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Foot Care

Our guest expert in January 2010 was chiropodist Justin Turner from Women’s College Hospital in Toronto.

Justin Turner is a registered chiropodist working at the Foot Care Centre at Women's College Hospital. He graduated from the Michener Institute for Applied Health Sciences and completed his clinical training at University Health Network in 2000. Since 2001 he has been on staff at the Foot Care Centre practicing in the area of biomechanics and orthotic management of foot problems. He is also a member of the Ontario Society of Chiropodists.

Here are his answers on Foot Care.

There was an overwhelming response by readers regarding their feet and their specific issues. In order to manage this and reach the broadest possible audience, I grouped the questions into themes. This is meant as general information and not to be taken as specific medical advice. Please consult with your family physician or foot health professional for advice regarding your specific issues.

Theme I – Fungal Infection of the Foot and Nail

Fungal infections of the foot and nail are very common in the general population – called tinea pedis in the foot (athlete’s foot) and onychomycosis in the nail. Footwear provides an ideal setting for fungi as it is a warm and dark environment, moist from sweat. Once infected, the skin can get itchy and burn; the space between the toes can get macerated (wet) and open. In the toenail, fungus can present as a yellowish colour with thickening and crumbling of the toenail.

Treatment of either condition usually requires the use of an anti-fungal cream or pill combined with good foot hygiene (see below). Topical anti-fungals are used successfully in the case of athlete’s foot involving the skin. In the case of the nails, the topical agents are usually unable to penetrate the nail plate and therefore do not reach the organism. This condition is best treated with the use of an oral anti-fungal medication that is available by prescription only. These pills have significant health risks and side-effects, so your situation should be fully assessed by your physician (including laboratory confirmation of the diagnosis) before and during this treatment. If you are unable to use these medications, then treatment with a topical is the best option, used in conjunction with proper nail debridement (removal of the excess nail) to allow the topical agent to reach the organism. If one topical agent is not working, speak to your physician about a different topical. Remember that it takes the toenail approximately one year to grow out, so it will take a while for the nail to grow out and look normal.

Good foot hygiene involves washing and drying your feet properly every day, wearing clean socks and changing them during the day if you perspire a lot, alternating your footwear to allow them to dry out properly, and wearing shower shoes in shared or public facilities.

Theme II – Plantar Fasciitis/Heel Pain

Plantar fasciitis is the most common foot condition we see at the Foot Care Centre. It is best described as an inflammation of the heel at the origin of the plantar fascia. Most people with plantar fasciitis experience pain when they first step out of bed or first bear weight after periods of sitting, with some relief after a few steps.

In the case of low-arched feet, as the arches collapse the plantar fascia is pulled from the heel bone, resulting in local inflammation and pain. Quite often a person has normal-arched feet when they are sitting, but the arch drops once they are standing, increasing the load and strain on the plantar fascia. In the case of high-arched feet, there tends to be a reduced amount of shock absorption in the heel, with each step causing inflammation.

There are several different ways to approach treatment of plantar fasciitis. Treatment needs to address the inflammation and the mechanical cause of the problem. It can include rest, simple strengthening exercises and stretching, a change in footwear, physiotherapy, anti-inflammatory medication, night splints and orthotics. Orthotics are medical devices made specifically from a mould of your foot with your specific needs and health status in mind. Therefore they can vary in materials and design. If your current treatment program isn’t working, let your physician or foot-care professional know so that other options may be explored.

Theme III – Diabetic Feet and Neuropathy

Diabetes is a serious medical condition that has a direct impact on the foot. Diabetes can impair blood circulation and nerve function (neuropathy). This can lead to loss of sensation, changes in foot structure and the reduced ability to heal an injury.

Diabetic neuropathy is a significant concern and can present as painful burning or tingling in the toes and feet, or as a complete absence of sensation. A person with diabetic neuropathy may unknowingly injure their foot (for example, walking on a pebble inside a shoe), leading to further complications such as infection and ulceration (wound) requiring extensive medical care. Also, changes in foot structure/shape can lead to areas of high pressure on the foot, leading to injuries.

Neuropathy (non-diabetic) can be caused by other medical conditions, heredity, mechanical trauma, alcoholism, medication and HIV. This should be assessed by a family physician and an appropriate specialist.

Diabetics should always follow their physician’s advice and take their medications properly as this is the best way to avoid complications.  Diabetics should check their feet daily for injuries; moisturize dry skin to prevent cracking (not between the toes – it won’t dry and the skin could open up); avoid heat because hot water bottles and heating pads can cause burns in those with reduced sensation; cut toenails straight across; wear properly fitting footwear and avoid going barefoot, even indoors. Seek advice from your physician/chiropodist/podiatrist or health-care professional if you have specific concerns or need help caring for your feet.

Unfortunately OHIP does not cover chiropody (DCh, DPodM) and covers only a portion of podiatry (DPM) care. If you have a private health insurance plan you may have some third-party coverage for these services. If you do not have any third-party insurance coverage you will need to pay out-of-pocket for these services. Some community health-care centres may provide chiropody services if you fit their eligibility criteria, and some hospitals may provide chiropody services on their own or as part of another hospital program. You can contact your local hospital/community health centre to see if such a service exists in your area and if you are eligible to receive those services.

Theme IV – Raynaud’s Phenomenon

Raynaud’s phenomenon is a disorder in which the blood vessels of the fingers and/or toes go into spasm, which cuts off the supply of blood to the digit and leads to pain and skin breakdown. It tends to primarily affect young women (18-40 years old) and is associated with exposure to cold or exposure to cold and an underlying connective tissue disease. When the vasospasm occurs, the digits go numb and turn white. With the reduced blood flow the tissues turn blue, and then become red and painful as the blood flow returns to the digit. Treatment for this condition includes avoiding cold (warm footwear, socks, warm gloves), and caring for any skin breakdown. The family physician should be involved to rule out any underlying systemic illness and provide pain management as needed.

Theme V – Corns, Calluses and Blisters

Wherever there are areas of high mechanical stress (i.e. pressure, or torsion) on the feet (such as the ball of the foot) the skin will act to protect itself by becoming thicker and harder, forming a callus. A corn (heloma) is an area of this hardened skin inverted into a cone pointing into the tissue. Corns can be quite painful and can involve deeper nerve and vascular structures. Corns can often be found on the weight-bearing surfaces of the feet, and also on the tops of toes, where they are caused by pressure from pushing into the toe cap of the shoe, and can even be found under the toenails themselves (subungual heloma)!

Treatment requires removal or reduction of the cause of the mechanical stress, such as poorly fitting shoes, as well as the use of an orthotic device and treatment of the skin lesions by a chiropodist/podiatrist.

Blisters, on the other hand, are caused by friction (shear) and are common amongst runners or anyone who wears poorly fitting footwear. In feet, blisters can be caused by footwear that is either too small, which results in direct contact with the shoe, or too large, which results in the foot sliding forward and back while running or walking. Ensure that the shoe fits and is laced properly to alleviate these issues. Additionally, if your foot is sliding into the end of the shoe, this repeated trauma to the nail (as seen in runners) can cause the nails to bruise, thicken or fall off. There are many over–the-counter shoe inserts, moleskin or custom orthotics available that may help in reducing the shearing forces with running or walking, reducing the severity of this problem. As well, excess moisture from sweating can contribute to forming blisters, so moisture management (i.e. moisture-wicking socks, foot powder etc.) can also be considered. Speak to your physician or foot-care provider prior to using these types of products if you have any systemic health issues such as diabetes or peripheral vascular disease.

Theme VI – Bunions, Hammertoes and Other Deformities

Bunions (hallux valgus) are a deformity of the big toe (hallux) that involves a deviation of the hallux towards the middle of the foot and the protrusion of the metatarsal bone outwards. It often becomes painful, red and inflamed. As the deformity progresses, the other digits may find themselves deforming to make space for the hallux. Bunions are commonly linked to heredity, biomechanical issues and to poorly fitting footwear physically pushing the toes into a deformed position over time. Women’s fashion shoes and high-heeled footwear are a common biomechanical cause. Systemic diseases such as rheumatoid arthritis can also be responsible for this type of deformity.

Hammertoes and claw toes are flexion deformities in which the toe takes on a flexed or clawed appearance, and can be mobile or immobile. These deformities often lead to areas of high pressure, corns or callus. They can be caused by muscular imbalance in the toe muscles, shoes being too short, or they may occur in the presence of other toe deformities such as a bunion. Splaying or separation of the digits away from each other may accompany these conditions.  Sometimes the fourth or fifth digit may curl under, which leads to pain because walking puts body weight directly on them.

Painful toe deformities can be managed conservatively through the use of proper footwear (with a wide or deep toe box) that fits correctly, the use of digital devices to separate and/or protect the toes, and off-the-shelf shoe inserts or custom orthotics to treat any biomechanical abnormality. Maintaining joint mobility through passive and gentle toe stretches may also help, along with regular treatment of painful corns or calluses by a chiropodist/podiatrist.

If conservative management of bunions and lesser toe deformities is not providing symptomatic relief, surgery may be an option. There are many different types of surgeries and approaches to treating these conditions. Ask your surgeon about what exactly is being done, how much deformity is being corrected and what type of surgery (bone, soft tissue or both) will be performed. Also ask what to expect after surgery regarding pain management, hardware (pins/screws) that may be used, mobility of the toe joints following surgery and any rehabilitation or physiotherapy that may be required, as well as possible complications and how these complications may be managed. If you have had foot surgery and are having complications since the surgery (balance issues, the bunion has returned, or other toe deformities), speak to your surgeon if possible, or seek a second opinion.


Thank you to everyone who took time to send in your questions. I hope that I was able to provide some general insight into the foot and its common disorders. For more specific information please do not hesitate to see your physician, chiropodist/podiatrist or other health professional regarding your concerns. The Foot Care Centre at Women’s College Hospital deals specifically with biomechanical (footwear/orthotic) foot problems and has a staff of chiropodists and occupational therapists/certified pedorthists who can help you. We do not provide any skin/nail care treatments. Although we prefer a physician’s referral it is not necessary. You can make an appointment by calling 416-323-6020 and speaking to our receptionist to book an assessment. There is no appointment fee for residents of Ontario.


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