Trips, Slips & Falls – Occupational Hazards

Last week I was invited to the Headquarters of  ESKOM our Electricity Supply Commission, to talk about footwear selection and the effects of high heels, amongst other things!

From the outset it was clear that ESKOM is very concerned about safety – we were briefed on where and how to get out of the venue should there be a ‘problem’ –  before the talks began.

It seems that the greatest cause of occupational injuries at Eskom HQ is Slips, Trips & Falls, nothing to do with electricity at all! So they decided to do something about the problem by discussing it. There were two scientists from the National Institute for Occupational Health also presenting and they showed some of the scary activities that employees do in incorrect footwear. Like climbing ladders, wearing high heeled shoes on slippery floors, or wet floors.

Even with the current fashion for lower heeled shoes amongst women, there was a slipping incident at ESKOM recently.

Flooring was identified as a major cause of slips at work, but also there is the choice of inappropriate footwear as I pointed out previously. Amongst other causes are uneven floors, poor lighting.

Having  a spare pair of shoes at work is one solution, so that when you have to go to meetings or interact with clients you can put on your more fashionable ones.

However, perhaps the most basic concept is to be aware of your surroundings. For example, how many of us have fallen on our backsides at sometime in our lives, when at the poolside? In other words look where you are going!

Responsibility for foot health safety rests with employee and employer.

The Health & Safety legislation is designed to protect everybody. Including the forklift driver who says he must wear tekkies instead of safety shoes, because the safety shoes hurt. Fine, but remember that if you get hurt, there is no compensation.

However, I do blame employers who budget for only the cheapest safety footwear, when being distracted by uncomfortable footwear could lead to an accident at work. There is a real need to look to buy the best safety footwear the company can afford. It’s people’s health after all.

On the other hand, the beautiful corporate HQ with imported tiled floors, may actually be an accident waiting to happen.

Paying attention to where you are walking and what you are doing is another important measure in preventing slips, trips & falls. What do I mean? The dreaded cellphone! Walking & talking can be just as dangerous as driving and talking.

We had a good discussion about high heels!

On my way through the campus I noticed a beautiful young woman tip-toeing along past a wet floor [it was well-marked by the cleaning staff with warning boards] on what I guess were 7cm high heels. Her strides were very short and she wobbled along to keep from slipping on the tiled floor.

As I’ve pointed out before, a high heel shortens your stride and reduces your ability to walk normally. Add to this a shiny floor and there is an accident waiting to happen.

In the ESKOM HQ and many others I’m sure, the floors are spotlessly clean and shiny. Usually tiled and very smooth. This means that there is little grip between the sole of your shoe and the floor. An ideal situation for a slip, trip or fall. 

Foot Health and Safety at work is everyones business and responsiblity.

Walk the Talk – 2010

Walking is probably the easiest and cheapest form of exercise available to us. The 702 Walk the Talk takes place on 25 July and 50,000 entrants are expected to hit the streets of Johannesburg.

Podiatry students from the University of Johannesburg will be walking aswell as offering foot care advice and screening at their Caravan Clinic. Some podiatrists will also be joining them. Some to walk and others – like me – to talk!

There are many benefits of walking; improved circulation, increased energy, longer life, being happier and stronger bones, are just a few.

30 minutes a day and 3 times a week is recommended! Where to find the time? You may ask. Well it doesn’t have to be all at once. Just think about your day and see if you aren’t already doing some walking.

The important thing is – BRISK – not strolling to check out the neighbours new extension!

Brisk means just that and starts by moving around more quickly with everything you do. Start by taking the stairs when possible. Obviously it’s a bit silly to walk up 15 floors, but you can work up to it. I used to work in a building where I gradually worked up to 7 floors. When I was in there again recently, I could still do it, but slowly! I need to walk more.

Start slowly by putting in say 10 minutes [distance doesn’t matter] every day. Set targets and slowly increase. If you rush out and do 30 minutes or try to get kilometres in under a specific time, I look forward to treating you for shin splints, plantar fasciitis, blisters etc.

Become familiar with your normal speed and pace and maintain it. Sudden rushes and surges only increase the risk of injury.

Try to walk with someone. especially someone you can talk to. As you get better, one of the tests of improvement is being able to hold a converstaion with your walking partner.

You must wear a decent tekkie/trainer. After a few weeks if you do develop pains that won’t go away, look at whether the shoes are deforming in any way. That could suggest a biomechanical problem. Then you need to see a podiatrist for advice.

 Sometimes, starting a walking programme reveals an underlying condition. Specifically there is a condition called intermittent claudication which is felt as a cramping or tightening of the muscles at the back of the lower leg. It occurs every time an afflicated person walks a specific distance at their regular pace OR when they walk up a slope or incline. The distance will vary with individual physical status, but it occurs regularly at the same distance.

Basically, what is happening is that the muscles are starved of oxygen because the arteries are hardened and narrowed – usually by cholesterol plaques. If this does happen, then beware, it could also be happening to another muscle your heart! Pay your doctor a visit for a check up.

So if you want to:

• improve circulation and reduce the risk of heart attack and blood clots
• reduce weight
• strengthen your bones
• burn off fat everywhere
• look leaner and wear smaller clothes
• relieve stress and anxiety and become more relaxed
• improve your posture
• just feel better

Start walking. No excuses! We’ve had a month sitting watching football.

Now fight the winter chills, improve your health and WALK.

Toxic leather shoes? Don’t panic!

“Warning: toxic leather shoes sold here” This scary headline appeared on page 5 of today’s The Sunday Independent, over an article about the potential danger  to the environment from the toxins/chemicals used in the tanning process of many of  the leathers used to make our shoes.

Chrome tanning has been the method of choice for years now and the article describes a report from the Swedish Society for Nature Conservation and its partners, expressing their concern at their findings. The major concern is the amount of chromium the could spread to the wearer and into the environment. This, coupled with the various dyes used in tanning is the source of the society’s concern.

As a podiatrist, I occasionally see a patient with a skin rash that is clearly associated with the patient’s footwear. Called contact dermatitis, it shows as a clearly demarcated rash at all sites where the skin has been in direct contact with the shoe. It is frequently associated with leather sandals and it shows the patient’s skin is irritated by the chemicals in the leather. However, there are numerous other causes of contact dermatitis, as any Dermatologist will tell you.

For example, with the need to produce shoes at lower cost, synthetic materials are more widely used. This also brought its own problems of skin sensitivity, increased sweating and sometimes burning feet. Environmental experts frequently point out that Plastic is of course another blight on the environment. 

From a foot health point of view, we recommend the use of natural materials, such as leather, because we believe it ‘breathes’, absorbs natural foot moisture (sweat) and is altogether more healthy. Unfortunately, all leather shoes are expensive and over time become dry and cracked due to the cycle of moisture and dryness associated with the normal foot. [which is on reason why leather is tanned in the first place].

So don’t panic, rather read the article and if possible the original report, before throwing out or burning your shoes; the smoke is also toxic! We are polluting our environment with far worse things than leather shoes.

Try to alternate your shoes from day to day. Keep them clean and polished to preserve the leather [if they are leather]. wash and dry your feet carefully to prevent the build-up of bacteria which cause smelly feet. Socks of natural fibre will protect your feet from direct contact with the materials used in manufacture, if you are sensitive.

If you do develop a rash or an itchy foot, after wearing a particular pair of shoes. Stop wearing them and see your podiatrist or doctor as soon as possible, because their are tests that will be done usually by the skin specialist – Dermatologist – to identify the exact cause and what you are sensitive to.

Whilst I think this particular article is a bit sensational, it does appear to be based on research evidence. Perhaps the take home message should be a timely reminder that we should all be doing more to re-cycle paper, plastic, metal and household refuse than we are.

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!

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.

May is World Foot Awareness Month – Diabetes & Crocs

Foot Health Awareness is vital for people with diabetes.

PEOPLE WITH DIABETES ARE 25 TIMES MORE LIKELY TO LOSE A LEG THAN PEOPLE WITHOUT THE CONDITION

Today I want to issue a timely reminder to people with diabetes who want to wear ‘Crocs’.

Last Friday, I saw a patient who “lived in her ‘Crocs’.” That was until she got splinters which penetrated the soles and stuck into her big toe, as she was walking across the university campus. The splinters were removed by her GP and today she told me there was a small remaining piece that also had to be removed. Fortunately, although she has neuropathy, the wounds are healing well.

Last Christmas, a family member (with no diabetes) also had a piece of metal go through the sole of  his ‘Crocs’, whilst walking across the garden.

Previously, I have not taken a strong stand on this, but these two events have prompted me to express my opinion in the form of a WARNING.

If you have diabetes, think very carefully about wearing ‘Crocs’. If you have poor circulation or reduced nerve sensation; do not wear them outside the home.

EVERY 30 SECONDS A LOWER LIMB IS LOST TO DIABETES SOMEWHERE IN THE WORLD

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->]

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.