Monthly Archives: October 2008

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

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

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.

Sweaty Feet

Sweaty feet affect everybody at some time of their lives. The complaint can be seasonal -worse in the warmer months – but can be present at any time of year. The medical term is hyperhidrosis (excessive sweat production) and if there is an accompanying bad odour, it is called bromidrosis.

There are many causes. The most common is poor foot hygiene associated with footwear with a high synthetic material content. Socks, stockings or tights made of nylon also cause the feet to sweat excessively. In teenage years glandular changes are a frequent cause amongst males and is made worse by poor hygiene and footwear. Occasionally, there is a systemic problem which shows in increased sweating of the hands and other body parts. Whenever we exercise, we develop sweaty feet, which is is quite normal, but it does lead to the smelly foot and shoe syndrome.

An excessively sweaty foot is susceptable to the development of fungal infections and because it is important to differentiate between sweating and fungal infections, I’ll write in detail about fungal infections in the future.

Treating sweaty feet needs patience and perserverence. Daily washing with soap and water is essential. Then dry feet thoroughly. Try to avoid wearing shoes with synthetic uppers and soles. Make sure your socks contain high percentages of cotton or wool. Read the labels to see what the socks are made of. Try using an anti-perspirant under the arches of your feet. There are some products advertised specifically for this application. Podiatrists usually recommend ‘Spiritus Pedibus’ also called Foot Spirit. It contains 3% Salicylic Acid in Ethyl Alcohol. Occasionally a weak solution of Formalin can be prescribed. Obviously any opportunity to have your feet bare in fresh air will help. So wear sandals whenever possible. However, beware of plastic and synthetics, go for leather if you can. If the condition is really severe, a change of socks may be necessary during the day.

There is a surgical procedure called a sympathetomy – which must be performed by a specialist surgeon – for very severe sweating of the hands and feet.

Smelly feet are usually caused by the bacteria which live on our feet normally, not being washed off thoroughly. They can of course be caused by the materials themselves, especially some rubbers. Washing and drying is a good start followed by any of the above treatments. Naturally if you favourite trainers make your feet smell, but your normal shoes don’t, you have a hard choice to make!

Powder is often used for sweaty feet, but be careful since it tends to solidify between the toes.

Sweaty feet are a common complaint and they can be embarassing. However, treatment is often very simple, starting with an intensive foot hygiene routine.