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Foot and Ankle Articles

Foot Odor

As someone who examines feet for a living all day long I can tell you that foot odor is definitely a problem for many people. While most people can maintain dry odorless feet others can not. Fortunately many of the factors that lead to bad foot odor can be controlled by simple measures while others may need a physician's care. The problem can be quite severe and embarrassing for some people who may even have to avoid social situations where their feet have to be exposed. Most foot odor is caused by bacteria in the feet. The warm moist environment that feet exist in is a perfect environment for bacteria to grow and thrive.

The more you exercise and sweat the warmer and more moist that environment becomes. Unfortunately we do not live in a country where walking or even competing in barefoot is practical. If a warm moist environment is the major cause of the problem then it only makes sense to try as much as possible to eliminate that situation. After exercise was your feet thoroughly preferably with a anti-bacterial soap. the next step is to dry your feet as much as possible. Dry initially with a towel and make sure you get between the toes. Then use a hair dryer to ensure there is absolutely no moisture left on your feet. If you are prone to sweat use a spray anti-presperant on your feet as you would spray under your arms to prevent prespiration. If possible keep your feet open and exposed to air by walking barefoot or with a sandal. Use a sock made of a material such as polypropylene that wick moisture away from the skin. Take a change of socks with you so you can try to keep your feet as dry as possible all day long. Wear shoes that breathe well and allow them to dry thoroughly between use. You may have to wash shoes in a soapy detergent and bleach if they become too malodorous. Some people swear by daily tea soaks. Tea contains tannic acid which can counteract the bacteria. Soak your feet daily into cooled tea for 20-30 minutes. If you still have a foul odor in your feet then you should probably seek the advice of a physician. One effective agent is aluminum chloride hexahydrate 20% solution.

Be careful of not creating an environment that is too dry. Sometimes a topical antibiotic must be used to eradicate the infection. These are applied topically to the feet. Alternatively some of the lotions used in acne to dry the skin out can be useful in this problem. Benzyl Peroxide can be purchased over the counter in a pharmacy or by a prescription by your doctor. If the above do not cure your foot odor problem it is beast to seek the advice of a physician. If there is a bacterial infection causing the problem than an antibiotic may have to be used. A dermatologist may have to be consulted in the difficult hard to treat cases. While bad foot odor may not ruin an athletic performance, it sure can hamper the locker room atmosphere for the athlete and their team mates. With these simple solutions the majority of these problems can be solved and pleasant smelling the result.


The Uncommon Ankle Sprain

How many people have not injured their ankle at some point in their life? Even though it may not have been severe almost every one has injured their ankle at some time. This would make the ankle the most injured joint. The ankle is so commonly injured due to the structures on the outside of the ankle that are easily damaged. These structures can simply not withstand the weight of the whole body as your foot turns underneath you. Almost always the injury involves some degree of tearing of the ligaments of the ankle. This can range to a minor strain to total disruption of the ligaments. Fortunately the most severe injuries are few and far between and the person if treated properly is back doing their regular activity from days to several weeks. Unfortunately some people go on to develop longer term problems. This includes pain, locking, and instability.

The majority are due to improper or no rehabilitation and those are easily solved with the correct treatment. Last month, Dr. Darrell Ogilvie-Harris, the Toronto Maple Leaf Orthopoedic Surgeon, published a paper on those ankles that are still a problem long after they have been injured. We know that the typical ankle sprain will get better within a certain period of time and if they do not then there must be something else injured that is causing the problem. If the ankle is still causing problems after six months then it must be investigated. The most common tests done on the ankle are x-ray, stress x-rays, CT scanning, bone scanning and MR scanning. A good clinical examination combined with the appropriate test give us the answer to what is causing the problem. Dr. Ogilvie-Harris states that the majority of problems fall into three categories.

1/INSTABILITY There are two types of instability. The most common is lateral instability where the person suffers repeated classic ankle inversion sprains. This is usually treated with therapy and a brace. If the instability is severe then an open operation to rebuild the ligaments is required. The other type of instability is called syndesmotic. This injury is caused by a rotation of the body with the foot planted. This is a common injury in hockey where the skate blade is stuck in the ice and the body rotates around. Here the ligament which joins the two long bones above the ankle is disrupted. Acutely, if they are severe they must be operated on. For the less severe ones that only cause long term pain, swelling and stiffness are helped by a simple operation with an arthroscope.

2/IMPINGEMENT The most common type of impingement is anterior impingement. These people usually had some spurring on the front of the ankle bones from previous activities. Athletes that are prone to this are ones that are constantly bending forward over their ankle like football lineman, gymnasts, and dancers. These are helped by an operation through the scope to shave the bone down. Less commonly you can get impingement on the outside of the ankle where the ligaments have been injured. The scope is used to take out the scar tissue causing the pain.

3/ JOINT LESIONS These patients had the most problems. Their usual complaints were locking clicking of the ankle. The most common problem here were fractures of the joint surface. These had to be removed and the joint surfaced shaved down until it was smooth. Sometimes a piece had actually broken off making a loose body in the joint. Although most ankle sprains will get better quickly on their own, there are some that simply will not. If that is the case then it is important to seek medical help to determine why and to fix the problem to allow you to return to your activities without problems.


Achilles Tendinitis

""THE ACHILLES HEEL"" The most famous tendon in the body has the bad rap as the bodies weakest. Everyones worst trait is said to be their ""achilles heel. The fact of the matter is that although it is the most prominent and visible tendon in the body, it is not the weakest. Nonetheless it is commonly injured and can cause a lot of problems. My colleagues at the University of British Colombia did a research paper on running injuries an found that 11% of running injuries were to the Achilles tendon. The question is what causes this very common injury to this large and strong tendon. The important thing is to understand the gait of the foot when you are running. As you land you typically land on the outside of the foot. This is what we call a suppinated position. If you look at your shoes you will usually see that the most worn part of the shoe is on the back outer edge where you land. As you land your foot comes down.

Your foot collapse and rolls to the inside in a controlled manner. This is called pronation and it functions to allow the foot to absorb the shock of landing. The foot then re-suppinates to push off and propel the foot forward. As the foot moves back and forth with every step, the Achilles tendon goes through a whipping motion as it follows the foot from suppination to pronation and then back to suppination again. If you stand and roll your foot from outside to inside and back again you will feel your Achilles going through this whipping motion. Eventually if the tendon might break down as it goes repeatedly through this motion. The Achilles then has microscopic tears which lead to inflammation. The most common part of the tendon is an area about an inch or two above the heal where there is the most motion.

It is usually swollen and very tender to touch. Often there is fluid between the tendon and the sheath around it and you can sometimes hear the fluid going back and forth as you move your foot up and down. The tendon is usually very sore as you start to exercise and as it gets worked in it feels better only to come back later while you are exercising or after you finish. Invariably it is very stiff and sore first thing in the morning as you hobble to the washroom. This problem is best treated sooner than later. Almost more than any other problem people seem to delay coming in for treatment for their Achilles as they thought it would go away on its own. Once you develop scar tissue in the tendon it becomes that much harder to treat. The key is to reduce the inflammation and correct all the predisposing factors.

TREATMENT

1/MODIFY The tendon has to heal and depending on the severity of the problem the offending activity has to be reduced. This may involve both a decrease in the amount of activity and how often it is down. The terrain is also important as hill running is harder on the Achilles. Cross training is important to keep fit and active. Cycling and swimming are very easy on the Achilles.

2/ICE Ice the tendon for 10-15 minutes several times a day and after any activity. 3/MEDICATION Your physician may prescribe an anti-inflammatory pill or cream or help reduce the inflammation.

3/PHYSIOTHERAPY This is perhaps the most important part of the treatment. The therapist will initially reduce the inflammation with various modalities such as ultra sound and laser. The next step is to strengthen the tendon with a special strength program to prevent further injury to the tendon. Flexibility of the tendon is also important.

4/SHOES Worn out shoes or shoes which can not control the pronation properly for this individual will have to be replaced.

5/BIOMECHANICS If the person excessively pronates the tendon will go through a bigger whipping motion and therefore more prone to breaking down. This can often be corrected with the proper shoe. If it can not, a custom foot orthotic can be made to help control the excessive motion of the foot. Often a simple heel lift in the shoe is enough to take some of the stress off the tendon.

6/SURGERY In the rare cases where the pain and inflammation is persistent we will have to operate to remove the inflammatory and scar tissue from the tendon. The recovery is about three months before you are back to exercising. The famous Achilles tendon can be the Achilles tendon of the body as well. If it becomes painful seek help from your physician sooner than later. Listen to your body and do not ignore the pain. This is one injury that is often ignored for a long time as it can be non painful once you are warmed up. Once on the recovery it is important to go back to your exercise or sport slowly to prevent it from coming back.


Plantar Fasciitis

Plantar fasciitis is the major problem leading to the painful heal. It occurs commonly to any athlete who involves landing on their feet to participate in their sport. Boris Becker is perhaps the most famous athlete where this infliction has been a career limiting injury. The pain usually starts as a dull intermittent ache in the heel which may progress to a sharp persistent pain.. Classically it is the worst in the morning where the affected individual will hobble out of bed in the morning until the pain subsides. In a similar fashion the pain will return after sitting sedentary for a prolonged period of time. The pain is usually there at the beginning of the sporting activity and goes away as the body warms up. The pain may reoccur as the activity goes on or after it is finished. The Planter Fascia is a thick fibrous band on the bottom of the foot. It is attached to the heel bone(calcaneous) and fans forward to attach at the base of the toes. It is mainly responsible for maintaining the long arch of the foot.

The problem usually occurs when part of this fascia is pulled away from the heel bone. With every foot strike there is a pull on the insertion of the plantar fascia which eventually breaks down and there are microscopic tears. This leads to inflammation and thus pain. Plantar fascia problems may also occur at the midsole or towards the toes but this is much less common. Rarely there is a sudden intense pain during sport where the plantar fascia is torn in a more dramatic fashion. When you are sleeping or are non weight bearing the plantar fascia starts to heal. Then when you step down on the heal you break down the healing which is why the pain is worst after a long period of being off your feet at night.

The following are the main predisposing factors;

1. FEET Both flat pronated feet and less commonly high arched rigid feet are more prone to fasciitis.

2. OVERUSE As with any inflammation overuse is the primary cause.

3. SHOES Inappropriate or worn out shoes.

4. ACTIVITY Toe running or hill running.

5. TERRAIN Soft terrain such as grass or especially sand

6. AGE The fascia becomes more prone to problems as you get older where the majority of people with this problem are over age 35.

The following is the treatment plan for an individual with plantar fasciitis.

1/MODIFY There is no doubt that plantar fascia is directly related to weight bearing activities. If your foot is too painful these sports can be replaced by swimming, cycling, skating to maintain cardiovascular fitness. Weight training can be used to maintain leg strength.

2/ ICE Often the foot is visibly swollen. Regular daily icing and after activity will help to control the inflammation and swelling.

3/ MEDICATION/ Your doctor may prescribe anti-inflammatory pills to help reduce the inflammation. Once the pain is more localized a cortisone injection may be used as an adjunct with the rest of the treatment plan to help cure the problem. This injection although painful can be very effective when used at the right time.

4/ PHYSIOTHERAPY The initial objective is to decrease the inflammation. Later the therapist will strengthen the small muscles of the feet to support the weakened fascia. Other imbalances will also be corrected by therapist to help prevent the problem from re-occurring.

5/ ORTHOTIC A foot orthotic is very effective if you have a flat pronated foot. The orthotic will support the arch and take the pressure off the fascia.

6/SHOES Often a change of shoe is all you need to cure the problem.

7/ HEEL PAD A heel pad can help to absorb the shock as the heel lands and ease the pressure on the plantar fascia.

8/ TAPE Your therapist can tape your foot to again ease the stress on the fascia.

9/SURGERY With the above protocol we have had to operate on very few people with this problem. I can only think of a few people out of the hundreds I have treated for this problem who have needed surgery. Not only is Plantar Fasciitis one of the most common problems I see in the office it is often the most resistant. I see many people who have the problem for an extended period of time with various treatments. The best scenario is to coordinate all aspects of the treatment so that not only is the problem healed expediently but it will not recur. The ones that I see that have been there for an extended period of time are always the toughest to treat. On the contrary the ones we can treat early with a complete program as outlined above do very well and are quickly back to full pain free activity.


Common Foot Problems
What part of the body takes the most abuse in most sports? Considering that most sports are weight bearing, the answer has to be the foot. It is the part of the body that hits the ground first and the body moves in the direction that the feet take it. Therefore it is the foot that takes the most abuse. Many consider the foot the ugliest part of the body and sports do the foot no favors in the abuse that the feet take while participating. The most common problem and one of the simplest are blisters. Although blisters can occur anywhere that there is friction between the skin and another surface, they are most common in the feet. A blister is a result of friction on the skin surface. Fluid develops underneath the superficial skin causing a swelling and the typical blister. On the foot they are most commonly found in and around the toes and the heel.

Although blisters are usually not serious except for the pain the cause, they can get infected and cause more serious problems if not taken care of properly. The best way to treat blisters is to prevent them. They often come when participating in a sport that you have not played in a while. The increased pressure on certain parts of the foot lead to the blister before the skin has had a chance to toughen up. The best thing is to ease into sports that you have not played in a while. Proper shoes for the sport that you are playing is important. The next thing is to make sure that the shoe fits properly. Shoes that are either to big or too small will cause blisters. The socks you wear are the only protection you have between your shoe and your skin. Make sure you wear proper athletic socks.

They even have double layer blister protection socks that the manufacturer will guarantee that you will not get blisters. If there are particular areas on your foot that are prone to getting blisters or you are doing a sport such as a marathon where the demands on your feet will be excessive then use a lubricant like petroleum jelly in the areas like your toes that are most prone to blisters What do you do when you have a blister? The best thing to relieve the pain is to release the fluid. Sterilize the skin with alcohol or peroxide. Then carefully make a small hole in the blister with a sterile needle. Slowly push as much as the fluid out of the blister without damaging the skin. Never remove the skin off the blister. The skin helps in the healing of the blister. I then apply a special blister dressing over the blister. Several companies make special blister dressings like Spenco Second Skin which are excellent dressings to protect the skin and allow you to continue doing your sports without pain.

In the first day or two the fluid will re-accumulate in the blister so you may have to repeat this procedure several times. Plantar warts are a viral infection in the foot. As opposed to other parts of the body where the wart will grow out forming a bump, a plantar wart gets pushed inward from the constant pressure. What starts as a small dark spot soon expands into a dime shaped area on the bottom of the foot. They are usually painful especially if on a weight bearing surface. You may have several of them at once. Like any wart they are hard to treat. If they are small they can be treated with acetylsalicylic acid dressings to soften the wart. The wart can then be pared off with a pumice stone or cut out by a physician. If it is persistent then the best treatment is to have it excised by laser.

To prevent warts it is best to wear foot wear in public bath and shower areas. The last common foot problem I will talk about today is athlete's foot. This is a fungal infection most commonly found between the toes especially the last two. The skin is red, macerated and peeling. It can be itchy or painful. In many athletes the f ungus will affect the toe nails as well causing thickened discoloured nails. To prevent athletes foot, wear shoes in wet areas and dry your feet well especially between your toes after showering or bathing. Good hygiene and over the counter creams may treat minor cases. In more severe cases or if your nails are involved see your doctor. Your doctor may prescribe a prescription cream or pills to treat your problem. Healthy feet are the key to keeping an athlete happy. By following a few basic principles, you can avoid these common problems of the most abused part of the body-the foot.


Foot Orthotics

The fitness boom in the last number of decades has led people to lead much more active lives. With this increase in activity there has been some injuries which has led to the field of Sport Medicine. We are always looking at what may be causing the injuries. This allows us to be able to treat the injury as well as in many cases prevent injuries. One of the main causes of injuries is abnormal or altered biomechanics. The most used device in Sport Medicine to treat these biomechanical problems is foot orthotics. The most common application for foot orthotics is in the pure runner or an athlete whose sport depends on running. Nonetheless they have also been proven to be effective in other sports such as aerobics and skiing. To understand why we might prescribe an orthotic it is important to know the basics of foot mechanics. The foot's function as it goes through the gait cycle is very complex.

The 16 foot bones have to coordinate the forward propulsion of the body efficiently while at the same time absorbing the body's weight to put as little stress as possible on the body. We usually land on the outside border of the heel with the foot turned in( supinated). The foot then in a controlled manner collapses in(pronates) to absorb the shock of the landing and support the body. The foot the re-supinates to propel the body forward by acting like a rigid lever. Therefore, not only pronation and supination normal they are a vital part of the body's function. It is only when you excessively pronate or supinate that you may run into problems. How do we assess if you are excessively pronating or supinating. This is accomplished by looking at a person stand, walk, and run. The foot is then examined to determine its mobility. We can get an excellent idea of what is happening when you run by examining the wear pattern of your shoes.

The ultimate best way is by a computerized biomechanical analysis on a treadmill. Excessive pronation is the most common abnormality. Just because you may have flat feet this in no way indicates whether you will have problems with over pronating. In fact the person who has a rigid high arch foot is more prone to injury then the worst over pronator. I will prescribe a foot orthotic when I feel a person has an injury that I feel is somehow related to a biomechanical abnormality. The shoes today are so good that we can control a lot of problems with the proper shoe. It is also important to look at the other causative factors and to treat the most important ones first. Orthotics were once only fitted by podiatrists who developed this technology over 20 years ago. Now they are fitted by chiropractors, therapists, doctors, retail stores and even by hawkers at malls and trade shows. There is no doubt that they are well over prescribed and in some cases, do more harm than good.

There are three main types of orthotics. Accommodative orthotics are usually pre made and are purchased in drug or sporting good stores. They are usually soft and are basically an arch support. They are often used as a first step and may be all you need. Partially controlling orthotics are soft or semi rigid. These are the best for the athletic population providing cushioning and considerable support. Rigid or controlling orthotics will fit into a smaller shoe but are usually to stiff to be comfortable for the athlete. While orthotics are often only needed temporarily for several months to a year while the injury is healing, someone with significant abnormalities will wear them long term. The judicious use of orthotics in Sport Medicine has been a great help to a lot of sport enthusiasts. The prescription of an orthotic must be made by a proper and thorough analysis of the injury and the person's biomechanics. Then and only then have an orthotic made by a person experienced in dealing with athletes.


Athletes Foot

One of the most common problems facing athletes is the so called ""Athletes Foot"" Now, while there have been very few people that have been unable to be active because of this problem it sure can be a nuisance. It has been stated that up to 40-80% of active people will suffer from athletes feet. The most common complaint when you have athletes foot is itching burning and irritation of one or both feet. The classic location where it usually starts is between the fourth and fifth toe. In the more severe cases it can affect the total sole of both feet and the nails. The area of the skin will be red, scaly and macerated. In the more severe cases there will be a bad odour and the skin may crack. The usual cause of athletes foot is a fungus called Trichophyton mentagrophyte or Trichophyton rubrum. Funguses exist in warm moist places like bathrooms and locker rooms. This is where most people will contact the virus.

Risk factors that will make you more prone to developing athletes foot are:

1/ Wearing shoes that do not ventilate well. Athletes foot almost does not exist in countries where people do not wear shoes.

2/ Wearing shoes without socks.

3/ Not washing your socks regularly.

4/ Living in a hot climate.

5/ Soaking in hot tubs or public baths. Once you contact the virus it may take several months for you to have symptoms. Over the counter medications can be used in milder cases. If the problem persists then you should see your doctor. Your doctor will examine your feet and make sure you do indeed have a case of athletes feet. There are other problems which can mimic athletes feet and requires other treatment. The cream must be used for several weeks after the infection appears to have gone away to make sure you totally eradicate the problem. You may have to take medication orally for more severe infection or if the nails are involved. Make sure that you keep your feet dry especially between the toes.

As always prevention is the most important thing. The basis of avoiding this fungus is to avoid contact with the fungus and to keep your feet dry. Here are a few tips.

1/ Wear rubber shoes(thongs)in a public shower, locker room, or bath.

2/ Dry your feet well after they get wet. Consider using a talcum powder or anti-fungal powder after showering if you have a problem keeping your feet dry.

3/ Wear polypropylene socks that wick away moisture from your foot.

4/ Go barefoot or wear sandals as much as possible.

5/ Choose athletic shoes that are designed to ventilate. If you have a problem treat it early before it festers. Remember, you do not have to have ""Athletes Foot"" to be an ""Athlete"".


Strug's Ankle
While most Canadians may remember the Olympic moment of Donovan Bailey's face just after winning the 100 meter race, the thought that most people the world wide especially the Americans will be little Keri Strug vaulting the Americans to Gold with a severely sprained ankle. How painful was that ankle and what did Keri Strug go through to complete that final vault that she trained for so long for? The ankle sprain is the most common of all sports injuries. It is a rare person who has not suffered even a mild sprain. Some studies have shown that ankle injuries are to blame for 25% of lost time in jumping and running sports. In some sports such as volleyball or basketball the ankle sprain accounts for up to 80% of the injuries. Most commonly the athlete sprains their ankle by their foot twisting underneath them. The foot inverts or twists in. Their is usually acute pain and swelling. The swelling may be quite sudden and severe. The athlete may hear a pop or snapping in the ankle. The damage to the ankle is torn ligaments which are there to provide stability to the ankle. (see diagram) The first step is to control the pain and swelling.

This is accomplished by

1/ Ice the ankle 15-20 minutes every 11/2-2 hours

2/ Compression of the ankle is the most important thing to do control the swelling.

3/ Elevate the ankle as much as possible.

4/ Your doctor may prescribe medication to control the pain and swelling. We rarely if at all possible totally immobilize the ankle such as in a cast. I usually recommend a brace which will protect the injured ligaments but still allow safe controlled motion in the ankle. The most important part of the treatment is sports therapy. Initially the therapist will reduce the pain and swelling in the ankle while helping the athlete to get back their full range of motion in their ankle. The next step is to work on getting back the strength in the ankle with specific exercises. The goal here is to get the athlete back to their sport and prevent further injury to their ankle. Patients with ankle sprains tend to lose what we call propioception or balance. Basically the nerves to the ankle get confused after an injury.

Therefore the muscles around the ankle can not react in time to the ankle going over again; leading to further injury. Specific balance exercises are crucial to get back the ankle to full function. I obviously do not know the extent of her injury but it certainly was a combination of the quick release of endorphins and more importantly the mental strength of an athlete with an intense desire to compete and win. They reported that she injured two ligaments that would constitute a second degree injury. Most people can not compete for 3-6 weeks after an ankle injury of this severity. It is of no surprise that Keri Strug did not come back to compete in the individual events, but what an effort to compete that vault without any sign that the ankle was injured until she had stuck her landing.