Dr. Michael Hercules Theodoulou, D.P.M.

Prevention of deformity can be challenging as many times this is a dynamic process resulting from familial or hereditary factors as well as foot function and structure. Generally speaking I manage these for the here and now. Large toe box shoes to minimize pressure on the deforming digits is imperative. These are represented by round or square toe shoe box with good height. Limiting any type of closed fashion shoe that is triangular or pointed at the end to minimize compression on the digits. Maintaining heel height to less than 2 inches. Even with these measures deformity may progress as shoes frequently are not the cause but can influence or splint the deformity.

Your assessment is quite correct and untimely healing of an injury warrants evaluation by a medical specialist with probable need for X-rays to assess for structural damage that my be impeding healing. There is a lot of local anatomy at risk for injury in this often downplayed process of the ankle sprain

The ability for a body part to move requires multiple organ systems to include bone, muscle tendon and nerve. The inability to flex the foot suggests some type of disruption in this process. This may result from muscle tendon pathology, neurologic failure to promote a muscle contraction or a combination thereof. Given the limited information provided by the question I would suggest that more than likely there is no neurologic component to this as you apparently also suggest pain but this is not guaranteed. More than likely failure is occurring through the musculoskeletal system and may result from overuse processes to produce tendinitis which can weaken function and produce pain when recruited. Depending chronicity of the disorder treatment and prognosis varies. In acute cases appropriate rest, ice and anti-inflammatory may be all that is required. In chronic cases, mitigating the factors that have caused the overuse process is required to include activity modification, addressing any biomechanical issues and physical medicine rehabilitation. Given that this is a recurring consistent problem I would recommend evaluation by a medical specialist who can more appropriately evaluate her presentation and obtain require test such as x-rays that may help define this process.

Unfortunately gangrene represents death of tissue that will necessitate debridement to vital healthy tissue. When it involves the distal extremity such as the foot, the amount of tissue that often has to be removed may leave the individual with a nonfunctional extremity that will be better served with amputation and prosthesis. As terrible as this may sound return to a better life may occur faster with this approach versus heroic measures requiring multiple surgeries, associated risks and no guarantees regarding outcome.

There are many reasons for a wound to fail to advance to appropriate healing. Globally, diabetes appears to be a significant factor regarding development of foot ulcerations and wounds and their ability to heal. The disease impacts multiple systems to include vascular, neurologic and immune mediated processes. Ongoing infection is a critical factor in wound healing failure. It requires appropriate medical management with topical or systemic antibiotics often dictated by appropriate cultures from the wound site. But medical management may be limited in resolving the process and surgical debridement of any nonhealing, devitalized tissue is also warranted when medical management does not produce adequate resolution. Inadequate blood flow can also be a factor as this is what provides appropriate oxygenation of tissue to advance the healing process and also to deliver necessary antibiotics if provided systemically. Wounds on the bottom of the foot are also exposed to significant mechanical stress load from daily walking and standing and appropriate pressure reduction is necessary to allow for advancement of healing. Plantar or wounds on the bottom of the foot are an extremely complicated presentation that required a wound care specialist frequently to address the specific needs and allow for timely healing and prevention of further infection, increase in wound size and greater complications. If there has not been an appropriate reduction of wound size and typically we suggest by at least 50% within 4 weeks with current management this warrants consideration of treatment modification and again I would recommend seeing a wound care specialist.

Wound healing is a complex cascade of cellular activity that promotes initially hemostasis or bleeding control followed by presentation of growth factors and other signaling events to advance laying down of collagen and ultimately advancement of cells to promote wound closure. After acute healing of the wound there is an ongoing remodeling process. There are
many factors that may interfere with wound healing. Mechanical factors such as repetitive stress to a wound that does not allow for appropriate maturation. This can occur over areas of excessive skin mobility or joint motion. It can also occur in areas of pressure loading on the sole of the foot. Our skin is a primary barrier of infection to the body. We colonize many
microorganisms on our skin that once this barrier is breached can then result in contamination and ultimately infection. Infection can retard the normal healing process and so it is imperative that it is resolved with local antiseptic care or systemic antibiotics. Intact vascular standing is also absolutely critical for appropriate wound healing particularly to the lower extremities and feet. Impairment of blood flow can slow healing as it impacts the ability for the previously mentioned signal factors and cells to migrate to the area. Individuals who
misuse tobacco products impact small vessel flow particularly to the skin and this can be a critical factor in delayed wound healing. Nutritional deficits and metabolic disorders also play a role in wound healing. Vitamin deficiencies and disease states such as diabetes can influence timeliness of healing. As I am uncertain as to what is meant by my foot wound has not healed and what it represents currently I cannot tell you whether it is appropriately recovering at this time. In an otherwise healthy individual superficial wounds will again heal with initial clotting and hemostasis for blood control followed by overlying eschar or scab with gradual contraction and loss of this eschar with new skin growth. If there remains a persistent open wound that is draining or failing to show contraction and closure then I do believe it would be best that this be medically evaluated and assessed for some of the common reasons if otherwise healthy as an individual to include persistent infection, failure to adequately protect the area from excessive stress or strain and potentially there may be a retained foreign body if in fact there was external forcible injury from a rock.

Hyperhidrosis or excessive sweating of the feet can be caused for many reasons. Typically, it is a chronic idiopathic (unknown) condition, but it can also be secondary to other medical conditions. The most common idiopathic presentation typically is localized to certain areas of the body and does affect the palms and soles of her hands and feet. Sweating helps us in thermoregulation, skin hydration as well as fluid and electrolyte balance. We identify 3 types of sweat glands on her skin to include eccrine, apocrine and apoeccrine. It is the eccrine sweat glands which are responsible for hyperhidrosis. These are found in highest #2 the palms and soles of the feet. The sweat glands are innervated by the sympathetic
nervous system. Emotional sweating is affected by different regions of the brain and may be a factor with regards to the development of this condition. It is for this reason that when under stress we tend to perspire more. Treatment clearly is to address factors that influence this. Things that overstimulate are sympathetic nervous system are attempted to be mitigated. Reducing stress, limiting caffeinated products can be quite helpful. First line of treatment is typically a topical antiperspirant most commonly with some type of aluminum chloride solution as a drying agent. Secondary therapy in severe cases can include use of botulinum toxin injections. These interfere with sympathetic nerve function by blocking the neurotransmitter acetylcholine. There are also oral systemic therapies to include anticholinergics, clonidine as well as beta blockers and benzodiazepines, however, there are side effects that limit primary use. Iontophoresis as a treatment based on electric current to inhibit sweating. Finally, in the most severe of cases when involving the upper extremities, endoscopic surgical thoracic sympathectomy has been performed.

The most common reason for heel pain due to overuse is plantar fasciitis. This is a repetitive injury of the broad band of connective tissue of the sole of the foot that helps statically support the instep. Contributing factors to this presentation is overuse with activity, being overweight, mechanical or structural issues of the foot and functional to include overtightening of muscle groups. Treatment for this is most commonly quite conservative to include activity modification, longitudinal arch support if identified as having overpronation or flatfeet, stretching exercises for the Achilles tendon and weight loss if indicated. Pain relief can be achieved with topical measures such as ice massage and is severe enough
medicine such as acetaminophen or ibuprofen if tolerated. Typically, this is a self-limiting process, but may require 6-9 months to fully recover. If pain becomes notably severe and does not demonstrate improvement, then an evaluation by foot and ankle specialist may be indicated.

Heel pain after running can result for multiple reasons at impact several types of tissue. Most commonly, this may simply represent a plantar fascial strain. The typical algorithm of rest, ice and elevation and judicious use of medication such as acetaminophen or ibuprofen can be considered. If this is a recurring problem there may be suggestion that there may be some inappropriate environmental factors or functional factors of the foot contributing to this. Environmental factors can include footwear utilized, terrain that you are running on. Further it is important to identify whether this is affecting both heels or just a singular heel. Functional factors can include poor foot posture such as an overpronation requiring some type of mechanical control or support, overtightening of the posterior muscle groups such as the Achilles tendon necessitating appropriate pre- and post-exercise stretching. Heel pain can also represent injury to the bone itself and may simply present as a bone bruise or contusion or even a stress fracture. I would suggest that this type of pain does not typically recover with rest and ice and continues to hurt with activities of daily life. If pain does not appropriately resolve with simple interventions as suggested or is a recurring problem, this may suggest that you would benefit from evaluation by a foot and ankle specialist.

This could represent many things. Starting from superficial to deep, the questions that must be asked include is there any changes of the overlying skin to include callus, skin rash or eruption. This can cause focal sensitivity with outward pressure. Immediately deep to the skin resides the extensor tendon to the great toe. If this becomes prominent it can produce
local irritation and sensitivity and tendinitis. In the surrounding soft tissue are the neurovascular bundles. Local pressure can produce nerve irritation and neuritis. Finally deep to this are the structures of bone and joint. Local bone spurs and degenerative arthritis can cause focal tenderness, but this would also most commonly occur with activity. I would suggest that if symptoms become increasingly worse to include involvement in activity or increasing pain you would be best served having evaluation by medical provider. If it is found that this is being impacted by a singular shoe or a certain style of shoe then these should be avoided.

Based on your description, you are presenting with what we call a pustule. These are raised skin lesions with accumulation of underlying purulence. There are multiple causes to include both noninfectious and infectious. Infectious can represent both bacterial and fungal. Noninfectious can include disorders of skin such as psoriasis. Sometimes this presentation can include systemic complaints of fever and general malaise. Given its persistence and clinical presentation I would encourage evaluation by a medical provider to include specialist of dermatology or podiatry. This may require local aspiration or incision and drainage with appropriate cultures and if deemed infectious appropriately treated with antimicrobial.

You may be quite accurate with your diagnosis. Thrombosed varix of superficial venules can develop and present as painful lesions of bluish hew often times on the soles of the feet. These may develop from local trauma. These lesions are self-limiting but may take several weeks to resolve. Warm compresses to the area can improve local symptoms. Clearly, if
the lesion fails to improve as suggested or there is worsening I would encourage evaluation by a medical specialist to include a podiatrist or dermatologist.

The postural deficit of a flat foot is not an uncommon clinical presentation. Many individuals do not have associated symptoms as a result of this. In fact, in the pediatric and adolescent population, we commonly do not treat for a flat foot unless the child presents with associated symptoms of pain and/or dysfunction. We consider this the same in the adult
population. When someone does start to complain of fatigue or soreness, particularly with physical activity, we usually do escalate treatment for the management of this deformity. Initial care is quite conservative to evaluate factors that have influenced the development of this discomfort. This can include evaluation of your training regimen as well as the
environment that you're running. Footwear can have a significant influence, too.

Skin calluses and corns can be caused for many reasons. The most common reason is repetitive friction or irritation of the skin with underlying bone prominence causing local impingement. The skin's reaction is to thicken and protect the area forming this organized corn or callus. The most effective treatment is to relieve the overlying pressure to include modification of shoes with larger toe box, digital pads and periodic reduction with some type of callus stone or pumice stone. Other reasons for corns and calluses can include dermatologic disorders that may be hereditary as well as infectious processes such as plantars warts. If these lesions become painful and persistent and are not simply a concern for aesthetic reasons, it would be appropriate to consult a medical specialist such as a podiatrist or dermatologist.

Swelling of the lower extremities can occur for many reasons. This does represent fluid exiting the vascular system into the surrounding tissue. The suggestion that this is occurring during the winter may support some type of vascular process. There are people with cold sensitivities that promote a constrictive effect to the blood vessels that then cause reactive hyperemia and focal swelling. These vascular constrictive disorders can include conditions such as Raynauds phenomenon or disease. If you have
associated complaints of joint pain or other systemic complaints, there may be consideration to be seen by her primary care provider or a rheumatologist to make sure that there is no underlying rheumatic process that may be contributing to this. Other factors besides the cold that may stimulate this process can include tobacco misuse, which should clearly be avoided. Obviously, continued protection from extreme thermal cold is also important, utilizing layered socks and avoiding immersion into water such as
street puddles that may develop.

Penetrating injuries to the bottom of the foot are not an uncommon presentation and can cause some lingering issues both with potential for retained material as well as the local trauma to the soft tissue. Frequently, a retained foreign body will present with residual local inflammation of the soft tissue, the occasional build-up of callus tissue,
local purulent or clear drainage, and focal tenderness. The inflammatory process is the body's response to the foreign substance in its effort to eliminate the material. It is not unheard of to see gradual elimination of foreign substance over time as a "splitting" or expression through an opening of the skin if it remains superficial. Deeper retained objects can encapsulate and remain benignly present, but if they produce pain or dysfunction, they will require surgical excision. Many times, the retained objected is removed at the time of injury, but the persistent pain is a result of the local penetrating trauma to the tissue. This should improve within a few weeks from time of injury. Signs that suggest a follow-up evaluation include persistent redness to the area, drainage, pain that does not trend in an improved or resolved fashion, visualization of a persistent wound, and even identification of the retained foreign object. If there remains a concern for a retained foreign object, X-rays and even an ultrasound can be performed to help identify its presence.

Foot pain at rest can be caused for a lot of reasons. Frequently, it is not musculoskeletal as discomfort is appreciated without loading of the injured foot and associated bone and soft tissue structures. Inappropriate sitting can cause postural impingement of peripheral nerves. This can occur at the lower back level, knee, ankle, and foot. Numbness and tingling sensation is often accompanied by this presentation. Frequent repositioning while sedentary can help minimize this. If pain and stiffness are appreciated after prolonged sitting and putting weight on the extremity, this can represent injury to the soft tissue and joint be it from an arthritic process or prior overuse injuries. When resting our body does limit blood flow to peripheral extremities and a "gelling phenomenon" occurs. Until the body part is moved and blood resumes, soft tissues can feel tight and present with discomfort. This is often reflected in the morning stiffness associated with arthritis conditions. Finally, poor circulation can present
as rest pain when inadequate arterial circulation reaches to the distal extremity. This can be a finding in patients with arterial occlusive disease prompted by atherosclerosis or tobacco misuse. Your presentation sounds quite benign and I believe can be relieved with postural repositioning when sitting for prolonged periods and pumping exercises of the foot to promote circulation to the area.

Ballerina foot frequently refers to the ideal ballet foot, which is found to be supple and possess an accentuated instep arch. Sadly, most ballerinas do not often present this way. The repetitive stress loading to the foot performing the required positions often results in over use injuries to tendon, ligament, bone, and joint. Some of the common ailments seen in ballerinas include posterior ankle impingement syndrome, flexor tendinitis, degenerative changes, particularly to the great toe, and acquired digital
contractures. It is an unfortunate tale that the ideal foot presentation is frequently lost due to the nature of the activity.

Swelling is a physiologic response to the trauma resulting in injury to small blood vessels promoting the bruising that is seen, but also an escape of fluid from the vascular system into the interstitial or soft tissue. The initial phase of healing following the bodies initial management of local bleeding through clotting is an inflammatory phase with introduction of factors and other transmitters promoting migration of cells necessary to promote healing of the tissue. There are many factors that may contribute to the swelling of the area and not all equate to severity of injury. With that said, it would make sense that the greater the injury, the more likely to have greater tissue involvement and the swelling would be worse. When this occurs in a closed compartment of tissue, a concerning secondary condition known as compartment syndrome may occur. For most injuries beyond swelling we consider pain to the area, local deformity, and associated dysfunction of part to grade severity. If there is no noted deformity, the part functions pain free with no appreciated altered movements and, in the case of an ankle's ability to bear weight on the extremity, understand swelling is a physiologic response that will resolve with rest, elevation, and time. If it fails to do so, this may be a greater indicator of injury.

The majority of cases with regards to heel pain relate to a condition known as plantar fasciitis. There are many reasons to get overuse fascioapthies and tendinopathies of the foot and ankle. This can be related to environmental factors such as foot wear and activities. Increased body weight can also play a significant role particularly when it
comes to lower extremity musculoskeletal conditions. Obviously, there is always concern regarding potential medical disorders such as different types of arthritis that may present with this type of discomfort. I have found moderation in everything seems to be the answer. Excessively high-heeled shoes as well as poorly supportive slip on flat shoes tend not to do well. A slight wedge can always be beneficial and can be achieved with many types of clogs as well as good walking shoes or running shoes with a
heel lift. We encourage stretching exercises particularly for the posterior leg muscle groups of the calf that are readily identified as runners wall lean stretches and foot dorsiflexion stretch exercises. If these modifications and exercises are done and pain relief is not achieved, then an evaluation by a qualified medical specialist would be a reasonable consideration.