Verrucae are caused by the human papilloma virus (HPV), which commonly infects the skin. It affects the lower layers of the skin and causes a change in the growth pattern of the skin which results in a small tumour. However, this tumour is BENIGN!
Traditionally, podiatrists were taught that verrucae affect the younger patient, but it is quite clear that they can affect any age group. I have recently treated a 70 yearold lady!
Warts occur on any part of your foot and even under the toe-nails. They also appear differently as they develop. Often starting as a small puncture mark they can develop to look like a cauliflower growing in the skin.
Plantar warts are the most common – that is on the sole of your foot – growing anywhere, including on weight-bearing areas, where they are really painful.
Diagnosis is a big problem, podiatrists believe that many hard corns are misdiagnosed as plantar warts – with resulting surgical excision – which is wrong and leaves painful scar tissue in many cases.
Recognising clinical appearance is very important and difficult. Although it starts as a small spot, later the skin striations are usually pushed aside in a wart. The growth looks like a cauliflower, with black dots in the middle. Often there is a group of them, not just a single growth. They can grow on any skin surface including the knees and hands. Pain like a pin- prick is common on pressing and also throbbing when the foot is lifted off the ground.
Treatment is variable! Some of us will freeze with Liquid Nitrogen. We also use Acids in pastes or solutions. Excision is the last resort (in my opinion), but electro-dessication under local anaesthetic does work. Although you have to get used to the smell of a bad braai whilst doing this treatment! The dead tissue always needs cutting off. This is not usually too painful.
Plantar warts are my worst nightmare and I tell my patients that I call them “reputation ruiners”, because they can take weeks to clear and often new ones grow during treatment. They also spread quickly in boarding school and some families – and sometimes they don’t!
That’s traditional treatment. If you don’t like the sound of it try some ‘home remedies’. Rubbing it with liver. Kissing a toad. Rubbing with various medicinal herbs (this works). Shouting at the moon, or finally, hoping that the Golden Lions rugby side wins one game in next years Super 14 competition!
So what to do
Chilblains are associated with cold winter conditions, often worsened by wet weather.
So as I go off to the Cape for a few days I’ll give you some suggestions to protect against ‘winter feet’.
Chilblains affect all age groups and both sexes, but girls and women do seem to suffer more.
Keep your feet warm and dry. Avoid socks with synthetic fibres, that can make your feet sweaty and cold.
Some modern fibres ‘wick away’ sweat, but you can get cold. Try a pair of mohair socks – Visit the Cape Mohair website.
If you are sitting for some time, try wrapping your legs in a loose-fitting blanket(think of the bottom of a sleeping bag).
Do wriggling and waggling exercises to keep the circulation moving in your leg muscles. Don’t sit for long periods, because if you have a sluggish circulation it makes it worse.
STOP SMOKING! The spasm or constriction of your blood arteries from ONE cigarette lasts 6 hours.
Take regular walks in well-fitting shoes. Tight shoes press the blood out of your toes. Thicker sole are important to protect your feet from the cold and wet. Boots are good but high fashion ones often don’t keep your feet warm.
Chilblains are the result of a defective response to a cold stimulus. For example: when you take the chicken out of the deep freeze, the nerves in your fingers send and receive a message which causes the nerves to the blood vessels to shut down to protect the fingers from the cold.
When you have the chicken out on the kitchen worktop and you are back in the normal temperature the reverse messages happens, and you get a bit of a tingling feeling as the blood flow returns to normal.
If this system has a delayed response – for whatever reason – the fingers remain cold, because the blood is lacking oxygen. Soon the body recognises this as abnormal and tries to fix it with an inflammatory response.
This can settle things with just a little swelling and pain in the fingers, but usually this process ends up with red, painful, swollen fingers, which look like cocktail sausages.
In some cases, this process is the result of a significant vascular disease, for example – Raynauds Syndrome(or Phenomenon). If you suffer from this you will know and should be havinr treatment – it is characterised by spontaneous spasm of the blood vessels of the hands – where you get an unexpected cold finger or fingers, at any time of year, but especially in winter.
Treatment for chilblains is difficult and usually centres around prevention. Shoes, socks and footwear as I have said.
There are some medicines prescribed by doctors called Vaso-dilators, but often topical preparations such as Thrombophob or Reparil Gel are tried.
Some Homeopathic preparations include Vitamin A and Nicotinic Acid which act as circulatory stimulants. Getting into a warm bed helps – but don’t sleep with your feet up against a hot water bottle!
As I write this in Hout Bay, I’m happy to report that it has been a beautiful sunny and dry day.
Take care of your pair. No more smoking. Regular exercise. Keep chilblains away this winter.
Heel pain as a result of [Traction Apophysitis->@case-histories] is usually debilitating. I wrote about this on 3 April, 11 February and 8 February. The progress report and full case history is now on the website under [Case Histories->]. Although this section is of greater interest to other health professionals, have a look at the X-ray pictures.
They were reported as normal – we could debate that – but what IS important is the improvement in the state of the bone after 3 months of care.
Today’s Foot Health Awareness Tip: Avoid Baby Walkers.
Children will decide to walk independently when their bodies are able to. Baby walkers place extra stress on joints before nature intended. In addition they cause the foot and lower limb to move in an unnatural walking pattern.
Research has shown the use of baby walkers is associated with a delay in normal walking and activites such as standing and crawling.
Their use is best avoided – they are banned in Canada.
Source: Children’s Feet. Gordon Watt. Lecturer in Podopaediatrics, Glasgow Caledonian University and Consultant Podiatrist, Royal Hospital for Sick Children, Glasgow. Society of Chiropodists and Podiatrists, UK.
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.
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
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.
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.
Babies do not need footwear. Anything that you put on a baby’s feet will constrict and damage it. Don’t be persuaded to buy ‘pram shoes’ they should be hanging from the rearview mirror of your car!
As children develop they are all action and this is part of the normal growth pattern so it is essential that they are allowed freedom of movement at every opportunity.
There can also be damage from clothing that we put our babies in. Romper suits (called a Babygro when my children were small) are often too small or tight and restrict the very important kickiing activity the all growing babies need. In South Africa there is a trend to cover babies when in the pram or stroller. DON”T. Any covering that reduces the normal developmental reflex movements will cause harm. Those beautiful knitted bootees from Aunty Tshidi – watch them – they must allow the wriggling, growing toes to keep doing just that.
If you look at ‘pram shoes’ you will see very little of their shape matches the baby foot, especially at the toes wher usually they are too narrow. It could be the equivalent of you or I wearing a shoe one size too small. Even the fastening around the ankle, although it may look OK has the potential to press into baby’s foot.
During the first 6 months total freedom should be the aim. This allows the unhindered development of the neuromuscular responses. Just take a moment to look at the feet of the newborn and infants before they start walking. What you will see is a range of curling, wriggling, turning in and out, twitching and so forth which need to bee allowed without being enclosed in footwear of any sort.
Barefoot is best. Loose covering obviously to keep warm. Yes keep the sun off, but don’t constrict the feet. Throw away the ‘pram shoes’n the only footwear you need for babies is bare skin.
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
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.