Category Archives for "Foot Care"

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.

Holidays: Sore Feet and Sunburn

Indian Ocean Shore line - Wilderness SA
Image by Donnie Ray via Flickr

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.


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Sesamoid Fracture – an interesting case – treatment

The case of the sesamoid fracture that I referred to the other day, has had an interesting development. You will have read that we ended up using an Aircast below knee walker. Unfortunately this was only successful for about one day. By the end of the day the pain was increasing.

I advised my patient to get advice from an orthopaedic surgeon who I know. The advice was really simple! Wear thick-soled soft trainers and take pain-killers until it is better. (Obviously only take the pain-killers as often as really necessary). This will allow normal movement – remember this condition is not treated by immobilisation in a cast – but not over use.

So what’s the lesson here? Simple treatments are often the most effective. Never ignore foot pain in the ball of your foot. Have it accurately diagnosed – it might be a sesamoid fracture.

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!

Sweaty Feet

Sweaty feet affect everybody at some time of their lives. The complaint can be seasonal -worse in the warmer months – but can be present at any time of year. The medical term is hyperhidrosis (excessive sweat production) and if there is an accompanying bad odour, it is called bromidrosis.

There are many causes. The most common is poor foot hygiene associated with footwear with a high synthetic material content. Socks, stockings or tights made of nylon also cause the feet to sweat excessively. In teenage years glandular changes are a frequent cause amongst males and is made worse by poor hygiene and footwear. Occasionally, there is a systemic problem which shows in increased sweating of the hands and other body parts. Whenever we exercise, we develop sweaty feet, which is is quite normal, but it does lead to the smelly foot and shoe syndrome.

An excessively sweaty foot is susceptable to the development of fungal infections and because it is important to differentiate between sweating and fungal infections, I’ll write in detail about fungal infections in the future.

Treating sweaty feet needs patience and perserverence. Daily washing with soap and water is essential. Then dry feet thoroughly. Try to avoid wearing shoes with synthetic uppers and soles. Make sure your socks contain high percentages of cotton or wool. Read the labels to see what the socks are made of. Try using an anti-perspirant under the arches of your feet. There are some products advertised specifically for this application. Podiatrists usually recommend ‘Spiritus Pedibus’ also called Foot Spirit. It contains 3% Salicylic Acid in Ethyl Alcohol. Occasionally a weak solution of Formalin can be prescribed. Obviously any opportunity to have your feet bare in fresh air will help. So wear sandals whenever possible. However, beware of plastic and synthetics, go for leather if you can. If the condition is really severe, a change of socks may be necessary during the day.

There is a surgical procedure called a sympathetomy – which must be performed by a specialist surgeon – for very severe sweating of the hands and feet.

Smelly feet are usually caused by the bacteria which live on our feet normally, not being washed off thoroughly. They can of course be caused by the materials themselves, especially some rubbers. Washing and drying is a good start followed by any of the above treatments. Naturally if you favourite trainers make your feet smell, but your normal shoes don’t, you have a hard choice to make!

Powder is often used for sweaty feet, but be careful since it tends to solidify between the toes.

Sweaty feet are a common complaint and they can be embarassing. However, treatment is often very simple, starting with an intensive foot hygiene routine.

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!

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

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.