Traction Apophysitis – progress report

I have just seen the 8 year old child with Traction Apophysitis featured in previous posts. Since January 26, when I first saw him, he has followed a strict programme of reduced activity.

He has been fantastic in wearing trainers at school – remember that all the other children are barefoot – and severely limiting or stopping any activity that caused pain. Although, about a month ago we did let him start swinging a golf club at the driving range!

His mother reports that he no longer sits on the side of the bed in the morning rubbing his painful feet. Has no pain after school, even though he has recently started playing some soccer at break time and he is completely pain-free.

Today’s X-rays show a normal appearance of the calcaneal epiphysis (the growth area/point at the back of the heel), and improved bone density.

The plan now is to slowly start activity again and that will be rugby.(He plays barefoot). The trainers must still be worn as often as possible. Follow up will be in 6 months.

The diagnosis of Traction Apophysitis is usually based on the presenting clinical symptoms, as the X-ray findings are often inconclusive. Nevertheless we must never ignore the younger child with painful heels and always consider Traction Apophysitis.

Management is clearly “rest”, by reducing or avoiding those activities that cause pain. A supportive but soft/cushioning trainer is the best footwear. There is a place for short term anti-inflammatories followed preferably by topical gels and plasters.

Whatever we try, there is always the question of ‘what would have happened if we had done nothing?” I believe that that decision can only be made with the individual patient in front of you, so that you can respond with clinical judgement and personal empathy. However there is no doubt that for many children it is a transient condition.

My apologies for not getting the case history on the site as promised.
THE COMPLETE CASE HISTORY WILL BE ON THE WEBSITE SOON.

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->]

A Word On Medical Matters – Talk Radio 702

I’ll be back again as a guest expert on Talk Radio 702 & 567 Cape Talk on Tuesday Feb 17.

The programme is called ‘A Word on Medical Matters’ anchored by Leigh Bennie with host Prof. Harry Seftel and is broadcast starting from 19.00 -20.30.

It’s a live phone-in, plus replies to text massages and emails so this is your opportunity to get the latest current advice if you have any pressing problems.

Traction Apophysitis-feedback

Here’s some feedback on the boy with the traction apophysitis. Did you think the overuse was extreme? What did you think of the training routine?

Firstly, he has wonderful parents! They have followed  my advice to wear shoes and avoid all activities that cause stretching of the Achilles tendon. Secondly,they have been surfing the Internet to find out more about the condition. They showed the youngster pictures and explained the reasons why he has to take it easy. This means that he understands that time spent recovering now will enable him to participate again when the condition settles. Thirdly, they have stopped all sport at school.

Fourthly and this is the best bit. His father tells me that he asked his son to rate the pain. If the pain was rated as a 10 when he saw the podiatrist what is the rating today? About 2 or 3 says the boy.

In our sports mad country its refreshing to get such team work going.

At this stage it is imposible to say how long healing  will take, but the initial response of the foot to simple rest and supportive footwear is encouraging. Rehabilitation will be very important; in the form of stretching very carefully, accompanied by orthotics or simple insoles.

Traction apophysitis does heal and all the better it seems with lots of TLC (Tender Loving Care).

Keep looking for the full case history – its nearly finished

P.S. Tune in to Talk Radio 702 17 February 19.00

A Sports Injury or Child Abuse?

How much sport is enough for a child? When does too much sport become abuse? Is an over-use injury at a young age, in the pursuit of excellence worth the possible long-term consequences? Consider this:

Last week, an 8 year old boy, barely able to walk, was brought to see me by his mother. He had a severe limp, walking with his foot out and his ankle stiff, to reduce the pain. Three days previously he had spent nearly 5 hours doing athletics at school. His mother told me that the initial pain began more than 6 months ago, after he had played a lot of rugby.

The school under 8 team had been very successful, winning their area age group, so had a long season. Then he moved up an age group to under 9 which extended the season further. Nevertheless he continued with all sports, despite the pain and the fact that he was not running as fast as before. A compounding factor is that athletics and rugby are both done barefoot.

The timetable of sports reads like that of a professional adult, with daily practice depending on the sport and season, with inevitable overlap; plus the fact that the school plays some sports out of season as well.

• Athletics: 1 hour a day, x 5 days, plus meetings
• Cricket: 1 & half hours a day x 5 days, plus club games on Saturdays for a university club junior side
• Rugby: 1 hour a day x 5 days, plus matches

The boy is obviously very good at his sports and according to his mother is always active at home whilst playing. However, this timetable with an injury would cripple most adults.

So what’s the point? How far must we/should we push or allow our children in pursuit of sporting excellence? We try to teach balance in most aspects of life, sleep, study, money etc., but when it comes to sport we seem to make up the rules as we go along.

After requesting X-rays of both feet and discussing them and my diagnosis with two different medical colleagues, it was agreed that the cause of the pain is damage to the growing part of the back of the heel bone, where the Achilles tendon inserts. Clinically called a Traction Apophysitis.

The initial treatment is rest and avoiding any vigorous activity that causes the Achilles tendon to pull on the heel bone. Raising the heel or possibly orthotics may help.

So ask yourself the question – is this youngster suffering an over-use injury or child abuse or both?

A full Case History will be posted during this week.

Sesamoid Fracture – A Holiday Injury

Best wishes for 2009. The first holiday injury came this week. Another sesamoid fracture . A  38 year old male patient returned to the practice for follow up to a visit in December, due to have impressions made for new orthotics.

He told me that on Christmas Eve he had slipped and fallen into a swimming pool with his  leg fully extended – ‘straight out in front and under me’. The leg had hit the bottom of the pool with the ball of his foot, jarring it severely.

Over the next few days he experienced varying degrees of severe pain, best relieved with wearing thicker soled shoes. However, with the weight off the foot there was a constant throbbing.

Remembering the young lady I wrote about about towards the end of last year, I sent for X-rays. Result a fracture shows clearly in one of the sesamoids.

Treatment? Take it easy. No excessive activity – but cycling in the gym is OK. Thick and soft soled shoes – probably sneakers. Be patient!

Sesamoid fractures should always be suspected with a history of sudden stamping under the foot. They usually heal well, but may take time.

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 

Merry Christmas! Happy Holidays!

Merry Christmas! Happy Holidays! We closed the practice today. Tomorrow I start a short break in Hout Bay with my family. Including my son who is visiting from the UK.

I know that some of you reading this site do not actually celebrate Christmas and so I wish you and your families well over the long weekend. If you are celebrating Christmas, I hope that you too can spend some time with those you love.

Travel safely and tread lightly. You never know when you will need a podiatrist!

Best wishes

Andrew

Holidays: Sore Feet and Sunburn

Sore feet or sunburn could ruin your holiday. Whether you are going to the coast, mountains or bush, you need to pay special attention to protecting your feet this summer.

As the holiday season gets going, many of us will be exposing our feet to the African sun for longer periods than usual. Remember that if your feet are usually covered by shoes and socks, they will need as much protection as your face and shoulders. (Or your bald head). Despite the fact that we spend a lot of time barefoot or in sandals in South Africa, during holidays the time is often extended.

The most vulnerable part of your feet is the skin on top of your arches. However you can also get sunburn on the soles of your feet if you like to indulge in serious ‘sun-worship.’ Obviously any part of your feet that is exposed is at risk. Initially you might not feel too much discomfort from sunburn, but when you put closed shoes on there will be pain.

Usually, sunburn is confined to a patch of inflamed, sensitive skin, which responds to protective after-sun preparations. The end result is skin dryness and peeling after a week or so and little harm is done. In severe cases however, the inflamed area starts to blister and itch. This is when scratching or opening the blisters can lead to infection.

Always apply sunscreen on top of your feet before you go to the beach, shopping or walking. You might need to re-apply after swimming, depending on what you use, or suits you. If you are spending a long time lying face down with bare feet protect the soles. After showering, treat your feet as you would the rest of your body with your choice of after-sun preparation.

Another common holiday foot problem is burning the soles of the feet. Here again it is usually because the soles of our feet are not as tough as we think and so we forget that the beach sand burns. The same thing applies to the patio tiles or paving.

Don’t do crazy things like walking barefoot over the car park. We all know that it’s thought to be very ‘macho’, to run around barefoot on holiday, but there is nothing ‘macho’ about peeling, blistered soles.

Unfortunately wherever you are, at the beach or around the dam your bare feet are not protected from broken glass, cool drink cans, palm thorns, bits of charcoal from the braai, even rubbing from your new sandals! Watch out for those beach thongs rubbing between your big toe and second toe too.

Always wash sea sand off your feet before you walk any distance, because it can chafe and irritate skin between your toes.

You might even get painful feet from all the extra walking that you do. This can be a big problem if you are walking along a beach where the sand is rough, or if you spend time jumping around in the sea on rough sand. It can also happen if you are enjoying the sights of a chilly Northern Hemisphere winter, as you spend more time walking around.

Finally, as you lie on that soft, sandy beach preparing to enjoy the warm Indian Ocean, remember it’s not just the sharks that can get you, look out for sea anenomes, puffer fish and coral!

So just think ahead. Protect your feet and those of your family, but above all, relax and enjoy putting 2008 behind you. Don’t let sore feet or sunburn spoil your holiday, but if it does, go and see a podiatrist.

TAKE CARE OF YOUR PAIR

Podiatrist Beaten By Technology and Health Professions Council

Regular visitors to the website will have noticed that recent blogs have suddenly disappeared. New visitors will wonder why nothing has appeared for over a month. Well, the administrative cyberstars behind the webmaster decided to carry out a major restructuring of ‘their systems’. As a result, in some remote part of cyberspace concerned with the management of the website the blogs have disappeared. Despite all attempts to find the blogs they seem to have phoned home like ET.

Please be patient and there will be new information up within the next few days.

At present the practice is very busy, which is just as well in view of the recent press release by the registration body in South Africa, the Health Professions Council of South Africa(HPCSA), which basically has recommended that the guideline for fees in future should be the Nationl Health Reference Price List(NHRPL). This is a backdown from the HPCSA position of accepting that a practitioner may charge up to three times the NHRPL.

Since the government took over control of what is usually ‘the Medical Aid Rates’, they have consistently ignored the recommendations of health economists appointed by them to adjust the fees of Health Care Professionals in South Africa.

What this means is continued problems for providers and consumers when dealing with Medical Aids (Insurers). Personally I think that people who value and receive quality healthcare will still be willing to pay for it, IF the financial crisis is not too severe.

Consider this: for spending 30 minutes performing skilled clinical removal of a corn or ingrown toenail,for example, the NHRPL fee is 57.10 SA Rands. Current exchange rates are R1.00 = USD 10.22 and GBP 15.00. Do the maths and see if you can see the value in that. (Of course there are other fees added for consultation and materials), but it is the principle that matters.

I was guest speaker at the graduation ceremony of the podiatry department at the University of Johannesburg, only 5 graduates, the other 12 are deferred until they have finished their research projects. And guess what? The top student is emigrating to Australia!

Look out for Your Career in Podiatry in South Africa, coming to this space soon.

In the meantime if it’s not broken don’t fix it, or you might get beaten by technology!