The Emerging Picture of Long COVID and Foot Health

As the COVID-19 pandemic has evolved into the era of “long COVID,” podiatrists have increasingly been consulted for foot symptoms that either began during acute COVID infection or developed in the weeks to months afterward. These manifestations are distinct, often unusual, and in some cases remarkably persistent.

At Balance Foot & Ankle in Howell and Bloomfield Township, MI, we evaluate post-COVID foot complaints using the same systematic approach as any other foot condition — but with awareness of the specific patterns that COVID-19 produces.

COVID Toes (Pernio-like Lesions)

One of the earliest recognized COVID foot manifestations — reported heavily during the 2020–2021 period — is “COVID toes”: chilblain-like (pernio) inflammatory lesions on the toes.

What COVID Toes Look Like

• Pink, red, or purple discoloration of the toes (and sometimes fingers)
• Swelling of one or more toes
• Burning, itching, or tender sensation
• Small blisters or bumps may develop
• Usually bilateral and symmetric

What Causes COVID Toes

The mechanism is debated. Most evidence points to an immune-mediated vascular response — either type I interferon activation causing vascular inflammation, or micro-clotting in digital capillaries. Interestingly, COVID toes appear to be more common in mild or asymptomatic COVID cases than in severe illness.

Most cases resolve spontaneously within 4–8 weeks without treatment. Topical corticosteroids or hydroxychloroquine have been used for persistent or severe cases.

Small Fiber Neuropathy in Long COVID

Multiple studies have identified new-onset peripheral neuropathy — specifically small fiber neuropathy (SFN) — in long COVID patients. SFN affects the small unmyelinated nerve fibers that carry pain and temperature sensation and regulate blood flow.

Symptoms of Long COVID Neuropathy

• Burning, tingling, or “pins and needles” in the feet and legs
• Allodynia — pain from normally non-painful stimuli (e.g., sheets touching feet)
• Autonomic symptoms — cold feet, color changes, abnormal sweating
• Often worse at night
• Can involve hands (glove-and-stocking distribution)

Diagnosis and Treatment

SFN can be confirmed with skin punch biopsy (measuring intraepidermal nerve fiber density) — standard NCS/EMG is often normal because SFN doesn’t affect large myelinated fibers. Treatment focuses on symptom management: gabapentin, pregabalin, duloxetine, topical lidocaine or capsaicin.

POTS and Foot Symptoms

Postural Orthostatic Tachycardia Syndrome (POTS) is a form of dysautonomia affecting up to 2–3% of long COVID patients. The autonomic nervous system fails to properly regulate blood flow distribution when standing.

Foot-Specific Manifestations

• Dependent rubor — feet turn bright red/purple when standing due to blood pooling
• Foot pain and burning with standing
• Significant swelling of the feet and lower legs
• Cold, mottled feet despite warm room temperature
• Symptoms improve immediately with lying down

Management

Compression socks (30–40 mmHg or higher) are a primary management tool for POTS-related lower extremity symptoms. Elevation, increasing salt and fluid intake, and progressive exercise programs are other evidence-based approaches.

Musculoskeletal Foot Pain in Long COVID

Many long COVID patients report generalized musculoskeletal pain including foot and ankle pain, believed to be related to systemic inflammation, deconditioning, and altered biomechanics from reduced activity during illness:

• New plantar fasciitis from deconditioning and weight gain
• Tendinopathy from sudden return to activity after months of rest
• Joint pain from post-viral inflammatory arthritis

When to Seek Podiatric Care for Post-COVID Foot Symptoms

• Persistent toe discoloration beyond 8 weeks
• New burning, tingling, or numbness in feet after COVID infection
• Foot swelling and redness with dependent positioning
• New heel or arch pain following COVID
• Any wound or skin breakdown in diabetic patients following COVID

Post-COVID foot manifestations are real, increasingly understood, and often treatable. Don’t dismiss foot symptoms that began after COVID infection — evaluation can identify specific conditions that respond to targeted treatment.

Ready to Get Relief? Book an Appointment Today.

Board-certified podiatrists Dr. Tom Biernacki, Dr. Carl Jay, and Dr. Daria Gutkin see patients daily at our Howell and Bloomfield Township, MI offices.

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📞 (810) 206-1402