SHORTENED VIDEO VERSION OF THIS ARTICLE


intractable plantar keratoma

--> intractable plantar keratoma

WHAT IS AN INTRACTABLE PLANTAR KERATOMA



Ok, here is the situation. All of a sudden you have noticed this pain on the ball of your foot. Additionally, you also noticed this “hard spot” in the same location. Prior to this you may have had the “hard spot” or callus and although you knew it was there it did not really bother you. Now, however, the area really hurts. Many people will complain that it feels like they have a stone in their shoe; the problem is, the “stone” is there all the time. It will hurt more if you are walking barefoot on a hard floor, it will feel better on a carpeted floor. It will hurt if you are wearing a thin soled shoe, or a high heel; it will feel somewhat better if you are in sneakers. You may have even tried to trim it away or put a pad on it to make it feel somewhat better, but ultimately it just hurts. So what is it?

The most common cause for this scenario is what is known as an intractable plantar keratoma or commonly referred to as an IPK. This is a benign condition that develops as a result of cystic degeneration in a callused area. In simpler terms, there is excessive pressure under one of the metatarsal heads. The pressure itself will initially cause a callus to form. The callus itself may or may not be a painful condition; some require treatment, many do not. This will result from excessive shearing forces occurring in the center of the callus.

ipk


WHAT CAUSES AN INTRACTABLE PLANTAR KERATOMA



In the diagram shown here the larger black circle represents the callus that you might have. All the straight lines represent the shearing forces that are occurring as you walk. What generally causes shearing forces is the pivoting on the metatarsal head as you walk. The point where all the shearing forces cross each other causes the skin to undergo cystic changes and thus this area becomes harder than the surrounding callus and a lot more painful (red circle). This is your IPK.

SPECIFIC CAUSES OF INTRACTABLE PLANTAR KERATOMA DUE TO FOOT STRUCTURE

The formation of this cystic lesion can be caused by a number of structural problems in the foot.

Elongated metatarsal head. Looking at the diagram, a ‘normal’ foot structure results in the formation of a parabola (arc), represented by the yellow line, where generally the second metatarsal head is the longest.

metatarsal_parabola

In situations where there is a distortion of the parabola such as an excessively long third metatarsal head, or even a second metatarsal head, a callus may eventually form underneath the bone and ultimately then a intractable plantar keratoma.

Excessively short first metatarsal head. In the case of the second metatarsal head the condition can be exacerbated by problems under the first metatarsal head. Either the first metatatarsal head is excessively short thus putting more pressure under the second metatarsal head, or the

First metatarsal head may be hypermobile. The first metatarsal head, more so than the other metatarsal heads, has the ability to move up and down during the gait cycle. In foot deformities where the head moves upward too much (hypermobile), it puts excessive pressure on the second metatarsal head and opens the door for an intractable plantar keratoma.

Plantarflexed metatarsal. Another situation that will cause an intractable plantar keratoma is the weightbearing capability of each metatarsal relative to each other. In theory, the lesser metatarsals (2-5) should each bear equal weight during the gait cycle. However, some people have a variation in the metatarsal heads and one metatarsal head may be more plantarflexed (bent downward) than the other metatarsal heads and so that particular metatarsal head will bear more weight and thus be more prone to formation of an intractable plantar keratoma.

metatarsal_heads

Looking at the diagram, if the horizontal yellow line represents the walking surface you can see that the third metatarsal head is below the yellow line meaning that it is subject to much more pressure than the adjacent metatarsal heads and so it will be more prone to forming an intractable plantar keratoma.

Shape of the metatarsal head. Along this line of thought is the idea that the shape of a given metatarsal head may also precipitate the formation of an intractable plantar keratoma. The underside of each metatarsal head consists of two condyles, which are rounded protrusions of bone. In some individuals the lateral condyle (the one on the outside) will be excessively large and this can contribute to the formation of an intractable plantar keratoma.

Hammertoes. Also to be considered are the effects of hammertoes , particularly what are known as rigid hammertoes. As the name implies, these are toes that stay bent or crooked during weightbearing and non-weightbearing. The excessively bent toe puts a retrograde or downward pressure on the metatarsal head just behind it, thus creating more pressure against the ground. This can contribute to the formation of an intractable plantar keratoma.

Lack of fat on ball of foot. Other anatomical considerations include the amount of fat that an individual has under the ball of their foot. The one part of the body where we do need to be fat is the bottom of the foot, unfortunately, the one part of the body where we lose fat as we age is the ball of the foot. Without the added cushioning, some people will be more prone to intractable plantar keratoma formation. I should also mention that conditions like rheumatoid arthritis will also exacerbate the formation of an IPK.

Common conditions that may mimic an IPK is a plantar wart and a porokeratosis. If you go to your family doctor complaining of a painful growth on the bottom of the foot, more often than not, you will get a diagnosis of wart. In all fairness, warts can “grow” in callused areas of the foot, but the majority of these lesions are intractable plantar keratoma.

TREATMENT OF INTRACTABLE PLANTAR KERATOMA



conservative care

Shoe selection. How do we go about treating this condition? In many instances changing the type of shoe that you wear will actually eliminate the problem. For example, the higher the heel that you wear, the more pressure you put on the ball of the foot. Wear lower heels. Very thin soled shoes will aggravate the condition; try wearing thicker soled shoes with a more cushioned bottom. Many of you will notice that the problem hurts much less when in sneakers compared to high style dress shoes.

Pads and cushions. Many people will resort to buying different types of pads to cushion the area and yes that can help. A few words of caution. If you are using adhesive pads, they should be changed daily. If not you run the risk of developing an infection under the pad or perhaps have an allergic reaction to the adhesive in the pad. Be careful when removing the pads, you do not want to tear the skin otherwise the foot will hurt more.

Avoid using medicated pads especially if you are diabetic or have poor circulation. Medicated pads contain an acid. The idea is for the acid to eat away at the IPK to make it feel more comfortable. The problem with acid, is that it does not know when to stop, so it will eat right through the IPK into healthy skin and you run the risk of creating a skin ulcer. Again, those who are diabetic or suffer from poor circulation are more at risk, but why would anyone want to continuously create this type of problem?

Professional medical care. Other treatment options include visiting a podiatrist periodically who will trim the callus and curette (carve out) the intractable plantar keratoma. This is generally not a permanent cure and has to be repeated periodically, but having said that, I can also tell you that over the years I have had a number of patients who had very painful IPK’s that gradually disappeared or reduced in size due to nothing more than regular professional care.

Orthotics. When the intractable plantar keratoma is due to a biomechanical problem such as an elongated metatarsal bone, or excessively hypermobile first metatarsal bone, an orthotic can be very helpful. Depending on the underlying cause, a custom orthotic can be built to take pressure off the IPK. This is accomplished either by adding a metatarsal pad behind the growth and thus reducing pressure on the IPK as the foot rolls forward or by the use of an accommodative padding which is essentially a pad that covers the whole forefoot with the exception of the IPK. Here the pad is cut out which basically allows the affected metatarsal head to "float" or reduce the direct ground pressure against the metatarsal head and reduce pressure on the growth. With either type of padding what generally happens is either the growth disappears over time, or the time it takes for the growth to come back is dramatically increased.

surgery

There are surgical approaches for the treatment of intractable plantar keratoma in those individuals where nothing else gives satisfactory relief. The problem here is that the success rate is not a high as it is for other foot procedures.

One surgical approach is to take the plantarflexed metatarsal, perform an osteotomy (surgical breaking of bone) and “raise” the metatarsal head to be in better alignment with the adjacent metatarsal heads and in theory that should eliminate the IPK. When successful, it does eliminate the IPK, but there are two major problems here.

One is over correcting the elevation and thus creating more pressure on the metatarsal bones next to it and ultimately the formation of an intractable plantar keratoma on one of those bones.

The other problem is that of a non-union of the osteotomy, where the surgical breaking of bone does not heal. This problem will tend to be more prevalent in procedures that look to shorten the offending the metatarsal bone to improve the parabola. In these cases, a portion of bone has to be removed in an effort to shorten the bone.

If it is determined that the problem is due to an enlarged condyle, a simple condylectomy (shaving of the condyle) may be indicated. This is a simpler procedure than an osteotomy and there is no worry of a non-union. The issue here has to do with which metatarsal head requires the condylectomy; some are easier to reach surgically than others. We generally try to avoid incisions on the bottom of the foot, so to get to the bottom of the foot, we have to make the incisions on top of the foot which as you can imagine can be difficult.

In summary, an intractable plantar keratoma is a condition that generally responds quite well to conservative care, in many cases just a change in shoe selection. Always try the simplest things first. If you cannot get the relief you are trying to achieve through conservative means, then discuss more invasive options with your doctor.

Want more information? CLICK HERE






download from Apple Store
Get it on Google Play

ORTHOTICS for multiple types of foot pain
best buy in a pre-made orthotic
click link below


SuperStepOrthotics


ORTHOTICS for heel and arch pain for those who must wear dress shoes
click link below


redithotics


Topical pain reliever
click link below


blu-mjk


Relief for nail fungus
click link below


clotrimazoil





I've been doing some aggressive research lately (it's how I found your incredible website) and realize now that my symptoms are not consistant with the diagnosis.

Jennifer

Hunterville, NC


….after reviewing your amazing site (great for the avg. jill). So thank you very much!!!

Liesbeth

NY
I am really, really impressed with your plain-speak explanations for the various conditions.

Jacqueline

NJ
This was an extremely helpful site. I have an appointment on the 18th and your info. Was right on target…..

Jack

Fla
A well organized site containing much information written in a manner that the average reader can comprehend.

Jean

Ontario, Canada
I found your website and articles most interesting.

Andrew

Fla.
Thank you for a quick response. I think your site is the best information site on foot pain and I have viewed many.

Judy

(location unknown)
I came to your website, footspecialist.net via www.foot-pain explained .com which I think is also your website? I thought explanations for different types of problems were well addressed and thoughtfully stated for the patient in mind.

L.W.

New York
You have an amazing and extremely informative site. I enjoyed looking through all of the data and stats.

Yvette

Memphis, TN
Thanks again so much for the information in the article. Very interesting.

Anna

Scotland
Great article. I have had plantar fasciitis since I was in high school……..

J. Simmons

(location unknown)
Dear Dr. Mitnick, The orthotics arrived four days ago and I slipped them into my shoes immediately. I was skeptical as to the usefulness of the item, they really didn't look very exotic. I have to say though, after using them for just four days, I have experienced grand relief from my foot pain. Even the very first day, I was able to do a lot of work while on my feet with at least a 75% reduction of pain. It has only gotten better every day, and I go nowhere without my shoes with the orthotics. I had been experiencing extreme heel and sole pain for about six months and had to take extended breaks off my feet many times a day as well as regular doses of Ibuprofen. Since getting the orthotics, my life has returned to normal and I feel good again. Just wanted to say thanks for the recommendation for a very effective item, I had no idea what a change this item could affect.

Yours truly,

J.C. Forbes

Tennessee
Thanks for the Response, you hit it on the head.

Steve

Redondo Beach, CA
Thank you for your time and expertise in answering my question…..

LH

(location unknown)
First, thanks for putting together this website. Its the most informative site I have found dealing with foot problems. Last June I started having pain and swelling at …….

Joe

(location unknown)
First of all, thank you for having all this useful information available in one place. I've been through most of your website and based on my research, pain and evaluations I think I've narrowed things down quite a bit.

Pete M.

(location unknown)
Thank you for the best site I have found when researching foot pain.

Glenda B.

Madison, Alabama
Thanks for replying so quickly. I was a bit concerned. I think your website is great, and chock full of info.....

Carol

Denison, TX
Dr. Marc, Thank you so much for your reply which seemed to be right on. I have researched many sites but you put me on the right path to the possible answer. My foot pain may not rule the rest of my life after all! I believe I'll make a sign that reads, "THE END IS NEAR!" Thanks Very Much,

Dawn

West lafayette, IN
Dear sir...no doubt you get positive comments re your site...May I please be added to the list of your admirers. In all of my years of web surfing I would say your site is right there with the very best. Thank you for taking the time to write the terrific info you provide and for putting things into laymen terms for us mere mortals. I pray you have much on going success and thank you again for a deed well done. As for me I did not find much help for my symptoms and will continue on my quest. Were you anywhere in the South I would make and appointment...Thanks again dear sir...m.e.

Michael E.

Tampa, Florida 33624
Hi. This is a great site! I'm a healthy middle aged woman who is in good health, but.....

Kelly

Texas
Just a wee word of thanks for your wonderful website...It is a terrific service...Thank you for providing your knowledge and help...With highest regards, m ebeling

Michael D. Ebeling

Tampa, Florida 33624


Thanks for a most interesting website, which has helped a lot.

Steve

UK


Dear Dr.Mitnick

I usually do my research on the Mayo clinic website. I think your website is the most informative site I have found when researching foot pain.

I thank you for putting together this incredible website.

Regards,

Dragica W.

Edmonton,Canada


....I have been told that it is not hard enough to be cut off. Please help, I am not sure what to do now! THANKS FOR A WONDERFUL AND VERY HELPFUL SITE!

Roxy

South Africa


You have an unusually clear, informative and well-written website for laypersons. Thank you for that.

Matthew W.

Mansfield Ctr, CT


First, I'd like to thank you for all the information that you provide on your website and the opportunity to write to you.

Steve

Placentia, California


First, I want to let you know that you have the best web site I've found related to foot issues. (The only thing I had difficulty finding was the "ask a question" page.)

Unknown

Unknown location


I received the orthotics Monday afternoon and began wearing them Tuesday. After two days I would say that I have noticed a huge improvement in the discomfort I have been experiencing. My foot feels better than it has in months.

Ric J.

Unknown location


I greatly admire someone like you who would donate and dedicate so much time and effort to helping strangers with no compensation. Truly, it is uncommonly kind. And your site is so intelligently arranged.

Ron R.

Pacific Grove, CA


I used to work for a podiatrist (front desk) back during summers in college years ago, so I know the benefits of good care. Again, I want to thank you for an EXCELLENT website. It was so great to get to your site (top of google search) and actually find all the answers I needed EASILY and QUICKLY! Clearly you put a ton of work into it and I really appreciate it.

All the best,

Victoria

Alameda, California


By the way, millions of websites could use yours as a guideline on how to organize information and make the site user-friendly. Kudos to you!

Anonymous


Thank you for your very interesting and informative site!

Anonymous




Hi. I come to your site often looking for information. It is really informative and I appreciate it very much. I have RA and have been having considerable amount of foot pain...... Dee RN


Thanks very much for the wonderful informative site.

Catherine

New Zealand


Thank You for my answer! I have been schedule for a bone density scan, allingment, and I am in the process of getting orthotics made, and checking out the natural remedies. Thank again! What a great web site!

Sincerely

Josette


Yes I want both pair of orthotics. You don't have an option of ordering 2 at one time so I had to place the order twice. Thanks. My husband likes these and wants to put them in all of his shoes. (referring to Superstep orthotics)

Cindy H.

Arizona
I searched the internet everywhere for a clear description and illustration of my symptoms/problem. http://www.foot-pain-explained.com/ was where I ended my search with answers. If I lived in Jersey (left 30 years ago) and didn't live in Florida I would definetly make an appointment with Dr. Mitnick.

Thanks, Kathy

Florida
1st of all THANKS A LOT for your great site......

Anna

Poland
Thank you so much for your response. I will let you know how I am doing if you would like. Your website is awesome!

M P

South Carolina
Hello! I want to thank you for such an informative website! I found you based on my ankle pain search and am happy to realize that there may be a relatively simple cause and solution....

Natalie

unknown location


...Thanks for your fantastic service.

Gary

Arlington, VA


Thank you so very much, that would be much appreciated. I love those insoles, by the way. (referring to Superstep orthotics)

Kelly W.

San Clemente, CA


Dr Marc is fantastic...He seems to know exactly what you are feeling with the problems you are having. I wish he was in my home town so I could go to him with my problems!!!!!!!!!!!!!

Pam

location unknown


Great insights! Thanks Doc, you're the best.

Glen

location unknown


I have been experiencing foot pain of various sorts and am working to figure out what it is. I found this site and can only say BRAVO!! What an excellent site! The time it must have taken to put all this together must've been a daunting task! I am sure it has helped so many people. Thank you so very much for doing this.

Bre

location unknown


Dr. Mitnick, Thank you so much for your reply. I did let my physician know and they took an x-ray - all is well! Also, thank you for providing this wonderful site, it is very helpful with lots of useful information! I appreciate your gift of time! God bless.

anonymous




Dr. Mitnick, Thank you, you were 100% correct. The pain finally brought me to the ER. I spent 8 days in the hospital. The Doppler you spoke of was able to show that there was no pulse in that foot. This was an arterial clot that split and traveled throughout my leg. My leg was almost amputated. I am in rough shape but have all my parts intact!! You certainly know what you are talking about. Thank you for taking the time to answer. Yours Truly!

anonymous




Staying at home after hallux surgery I spend quite a lot of time seaching info useful for avoiding problems which might come back. Today I found your site and I am .... delighted it happened. It's one of the best site I found last days.

Anna

Poland




Thanks for taking time to read and answer so many questions. It is truly a public service!

Esh

Seattle, WA


I just wanted to say that I am very greatful for this website!!

Bonnie

location unknown




Also, and importantly, just want to praise this web site. Thorough and thoughtfully presented, it certainly must be of considerable assistance to anyone with a foot problem. Terrific -- and very interesting.I trust the address comes up easily for those seeking information.

Bill

New Jersey




Thanks so much for answering my question. You've been more help to me than my own Dr. has been lately. Thanks again....I hope to be able to walk without pain someday.

Debbie

location unknown




Wow, that is exactly the information needed!!! thank you thank you thank you!!! I appreciate this help so very much from Marc Mitnick DPM. Excellent information and help to improve One's life.

Chrissy

location unknown




Thanks so much for this website Dr. Marc! It is so nice that you have this ask the doctor feature..I'm sure I'ts been helpful for alot of people. I will try what you suggested and see if it helps...thanks again!

Tracy

Evansville, IA




Dear Marc

I just want to say thank you for the quick response and the good info. I find it amazing and a super nice thing that you do here by answering medical questions at no charge.

Russ W.

location unknown




Your website is full of a lot of helpful information, and I am very impressed with the time in which you responded to my post. Thank you again for your time and consideration in your response.

-Sunny.

location unknown




Thank you very much for the information, I will consider it. Excellent web site.

Jackie

San Diego, CA




Dr. Mitnick, Just want to say thank you so very much for your quick response and very informative reply! After reading what you had to say, I called the doctor's office and was able to get in and see him the same day as my injury. Toe was x-rayed and luckily, it is not broken or fractured. Very badly bruised and will probably lose the toe nail. And although my toe and toe nail are still very black and blue and very sore, they ARE both starting to feel a little better. So again, thank you! I am so very happy that I came across your website. The service you provide is outstanding and immeasurable!

Rivi,

Albany, NY




Thank you so much for all of your advice. In searching the web for people dealing with this same issue i can tell you that you are a Knight In shining Armor! If I lived in Jersey I would gladly be your Spokesperson. Hopefully next time you hear from me it will be good news. God Bless,

Jill S.

location unknown




THANK YOU SO VERY MUCH FOR YOUR TIME AND EFFORTS, YOU ARE SO VERY APPRECIATED. THANK YOU FOR ALL YOU DO.

Jackie

Whichita, KS




thanks again, this site is very helpful.

mark

Boston, MA




Like others have stated...This site is amazing and I am so thankful that it was created.

....Keep up what your doing. Your a life saver.

Michelle

Colorado




Thanks again for the information provided on your site. It's easy for non-medical folk to understand your writing, and helps provide better communication between patient and doctor.

annielou

Colorado


Wonderful advice

by: Anonymous

This is the best site for foot problem info.


Thank you for this information. This description fits my pain and inflammation behind my 2nd toe perfectly.

by: Max

location unknown
Again, I really appreciate that you responded to my inquiry, and that your mention of Parkinson's helped me to find my way to a diagnosis of this difficult to diagnose disease. Most patients see on average 16 doctors before they are diagnosed. I hope that you can help other people that ask for your expertise in the future.

Barb D.

Canada
I just wanted to say that I am very greatful for this website!! I have had a fusion in my rt foot and am finally getting a little bit better......

Bonnie

location unknown
Again, Thank you from the bottom of my heart for taking the time to answer my question....your an angel!

Nancie

Wisconsin
Thank you for your response. You have provided some great insight (to my question)....

Julie

location unknown
Thank-you so very much for responding so quickly and in such detail to my question!! I will give my surgeon a call today!! This website is terrific!!!! Thank-you again!

Renae

North Carolina
Many Thanks Dr Marc!
Thank you for your response. It sounds like a good plan to me. He did not cut the wart out first ...

KG

location unknown


Thanks again doc for having this website and we STILL need qualified Podiatrists in beautiful sunny Tampa Bay (Bradenton) Florida.

Bessie Mae

Florida
Dear Dr. Mitnick, Thank you so very much for taking your time to answer my question. You have greatly relieved my anxiety related to the continual tingly I feel in my feet. I will share your response with my podiatrist next week. God bless you for having this question and answer page on your website! Most gratefully,

Lynne T.

location unknown
Your webpage is excellent, I commend you on sharing your knowledge to the public.

Robert

New Jersey


Thank you. you were more detailed than what others have told me they finally called from the last xrays and my son is now in a cast for 2 weeks he did have a fracture that was not noticeable.

a mom

location unknown


I have read your website and I have to admit that I am amazed at all the information that is on here. I have learned more than the three years I have been going to several doctors that I have seen!!

Melody

Lenoir, NC


Thank you so much Doc for a quick and thorough response!

Rustam

Bellevue, WA


I cannot thank you enough for your response, opinion, and suggestions! I want you to know how much it means to me, and I'm sure everyone else who has ever asked you a question! I feel like you're a lifesaver and have empowered me to take a stronger role and stand up for myself and my feet!

Jodi

location unknown