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In podiatry, for the child with arthritis, we find that foot problems are not necessarily caused by the arthritis alone. Before the disease is correctly diagnosed, swelling, pain and lack of mobility are the main signs and symptoms. This usually affects the hands, knees, feet and ankles. Malfunctions of the foot, ankle and leg as a result of painful joints usually respond to medication. However, many structural problems [what podiatrists call biomechanical anomalies] remain, because they were present before the arthritis developed.
I have found that podiatric intervention is necessary and effective during the painful stages at the start of medication and after the disease has gone into remission following medication. The intention is to balance or control foot function, thereby reducing the load on the painful foot joints. This counteracts the effects of these underlying anomalies and aims to protect the feet from long-term damage.
Even children without foot pain but with significant biomechanical anomalies are prescribed foot orthotics. This is at present only an opinion, but we are recording all interventions at our clinic in an attempt to collect some meaningful data.
However, often the initial treatment involves making sure that the footwear is a correct fit. Many children that I see choose to wear soft slippers because their feet are painful and school shoes hurt. Slippers make matters worse as they give neither support or protection to the feet. Fortunately we can request that these children be allowed to wear trainers and so far teachers have been co-operative. For the really poor patients we actually buy an appropriate trainer.
The use of foot orthotics always stimulates debate. There is published research to show the benefits of prescription foot orthotics for adults with rheumatoid arthritis, but to date evidence for children is scarce. By using foot orthotics for all children with biomechanical anomalies with or without pain, we hope to prevent them from developing serious foot function problems as adults.
In some cases, we start by using a very basic treatment of figure 8 crepe bandage to support painful ankle joints. This can be easily taught to family members and starts to get the family involved in treatment – especially when they experience a reduction in pain and improved foot function.
I read in the June 2008 edition of PodiatryNow (the monthly Journal of the Society of Chiropodists and Podiatrists, in the UK), that "a 3-year trial is to commence aimed at reducing pain, stiffness and deformity in the feet of up to 60 children and young people." The study is a cooperation between academic podiatrists from Glasgow Caledonian University, the Royal Hospital for Sick Children in Yorkhill and the Centre for Rheumatic Diseases at the University of Glasgow.
They have been awarded nearly 90,000 British Pounds, about 1.3 million SA Rands. Is there anybody reading this who would like to fund similar research at our clinic at Chris Hani Baragwanath Hospital in Soweto? (Subject to all the necessary protocols)!!
This type of research will enable us to be much more accurate in our interventions for foot problems in the child with arthritis.
J.I.A. or juvenile idiopathic arthritis is just one of the manifestations of arthritis in children. Just like adults children get pain, stiffness in the morning that can last for some hours, restricted movement of their joints, swelling of their hands and feet. In other words serious incapacity. Unlike the adult form where we see a pattern of rheumatoid arthritis starting to affect women mainly around the age of 40, in children it can happen anytime.
Awareness is the key for both parents and health care professionals. I have been seeing children with local areas of tenderness or pain under the heels, or at the back of them. Pain along the soles of the feet. Ankles that are painful all the time either when moving or resting. Showing reluctance to run around because of the pain. Complaining of swollen and painful toes. Not wanting to wear their school shoes because they hurt. There are many other signs and symptoms that usually the doctor will identify.
Some of my patients are so badly affected by arthritis that they are only able to wear soft slippers to school. Fortunately a donor has offered to provide appropriate soft but firm footwear for them. Some children are completely pain free thanks to the medication that has been prescribed, but they have structural foot problems and so need some form of support – usually with an orthotic – but often just a decent shoe and some advice is enough.
The secret of success in managing these children is teamwork, and I am lucky to be part of the paediatric rheumatology team at Chris Hani Baragwanath Hospital. The specialist doctors are able to prescribe the appropriate medication which frequently brings relief to the painful joints and removes symptoms.
Don't ignore the child with a painful foot. It probably isn't arthritis, but it might be.
The diabetic foot is often associated with patients who are on dialysis for kidney failure as a result of their diabetes. There is a well known 'triad' of eyes/kidneys/feet. What health professionals call retinopathy/nephropathy/neuropathy.
We are managing a gentleman who is suffering the effects of many years of poorly-controlled diabetes, acompanied by smoking. The effect of this has been serious damage to the circulation to his legs. As a result, he has needed arterial bypass surgery and now, three times a week he comes to the hospital for dialysis, because his kidneys are malfunctioning,so his specialist asked us to look after his feet.
On first view we got a real shock – the three outer toes on his right foot were dry, shrivelled and black – typical of dry gangrene. These toes will probably fall off by themselves! The back if the left heel is one large blood blister, fortunately it's dry and not infected.
The principle of managing cases like this is to keep the areas clean and dry. For the patient they have to do their best to control their blood sugar. The targets for good blood sugar control for a person with diabetes are between 5.5 and 7.0 mmol/litre, so you can imagine my concern at the last visit when I found out that this gentleman was running 15mmol/litre.
Every time the dressings are changed there is the opportunity for bacterial infection and high blood sugar usually worsens the situation. Of course the state of the feet and limbs in an obvious potential cause for the raised blood sugar too.
So what's the lesson? Mismanage diabetes at your peril! Damage to the nerves and circulation will have a major impact on your life the longer you live. The complications of diabetes are largely preventable, yet vast amounts of money are spent worldwide on managing the complications of diabetes.
Control of blood sugar and not smoking will protect both arteries and nerves from serious damage. Nephropathy or damage to kidneys is life threatening and not everybody can access a dialysis unit. Loss of sensation or neuropathy, where there is no sensation in the feet, allows for injuries to happen without the person noticing.
Don't become a victim of circumstance – take control of your diabetes now – and avoid dialysis later.
Thousands of South African children go back to school tomorrow. How many with foot pain?
We don't know the facts, because the research hasn't been done. But as children grow, so do their feet. So it's a safe bet that many feet will be pushed into shoes that were bought at the beginning of the school year in January and are too small 6 months later in July.
On the other hand there will be some children who will suffer the discomfort of a brand new pair of school shoes! It's not true that shoes have to be "worn in." They should fit properly and be comfortabl from the start.
Most children wont tell their parents that their shoes are too small, because the soft, developing bones can be easily squeezed and squashed into position. In addition, in the current economic climate, the cost of a new pair of school shoes often has to be balanced against food, rent or travel expenses.
Try to look at your children's shoes as soon as possible after the start of the term. They have probably complained about having to wear them anyway – having not worn them for a month. Get them to stand up in their school socks and you press gently on the end of each shoe to find the ends of the toes. If there isn't a finger space at the end, they are too short.
Don't try the other method of pushing a finger down the back of the foot behind the heel. The shoes should fit around the heels and allow the feet to lie nicely in their normal position. Check also for uneven wear on either side of the shoes – this shows flattening or 'out-turning'. If the shoes are deforming you should get to see a podiatrist for a check up.
A final word on hockey, rugby and soccer boots. If your child complains that the soles of the feet are sore, have a look for red marks over the areas where the studs are. You probably need to put a soft cushion insole inside to limit stud pressure.
Can't wait for the next school holidays!
