One area on each foot hurts when I put pressure on them

I am attaching a photo of the feet that have the sore areas.

I have been to a foot Dr.and had about 5 or so treatments for laser on these.
At the last treatment he said they were gone. but now they are back and as painful as before. I for get what he called them.
So can surgery help these to not come back?

RESPONSE

Hi,

Do you find it at all curious that the growth on the bottom of each foot is occurring in almost the exact same spot? Your podiatrist should certainly have.

I cannot enlarge the photo enough to get a clear picture of the growths, but since I have seen this condition hundreds, if not thousands of times over my career I will discuss what this is in the majority of the cases I have seen.

Your condition is known as an intractable plantar keratoma. This is a long term for essentially what is callus formation as a result of one your metatarsal bones being plantarflexed, meaning it is in a more downward position than the adjacent metatarsal bones. So this particular bone bears more weight, or pressure, when you walk and what has happened as a result of this excessive pressure is that you have developed a deep seated callus.

These are generally not your "garden variety" calluses in the simple fact that they tend to become cystic underneath. So, just shaving down the the excessive skin growth will, in most cases, leave you with cystic changes in the skin that have to be "carved out" for lack of a better term. Once done you should experience relief for a period of time. This period of time will vary from patient to patient based on a number of factors.

Now, sometimes, because this callus tissue is essentially dead tissue, warts may begin to develop within the callus. I am assuming this may be your case, because that would be the only reason to perform laser on these growths.

Laser ablation is otherwise useless in the treatment of intractable plantar keratoma. Since these growths are the result of excessive pressure on the head of one particular metatarsal bone, lasering them does absolutely nothing to address the underlying cause.

So, what are your options? If you are looking for the simplest, least involved way out, then periodic debridement of the callus and curetting the underlying cystic lesion is the way to go. By the way, I would assume this was done by your podiatrist before he lasered them and that is why they felt better for a while.

The decision to go this route is basically predicated on one condition: How long do you get relief?

If you find relief for perhaps three months or more, then it might make sense to see a podiatrist four times a year for a treatment that is simple and usually painless.

If you only get relief for a couple of weeks and the pain returns, then this type of treatment does not make much sense, as it will require many visits to the podiatrist during the course of a year. (If you do not mind going so frequently, then it would be ok, as well)

Another method in treating this condition is by attempting to take pressure off the plantarflexed metatarsal. We do this through the use of an orthotic with built in padding in the forefoot. If, through the use of an orthotic, we can reduce pressure on the metatarsal bone, then the time it takes for the callus to grow back will be extended. In fact, over the years I have actually seen some of these growths completely disappear just through the use of an orthotic.

If both of these options do not appeal to you or do not work, then you are looking at surgical intervention.

There are various procedures available but the goal of most of them is to surgically break the affected metatarsal bone and then elevate the head of the bone to put it in at the same level of the adjacent metatarsal bones.

This type of surgery does have its pitfalls. Two problems common in this surgical approach is over-elevating the affected bone which will make the callus and skin cyst disappear but more than likely will cause a similar problem at the level of the adjacent metatarsal. The second problem is that of non-union, where the surgical breaking of bone does not properly heal. This is a problem because it is difficult to fixate inside metatarsals as opposed to outside metatarsals like the first and fifth metatarsal. BTW, it appears that your third metatarsal bone is the affected bone.

The final point I would like to make is that if you have hammertoes, which you generally see in this type of condition, the hammertoe exacerbates the problem and if you decide on surgical intervention, that problem would have to be addressed as well.

Marc Mitnick DPM
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