“My Corn Has Come Back, so I Want My Money Back!”

Have you as a podiatrist ever had this said to you? This week a patient was most infuriated his corn had returned. He believed that once a corn was removed, enucleated it would not come back, that experiencing a corn was a transitory problem like a troublesome boil which when ‘lanced’ would resolve. If only it was that simple.

Corns, also termed Clavus, have a reason for developing in the first place, they do not just spontaneously appear. Making an appointment with a podiatrist will help you to understand why your corn developed and what can be done to prevent it coming back so quickly or not at all.

Interestingly chiropodists used to be called ‘Corn-Cutters’ in the Seventeenth century.  Napoleon and Abraham Lincoln had their own ‘Corn- Cutters’. It was a lucrative profession, centuries ago when a Corn-cutter could earn £150 per hour. Those days are well gone, but expectations are still as high.

What causes a corn?

The most common etiological cause is mechanical pressure and friction on the skin resulting in thickening of the stratum corneum (hyperkeratosis). If the pressures and stresses are concentrated over an area for a sustained period of time, a corn and surrounding callous will form as a pathophysiological response.

 Main contributing factors are ill-fitting footwear, foot deformities and gait abnormalities. Corns can be observed in individuals who put repetitive stresses onto their feet either through sport or occupation. The elderly are susceptible to developing corns as they ‘lose the spring in their step’. There are then those individuals like diabetics who have peripheral neuropathy (altered sensation). Having feet which are numb can lead to increased weight bearing pressures and friction.

Corns are also seen in individuals who have plantar fat pad atrophy, whereby they have lost the protective cushioning padding in their feet. Also, if the condition of the skin is compromised and the skin is very dry or thin it can lose it’s suppleness and elasticity making it less resistant to mechanical friction. Skin that is tightly stretched on the sole of the foot can develop ‘seed corns’. In cases like this, podiatrists are always harping on about applying a regular application of a moisturising cream to the skin to reduce tensile and shearing stresses.

What is a corn?

Corns are hard plugs of dense keratin, termed the nucleus. They are almost conical in shape and extend down quite deeply into the papillary dermis to become very painful on pressure. There are different types of corns and they are predominantly found in the forefoot:

  1. Heloma Durum – singular localised hard corn located on a point of pressure e.g. hammer toe, pronounced metatarsal phalangeal joint on ball of foot

  2. Heloma Molle – a corn cause by pressure found between toes which has become macerated and soft from increased moisture retention

  3. Heloma Mille – multiple tiny ‘seed’ like corns which generally form of the sole, plantar aspect of the foot caused by shearing friction stresses

  4. Burstic – This is a corn generally over a toe joint which becomes acutely sore due to the protective bursal sac above the joint and below the corn becoming inflamed and distended.

  5. Neurovascular – Corns which are innervated with both nerves and blood vessels and are extremely painful on pressure

  6. Subungual or Periunugual – These are corns that develop under or around the nail plate.

Can corns be harmful?

Having a corn can be very painful. The slightest pressure on them causes pain and irritability. Sufferers have problems in finding comfortable footwear and can start to limp. Having a limp can cause knock-on biomechanical issues up the kinetic chain to cause knee or back pain. Individuals can develop a ‘compensatory’ gait style whereby they are shifting weight away from the foot with the corn. A real problem if you are suffering with a corn on each foot!

Soft corns can develop a secondary fungal infection. Corns subject to considerable pressure can breakdown and ulcerate leading to secondary complications of infection especially if an individual’s health is compromised as with diabetes or peripheral vascular disease. A deep seated chronic infection could lead to cellulitis, or at it’s worst osteomyelitis (bone infection) and thus require surgical intervention such as amputation.

How can I get rid of my corn once and for all?

The reason we get a corn is multi-factorial as previously discussed. A podiatrist can expertly par down the overlying hard skin and remove the central hard plug, in what is termed enucleation to give relief, but it can come back. Corns are essentially a secondary condition caused by a primary factor like a tight, unaccommodating shoe or pronounced toe joint. If the primary cause is not addressed and no changes are made, then the chances are the corn will come back. It really is that simple, but hard to convey to some patients.

The answer lies is in a good initial assessment of what the etiological causes may be and how they can be mitigated. Patient compliance is crucial. If a patient does not appreciate that their choice of footwear is the primary cause no progress can be made. The following are suggestions on prevention and treatment of corns:

  • Good appropriate fitting footwear. If unsure what to wear or your shoe size and fitting, ask a podiatrist

  • If you feel you are walking badly, have a specialist biomechanical assessment with a podiatrist. By correcting the foot alignment, abnormal weightbearing pressures in the foot can be reduced or avoided.

  • You may require a specialist insole or orthotic

  • Off-load the corn with deflective padding or cushioning. There are so many products to choose from in the chemist or online. If, not sure what will work for you see a podiatrist.

  • Choose shoes with cushioning soles if you lack fibro-fatty padding on the soles of your feet, or select a specialist shoe e.g. Joya which have a rocker sole to off-load forefoot

  • Keep the condition of the skin in good condition – apply moisturising creams regularly, carefully dry between toes, use a light astringent e.g. Teatree, surgical spirit

  • Wear good fitting hosiery, socks e.g. avoid seams that may rub across toes or wear surgical compression stockings which constrict toes

  • If you know you have a particular ‘hot spot’, vulnerable area and will be putting your feet through their paces then, put on a protective cover, pad e.g. Compeed plaster before you set out

What should I do if nothing works to get rid of my corn?

For those individuals who have troublesome corns and nothing seems to work there are minor surgical solutions. Often when individuals have had a treatment resistant corn for years it can become more painful over time and harder to conservatively enucleate in clinic. The corn may become fibrous with scar tissue and be innervated with capillaries and small nerve endings. These neurovascular corns are very painful. Electrosurgery is a good treatment option to deeply remove the corn.

Electrosurgery

Electrosurgical removal of a corn is done with a Hyfrecator. A low electrical current is delivered through a specialist electrode into the corn to help excise it. A scalpel is used in conjunction with the hyfrecator to get to the base of the corn. The corn is first numbed with local analgesia. All innervating nerve endings are destroyed, and infiltrating blood vessels cauterised. It is a very effective treatment, but attention should still be paid to elevating any primary abnormal pressure from area or in time the corn could return.

Volumising Foot Fillers

Injecting medical grade dermal fillers of hyaluronic acid directly injected into the area of concern will plump up thinning susceptible tissues to make the area more resilient to pressure and mechanical stress. This can resolve a troublesome painful corn. It is a very effective treatment with the cushioning effect of the fillers lasting 12 – 18 months depending on the initial problem.

Surgery

If all conservative and minor surgical treatments have failed to alleviate a painful corn a surgical option maybe the only solution. This can work well for toe deformities. Ensure you look for a specialist foot surgeon. If you have a painful corn on the second toe it may be worth having it removed.

Conclusion

There is always a primary reason why an individual may get a corn and simply having it removed by a podiatrist may not always result in long term solution if the cause is not removed or reduced. Unfortunately, some people feel podiatrists can magically make them disappear, but sadly this cannot always be achieved despite all attempts of off-loading and protecting from pressure and friction. I have before now said in jest to patients; “Well you could shuffle on your bottom or walk on your hands”, but the chances are they could develop corns there and no podiatrist would want to remove those!