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!

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.

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.

Closed Kinetic Chain Exercise for Joint Rehabilitation – Jump for Joy!

Closed Kinetic Chain Exercise for Joint Rehabilitation was the title of a Rehabilitation Workshop that I was invited to yesterday. It took place at the University of the Witwatersrand Sports Science Institute and introduced  me to Reboundology and a quite extraordinary piece of kit called Kangoo Jumps.

Kangoo Jumps are a Swiss designed boot that almost defies description – the nearest that I can come to is – a Ski boot with an oversized doughnut lying on its side as a sole!

They have the ability to reduce the impact force to the ground by up to 80%. This patented Impact Protection System utilises the principles and practice of closed chain kinetics.

Basically, the difference between open and closed chain kinetics is that in open chain there is still some movement in part of the limb, this allows additional twists or rotations to affect other body parts. In the closed chain, the part is stabilised (eg foot or hand) against a hard surface. It’s actually more complicated, but this is what I understand at present. 

Rebound exercise is different due to the following factors: During rebound exercise; We are opposing gravity and acceleration: Acceleration in the vertical plane develops a greater G-force: All these forces come together at the bottom of the bounce: Cells have to work harder to maintain their position in space: This explains why trampolinists have extra unexplained strength.

Kangoo Jumps utilise these principles by allowing you to jump up and down, whilst concentrating your body weight through your centre of gravity.

I was able to test the theory in practice when we were put through an exercise session. I had a great time bouncing around the gym, being guided in various exercises. The first thing I became aware of was that my posture improved immediately, I stood up straighter and my core lower abdominal muscles were getting a workout! My heart rate went up quite quickly too. In addition, yesterday and more importantly, today, I don’t have any muscle soreness or stiffness.

Where you will be asking is the Science? There have been many studies worldwide, but there is ongoing research underway at the University of the Witwatersrand. Have a look on the website www.kangoojumps.co.za

Reboundology has also been the subject of considerable research by N.A.S.A

The application of this technology is for rehabilitation as well as strengthening. (You would be surprised who is using them!) For example they will improve balance, co-ordination and agility; improve foot alignment; increase overall muscular tone. They stimulate cellular bone rebuilding ability. The potential application in managing arthritis is an exciting thought.

Closed chain kinetics using Kangoo Jumpssseems to me to be offering a new clinical modality and challenge to our current way of thinking. You can be any age from 6 to 90! I can’t wait to start rebounding!

Foot Pain & Posterior Tibial Tendon Rupture

Never ignore foot pain. A recent case of tibialis posterior tendon rupture is a case in point.

A 76 year old lady was brought to me by her daughter because she could barely walk and was in constant pain. She had been prescribed anti-inflammatories and sleeping tablets for ‘the arthritis.’

At her only previous visit to me in 2003, I had diagnosd the potential for flat foot related problems and made orthotics. The lady never kept any follow up appointments.

This time, the lady described her symptoms as “the left foot is giving me hell. Over the past year, it’s been getting gradually worse and now I can’t wear my shoes.”

When I asked about the previous treatment, she informed me that she gave up with orthotics because they didn’t fit easily into her shoes.

When I examined the foot, it was completely flat and rolled over and the arch was non-existent. The lady was unable to stand for more than a few seconds and she couldn’t manage more than two steps across the room. In addition she was unable to raise up onto tiptoe.

As I traced a path along the inside of the foot up behind her ankle to the lower part of her calf she experienced significant pain. This is the path of the Posterior Tibial Tendon, the main tendon to help form and hold the arch of the foot.

Posterior Tibial Tendon

I immediately sent the lady for X-rays and an Ultrasound scan.  The scan revealed a rupture of the Posterior Tibial Tendon.

Referral for surgery has been completed and now we wait for the outcome, except that she has developed a problem with her eyes that needs treating before any surgery can take place.

The moral of this story? Follow up is vital from both sides of the medical equation. Ignoring foot pain can have serious consequences, so managing it is a team effort.

READ THE FULL CASE HISTORY IN [Case Histories->]

New Year Resolution – Become a Podiatrist

In just under 7 hours time South Africa will welcome 2009. Will you make a resolution to become a podiatrist? Maybe one of your family or friends will?

Are you sitting with your ‘Matric’ results and not sure what to do next? South Africa has a serious shortage of podiatrists and as I wrote the other day even our new graduates are emigrating. There are fewer than 200 registered podiatrists for our population of about 48 million people.

However, with increasing access to health care and awareness of the benefits of a healthy lifestyle, there is a growing demand for foot care, especially for children and people with foot problems associated with diabetes and arthritis. Nevertheless, many sectors of the South African population still don’t know what a podiatrist is or what we do. As our population changes more people will need foot care.

A podiatrist is really a ‘doctor of the feet’. We diagnose and treat foot disorders and abnormalities. This is done in many ways. Biomechanical examination involves assessing the whole lower limb and its function and then prescribing the appropriate treatment to maintain or restore normal mobility or function.

Many systemic diseases affect the feet and may even be diagnosed from foot symptoms. As a podiatrist you may need to refer your patient to a specialist for further management. A large part of podiatry treatment involves the skilled use of sharp instruments to treat corns or callus or possibly perform detailed corrective surgical procedures on toe nails.

Some of the conditions that Podiatrists treat are fungal infections of the feet and toenails; corns and calluses; ingrown toenails; foot ulcers in diabetes; causes of foot pain in arthritis. Most podiatrists incorporate orthotics and insoles into their treatment when necessary. 

The assessment and management of childrens’ foot problems forms an important part of a podiatrists work, whilst some podaitrists are skilled in the managemment of foot problems arising from sports. Nowadays, prevention of foot problems has become very important, so foot health education is also part of podiatry practice.

Although there is no official specialist register for podiatrists, many of us have developed ‘special interests’ in sports injuries, chronic disease, children or the elderly.

The day to day work of a podiatrist is interesting and varied. Giving relief from pain or diagnosing the cause of a foot problem is both challenging and stimulating. You do need to be able to work alone but also need to be a ‘people person’ to relate to the different patients you meet every day. Most podiatrists are in private practice, but we hope there will be an increasing deployment of podiatrists in the State Health services in future. For example Limpopo Province appointed their first graduate podiatrist.

To practice in South Africa you have to register with the Health Professions Council of South Africa.(HPCSA). This means that you become part of the Team of health care professionals providing care to South Africans and that you adhere to ethical standards.(By the way, it is illegal to practice as a podiatrist in South Africa if you are not registered with the HPCSA. So always check the credentials of a podiatrist).

To become a podiatrist in South Africa requires four years of full-time study at the University of Johannesburg. You will obtain a Bachelors degree and be able to go into practice immediately. Although bursaries are limited I believe this is changing as Provincial Health Departments begin to realise the value of foot care. Your entrance is dependent on your Admission Points Score (APS) or your M-score.

There are still vacancies for 2009 enrolment. So why not contact the University of Johannesburg – they reopen on 5th January 2009 – at 011 559 6167 or www.uj.ac.za

However you welcome in the New Year, dancing  the night away, taking it easy at home with friends, walking on the beach on an exotic island or if you are unlucky, at work! Enjoy yourself and I wish you all good foot health and happiness in 2009.

TAKE CARE OF YOUR PAIR! SEE A PODIATRIST 

An interesting case: Sesamoid Fracture

I diagnosed a sesamoid fracture in a young woman this week. The presenting complaint, on Wednesday, was of “pain in the ball of the foot under the big toe joint for nearly 9 months, but 3 days ago (Sunday), whilst doing a long day shift the pain got really bad and only stops when I take weight off the foot.”

The ball of the foot was noticeably swollen, but not inflamed. However, when I applied light finger pressure to the area the pain increased and was particularly bad at one spot. The lady has a high-arched foot (pes cavus), but it is flexible not rigid. She is not overweight, but is very active everyday of the week -including some weekends – working long hours. She told me that she usually wears a low heeled shoe or sandal, but it had become impossible to wear slip-ons or ‘push-ins’ because of the pain. The only relief was to wear trainers with a thick sole. When the weight was removed by sitting or resting in bed there was no pain.

By applying a protective pad to the sole and the arch, with a cut-out around the painful area, painfree walking was possible. An X-ray was requested; both feet for reasons that I’ll explain shortly and a follow-up appointment was arranged for Thursday morning.

We met on Thursday and the X-ray showed a clear break in the lateral sesamoid. The pain was also worse because the padding had slipped backwards and out of position. By repositioning the pad, the pain was relieved again. I instructed her to use trainers as often as possible and suggested that she do the replacement padding herself. In addition I arranged for her to be fitted with an Aircast below knee walker, which she could borrow from the practice on Friday after work.

The treatment for this condition is mainly patience and removal of pressure. Which is why I decided on the Aircast. When we fitted the Aircast walking was immediately painfree. Now we both have to wait for the bone to fuse as one or even two bones.

There are two sesamoids under the ball of each foot. They allow a particular muscle to pull the foot down during standing and walking; they also survive a lifetime of bending at the ball (the first metatarso-phalangeal joint). In some people, one of the sesamoids is naturally bifurcate and can look as if it is fractured – called a normal variant -that is why I asked for both feet to be X-rayed. This fracture may heal in two parts also, which won’t be a problem.

Pain in this part of the foot is quite common. It is caused by excessive amount of shearing, compression or tensile stress over the joint. It can be associated with sports like golf and tennis. Starting running or training and doing too much or running in old trainers. Wearing old worn shoes, where the inner sole gets a deep imprint. It can be associated with rheumatoid athritis, or even standing on a ladder for long periods, when you aren’t used to doing that! Nearly always it affects people with a high arched foot who have over-used their feet.

Initially the bone and the joint under them become inflamed and that is called sesamoiditis. Ignore this and a sesamoid fracture may result.

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!

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

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

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.

Podiatry and the Child with Arthritis

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.