We’ll discuss simple steps to keep your feet strong and mobile. With proper detection, intervention and care most foot and ankle problems can be lessened or prevented. Learn from our expert about preventative care and the latest treatments for common and athletic foot injuries, diabetic foot complications, arthritis and skin and nail disorders.

1. Foot Health 101
Ali El-Saheli DPM,FACFAS
Foot and Ankle Surgery
April 23, 2019

2. Common Foot and Ankle Conditions
• Plantar Fasciitis
• Achilles Tendon Disorders
• Osteoarthritis of the Foot and Ankle
• Stress Fractures
• Sesamoid Injuries in the Foot
• Chronic Ankle Instability
• Skin and Nail Diseases
• Skin Cancer of the Foot and Ankle
• Malignant Melanoma of the Foot
• Peripheral Arterial Disease (PAD)
• Diabetes Complications, Amputation, and Prevention

3. Plantar Fasciitis - Causes
• Plantar fasciitis is an inflammation of the band of tissue (the plantar
fascia) that extends from the heel to the toes. In this condition, the fascia
first becomes irritated and then inflamed, resulting in heel pain.
• Causes
• The most common cause of plantar fasciitis is related to faulty structure of the
foot.
• Wearing non-supportive footwear on hard, flat surfaces (this is particularly
evident when one’s job requires long hours on the feet)
• Obesity
• Trauma
• Overuse

5. Plantar Fasciitis - Symptoms
• Symptoms
• Pain on the bottom of the heel
• Pain in the arch of the foot
• Pain that is usually worse upon arising
• Pain that increases over a period of months
• Swelling on the bottom of the heel

6. Plantar Fasciitis - Diagnosis
• Diagnosis
• Rule out other diagnosis
• Diagnostic imaging studies, such as x-rays.
• Sometimes heel spurs are found in patients with plantar fasciitis, but
these are rarely a source of pain. When they are present, the condition
may be diagnosed as plantar fasciitis/heel spur syndrome.

7. Plantar Fasciitis - Treatment
Treatment of plantar fasciitis begins with first-line strategies, which you can
begin at home:
• Stretching exercises
• Avoid going barefoot
• Ice
• Limit activities
• Shoe modifications Wearing supportive shoes that have good arch support and
a slightly raised heel reduces stress on the plantar fascia.
• Medications Oral nonsteroidal anti-inflammatory drugs (NSAIDs), such as
ibuprofen.
Nonsurgical Treatment

8. Plantar Fasciitis - Treatment
• IF pain persist:
• Padding, taping and strapping
• Orthotic devices. Custom orthotic devices that fit into your
shoe help correct the underlying structural abnormalities
causing the plantar fasciitis.
• Injection therapy
• Removable walking cast
• Night splint
• Physical therapy

9. Plantar Fasciitis
• When Is Surgery Needed?
• About 80% of patients with plantar fasciitis respond to nonsurgical
treatment
• A small percentage of patients may require some form of surgical
intervention.
• Long-Term Care
• No matter what kind of treatment you undergo for plantar fasciitis, the
underlying causes that led to this condition may remain.
• Wearing supportive shoes, stretching and using custom orthotic devices
are the mainstay of long-term treatment for plantar fasciitis.

10. Achilles Tendon Disorders - Overview
• What is the Achilles Tendon?
The Achilles tendon is a band of tissue that connects a muscle to a
• Achilles Tendonitis and Achilles Tendonosis
• Two common disorders that occur in the heel cord are Achilles
tendonitis and Achilles tendonosis.
• Achilles tendonitis is an inflammation of the Achilles tendon. This
inflammation is typically short-lived.
• Over time, if not resolved, the condition may progress to a
degeneration of the tendon (Achilles tendonosis)

12. Achilles Tendon Disorders - Causes
• Causes
• As "overuse" disorders, are usually caused by a sudden increase of a
repetitive activity involving the Achilles tendon
• Athletes are at high risk for developing disorders of the Achilles tendon
• Common in individuals whose work puts stress on their ankles and
feet, such as laborers
• Weekend warriors—those who are less conditioned and participate in
athletics only on weekends or infrequently
• People with excessive pronation (flattening of the arch).
• Equines deformity

13. Achilles Tendon Disorder - Symptoms
• Symptoms
• Pain—aching, stiffness, soreness or tenderness—within the tendon
• Tenderness, or sometimes intense pain, when the sides of the tendon
are squeezed

14. Achilles Tendon Disorders - Treatment
• Treatment
• Immobilization
• Ice. To reduce swelling due to inflammation, apply a bag of ice over a thin towel to the
affected area for 20 minutes of each waking hour. Do not put ice directly against the
skin.
• Oral medications
• Orthotics. For those with overpronation or gait abnormalities, custom orthotic devices
may be prescribed.
• Night splints
• Physical therapy

15. Achilles Tendon Disorders –
Treatment/Prevention
• When Is Surgery Needed?
If nonsurgical approaches fail to restore the tendon to its normal condition,
surgery may be necessary.
• Prevention
• Strengthening and stretching of the calf muscles through daily
exercises
• Wearing proper shoes for the foot type and activity is also important in
preventing recurrence of the condition.

16. Osteoarthritis of the Foot and Ankle -
Overview
• What Is Osteoarthritis?
• Osteoarthritis is a condition characterized by the breakdown and
eventual loss of cartilage in one or more joints.
• Develops as part of the aging process
• In the foot, the disease most frequently occurs in the big toe, although it
is also often found in the midfoot and ankle.

18. Osteoarthritis of the Foot and Ankle - Causes
• Causes
• Osteoarthritis is considered a wear-and-tear disease.
• An injury may also lead to osteoarthritis, for example, osteoarthritis in
the big toe.
• Osteoarthritis in the midfoot is often caused by trauma.
• Sometimes osteoarthritis develops as a result of abnormal foot
mechanics, such as flat feet or high arches.

19. Osteoarthritis of the Foot and Ankle –
Symptoms/Diagnosis
• Symptoms
• Pain and stiffness in the joint
• Swelling in or near the joint
• Difficulty walking or bending the joint
• Bone spur (a bony protrusion) at the affected joint.
• Diagnosis
• Look for swelling in the joint, limited mobility and pain with movement.
• Deformity and/or enlargement (spur) of the joint may be noted.
• X-rays may be ordered to evaluate the extent of the disease.

20. Osteoarthritis of the Foot and Ankle -
Treatment
• To help relieve symptoms, nonsurgical approaches include:
• Oral medications.
• Orthotic devices.
• Bracing.
• Immobilization.
• Steroid injections.
• Physical therapy.
• When Is Surgery Needed?
• If failed to improve with nonsurgical treatment.
• In advanced cases, surgery may be the only option

21. Osteoarthritis of the Foot and Ankle –
Prevention
• Prevention
• Trauma to the foot and ankle need to treated, untreated trauma will cause
osteoarthritis in the joint
• Know your foot type and pick your shoes accordingly
• Don’t not ignore pain and continue you normal activities
• Know your limit

22. Stress Fractures in the Foot
• Stress fractures are tiny hairline breaks that can occur in the bones of the
foot.
• Symptoms include pain, swelling, redness and bruising
• They can be caused by:
• Overtraining or overuse
• Improper training habits or surfaces
• Improper shoes
• Flatfoot or other foot deformities and osteoporosis
• Can lead to a complete break if left untreated
• X-rays and other studies are used to diagnose the stress fracture.
• Treatments include rest and possible immobilization of the foot. In some
cases, surgery may be required

24. Stress Fractures in the Foot - Prevention
• Prevention
• If you want to start any type of high impact activity, start gently and
increase by 10% every week.
• Majority of patients that need surgery with stress fractures are that ones
that ignored their pain
• Check with your primary medicine doctor for osteoporosis
• Vitamin D and Calcium

25. Sesamoid Injuries in the Foot -
Overview/Causes
• What is a Sesamoid?
• Bone embedded in a tendon.
• Two pea-shaped bones located in the ball of the foot, beneath the big toe
joint.
• Acting as a pulley for tendons, the sesamoids help the big toe move normally
and provide leverage
• Sesamoid injuries often associated with activities requiring increased
pressure on the ball of the foot, such as running, basketball, football, golf,
tennis and ballet.
• People with high arches are at risk for developing sesamoid problems.
• Wearing of high-heeled shoes can also be a contributing factor.

27. Sesamoid Injuries in the Foot - Types
• There are three types of sesamoid injuries in the foot:
• Turf toe
• Fracture. A fracture (break) in a sesamoid bone can be either acute or chronic.
• acute fracture is caused by trauma
• chronic sesamoid fracture produces longstanding pain in the ball of the foot
beneath the big toe joint.
• Sesamoiditis. This is an overuse injury involving chronic inflammation
of the sesamoid bones and the tendons involved with those bones.

28. Sesamoid Injuries in the Foot - Diagnosis
• Diagnosis
• In diagnosing a sesamoid injury, clinical symptoms are the key in
diagnosis.
• X-rays are ordered, and in some cases, advanced imaging studies may
be ordered.

29. Sesamoid Injuries in the Foot - Treatment
• Nonsurgical Treatment
• Padding, strapping or taping
• Immobilization
• Oral medications
• Physical therapy
• Steroid injections. In some cases, cortisone is injected into the joint to
reduce pain and inflammation.
• Orthotic devices

30. Sesamoid Injuries in the Foot - Treatment
• When Is Surgery Needed?
• When sesamoid injuries fail to respond to nonsurgical treatment,
surgery may be required.

31. Chronic Ankle Instability - Overview
• What is Chronic Ankle Instability?
• Chronic ankle instability is a condition characterized by a recurring
giving way of the outer (lateral) side of the ankle. This condition often
develops after repeated ankle sprains. Many athletes, as well as
others, suffer from chronic ankle instability.
• People with chronic ankle instability often complain of:
• Repeated turning of the ankle, especially on uneven surfaces or when
participating in sports
• Persistent (chronic) discomfort and swelling
• Pain or tenderness
• The ankle feeling wobbly or unstable

33. Chronic Ankle Instability – Causes/Diagnosis
• Causes
• Chronic ankle instability usually develops following an ankle sprain that
has not adequately healed or was not rehabilitated completely.
• Repeated ankle sprains often cause—and perpetuate—chronic ankle
instability. Each subsequent sprain leads to further weakening (or
stretching) of the ligaments, resulting in greater instability and the
likelihood of developing additional problems in the ankle.
• Diagnosis
• Clinical instability
• X-ray
• MRI

34. Chronic Ankle Instability - Treatment
• Nonsurgical Treatment
• Physical therapy. To improve balance and range of motion and retrain
your muscles. Proprioception
• Bracing
• Medications. Nonsteroidal anti-inflammatory drugs (NSAIDs), such as
ibuprofen, may be prescribed to reduce pain and inflammation.

35. Chronic Ankle Instability - Treatment
• When Is Surgery Needed?
• In some cases, Surgery is recommended based on the degree of
instability or lack of response to nonsurgical approaches. Also based
on the patient age and the level of activities

36. Chronic Ankle Instability – Prevention
• Prevention
• The proper sneakers or shoes for your activity of choice
• With any type of ankle sprain, early treatment is the key to prevent instability

37. Overuse Foot Injury Preventions
• Painful stress fractures, tendonitis can be avoided by easing into sports activities.
• Overuse injuries occur in many different sports, such as:
• Tendonitis (painful inflammation of a tendon) is most commonly associated with the
side-by-side or jumping motions performed in activities, such as tennis, soccer and
dance.
• Tendon ruptures (tears in the tendon) are typically linked to sports that use swift,
abrupt movements, such as basketball, football and soccer.
• Stress fractures are often seen after too vigorously starting a walking routine or in
sports that involve running. But any of these injuries can happen with any sport.
• 10 percent rule is a good place to start, which calls for increasing the activity by only 10
percent each week.
• If the pain does not improve in three to seven days, seek professional evaluation
• most overuse injuries will resolve through rest, and most are prevented by setting
realistic, common-sense goals—and that calls for refraining from doing too much too
soon.

38. Types of Skin and Nail Diseases
• Foot rash
• Athlete’s Foot
• Eczema of the Foot
• Thick Toenails
• Nail Fungus
• Yellow Toenails
• Skin Cancer of the Foot and Ankles
• Malignant Melanoma of the Foot

39. Skin and Nail Diseases – Foot Rash
• Foot Rash - a rash on the foot can have a variety of causes:
• Eczema, which is usually very itchy.
• Contact dermatitis - may be an allergic reaction to something with
which your feet have come into contact, such as materials in your shoe
or poison ivy.
• Athlete's foot, which is caused by a fungal infection.

40. Skin and Nail Diseases – Athlete’s Foot
• Athlete's Foot
• A skin infection caused by fungus. Fungus thrives in a dark, moist and
warm environment, such as a shoe.
• Common in warm weather when feet tend to sweat more. They thrives
in damp areas, such as swimming pools, showers and locker rooms.
• Produces itchy, dry, scaling skin. The fungus can spread to other areas
of the body, including toenails.

41. Athlete’s Foot Prevention
• Avoiding walking barefoot combined with good foot hygiene
can help reduce the spread of the fungus.
• Feet should be washed every day with soap and water and
thoroughly dried, including between the toes.
• Feet should be kept as dry as possible.
• Treat hyperhidrosis and change socks twice daily

42. Skin and Nail Diseases – Eczema of the Foot
• Eczema of the Foot
• Includes many conditions that cause inflammation of the skin.
• Appears as dry, red and extremely itchy patches of skin.
• No known cause for eczema, but it often affects people with a family
history of allergies.
• Although there is no cure for this disease, treatments make it very
manageable. The most helpful treatment is to prevent scratching.
• Cold compresses can be applied to help reduce itching.
• Lotions and creams are often used to help keep the skin as moist as possible.
• Corticosteroid creams can also be used to help reduce inflammation.

43. Skin and Nail Diseases – Thick Toenails
• Thick Toenails
• Toenails will often become thick as an individual grows older.
• Thickening may also occur as a result of trauma to the toenail
• Thick toenails can also be seen in individuals with nail fungus
(onychomycosis), psoriasis and hypothyroidism.

44. Skin and Nail Diseases – Nail Fungus
• Nail Fungus
• Fungus of the toenails is a common problem that can affect people of
all ages, although it most commonly affects individuals who are older.
• Toenail fungus often begins as an infection in the skin called tinea
pedis (also known as athlete’s foot).
• Fungus often starts under the nail fold at the end of the nail.

45. Skin and Nail Diseases – Nail Fungus
• Treatment of Nail Fungus
• Nail biopsy
• Topical medication
• Oral medications
• Laser
• Nail avulsion

46. Nail Fungus - Prevention
• Nail salon?
• Avoid using gym showers
• Treat hyperhidrosis
• Prevent fungal skin infection

47. Skin and Nail Diseases – Yellow Toenail
• Yellow Toenails
• The most common cause of yellow discoloration in the toenails is a
fungal infection. The fungus often develops underneath the nail,
resulting in it becoming thick, raised and yellow in color.
• Other potential causes for yellow discoloration of the nail include
diabetes mellitus and lymphedema (chronic leg swelling).
• Nail polish
• A stained nail may take several months to grow out.

48. Skin Cancer of the Foot and Ankle
• Skin cancer is a general term for three distinct cancers that can
appear on the foot:
• Basal cell carcinoma, the most common type of skin cancer, appears
on sun-exposed areas as a smooth, raised bump or a sore that is not
healing. It rarely metastasizes or causes death because it grows slowly
and rarely spreads. It is easily treated with surgery or radiation.
• Squamous cell carcinoma appears on sun-exposed areas as thick,
red, scaly patches or as a bleeding ulcer. It is more serious than basal
cell carcinoma because in some instances, it may spread to other
areas of the body.
• Melanoma, the most serious skin cancer, begins in the cells of the skin
that produce pigmentation (coloration) and spreads to other areas of
the body as it grows beneath the surface of the skin.

49. Skin Cancer of the Foot and Ankle - Prevention
• Keep your feet safe from the sun and follow these tips:
• USE SUNSCREEN ON YOUR FEET.
• CHECK YOUR FEET.

50. Skin Cancer of the Foot and Ankle
• RISK FACTORS
• Excessive unprotected time in the sun
• Family history and fair skin
• EARLY DETECTION IS KEY
• Check your feet for lesions.
• Early detection and treatment could help to save your life.

51. Malignant Melanoma of the Foot - Overview
• What Is Malignant Melanoma?
Melanoma is a cancer that begins in the cells of the skin that
produce pigmentation (coloration). It spreads to other areas of
the body as it grows beneath the surface of the skin. Melanoma
strikes people of all age groups, even the young.
• Melanoma in the Foot
Melanoma that occurs in the foot or ankle often goes unnoticed
during its earliest stage . By the time melanoma of the foot or
ankle is diagnosed, it frequently has progressed to an advanced
stage. This makes it extremely important to follow prevention and
early detection measures

58. Malignant Melanoma of the Foot - Causes
• Causes
• Too much exposure to ultraviolet (UV) rays from the sun or tanning
beds.
• Some factors put a person at greater risk for developing this type of
cancer. These include:
• Fair skin; skin that freckles; blond or red hair
• Blistering sunburns before the age of 18
• Numerous moles, especially if they appeared at a young age
• Diagnosis
• Biopsy

59. Malignant Melanoma of the Foot –
Prevention/Early Detection
• Prevention & Early Detection
• Wear water shoes or shoes and socks—flip flops do not provide
protection!
• Use adequate sunscreen in areas that are unprotected by clothing or
shoes.
• Inspect all areas of the feet daily, including the soles, underneath
toenails and between the toes.
• Avoid UV radiation during the sun’s peak hours (10:00am to 4:00pm)
beginning at birth.
• Wear sunglasses that block 100 percent of all UV rays
• Wear a wide-brimmed hat.
• If you have discoloration beneath a toenail that is unrelated to trauma,
seek a professional evaluation

60. Malignant Melanoma of the Foot
• What Should You Look For?
• Looks like a spot on the skin that is predominantly brown, black, or blue,
although in some cases, it can be red or even white.
• There are four signs—known as the ABCDs of melanoma—to look for when
self-inspecting moles and other spots on the body:
• Asymmetry -- Melanoma is usually asymmetric, which means one half is different in
shape from the other half.
• Border -- Border irregularity often indicates melanoma. The border, or edge, is typically
ragged, notched or blurred.
• Color -- Melanoma is typically a mix of colors or hues, rather than a single, solid color.
• Diameter -- Melanoma grows in diameter, whereas moles remain small. A spot that is
larger than 5 millimeters (the size of a pencil eraser) is cause for concern.

62. Peripheral Arterial Disease (PAD) - Overview
• What Is Peripheral Arterial Disease?
• Commonly referred to as poor circulation, Peripheral Arterial Disease
(PAD) is the restriction of blood flow in the arteries of the leg.
• The presence of PAD may be an indication of more widespread arterial
disease in the body that can affect the brain, causing stroke, or the
heart, causing a heart attack.

63. Peripheral Arterial Disease (PAD) - Symptoms
• Signs & Symptoms
• Most people have no symptoms during the early stages of PAD. Often,
by the time symptoms are noticed, the arteries are already significantly
blocked.
• Common symptoms of PAD include:
• Leg pain (cramping) that occurs while walking or lying down
• Leg numbness or weakness
• Cold legs or feet
• Sores that will not heal on toes, feet or legs
• A change in leg color
• Loss of hair on the feet and legs
• Changes in toenail color and thickness

64. Peripheral Arterial Disease (PAD) – Risk Factors
• PAD Risk Factors
• Being over age 50
• Smoking (currently or previously)
• Diabetes
• High blood pressure
• High cholesterol
• Personal or family history of PAD, heart disease, heart attack or stroke
• Sedentary lifestyle (infrequent or no exercise)

65. Peripheral Arterial Disease (PAD)
• PAD & Foot Problems
• Simple foot deformities (hammertoes, bunions, bony prominences) or
dermatologic conditions, such as ingrown or thickened fungal nails,
often become more serious concerns when PAD is present.
• Seemingly small problems, such as cuts, blisters or sores, can result in
serious complications.
• Having both diabetes and PAD further increases the potential for foot
complications.

66. Peripheral Arterial Disease (PAD) - Treatment
• General Treatment of PAD
• Treatment for PAD involves lifestyle changes, medication and, in some
cases, surgery:
• Lifestyle changes. These include smoking cessation, regular exercise and a
heart-healthy diet.
• Medications. Medicines may be used to improve blood flow, help prevent blood
clots or control blood pressure, cholesterol and blood glucose levels.
• Surgery. In some patients, small incision (endovascular) procedures or open
(bypass) surgery of the leg are needed to improve blood flow.

67. Peripheral Arterial Disease (PAD) – Prevention
• Avoiding PAD Complications
• Getting regular foot exams
• To avoid complications, people with this disease should follow these
precautions:
• Wash your feet daily.
• Keep the skin soft and use lotion that does not contain alcohol.
• Trim toenails straight across and file the edges. Keep edges rounded to avoid
ingrown toenails, which can cause infections.
• Always wear shoes and socks and never go barefoot—even indoors.
• Choose the right shoes and socks.
• Check your feet every day. Check all over for sores, cuts, bruises, breaks in the skin,
rashes, corns, calluses, blisters, red spots, swelling, ingrown toenails, toenail
infections or pain.
• Do not try to take care of cuts, sores or infections yourself.

68. Diabetes Complications and Amputation
• People living with diabetes are prone to having foot problems,
often because of two complications of diabetes:
• Neuropathy causes loss of feeling in your feet, taking away your ability
to feel pain and discomfort.
• Poor circulation in your feet reduces your ability to heal
• Having diabetes increases the risk of developing a wide range
of foot problems.

69. Diabetes Complications and Amputation -
Symptoms
• Diabetes-Related Foot & Leg Problems:
• Infections and ulcers (sores) that do not heal.
• Corns and calluses . Corns and calluses can develop into ulcers.
• Dry, cracked skin.
• Nail disorders.
• Hammertoes and bunions. Nerve damage affecting muscles can
cause muscle weakness and loss of tone in the feet, resulting in
hammertoes and bunions.
• Charcot foot. This disabling complication is so severe that surgery,
and occasionally amputation, may become necessary.
• Poor blood flow.

70. Diabetes Complications and Amputation
Prevention – Diabetes Foot Care Guidelines
• To avoid serious foot problems that could result in losing a toe,
foot or leg, follow these guidelines.
• Inspect your feet daily.
• Bathe feet in lukewarm, never hot, water.
• Be gentle when bathing your feet.
• Moisturize your feet but not between your toes.
• Cut nails carefully.
• Never treat corns or calluses yourself. No “bathroom surgery” or
medicated pads.

71. Diabetes Complications and Amputation -
Prevention
• Consider socks made specifically for diabetic patients.
• Wear socks to bed. Never use a heating pad or a hot water bottle.
• Shake out your shoes and feel the inside before wearing.
• Keep your feet warm and dry.
• Never walk barefoot. Not even at home!
• Do not smoke. Smoking restricts blood flow in your feet.
• Get periodic foot exams.

72. Diabetes Complications and Amputation –
Take Home Message
• Diabetes can lead to decreased sensation in your feet,
decreased blood flow to your feet, ulcerations with poor healing
and infections requiring amputation
• Amputation rates can be reduced by 45 to 85 percent with a
comprehensive diabetes and foot care program
• Every patient with Diabetes should have at least annual foot exam