Learn About Foot Conditions
COMMON FOOT CONDITIONS IN PERTH

Many people have minor yet irritating problems with corns and calluses. In some cases, this can be very painful and interfere with activity. Excess pressure or friction on various regions of the foot can produce protective skin tissue, which may become excessively thick and painful. This is termed hyperkeratosis. The callus is a diffuse distribution of keratin tissue, and corn is a more impacted and dense site.

The heels are a common area of concern with dry, thick, cracked skin and are often described as unattractive.

Corns and calluses may occur on the ball of the foot due to abnormal weight distribution and loading through the foot. They can be isolated over one or two metatarsal head regions or across the whole ball of the foot.

The toes may also be affected, especially if they are clawed, and footwear impinges on them. Corns can be present on the top, the tips and between toes.

Some people have a greater genetic tendency to produce such irritating skin tissue. Some skin conditions produce excess keratin tissue. Smoking has a documented link to increased hyperkeratosis or thickening of the skin. Areas of increased pressure or overload from ground forces increase the potential for callus. Feet that are either high arched or flat have altered pressure regions and are at risk of corns and calluses. Footwear irritation contributes to calluses and corns. Clawed or retracted toes or any part of the prominence of the foot is subjected to excessive force. Resulting in corn or callus. Dehydration can increase callus and corns with fissuring, more common on the heels.

Regions of significant thickening of the skin are noted. There may be no associated discomfort but may be unsightly. The skin tissue may become so dense that it is inflexible or become deed seated like a "plug". There can be associated splitting and fissuring with surrounding redness. Some areas are more painful than others. There may be so much pressure at the corn site. That there is soft tissue breakdown beneath the corn in the form of an ulcer. Some calluses may have been associated with blistering.

Treatment usually consists of removal of the offending thickened corn or callus. The application of various paddings may be useful depending on the site. Moisturising type creams may be required. Many patients are happy with this treatment and manage the problem with regular Podiatry visits. Other situations require assessing and addressing the cause. This may include assessment of the foot type and balancing abnormal forces with various insoles or orthotic devices.

Some regions of the foot can be treated with surgical procedures to correct the malposition or remove bony growths causing the problem. In some individuals, corn and calluses may develop into ulcers. This is serious in people with diabetes or conditions leading to poor circulation. Dr Marino, Podiatric Surgeon, can assist you with surgical consultation.

These include conditions such as Psoriasis, Eczema, Trauma, Splitting, Bacterial infections, Clubbing, Other discolouration, Melanoma etc. The Podiatrist will determine the likely diagnosis, and referral may be required in some cases to exclude other causes.

They are also known as tinea pedis, a fungal skin infection that causes scaling, flaking, and itching of affected areas. It is typically transmitted in moist communal areas where people walk barefoot, such as showers or bathhouses. The disease requires a warm, humid environment, such as the inside of a shoe, to incubate.

Tinea pedis most often manifests between the toes, with the space between the fourth and fifth digits most commonly afflicted.

Antifungal treatment will be required.

CentrePod Podiatry Podiatrists can assess and treat this condition.

Onychomycosis is estimated to affect up to 1.6 million Australians. Currently available treatments include topical antifungal nail lacquers applied daily/weekly and oral medications. The frustration of months of topical application and long-term oral medicines can lead to non-compliance and failed therapy. Oral medications can also produce adverse effects, limiting suitability.

Photodynamic Therapy offers treatment not requiring medication or active patient involvement. Photodynamic therapy has now been developed and adapted for successfully treating fungal nails without damaging side effects.

Micro organisms, including bacteria, viruses and fungi, all possess a cell wall, whereas typical human cells have a cell membrane. Photodynamic therapy (PDT) involves using photochemical reactions mediated through the interaction of photosensitising agents, light, and oxygen. Following the application of the gel photosensitising agent, the pathological site is exposed to a specific wavelength of light (630nM). This mediates cellular toxicity/damage-inducing fungal cell death without affecting the surrounding tissue. The nail is restored with growth.

Plantar warts or plantar verruca are dense, benign lesions of the bottom of the weight-bearing aspect of the foot caused by infection with the human papilloma virus (HPV). Verruca means “wart”, and plantar means “the region of the bottom surface of the foot”. Once the skin is infected with the virus, it may remain latent within the deep skin layers or develop and become clinically observable. The plantar verruca may appear in a solitary, multiple or mosaic-type pattern. It does not cross the blood barrier and is therefore difficult for the body to fight the virus. Verruca may appear in other areas of the foot, for example, on the top of the bridge, but these have different characteristics to the plantar verrucae. They tend to be more prominent, whereas the plantar verruca tends to be flatter because, with weight-bearing, the wart gets pushed into the foot and becomes deep-seated.

Plantar warts may occur at any age but more commonly affect the young, elderly and immunosuppressed.

The wart virus may be attained with the use of shared facilities such as swimming pools, sports centres and gymnasiums. Another method of inoculation may occur through a mechanical or micro-injury of the skin. Hence wart infections are likely to occur during barefoot activities or when the skin has been wet for some time, e.g. swimming, sweating and showering. Unfortunately, as the virus may remain latent within the skin layers, it can still spread to other hosts. It is also known that the virus is prevalent and difficult to treat in those with poor immunity.

Common features of plantar warts include loss of skin pattern, presence of many minute dark spots being the tips of blood vessels, callus formation, pain with compression and sometimes weight-bearing. Symptoms may vary from nil to severe pain and discomfort depending on the size and location of the plantar wart. Pain may be elicited with lateral compression of the verrucae. Spot bleeding may occur with removal or injury of the skin or callus overlying the wart due to its vast blood supply.

In some cases, the virus may regress spontaneously between 2 weeks to over two years, but this is not predictable. If there is a concern with the virus's possible spread or pain is present from the wart, the following treatment options may be considered.

• Cryotherapy or freezing of the wart
• Keratolytic agents to break down skin tissue
• Caustic agents to chemically "burn" the wart
• Electrocautery to destroy the lesion
• Curettage or surgically "scooping out" the lesion
• Surgical excision requiring stitches to close the wound
• Others including Homeopathy - zinc supplementation to boost the immune, Cimetidine tablets (gastric ulcer tablets), Various chemical injections, Duct tape, Needling the lesion; Wives tail remedies (banana peel on the wart, taping a coin over the lesion)

Combinations of the above treatments may be considered if the virus and or lesion is stubborn or becomes resistive to a particular treatment. Removing a specific wart may prove successful, but on occasions surrounding dormant virus may produce more warts, not necessarily the original wart returning. Patience is required in the treatment of this condition. Healing at the site of the wart removal may take some time.

The arteries supplying blood to the feet and toes are affected by diabetes. This results in less blood flowing through the arteries. This lack of blood flow affects the tissues; therefore, any cut or wounds to the feet will not heal quickly. This increases your risk of infection or an ulcer. If the blood supply is reduced, there is inadequate nutrition of the tissues, and if damaged or infected, the body has a reduced ability to heal and also reduces the ability of any antibiotic reaching the site.

• Sharp cramping in legs or feet when walking short distances
• Sharp cramping or pain in legs or feet when resting or sleeping
• Feet are cold to touch
• Skin appears red/blue in colour
• Slow to heal cuts or abrasions
• Loss of hair on toes and top of the foot
• Dry, thin skin
• Weak, distorted or slow-growing nails

Diabetes affects your nerves. It may only be temporary but is more likely to cause permanent damage. The degree of nerve damage is often related to the time you have had diabetes and the stability of your blood glucose levels. Low, high or irregular blood glucose levels cause damage to small nerves. This is termed neuropathy.

Neuropathy increases the risk of injury as you lose protective sensation and or motor nerve functions. Hence, you may overlook injuries without protective sensation and consequently fail to care for them appropriately.

• Pain or burning feeling in the feet 
• Hot or cold sensation 
• Numbness 
• Pins and needles or tingling in the feet 
• Weakness of the feet or legs 
• Some instability 
• Injury, lesions or ulcers without pain 
• Sharp shooting pains in the feet and or legs

As a precaution to avoid injury to your feet the following steps should be performed daily.

1. CHECK YOUR FEET: This is important as the sensation to your feet may be impaired. If you have trouble reaching your feet use a mirror to check the soles of your feet. You should be aware of any cuts, scratches, abrasions, blisters, cracks, corns and calluses. 
2. Cuts and blisters should be treated appropriately, and corns and calluses removed by a Podiatrist on a regular basis. This is important in reducing your risk of infection and ulceration. 
3. Wash your feet well and dry them carefully, check between toes. 
4. Moisturise with a suitable cream (avoid cream between the toes). 
5. Use clean cotton or woollen socks that are not too tight. 
6. Protect your feet indoors and out with shoes that fit well. 
7. Take extreme care or avoid heaters, hot water bottles or cold to your feet. 
8. Seek professional advice with foot care. 
9. Avoid corn plasters or any products with acids unless directed to do so by a trained health care professional. 
10. In case of injury, wash and pat dry the area. Apply a good antiseptic (e.g., Povidone Iodine) and cover with a sterile dressing. If no improvement is noted within 24hrs seek professional help to avoid complications.

You should check your feet daily; with regular assessment of your feet carried out by your doctor, podiatrist, or diabetic nurse. Seek professional help if you have any open wounds, corns/calluses, ingrown toenails or if you are unable to care for your own toenails, if your feet are unusually red or swollen or if you have any concerns regarding your foot health.

Interdigital corn is often termed soft corn. It is a dense thickening of skin between the toes in regions with impingement or rubbing. Often the condition is present between the 4th and 5th toes or with deranged toes. This depends on the shape, level of bony prominence and the amount of flexibility the toe displays. In simple terms, it is best described as impingement between two distinctions. This is a common condition and causes problems when footwear contributes to constriction.

• Redness, inflammation or pain between toes
• Pain associated with a small thickened area of the toe
• Often associated with deformed toes or prominences
• There may be overlapping toes
• Skin may breakdown causing ulceration which can become infected
• A smelly white region may be noted between the toes

• Foot mechanics – pronated/flat feet producing toe deformities 
• Prominence of joint or small bone spur of toe 
• Poor/tight footwear 
• Rheumatoid or other arthritic conditions 
• Previous damage to toes

Treatments vary depending on the severity of pain and deformity. The main goal of early treatment is to remove the impingement;

• Padding/strapping
• Wearing correct fitting footwear that has a wide and deep toe box
• Corns and calluses can be managed by Podiatric treatment.

Foot orthoses to realign the foot to a more "normal" position and assist in balancing the tendons, stabilising the toe joints and halting or slowing the progression of the deformity.

Surgery – When conservative treatment does not provide satisfactory relief from symptoms or when the condition interferes with activities, surgery may be necessary. Evaluation by a podiatric surgeon should be sought at the first sign of pain, any concern or discomfort so that severe deformity can be avoided.

Common Conditions include heel pain, shin splints, stress fractures, Achilles pain, knee pain, ankle pain and lower back pain, to name a few. The foot type can also cause bunions, clawed toes and nerve entrapment problems. Injuries and issues of this nature that are left poorly treated are often ongoing and very frustrating to the sufferer.

Early detection reduces the frequency and severity of injury or problems.

At one time, flat feet/fallen arches were considered a "deformity" that prevented entry into the armed forces due to the correlation between this foot type and foot/leg problems.

Parents are often concerned with children and this foot type, often being a standard variant or family trait. There may be no associated pain. It will not always cause problems in adulthood, but the likelihood is higher depending on the flat or high arched foot type. The foot should be assessed to determine this.

Pain-related to poor foot position should be addressed. This requires special insoles or orthotics to assist in maintaining the foot in a more neutral or normal position. The appropriate insole or orthotic device for either a pes planus or pes cavus foot type is prescribed following the podiatrist's assessment of the foot and lower limb mechanics. See "Orthotics".

The plantar fascia is located in the sole. It is a tough fibrous band that stretches from under the surface of the heel bone. It runs under the foot, fanning out to attach to the base of the toes and functions to maintain the foot arch. The medial aspect of the band (region towards the midline of the body) has a thicker and denser structure. This band can become inflamed or injured, termed plantar fasciitis. A common cause of heel pain is "heel spur syndrome", an inflammatory condition of the plantar fascia at its attachment site into the heel bone and, in severe cases, a heel spur due to a strain or overuse.

The most significant plantar fasciitis incidence is in middle-aged men and women. Strain is also caused in those who partake in high-impact sport, constant exercise or long hours of work duty. The overweight is also prone to plantar fasciitis because of the increased load on their feet.

It generally starts as a dull pain in the arch or on the bottom of the heel and may progress to sharp, persistent pain. It tends to feel worse in the morning due to the sudden elongation of the plantar fascia tissue band, which has contracted during the night. As in other overuse injuries, the pain develops at the beginning of a workout but may diminish during running, only to recur at the finish or later.

The most common cause of this condition is overuse and stress on the fascia or pulling away from the heel bone, usually associated with poor support from the bony arch of the foot. This causes inflammation and pain. Every step taken is an aggravation, and the condition worsens. The pulling away from the bone by the fascia causes inflammation and may lead to the development of a bone spur as new bone is laid down. The inflammation causes the pain, not the spur. Occasionally, local nerves may become sensitised.

Factors that may cause or contribute to the development of this painful heel condition. 

• Biomechanical abnormalities of the foot or lower leg i.e. flat pronated feet, high arched rigid feet, tight calf muscles 
• Tight plantar fascia 
• A sudden increase in training intensity
• Inappropriate/improper shoes for the activity or foot 
• • Toe running, hill running 
• Soft terrain, e.g. running on sand 
• Age and decreased fatty heel pad 
• A result of an injury 
• Arthritic or other medical inflammatory condition 
• Possible associated nerve entrapment 

Treatment aims to reduce inflammation, restore tissue strength and flexibility and improve any biomechanical abnormality.

• Ice packs for 15-20 minutes, several times daily, especially after activity
• Contrast footbaths – warm and cold. Immerse the feet in one footbath for 2-3 minutes, then alternate to the other and repeat the process
• Stretches for the plantar fascia and calf muscle
• Massage of the heel and plantar fascia
• Well-fitting shoes with a supportive arch, heel pad and heel cup
• Weight loss
• Foot taping to reduce stress on the plantar fascia and improve foot biomechanics
• Anti-inflammatory medication – oral and topical
• Podiatry assessment for biomechanical abnormalities requiring orthotics
• Physiotherapy, laser, acupuncture, shockwave therapy etc
• Cortisone injections
• Podiatric Surgical review for possible fascia release
• Podiatric Surgical review for a possible nerve problem

Achilles Tendinitis is an inflammation of the large tendon in the back of the lower leg known as the "Achilles' tendon". There are cases without the usual process of inflammation, termed tendinosis or tendinopathy. The inflammation and pain are associated with physical activity and overuse. In some instances, pulling the Achilles tendon can result in spurring or calcifying the tendon at the site of insertion at the back of the heel. This may be associated directly with the Achilles tendonitis/tendinosis or as an isolated entity. The tendon's thin lining, called the paratenon, may become inflamed, similar in symptoms.

Achilles tendonitis/tendinosis can occur at any age and is common in active individuals, particularly those involving running or jumping. However, as one ages, the Achilles loses some of its resilience, with more tendency to the condition. As one ages, the tendon becomes more like a "brittle rope" rather than a thick, strong "elastic band".

Poor circulation to the Achilles tendon contributes to tendonitis/tendinosis, a chronic condition.

In some cases, rupture of the tendon may occur. The Tendon lining can also be involved in the pathology..

The following symptoms are often associated with Achilles' tendinitis:

• Pain may be immediate in onset or may begin gradually and worsen with activity 
• Swelling may be localised or diffuse 
• Pain when pressing along the tendon course or specific site 
• Pain at the back of the heel 
• Limping to avoid weight-bearing
• Crepitus or creaking with movement along the tendon

• Physiological changes to the tendon tissue with age
• Overuse ("too much - too soon")
• Biomechanical abnormalities of the foot and leg, including flat feet, tight leg muscles, and high arched feet, all causing bowing or overload of the tendon
• Poor or inappropriate training regime or surfaces
• Inappropriate footwear
• Direct trauma
• Other: Various arthritic conditions, and nutritional, hormonal or metabolic abnormalities may affect the health of the tendon

• Rest
• Anti-inflammatory and or analgesic medication
• Physical therapies: ice, heat, massage, electrotherapeutic modalities (ultrasound, TENS, myofascial therapy techniques)
• Gentle calf stretching
• Heel raise – short term
• Prevention: o Address any biomechanical abnormalities o Warm up before and after exercise o Address the cause, eg. footwear, training regime
• Injection therapy or surgical intervention may be required in some instances

Bunions are one of the most common deformities of the forefoot. The first metatarsal bone is displaced towards the mid-line of the body. A simultaneous displacement of the great toe away from the mid-line (and towards the smaller toes). This causes a prominence of bone on the inside margin of the forefoot. This is termed a "bunion", with continued drifting of the great toe (hallux) towards the smaller toes. The smaller toes may be forced into a clawed position and ride up over the big toe. There are different stages of bunion development, depending on the severity of the angulation of the big toe. Arthritis can also develop, producing pain within the joint.

Bunions are common in people who have a family history of deformity. Women are more prone to developing bunions than men, most likely due to a predisposition to the condition and sometimes triggered by poor footwear. Wearing narrow, tight, confining or high-heeled shoes can significantly accelerate the formation of a bunion. Middle age to older people is more likely to suffer from bunions. Bunions can affect children and young people.

Redness, inflammation, pain and  or stiffness around the big toe

• Moderate to severe discomfort at the bunion when wearing shoes
• Calluses and corn development on the outside of the big toe. Between the big toe and the second toe and or underneath the big toe and ball of the foot
• There may be overlapping of the second toe, causing a hammer toe
• Skin over the bunion may breakdown causing ulceration which can become infected

Foot mechanics – pronated/flat feet producing an excess load of the 1st toe joint

• Family history of bunions. However, it is the foot type that is hereditary, not the bunion 
• Poor/tight footwear – particularly in those already predisposed to bunions 
• Arthritic conditions
• Trauma or previous surgery around the great toe joint

Treatments vary depending on the severity of pain and deformity. The main goal of early treatment is to relieve pressure on the bunion and smaller toes and to diminish the progression of joint deformities;

• Padding the bunion to protect the bony prominence from shoe pressure 
• Wearing correct fitting footwear that has a wide and deep toe box.
• Corns and calluses can be managed by Podiatry treatment. 
• Medications, such as anti-inflammatory drugs or cortisone injections, may be used to ease pain and inflammation. This is especially useful if there is an associated bursitis. 
• Foot orthoses - realign the foot to a more "normal" position and can assist in balancing the muscles around the big toe, stabilising the joint and halting or slowing bunion development. 
• Surgery – Surgery may be necessary when conservative treatment does not provide satisfactory relief from symptoms when the condition interferes with activities or concerns the foot shape. Evaluation by a podiatric surgeon is advised at the first sign of concern, pain or discomfort so that severe deformity can be avoided.

A contracted toe is often termed a clawed mallet or hammertoe. This depends on the level and the amount of flexibility that the deformity displays. In simple terms, it is best described as a buckling of the toe. This is a common condition that causes problems when footwear rubs on the top of the toes, producing corns or calluses. The tips of the toes may also be affected due to ground contact.

Clawed/hammer toes are common in people with a family deformity history. Women are more prone to having discomfort, most likely due to poor footwear. Wearing narrow, tight, confining or high-heeled shoes can significantly accelerate the formation of clawed toes and associated corns. Men may have trouble in specific sports footwear or work wear. Hammertoes are often associated with a bunion.

• Redness, inflammation, pain and or stiffness top of toes
• Pain around the "balls" of the feet due to retraction of toes causing dysfunction
• Possible associated bunion
• Calluses and corns at the toes and or the ball of the foot
• There may be overlapping toes
• Inflammation around the joints of the toes and possible fluid under the skin around the joint (bursitis)
• Skin over the toe joints may breakdown causing ulceration which can become infected
• Toenails may become thickened or distorted

• Foot mechanics – pronated/flat feet are producing tendon imbalance.
• Family history
• Poor/tight footwear – particularly in those already predisposed
• Rheumatoid and other arthritic conditions
• Neurological problems affecting muscles of the lower leg

Treatments vary depending on the severity of pain and deformity. The main goal of early treatment is to diminish the progression of joint deformities, these include;

• Padding, strapping or toe splints
• Wearing correctly fitting footwear that has a wide and deep toe box
• Corns and calluses can be managed by Podiatric treatment.
• Foot orthoses. - For example, if flat feet are the cause, custom-made functional foot orthoses may be required to help support and control abnormal foot movement. Making the foot more stable assists in balancing the tendons, stabilising the joints and halting or slowing the progression of the deformity.
• Surgery may be necessary when conservative treatment does not provide satisfactory relief from symptoms or when the condition interferes with activities. Evaluation by a podiatric surgeon should be sought at the first sign of pain or discomfort so that severe deformity can be avoided.

Hallux rigidus is used to describe a limited amount of ‘upward motion’ or dorsiflexion of the big toe joint. The restriction of motion and pain associated with hallux rigidus is often attributed to mechanical jamming of the joint and or the presence of arthritis. X-ray investigation will often illustrate a loss of joint space with the presence of osteophytes (small bone fragments) and other indicators of arthritis.

Hallux rigidus may affect the adolescent to adult populations. Still, early signs of limitation in joint function often can be identified with certain foot types in the younger age group, which may develop into significant hallux rigidus. This usually is a foot type that overloads the 1st toe joint.

These include the following, with not all necessarily present;

• Intermittent pain of the great toe joint that is worsened by activity
• Pain may be exacerbated with high-heeled footwear or cold, damp weather
• Joint stiffness and decreased or loss of motion
• Grating may be noted in the joint
• Local swelling and redness
• Pain over the bony prominence (exostosis) with footwear
• Pain along the joint line
• Callus and corns on the mid-bottom region of the great toe
• A cocked-up end portion of the great toe with possible nail distortion
• Walking either intoed or out toed to prevent excess load on the joint
• Pain of the ball of the foot due to walking differently and hence overloading this region
• A bunion or angulation of the big toe towards the 2nd may be present
• The flexing region of the sole of the shoe is more towards the toes than normal

Hallux rigidus may result from several different factors outlined below:

• The mechanical jamming or impingement of the top (dorsum) of the big toe joint resulting in arthritis formation.
• The shape of the metatarsal head
• A long or short first metatarsal may result in increased pressure or abnormal forces through the joint
• Elevated first metatarsal causing excess load and malfunction through the joint
• A pronated or ‘flat foot.’
• Trauma to the joint e.g. stubbing, sport or activity such as soccer, dance etc
• Arthritic conditions such as rheumatoid, gout, joint infection etc

• Anti-inflammatory medication to assist in pain reduction
• Mobilisation of joint exercises in early signs of limitation
• Local anaesthetic and or cortisone injections
• Footwear modifications, eg. Extra-depth/width or rocker bar sole
• Address biomechanical factors such as flat feet etc. that cause an overload of the 1st toe joint with appropriate insoles/orthotics prescribed by the Podiatrist

Surgical procedures: May include some or all of the following

• Removal of excess bony spurs or fragments
• Removal of inflamed joint tissue
• Release contracted tissue to enhance joint motion
• Removal of portions of damaged cartilage
• Correcting position of 1st metatarsal
• Removal of the degraded joint surface and creating a modified and greater joint space to improve motion
• Possible joint implant
• Fusion of the eroded joint

Dr Nick Marino, Podiatric Surgeon, can assist you with this problem.

An intermetatarsal neuroma is a type of nerve entrapment or irritation. It most frequently involves the forefoot nerve that supplies sensation to the ball of the foot and adjacent sides of the 2nd and 3rd and or 3rd and 4th toes, but can also affect other toes of the foot. A neuroma is a benign thickening of the nerve that develops when the nerve between two metatarsal heads is traumatised. A neuroma is a reactive, degenerative process. Intermetatarsal bursitis (inflamed bursa) is often in association and exacerbates symptoms.

Women are affected at least four times more than men, and the condition can affect adults of any age.

The symptoms vary from occasional pins and needles, numbness or burning sensation to a sudden pain on the sole of the ball of the foot, which can bring the sufferer to a halt. The pain frequently radiates forwards into one or two toes. A painful attack typically occurs suddenly after a period of walking or standing on a hard or possibly uneven surface. Shoes, which constrict the forefoot or are higher heeled, may precipitate or worsen the pain, and removing the shoe and massaging or squeezing the forefoot often gives relief, as does rest.

Several factors contribute to its occurrence. Any condition that causes constriction or irritation of the nerve can lead to the development of an intermetatarsal neuroma.

• Abnormal shearing stresses in the area due to excessive pronation/flattening of the foot
• Unstable feet are often associated with bunions etc
• Highly arched feet with retracted toes.
• Footwear that constricts the forefoot, i.e. high heels
• Trauma

The goal of treatment is to reduce or eliminate symptoms and maintain a normal lifestyle. It is expected that the vast majority will gain significant improvement from therapy. Treatment may be conservative (non-surgical) or surgical. Non-surgical treatment is usually attempted before surgical intervention.

• Padding and or strapping to reduce the pressure of weight-bearing on the affected area and also to improve functional alignment
• Footwear recommendations
• Appropriately designed orthoses or arch supports to restrain abnormal pronation
• Physical modalities
• Anti-inflammatory and analgesic medication as indicated
• Cortisone injection or other injection therapy

These conservative non-surgical therapies may provide complete or partial relief of symptoms. However, on occasions, minimal or no relief is achieved conservatively. This means that the condition is more sinister and requires more assertive treatment.

A neurectomy or surgical removal of a neuroma is performed when conservative treatment proves ineffective. This can be performed by either local or general anaesthetic. The initial choice of incision is on the top of the foot to allow walking as soon as possible (as shown below). The procedure is usually on a day case basis. The decision to surgically intervene is based on the severity of symptoms following clinical review and diagnostic modalities.

Tailors bunions are a common deformity of the forefoot. The fifth metatarsal bone displaces outwards away from the mid-line of the foot, and a simultaneous displacement of the fifth toe towards the fourth. This causes a prominence of bone on the outside or upper margin of the fifth metatarsal head region; this is termed a “Tailors Bunion” or “Bunionette”. Continued drifting of the fifth toe towards the fourth toe may force it into a clawed position and ride up over or under the toe. There are different stages of Tailors Bunion development, depending on the severity of the angulation of the fifth toe or prominence of the fifth metatarsal head. Arthritis can also develop, producing pain within the joint.

Tailors Bunions are common in people who have a family history of deformity. Women are more prone to developing Tailors Bunions than men, most likely due to a predisposition to the condition and sometimes triggered by poor footwear. Wearing narrow, tight, confining or high-heeled shoes can significantly accelerate the formation of a Bunionette.

• Redness, inflammation, pain and or stiffness around the fifth toe joint 
• Moderate to severe discomfort at the Bunionette when wearing shoes 
• Calluses and corn development on the outside of the fifth toe or between the fifth and the fourth toe 
• There may be overlapping or under riding of the fifth toe 
• Skin over the Bunionette may breakdown causing ulceration which can become infected

• Foot mechanics 
• Family history of Tailor’s Bunions. 
• Poor/tight footwear – particularly in those already predisposed to Tailors Bunions 
• Arthritic conditions
• Trauma or previous surgery around the 5th toe joint.

Treatments vary depending on the severity of pain and deformity. The main goal of early treatment is to relieve pressure on the bunionette and smaller toes and to diminish the progression of joint deformities;

• Padding the bunionette to protect the bony prominence from shoe pressure
• Wearing correct fitting footwear that has a wide and deep toe box.
• Corns and calluses can be managed by podiatric treatment.
• Medications, such as anti-inflammatory drugs or cortisone injections, may be used to ease pain and inflammation. This is especially useful if there is an associated bursitis.
• Foot orthoses - realign the foot to a more “normal” position and can assist in balancing the muscles and tendons, stabilising the joint and halting or slowing bunionette development.
• Surgery – Surgery may be necessary when conservative treatment does not provide satisfactory relief from symptoms when the condition interferes with activities or there is a concern with the foot shape. Evaluation by a Podiatric Surgeon should be sought at the first sign of concern, pain or discomfort so that severe deformity can be avoided.

“Shin Splints” is a term to describe shin pain along the front and or inner aspect of the shin associated with overuse or overload of the shin bone and or the adjacent muscles. The shin pain may be due to increased pressure within the muscle of the calf (compartment syndrome) or, in some instances, a result of inflammation of the lining of the shin bone (periostitis) and, in extreme cases, stress fracture of the shin bone.

Shin pain can occur at any age and is most commonly seen in athletes or higher activity individuals, particularly in those involved in jumping or running activities.

• Pain along the inner and or outer borders of the shin 
• Pain may worsen with activity and ease with rest. 
• Feeling of deep shin pain and or persistently tight musculature 
• Pain may be elicited by pressing along the shin bone or its adjacent muscles 
• The shin border may have a localised region of greater pain 
• The shin border may have small areas of prominence associated with pain.

• Repetitive loading or overuse 
• Abnormal biomechanics of the foot and or leg 
• Tight musculature 
• Training regime 
• Training surfaces 
• Footwear 
• Trauma

Treatment may vary according to the causative factors of the individual's shin pain. Some treatments commonly utilised are:

• Rest and adjustment of training regime to reduce the impact on the shins and to prevent further damage
• Anti-inflammatory medications
• Assessment of foot and lower limb biomechanics
• Foot strapping
• Orthoses
• Myofascial therapy
• Acupuncture or Dry Needling
• Footwear advice
• Physiotherapy
• Surgical intervention may be required in some instances

• Warm up before and after exercise 
• Improve muscle strength and flexibility 
• Avoid sloping and uneven surfaces 
• Gradual build-up of training load, incorporate rest days 
• Address any abnormal biomechanical factors

Young active males aged between 8 and 14 are affected more commonly than girls.

The symptoms often involve pain at the back of the heel. A slight limp may also be noticed. The child may also have a reduced amount of ankle joint motion. The Achilles tendon insertion site is often tender with palpation and lateral compression. The pain is often felt to be worse after activity. Constant pain and swelling are more commonly seen in chronic cases. X-Rays usually fail to represent any significant findings apart from a fragmented growth plate but may be required to exclude other causes of pain.

Several factors may contribute to the occurrence of this heel pain.

• Tight Achilles tendon 
• Rapid growth 
• Trauma 
• Reduced heel shock absorption 
• Abnormal foot biomechanics 
• Poor footwear or training regimes 
• Overweight

The goal of treatment is to reduce symptoms and address any causative factors contributing to heel pain. Remember, this form of heel pain is self-limiting and will resolve with growth plate closure, but the time taken for this can vary between children. This commonly occurs between the ages of 12 and 15 (sometimes later depending on child development). In the meantime the following treatments may be suggested:

• Rest with activity or training regime alterations
• Address any abnormalities of the biomechanics of the feet with insoles or orthotics
• Physical therapies e.g. ice and heat treatments
• Anti-inflammatory medication
• Stretching exercises
• Heel raise in shoe
• Increase shock absorption in footwear/insoles
• Appropriate footwear

Patello-femoral pain is one of the most common causes of knee pain involving the patella (knee cap) and surrounding soft tissue. It can result in diffuse or sharp pains felt either surrounding or behind the patella or deep inside the knee and can sometimes be associated with referred pain to the back of the knee. The condition is often referred to as "runner's knee" or "chondromalacia patella".

The patellofemoral syndrome is a common condition experienced in all ages, predominantly active or sports people. It affects one in two adolescent athletes and one in four adult athletes.

The pain is due to an overuse of inflammatory syndrome at the back of the knee cap, causing pain and swelling. It tends to be aggravated by any bent knee activity, such as running, kneeling, squatting, sitting for prolonged periods, or taking stairs with going down worse than up. Often, this is associated with creaking or grinding sensations under the knee cap.

In a normal knee, the patella glides up and down. Through a groove in the bottom end of the femur. When the knee is flexed (bent), the pressure between the patella and femur is increased, and or repeatedly causing this increased pressure can lead to irritation, which in turn causes an inflammatory response. This pressure is increased if the patella does not ride smoothly through the groove but 'tracks' more to one side. This is the effect of a muscle imbalance between the medial (inside) muscles called vastus medialis and the lateral (outside) muscles of the thigh. The inside usually being weaker or placed at a mechanical disadvantage, with the leg internally rotating through the walking or running cycle. The patella's tight outer fascia or retinaculum can also pull the patella outward. A portion that internally rotates with flattening the foot also has this effect. Any imbalance results in the patella rubbing against the femur unevenly. The inflammation causes pain, swelling, and further muscle imbalance and may lead to roughening of the cartilage of the underside of the patella.

Other factors that contribute to this type of pain include:

• Previous knee injuries
• Poor lower limb biomechanics, including pronated or flat feet, internal knee position (squinting patella), narrow groove in the femur, wide hips increasing femur angle (Q angle), asymmetrical patella, knocked knees
• Tight outer leg muscles or fascia/retinaculum
• Weak inner leg muscles
• Enhanced training schedule
• Surface terrain used for activity
• Technique deficiency

The treatment for this condition is aimed at reducing pain and inflammation and restoring the correct mechanics of the joint.

• Resting the knee, i.e. avoid any activity that causes pain. Continuing painful exercise will aggravate the condition. In particular, avoid activities such as squatting, kneeling, stairs, sitting for prolonged periods with knees bent etc.
• Ice therapy, applied with leg straight for 20 minutes 2-3 times a day and after any activity
• Anti-inflammatory medication may be prescribed
• Physiotherapy including ultrasound, electrical stimulation, taping and exercises
• Appropriate assessment and correction for abnormal lower limb mechanics, including the effect of foot malposition requiring orthotic devices prescribed by the podiatrist
• Correct muscle training, stretching and strengthening of the thigh muscles
• Proper training principles, i.e. warm-up and down, gradual increases in activity level. Non-weight-bearing activities such as swimming may be more appropriate during the initial treatment.
• Proper footwear for the nature of activity and foot type
• Maintain desirable body weight
• Braces or supports to hold the patella in the groove
• Possible surgery to release tight fascia, remove damaged cartilage or re-align the angle of the patella tendon
• Provided treatment is commenced before the onset of significant changes to the patella joint surface, conservative treatment has a high success rate.

• Heel Pain 
• Foot and Ankle Pain and Recurrent Sprains 
• Flat Feet 
• Imbalance 
• Achilles Tendonitis 
• Other Tendonitis
• Shin Pain 
• Knee Pain 
• Hip Pain 
• Lower Back pain 
• Limb Length Imbalance
• Bunions and Clawed toes 
• Morton’s Neuroma