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Women’s Foot Complaints

The most common foot ailments in women are onychomycosis, Morton neuroma, stress fractures, and plantar fasciitis.

A variety of foot conditions plague women more often than men. Many are aggravated by the shoes that women wear but also can be caused by loss of bone density as women age. The most common foot ailments in women are onychomycosis, Morton neuroma, stress fractures, and plantar fasciitis.

ONYCHOMYCOSIS

A fungal infection of the toenails, onychomycosis most often is caused by dermatophytes (Trichophyton rubrum and T. mentagrophytes) or yeasts and molds, primarily Candida.¹ Although diagnosis often is based on the clinician’s judgment, acceptable methods for confirming fungal involvement include use of dermatophyte test medium or a potassium hydroxide test. Onychomycosis results in cosmetically unacceptable nails that are dystrophic, lytic, thick, painful, and discolored. The condition can develop as a consequence of tinea pedis, trauma to the nail, an immunocompromised state, or pedicures (removal of the cuticle creates microtears that allow fungus to enter the nail). Treatment options include debridement, oral or topical antifungal therapies, or permanent removal of the toenail with a chemical or surgical matrixectomy. Simple removal of the toenail without treatment of the fungus will lead to regrowth of the fungal nail. Combination therapy is the most successful approach; for example, results of a 2006 study showed that oral terbinafine plus nail debridement led to higher mycologic cure rates than did treatment with oral terbinafine alone (68% vs. 63%).²

MORTON NEUROMA

This condition develops from enlargement of the third common digital branch of the medial plantar nerve. Pressure from the corresponding third and fourth metatarsal heads and adjacent deep transverse metatarsal ligament causes pain in the third intermetatarsal space. Burning or sharp, shooting pain to the corresponding toes and the sensation of walking on a pebble or a marble are common complaints. Compressive forces on the forefoot (e.g., from wearing shoes with pointed toes or engaging in certain athletic activities) exacerbate these symptoms. A positive Mulder sign (clicking as the neuroma rubs on the adjacent metatarsal heads) can occur on dorsal-to-plantar or side-to-side compression of the forefoot.³ The diagnosis is best made based on clinical examination or with a diagnostic injection of local anesthetic in the interspace between the metatarsal heads.

Neuromas also can be diagnosed with magnetic resonance imaging (MRI), ultrasound, or nerve conduction studies. Other pathologies that can cause similar symptoms are capsulitis, metatarsalgia, avascular necrosis or stress fractures of the metatarsals, soft-tissue tumors, tarsal tunnel syndrome, and plantar plate ruptures. After diagnosis of the neuroma, the patient should be referred to a podiatrist or other foot specialist for evaluation and treatment. Conservative treatments include padding and strapping, orthotic devices, and steroid injections. A less-widely used but successful conservative regimen involves weekly injections of a sclerosing alcohol mixture (a combination of local anesthetic and dehydrated ethyl alcohol). In a 1999 study, 82% of patients who were given weekly sclerosing alcohol injections for 3 to 7 weeks experienced complete relief.⁴ If conservative therapies are not successful, the neuroma can be excised surgically; however, this will lead to a decrease in sensation in the corresponding digital interspace.

STRESS FRACTURES

Metatarsal stress fractures commonly affect women during and after the menopausal transition; however, athletes and military recruits also can suffer from the condition. The lesser metatarsals are a common location for stress fractures. Patients complain of persistent pain and swelling in the forefoot and might report recent periods of weight-bearing activity (often involving a particular repetitive motion). Initially, the injury is limited to cortical bone — but, if left untreated, the fracture can extend through the entire bone and even become displaced.⁵ Although conventional radiographs might be negative for the first 21 days after injury, bone scans or MRIs can reveal the fracture earlier. One study that included 37 female athletes (primarily runners) showed that 47% of stress fractures were identifiable with initial radiographs, whereas 96% were detectable with bone scans.⁶ Successful conservative treatment consists of compressive bandaging and immobilization (surgical shoe, cam walker boot, or cast). To prevent fracture recurrence, modification of physical activities and shoe gear should be addressed; in addition, treatment for bone density loss, if present, is warranted.

PLANTAR FASCIITIS

This inflammatory condition of the plantar fascial band (which courses along the plantar aspect of the foot) is one of the most common foot ailments, accounting for 15% of all adult foot complaints.⁷ Pain often is localized to the medial plantar region of the heel. Patients report pain when they stand after periods of rest (poststatic dyskinesia). Typically, a brief period of walking offers some relief.

Common causes of plantar fasciitis include foot structure, obesity, changes in physical activity, and lack of supportive shoe gear. Plantar fasciitis is best diagnosed clinically, but ultrasound and MRI often are helpful for visualizing changes in the thickness or continuity of the plantar fascial band. Radiographs can reveal the plantar calcaneal spur that often accompanies this condition. Several other conditions that can cause heel pain (i.e., nerve entrapments, bone cysts, calcaneal stress fractures, systemic arthritic conditions, and lumbar spine disorders) should be considered if the patient has an atypical presentation or is not responding to conservative measures.

Conservative therapy renders successful outcomes in most patients and usually should be employed for a minimum of 6 months. The best conservative therapy employs a combination of icing, stretching, nonsteroidal anti-inflammatory drug therapy, padding, strapping, custom molded orthotics, night splints, physical therapy, steroid injections, short-term oral steroid therapy, or immobilization with a cast or cam walker boot. When warranted, surgical treatments for this condition include open or endoscopic plantar fasciotomies. Newer therapies that show promise but are not yet widely used include extracorporeal shockwave therapy,⁸ cryotherapy, and Topaz coblation (radiofrequency technology).

CONCLUSION

Several podiatric conditions have higher incidence in women than in men. Early diagnosis of these pathologies can lead to more-focused, successful treatment.

— Mary Ann Bender, DPM

Dr. Bender is a podiatrist and foot surgeon in private practice with J.B. Jenkins and Associates in Chicago, IL. She is also a clinician for the Cook County Community Service rotation at William Scholl College of Podiatric Medicine, Rosalind Franklin University, and serves uninsured and homeless patients at eight clinics and shelters in Chicago.

Published in Journal Watch Women's Health November 20, 2008

Citation(s):

1. Norton LA. Nail disorders. J Am Acad Dermatol 1980 Jun; 2:451.

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2. Jennings MB et al. Treatment of toenail onychomycosis with oral terbinafine plus aggressive debridement: IRON-CLAD, a large, randomized, open-label, multicenter trial. J Am Podiatr Med Assoc 2006 Nov/Dec; 96:465.

• Original article (Subscription may be required)
• Medline abstract (Free)

3. Mulder JD. The causative mechanism in Morton’s metatarsalgia. J Bone Joint Surg Br 1951 Feb; 33B:94.

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4. Dockery GL. The treatment of intermetatarsal neuromas with 4% alcohol sclerosing injections. J Foot Ankle Surg 1999 Nov/Dec; 38:403.

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5. Orava S. Stress fractures. Br J Sports Med 1980 Mar; 14:40.

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6. Taunton JE et al. Lower extremity stress fractures in athletes. Physician Sports Med 1981 Jan; 9:77.

7. Michetti ML and Jacobs SA. Calcaneal heel spurs: Etiology, treatment, and a new surgical approach. J Foot Surg 1983; 22:234.

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8. Norris DM et al. Effectiveness of extracorporeal shockwave treatment in 353 patients with chronic plantar fasciitis. J Am Podiatr Med Assoc 2005 Nov/Dec; 95:517.

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• Medline abstract (Free)