The average American walks 4-5 miles per day, 70,000 miles lifetime, with the feet supporting a cumulative pressure of several hundred tons. Each road warrior is made up of 28 bones, 33 joints and a complex web of greater than 100 tendons, muscles and ligaments (Conkling, 1994). It is estimated that 1 in 6 Americans (43.1 million) suffer from foot discomfort or disease. Women are 9 times more likely than men to develop pain and deformity; causative factors include poorly fitting shoes, shoes that are too small for the foot, and heels higher than 2 1/4 inches (North Carolina Medical Society, 1995). A survey of 813 bunionectomies revealed that 94% involved females (Conkling, 1994). Medical costs and associated time off work are estimated at $3.5 billion per year (North Carolina Medical Society, 1995).
Generalized musculoskeletal changes associated with aging include loss of muscle fiber, strength and limitations in mobility. Ligaments become stretched, resulting in joint stiffness and reduced motion. Postural changes include a shift from the hips as the center of gravity, to the chest (Jaffe, 1991). In order to increase stability, the elderly begin to walk with their feet directed outward, which does not follow the design or last of most shoes (Helfand, 1989). This alteration in gait elicits a foot-shoe incompatibility that accentuates pressure points on the feet (Helfand, 1989).
Bunions are the result of a subluxation of the metatarsal-phalangeal (MP) joint of the great toe, creating a lateral angulation that produces pressure from two distinct directions. The MP joint becomes enlarged, and may be reddened and inflamed from friction with a toe-box or instep. Either an inherited joint weakness or poorly fitting shoes may be culpable.
The top photo demostrates a bunion on the 1st digit and a hammer toe on the 2nd digit. There is evidence of corn on the 2nd digit.
A hammertoe may be caused by lateral derangement of the second toe due to a bunion. This deformity is a combination of extension at the MP joint and flexion at the proximal inter-phalangeal (PIP) joint. Pain results as the plantar muscles tear and soft tissue lesions form from friction at the dorsal PIP joint, with corn development at the tips of the toe (Lian, 1992). Conservative treatment with hammertoe pads, designed to fit over the toe and hold down the PIP joint may be used in conjunction with a roomier, high toe-box shoe (Lian, 1992). The treatment provides symptomatic relief and is not curative.
Careful assessment of footwear for signs of uneven wear, friction, pressure and poor fit is basic to preventive foot care. All footwear should be replaced when worn, and inspected periodically for torn linings or rough edges. Padding may restore neutral functions, and prevent repeated microtrauma of the foot in patients with degenerative changes (Helfand, 1989). Leather or canvas shoes allow moisture to evaporate, and should be purchased in the afternoon, when the feet are largest. Cotton or wool socks should be worn, instead of nylon, to absorb moisture and wick it away from the foot. White socks are preferable if lesions exist, entry of dyes into the wound is eliminated (Ruscin et al, 1993). Patients should never go barefoot, thus reducing the risk of penetrative or abrading injury from foreign body (Helfand, 1989).
Daily inspection of the feet should be encouraged, twice daily for patients at high risk for complications, using a mirror to enhance visualization, if needed. Assessment should include blisters, sores or cracks in the skin, changes in toenails, skin temperature and color (Ruscin et al, 1993).
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