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Neglected feet can become a serious problem. So to0 can neglected patients or visitors using this website. Welcome back to all of you – feet as well as people!
Good time management has never been one of my strengths and over the past 2 months I have had a struggle to make time for this fascinating communication channel with my blog visitors as well as the core professional duties of my daily practice and some additional duties on behalf of the podiatry profession.
So, look out for replies to all the comments posted. Do keep posting comments – the warning is only there because one person posted a comment with too much personal detail – failing to realise that what you post EVERYBODY reads.
Anyway, what has been going on? The "chairpersonship!" of the SA Podiatry Association(SAPA) is proving to be an enormous task; fortunately the Executive are really dedicated people and have taken up the challenge of a new (& very different chair with enthusiasm). We are developing a new website that will be more interactive for podiatrists and public. You should see podiatry visibilty in future.
Podiatry has been featured on SABC 3 with Noleen, Talk Radio 702 with Redi, chai fm community radio in Johannesburg and I understand there is something in the November edition of ELLE magazine.
The University of Johannesburg has also been active, honouring the top achievers of 2008 – guess where the top podiatry student is – yes, you're right, emigrated to Australia!
By the way, it's not too late to apply for a place on the course for 2010. However, tomorrow sees the start of the exams – more time pressure as I am an examiner and moderator for a couple of subjects.
Then come some big events. First up is the birth of our second grandchild, due in 2 weeks, followed by a trip to Harrogate in the UK for the Society of Chiropodists and Podiatrists Annual Conference – I am presenting a Poster on the work we have done at Chris Hani Baragwanath Hospital, Paediatric Rheumatology clinic.
Meanwhile, in the practice recently a lady with a classic case of neglected feet was brought in by her daughter. The lady lives in Limpopo Province north of Johannesburg; she had no idea how she damaged her foot so badly that the tendons were showing through the top of her foot! She felt no pain either (undiagnosed neuropathy?).
X rays revealed the bones inside were infected and had collapsed to create a very fat, swollen shape. (Charcot neuroarthropathy). As there was no pain it had been left under the care of the patient and her GP. Basically because the lady had poor access to health care, but more importantly no insight into her diabetes what would you expect? A classic example of poor communication all round.
Talking of communication, look out for activities associated with World Diabetes Day on November 14th. Check what your local podiatrist or clinic is doing. There is a big event in KZN, with a SAPA presence, there are events in Cape Town too.
As the Southern Hemisphere is into "exams fever," I'll leave you with this thought from a postcard that I bought in Oxford some years back.
Why study?
The more I study, the more I know.
The more I know, the more I forget.
The more I forget, the less I know.
So why study?
Heel pain can be a really crippling problem at all ages and especially for adult males. I have recently had an email from a 60 year old man complaining of heel pain.
He described "sharp shooting pains in the left heel area. Usually when it comes under tension – even slightly, say from bending at the waist – or on impact – even the slightest."
He went on to explain the pain as "odd, insignificant, but very sharp when it occurs." He had only become aware of the pain in the past few days and said that the only change of habits was that he had started doing quite a lot of swimming. He didn't indicate that he had had any injury.
My first thoughts were a series of questions:
- "Do you have any lower back pain?
- "How strong are your abdominal muscles?"
- "Does it come on spontaneously when sitting in the car or at the computer?"
- "Do you have any residual joint damage from sports injuries or osteo-arthritis?"
Shooting pains like this are usually associated with nerve entrapment, pinching, or tight muscles like the hamstrings. At this age, osteoarthritis of the spine is a common cause. However, in this case, I suggested that the pain could be associated with the new range of movement since he started swimming.
Treatment for heel pain, begins with trying to find the cause, including the possible underlying cause at this age of being overweight, with a protruding belly! Not so in this case. Bearing in mind that this was an email communication and the symptoms were clearly described, I suggested the following:
- Start by gently stretching your lower back when lying on your back on the floor
- In this position, with knees bent and feet flat, roll gently side to side, all the time pressing your lower stomach into the ground
- In the same position, curl your knees up to your chest
- Another fun exercise is to kneel on all fours; extend your left arm out in front and your right leg out behind you; hold this for 10 seconds and change sides!
- A Physiotherapy consult is advisable at the same time
A few days later, the gentleman diagnosed the problem as tension-related. He actually tried a rather risky move - "I can provoke sustained pain by crouching and then arching my back to put the whole back, rear leg muscles under tension."
Luckily he was able to get up from this position, not call the Fire Brigade to lift him up and take him to hospital!
There is no apparent foot problem of pronation or flat feet, so it does sound like a nerve – related problem.
Then out of the blue, another man of similar age visited the practice with similar symptoms. By me moving the foot into certain positions that stretched his lower back, I was able to reproduce the burning, shooting and tingling pains he complained of.
Doing some research on heel pain reveals many causes; nerve entrapment is one of the more difficult to diagnose.
When an Achilles tendon ruptures, the patient may tell you they heard a sound like a gunshot and they cannot walk, but with an Achilles tendon tear it is still possible to walk around without knowing your injury.
This week a lady consulted me complaining of pains at the back of both heels and into the calves, which had been there for more 6 weeks. She experienced aching, throbbing and a stretching sensation, especially in the evening. She felt less pain wearing higher heeled shoes. In addition, the pain was worse when she got up after sitting for some time.
There was a history of a right ankle fracture and some persisitent left knee pain. She also told me that she had been diagnosed with calcaneal spurs many years ago. The lady was overweight and of short height.
During my examination, I could see and feel that both Achilles tendons were swollen and had nodules in them. Her walking stride was short and stamping. There were other significant biomechanical problems too.
Temporary treatment consisted of in-shoe wedging. I also referred the lady for an ultrasound scan of the Achilles tendons.
Two days later the scan reported the left tendon as having "….an almost full thickness intra-tendon tear ……approximately 2.8mm thick, extending 30mm longitudinally." On the right "……loss of fibrillar pattern, consistent with fraying."
There were other features, but this was one lucky lady, because there could have been a rupture at any time. This time she was referred to an orthopaedic foot surgeon.
So whether you are a patient or podiatrist, when managing chronic pain at the back of the heel, consider the benefits of ultrasound scanning to assist in diagnosis and always act quickly, you might discover an Achilles tendon tear.
Choosing the correct footwear for walking is very important. With the Talk Radio 702 Walk the Talk coming up this Sunday 26th July, there will be 50,000 people strolling, walking, meandering, marching and even racing through the streets of Johannesburg.
The most important thing is to keep to the footwear that you have been using, don't treat yourself to a new pair of trainers for the day, because although they may feel quite good at first, they need a bit of wear to 'bed in'.
Walk the Talk 2009 - Click to Enlarge
I suppose that there will be some serious hikers/walkers in the race and they will know that the best footwear is your regular well worn (not worn out) footwear. If you are walking, just for fun, in your old worn out trainers, you might be better to walk in your most comfortable more formal shoes!
A firm but cushioning sole is best. Firmly laced, not too tightly, because your feet will swell a little and if laced too tightly, the lacing and tongue will press on the nerves on top of your feet, making them numb or tingly.
If you do get these symptoms, stop and re-tie your laces, rather then get pain. The fit around the heel must be close, so that there is no excessive sliding of your foot, because excessive sliding or shearing causes blisters.
Choice of socks is very personal. Thick or thin they should be able to absorb some of the sweat that you are going to shed. It's worth using a thicker cotton sock rather than a woollen one.
Although many walkers and runners use no socks or even the feet out of stockings, again use what you are used to.
If you have been getting blisters during your preparation for the race, try putting a 'blob' of Vaseline over the place that blisters, it works as a lubricant and will reduce the risk of blistering.
An alternative is to cover a sensitive area with plaster, just beware of putting it where it could roll up and cause a sore spot.
Tactically, watch out for getting sucked along at a faster pace than you want to, or are able to go. This is one way to pick up an injury and get painful feet. You must try to keep to your own pace.
After the race, if you have blisters or any foot problem, look out for the University of Johannesburg Podiatry Caravan and treatment area, they will be able to help with most foot problems.
