Diabetic Foot Congress: Johannesburg 2008

Tomorrow morning sees the start of the first Diabetic Foot Working Group (DFWG) Congress in Johannesburg. In South Africa it is also a long weekend – meaning that Monday June 16 is a National Holiday, when we remember the youth of SA and their part in the struggle against apartheid. Especially the riots which broke out on June 16 1976.

For those of us dedicated to another great cause, we will spend the next 3 days learning, sharing and discussing the causes and effects of the diabetic foot, with a special emphasis on our local problems and solutions. We have speakers from Cameroon, the UK and USA, in addition to a variety of local speakers. The benefit of this type of congress is that you get to meet the members of the wider multidisciplinary team and the exchange of ideas and information will help to increase the core of health professionals available to manage the feet of people with diabetes in South Africa.

Recently I have been requested to try to assist with the development of training in foot health in Nigeria and have a new contact with an orthopaedic surgeon in Iraq. There are no podiatrists in Nigeria at all, where the population is more than 140 million. Furthermore there is no government support for foot care either.

I am very pleased to report that the lady featured in the ‘bean bag’ blogs, is making fantastic progress, thanks to the skill of my associate Tshidi Tsubane. We are also very proud of the fact we have had a paper published in a new journal – Wound Healing Southern Africa – Volume 1 No 1. visit www.woundhealingsa.co.za

Currently we are working onpapers concerning nail surgery for people with diabetes and the costs of ulcer care from a podiatrist.

Finally for Friday 13th! I spent the day as an examiner for the podiatry students at the University of Johannesburg. I’m not sure who was more tired the students or me. At the end of two sessions of assessing competency in clinical skills you actually feel quite sorry for them.

Have a great weekend.  

Diabetic Foot Congress 2008

June 14,15,16 are landmark dates in the history of diabetic foot care in South Africa.

The Diabetic Foot Working Group (DFWG) is holding its first congress. Noted overseas speakers will be Professor Andrew Boulton (Miami and Manchester) and Dr Zaheer Abbas from Tanzania.

This will be the first truly multidisciplinary diabetic foot meeting to be held in South Africa.

More information from www.DFWG.co.za

The Diabetic and the barley bag – part 2

Loss of sensation and reduced blood flow to the lower limbs and feet are a well known complication of diabetes. As winter progresses, people with diabetes are at increased risk from problems associated with damage caused by trying to keep the feet warm. The lady I wrote about on May 7 is still at high risk.

Fortunately she is sticking to her care routine and the toe has stabilised. The blistered skin dried and formed a hard crust – actually this is a dry gangrenous crust – has formed over the centre of the wound, but the edges are clean and pink. The primary key to a successful outcome is control of blood sugar and that is good. Secondary is the quality of wound care and hopefully we are up to standard.

The biggest problem we have when treating diabetic foot ulcers is to keep weight off, called off-loading. Naturally, this is very difficult for a patient who knows they have a foot ulcer, but doesn’t feel any pain. Remember, pain stops us from doing further damage to an injured body part.

Here are a few WINTER FOOT TIPS FOR PEOPLE WITH DIABETES.(It’s winter in the southern hemisphere).

Keep up the daily washing and drying -especially drying

Keep up/start a daily routine of gently massaging moisturiser into your legs and feet

Remember that your shoes may become tighter because you are wearing socks and closed shoes

When you take off your shoes, check your feet for tell-tale red marks – this means dangerous pressure

Check that your shoes do fit, you possibly haven’t worn then for some months

Thicker-soled shoes will keep your feet warmer

Don’t let your boots squeeze your calf muscles and reduce circulation

Keep your feet warm at night – wear socks. NOT nylon, but cotton or wool or mixtures

Heat your bed BEFORE you get in and turn off electric blankets and heating pads. Remove hot water bottles

Try to avoid sitting in draughts – difficult, because we have houses that are designed for coolness

Wrap a blanket around your legs and feet if you are in a cold room

Never sit too close to any fire or heater – (people have fallen asleep and burnt their legs & feet)

Try to keep your excercise routine going, even though it’s darker morning and evening

p.s. Cape Mohair make excellent socks

When did you last have a Holiday?

I had forgotten how well you can feel just by taking some time off. Having just spent 10 days away from the practice I feel really good and ready for anything. I have just asked my colleague’s patient when last did he have a holiday? His reply? “Holiday is a swear word.”

My colleague also says she hasn’t had a holiday in along time and needs to get away. The Eastern Free State and then the Drakensberg is beautiful in the Autumn. (Before I went away, our receptionist had resigned, the ADSL line had been out of order for 10 days and I hurt my back!)

However, it only takes a few days for reality to hit back in the practice. A patient of ours with diabetes and a history of ulcers, returned after an absence of two years because she had a problem. Some problem too!

An ulcerated bunion joint with a massive swelling and a local skin temperature of 37 Celsius. She said it happened just a few days ago after the foot began to swell. Unfortunately the skin damage was so severe that I decided that the best plan was to admit the lady for a full work up of blood tests, wound swabs and X-rays, plus the opinion of the diabetic foot team, but she requested to go to the local State hospital the following day!

This cavalier approach to diabetes and its complications is being researched as a probable additional complication of diabetes. The behaviour changes possibly being the effect of damage to the central nervous system.

Don’t delay that holiday.

Diabetic Foot Dangers – ‘the barley bag’

As winter approaches the southern hemisphere, the risks of damage to the feet of people with diabetes increase. The weather turned nasty in Johannesburg last weekend – wet and cold – as a result I saw my first Autumn diabetic foot disaster yesterday. A burn on the big toe of a lady who went to bed with her ‘barley bag’. It doesn’t have to be barley, rice, lentils, in fact anything that can be heated in the microwave.

After heating the bag in the microwave this lady put it into the bed to warm it up. Her big mistake was, that when she went to bed she didn’t remove the bag from the bed. During the night her foot came to rest on the bag and burned her big toe, leaving a blister along the whole length it.

When she saw me, the blister had broken and the base was infected. So now she is under treatment for a foot ulcer. The sad thing is that I spent months in 2007 succesfully healing an ulcer on this lady’s other big toe.

So what’s the message? You could say the ulcer is a result of a failure of diabetic foot health education – we didn’t get the right message across – but it does highlight the fact that everybody involved in diabetic foot care has to be constantly alert to potential dangers. In this case we have a high risk patient with peripheral vascular disease and diminished sensation who made a mistake with serious consequences. So what are the key messages for winter protection for the diabetic foot?

• wash and dry your feet thoroughly
• remove any heating bags or hot water bottles before getting into bed
• turn off any heating pads or electric blankets when you get into bed
• make sure your winter socks are not too tight on your feet and around your legs
• take care that you can wriggle your toes in your shoes when you have thicker socks on
• remember that a thicker-soled shoe will keep your feet warmer
• if you live in a winter rainfall area, dry your feet as soon as possible after they get wet
• try wearing loose-fitting cotton or woollen socks in bed
• if your feet swell during the day, remember to allow for it when you wear your winter shoes or boots
• STOP SMOKING!

Take care of your pair and see a podiatrist

Outrageous footwear!

High heels – of course they damage your feet. But women still buy them. Just take a look at an outrageous South African blog: Google- Shoegirl South Africa and see what you get!

Apparently a new fashion trend is to wear socks with your high heels. Socks with high heels? Almost as bad as socks with sandals for men.

Even better is the website for FitFlops, yes you read correctly. I saw them with my wife at a Johannesburg shoe store last Saturday. What about footwear advertised as: The flip flop with the gym built in! Cushioned heel absorbs 36% more shock than regular footwear. Micro wobble-board midsection slows eversion rate by requiring 15% more energy to walk. Firm toe area promotes faster toe-off.

And the result? Firmer buttocks and leg muscles. One wearer says she does feel like she has just done a workout after wearing them.

They are available through one string of outlets – I’m not advertising them! Check the website. www.fitflop.com

I’m dying to know more about them.

Here’s another idea, from Bignews page 14 January 2008.(This is a local business newspaper.)Transparent shoeboxes.(Very politically correct in SA today!). Boitunelo Mofokeng has obtained the rights to exclusively distribute Shoebby, a transparent shoe box manufactured in the United States.

So no more searching for ‘that’ pair of shoes, because all your pairs are visible in these neat transparent boxes. For the guys it could mean the end of sifting through that disorderly pile of assorted shoes in the bottom of the wardrobe! Contact Mofokeng at 082 453 8692.

Goodnight!

Can High Heels Heal?

‘Walking on sunshine.’ ‘Sexual heeling.’ ‘Toeing the line.’ All headlines for articles recently printed in the South African press taken from The Telegraph, The Sunday Times and The Times respectively, all from London. Toeing the line is all about the Chinese tradition of foot binding and I’ll pick up on that later this week.

The other articles are all about the benefits and effects of wearing high heels! Both suggest that wearing high heels is sexy and in ‘sexual heeling’ the research of a University of Verona urologist, Dr Maria Cerruto, is reported where she tackled “bizarre” theories about the effects of wearing high heeled shoes. The idea of sexual heeling refers to the Dr Cerruto’s assertion that pelvic floor activity is affected.

Traditionally we have blamed high heels for a variety of ailments, such as bunions, stress fractures, knee pain, lower back pain and increased risk of arthritis. South African research by Drs. Zipfel and Berger of The University of the Witwatersrand in Johannesburg showed scientific proof that wearing shoes had bad effects on the wearers when compared to unshod people. (I know this was on old bones but they have the proof). Dr. Cerruto’s evidence is due to be published in the journal European Urology. Since I am concerned with your foot health, I’ll leave that train of thought for you to follow.

However, in the article there is a comment from a UK fitness instructor who runs classes in London for women with high heels called Sweat and Stilletos. These sessions are designed to help women wear stilletos more comfortably. Whilst she agrees with the effects of muscle toning in the buttock region, she says that there must be compensation somewhere else and therefore her classes help with postural alignment.

Now as podiatrists we spend a lot of time dealing with and correcting the effects of postural malalignment. A personal trainer to some celebrities was quoted as saying that” the knees and metatarsals are put under strain, the hips are out of position. It can lead to long-term health risks.”

For me the evidence is there that the movement of the body’s centre of gravity forward causes increased loading and pressure. There is an increase in callus formation and the calf muscles shorten over time. This will lead to deformities of the toes. I agree however that exercises specifically to strengthen the intrinsic muscles of the foot will resist these deformations.

In “Walking on sunshine” they report on a New York sports therapist who holds classes for women to strengthen their foot muscles to cope with wearing high heels. Yamuna Zake also gives some good advice on foot care. She has been working with dancers for 25 years and those of you who struggled to get your (or your child’s) feet into the basic ballet positions without them falling flat will appreciate this. The essence of ballet is to be able to get your foot extended down from the ankle as far as possible and have almost 90 degrees of flexibility at the big toe joint.

So what’s the bottom line? Let me quote from the articles. ‘It’s a way to appeal to the male species. I have men who say heels have saved their marriage.’ Yamuna Zake says, ‘my husband is a freak about high heels. He thinks they’re very sexy.’ During my recent tutorials with Wits University medical students I was demonstrating the possible effect of rheumatoid arthritis on the way a person walks. I asked on of the girls to walk across the room in her high heels and then again barefoot to show the difference in patterns of healthy person. Guess what she said before walking barefoot? ‘Oh please I’ll walk like a boy!’

I wonder if walking in high heels will become an Olympic sport?

Read the articles:

Walking on sunshine. Melissa Whitworth. The Telegraph, London. In The Sunday Times (Johannesburg)Lifestyle section. [not sure when, towards the end of 2007].

Sexual heeling. Roger Dobson & Steven Swinford. The Sunday Times, London. In The Sunday Times (Johannesburg) Lifestyle. February 24 2008. Page 17.

Eschewing shoes may save your soles. Gill Gifford. The Star, Johannesburg. Friday October 26 2007.Page 6.

Is Your Backache Caused by Your Leg Length?-2

Having legs of different length is recognised as a common cause of low back pain; but as I said the other day usually the body compensates for the difference. These compensations or adaptations place increased stress on various joints throughout the body and hence the pains.

Not surprisingly this condition affects growing children and they can show some funny signs when you examine them. For example one of the basic observations that we do is to look at the relative heights of the knees with the child lying flat on his/her back; a higher knee means a longer leg in the thigh(femur bone) segment.

Usually the bone on the inside of the ankle is also lower on the longer leg when you have the legs stretched out. Easy! there is a subjective dianosis based on clinical examination and suspicion. That’s fine until you see that it’s the other leg that is actually longer at the ankle!!! So what’s the message here? Be very careful about jumping to conclusions with any patient but especially with children.

This simple example shows why the definitive test is the X-ray called the scanogram, because the radiologist views and measures the lower limbs (yes both) from hips to toes. The first place to look is in the hip joints to assess the alignment of the hip joint which is made up of the head of the femur and a cavity in the side of each hip called the acetabulum.

As podiatrists we are able to prescribe the local treatment based on biomechanical and gait analysis. This is only part of the team approach I referred to though. In younger people regular re-asssessment is needed to see if any correction has occured and then the local foot therapy will change. In older people the foot therapy is usually permanent. This is the situation in many people who have had hip replacement surgery. Which reminds me of a story.

I have a patient who has been a very successful ballroom dancer for more than 50 years. When she required hip replacement surgery she did her research and was distressed to find out that she might end up with a shorter leg, like some of her friends. As a result she threatened her surgeon – who happens to be “the hip expert of Johannesburg” – that she wanted a guarantee that her legs would still be equal after the operation. Believe me when I tell you that she is still dancing!

Take care of your pair – see a podiatrist

Is Your Backache Caused by Your Leg Length?

Well it could be. Are your legs the same length? Do you have a Limb Length Discrepancy? When you stand, is one foot flattening or collapsing whilst the other one stands up straight? Do you suffer from chronic back pain?

During the past few weeks, we have been people of all age groups with significant differences in the length of their legs. Limb Length Discrepancy or LLD as we call it. This condition causes all sorts of problems and pains. people complain of pain in the lower back, between the shoulder blades, in the knees, in the soles of the feet, at the heels and at the ball of the foot.

Usually the longer limb gives the most trouble and the typical view the podiatrist gets is of a person who rolls from side to side as they walk with one shoulder higher. In technical terms the condition is referred to as being Functional or Measurable.

The LLD can be very subtle and is often difficult to spot, especially if the person is an athlete or physically fit. This is because well-toned muscles enable the body to compensate for the oddity in structure. We usually diagnose it visually during a biomechanical examination and gait analysis.

There are signs such as spinal curvature – scoliosis – dropped shoulders on the side opposite to the short limb plus some changes in arm swing. The diagnosis of a Functional LLD is confirmed by something called a Scanogram, which is carried out by a radiologist.

The management requires teamwork involving podiatrist, physiotherapist and biokineticist, because it is easy to jump in with heel raises or to buy ready-made devices from the pharmacy without fully analysing the components of the condition.

More on this tomorrow

Podiatry Students Unethical?

Not at all! As I said last week, the 4th year Podiatry Students at the University of Johannesburg(UJ), had their first taste of me starting the lectures on Practice Management and Ethics. There are many concepts to take on board including grasping the difference between ethical values & standards – represented by core values which are aspirational or value-oriented – such as Respect for persons, Human rights, Truthfulness,  etc., and ethical guidelines -represented by specific rules or duties associated with professional practice. We started to examine the challenges faced in daily practice and led into how we apply ethical reasoning to move from the understanding of guidelines to using them to influence our practical decision making and choices.

I’m usually never short of a word or two on most subjects! But beginning this course has made me think very hard again at the way in which I reach and make my day to day decisions. So just for fun!!! Let’s look at the 4 steps of ethical reasoning:

The problem: formulate  the problem and ask is there a better way of understanding it?    

Information: gather all the relevant data, clinical, personal, social etc.

Options: under the circumstances, consider all reasonable options, choices or actions.

Moral assessment: weigh the ethical content of each option by asking –

•     what are the likely consequences of each option
•     what are the most important values, duties and rights? which is strongest?
•     what are the weaknesses of your view?
•     how would you want to be treated in the circumstances of the case? i.e. apply the Golden Rule

(I acknowledge the Health Professions Council of South Africa (HPCSA) as the source of the above).

Easy isn’t it? Hopefully someone at the HPCSA will be able to tell me this week what the Golden Rule is, I think I know but I’d better get the official opinion on it!

Naturally we are all making choices every moment of our lives, some better some worse, but getting into deep philosophical discussions can be quite daunting – especially when all most of us want to do is practise our profession.(Oh, and make lots of money!)

Perhaps as you read this you should start to apply some ethical reasoning to why you should or should not book an appointment with your podiatrist. Are you a person with diabetes who hasn’t had a diabetic foot assessment recently or ever? Have you any idea what a podiatrist can do to help your feet if you suffer from some form of arthritis? Are your children normal or do they have some biomechanical anomaly (odd alignment) that is undiagnosed but could be treated by a podiatrist? Do you care if your Gran can’t cut her toenails? Do you really have to but another pair of running shoes to get relief from foot and leg pain or should see a podiatrist? Is it possible that a podiatry consult could shed some light on the cause of by chronic back pain?

This morning I saw the effects of good podiatry care in a 5 year old who has good foot alignment although she has rheumatoid arthritis. She has been wearing foot orthotics for one year and has not developed any deformity in this time. As part of the team at Chris Hani Baragwanath Hospital I hope that the future choices we make will produce such pleasing results. It comes as a surprise to most people that children can suffer with arthritis, so I’m going to write about this during the next few weeks.

In the mean time spare a thought for my students who must be faced with ethical decisions about whether they should do the assigned reading for this week or go to the movies in the hope that  I’ve got it all sorted!