extremity is Malignant Melanoma. A physician should evaluate any pigmented lesion that suddenly occurs or a pigmented lesion that starts to change its appearance. These changes are usually subtle and may consist of increased size and depth of color, onset of bleeding, seepage of clear fluid, tumor formation, ulceration and formation of satellite pigmented lesions. The color is usually not uniform but is likely to be scattered irregularity, being brown, bluish black or black. An increase in pigmentation may precede enlargement of the lesion by several months. Although any part of the body may be affected, the most frequent site is the foot, then in order of frequency, the remainder of the lower extremity, head and neck, abdomen, arms and back. Malignant melanoma may also form under the nails of the feet and hands. The thumb and big toe are more commonly affected than the other nails. Quite often the adjacent skin to the nail is ulcerated. Usually a fungal infection is suspected and antifungal treatment may be administered for months before the true nature of the lesion is discovered. A black malignant melanoma of the toe can also be mistaken for gangrene. Overall, the incidence of malignant melanoma is quite low.

Actinic Keratosis

Another cancer causing lesion that can occur on the feet are called Actinic Keratosis. Although most commonly found in sun-exposed areas of the body such as the face, ears, and back of the hands, these lesion can also occur on the foot. They are characterized as either flat or elevated with a scaly surface. They can either be reddish or skin colored. On the foot they are frequently mistaken for plantars warts. These lesions are the precursor of epidermoid carcinoma. Treatment for these lesions should be through as they are definitely precancerious. Treatment consists of freezing the lesions with liquid nitrogen or sharp excision.

Kaposi's Sarcoma

Yet another cancerous lesion that can occur on the foot is called Kaposi's Sarcoma. These lesions occur most commonly on the soles of the feet They are irregular in shape and have a purplish, reddish or bluish black appearance. They tend to spread and form large plaques or become nodular. The nodular lesions have a firm rubbery appearance. The appearance of these lesions is an ominous sign. In the late 1970's and early 1980's an outbreak of Kaposi's sarcoma occurred in San Francisco, California. It was later learned that the disease was associated with AIDS infection. It can occur without the concurrent AIDS infection but this is very rare.

Chronic athlete's foot can cause an increased pigmentation to the bottom of the foot. It is associated with dry scaling skin and may have a reddish appearance.

Venous Stasis

Generalized increased pigmentation occurs for a variety of other reasons. Dark patches of skin occur about the ankles and lower legs in persons who suffer from Venous Stasis. Venous stasis is caused by an accumulation of fluid in the lower extremities. This is due to poor venous return of blood to the heart. Venous blood flow back to the heart occurs by way of the veins in the feet and legs. Venous stasis is associated with varicose veins that do a poor job of returning blood to the heart. As a result the blood flow is slowed, becomes stagnant, and fluid accumulates in the ankles and lower legs. As the fluid accumulates in the lower legs, the small and medium-sized veins break or leak fluid into the tissues. As blood cells break up in the tissue, they deposit the iron that is part of hemoglobin in the blood cell. The iron stains the skin causing a light to dark brownish appearance. With time, the skin and subcutaneous fat becomes thinned and will break down creating weepingvenous stasis ulcerations. At times, blistering will form with a clear, watery fluid weeping from the skin. This condition requires professional attention by a physician.

Diabetic Dermopathy

Another cause of generalized increased pigmentation is diabetes. The condition termedDiabetic Dermopathy occurs most frequently on the shins and lower legs. They may have the appearance of small scars. Their appearance may precede the diagnosis of diabetes by several years. The actual cause of diabetic dermopathy is not well understood, but it does not cause any particular problem or pose any particular health threat.

Small, spider-like areas of increased pigmentation on the ankles are caused by the break down of small veins in the area and are called Spider Veins; they also pose no health risks.

Diabetic Peripheral Neuropathy

People with diabetes have an abnormal elevation of their blood sugar, and lack adequate insulin to metabolize the blood sugar. As a consequence, the blood glucose (sugar) abnormally enters certain nerve tissue and damages the nerve. This can occur in any type of diabetes. It does not matter if the patient is on insulin, is taking pills, or is diet controlled. The nerve damage that occurs is considered to be permanent.

As the nerve damage occurs, the protective sensations are affected. These include a person's ability to determine the difference between sharp and dull, hot and cold, pressure differences, and vibration. These senses become dulled and/or altered. The process begins as a burning sensation in the toes and progresses up the foot in a "stocking distribution". As the condition progresses, the feet become more and more numb. Some people will feel as though a pair of socks on their feet, when in fact they do not. Other patients will describe the feeling of walking on cotton, or a water-filled cushion. Some patients complain of their feet burn at night, making it difficult to sleep. The feet may also feel like they are cold, however, to the touch, they have normal skin temperature. Diabetic peripheral neuropathy is not reversible. The progression of the condition can be slowed or halted by maintaining normal blood glucose levels.

As the patient develops diabetic neuropathy, they have a greater risk of developing skin ulcerations and infections. Areas of corns and calluses on the feet represent areas of excessive friction or pressure. These areas, if not properly cared for by a foot specialist, will often break down and cause ulcerations. Ulcerations and infection can form under the callused area. These callused areas may not be painful. As a result, they can progress to ulceration without being noticed. Ingrown toenails can progress to severe infections in people with neuropathy. Simple things like trimming the toenails present a risk to these patients because they may accidentally cut the skin and not feel it. People with neuropathy must be very cautious and inspect their feet daily. They should not soak their feet in hot water or use heating pads to warm their feet. This can result in accidental burns to the skin. Barefoot walking should be avoided because of the risk of stepping on something sharp and not being aware of it. The inside of the shoes should be inspected before putting the shoes on to insure that no foreign object is inside the shoe ( see Do's and Don'ts-Diabetic Foot Care Tips).

Alcoholic Peripheral Neuropathy

Alcoholic neuropathy is caused by the prolonged use of alcoholic beverages. Ethanol, the alcoholic component of these beverages, is toxic to nerve tissue. Over time, the nerves in the feet and hands can become damaged resulting in the same loss of sensation as that seen in diabetic neuropathy. The damage to these nerves is permanent. A person with this condition is at the same risk, and should take the same precautions as people with diabetic peripheral neuropathy. Peripheral neuropathy can also be caused by exposure to toxins such as pesticides and heavy metals.

Treatment For Peripheral Neuropathy

Treatment for peripheral neuropathy is, for the most part, directed at the symptoms of the condition. Vitamin B12 injections may be helpful if the patient has a vitamin B deficiency. There are certain oral medications that may ease the burning pain that can be prescribed by your doctor. Topical ointments should only be used with the advice of your doctor. Magnetic therapy and Galvanic Stimulation are alternative forms of treatment but results are varied and difficult to quantify.

As recently as thirty-five years ago, athletic shoes consisted of just a few shoes that were used for a wide variety of athletic events. There were a few tennis and basketball shoes. There were no shoes marketed specifically as walking shoes. Aerobics or fitness shoes were nonexistent. Running shoes only amounted to a few in number.

However, in today's athletic shoe stores, the number of brands and styles of shoes for all types of sports is staggering. There are shoes made specifically for wrestling, rock climbing and windsurfing in addition to the more common sports such as running, basketball, tennis, racquetball, aerobic dance and walking. In the running shoe market alone, there are nine major shoe manufacturers with each manufacturer having about five to ten running shoe models within their line. Even though the increased selection of shoes increases the possibility of finding just the right shoe for each set of feet, the large selection of models creates a large degree of confusion among the consumer.

It is actually this diversity and complexity within athletic shoes that is their most interesting aspect. Shoes that have different shapes, are made of different materials, and which are put together by different construction methods all will function on the foot differently. The purpose of this article is to explain the major structural differences between the three broadest categories of athletic shoes (i.e. running shoes, court shoes and fitness shoes) so that their functional differences may be better appreciated.

Running Shoes

Running, like walking, is considered a straight ahead sport since it involves no sudden stops, turns or other maneuvers. Most runners land on their heels and then propel off of their toes. This heel to toe cycle is repeated hundreds and thousands of times every running session. The major biomechanical differences between running and walking are that in running there is always one point during running when both feet are off the ground and also during running the impact forces which the foot absorbs are at least twice as great as that found in walking.

Most runners strike on the outside of the heel, rapidly pronate, stay pronated for a brief instant and then resupinate as the heel leaves the ground during the push-off phase of running. [Pronation of the foot is a rolling inward of the ankle in which the arch flattens. Supination of the foot is a rolling outward of the ankle in which the arch increases in height.] Due to the large degree of variation within the population, there are a large number of runners who pronate excessively during running causing a multitude of running injuries such as posterior tibial tendinitis, plantar fasciitis and pes anserinus bursitis, to name a few.

Because of the increased impact forces and increased excessive pronation seen in running, running shoes must be designed both to help reduce excessive shock to the body and also help reduce pronation in the foot (Fig. 1). Unfortunately, the same shoe design characteristics that are best at helping to control pronation also tend to lessen the ability of the shoe to cushion the foot. And conversely, any shoe designed to maximize the cushioning of the foot during running will tend to have decreased ability in helping to control pronation.

To better understand how the characteristics of running shoe design affect foot function it is important to detail the structural components of the running shoe. Every shoe is made of two basic parts, the sole and the upper. The sole protects the foot from the ground and provides a layer of cushion for the foot. The upper covers the top and sides of the foot to provide a comfortable fit between the foot and the shoe and to improve stability of the foot on the shoe sole.

In the running shoe, the sole is made up of two distinct layers, the outersole and the midsole. The outersole is the part of the sole that contacts the ground. It is made of a thin layer of relatively hard, abrasion resistant material which functions to resist wear, provide traction and allow flexibility in the forefoot for propulsion.

Many running shoes use a rubber compound with a high carbon content in the heel and forefoot area, which is similar in composition to an automobile tire, so that the outersole will resist the abrasion that comes from the heel striking the ground. Running shoe outersoles also are constructed with studs or ridges in the midfoot and forefoot area to aid traction on soft or slippery surfaces, such as wet grass or slick pavement. In addition, most running shoe outersoles also incorporate some form of transverse grooves placed in the area of the forefoot so that the shoe will be more flexible in the forefoot once the heel leaves the ground during the push-off phase.

The midsole, however, is the part of the running shoe that either makes it work well or makes it work poorly. The midsole is sandwiched between the upper and the outersole. The upper is glued or bonded to the top surface of the midsole. The midsole is the most important part of the running shoe because its design and construction largely determine whether the running shoe will be a shoe which is good at providing cushioning, good at controlling pronation, good for heavy runners or good for nothing.

Running shoe midsoles are designed so that there is thick cushioning under both the heel and forefoot to help provide cushioning to the heel and forefoot. The total height of the midsole and outersole under the heel is generally about 1 inch and the total height of the midsole and outersole under the forefoot is about 5/8"". The 3/8"" difference of sole thickness between the heel and forefoot in many running shoes tends to be preferred by most runners and also reduces the strain on the Achilles tendon, therefore, reducing the likelihood of Achilles tendinitis.

The midsole may be constructed of various materials to provide cushioning and pronation control. The two most common materials used in the construction of running shoe midsoles is ethyl vinyl acetate (EVA) or polyurethane (PU). EVA is a copolymer of ethylene and vinyl acetate that has microscopic air bubbles within it that makes it lightweight and very cushiony. PU also has a microscopic air bubble structure like EVA but is generally firmer and more resistant to compression than EVA.

Running shoe manufacturers use combinations of different densities of EVA and/or PU within the midsole of the shoe, along with gel packets, air bags, plastic plates and other exotic materials to provide what they believe is the proper amount of cushioning and pronation control for the shoe. Many running shoe midsoles have a firmer midsole material or a hard plate under the medial heel and a softer midsole material under the lateral heel so that the medial heel resists compression more than the lateral heel when the heel strikes the ground in running [Medial is toward the big toe, lateral is toward the little toe]. This ""dynamic varus wedge"" effect does effectively help control foot pronation to some extent. The softest midsole material is generally placed under the forefoot since most runners find that good forefoot cushioning is a very desirable feature when running on hard surfaces.

The upper of the running shoe is usually made of a combination of lightweight nylon and thin synthetic or natural leather to reduce the total weight of the shoe. Since running involves at least a thousand footstrikes per mile, a lightweight running shoe is critical to insure that the runner can move at a faster pace with less fatigue. One drawback to the lightweight materials used in running shoe uppers is that they all tend to suffer in side to side stability since the thin material in the upper is ineffective at resisting medial and lateral shifting of the foot on top of the sole of the shoe.

The upper of a running shoe also incorporates a stiff heel counter that is commonly stiffer than in other athletic shoes to help control excessive pronation or supination during running. Most running shoes also incorporate a raised padded ""Achilles tendon protector"" within the design of their upper to supposedly help protect the Achilles tendon. Most runners find that the ""Achilles tendon protector"" serves only as a convenient handle by which to pull their running shoes on with and serves little importance in protecting the Achilles tendon from injury.

Within the interior of today's running shoes are removable insoles known as sockliners. Sockliners serve to cushion the foot and provide some arch support. Many sockliners in more expensive running shoes serve to support the arch of the foot more effectively than those seen in cheaper shoes. Nearly all sockliners can be removed easily from the shoes so that custom foot orthoses may be added to the shoe to replace the sockliner if needed.

One more important fact about running shoe design is that running shoes make excellent walking shoes. Since running and walking are both straight-ahead activities, their basic shoe designs are quite similar. In fact, I recommend running shoes for my patients who walk for exercise in favor of many walking shoes since running shoes are lighter, more comfortable and biomechanically more efficient at helping control excessive foot pronation than the majority of walking shoes.

Court Shoes

Court sports include tennis, racquetball, basketball, squash, badminton and volleyball. Because court sports require sudden starts, stops and side to side motions, the best shoe construction for court sports is much different than that required for running (Fig. 2). The sudden side-to-side movements seen in court sports tend to make the foot slide forcefully either in a medial or lateral direction on the shoe sole. For example, if a tennis player is moving quickly toward the right and then uses the right foot to come to a complete stop, the foot will tend to slide laterally on top of the shoe sole. The only thing preventing the foot from sliding directly laterally off of the shoe sole is the upper of that shoe. It is because of this necessity for side-to-side stability that court shoes must be constructed much differently than running shoes.

Like running shoes, court shoes come in all shapes and sizes depending not only on the sport which the shoe is designed for but also on the manufacturer. Unlike running shoes in which the upper of the shoe always ends just below the ankle bones (i.e. a low-cut shoe), the upper of court shoes may extend partially over the ankle bones to about the ankle joint level (i.e. a mid-cut shoe) or may extend above the ankle bones completely covering them (i.e. a high-cut or high-top shoe). Many basketball shoes tend to be made of a higher cut than other court shoes due to the relatively great frequency of ankle sprains seen with basketball. All other shoe design parameters being equal, the higher the cut of the upper of the shoe, the better that shoe will be at preventing ankle instability during the activity and the heavier that shoe will be.

Since the goal in a well designed court shoe is to make the upper hold the foot on top of the sole, the uppers of court shoes are thicker and made of heavier weight materials than running shoes or fitness shoes. The uppers of court shoes are constructed of thicker leathers or synthetic leathers than either running or fitness shoes. Lightweight and thin materials such as nylon are used less frequently in court shoe uppers. In addition, many tennis shoes may have an extra layer of synthetic or natural leather toe box reinforcement to prevent the upper from wearing through in the toe box area from the scuffing which occurs during tennis serves.

Many court shoes also are constructed with an extended outersole or midsole which rises up on the sides to the bottom edge of the upper to give added strength to the sole/upper interface. As a result of the use of thicker upper materials and the side reinforcement of the sole up onto the upper, court shoes are nearly always heavier than the same size of running shoe.

The outersole of court shoes are usually made of a non-marking rubber compound for traction on outdoor or indoor courts. Court shoes have a much lower profile of tread patterns on their outersoles than running shoes since court sports are nearly always played on a dry, flat and smooth surface. In addition, court shoes often have a circular designs constructed into the outersole under the forefoot area of the sole to act as a ""pivot point"" for the shoe during rotational motions of the foot on the playing surface.

Like running shoes, court shoe midsoles are predominantly made of either EVA or PU. However, the midsoles of court shoes are firmer and thinner than running shoes to reduce the instability of the court shoe during side-to-side movements. Shoes with firmer soles have better side-to-side stability since the force of body weight through the foot will not deform a firm sole as much compared to a cushiony sole. The more that a shoe sole deforms under the forces which the foot exert on it during aggressive maneuvers, the more likely the shoe sole will tilt to one side or the other which may lead to either pronation or supination instability at the ankle joint complex.

Thicker soles increase the height of the foot and ankle from the ground that, in turn, increases the distance of the ankle joint complex from the ground. The higher that the ankle joint complex is from the ground, the longer is the lever arm for the reaction force from the ground to cause a either a pronation or supination force on the foot and ankle. Therefore, the thinner soles of court shoes decrease the likelihood of ankle sprains since the ground has a much shorter lever arm to produce pronation or supination forces on the ankle joint complex.

Fitness Shoes

About fifteen to twenty years ago there was a dramatic increase in the popularity of aerobic dance. At that time, the shoes worn for aerobic dance were either running or court shoes. Unfortunately, since running and court shoes were not specifically designed for the demands of aerobic dance, many injuries occurred. Those aerobic dancers wearing running shoes had good cushion to the forefoot, but suffered from ankle sprains due to the lack of lateral stability in running shoes. Those dancers wearing court shoes had good side-to-side stability, but suffered from painful symptoms in the forefoot due to the lack of cushioning in the forefoot in court shoes.

Shoe manufacturers responded with the aerobics shoe that blended technologies from both the running shoe and court shoe. The result was a shoe with a midsole thickness and degree of cushioning midway between that of court shoes and running shoes. In addition, the aerobics shoe had an upper that was midway between the court and running shoe in material weight and thickness.

Today, shoes made for aerobic dance are very similar in design to those shoes made for the various activities available in a health or fitness club. Therefore, shoes made for aerobic dance and cross-training are now known as "fitness shoes". Understanding the construction of fitness shoes is important since they not only are a very popular style of shoe, but their relatively recent birth into the shoe marketplace demonstrates the ability of shoe manufacturers to design a totally new and unique style of shoe to meet the biomechanical demands of a new sport (Fig. 3).

The fitness shoe has been designed using technological features from both running shoes and court shoes to create a shoe that is actually a better all-purpose shoe than either the court shoe or the running shoe. It is lighter in weight and more well cushioned than the court shoe and much more able to resist side to side movements of the foot than a running shoe.

The upper of fitness shoes can range from a low-cut to a high-cut with the most popular height being a mid-cut. The mid-cut upper is a very popular style in fitness shoes since it does provide extra lateral stability without adding a great deal of extra weight to the shoe. The fitness shoe upper is made from a combination of thinner natural or synthetic leather and nylon that decreases the weight of the shoe compared to a court shoe. However, since the fitness shoe upper is more substantial than the upper found in running shoes, the lateral stability of the fitness shoe is greater than in the running shoe.

Like court shoes, many fitness shoes use an extended outersole or midsole on the medial and lateral sides of the upper to provide extra bonding strength to the sole/upper junction. The extended midsole is now very popular in fitness shoes and does provide an extra degree of lateral stability to the shoe.

The outersole of fitness shoes are very similar to court shoes being made from non-marking rubber compounds in a low profile. However, the midsole in a fitness shoe is thicker than that seen in the court shoe to provide extra cushioning to the forefoot and rearfoot during aerobic dance, running and other impact activities. Even though the midsole in a fitness shoe is not as thick as that in running shoes, the fitness shoe can safely have a thicker midsole in its design since the side to side activities seen in fitness shoes are not as aggressive as that seen in court sports.

Conclusion

Certainly in the case of all the shoes described, it is clear that the structure of the shoe determines how the shoe will affect the function of the foot within that shoe. Whether it is the composition of the outersole, midsole or upper, or it is how the sole is attached to the upper, or it is any other shoe design parameter, the construction of athletic shoes must match the biomechanical requirements of the specific athletic activity in order for the shoe to be useful and desirable for the athlete.

What is Deep Vein Thrombosis?
The blood supply of the leg is transported by arteries and veins. The arteries carry blood from the heart to the limbs; veins carry blood back to the heart. The leg contains superficial veins, which are close to the surface, and deep veins, which lie much deeper in the leg. Deep vein thrombosis (DVT) is a condition in which a blood clot (a blockage) forms in a deep vein. While these clots most commonly occur in the veins of the leg (the calf or thigh), they can also develop in other parts of the body. 

DVT can be very dangerous and is considered a medical emergency. If the clot (also known as a thrombus) breaks loose and travels through the bloodstream, it can lodge in the lung. This blockage in the lung, called a pulmonary embolism, can make it difficult to breathe and may even cause death. Blood clots in the thigh are more likely to cause a pulmonary embolism than those in the calf.

Risk Factors for DVT: Blood or vein conditions:  Previous DVT Varicose veins Blood clotting disorders Family history of DVT or blood-clotting disorders Other medical conditions: Heart disease Chronic swelling of the legs Obesity Inflammatory bowel disease Cancer Dehydration Sepsis Women's Health issues: Hormone replacement therapy Birth control pills containing estrogen Pregnancy or recent childbirth Other: Age over 40 years old Immobility (through inactivity or from wearing a cast) Recent surgery Trauma (an injury) Smoking

Causes of DVT  
Many factors can contribute to the formation of a DVT. The more risk factors a person has, the greater their risk of having a DVT. However, even people without these risk factors can form a DVT.

Signs and Symptoms of DVT in the Leg
Some people with DVT in the leg have either no warning signs at all or very vague symptoms. If any of the following warning signs or symptoms are present, it is important to see a doctor for evaluation:

• Swelling in the leg
• Pain in the calf or thigh
• Warmth and redness of the leg

Diagnosis
DVT can be difficult to diagnose, especially if the patient has no symptoms. Diagnosis is also challenging because of the similarities between symptoms of DVT and those of other conditions such as a pulled muscle, an infection, a clot in a superficial vein (thrombophlebitis), a fracture, and arthritis.

If DVT is suspected, the doctor will immediately send the patient to a vascular laboratory or a hospital for testing, which may include a blood test, Doppler ultrasound, venogram, MRI, or angiogram.

Treatment of DVT
If tests indicate a clot is present, the doctor will make a recommendation regarding treatment. Depending on the location of the clot, the patient may need hospitalization. Medical or surgical care will be managed by a team of physicians which may include a primary care physician, internist, vascular (blood vessel) surgeon, or hematologist (blood disease specialist).

Treatment may include:

• Medication. A blood-thinning medication is usually prescribed to help prevent additional clots from forming.
• Compression stockings. Wearing fitted hosiery decreases pain and swelling.
• Surgery. A surgical procedure performed by a vascular specialist may be required.

Complications of DVT
An early and extremely serious complication of DVT is a pulmonary embolism. A pulmonary embolism develops if the clot breaks loose and travels to the lung. Symptoms of a pulmonary embolism include:

• Shortness of breath
• Chest pain
• Coughing up blood
• A feeling of impending doom

A long-term consequence of DVT is damage to the vein from the clot. This damage often results in persistent swelling, pain and discoloration of the leg.

Preventative Measures
For those who have risk factors for DVT, these strategies may reduce the likelihood of developing a blood clot:

• Take blood-thinning medication, if prescribed.
• Reduce risk factors that can be changed. For example, stop smoking and lose excess weight.
• During periods of prolonged immobility, such as on long trips.
  • Exercise legs every 2 to 3 hours to get the blood flowing back to the heart. Walk up and down the aisle of a plane or train, rotate ankles while sitting, and take regular breaks on road trips.
  • Stay hydrated by drinking plenty of fluids; avoid alcohol and caffeine.
  • Consider wearing compression stockings.

Deformities of the toes are common in the pediatric population. Generally they are congenital in nature with both or one of the parents having the same or similar condition. Many of these deformities are present at birth and can become worse with time. Rarely do children outgrow these deformities although rare instances of spontaneous resolution of some deformities have been reported.

Malformation of the toes in infancy and early childhood are rarely symptomatic. The complaints of parents are more cosmetic in nature. However, as the child matures these deformities progress from a flexible deformity to a rigid deformity and become progressively symptomatic. Many of these deformities are unresponsive to conservative treatment. Common digital deformities are underlapping toes, overlapping toes,flexed or contracted toes and mallet toes. Quite often a prolonged course of digital splitting and exercises may be recommended but generally with minimal gain. As the deformity becomes more rigid surgery will most likely be required if correction of the deformity is the goal.

Underlapping Toes

Description

Underlapping toes are commonly seen in the adult and pediatric population. The toes most often involved are the fourth and fifth toes. A special form of underlaping toes is calledclinodactyly or congenital curly toes. Clinodactyly is fairly common and follows a familial pattern. One or more toes may be involved with toes three, four, and five of both feet being most commonly affected.

The exact cause of the deformity is unclear. A possible etiology is an imbalance in muscle strength of the small muscles of the foot. This is aggravated by a subtle abnormality in the orientation on the joints in the foot just below the ankle joint called the subtalar joint. This results in an abnormal pull of the ligaments in the toes causing them to curl. With weight bearing the deformity is increased and a folding or curling of the toes results in the formation of callus on the outside margin of the end of the toe. Tight fitting shoes can aggravate the condition.

Treatment

The age of the patient, degree of the deformity and symptoms determine treatment. If symptoms are minimal, a wait and see approach is often the best bet. When treatment is indicated the degree of deformity determines the level of correction. When the deformity is flexible in nature a simple release of the tendon in the bottom of the toe will allow for straightening of the toe. If the deformity is rigid in nature then removal of a small portion of the bone in the toe may be necessary. Both of these procedures are common in the adult patient for the correction of hammertoe deformity. If skin contracture is present a derotational skin plasy may be required.

Overlapping Toes - Overlapping Fifth Toe

Description

This deformity is characterized by one toe lying on top of an adjacent toe. The most common toe involved is the fifth toe. When one of the central toes is involved the second toe is most commonly affected. The etiology of the condition is not well understood. It is though that it may be caused by the position of the fetus in the womb during development. The condition my run in families so there may be a hereditary component to the deformity.

Treatment

Effective conservative treatment depends upon how early the diagnosis is made. In infancy, passive stretching and adhesive tapping is most commonly used. This may require 6 to 12 weeks to accomplish and reoccurrence is not uncommon. Rarely will the deformity correct itself. As the individual matures the deformity becomes fixed. When surgical correction is warranted a skin plasty is required to release the contracture of the skin associated with the deformity. Additionally a tendon release and a release of the soft tissues about the joint at the base of the fifth toe may be required. In severe cases the toe may require the placement of a pin to hold the toe in a straightened position. The pin, which exits the tip of the toe, may be left in place for up to three weeks. During this period of time the patient must curtail their activities significantly and wear either a post-operative type shoe or a removable cast. Excessive movement at the surgical site can result in a less than desirable result. The pin can be easily removed in the doctor's office with minimal discomfort. Following removal of the pin splinting of the toe may be required for an additional two to three weeks.

Hammertoes and Mallet Toes

Description

Another common digital deformity is contracture of the toes in the formation of hammertoes and mallet toes. Hammertoes are described in depth in another article. Mallet toes are a result of contracture of the last joint in the toe. In the pediatric population it is often flexible and not painful. Over time the deformity becomes rigid and a callus may form on the skin overlying the joint at the end of the toe. Additionally the toenail may become thickened and deformed form the repetitive jamming of the toe while walking. The deformity usually involves one or two toes, with the second toe most commonly affected. Mallet toes have several etiologies. Longer toes that are forced against a short toe box in the shoe will, over time, develop a contracture of the last joint in the toe causing a mallet toe.

Treatment

Conservative treatment consists of padding and strapping the toes into a corrected position. This treatment may alleviate the symptoms but will not correct the deformity. Diabetic patients often develop ulcerations on the ends of their toes secondary to mallet toe deformity and the pressure that results from the toe jamming into the shoe. When standing, the toe will demonstrate a contracture, with the tip of the toe facing downward into the floor. If the deformity is flexible a simple release of the tendon in the bottom of the toe will allow straightening of the toe. Following the procedure the patient must avoid shoes that cause jamming of the toe or the deformity can reoccur. When the deformity is rigid surgical correction requires the removal of a small section of bone in the last joint of the toe. On occasion fusion of the last two bones in the toe may be necessary. This requires removing the cartilage from the last joint in the toe and pinning the bones together. When the bone heals it forms a single bone and the toe remains in a straightened position. Healing time is dependent upon the procedure selected. If a tendon release is performed the patient my return to a roomy shoe within a week. If the toe is straightened by removing a section of the bone in the toe it make ten days to three weeks for a patient to return to normal shoes. If a fusion is performed to straighten the toe, the patient may not return to normal shoes for 6 to 8 weeks. Time off from work will depend upon the type of shoe gear that must be worn and the level of activity necessary to perform the job. A minimum of three to four days off from work is generally recommended and longer if the job responsibilities can not be modified to accommodate the normal healing time for the surgery.

Corns and calluses are areas of thick skin that result form excessive pressure or friction over a boney prominence. When these areas develop on the bottom of the foot they are called calluses. When they occur on the top of the toes they are called corns. They can also occur between the toes, the back of the heels and the top of the foot. The thickening of the skin is a normal body response to pressure or friction. Often times they are associated with a projection of bone called a bone spur. Not all areas of thickened skin are corns or calluses. Planter warts, inclusion cysts and porokeratoses also cause a discreet thickening of the skin that resembles corns and calluses.

Calluses

The most common area for the formation of calluses on the bottom of the foot is in the area of the ball of the foot. This is a weight bearing area where the long bones behind the toes called metatarsals, bear the greatest amount of weight and pressure. If one or more of these long bones (metatarsals) is out of alignment then excessive pressure is generated in the area producing a callous. The callused area can be very discreet and have a "core" or they can be more dispersed covering a larger area. These areas can become quite painful as the skin thickens. People who have diabetes are at risk of these areas breaking down producing sores or ulcerations that can become infected. People with diabetes should not try home remedies and should see a doctor for the treatment.

Treatment of Calluses

There are numerous over the counter treatments for corns and calluses. Some of these remedies have an acid in them that burn the callous off. Care should be taken when using these medications. If used incorrectly they can cause a chemical burn to the skin. Additionally these remedies are only temporary because the source of the pressure has not been alleviated. Professional treatment consists of using a special shoe insert called a functional orthotic that corrects foot function. In certain instances surgery may be recommended. Surgery is directed at correcting the alignment of the offending bone. Cutting out the callous will only make the condition worse if the underling boney problem is not corrected. Metatarsal surgery is discussed in another section.

Corns

Corns are areas of thick skin that most commonly occur on the top of the toes. Generally there is an associated hammertoe deformity, which causes the toes to rub on the top of the shoes. Professional treatment is directed at correcting the hammertoe deformity. Small corns can also occur on the side of the little toe next to the toenail. A small bone spur causes this problem. Professional treatment consists of removing the bone spur. Bone spurs also cause corns between the toes.

Soft corns are areas of white moist skin between the toes. They most commonly occur between the fourth and fifth toes. They can be very painful and if not treated can form small ulcerations or sinus tracts that can become infected. Acute athlete's foot can mimic the soft corn. The soft corn is due to an irregularity in the shape of the bone in the fourth or fifth toes.

Treatment of Corns

Home treatment should be directed at reducing the pressure between the toes with cotton or a foam cushion and using an antibiotic ointment to reduce the risk of infection. Over the counter corn removers should never be used in this area because of the risk of increased damage to the skin resulting in infection. Professional treatment consists of removing the irregular shaped bone that causes the development of the corn. Some patients prefer that the doctor simply trim down and pad the calloused areas. This is a common form of treatment in patients with diabetes. See correcting soft corns, removing bone spurs, and hammertoe surgery.

Your doctor may order a computed tomography examination to aid in the diagnosis and treatment of your foot and ankle problem. Computed Tomography (CT) imaging, also known as "CAT scanning" (Computed Axial Tomography), combines the use of a digital computer together with a rotating x-ray device to create detailed cross sectional images or ""slices"" of the different parts, particularly bony structures, of the foot and ankle. This test helps to delineate the structures of your foot and ankle and can give your doctor 3-D visualization of these structures to aid in your treatment. For many patients, CT can be performed on an outpatient basis without requiring admittance to a hospital. CT imaging is commonly ordered for the following foot pathologies:

• Bone Tumors
• Fractures - acute and stress fractures
• Non-unions or delayed unions
• Infection
• Foreign Bodies
• Degenerative and rheumatoid arthritis
• Angular deformities
• Flat feet
• Cavus feet
• Post-operative monitoring
• Avascular necrosis

During the procedure, you will lie very still on a table. This table passes your foot and ankle through the x-ray machine, which is shaped like a doughnut with a large hole. The machine, which is linked to a computer, rotates around the patient, taking pictures of one thin slice of tissue after another. The length of the procedure depends on the size of the area to be x-rayed. The computer then processes images from these x-rays. The final image, called a "computed tomogram" or "CT slice," is displayed on a cathode-ray tube (CRT), a device similar to a television picture tube and screen. This image can be recorded permanently on film or can be stored on magnetic tape or optical disk.

Computed tomography offers some advantages over other x-ray techniques in diagnosing disease, particularly because it clearly shows the shape and exact location of soft tissues and bones in any "slice" of the foot and ankle. CT scans help doctors distinguish between a simple cyst and a solid tumor and any involvement of the bone. CT scanning is more accurate than conventional x-ray in determining the stage (extent) of some bone tumors. Information about the stage of the disease helps the doctor decide how to treat it.

Spiral CT scanners are one of the latest innovations. They use continuous scanning to generate cross-sectional slices and make a set of 3-dimensional images. Spiral CT has decreased the time it takes to produce tomographic pictures.

In preparing for the examination, you can eat and take your normal medications. The examination will take from 45 minutes to an hour based on the area being scanned. Patients are encouraged to bring something to read or do in case there are any delays prior to their CT exam. Patients should wear comfortable, loose fitting clothing for their CT exam. Some people may be concerned about the amount of radiation they receive during a CT scan. It is true that the radiation exposure from a CT scan is slightly higher than from a regular x-ray. Because of the radiation exposure, pregnant women should not have a CT exam or any x-ray examination, especially if the woman is in her first trimester (first of three-3 month periods of pregnancy). Depending on the condition, there may be other exams available, such as ultrasound, to help diagnose a medical condition. Pregnant women should always inform their imaging technologist or radiologist that they are pregnant, or may be pregnant.

Your physician will discuss the results with you. If you have any further questions regarding why this test was ordered for you, please ask your physician.

Each of the muscles in the lower leg are contained in what is called a muscle compartment. Just like an orange or grapefruit, where the fruit is divided by fibrous sheaths into identifiable sections, the muscles of the lower leg are also divided by fibrous sheaths into identifiable muscle compartments. There are four muscle compartments in the lower leg: two in the back of the lower leg (i.e. posterior compartments), one on the front of the lower leg (i.e. anterior compartment) and one on the outside of the lower leg (i.e. lateral compartment). Each of the four muscle compartments contain at least two individual muscles, which are surrounded by the fibrous sheath which wraps around the muscles of the compartment.

Because of the arrangement of the muscles of the lower leg into four compartments, an individual can develop two types of compartment syndrome: acute and chronic. Acute compartment syndrome is caused by direct trauma to the lower leg, such as that occurs during a motor vehicle accident where possibly one of the leg bones is broken. Blood rushing into the muscle compartment has no way to escape, causing a relatively sudden rise in the pressure in the muscle compartment. The increased pressure inside the muscle compartment can become so high that it clamps down on the arteries and nerves going through the leg into the foot. The result may be a loss of pulse and blood supply to the foot, loss of nerve function to the foot, and severe pain. Acute compartment syndrome requires immediate surgical attention or the individual may develop permanent deformity and disability in the leg and foot.

The more common form of compartment syndrome is seen in athletes who exercise heavily and is called chronic exertional compartment syndrome (CECS). CECS is caused by the increase in pressure in the muscle compartment, which results from the muscles actually expanding in volume because of the increased blood flow to the muscles during exercise. If the sheath or compartment wall is particularly tight and thick, then as the athlete's muscles become larger over time from exercise the muscle compartment will become tighter. The compartment at the front of the leg is the most common muscle compartment to be affected by CECS and the pain that results is thought by many athletes to be shin splints. For runners, pain from CECS will generally occur within 20-40 minutes into a run and the pain may become so severe that continuing exercise past that point is impossible.

Diagnosis

A thorough history and physical examination must be made of the individual with suspected chronic exertional compartment syndrome. The podiatrist will be most interested as to the time during exercise that the pain starts in the leg, where the pain is located, and whether the pain dissipates somewhat with rest. The symptoms from CECS generally starts at the same time or at the same mile mark during running and also usually gets better soon after as the individual stops exercising.

During the physical examination, the podiatrist will inspect the leg to determine which muscle compartment is affected and try to rule out any other pathology in the same area such as stress fractures, muscle strain, tendinitis, or shin splints. Additional tests such as x-rays, bone scans or MRI scans may be ordered depending on the most likely cause of the pain. Even though the podiatric physician can diagnose CECS relatively confidently by taking the proper history and physical of the patient, the only certain way to diagnosis the condition it is to have the muscle compartmental pressure measured at rest, during exercise and after exercise. Most doctor's offices do not have the special instrumentation to make this diagnosis and often the patient must be sent to a large hospital or sports clinic to have the test performed.

Treatment

Chronic exertional compartment syndrome may be treated conservatively by modifying the type, duration and frequency of the sports activity that causes the pain. The condition is often successfully treated by altering the surfaces the individual runs on and the shoes they run in. In addition, CECS sometimes responds to altering the function of the muscles of the lower leg with in-shoe custom supports such as functional foot orthotics. If all conservative measures do not resolve the pain from CECS adequately, the podiatrist may refer the patient to an orthopedic surgeon for possible surgical release of the sheath surrounding the muscle compartment. In general, most patients who have surgical release of the muscle compartment sheath are able to resume unrestricted exercise within a few months of the procedure. Many notable athletes have had the compartment release surgical procedure performed and have returned to training without pain or limitations.