Foot & leg care: Stocking feet

There are plenty of steps pharmacists can take when customers’ foot problems arise...

Learning objectives

After reading this feature you should be able to:
• Explain the causes of foot pain
• Recognise common foot ailments
• Know when to treat a problem and when to refer to a podiatrist.


Feet perform a vital set of functions – they support our weight, they act as shock absorbers, they are the levers which propel our legs forward when walking and they help maintain balance by adjusting to uneven surfaces.

The impact of every step a person takes exerts tremendous force on their feet. While walking, this force is about 50 per cent greater than the person’s body weight – but during exercise it can increase to as much as 300 per cent. During a typical day, someone might spend about four hours on their feet and take 8,000-10,000 steps – so feet are expected to support a combined force equivalent to several hundred tons every day.

Foot structure

The foot is a complex structure consisting of 26 bones, usually divided into three units – the hindfoot, the midfoot and the forefoot:
• The hindfoot consists of the ankle bone (the talus) and the heelbone (the calcaneus)
• The midfoot includes the frontal part of the talus, the navicular, cuneiforms and cuboid
• The forefoot consists of the metatarsals (so often in the sports pages headlines when footballers suffer fractures) and the digits, or toes.

An equally intricate structure of muscles and tendons ensures that the foot flexes correctly and also controls acceleration and deceleration. It is important for the foot to maintain the correct anatomical and biomechanical action when walking as abnormalities of the feet and the motion during walking or exercise can have a significant impact on the health of joints and soft tissue, not only in the whole leg, but also in the rest of the body. If the foot and knee are not in correct alignment and rotate outwards or inwards, this can cause pain in the foot and lower leg and increase the risk of injury.

The muscles and joints of the leg interact closely, so any imbalance or inefficient movement in the lower limb can lead to pain in the muscles, tendons and ligaments or cause joint pain through excessive loading and give rise to accelerated wear and tear, or osteoarthritis.

Causes of foot pain

There are three main causes of pain in the feet:
• Poorly fitting shoes
• Medical conditions
• High impact exercise.

Poorly fitting shoes
Shoes should be the correct size and width and have adequate support to keep the foot in the correct position. High-heeled shoes tend to concentrate pressure on the ball of the foot and toes and this can aggravate problems. Ill-fitting shoes can cause blisters, corns and calluses and are also thought to make bunions worse.

Medical conditions
If someone has a condition that causes them to alter the way they walk, this can contribute to foot pain. This may include conditions that cause numbness or pain in the feet, such as diabetes (an important cause of serious foot problems); leg and foot deformities; spinal problems; and neurological disorders such as cerebral palsy or Parkinson’s disease.

Other conditions that can lead to foot pain include:
• Arthritis, particularly osteoarthritis and gout
• Obesity, which places added stress on feet and increases the risk of foot and ankle injury. The extra pressure on the joints and soft tissue in the feet of overweight people increases the chance of developing plantar fasciitis or tendinitis
• Pregnancy, where excess weight increases the stress on the feet, leading to fluid build-up and swollen feet
• Some medications, such as calcitonin (used to treat post-menopausal osteoporosis and other problems) and certain antihypertensives, may cause the feet to swell.

High impact exercise
Vigorous activities, such as jogging, running, strenuous aerobics or sports which involve short bursts of running and sudden changes of pace and direction, can injure the feet. The results may include corns, calluses, blisters, muscle cramps, sprains, strains, toenail damage, plantar fasciitis, heel spurs, sesamoiditis, inflammation of the Achilles tendon, pain in the ball of the foot (metatarsalgia) and stress fractures.

Problems in bones, joints and muscles can lead to pain in the lower leg.
• Muscle cramps are often caused by muscle fatigue, heat or dehydration. They are commoner in older people and endurance athletes
• Inflamed or torn tendons and muscles may show up as pain in the lower calf or back of the heel
• Sprained joints or ligaments are painful and may cause swelling or inflammation.

Who is at risk?

Some people are more likely to experience pain in their feet and lower leg than others. Risk factors include:
Age: Feet flatten and widen with age, the fat padding the sole of the foot wears down and skin becomes drier. Foot pain in older people may be an early sign of age-related illnesses such as diabetes, arthritis and circulation issues. Foot problems may also impair balance.
Gender: Women are more likely than men to suffer severe foot pain and this may be due to the type of shoes they wear.
Occupation: Foot problems, including arthritis in the foot and ankle, toe deformities, pinched nerves between the toes, plantar fasciitis, adult-acquired flat foot and tarsal tunnel syndrome, have been attributed to repetitive use at work – for example, in people whose job means they have to walk long distances or stand for many hours at a time.
Activity: Sports players and people who take part in vigorous exercise. Women are at higher risk of stress fractures than men.

What to do

Anyone who suffers significant foot or leg pain for the first time should be referred to their GP or, in an emergency, visit A&E. However, many painful conditions of the leg and feet, once diagnosed, can be treated at home with OTC medicines.

Sprains and strains: When a ligament is stretched, torn or twisted, this is referred to as a sprain, while a strain occurs when muscle fibres have been stretched or torn. Sprains and strains are common, often occurring as a result of an injury while playing sport or exercising, and the affected area can be swollen, bruised and tender.

Less serious sprains and strains may be treated at home using the Protect, Rest, Ice, Compression and Elevation (PRICE) therapy. Cold sprays, gels and patches can be carried in sports bags so they are always available and are often more convenient to use when people need to carry on with their normal lives, especially as cold therapy should be continued for up to 72 hours after the injury to help limit swelling and inflammation. After this period, heat products may be used to help increase blood flow to the area and aid healing.

Gout: Ice packs or cold sprays, gels and patches, and NSAID painkillers can all help ease the pain of gout.

Plantar fasciitis: This is caused when the tough band of tissue (fascia) that runs under the sole of the foot is damaged, causing pain in the heel. The pain tends to be worse at the beginning and end of the day. Regular stretching, rest, applying ice packs or cold products, taking painkillers and wearing well-fitted, supportive shoes can often help relieve the pain.

Metatarsalgia: This pain, occurring in the front section of the foot, is often described as burning or aching and is made worse by walking. Extra strain or pressure on the ball of the foot (e.g. wearing tight-fitting shoes for a long period of time, high impact sports or being overweight) can bring on the pain. Most cases can be managed using the PRICE approach, painkillers, changing footwear and using shock-absorbing insoles.

Arthritis: In older people, repeated foot pain and stiffness can indicate a sudden worsening of osteoarthritis, which is caused by wear and tear and results in swelling of the tissues in and around the joints, including the big toe and heel. Treatments include wearing suitable footwear, anti-inflammatory medication including topical NSAIDs, physiotherapy and, in some cases, surgery.

Less commonly, foot pain can be caused by rheumatoid arthritis, in which the immune system attacks the joints, causing inflammation in the joint tissues. The main treatments include medication to relieve symptoms and slow the progress of the condition, physiotherapy, and occasionally surgery.

Achilles tendon injuries: Pain and stiffness along the back of the heel may be a sign of Achilles tendon damage, or Achilles tendinopathy. The pain can often be relieved with rest, cold therapy and painkillers, although it may take several months to resolve. Sudden, severe pain in the heel, often accompanied by a “popping” or “snapping” sound, indicates a possible rupture to the Achilles tendon and medical advice should be sought at once.

OTC assistance

A comprehensive range of products, including topical analgesics, cushioned or gel insoles and supports, is available over the counter to deal with less severe foot and leg pain.

Cold therapy: Cold products are the ones to recommend when customers complain of sprains and strains or sharp, shooting pain in joints or muscles. When cold is applied topically, it activates receptors in the skin that send signals to the brain, mitigating the effects of the pain. It also causes the blood vessels in the affected area of soft tissue to constrict, which can help limit swelling and inflammation. OTC cold products come in a variety of formats, including gels, sprays and patches.

Heat therapy: Comforting, warming heat therapy can be recommended to help ease painful, stiff and aching muscles, and for use before exercise to relieve any muscular aches and pains. Heat may also be used for problems such as sprains and strains once the initial cooling period of up to 72 hours is completed. Like cold, when heat is applied topically, it activates receptors in the skin, sending signals to the brain that counteract the pain. Heat also increases blood flow to the affected area, bringing oxygen and nutrients to aid the healing process and help restore movement. The range of heat products available OTC includes rubs, sprays, roll-on lotions and patches.

Tackling inflammation: Topical NSAIDs offer anti-inflammatory action to help reduce inflammation and ease pain and can be recommended for inflammatory pain in joints and muscles. Some topical anti-inflammatories can also be recommended to relieve pain associated with non-serious arthritic conditions. Topical anti-inflammatories can provide powerful, targeted pain relief at the site of the discomfort, helping to reduce swelling. Topical NSAIDs are available in a number of formats, including gels, creams and patches.


Other common foot problems

Athlete’s foot
Athlete’s foot, a common fungal infection that usually develops between the toes, most commonly affects teenagers and young adults. Symptoms include dry skin, redness, blisters, itching and peeling. The infection usually clears up within days or weeks with antifungal treatment. Customers can choose between fungicidal products that kill the fungus and fungistatic products, which slow down its growth until it stops. A low-potency steroid cream may be recommended if the skin is very sore.

Athlete’s foot is highly infectious, as the fungi multiply quickly in warm and humid environments, such as swimming pools, showers and changing rooms. Good foot hygiene can help to reduce the spread of an infection and involves drying the feet thoroughly, particularly between the toes, wearing clean cotton socks, rotating footwear and avoiding walking barefoot in changing rooms.

Blisters are small pockets of fluid that collect under damaged skin to cushion the tissue underneath and protect it from further damage. Blisters on the feet are usually caused by friction from ill-fitting shoes and are commonest in hot weather when sandals or flip-flops rub against skin. Anti-blister sticks and blister plasters can provide instant relief and prevent further damage.

Blisters should not be burst as this could lead to an infection or slow down the healing process. Instead, the area should be covered with a protective gel dressing. Infected blisters need medical attention as they could lead to a secondary infection.

Corns and calluses
Corns (which usually appear on the tops or sides of toes) and calluses (found on the soles of feet) are areas of hard, thickened skin that develop when the skin is exposed to excessive pressure or friction. Problems can be prevented by wearing well-fitting shoes and using protective gel pads or strips to reduce pressure. Hardened skin can be gently removed with a pumice stone or foot file. OTC products containing salicylic acid are available to treat established corns or calluses, but severe cases or people with diabetes or circulation problems should be referred to a podiatrist.

Cracked heels
Cracked heels are often caused by open-backed shoes such as sandals or flip-flops striking the heel. Older people are most at risk of cracked heels, as well as those who stand for prolonged periods. Limiting unsupportive footwear can help to prevent the problem arising, while regularly applying a moisturising foot cream can help keep feet smooth and soft. A pumice stone or foot file can be used to remove hard skin; these are particularly effective when used after a bath or shower.

Foot odour
The main cause of foot odour is sweaty feet combined with wearing the same shoes every day. Adolescents and pregnant women are particularly prone to sweaty feet, due to hormonal changes that increase perspiration. Foot odour can be treated by washing feet with an antibacterial soap, changing socks every day and alternating footwear. Those who are particularly prone to sweaty feet can be advised to dab between their toes with cotton wool soaked in surgical spirit. Medicated insoles and sports socks with ventilation can also help combat the problem.

Fungal nail infections
Most fungal nail infections (onychomycosis) are caused by the same fungus responsible for athlete’s foot. The infection develops slowly and causes the nail to become discoloured, thickened and distorted, and later, painful, brittle and crumbly. Fungal nail infections are commonest in people who wear shoes that allow their feet to get hot and sweaty, while people with weakened immune systems and certain medical conditions, including diabetes and psoriasis, are also more at risk. Mild fungal nail infections usually clear up on their own, although a GP may check for any underlying conditions. Antifungal nail lacquer containing amorolfine is available OTC but treatment needs to be used for up to six months or even a year.

A verruca is a wart on the sole of the foot caused by infection with the human papilloma virus (HPV), which is picked up from contaminated floors in changing rooms or around swimming pools. The affected skin is usually white and may have a black spot in the centre. Verrucas may clear up naturally, but treatment is advisable to prevent the infection spreading. Several treatment options are available OTC, including salicylic acid gels, creams, plasters and paints, cryotherapy sprays containing dimethyl ether propane and silver nitrate. To make verrucas more susceptible to treatment, the affected area should be soaked in warm water for a few minutes and gently filed with a pumice stone or emery board. Waterproof plasters are available to protect the verruca and prevent the infection from spreading.


Key facts

• The foot is a complex structure comprising 26 bones

• A number of medical conditions can cause numbness or pain in the feet

• Some people are more likely to experience pain in their feet and lower legs than others


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