Category: Medicine

Celiac disease primarily affects the digestive system but can have significant consequences for the entire body, including the feet. Individuals with celiac disease frequently experience complications in the feet due to two main mechanisms: nutritional deficiencies and autoimmune-related neurological and musculoskeletal effects.

Peripheral Neuropathy

Peripheral neuropathy is one of the most common foot manifestations in people with celiac disease. This condition results from damage to the peripheral nerves, causing symptoms such as numbness, tingling, burning, pain, and even weakness in the feet. The nerves in the feet are often the first affected due to their length and vulnerability. This damage can lead to:

• Numbness and decreased sensation, making it harder to detect injuries or pressure sores.f
• Tingling or prickly sensations, which are uncomfortable and may disrupt normal walking.
• Burning or shooting pain in the feet, sometimes described as electric or stabbing
• Instability and a loss of balance, increasing the risk of falls.

Treating the underlying celiac disease through a strict gluten-free diet may reduce the risk of further nerve damage and even improve symptoms for some individuals. However, prolonged exposure to gluten before diagnosis can cause lasting damage.

Musculoskeletal Manifestations

Celiac disease also impacts the bones and joints, often causing osteoporosis, osteomalacia (bone softening), and arthritis-like symptoms. Reduced bone density increases the risk of fractures in the feet. Joint pain and stiffness, particularly in the small joints like those in the ankles and feet, are also reported.

Patients often experience:

• Morning stiffness in the feet and ankles.
• Swelling and soreness in joints after physical activity or gluten exposure.
• Polyarthralgia (pain in multiple joints), sometimes including those of the feet.
• Back, lower back, and pelvic pain that may indirectly affect gait and weight distribution, aggravating foot issues.

Additionally, children with celiac disease may show joint abnormality in the feet, such as effusion or synovitis, detectable even without obvious arthritis symptoms. In untreated cases, joint abnormalities and enthesitis (inflammation at the site of attachment of tendon or ligament to bone) are more frequent.

Dermatological Manifestations: Dermatitis Herpetiformis

Some people with celiac disease develop dermatitis herpetiformis, a blistering, itchy rash that often appears on the limbs, including around the ankles and occasionally on the feet. The discomfort and ulceration from this rash can make standing and walking painful and may lead to secondary infections if lesions are scratched or unhealed.

Nutritional Deficiencies and Impact

Malabsorption of key nutrients is a hallmark of celiac disease and can significantly affect foot health:

• Iron deficiency can lead to anemia, causing fatigue and limiting mobility.
• Low calcium and vitamin D levels can cause bone weakness and cramps in the feet.
• B12 deficiency contributes to neuropathy and muscle weakness.

Prolonged deficiency makes bones more brittle, increasing the risk of fractures during routine activities. In children, poor nutrition may result in delayed growth and development, affecting foot structure and gait.

Mobility and Quality of Life

The combination of nerve and skeletal damage, pain, numbness, and balance difficulties can severely limit the mobility of those with undiagnosed or poorly managed celiac disease:

• Difficulty walking and maintaining balance increases fall risk and may require assistive devices or physical therapy.
• Loss of sensation in the feet makes new injuries harder to notice and slower to heal, raising the danger of chronic wounds.
• Instability may persist even after a gluten-free diet is initiated, especially if diagnosis was delayed and nerve or bone damage is severe.

Special footwear, orthotic inserts, and routine foot care are recommended to compensate for these risks and improve function.

Secondary Complications

Longstanding nerve and bone problems in the feet increase the risk of secondary complications:

• Ulcers and pressure sores may develop silently due to numbness.
• Poor circulation, combined with nerve damage, increases risk for infections that may be slow to resolve.
• Deformities in foot structure may occur due to abnormal gait and pressure distribution, such as hammertoes or pes planus (flat feet)

Managing Foot Health in Celiac Disease

Routine visits to a podiatrist are crucial for early detection and management of foot complications in people with celiac disease.

Treatment options include:

• Strict adherence to a gluten-free diet.
• Pain management and physical therapy to maintain function.
• Vitamin and mineral supplementation to address deficiencies.
• Specialized shoes or orthotic inserts for those with instability or deformity
• Patient education on inspecting feet regularly to detect injuries or changes early, since sensation may be blunted.

Celiac disease is far more than a digestive disorder—it creates cascading effects throughout the body, with the feet being uniquely vulnerable due to the complexity of nerve and bone systems in this area. Peripheral neuropathy, musculoskeletal changes, dermatological manifestations, and nutritional deficiencies combine to make foot health a crucial and sometimes challenging aspect of living with celiac disease.

Early diagnosis, strict dietary management, and proactive foot care are essential for preventing long-term complications. Individuals should seek both routine medical and podiatric evaluation to address symptoms and mitigate risks, aiming for mobility, comfort, and quality of life even while managing a chronic autoimmune disorder.

Caring for the diabetic foot is a critical aspect of diabetes management due to the high risk of complications such as foot ulcers, infections, and amputations. Individuals with diabetes often suffer from neuropathy and impaired circulation, which can result in even minor injuries escalating rapidly if not properly managed. Effective diabetic foot care requires a comprehensive approach that encompasses daily foot hygiene, appropriate footwear, regular medical assessments, and prompt attention to any abnormalities.

Understanding Diabetic Foot Risks

Diabetes affects the feet primarily through two mechanisms: nerve damage (neuropathy) and poor blood circulation (peripheral arterial disease). Neuropathy diminishes sensation, so injuries may go unnoticed, while poor circulation hinders healing and increases the risk of infection. Together, these complications significantly raise the risk of foot ulcers and amputations in people with diabetes.

Daily Foot Care

Good foot care habits can dramatically reduce the incidence of complications. Patients are advised to:

• Wash their feet daily using mild soap and lukewarm water, gently drying them afterward, especially between the toes.
• Moisturize dry skin to prevent cracking, but avoid applying lotion between the toes, as this can encourage fungal infections.
• Inspect their feet every day for any cuts, blisters, redness, swelling, or temperature changes. Early identification of abnormalities enables prompt treatment and reduces the risk of ulceration.

Nail and Skin Care

Proper nail care is essential:

• Toenails should be trimmed straight across and filed to prevent sharp edges, which might lead to ingrown toenails or trauma
• Corns and calluses should never be self-treated due to the possibility of unnoticed injuries and subsequent infection. Instead, treatment should be performed by a podiatrist or healthcare provider.

Maintaining clean and silky skin prevents cracking and infection. However, excessive moisture between the toes can be problematic and should be minimized.​

Footwear and Protection

Choosing the right footwear is crucial:

• Always wear closed-toed, well-fitting shoes or slippers, even at home, to protect feet from injury.
• Avoid shoes with high heels or pointed toes that may cause pressure sores or blisters. Shoes should be checked before wearing to ensure no foreign objects are inside.
• Well-fitted, moisture-wicking socks help prevent blisters and fungal infections. Diabetic-specific socks may boost circulation, reduce moisture, and provide additional cushioning.
• Patients with significant deformities or high-risk feet may require custom therapeutic shoes or insoles that provide extra protection and offloading.

Activity, Circulation, and Lifestyle

Regular exercise helps promote blood flow to the lower extremities. However, patients should not walk when they have sores, and walking should be done in sturdy, comfortable shoes. Smoking cessation, blood glucose control, and management of blood pressure and cholesterol are essential for optimizing vascular health and minimizing risk.​

Early Detection and Professional Assessment

Everyone with diabetes should undergo annual foot assessments by their healthcare team. Those at higher risk, such as those with previous foot ulcers, deformities, or neuropathy, may require more frequent evaluations and podiatry referrals. Clinical assessments typically include inspection, sensory testing, vascular evaluation, and education about foot care.

Management of Foot Problems

If a foot problem is detected, such as a blister, ulcer, cut, or persistent redness, individuals should seek prompt medical attention. Delays can lead to severe infections and potentially amputation. Treatments include cleansing wounds, using appropriate dressings, offloading pressure from ulcers (with special shoes, boots, or casts), and possibly prescribing antibiotics or surgical interventions for advanced infections.

Patient Education

Education is a cornerstone of diabetic foot care. Patients, families, and caregivers should all understand:

• The importance of daily inspection and hygiene.
• How to recognize warning signs of complications, including color changes, swelling, non-healing wounds, or nail changes.​
• When and how to seek medical help for foot problems.

Special Considerations

• Never go barefoot, not even indoors, to minimize the risk of puncture wounds or accidental trauma.
• Avoid soaking feet, as this may dry out the skin and increase the risk of cracking and subsequent infection.
• Manage underlying medical conditions and adhere to the treatment plan recommended by the diabetes care team.

Innovation and Advanced Care

For patients who develop hard-to-heal ulcers or who require advanced support, there are specialized treatments such as total contact casts, wound debridement (removal of dead tissue), growth factor therapies, and even biologic wound dressings. Adherence to off-loading protocols and working closely with healthcare providers is vital for maximizing healing and preventing recurrence.

The care of the diabetic foot is multifaceted, encompassing meticulous daily self-care, appropriate footwear, and regular professional monitoring. Prompt recognition and treatment of problems, combined with education and comprehensive management of diabetes and vascular health, are vital to reduce the risk of serious and costly complications, such as ulcers and amputation. Emphasizing proactive strategies and patient empowerment in diabetic foot care not only preserves limb health but also improves the overall well-being and quality of life for people living with diabetes

Concussion significantly increases the risk of subsequent injury in the lower limb, particularly among athletes returning to play after such an event. This essay explores the epidemiological evidence, biomechanical and neurological mechanisms, timeframes of elevated risk, and implications for injury prevention.

Epidemiological Evidence

Recent studies consistently show a heightened incidence of lower limb injury following concussion, with risks elevated both among amateur and professional athletes. For example, collegiate athletes demonstrated a 58% greater risk of lower extremity musculoskeletal injury post-concussion. This added risk may remain for months up to a year, especially pronounced within the first 90 days after return to play. A large-scale analysis of soldiers found a 38–45% greater hazard for lower extremity injury among those who had sustained concussion compared with matched non-concussed controls

The consistency of increased risk across populations—high school, collegiate, professional athletes, and military personnel—supports the generalizability of this association. Additionally, a history of multiple concussions is correlated with an even higher risk of future musculoskeletal injuries in the lower limb.

Neuromechanical Explanations

The mechanism underlying this increased risk appears to be related to persistent neuromuscular control deficits following concussion. While standard concussion protocols focus on symptom resolution, individuals may continue to experience subtle motor abnormalities despite feeling symptom-free. Studies examining post-concussion athletes found altered movement patterns, such as greater knee valgus and increased knee internal rotation during jump-cut maneuvers—both implicated in higher injury risk, such as ACL tears

Changes in lower limb stiffness during landing, delayed muscle activation, and disruptions in motor planning are commonly observed in post-concussion athletes. These neuromuscular disturbances may result from lingering impairment of central nervous system processing, affecting joint position sense, balance, and coordination.

Biomechanical Changes and Injury Risk

Biomechanical studies highlight that many post-concussion athletes display atypical gait and landing mechanics, which can predispose them to non-contact injuries such as sprains, strains, and tears. For example, increased dynamic knee valgus is strongly associated with non-contact ACL injuries. Inadequate neuromuscular control may undermine the protective mechanism during rapid direction changes or load absorption, commonly required in many sports.

These alterations are not necessarily detected by routine return-to-play evaluations, which may depend heavily on subjective symptom reporting and basic balance testing. Consequently, some athletes are cleared for play while still harboring deficits that increase lower limb injury risk.

Duration of Increased Risk

While the pattern is clear, the duration of elevated injury risk is still debated. Some research indicates risk persists for up to one year, with the highest vulnerability within the first three months following concussion. However, as neuromuscular function gradually improves, this heightened risk may diminish. Sub-analysis indicates college athletes are less likely to experience increased lower extremity injury risk at one year post-concussion compared to immediately after return to play.

Such findings have critical implications for post-concussion management in athletes. Continuous evaluation and gradual reintroduction to full activity may help minimize the window of heightened risk.

Mechanistic Theories

Several mechanistic theories seek to explain the link between concussion and lower limb injury risk:

• Central Sensory Deficits: Concussive injuries can disrupt integration of sensory inputs needed for coordinated movement, balance, and agility, increasing susceptibility to missteps or awkward landings.
• Motor Planning Disruption: Subtle deficits in executive motor control can delay muscle activation or alter movement strategies during sport-specific tasks.
• Delayed Reaction Time: Even after apparent clinical recovery, cognitive and motor reaction times may remain slowed, hampering athletic responses to unpredictable situations and thus increasing injury risk.
• Psychological Factors: Anxiety about re-injury or decreased confidence in movement ability may also alter biomechanics in the lower limb.
• Insufficient Rehabilitation: Rapid clearance and return to play without comprehensive neuromuscular and functional assessments may leave athletes vulnerable.

Implications for Clinical Management

Given the evidence, clinicians should recognize that symptom resolution does not necessarily equate to full physiological recovery post-concussion. Consideration of underlying neuromuscular deficits is essential. Standard concussion tests may miss subtle deficits in coordination, proprioception, and muscle firing patterns crucial for safe athletic movement.

Actual injury rates after concussion suggest the need for more robust clearance protocols, possibly including validated neuromuscular testing, gait and movement analysis, and continued monitoring post-return to play. Moreover, periodic re-evaluation may catch lingering deficits that predispose athletes to injury.

Future Directions

Ongoing research should further explore:

• Quantifying the time course of motor recovery and injury risk after concussion.
• Expanding biomechanical and neuromuscular assessment protocols for return-to-play decision-making
• Developing specific rehabilitation programs aimed at restoring neuromuscular control and reducing lower extremity injury risk.
• Investigating individualized recovery paths, given variation in concussion effects, and tailoring intervention strategies accordingly.

Concussion acts as an important risk factor for subsequent lower limb injury, particularly in the months immediately following return to play. Elevated risk may be attributed to lingering neuromuscular and biomechanical deficits, not always detectable via standard clinical evaluation. Integrating neuromuscular assessment and targeted rehabilitation into concussion protocols—and recognizing the need for extended vigilance—can help reduce injury rates and safeguard athlete health. The observed association underscores the importance of holistic concussion management beyond symptom resolution, highlighting a new facet of injury prevention in sports medicine

Cancer can have profound and multifaceted effects on the feet, influencing the skin, soft tissue, bones, and overall mobility. Although cancers of the foot are uncommon, they can be both primary—originating in the foot—or secondary, where cancer from another part of the body spreads to this region. The following essay explores the different types of cancers that can affect the feet, their symptoms, diagnostic challenges, the impact of cancer treatments on foot health, and the broader implications for patient quality of life.

Types of Cancer That Affect the Feet

Cancers that develop in the foot fall primarily into three categories: skin cancers, bone cancers, and soft-tissue cancers. Skin cancers are the most common, but each type presents unique challenges and risks.

Skin Cancers:
Among skin cancers, squamous cell carcinoma, basal cell carcinoma, and malignant melanoma are most frequently seen on the feet. Squamous cell carcinoma usually manifests as small rough patches or open sores that can appear deceptively benign. If untreated, it can invade deeper tissues or spread to other areas. Basal cell carcinoma is less aggressive and tends to remain localized, presenting as pearly or scaly patches most often on the tops of the feet. Melanoma, particularly acral lentiginous melanoma, is the most dangerous skin cancer affecting the foot because it can appear in places that are not exposed to sunlight, such as under the toenails or on the soles, making diagnosis difficult. Melanoma often masquerades as a mole or fungal infection and has a higher risk of metastasis.

Bone Cancers:
Bone cancers of the foot, though rare, can be particularly aggressive. The most prevalent types include osteosarcoma, Ewing’s sarcoma, and chondrosarcoma. These cancers often present as persistent, deep-seated pain that worsens at night, along with swelling or visible lumps. Studies have shown that bone cancer of the foot can affect any region—ranging from the toes and forefoot to the midfoot and hindfoot—with variable manifestations. For instance, osteosarcoma and chondrosarcoma are more likely to occur in the forefoot and toes, while Ewing’s sarcoma often arises in the hindfoot. The challenges of diagnosing these conditions lie in their resemblance to benign foot disorders or sports injuries.

Soft Tissue Sarcomas:
Soft-tissue sarcomas are cancers that develop in connective tissues, including muscles, fat, and blood vessels. Synovial sarcoma, for example, commonly appears around the foot and ankle. Because the foot contains limited soft tissue, these cancers often mimic benign growths and are overlooked until they grow significantly. Soft-tissue sarcomas can cause noticeable lumps, restricted mobility, and pain as they invade adjacent nerves and structures.

How Cancer Manifests in the Feet

Cancer presents uniquely in the feet due to the anatomy and physiological demands of this area. Symptoms may include persistent pain, visible or palpable lumps, non-healing sores, and discolored patches that may be mistaken for fungal infections, warts, or trauma. The subtle nature of these symptoms often leads to misdiagnosis or delayed intervention.

Bone cancers such as osteosarcoma weaken the structural integrity of foot bones, increasing the risk of fractures even under normal walking conditions. In soft-tissue tumours, patients may notice swelling or mass growth that affects their gait or ability to wear shoes comfortably. Similarly, melanoma may present as a dark streak under the toenail or a pigmented lesion on the sole, occasionally accompanied by bleeding or ulceration.

Secondary Cancers and Metastasis to the Feet

In some cases, cancers that begin elsewhere in the body metastasize to the feet. This phenomenon is primarily seen in advanced stages of cancer, where malignant cells spread through the circulatory or lymphatic system. Common primary sources include lung, breast, kidney, and prostate cancers that eventually lead to secondary tumors in the bones or soft tissues of the feet. These metastatic lesions often cause pain, swelling, and decreased mobility, complicating the patient’s overall prognosis.

Impact of Cancer Treatments on Foot Health

Beyond the effects of cancer itself, modern cancer treatments can profoundly impact the feet. Chemotherapy, radiation, and targeted therapies often produce dermatologic and neurological side effects collectively known as podiatric adverse events.

Chemotherapy-related Effects:
Chemotherapy can weaken nails, causing discoloration, brittleness, and separation from the nail bed. The treatment is also known to cause hand-foot syndrome, characterized by redness, swelling, pain, and sensitivity in the palms and soles. This condition can make walking painful, forcing some patients to reduce activity or modify treatment regimens.

Neuropathy and Circulatory Changes:
Many cancer medications cause peripheral neuropathy—damage to nerves responsible for sensation in the feet—which leads to tingling, numbness, or burning pain. Neuropathy not only diminishes quality of life but also increases the risk of injuries and infections, as patients might not feel minor wounds or pressure sores developing due to ill-fitting shoes. Radiation therapy may also damage blood vessels, impairing circulation and slowing the healing of wounds on the feet.

Secondary Infections and Dermatologic Changes:
Patients undergoing treatment often experience compromised immune systems, making them more susceptible to infections. Xerosis (dry skin), hyperkeratosis (thickened skin), and edema (swelling) are common secondary effects. These changes can exacerbate discomfort, limit movement, and increase susceptibility to cracks or sores, serving as potential entry points for pathogens.

Diagnostic Challenges in Foot Cancers

Diagnosing cancer in the foot is a significant challenge due to the foot’s complex anatomy and the overlap between cancer symptoms and benign conditions. Conditions such as plantar warts, fungal infections, and trauma-induced lesions can mimic early cancer symptoms. Moreover, the nonspecific nature of pain or lumps can delay imaging tests and biopsy procedures. For example, synovial sarcoma often grows slowly and painlessly, leading patients and clinicians to dismiss it as a benign cyst or fibroma.

For accurate diagnosis, specialists rely on imaging such as MRI or CT scans to determine the extent of soft tissue or bone involvement, followed by a biopsy for definitive pathological analysis. Patient education plays a crucial role in ensuring early medical attention for persistent foot abnormalities.

Psychological and Lifestyle Impact

Cancer affecting the feet not only disrupts physical function but also profoundly influences psychological well-being. The feet are crucial for mobility, independence, and quality of life; therefore, pain or structural damage from cancer or its treatment can impair the ability to walk, work, or engage in social activities. Swelling, ulceration, or surgical amputations necessary in some cases can lead to body image concerns and depression.

Cancer survivors often face long-term complications such as chronic pain or neuropathy, requiring continuous podiatric care and physiotherapy. Support from podiatrists, oncologists, and rehabilitation specialists is essential to restore mobility, manage pain, and prevent infections.

Cancer’s effect on the feet exemplifies the disease’s systemic and multifactorial nature. Whether through direct malignancies such as melanoma, synovial sarcoma, or osteosarcoma, or through indirect damage from chemotherapy and radiotherapy, the feet are not immune to the impact of cancer. Symptoms like non-healing sores, lumps, or persistent pain should never be ignored, as early detection greatly improves outcomes. Comprehensive care—encompassing prompt diagnosis, effective treatment, foot care management, and patient education—is crucial to maintaining mobility and preserving quality of life for those affected by cancer in the feet.