Arthritis Affects Children’s Feet
J.I.A. or juvenile idiopathic arthritis is just one of the manifestations of arthritis in children. Just like adults children get pain, stiffness in the morning that can last for some hours, restricted movement of their joints, swelling of their hands and feet. In other words serious incapacity. Unlike the adult form where we see a pattern of rheumatoid arthritis starting to affect women mainly around the age of 40, in children it can happen anytime.
Awareness is the key for both parents and health care professionals. I have been seeing children with local areas of tenderness or pain under the heels, or at the back of them. Pain along the soles of the feet. Ankles that are painful all the time either when moving or resting. Showing reluctance to run around because of the pain. Complaining of swollen and painful toes. Not wanting to wear their school shoes because they hurt. There are many other signs and symptoms that usually the doctor will identify.
Some of my patients are so badly affected by arthritis that they are only able to wear soft slippers to school. Fortunately a donor has offered to provide appropriate soft but firm footwear for them. Some children are completely pain free thanks to the medication that has been prescribed, but they have structural foot problems and so need some form of support – usually with an orthotic – but often just a decent shoe and some advice is enough.
The secret of success in managing these children is teamwork, and I am lucky to be part of the paediatric rheumatology team at Chris Hani Baragwanath Hospital. The specialist doctors are able to prescribe the appropriate medication which frequently brings relief to the painful joints and removes symptoms.
Don’t ignore the child with a painful foot. It probably isn’t arthritis, but it might be.
Dialysis and the Diabetic Foot
The diabetic foot is often associated with patients who are on dialysis for kidney failure as a result of their diabetes. There is a well known ‘triad’ of eyes/kidneys/feet. What health professionals call retinopathy/nephropathy/neuropathy.
We are managing a gentleman who is suffering the effects of many years of poorly-controlled diabetes, acompanied by smoking. The effect of this has been serious damage to the circulation to his legs. As a result, he has needed arterial bypass surgery and now, three times a week he comes to the hospital for dialysis, because his kidneys are malfunctioning,so his specialist asked us to look after his feet.
On first view we got a real shock – the three outer toes on his right foot were dry, shrivelled and black – typical of dry gangrene. These toes will probably fall off by themselves! The back if the left heel is one large blood blister, fortunately it’s dry and not infected.
The principle of managing cases like this is to keep the areas clean and dry. For the patient they have to do their best to control their blood sugar. The targets for good blood sugar control for a person with diabetes are between 5.5 and 7.0 mmol/litre, so you can imagine my concern at the last visit when I found out that this gentleman was running 15mmol/litre.
Every time the dressings are changed there is the opportunity for bacterial infection and high blood sugar usually worsens the situation. Of course the state of the feet and limbs in an obvious potential cause for the raised blood sugar too.
So what’s the lesson? Mismanage diabetes at your peril! Damage to the nerves and circulation will have a major impact on your life the longer you live. The complications of diabetes are largely preventable, yet vast amounts of money are spent worldwide on managing the complications of diabetes.
Control of blood sugar and not smoking will protect both arteries and nerves from serious damage. Nephropathy or damage to kidneys is life threatening and not everybody can access a dialysis unit. Loss of sensation or neuropathy, where there is no sensation in the feet, allows for injuries to happen without the person noticing.
Don’t become a victim of circumstance – take control of your diabetes now – and avoid dialysis later.
More Foot Pain For South African School Children?
Thousands of South African children go back to school tomorrow. How many with foot pain?
We don’t know the facts, because the research hasn’t been done. But as children grow, so do their feet. So it’s a safe bet that many feet will be pushed into shoes that were bought at the beginning of the school year in January and are too small 6 months later in July.
On the other hand there will be some children who will suffer the discomfort of a brand new pair of school shoes! It’s not true that shoes have to be “worn in.” They should fit properly and be comfortabl from the start.
Most children wont tell their parents that their shoes are too small, because the soft, developing bones can be easily squeezed and squashed into position. In addition, in the current economic climate, the cost of a new pair of school shoes often has to be balanced against food, rent or travel expenses.
Try to look at your children’s shoes as soon as possible after the start of the term. They have probably complained about having to wear them anyway – having not worn them for a month. Get them to stand up in their school socks and you press gently on the end of each shoe to find the ends of the toes. If there isn’t a finger space at the end, they are too short.
Don’t try the other method of pushing a finger down the back of the foot behind the heel. The shoes should fit around the heels and allow the feet to lie nicely in their normal position. Check also for uneven wear on either side of the shoes – this shows flattening or ‘out-turning’. If the shoes are deforming you should get to see a podiatrist for a check up.
A final word on hockey, rugby and soccer boots. If your child complains that the soles of the feet are sore, have a look for red marks over the areas where the studs are. You probably need to put a soft cushion insole inside to limit stud pressure.
Can’t wait for the next school holidays!
More Diabetic Foot Disasters
Two more diabetic foot disasters arrived in the practice and at my Hospital clinic this weekend. Another hot water bottle burn, plus a corn paste induced abscess.
Loss of sensation and lack of foot health education contributed to the elderly lady with Type 2 diabetes burning her left little toe and the lower part of her calf, plus blistering her right big toe. The lower calf is about 2mm deep and the blisters were still covering intact skin.
If you are in any way involved with people with diabetes this winter please warn them of the dangers of hot water bottles, heating pads etc. Remind them of the tips I put out recently for winter foot care.
When diabetes causes loss of sensation in the lower leg then putting hot objects like hot water bottles next to the skin can lead to serious damage.
Medicated corn plasters and pastes have been around for years and are usually used by desperate people who don’t know that a podiatrist can give them relief from their painful corns and calluses.
Sadly my patient is also a Type 2 diabetic, but without complications and therefore was in great pain.
I drained the abscess, applied appropriate dressings and prescribed antibiotics. This lady is booked off work for 3 days plus the weekend and I will see her again on Thursday.
That’s a big penalty in lost working time for a lady who was simply trying to take care of her feet but did not understand the value of taking professional advice until it was too late.
So who is to blame for these disasters? If the patients concerned didn’t know, then I am for not getting the good foot health message across to enough people. On the other hand the patients did know who to come to for help.
SA Men “Push and Bhobhoza” their feet
Men usually escape the painful feet we associate with poorly-fitting shoes. Surely it’s women who are wearing high heels and sharply pointed toes. They were doing it when I was at varsity. However I was amused by an article by Thando Pato entitled ” Men in sharp shoes miss the point” in the Sunday Times Lifestyle section on May 18th.
I checked with my associate Tshidi and sure enough “P&Bs” as they are known, are a real fashion item. Especially amongst black men. Ms Phato expresses her concerns about the growing number of South African men in all situations wearing shoes “so long and pointy that they look like spears.” (The word ‘bhoboza’ means to pierce in Zulu).
She also expresses a concern that I often use as a humour line in foot health talks – that shoes for women are designed by “cruel European men who claim to love women”. The message from Thando Pato is a great – not only are these shoes sold in garish colours, apparently white is cool – but she is also “traumatised” by the damage inflicted on the wearer’s feet.
She uses a great expression to describe corns, bunions, calluses and a host of other foot deformities that we traditionally associate with women; “Hammer Time”. I think this should become part of podiatry terminology. Her description of the pain experienced by one guy she sees is really funny. Thando Pato you must have been a podiatrist in a former life!
If you want to study the effect of high heels on how you walk, get along to the Victory Theatre in Johannesburg and take in The Rocky Horror Show. We went last night and it was a great show. Obviously I went for the anatomical study!
By the way the references for Angiosomes are: Taylor 1991. Plastic & Reconstructive Surgery.102.599. There is a fully illustrated article in Plastic & Reconstructive Surgery. 2006.117. 261-293.
I know these are not 100% accurate but that’s what I wrote down at the congress, so put on your best Google and see what you get!
A Fresh Start At The Practice?
Fresh from the long weekend we welcome Ms Lauretta Zikalala to our podiatry practice. Lauretta is our new receptionist and will be the voice of the practice from today. Back at the practice today, (not exactly fresh!) after a tiring but stimulating weekend at the Diabetic Foot Working Group (DFWG) Congress. Armed with some new knowledge and revision of existing, Tshidi and I feel that we have more to offer our patients with diabetes.
We know that Podiatry and diabetes is not just about managing the serious complications such as foot ulcers. The key issue is the prevention of this complication and research shows that multidisciplinary interventions can reduce both ulcers and amputations. There is a major challenge in South African health care to educate everybody involved in diabetes about the need for proper foot health care.
Just to get patients and professionals to look at feet could prevent many complications. So many patients do not feel pain and are therefore misled into thinking that there is nothing wrong with their feet. Meanwhile they develop blisters from footwear, ulcers from objects like drawing pins, stones and other foreign bodies and burns and scalds from heaters or hot water. It is clear that we will have to develop innovative and cost effective interventions to reduce the numbers of amputations and to improve foot health awareness in South Africa.
For any health professionals reading this; do you know what an angiosome is? I’ll publish some references tomorrow. (I think you will be amazed). For the lay person, angiosomes allow vascular specialists and podiatrists, in the context of patient examination, to accurately assess the quality of blood flow to every part of the lower limbs and feet. This enables really accurate identification of those areas at risk due to inadequate blood supply. Most of us are familiar with the dermatomes which map out the nerve supply, but angisomes are something new. (Well they are to me!).
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.