Preventing fungal infections in the feet

& Nail care after laser treatment

Fungal spores are a natural part of everyone’s skin flora.  No matter what you do, these bugs are everywhere all the time. However, it is important for the prevention of infection (or re-infection) that you control the numbers of fungi in your environment, even if we can’t remove them all.

The main culprits that allow infection to enter the skin or nails are:

•    Contaminated footwear and hosiery
•    Waterlogged skin
•    Defects in the shiny nail surface
•    Contamination from another human

Reducing the fungi in your environment.

Don’t let perspiration build up in your footwear.   Sweat is very nutritious stuff as far as fungi and bacteria are concerned.  It is obviously a lot easier to launder a sock than it is to effectively clean the insides of your shoes so always use some kind of stocking in closed shoes.  It is also a good idea to use a disposable insole like an odour-eater than can be replaced at regular intervals.

Light and air are the natural enemies of these micro-organisms. If your shoes have a removable insole, pull it out to air at night.  Expose it to the sun when you can.  The more open toed, airy footwear you can adopt, the better the chances of success. Avoid using the same shoes everyday to give them time to  dry and don’t stuff socks into shoes after wearing, inhibiting evaporation.

Use an anti-fungal product in your shoes and on your skin to reduce the colonisation by fungi.

Soak socks well in an anti-fungal laundry product such as Milton’s solution.

Keeping feet dry.

Dry feet well, paying particular attention to the areas between the toes.  As much as possible, time bathing and swimming so that your feet have time to dry out completely before putting on socks or shoes.

Use an anti-perspirant to reduce sweating from the glands in the feet.

If you get sweaty during the day, change socks at half time.

Keep your nails reasonably short to discourage the build up of debris, a haven for infection. Keep thickened skin down as dead upper layers of the skin have no resistance to infections.

Do not use nail polish for more than a day or two at a time.  Nail polish will paint the fungal spores in place onto your nail, allowing them to invade the nail.  Polish is also like a vinyl layer that traps moisture into the waterlogged tissues after bathing.

Physical Trauma

As nails are not living tissue, the only barrier to fungal infection of a nail plate is the shiny surface of the nail. It should not be disturbed by pushing back the cuticles, buffing, scraping or polishing the nail.  Application of adhesive gel nails should always be avoided.  Shoes should not fit too loosely, allowing the foot to slide forward bruising the nails.

Contamination & Cross Infection

If you have had a fungal nail infection , any bladed tools that have been used on the affected nails can be cleaned with bleach and water.  Files should be disposed of as should any open bottles of nail polish used on those nails.

Nail salons should be avoided unless they met the following standards:

 Water must be changed between patrons
 The tub must be cleaned between patrons
 If water is sucked through a spa, the inner receptacle must be cleaned regularly
 Pedicure tools MUST be presented to you in a sterile pack, having passed through an autoclave.
With autoclaves costing between $5,000 to $10,000, you need to consider if the salon you choose values your health enough to incur this sort of costs. Remember that any tools used in a pedicure may draw blood. The number one pathogen that is spread in a pedicure salon is fungal, followed by bacterial and then viral.

Viral infections can be the most serious – they include HIV and Hepatitis B and C. Fortunately, these virus are relatively easy to kill although salons that do no sterilisation do not protect you adequately against these life – threatening diseases.

Fungal infections are the hardest to prevent, though on the upside, these infections are generally not a threat to life and limb. Things that don’t kill fungi include:  alcohol, heat, blue light, ‘sterilisers’ and rinsing / scrubbing.  Things that do kill fungi make a much briefer list.

Nail polish pots can also be a source of infection.  If the person before you has a fungal infection, using the paint and brush that was used on them will nicely paint the fungal infection in place on your nail where it is easy for it to feast on your nail tissue.

When you think about it – who is likely to have been the client before you at a nail salon ?  Someone whose nails are ugly because of fungus ?  Someone who often frequents nail salons and is therefore prone to already having fungal nail infection ?

Headaches and Feet

Does standing and walking cause Headaches?

If you regularly suffer from headaches on days involving a lot of standing or walking, it is possible that poor foot mechanics can be the cause. Each day, we walk and stand on hard unyielding surfaces.  Our feet have a natural method of absorbing shock  which is hampered  by excessive foot pronation.  This means that, for nearly 40% of us, the feet waste their natural ‘bounce’ at the wrong time in the gait cycle. This leads to a jarring effect travelling up the body. This chain-reaction creates affects throughout the body – including the feet, shins, kneecaps, hips, shoulders and even result in headaches & and neck pain.  In some extreme cases, even temperomandibular joint affects (your jaw’s hinge joint) have been reported.  While you might take an anti-inflammatory or aspirin to ease short term pains, that is not an suitable answer in the long run. You should always aspire to treat the cause and not just the symptoms. To assess if your feet are affecting you this way, call today to arrange an appointment for assessment by our podiatrist.  The answer may be simpler than you think !

Sinus Tarsi Syndrome:

What is Sinus Tarsi Syndrome?

Sinus Tarsi and the Lateral Subtalar Joint

The sinus tarsi is a bony canal inside the foot.  It runs roughly crossways (like left to right) just in front of the outside ankle bone.  If you feel that area, you will find a deeper spot where you can push your finger further inwards than in the bony areas that surround it. The canal is formed by two ‘half-pipe’ like grooves carved into the bones that meet there – the Talus on the top and the Calcaneus (heel bone) on the bottom.  Inside the canal is a ligament, blood vessels, nerves, fat and some gristle-like tissue that binds the bones together. The joint that is made up by those two bones is called the subtalar joint.  This joint sits ~3 cm below the ankle joint and, where the ankle joint can only move in one plane (up and down like a nodding head), the subtalar joint is where your foot can move in every plane.  This allows it to make circular rotations and to cope with uneven terrain underfoot.

In true sinus tarsi syndrome, the tissues in the canal will show laboratory signs of inflammation, cellular damage and fibrosis – an overgrowth of tissue similar to scar tissue.

Subtalar Joint and the Sinus Tarsi

The underlying cause of the damage might be:

•    a tear of the ligament that binds subtalar joint together
•    damage to the cartilage of the joint (an osteochondral defect)
•    injury to the subtalar joint, especially where the joint ends up less tightly bound together allowing too much motion to occur
•    degenerative disease of the subtalar joint
•    a birth condition that binds the two bones together too much
•    long term inflammation of the soft tissue within the sinus

What are the signs and symptoms of Sinus Tarsi Syndrome ?

Pain will be felt in the location of the sinus tarsi, near the outside ankle bone as described above. Walking on uneven ground is usually painful and often there is a history of ankle injury. To test for the condition, pain is usually worsened by standing on the feet and tipping the soles inwards – like a sprained ankle position.  The pain will be temporarily relieved by injecting local anaesthetic into the canal. This is a diagnostic test – not a treatment – as the effect only lasts a few hours.

X rays of the joint are generally normal unless the deterioration is caused by something that is visible on films, such as degenerative arthritic disease. MRI is the investigation of choice and will show the soft tissue conditions well if there is significant inflammatory and fibrotic changes. It also allows a good view of the cartilage and bone components of the joint which is difficult to see on plain x ray as the joint’s curves make it difficult to get a good shot ‘through’ it.

How do you treat Sinus Tarsi Syndrome ?

Treatment would usually start with providing mechanical support to the foot to control ‘bad’ movements in the subtalar joint and address poor function of the tendons around the ankle (see a podiatrist). If the condition has been present only a short time and might be transitory, oral pain killers and anti-inflammatory agents may help. If this does not have the desired effect, steroid injected into the joint should be considered as the next step. There are surgical options for the recalcitrant cases which could mean an open incision or surgery by arthroscopy. A 1999 study (by Frey) indicated largely good results via the keyhole method.

If not Sinus Tarsi Syndrome, what else might it be ?

It would be fair to say that true Sinus Tarsi syndrome is quite uncommon.  There is, however, a very common complaint that creates pain in the area of the Sinus Tarsi that is not the condition described above.  The subtalar joint, which contains the sinus tarsi canal, is a complex joint with three articular facets.  This means that three pairs of cartilage coated bony areas rub together during each part of the joint’s movement.  The bottom bone is shaped a bit like a horse’s saddle and the top bone is equally contoured in the reverse way.  It is difficult to imagine the joint at work, but some idea of the concept will help to understand this other condition.

Imagine that you went to the gym and picked up a heavy hand weight.  If you did bicep curls the right way – without straightening the elbow all the way out – the session should pass without incident.  If instead of this, you flung your arm straight out at speed until your elbow joint was forced to stop the movement because you have reached the point where bone hit on bone, you can see that you would hurt yourself.  This is a good analogy for what happens in the subtalar joint.  If your foot posture and function is bad (almost always over-pronation tipping in the heel bone), instead of working in the middle of the range of motion of the subtalar joint, you work at the end. Each time you do this, it ‘pinches’ the joint on the outside edge and causes pain in the region of the sinus tarsi.  Over time, the joint can develop serious wear and tear which means osteoarthritis in medical terminology.  This condition doesn’t have a single agreed on common name but is probably best termed Lateral Subtalar Joint Impingement. The good news with this condition is that treatment is simple, non surgical and has very good rates of success.  As with all degenerative conditions, the earlier the treatment is commenced, the less damage has time to build up so see your podiatrist without delay.

To learn more about foot pain including Sinus Tarsi Syndrome, return to our Podiatry FAQs.

Lateral Subtalar Joint Impingement

Site of Lateral Subtalar Joint pain.

There is a common condition that causes pain in the area just forward of the outside ankle bone. If you poke around this area, you will find a deeper spot where you can push your finger further inwards than in the bony areas that surround it. This is the Sinus Tarsi and the Subtalar Joint. Often the pain is difficult for the sufferer to pin down though and is generally just described as being in the outside ankle area.  Between the two long leg bones at the ankle is a small blockish bone called the talus that has a bottom surface that is roughly horizontal It sits on top of the heel bone / Calcaneus which again has a roughly horizontal top service. The joint comprised of those two bones is called the subtalar joint.  This joint sits around 3 cm below the ankle joint and, where the ankle joint can only move in one plane (up and down like a head nodding), the subtalar joint is where your foot can move in every plane, making circular rotations and dealing with uneven terrain underfoot.
The subtalar joint is a very complex joint with three articular facets.  This means that three pairs of cartilage coated bony processes rub together during each part of the joint’s movement.  The top bone is shaped like a horse’s saddle and the lower bone is equally contoured in the reverse way.  While it is difficult to visualize the joint at work, some idea of the concept will help to better understand this condition.

Imagine that you went to the gym and used up a heavy hand weight.  If you did bicep curls the correct way – without straightening your elbow all the way out – you would not expect to have an incident.  If instead of this, you flung your arm out straight until your elbow joint was forced to stop the movement because you have reached the point where bone hits onto bone, you can see that you would hurt yourself.  This is a pretty good analogy for what happens inside the subtalar joint.  If your foot function is poor (almost always over-pronation tipping in the heel bone), instead of working in the middle of the range of motion of the joint, you work at the end – like the elbow coming to a sudden stop. Each time you do this, it ‘pinches’ the joint on the outer edge and causes pain in the outside ankle area.  Over time, the subtalar joint can develop serious wear and tear (osteoarthritis / degenerative joint disease).  This condition doesn’t have a common name but is probably best called Lateral Subtalar Joint Impingement. The good news if you have this condition, is that treatment is simple, non surgical and has an extremely good rates of success.  As with all degenerative conditions, the earlier you seek treatment, the less damage has time to build up so see your podiatrist without delay.

Subtalar Joint and Sinus Tarsi.

It is also worth knowing that, until it is quite advanced, the condition cannot be visualised on standard x-rays of the foot.  So, if your family doctor has advised you that nothing is wrong with your x-ray, it generally means that you are yet to suffer serious permanent damage.  It doesn’t mean that your pain is imaginary, untreatable or not serious enough to address.

Should I get an X-ray for Sever’s disease?

A heel bone showing signs of advanced Sever's disease.

Generally, the answer is no.  A diagnosis of Sever’s Disease is usually strongly based on the history of the problem and tests a podiatrist will perform when they assess the child.  The main reason x-ray is not relied upon is because early signs of the condition are not detectable on x-ray. These changes will occur with actual bone tissue death and we are always aiming to begin treatment well before there is permanent tissue damage.

Also, in general, any health professional will only take an x-ray if the findings are likely to affect the treatment plan.  If we are considering that your child has Sever’s disease, we will lay out a tretment plan to address it.  Taking an x-ray may confirm the diagnosis but is much more likely to be inconclusive. This step can be unnecessarily confusing for parents and is a waste of time where treatment could be commenced and the condition resolved. Added to this is the  general rule that we will avoid exposing a child (or indeed an adult) to ionising radiation, even if it is a very small dose, without a potential benefit.

Buerger’s Disease or Thromboangiitis Obliterans

Buerger's Disease affecting the great toe.

Buerger’s Disease is a reasonably rare condition in which the small blood vessels of the hands and feet are occluded (or blocked) by inflammation of the vessels.  This inflammation is called vasculitis.  The reduced flow of blood will cause pain in the short term.  If it continues for a long enough period, patches of skin and other tissues in the hands and feet can become damaged or die. It can affect the palms and soles of the feet as well as the digits.

This condition afflicts ~ 60 people in 100,000 people, the majority being males aged 20 to 40 who use tobacco. Only 10 % of sufferers are female and children are rarely affected.

Symptoms of Buerger’s Disease include the extremities being cold, painful and of altered colour, appearing pallid, blue or red during an episode.  The pain is of a burning or buzzing nature and is usually quite severe.  It  may occur at rest or with activity but is often triggered by cold or emotional stress.  It is usual that more than one extremity is affected.

Examination of the areas affected by Thromboangiitis Obliterans may show enlarged blood vessels, poor pulses and skin damage similar to frostbite or ulcers. Blood tests may be done to exclude other autoimmune diseases and occasionally a biopsy of the blood vessel may be required to confirm the diagnosis.

There is no cure for Buerger’s disease. The aim of treatment is to reduce the severity of symptoms, specifically to deter amputation. Tobacco must be avoided under all circumstances and exposure to cold should be limited. During an episode, the application of moderate warmth and moving the part gently may increase circulation. Care should be taken not to expose the area to very hot conditions – submerging the feet in a bucket of boiling water will cause further injury. Some drugs that dilate the vessels (including Aspirin) may be useful in treating the condition and a sympathectomy (cutting the sympathetic nerve to the area) can reduce pain. Amputation can become necessary if large areas of tissue die or if severe infection takes hold.  Always seek medical assistance early if it is clear that something is going wrong.

Symptoms of Thromboangiitis Obliterans may disappear if the person stops tobacco use.

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If you have corns on the little toes or in between the 3rd & 4th  or  4th & 5th toes, chances are there one of two things going on.  Perhaps your shoe is too tight for your foot. If this is the case, you will have probably worked it out for yourself. This just leaves you with the choice of whether to forgo the fashion or the pain.

However, if your shoes seem like they should be wide enough but still you get the corns, your shoe shape might not be compatible with your foot shape.  Most people we see with these problems have a very ‘straight’ foot.  The best way to see if this is you, is simply to trace your foot on a piece of paper.  Run a line to bisect the heel and see where it runs with respect to the front of the foot.  Now do the same with the bottom of the shoe.

Looking at the pictures opposite, it should be pretty obvious that a straight foot will be happy the the right shoe and not so happy in the one on the left.  The little toe side of the foot will be subject to a lot of force to push it over into the shoe space.  As we have already discussed, skin + pressure = corns.

To treat this problem, I use in-shoe padding that I call a ‘comet’. Unfortunately, no-one else seems to have the good sense to use the same name but that is what they look like to me and I am going to stick with it

How to treat a corn between the toes?

How to best treat a corn between the toes depends on a number of factors.

The photograph opposite shows a corn at the very apex or the skin between the digits.  These are very tricky to remove because the good skin rises up around the corn on all sides, making it impossible for the owner to attempt self treatment. See a podiatrist to have the corn painlessly trimmed away.

Likewise, a podiatrist should be consulted if there is any infection, discharge, bad odour or night pain from the area. The dead tissue of the corn can allow a nasty infection, abscess or ulcer to occur below it and should be properly addressed as soon as possible. Under no circumstances should you apply any corn pads, medicated discs, corn paint or other corrosive chemicals to such an area.

A simple corn on the inner sides of the toe (rather than right in the tight space of the apex of the cleft) are more easily addressed by simply debriding the dead tissue away from the living. This is still a task best left to a podiatrist as visualising the area is very difficult on one’s own foot.

After removing the corn, there are three things to check to avoid its return:

1)  Determine what feature of which shoe created this problem.  Avoid these or similar shoes in the future. For example, it may be a line of stitching that runs directly across the area which will always stop shoe material from stretching in the direction of the stitch. Alternatively,  it may be simply too narrow.

2) Appropriate Padding.  The podiatrist can make for you a device to go between the toes with a gap where the corn is.  This changes the pressure from being virtually only on the corny spot to be shared by the rest of the surface area of the toes, sparing the existing problem zone. Any sort of padding that adds thickness over the painful spot – such as a strip of plaster or padding directly on the corn – will generally increase the pressure on it and also the pain.

3) Shoe Last and “Comets”.  Sometimes, the shoe isn’t so much narrow as just not the same shape as your foot.  This is an important idea and we look at it more closely in the next FAQ:  Shoe Shape and Pressure Comets.

Alternatively, use this link to return to the FAQ list.

the curve of the shoe may not suit your foot or

What is a soft corn ?

What is an interdigital corn ?

What is that painful white sore between my little toes ?

If you look at the opposite picture showing the bones of the lesser toes, you will see that they are quite knobbly little things.  There is quite a prominent flare out of the base of each of the bones. If you have the misfortune to have two of these knobbly parts adjacent to each other, the small piece of skin between them can be squeezed very hard – particularly if shoes are not roomy enough or the wrong shape for your feet.  The pressure that this creates is responsible for the corn formation.

As to why these are called ‘soft corns’, it is simply that the area between toe toes is difficult to keep dry from both showering and the production of sweat.  Just the same way that your thumbs will go white and wrinkly when you are in the bath too long, so will the corn.  It will often appear to be a very white lump in the interdigital space or may break down from too much pressure to then form an ulcer.  This may weep clear fluid, blood or pus.

Go to the next FAQ to read How do I treat my Soft corn? Alternatively, use this link to return to the Podiatry FAQ list.