Fungal Infection – Your Christmas Present?

Athletes Foot is the name used to describe a fungal infection of the skin of the foot. Characterised by an itchy, blistering rash on the skin in the arch of the foot - which rapidly spreads to between the small toes and even the heels, it can ruin your Christmas.

Tinea Pedis is the medical name for this condition. It is worse in the hot summer months when feet are either trapped in their usual dark, sweaty environment, or exposed to areas where someone with the infection has walked.

Usually communal showers at the gym, in hotels, airplane carpets - the fungal spores are everywhere - just waiting for the perfect dark, moist environment to enable them to grow.

A fungal infection can also be spread by your favourite leather sandals, as the spores can live in the leather for ages!

Try to prevent Athletes Foot by following a few simple steps.

• AFTER WASHING ALWAYS DRY YOUR FEET THOROUGHLY, ESPECIALLY BETWEEN THE TOES
• WEAR CLEAN SOCKS EVERY DAY
• AVOID SYNTHETIC OCCLUSIVE FOOTWEAR IF POSSIBLE
• WEAR SLIP-SLOPS IN ANY COMMUNAL SHOWERING AREA
• USE AN ANTI-FUNGAL OR ANTISEPTIC FOOT SPRAY
• EXAMINE YOU FEET FOR SIGNS OF A RASH, SMALL BLISTERS IN THE ARCH OR WHITE ITCHY SKIN BETWEEN YOUR TOES
• BAREFOOT AND FRESH AIR IS GOOD, UNLESS THERE IS A MEDICAL REASON NOT TO BE

If you have a fungal infection treatment with oral medication can be costly, so start simple:

• GOOD FOOT HYGIENE
• SPIRITUS PEDIBUS FOOT SPRAY OR PROPRIETARY ANTIFUNGAL SPRAYS
• TOPICAL ANTIFUNGAL CREAMS
• HOWEVER, A COURSE OF ANTIFUNGAL TABLETS MAY BE NEEDED

Unfortunately, the fungal organisms that cause Athletes Foot tend to be very difficult to kill off. So even when your foot looks clear continue with the treatment for at least two more weeks.

One final word of warning. Not all rashes, or areas of itchy, moist skin are fungal infections. In the arch you might have a dermatitis. Between the toes it might be because your toes are stiff and bent. Or you might just need a good wash!!!

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High Heels in the Spotlight Again

The visual delights of high heels were the subject of a post on this website on 24 March 2008 – go back and have a look. Recently however, the “high heels issue” was the subject of a motion at the UK Trades Union Congress (TUC), in September this year.

High heels

The Society of Chiropodists and Podiatrists (SCP) tabled a motion calling on employers who promote the wearing of high heels………..to examine the hazards involved. They suggested further that employers should not be able to insist on the wearing of high heels by female workers as part of a dress code.

It received massive media coverage, even pushing  Prime Minister Gordon Brown off the the early pages of some newspapers.

The dangers of long term (even short term) wearing of high heels are of back, hip and knee pains caused by the change in natural lower limb alignment. The forces placed on the metatarsals (balls of the feet) are estimated to increase sevenfold as the heel height increases. In addition there is an increased risk of  falling or tripping.

Needless to say there was intense debate of the issue. With one newspaper calling  it ‘raucous.”

If you compare your gait (way you walk)  barefoot or in low heeled shoes, with your gait in high heels, you can easily see that in heels your knees don’t extend, the heel can’t hit the ground first followed by the rest of the foot going over it – ‘heel over toe walking’ – so the muscles act differently and the joints get stressed. High heels shorten stride and cause a jarring to the joints.

There is evidence of the use of lower heels on airplanes, when female cabin crew use lower heels for their in-flight duties when they often spend long periods on their feet.

However, when we look back at the post of 24 March 2008, we get to see that high heels are all about image! The hunter and the hunted. The allure of a long leg attached to a 9cm stilleto heel and the associated ‘rock & roll’ of the hips, arms, shoulders and anything else, is why high heels are worn by women and men will watch whilst women endure!

So until your bunions get really painful, your feet look like the front of a bricklayers trowel, the varicose veins resemble a set of train tracks, your corns are hard and yellow and your joints ache all the time due to arthritis. Ladies strut your stuff and visit your podiatrist regularly.

On the other hand, according to the SCP, this is a serious health and safety issue  in the UK, with ‘two million days lost each year to ilness resulting from lower limb disorders.’

Ultimately, it comes down to the right to choose. Or should that be Jimmy Choo’s!

Neglect your feet and patients at your peril!

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?

Interesting cause of Heel Pain

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.

Undiagnosed Achilles Tendon Tear

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.

702 Walk the Talk – footwear

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.

South African Podiatry Association

The Biennial Congress of the South African Podiatry Association took place this last weekend.

The first two days were a Biomechanics Boot Camp taught by renowned Australian podiatrist Craig Payne and today there were presentations by local podiatrists on rheumatology, diabetes, paleo-anthropology and education.

Most podiatrists  routinely perform biomechanical examinations on their patients – but this Boot Camp was something else – it has changed my thought paradigms and will alter the way I examine my patients and any orthotic treatment I decide to use. (I know this is true for every one else who attended the Boot Camp).

There was another interesting development at the Congress, I was elected Chairman of the South African Podiatry Association for the next two years.

This is a real privilege and challenge as podiatry in South Africa needs to have a much higher profile and take a more prominent place in the South African health care scene.

Expect to see much more about feet and foot care in the future.

Prevent a fall-visit your podiatrist

Many older people suffer a fall with consequent injury such as a fractured  shoulder, wrist, hip, ankle or foot. In the UK there is an active falls prevention initiative, promoted by the National Health Service.  Not so in South Africa, although we are aware of the problem.

Have you ever thought how the state of your feet could contribute to a fall? Podiatrists should be  involved in preventing falls and your visit to one could help to prevent one.

Hazel Tomkins, a British podiatrist, writing in Podiatry Now has detailed how your feet can cause a fall.

So, if you want to stand on your own two feet here’s what to look out for.

Any corn, callus, ulceration, painful nail condition alters the way your foot hits the ground. This usually makes walking uncomfortable and unsteady. With age, the cushioning fatty pad on the soles  of the feet thins out – giving less protection to the bones and joints underneath.

Changes to the basic shape of the feet alters the ability to walk evenly. Often the cause of these changes is reduced muscle strength. On the other hand, any change in posture – quite common as we age – is associated with weakening of our muscles, so there is the potential for loss of balance or unsteadiness.

Watch out for changes to the length of your legs after hip or knee replacement surgery. The pain has gone but you really do need to do all the physiotherapy to restore muscle strength and balance.

At the same time there are many changes to hearing and eyesight which affect the ability to balance and see clearly what is going on around us.

If you have any nerve changes associated with diabetes (neuropathy), you are disadvantaged, because you have a reduced ability to respond to the sensory stimuli around you. On the other hand, arthritis can cause deformity as well as stiffness, making movement difficult, slower or unsteady.

Research into barefoot walking showed a 19% worse performance when barefoot compared with even a least unstable shoe. Going barefoot or stocking feet dramatically increases the falls risk.

Simple you might think, I’ll wear slippers or shoes. Well this is an area of some dispute. There is good scientific evidence that if you change to a lower or flat heel after a lifetime of wearing high heels, you have a greater risk of falling! At the same time there is research which suggests that the most important feature of footwear in preventing falls is the grip of the sole on the ground. Added to that is the need for good fit and thicker soles.

So what to do?

Keep mobile – exercise regularly – start walking, even if you use a walking aid. Maybe you need to start using one? Make sure that you can see and hear as well as possible.

A visit to a podiatrist for a biomechanical assessment is an important way to identify any underlying structural and functional problems. Treatment of any painful foot condition, such as corns and calluses, is essential and  information on the best shoes for you, will be provided.

Avoid higher heels, barefoot walking and slippers. Consider wearing trainers with a rippled sole. A word of warning though, some trainers have really ‘grippy’ soles and that can cause a fall!

Try to remove all loose carpet runners and potential hazards that you could trip over. Make sure the lighting in your home is adequate (most falls occur at home!).

It takes team work to prevent falls, so get any advice that you can, or share it with those who you know are at most risk of a fall.

Onychomycosis – A Fungal Infection

I recently had an enquiry by email which brought home to me the advantages that we have in this day and age because the patient included some photographs of his condition.

It also illustrated the importance of making regular inspections of your feet which are a frequently neglected extremity of our bodies.

His story went like this:  “Until recently, toenail number 2 used to look like number 4, i.e. a bit of white at the base of the nail that I put down to left over soap from the shower when I glanced at it from a great height.

(Click the photos to Enlarge)

When the edge of the nail is pressed back from the front edge it appears that the nail is cracked across about half way down the length as though it has had an impact.  As a result it curves down from mid point towards the front.  I don’t have any shoe problems that might cause this so if an impact rather than constant pressure has caused this then I was unaware of it. (or maybe aware at the time but not of the ongoing effect.)

Left foot is normal.”

From the written description it might be difficult to understand what might be happening.  But the inclusion of the photographs (not difficult in this age of digital cameras) made the diagnosis much easier.

The description and the appearance is typical of Onychomycosis = fungal infection.

The 4th toe shows the typical crumbly? yellow, patchy discolouration the 2nd is a classic presentation.

An alternative diagnosis is psoriasis; with this, developments like you describe are more associated with stress; however,normally there is a history of the underlying condition (psoriasis), which I don’t think you have.

Mycoses or fungal infections are usually picked up from communal shower facilities – gyms, change rooms, boarding school – they develop in a warm, moist environment -closed shoes, stockings, central heating, high humidity in summer.
They are contagious and spread easily when the growth conditions are optimal. (Like mushrooms).

Simplest treatment: Tea Tree Tincture or Oil twice daily.
Use an emery board to GENTLY abraid the nail, this creates a rough surface, then drip on the solution and wipe away the excess. Does not matter if solution gets onto the surrounding skin.

Commonly prescribed treatment: topical anti-fungal agents, some of which are over the counter. Or prescription oral agents if there is multiple toe involvement.

Warning: watch out for any rash in your groin or the soles of your feet. That indicates surface Tinea i.e. fungal infection.

Just be patient and observant for more toes getting it.

In an otherwise healthy person the development of this fungal infection of Onychomycosis is easily passed over as happened in this case until it had a good hold.  So keep a careful eye on your extremities.

Chilblains

Chilblains are associated with cold winter conditions, often worsened by wet weather.

So as I go off to the Cape for a few days I’ll give you some suggestions to protect against ‘winter feet’.

Chilblains affect all age groups and both sexes, but girls and women do seem to suffer more.

Keep your feet warm and dry. Avoid socks with synthetic fibres, that can make your feet sweaty and cold.

Some modern fibres ‘wick away’ sweat, but you can get cold. Try a pair of mohair socks – Visit the Cape Mohair website.

If you are sitting for some time, try wrapping your legs in a loose-fitting blanket(think of the bottom of a sleeping bag).

Do wriggling and waggling exercises to keep the circulation moving in your leg muscles. Don’t sit for long periods, because if you have a sluggish circulation it makes it worse.

STOP SMOKING! The spasm or constriction of your blood arteries from ONE cigarette lasts 6 hours.

Take regular walks in well-fitting shoes. Tight shoes press the blood out of your toes. Thicker sole are important to protect your feet from the cold and wet. Boots are good but high fashion ones often don’t keep your feet warm.

Chilblains are the result of a defective response to a cold stimulus. For example: when you take the chicken out of the deep freeze, the nerves in your fingers send and receive a message  which causes the nerves to the blood vessels to shut down to protect the fingers from the cold.

When you have the chicken out on the kitchen worktop and you are back in the normal temperature the reverse messages happens, and you get a bit of  a tingling feeling as the blood flow returns to normal.

If this system has a delayed response – for whatever reason – the fingers remain cold, because the blood is lacking oxygen. Soon the body recognises this as abnormal and tries to fix it with an inflammatory response.

This can settle things with just a little swelling and pain in the fingers, but usually this process ends up with red, painful, swollen fingers, which look like cocktail sausages.

In some cases, this process is the result of a significant vascular disease, for example – Raynauds Syndrome(or Phenomenon). If you suffer from this you will know and should be havinr treatment – it is characterised by spontaneous spasm of the blood vessels of the hands – where you get an unexpected cold finger or fingers, at any time of year, but especially in winter.

Treatment for chilblains is difficult and usually centres around prevention. Shoes, socks and footwear as I have said.

There are some medicines prescribed by doctors called Vaso-dilators, but often topical preparations such as Thrombophob or Reparil Gel are tried.

Some Homeopathic preparations include Vitamin A and Nicotinic Acid which act as circulatory stimulants. Getting into a warm bed helps – but don’t sleep  with your feet up against a hot water bottle!

As I write this in Hout Bay, I’m happy to report that it has been a beautiful sunny and dry day.

Take care of your pair. No more smoking. Regular exercise. Keep chilblains away this winter.