If you've ever felt a sharp pain in your heel or winced with each step, you're not alone. Foot pain is a common ailment, and understanding its causes and treatments is essential for maintaining overall health and well-being, especially within the African American community. This article delves into the specific foot health issues affecting African Americans, including plantar fasciitis, flat feet, and the importance of differentiating benign hyperpigmentation from melanoma.
Illustration of flat feet.
The Foot: A Complex Mechanical System
The foot is a complex mechanical system of the human body. It has 33 joints, 26 bones, and over a hundred muscles, tendons, and ligaments. The two primary functions of the foot joints are weight-bearing and propelling during activities like walking, running, and jumping. To be able to carry out these tasks, the foot needs to be very flexible and stable. However, stability in the foot is the result of how the joint are connected (articulation) and the foot's capacity to function as both a stiff and a flexible lever during the normal gait cycle. These features make the foot act like a solid lever when pushing off the ground and help it handle weight when landing.
Plantar Fasciitis: A Common Cause of Heel Pain
Heel pain often comes from a condition called plantar fasciitis, caused by stress on the tissue at the bottom of your foot from repetitive activities. Plantar fasciitis is quite common, affecting around 10% of people globally at some point in their lives. Among adults, it's the most common cause of heel pain. Women aged 40 to 60 years are affected most. While it can be triggered by various activities, most cases (about 5% to 10%) occur in both serious and casual runners.
Plantar Fasciitis Treatment with Massage, Stretches, & Exercises - Ask Doctor Jo
Plantar fasciitis happens when the strong fibre-like tissue (plantar fascia) that connects the heel bone to the bones in the ball of the foot gets irritated, stretched or torn. The plantar fascia, which has three parts originating from the heel bone, is important for normal foot movement and helps support the arches (curvatures) of the foot while absorbing shock. The plantar fascia, which runs along the arch and connects the heel bone to the toes, is crucial. It plays a key role in maintaining the foot's arch through something called the windlass mechanism. When you lift your toes upward, the plantar fascia, which contains small bones near the base of your toes, gets pulled. If the plantar fascia is strong enough to keep its shape, the bending of the toes and the lifting of the arch should happen together. Plantar fasciitis often happens due to small tears in the plantar fascia, caused by repetitive stress on the foot.
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Fig. 1: Inside view of the foot illustrating common location of pain in plantar fasciitis.
Symptoms and Risk Factors
Pain: This is the most significant complaint that you have with plantar fasciitis. The pain occurs more commonly in one foot and rarely in both. You may feel it more in the inner and lower parts of your heels. In severe cases, it may spread forward towards your toes or upward into your leg. Standing or sitting for a long time can make your pain worse. You feel more soreness on touching and moving your foot or toes, usually at the spot where the plantar fascia connects to the heel bone.
Excessive inward or outward rolling of the foot can all play a role. Occupational factors: Jobs that involve a lot of walking or standing on hard surfaces, such as factory work or teaching, can also increase the risk of plantar fasciitis.
Treatment Options
Most people with plantar fasciitis get better within a year without surgery. The American College of Foot and Ankle Surgeons suggests adapting treatment to fit each person's symptoms, lifestyle, and activity level rather than following a strict treatment plan. This is because many treatments don't have strong scientific evidence, even though they often help when used.
Your physical therapist can show you how to use stretch exercises to relieve your foot pains and strengthen your calf muscles. Your therapist can also teach you how to support the bottom of your foot by taping. This involves adjusting the ankle joint to reduce stress on foot. Research has shown that taping can provide short-term relief from the discomfort of plantar fasciitis. Your therapist may use dry needling and acupuncture to treat your plantar fasciitis. It is believed that the procedures work by changing the local blood flow and biochemical environment. Your therapist might recommend the use of a night splint during sleep to keep your ankle dorsiflexed or neutral to avoid contraction of the calf muscles. Your therapist might recommend that you use special products made to support the arch of your foot.
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Temporary pain relief may be achieved by injecting steroid medication directly into the painful area. To promote healing, sound waves are aimed at the heel pain location. This is for long-term plantar fasciitis when more conservative measures have failed. With the help of ultrasound imaging and using a minimally invasive technique, a needle-like probe is inserted into the injured plantar fascia. After that, the injured tissue is broken up by fast vibrations at the probe tip.
Surgery is rarely required to separate the plantar fascia from the heel bone. Usually, it is only a possibility if all other forms of treatment have failed and the pain is severe. Surgery should only be thought about if nothing else works, usually after trying non-surgical treatments for six to twelve months.
Flat Feet (Pes Planus): Prevalence and Management
What do Angelina Jolie, Usain Bolt, and Elton John have in common? They each have pes planus, or more commonly flat feet. Pes planus is a condition where the arches of the feet are lower than usual or completely collapsed. It can be either congenital or acquired, occur in one or both feet, and may affect people of all ages. If not congenital, people can acquire flat feet from traumatic injury, arthritis, diabetes, and obesity. In some cases, arches never develop properly during childhood. Most children with congenital pes planus develop an arch by age five to 10, and any symptoms should resolve.
Pes planus has a 17% prevalence in non-Hispanic whites and a 34% prevalence in African Americans. While flat feet are common and often painless, they can lead to discomfort and other complications if not properly managed. In most cases, flat feet can be managed with non-surgical methods including supportive footwear and orthotic devices, exercise, and weight management.
Physical therapy can help improve foot mechanics and reduce discomfort. If are person experiences persistent pain, swelling, or difficulty walking, it's important to consult a healthcare professional.
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Racial Disparities in Foot Disorders
February is Black History Month, a time to reflect on issues of historical importance and to celebrate the many achievements of African Americans in the arts, academia, medicine, and more. Is there a history of disparities between whites and blacks and their foot health? Well, a 2010 study out of the University of North Carolina School of Medicine had some interesting findings about African Americans’ foot health. The study followed common foot disorders of individuals from various racial backgrounds over 5 years. Researchers then culled statistical information specific to race.
In the study, 1,536 participants were clinically evaluated for foot disorders from 2006 to 2010. African Americans in the study age 45 or older were three times more likely than whites of the same age to have corns or flat feet (medical name: pes planus). With obesity removed as a factor, bunions and hammertoes were twice as prevalent in blacks as in whites. What the study suggests is that race does seem to play a role in who is afflicted with certain foot disorders.
A study of 1,691 participants, 31.2% of whom were African American, revealed that structural foot disorders and pes planus were common among adults 50 years of age and older. After the regression models accounted for the effects of age, gender, BMI, and education, pes planus was nearly 3 times more common in African Americans than Caucasians with an adjusted odds ratio (aOR) of 2.94, (95% confidence interval [CI] = 2.31-3.75). Statistically significant interactions were observed between race and BMI for hallux valgus, hammer toes, and overlapping toes. Among participants who were not obese (BMI<30 kg/m2), African Americans were approximately 2 times more likely than Caucasians to have hallux valgus (aOR = 2.01, 95% CI = 1.39-2.92), 2.6 times more likely to have hammer toes (aOR = 2.64, 95% CI = 1.88-3.70), and 1.5 times more likely to have overlapping toes (aOR =1.53, 95% CI = 1.09-2.13).
| Foot Disorder/Type | African Americans (%) | Caucasians (%) | Adjusted Odds Ratio (aOR) |
|---|---|---|---|
| Hallux Valgus | 64 | - | - |
| Hammer Toes | 35 | - | - |
| Overlapping Toes | 34 | - | - |
| Pes Planus | 23 | - | 2.94 |
| Tailor’s Bunions | - | - | Nearly 5 times less likely |
| Pes Cavus | - | - | Nearly 5 times less likely |
Plantar Hyperpigmentation and Melanoma
Plantar hyperpigmentation (also known as plantar melanosis) is a benign finding in many individuals and is especially prevalent in those with darker skin tones. It is critically important to differentiate benign hyperpigmentation, which is common in patients with skin of color, from melanoma. Although rare, Black patients in the United States experience high morbidity and mortality from acral melanoma, which often is diagnosed late in the disease course.
In a 1980 study (N=251), Black Americans had a high incidence of plantar hyperpigmentation, with 52% of affected patients having dark brown skin and 31% having light brown skin. Melanoma in Black individuals is relatively rare, with an annual incidence of approximately 1 in 100,000 individuals. However, when individuals with skin of color develop melanoma, they are more likely than their White counterparts to have acral melanoma (acral lentiginous melanoma), one of the deadliest types.
Because of the high morbidity and mortality rates of acral melanoma, clinicians should biopsy or immediately refer patients with concerning plantar hyperpigmentation to a dermatologist.
The mortality rate for acral melanoma in Black patients is disproportionately high for the following reasons:
- Patients and health care providers do not expect to see melanoma in Black patients (it truly is rare!), so screening and education on sun protection are limited.
- Benign ethnic melanosis makes it more difficult to distinguish between early acral melanoma and benign skin changes.
- Black patients and other US patient populations with skin of color may be less likely to have health insurance, which contributes to inequities in access to health care.
The Story of Dr. Foluso Fakorede: Addressing Health Disparities in the Mississippi Delta
The story of Dr. Foluso Fakorede, the only cardiologist in Bolivar County, Mississippi, highlights the stark realities of health disparities in the African American community. Dr. Fakorede grew obsessed with legs, infuriated by the toll of amputations on African Americans. Black patients lose limbs at a rate triple that of others.
Two maps explain why Fakorede has stayed in the Mississippi Delta. One shows America’s amputations from vascular disease. The second shows the enslaved population before the Civil War; he saw it at a plantation museum and was stunned by how closely they tracked.
Fakorede was drawn to Bolivar County, in part, because of its history. For a brief moment, Bolivar was the center of a movement for public health care, driven by the conviction that racial equality was not possible without justice in health. By the time Fakorede moved to the Delta, in 2015, the state had the nation’s lowest number of physicians per capita. It had not expanded Medicaid to include the working poor. Across the country, 15% of African Americans were still uninsured, compared with 9% of white Americans.
Fakorede understood that to reach patients, he needed referrals, so he met primary care providers at hospitals and clinics. He asked them to screen for vascular disease, measuring blood pressure at the ankle and the arm. Preventive Services Task Force, an independent panel of preventive care experts, had not recommended testing anybody without symptoms, even the people most likely to develop vascular disease - older adults with diabetes, for example, or smokers.
