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!
Annual Foot Examination for People with Diabetes
Every person who has diabetes, should have an annual foot examination. Feet, along with kidneys and eyes, form the “terrible triad” as it is sometimes called in medical circles; because people with diabetes can develop peripheral arterial disease or peripheral neuropathy(feet); nephropathy(kidneys) and retinopathy(eyes). I have spent the past two days conducting the Annual Foot Examination for people who attend the Potchefstroom Centre for Diabetes (CDE).
How many people with diabetes undergo this annual examination? Who knows? What is certain is that CDE members have to comply with rules which gives them access to all the basic health care professionals they need. (CDE is a Managed Health Care network of over 250 medical practices contracted to certain medical aid schemes).
The benefit of this annual examination is that patients, families and health carers know if the feet are at risk of developing futher complications associated with diabetes. The examination involves checking vascular, neurological, dermatological and orthopaedic status. Footwear is also checked and commented on. The International Consensus for managing the diabetic foot states that early identification of vascular insufficiency and referral to the vascular specialist does save many limbs.
Worldwide of course there is evidence that smoking damages your health, but even in the group at Potchefstroom there were smokers. All of whom had diminished circulation, plus the typical signs of cool feet, absent hair, discoloured pink/blue feet – especially when hanging over the side of the examination couch – and a cough.
Checking the state of sensation is vital for good diabetic foot health. The loss of sensation – neuropathy – is often an insidious process, not being fully appreciated by the patient until they are aware of “funny feelings” in their feet. Patients describe sensations of “pins and needles,” “shooting pains,” “ants running over my feet,” “I thought my sock was folded over under my foot, but it wasn’t,” “it feels like I’m walking on cotton wool” and many others. This could be the first step to damaging the foot and developing an ulcer.
People with diabetes get all the conditions that affect the rest of us. However, if not identified and managed properly an area of callus(which indicates increased local pressure) can easily develop into an ulcer. Various nail conditions are common amongst people with diabetes, especially fungal infections and they are difficult to get rid of.
They structure of any foot affects its function and so in the diabetic foot assessment we look at the alterations in shape that could cause load increases and potential blister or ulcer sites. In addition disorders such as gout are very often associated with diabetes.
Footwear is responsible for at least 50% of foot ulcers, so this is examined very carefully. Unfortunately, many people do not have suitable footwear, so it’s important to check it and give good advice.
Diabetes is a life-threatenting disease, but modern medicine has moved to early diagnosis and treatment and an important part of this is recognition by podiatrists of the signs in the feet. However for the person with diabetes one of the simplest acts to ensuring long life is to have your feet examined annually and know your foot status or risk.
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.
Talk Radio 702: A Word on Medical Matters: Feet & Podiatry
Talk Radio 702 in Johannesburg and 567 Cape Talk present a nightly series of talk shows devoted to specific topics. On Tuesdays it is A Word on Medical Matters and this coming week the topic is going to be feet. Hosted by Leigh Bennie and Prof. Harry Seftel, the programme is broadcast from 7.00 pm. For this programme I have been asked to be the guest on the show!
Anything can happen as it is an open line phone-in programme linking the sister stations of 702 & 567. It is great fun although a bit scary since you have no idea what questions are coming until you see them on the computer screen in front of you. Nevertheless it is an excellent forum for publicising the role of the podiatrist in providing health care in South Africa.
Maybe that role will become more recognised and change for the better, now that we have a new Minister of Health. Perhaps now we can also get a sensible line of communication to the Minister concerning the scale of fees payable for our services.
Today was another busy day in the practice culminating in the latest visit of the patient I wrote about with gangreous feet and undergoing dialysis. Well, the toes are still attached although black and dry – but the gentleman is really unwell. I have arranged for his wife to do some dressings, so that he could reduce the number of visits he needs per week. This is an important factor of the International Consensus on the Diabetic Foot, where the patient, family and health care professionals get involved in care. The intention is to develop an interactive and educated team.
Yesterday was another Paediatric Rheumatology clinic at Chris Hani Baragwanath – every week there is something new and we are beginning to have success in managing the painful foot complaints of some of the children. Incorrect footwear is still one of the main obstacles to achieving success though, because I can’t put an orthotic into a shoe that is already 2 sizes too small. This happened yesterday; the shoes in question were a pair of stylish Lacoste sneakers – bought at considerable cost by a loving mother but they were too small after a few months. With the result that the toes were buckling and painful – nothing to do with arthritis of course.
As summer approaches there has been an increase in ‘sweaty foot disorders’ so in the next week I’ll give some advice on how to recognise, treat and possibly avoid them. But if you can’t wait, listen to A Word on Medical Matters on Tuesday 30 September where the topic is Feet ard Podiatry, because the question always comes up.
In the meantime – TAKE CARE OF YOUR PAIR
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.
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.
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!).
Podiatry Students Unethical?
Not at all! As I said last week, the 4th year Podiatry Students at the University of Johannesburg(UJ), had their first taste of me starting the lectures on Practice Management and Ethics. There are many concepts to take on board including grasping the difference between ethical values & standards – represented by core values which are aspirational or value-oriented – such as Respect for persons, Human rights, Truthfulness, etc., and ethical guidelines -represented by specific rules or duties associated with professional practice. We started to examine the challenges faced in daily practice and led into how we apply ethical reasoning to move from the understanding of guidelines to using them to influence our practical decision making and choices.
I’m usually never short of a word or two on most subjects! But beginning this course has made me think very hard again at the way in which I reach and make my day to day decisions. So just for fun!!! Let’s look at the 4 steps of ethical reasoning:
The problem: formulate the problem and ask is there a better way of understanding it?
Information: gather all the relevant data, clinical, personal, social etc.
Options: under the circumstances, consider all reasonable options, choices or actions.
Moral assessment: weigh the ethical content of each option by asking –
- what are the likely consequences of each option
- what are the most important values, duties and rights? which is strongest?
- what are the weaknesses of your view?
- how would you want to be treated in the circumstances of the case? i.e. apply the Golden Rule
(I acknowledge the Health Professions Council of South Africa (HPCSA) as the source of the above).
Easy isn’t it? Hopefully someone at the HPCSA will be able to tell me this week what the Golden Rule is, I think I know but I’d better get the official opinion on it!
Naturally we are all making choices every moment of our lives, some better some worse, but getting into deep philosophical discussions can be quite daunting – especially when all most of us want to do is practise our profession.(Oh, and make lots of money!)
Perhaps as you read this you should start to apply some ethical reasoning to why you should or should not book an appointment with your podiatrist. Are you a person with diabetes who hasn’t had a diabetic foot assessment recently or ever? Have you any idea what a podiatrist can do to help your feet if you suffer from some form of arthritis? Are your children normal or do they have some biomechanical anomaly (odd alignment) that is undiagnosed but could be treated by a podiatrist? Do you care if your Gran can’t cut her toenails? Do you really have to but another pair of running shoes to get relief from foot and leg pain or should see a podiatrist? Is it possible that a podiatry consult could shed some light on the cause of by chronic back pain?
This morning I saw the effects of good podiatry care in a 5 year old who has good foot alignment although she has rheumatoid arthritis. She has been wearing foot orthotics for one year and has not developed any deformity in this time. As part of the team at Chris Hani Baragwanath Hospital I hope that the future choices we make will produce such pleasing results. It comes as a surprise to most people that children can suffer with arthritis, so I’m going to write about this during the next few weeks.
In the mean time spare a thought for my students who must be faced with ethical decisions about whether they should do the assigned reading for this week or go to the movies in the hope that I’ve got it all sorted!
Podiatry Students Under Threat?
University of Johannesburg 4th year podiatry students are in for a new experience on Tuesday 5th February! For the first time in 12 years I am returning to lecturing. I will be lecturing Private Practice Management, which is part of the course on Health Systems Management. I’m looking forward to re-joining the academic team, despite a dislike of marking. It seems to me that full-time academic life in 2008 is like a road full of potholes called "admin," so I hope I can avoid these potholes as a part-timer! Being burdened with too much "admin" was one my reasons for leaving in 1995!.
Podiatry education in South Africa started in 1977 at the Witwatersrand College for Advanced Technical Education (WCATE), as a 3-year Diploma plus a year of in-service training. Then it became a National Higher Diploma after 4-years of study after WCATE became Technikon Witwatersrand(TWR). It evolved into a 4-year Bachelor’s Degree at TWR and when TWR and the Rand Afrikaans University merged to form the University of Johannesburg(UJ), this became the latest home for the degree. The degree isn’t offered by any other University in South Africa, which is disappointing and leads to all sorts of difficulties in enrolling students from around the country. However graduates from UJ are distributed all over the world and many have gone on to become leaders in the profession in their new countries. In fact this week another young podiatrist is leaving Johannesburg for Australia, another went to Canada last Christmas and another two also left for Australia in 2007 whilst yet another relocated to Saudi Arabia (Hopefully this is only a temporary posting).
Fortunately there are some of us left in South Africa, mostly in private practice, but there are more posts being created in the State Health Services, including the Military, with students having to work back their bursary committments. As yet there is no requirement for podiatrists to do Community Service, mainly it seems due to the lack of available supervisors and posts. If and when Community Service becomes a requirement, podiatrists are well qualified to perform an important role in the management of foot problems associated with chronic disease and more importantly I think those affecting children.