New Year Resolution – Become a Podiatrist

In just under 7 hours time South Africa will welcome 2009. Will you make a resolution to become a podiatrist? Maybe one of your family or friends will?

Are you sitting with your ‘Matric’ results and not sure what to do next? South Africa has a serious shortage of podiatrists and as I wrote the other day even our new graduates are emigrating. There are fewer than 200 registered podiatrists for our population of about 48 million people.

However, with increasing access to health care and awareness of the benefits of a healthy lifestyle, there is a growing demand for foot care, especially for children and people with foot problems associated with diabetes and arthritis. Nevertheless, many sectors of the South African population still don’t know what a podiatrist is or what we do. As our population changes more people will need foot care.

A podiatrist is really a ‘doctor of the feet’. We diagnose and treat foot disorders and abnormalities. This is done in many ways. Biomechanical examination involves assessing the whole lower limb and its function and then prescribing the appropriate treatment to maintain or restore normal mobility or function.

Many systemic diseases affect the feet and may even be diagnosed from foot symptoms. As a podiatrist you may need to refer your patient to a specialist for further management. A large part of podiatry treatment involves the skilled use of sharp instruments to treat corns or callus or possibly perform detailed corrective surgical procedures on toe nails.

Some of the conditions that Podiatrists treat are fungal infections of the feet and toenails; corns and calluses; ingrown toenails; foot ulcers in diabetes; causes of foot pain in arthritis. Most podiatrists incorporate orthotics and insoles into their treatment when necessary. 

The assessment and management of childrens’ foot problems forms an important part of a podiatrists work, whilst some podaitrists are skilled in the managemment of foot problems arising from sports. Nowadays, prevention of foot problems has become very important, so foot health education is also part of podiatry practice.

Although there is no official specialist register for podiatrists, many of us have developed ‘special interests’ in sports injuries, chronic disease, children or the elderly.

The day to day work of a podiatrist is interesting and varied. Giving relief from pain or diagnosing the cause of a foot problem is both challenging and stimulating. You do need to be able to work alone but also need to be a ‘people person’ to relate to the different patients you meet every day. Most podiatrists are in private practice, but we hope there will be an increasing deployment of podiatrists in the State Health services in future. For example Limpopo Province appointed their first graduate podiatrist.

To practice in South Africa you have to register with the Health Professions Council of South Africa.(HPCSA). This means that you become part of the Team of health care professionals providing care to South Africans and that you adhere to ethical standards.(By the way, it is illegal to practice as a podiatrist in South Africa if you are not registered with the HPCSA. So always check the credentials of a podiatrist).

To become a podiatrist in South Africa requires four years of full-time study at the University of Johannesburg. You will obtain a Bachelors degree and be able to go into practice immediately. Although bursaries are limited I believe this is changing as Provincial Health Departments begin to realise the value of foot care. Your entrance is dependent on your Admission Points Score (APS) or your M-score.

There are still vacancies for 2009 enrolment. So why not contact the University of Johannesburg – they reopen on 5th January 2009 – at 011 559 6167 or www.uj.ac.za

However you welcome in the New Year, dancing  the night away, taking it easy at home with friends, walking on the beach on an exotic island or if you are unlucky, at work! Enjoy yourself and I wish you all good foot health and happiness in 2009.

TAKE CARE OF YOUR PAIR! SEE A PODIATRIST 

Merry Christmas! Happy Holidays!

Merry Christmas! Happy Holidays! We closed the practice today. Tomorrow I start a short break in Hout Bay with my family. Including my son who is visiting from the UK.

I know that some of you reading this site do not actually celebrate Christmas and so I wish you and your families well over the long weekend. If you are celebrating Christmas, I hope that you too can spend some time with those you love.

Travel safely and tread lightly. You never know when you will need a podiatrist!

Best wishes

Andrew

Holidays: Sore Feet and Sunburn

Sore feet or sunburn could ruin your holiday. Whether you are going to the coast, mountains or bush, you need to pay special attention to protecting your feet this summer.

As the holiday season gets going, many of us will be exposing our feet to the African sun for longer periods than usual. Remember that if your feet are usually covered by shoes and socks, they will need as much protection as your face and shoulders. (Or your bald head). Despite the fact that we spend a lot of time barefoot or in sandals in South Africa, during holidays the time is often extended.

The most vulnerable part of your feet is the skin on top of your arches. However you can also get sunburn on the soles of your feet if you like to indulge in serious ‘sun-worship.’ Obviously any part of your feet that is exposed is at risk. Initially you might not feel too much discomfort from sunburn, but when you put closed shoes on there will be pain.

Usually, sunburn is confined to a patch of inflamed, sensitive skin, which responds to protective after-sun preparations. The end result is skin dryness and peeling after a week or so and little harm is done. In severe cases however, the inflamed area starts to blister and itch. This is when scratching or opening the blisters can lead to infection.

Always apply sunscreen on top of your feet before you go to the beach, shopping or walking. You might need to re-apply after swimming, depending on what you use, or suits you. If you are spending a long time lying face down with bare feet protect the soles. After showering, treat your feet as you would the rest of your body with your choice of after-sun preparation.

Another common holiday foot problem is burning the soles of the feet. Here again it is usually because the soles of our feet are not as tough as we think and so we forget that the beach sand burns. The same thing applies to the patio tiles or paving.

Don’t do crazy things like walking barefoot over the car park. We all know that it’s thought to be very ‘macho’, to run around barefoot on holiday, but there is nothing ‘macho’ about peeling, blistered soles.

Unfortunately wherever you are, at the beach or around the dam your bare feet are not protected from broken glass, cool drink cans, palm thorns, bits of charcoal from the braai, even rubbing from your new sandals! Watch out for those beach thongs rubbing between your big toe and second toe too.

Always wash sea sand off your feet before you walk any distance, because it can chafe and irritate skin between your toes.

You might even get painful feet from all the extra walking that you do. This can be a big problem if you are walking along a beach where the sand is rough, or if you spend time jumping around in the sea on rough sand. It can also happen if you are enjoying the sights of a chilly Northern Hemisphere winter, as you spend more time walking around.

Finally, as you lie on that soft, sandy beach preparing to enjoy the warm Indian Ocean, remember it’s not just the sharks that can get you, look out for sea anenomes, puffer fish and coral!

So just think ahead. Protect your feet and those of your family, but above all, relax and enjoy putting 2008 behind you. Don’t let sore feet or sunburn spoil your holiday, but if it does, go and see a podiatrist.

TAKE CARE OF YOUR PAIR

Podiatrist Beaten By Technology and Health Professions Council

Regular visitors to the website will have noticed that recent blogs have suddenly disappeared. New visitors will wonder why nothing has appeared for over a month. Well, the administrative cyberstars behind the webmaster decided to carry out a major restructuring of ‘their systems’. As a result, in some remote part of cyberspace concerned with the management of the website the blogs have disappeared. Despite all attempts to find the blogs they seem to have phoned home like ET.

Please be patient and there will be new information up within the next few days.

At present the practice is very busy, which is just as well in view of the recent press release by the registration body in South Africa, the Health Professions Council of South Africa(HPCSA), which basically has recommended that the guideline for fees in future should be the Nationl Health Reference Price List(NHRPL). This is a backdown from the HPCSA position of accepting that a practitioner may charge up to three times the NHRPL.

Since the government took over control of what is usually ‘the Medical Aid Rates’, they have consistently ignored the recommendations of health economists appointed by them to adjust the fees of Health Care Professionals in South Africa.

What this means is continued problems for providers and consumers when dealing with Medical Aids (Insurers). Personally I think that people who value and receive quality healthcare will still be willing to pay for it, IF the financial crisis is not too severe.

Consider this: for spending 30 minutes performing skilled clinical removal of a corn or ingrown toenail,for example, the NHRPL fee is 57.10 SA Rands. Current exchange rates are R1.00 = USD 10.22 and GBP 15.00. Do the maths and see if you can see the value in that. (Of course there are other fees added for consultation and materials), but it is the principle that matters.

I was guest speaker at the graduation ceremony of the podiatry department at the University of Johannesburg, only 5 graduates, the other 12 are deferred until they have finished their research projects. And guess what? The top student is emigrating to Australia!

Look out for Your Career in Podiatry in South Africa, coming to this space soon.

In the meantime if it’s not broken don’t fix it, or you might get beaten by technology!

Sesamoid Fracture – an interesting case – treatment

The case of the sesamoid fracture that I referred to the other day, has had an interesting development. You will have read that we ended up using an Aircast below knee walker. Unfortunately this was only successful for about one day. By the end of the day the pain was increasing.

I advised my patient to get advice from an orthopaedic surgeon who I know. The advice was really simple! Wear thick-soled soft trainers and take pain-killers until it is better. (Obviously only take the pain-killers as often as really necessary). This will allow normal movement – remember this condition is not treated by immobilisation in a cast – but not over use.

So what’s the lesson here? Simple treatments are often the most effective. Never ignore foot pain in the ball of your foot. Have it accurately diagnosed – it might be a sesamoid fracture.

An interesting case: Sesamoid Fracture

I diagnosed a sesamoid fracture in a young woman this week. The presenting complaint, on Wednesday, was of “pain in the ball of the foot under the big toe joint for nearly 9 months, but 3 days ago (Sunday), whilst doing a long day shift the pain got really bad and only stops when I take weight off the foot.”

The ball of the foot was noticeably swollen, but not inflamed. However, when I applied light finger pressure to the area the pain increased and was particularly bad at one spot. The lady has a high-arched foot (pes cavus), but it is flexible not rigid. She is not overweight, but is very active everyday of the week -including some weekends – working long hours. She told me that she usually wears a low heeled shoe or sandal, but it had become impossible to wear slip-ons or ‘push-ins’ because of the pain. The only relief was to wear trainers with a thick sole. When the weight was removed by sitting or resting in bed there was no pain.

By applying a protective pad to the sole and the arch, with a cut-out around the painful area, painfree walking was possible. An X-ray was requested; both feet for reasons that I’ll explain shortly and a follow-up appointment was arranged for Thursday morning.

We met on Thursday and the X-ray showed a clear break in the lateral sesamoid. The pain was also worse because the padding had slipped backwards and out of position. By repositioning the pad, the pain was relieved again. I instructed her to use trainers as often as possible and suggested that she do the replacement padding herself. In addition I arranged for her to be fitted with an Aircast below knee walker, which she could borrow from the practice on Friday after work.

The treatment for this condition is mainly patience and removal of pressure. Which is why I decided on the Aircast. When we fitted the Aircast walking was immediately painfree. Now we both have to wait for the bone to fuse as one or even two bones.

There are two sesamoids under the ball of each foot. They allow a particular muscle to pull the foot down during standing and walking; they also survive a lifetime of bending at the ball (the first metatarso-phalangeal joint). In some people, one of the sesamoids is naturally bifurcate and can look as if it is fractured – called a normal variant -that is why I asked for both feet to be X-rayed. This fracture may heal in two parts also, which won’t be a problem.

Pain in this part of the foot is quite common. It is caused by excessive amount of shearing, compression or tensile stress over the joint. It can be associated with sports like golf and tennis. Starting running or training and doing too much or running in old trainers. Wearing old worn shoes, where the inner sole gets a deep imprint. It can be associated with rheumatoid athritis, or even standing on a ladder for long periods, when you aren’t used to doing that! Nearly always it affects people with a high arched foot who have over-used their feet.

Initially the bone and the joint under them become inflamed and that is called sesamoiditis. Ignore this and a sesamoid fracture may result.

Bunions – Should they go or stay?

Bunions create as much comment and discussion as they do pain for their ‘owners’. Let’s assume that your bunions are bony lumps. First ask yourself are they getting bigger and more painful? Being disappointed with the look of your feet is not reason enough for surgery. Possibly you have some underlying arthritis and the joint is painful at every movement and it is seriously affecting your quality of life. Rheuma-surgery,as it is known is becoming more appropriate nowadays. Another cause for concern is if the big toe is deviating away towards the smaller toes so much that your foot is beginning to look like a tennis racquet.

Whatever the nature of your problem, if you do decide to undergo surgery I believe there are some basic truths to come to terms with. Perhaps the most basic is the most obvious – make sure your surgeon is a specialist foot surgeon – not one who includes foot surgery with the rest of his/her practice.

Then you have to fully understand and accept the conditions surrounding the surgery. This usually includes at least six weeks of careful rest, individualised treatment and immobilisation, plus the general life disruption. It’s my opinion that most “disappointing” surgical outcomes are the result of patients being unable or unwilling to fully comply with the post-operative care requirements.

So what to do about your bunions? Try every conservative measure that you can to preserve your feet. if your life has become interrupted and painful because of your bunions then DISCUSS with your surgeon all about the procedure and after care before you go ahead. Or maybe don’t!

Annual Foot Examination for People with Diabetes

Every person who has diabetes, should have an annual foot examination. Feet, along with kidneys and eyes, form the “terrible triad” as it is sometimes called in medical circles; because people with diabetes can develop peripheral arterial disease or peripheral neuropathy(feet); nephropathy(kidneys) and retinopathy(eyes). I have spent the past two days conducting the Annual Foot Examination for people who attend the Potchefstroom Centre for Diabetes (CDE).

How many people with diabetes undergo this annual examination? Who knows? What is certain is that CDE members have to comply with rules which gives them access to all the basic health care professionals they need. (CDE is a Managed Health Care network of over 250 medical practices contracted to certain medical aid schemes).

The benefit of this annual examination is that patients, families and health carers know if the feet are at risk of developing futher complications associated with diabetes. The examination involves checking vascular, neurological, dermatological and orthopaedic status. Footwear is also checked and commented on. The International Consensus for managing the diabetic foot states that early identification of vascular insufficiency and referral to the vascular specialist does save many limbs.

Worldwide of course there is evidence that smoking damages your health, but even in the group at Potchefstroom there were smokers.  All of whom had diminished circulation, plus the typical signs of cool feet, absent hair, discoloured pink/blue feet – especially when hanging over the side of the examination couch – and a cough.

Checking the state of sensation is vital for good diabetic foot health. The loss of sensation – neuropathy – is often an insidious process, not being fully appreciated by the patient until they are aware of “funny feelings” in their feet. Patients describe sensations of “pins and needles,” “shooting pains,” “ants running over my feet,” “I thought my sock was folded over under my foot, but it wasn’t,” “it feels like I’m walking on cotton wool” and many others. This could be the first step to damaging the foot and developing an ulcer.

People with diabetes get all the conditions that affect the rest of us. However, if not identified and managed properly an area of callus(which indicates increased local pressure) can easily develop into an ulcer. Various nail conditions are common amongst people with diabetes, especially fungal infections and they are difficult to get rid of.

They structure of any foot affects its function and so in the diabetic foot assessment we look at the alterations in shape that could cause load increases and potential blister or ulcer sites. In addition disorders such as gout are very often associated with diabetes.

Footwear is responsible for at least 50% of foot ulcers, so this is examined very carefully. Unfortunately, many people do not have suitable footwear, so it’s important to check it  and give good advice.

Diabetes is a life-threatenting disease, but modern medicine has moved to early diagnosis and treatment and an important part of this is recognition by podiatrists of the signs in the feet. However for the person with diabetes one of the simplest acts to ensuring long life is to have your feet examined annually and know your foot status or risk.

On Safari – AFLAR Rheumatology Updates – Nairobi

Back from the AFLAR Nairobi Rheumatology Updates. Hard work, but enjoyable and successful.  I presented my “Foot Problems in Arthritis” talk to the Allied Health Professional’s Workshop and the formal Regional Rheumatology Symposium.

An ‘on safari’ report was intended, but my laptop was attacked by Trojan Horse and worm viruses, after picking them up from the generic computer we used for the workshop. Fortunately the IT expert at my hotel was able to clean the flash drive and I just shut the computer down. Now all is clean and healthy again.

Andrew Clarke receiving a gift from Dr Andrew Juma Sulah, National Chairman, Kenya Medical Association

The big ‘take home ‘ message of the workshop was the need for team work in assessing and managing the effects of arthritis in any form.

The interaction between the physiotherapist, occupational therapist, rheumatology specialist nurse, podiatrist and rheumatologist; plus all the other health professionals, was highlighted by the team that came to Nairobi from Glasgow.

Their big message was that the centre of focus must always remain the patient. They also showed how their individual professions have developed extended scopes of practice to enable a massive reduction in waiting lists in Scotland, due to the screening interventions that they are allowed to do.

Despite the apparent skills shortage in Kenya – there is only one rheumatologist in the whole country – there are many skilled and enthusiastic allied health professionals plus other doctors such as GP’s, physicians and orthopaedic surgeons interested in getting involved with managing arthritis. I met many of them during the week.

Delegates at the Regional Rheumatology Symposium

Additional talks were on ‘Arthritis, feet and podiatry’ and ‘Footwear for problem feet’. In the practical sessions, delegates were shown how to make a basic insole and use padding onto the foot and into the shoe. More on this another time.

Oh yes. Traffic. I will never complain about Johannesburg traffic jams or driving again. The rush hours are gridlock in extremis; unbelievable.

Thank you AFLAR for the invitation and Roche Pharmaceuticals for the financial assistance.

Footwear For Babies – Barefoot is Best

Babies do not need footwear. Anything that you put on a baby’s feet will constrict and damage it. Don’t be persuaded to buy ‘pram shoes’ they should be hanging from the rearview mirror of your car!

As children develop they are all action and this is part of the normal growth pattern so it is essential that they are allowed freedom of movement at every opportunity.

There can also be damage from clothing that we put our babies in. Romper suits (called a Babygro when my children were small) are often too small or tight and restrict the very important kickiing activity the all growing babies need. In South Africa there is a trend to cover babies when in the pram or stroller. DON”T. Any covering that reduces the normal developmental reflex movements will cause harm. Those beautiful knitted bootees from Aunty Tshidi – watch them – they must allow the wriggling, growing toes to keep doing just that.

If you look at ‘pram shoes’ you will see very little of their shape matches the baby foot, especially at the toes wher usually they are too narrow. It could be the equivalent of you or I wearing a shoe one size too small. Even the fastening around the ankle, although it may look OK has the potential to press into baby’s foot.

During the first 6 months total freedom should be the aim. This allows the unhindered development of the neuromuscular responses. Just take a moment to look at the feet of the newborn and infants before they start walking. What you will see is a range of curling, wriggling, turning in and out, twitching and so forth which need to bee allowed without being enclosed in footwear of any sort.

Barefoot is best. Loose covering obviously to keep warm. Yes keep the sun off, but don’t constrict the feet. Throw away the ‘pram shoes’n the only footwear you need for babies is bare skin.