By Dr. Kenneth Rehm

In my many interviews with patients, I have observed that the majority of primary care physicians do not examine their patient’s feet on a regular basis. They do, however, look in their ears, observe their eyes, palpate their belly, listen to their heart, hear their lungs and tap their knees…routinely! 

But they don’t seem to care about the feet. What?...the feet are not attached to the rest of the body? Guess What? The feet are attached to the rest of the body, in spite of what anyone else thinks!

Because this is true, things that happen to the body do affect the feet; and what happens to the feet, likewise affect the rest of the body.

Armed with this information, one can look and evaluate their foot problems in a rather different light. This equips you with the tools needed to be an informed consumer of healthcare….instead of just a passive observer when in the company of your healthcare provider. Being knowledgeable about your overall medical and health status gives you the armamentarium to ask the proper questions, hear the appropriate answers and respond in a suitable way.

What are the most common foot problems that most people deal with? What causes them? And how do we deal with these problems considering the many factors of influence involved?


Thick discolored toenails that have become infected with fungus

People ask me all the time why they get thick discolored fungal toenails? Well, I answer the question with a question. And that is: Do you brush your teeth? And they say yes, of course! And then I ask them if they brush their toenails. By far the vast majority of people never pay attention to their toenails except to cut them once in a while, let alone brush and clean them everyday like they do to their teeth. Then I proceed to inform them that the teeth are specialized structures formed by the skin, just like the fingernails and toenails are. Further, the teeth are entrenched in their own specific environment, which is the mouth; and is influenced by the individual’s unique makeup and body chemistry. This situation is analogous to the situation that the toenails confront. The environment of the shoe directly affects the toenails. Both the teeth and the toenails if not cleaned or brushed on a daily basis will build up unhealthful and detrimental debris.

In the case of the teeth, they build up damaging plaque and tartar. Plaque carries bacteria that can damage tooth enamel and lead to cavities. But if you remove plaque regularly, you can prevent permanent tooth decay and gum disease. Bigger problems arise, however, if plaque stays on your teeth and hardens into tartar.

Similarly, the toenails can build up Nail fungus. When this happens, its called Onychomycosis.

Depending on the type of protein that structures are made of, they can be soft and pliable, like hair, or designed for sturdiness, as is the case with nails. Some conditions, such as onychomycosis, can break down these proteins. One such protein, known as keratin, that normally keeps the nail strong and hard, can be destroyed and turned into keratin debris. This may cause the end of the nail to turn yellow or white, while keratin debris develops under the nail causing the nail plate to become separated from the nail bed. The fungus also grows in the substance of the nail causing it to become fragile, discolored, brittle, distorted and actually crumble; destroying the sturdy integrity of the nail plate. In some cases white keratin spots under toenail may develop due to nail diseases such as onycholysis, or lack of nutrition. Traumatic injury to nail can also cause its buildup.

It’s easy to see then that the reason that people get thick discolored fungal nails is that they allow fungus buildup. The best way to prevent this situation from ruining your nails is to treat them as you would your teeth; and start a preventive protocol, which includes cleaning the toenail surface, corners, cuticles and under the tip of the nail. Maintaining a healthy body chemistry and hygienic environment for your toenails is essential to maintaining good, healthy and strong toenails.

Athletes foot

Athlete's foot is a skin infection caused by fungus. Fungus infections can occur anywhere on the body but is common on the foot. When this occurs it is called athlete’s foot, or tinea pedis. It’s common on the foot because the fungus thrives on warm, moist and dark environments, such as a shoe, the same environment that promotes fungus infection of the toenails. In addition, when feet sweat, as in a condition called hyperhidrosis; or in warm weather, when feet tend to sweat more, fungus infection flourishes. Fungus thrives in damp areas, such as swimming pools, showers and locker rooms; and people who are susceptible are likely to become infected with the fungus. Athletes often have sweaty feet and use the facilities where fungus is commonly found, thus the term "athlete's foot."

Athlete's foot usually produces itchy, dry, scaling skin. It is commonly seen on the soles of the feet and in between the toes. In advanced cases, inflammation, cracks and blisters may form; an infection caused by bacteria can also result. The fungus can spread to other areas of the body, including toenails.

Prevention is geared at optimizing the environment of the foot that is decreasing sweating by socks or powders that wick up the moisture, drying thoroughly after bathing, wearing protective shoes in public pool or shower areas and keeping the skin healthy by keeping them conditioned and avoiding dry cracked skin that could encourage the growth of fungus. Treatment revolves around various natural, over-the-counter and prescription anti-fungal preparations.

Heel Pain and Plantar Fasciitis

One of the most common complaints people have regarding their feet is a combination of heel and arch pain. These complaints are usually intertwined and more often than not emerge and occur together because their causes are intimately related.

We have a structure on the bottom of the feet called the plantar fascia. This is a thick connective tissue that is histologically neither a muscle, tendon nor ligament, but is a combination of these; and is classified as an aponeurosis. It supports the arch on the bottom (plantar side) of the foot. It runs from the tuberosity of the calcaneus (heel bone) forward to the heads of the metatarsal bones (the bone between each toe and the bones of the mid-foot). If the foot is in balance and is stable during the walking cycle, this plantar fascia is not over-stretched and does not pull too hard on the bottom of the heel or irritate the surrounding structures. If the foot is off balance and over-pronates, or if the Achilles tendon is to tight, then this plantar fascia pulls on the heel bone, over stretches, gets inflamed and causes pain to the surrounding tissues. This pulling can even cause a heel spur, which in itself is not painful, but is a marker for this damaging scenario.

If the feet are balanced throughout the walking cycle, then plantar fasciitis usually does not occur. To insure the feet are in their stable position, it is important, once again to consider the affect of the whole body mechanics. This involves the position of the head, neck, shoulders, spine , hips, knees, the condition of the core muscles, the tightness of the muscles in the lower extremities, and the health of these structures in general. Once the body and feet are balanced through proper strengthening, stretching and foot wear (good shoes and orthotic devices) then plantar fasciitis can usually be controlled.

Painful Corns and Calluses

These are painful thickenings of the skin as a result of repeated pressure on the bottom of the feet or on the tops or tips of the toes. They show up differently according the type of pressure insult they receive. If the foot pounds directly on the ground without much shock absorbtion or pressure hits the top of the toes, then the skin becomes hard and could develop a painful core, called a nucleation, which is nothing more than a compacting of the layers of the skin. When this occurs on the toe, it is called a corn (heloma durum in medical language) ; and when it occurs on the bottom of the foot it is called a callus (or nucleated keratorma in medical language). When there is tearing or shearing pressure, these problems can show up as a wide flat area of thickened skin by itself, or surrounding the nucleation. This signifies that the foot is off balance and the remedy could involve inserts, arch supports or orthotic devices for the foot. Friction, or rubbing could affect either the corn or callus or can actually cause a blister. Reducing friction, requires, not just balancing gait but may require eliminating a constant low pressure on the toes, as what happens when someone is wearing a shoe that is too tight or brand new.

Corns and calluses are not caused by a skin problem directly or primarily, but can certainly be affected and made worse by dry skin as well as inflammatory conditions of the skin.

Bunions, Hammertoes, Mallet toes and Claw toes

The bunion deformity, sometimes called Hallux Valgus, is the enlargement of the head of the first metatarsal bone due to the pressure put upon it with the foot trying to balance the body, usually a result of an in-turning movement of the foot called pronation. Depending on the shape of this joint, it may move toward the little toe permanently, or develop a locked joint, if the imbalance is not corrected.

A hammertoe is a bending deformity of any of the toes. In this condition, the toe is bent at the middle joint, so that it resembles a hammer. Initially, hammertoes are flexible and can be corrected with simple measures but if left untreated, they can become fixed and may require surgery. This abnormal bending can put pressure on the toe when wearing shoes, causing painful problems to develop. Hammertoes usually start out as mild deformities and get progressively worse over time.

Related to the hammertoe are the mallet toe and the claw toe. A mallet toe occurs when the bending is only at end joint of the second, third, fourth or fifth toe; and can cause problems on the top of that joint or the tip of the toe.

A claw toe is a toe that is contracted at the middle and end joints in these toes, and can lead to severe pressure and pain.

The hammertoe, mallet toe and claw toe deformities are each caused by the toes grabbing and eventually becoming deformed. Similar to the bunion deformity, these are also anatomic misalignments, which are representative of the body trying to gain balance through the actions of the foot. Hereditary shapes of the joints involved are variably reactive to the balancing forces put upon them; and represent the reasons for the differences in the severity of these conditions.

Again the message becomes clear: proper shoes and orthotic devices are the keystone to balancing the foot; and balancing the foot is fundamental to preventing and treating the progression of these problems. If your lifestyle is significantly hampered by the ultimate progression of these deformities, surgical intervention might be indicated.


A neuroma is a thickening of nerve tissue that commonly happens in the foot, although may develop in various parts of the body. The most common neuroma in the foot is a Morton’s neuroma, which occurs behind between the third and fourth toes inbetween the metatarsal bones. Neuromas may also occur in other intermetatarsal spaces or different locations in the foot. This thickening of the nerve is the result of compression and irritation, which eventually results in enlargement of the nerve, eventually leading to permanent nerve damage.

The patient usually comes to me with a feeling of sharp, tingling or burning pain on the bottom or ball of the foot. Classically, they have to stop and rub the foot until the pain goes away. Sometimes the patient complains of a feeling that something is inside the ball of the foot or there is something in the shoe or a sock that is bunched up .

Anything that causes compression or irritation of the nerve can lead to the development of a neuroma. One of the most common offenders is wearing shoes that have a tapered toe box or high-heeled shoes that cause the toes to be forced into the toe box. Commonly, the balancing motion of the foot when the foot rolls toward the big toe during walking, (called pronation, the same motion associated with other deformities such as bunions, hammertoes, mallet toes, claw toes and plantar fasciitis) is the causative factor for the irritation of the nerve and the formation of the neuroma. The more active a person is, and the more his walking or running is characterized by pronation, the more susceptible is that person to getting a neuroma. Before surgical intervention becomes necessary; and to prevent the progression of this nerve abnormality, it is essential to control abnormal pronation with proper shoes and orthotics. Sometimes various types of injections are used to soothe the painful nerve, but should never be a substitute for controlling the imbalance that causes it.


In addition to the direct causes of foot problems as discussed above, there are major influences that may alter the presentation or the intensity of the pathology, such as:

Topical/ Environmental
Biomechanical /Overuse
Medical/Metabolic/Endocrine related

Keep in mind nothing is black and white. There are no clear-cut boundaries here, in medicine or life in general. All these causes and influences are interconnected, blend into each other and have impact on each other. These each have major impact on all foot, and by the way, all health and medically related problems as well. This is a major lesson when evaluating your own foot problems and helping your provider understand the underlying causes and influences, so that you as a patient can be proactive instead of reactive; and be the captain of your own ship.

In summary, prevention is always the best treatment. And prevention of foot problems start with 10 pointed principles to be aware of:


By Dr. Kenneth Rehm


Feet are attached to the rest of the body and are as important as the rest of the body.

Realize that the feet are attached to the rest of the body and are at least as important as the rest of the body. The feet are affected by other conditions in the body and in turn have a reciprocal influence on them. The areas of mutual effect are those considerations that medically, psychologically and structurally influence a person’s balance of mind, body, spirit and posture . It all affects the foot; and the foot affects the body.

You have to be aware of your feet because they are the weakest link

and are often the first sign of diseases because...

    1. You walk on your feet. Remember the three types of pressure conveyed to your feet with each step: 
      1. pounding or direct pressure
      2. friction or rubbing pressure 
      3. sheering or tearing pressure. Remember 3-8 times the body weight is transmitted to your feet with each step, depending on the speed, the surface and the footwear worn. 
    2. They are the furthest away from your heart. They have less blood flowing to them, even in the healthiest individual and the blood has the hardest time getting back up to the heart against gravity to be supplied with fresh oxygen so that the health of the tissues so that health can be maintained.

You have to pay attention to the skin and nails.

Be as diligent about your feet as you are about any other part of your body. Dry cracked skin and thick diseased nails can be a source and a marker for further problems. Keep your skin conditioned and pampered and the toenails clean, thinned and cut properly.

Maintain proper posture and muscle balance and conditioning.

Any physical imbalance in the body, the condition of the abdominal core, the strength and health of the neck, shoulder, hip and lower extremity as well as the resultant over all posture all have it’s effect on walking and the feet. The balance of the body is adjudicated through the feet and sometimes the feet breakdown to maintain this balance. The foot stays healthy when it normally functions in a stable position, but when the body is out of balance, the foot tries to compensate, this stable balanced position is broken down and the foot cannot carry the load of the body. We have to keep the whole kinetic chain strong.

Maintain the foot balance and shock-absorption.

The only way science knows how to deal with this is through foot exercises, orthotics, and shoes. There is new information about the foot having its own core (muscles) that keeps it structurally in integrity. It is analogous to the core of the body that keeps the body in integrity. Foot exercises combined with appropriate orthotic inserts, which keep the foot in its neutral and locked stable position, allows the ground to come up to the foot instead of having the foot falling to meet the ground. It is necessary to have enough shock absorption while walking on hard flat surfaces or there will be increased direct and pounding pressure to the foot. These actions prevent throwing the whole kinetic chain off kilter thereby helping to avoid it’s detrimental effects.

Maintain the overall health of the body.

If the body chemistry and the health of the body are off balance, all the body organs and systems are affected including the skin, becoming dry and flaky and callused, muscles becoming weak, the bones becoming thin and brittle, circulation diminishes, nerves are affected, healing potential reduced, sleep compromised, and this all comes back to affect the feet! Know that being overweight puts extra weight and pressure on the feet, puts the feet out of balance and the body out of balance. Because of extra weight on the feet, inflammation is developed and the inflammatory markers of the body increase causing the feet to hurt. We notice that those people who lose weight and have shoulder arm and or neck pain, for instance, have reduced pain after losing weight. Not only the extra weight causes additional pressure and pain on weight bearing areas but in non-weight bearing areas as well, because of the reduction in the inflammation as well.

Maintain the nutrition of the body.

We have to balance our fats, and the proteins, and the carbohydrates. One should focus on an anti-inflammatory diet. Key to eating healthy:

  1. Eat just food, staying away from preservatives and simple carbohydrates that are not combined with their native fiber as in fruits and vegetables. The natural fiber helps modulate the metabolism of carbohydrates such that they help eliminate inflammation and an abnormal insulin reaction. 
  2. Not too much 
  3. Mostly plant based 
  4. Healthy Fats 
  5. Lean, small portions of healthy meat, chicken or fish


Maintain beyond positive attitude.

Positive attitude doesn’t mean we have to be happy all the time. It means we have to develop the skill of putting things in perspective and being able to reframe situations such that we can see the positive in them; and they don’t give us anxiety, depression and fear. This builds up or healing juices in the body, positively affecting our immunity to germs and diseases, positively affecting our blood flow, decreasing our stress hormones like cortisol, decreasing inflammation in the body, and positively affecting certain inflammatory diseases such as arthritis.

We must be committed to the saying So What…Now What? Face the fact that we have to go through stuff, face situations and learn how to reframe it. I have had a lot of healthy 100 year olds in my practice and, by and large, they all have been able to reframe their negative circumstances…. And see the bright side of life!

Keep your feet clean, conditioned, protected, safe, and warm.

Caution in all areas of life, including taking care of your body and feet, requires purposeful action, caution, and not giving into to blind impulsivity. There should be no lawn mower accidents, stepping on needles or motocycle accidents. Do not neglect your body or your feet, keeping them clean, conditioned, protected, safe and warm. A lot of chronic problems result from pure neglect and ignorance and the person is permanently affected!

Keep your feet in check.

Know what to watch for to cut problems in the bud and apply that knowledge by checking your feet on a periodic basis. This goes for all important areas of your body. Know when and where to have these problems checked out professionally; and choose your health care professional very wisely. Go to the doctor prepared in all ways. It could literally make the difference between living a full or limited life, or even life or death. Take it from me!


In Conclusion, the secrets our feet hold are told to us through the rest of the body. To hear those positive messages loud and clear,

  1. You have to start early to have good habits. 
  2. You have to have a good mindset.
  3. You must learn to reframe things that go wrong.
  4. You must be self-reliant; you cannot depend on a medical system that is changing so fast.
  5. You must keep your feet in mind.

and we should cherish our body and our feet because without them …we literally could not stand for good health !