Kameeldoring tree:A rare Bush injury?

Walking in the Bush can be one of the joys of living in Africa. However, it does have its drawbacks apart from the animals you may encounter!

Last week a young man came in as an emergency, telling me that whilst walking in the bush, a thorn had gone into the inside of his left ankle. The thorn was removed completely and initially there was no pain, but about 4 hours later it was excruciating. The thorn was from a tree called in Afrikaans Kameeldoring, one of the Acacia species, certain of which are poisonous.

A local Doctor prescribed antibiotics for 10 days, but now, the foot was still very painful and only relieved by taking an anti-inflammatory every 8 hours.

Examining the site of entry(parallel to the ground and straight into the medial malleolus – that’s the lump on the inside of your ankle), – there was no inflammation, but lower down towards the arch there was some swelling and inflammation.

Standing on tip-toe was painful so initially thought of damage to the Tibialis Posterior Tendon. However, the pain was described as …”burning and running over the bridge(arch) of my foot.” As I palpated down the foot towards the sole, it was possible to create the pain, which also went “into the foot”.

A Sonar scan was ordered which showed some fluid collection around the tendon when compared to the right foot. No other pathologies were detected, such as a foreign body, thrombus, tendon tear etc.

So what is the provisional diagnosis? Possible trauma to the Tibial nerve. The diagnosis is based on the nature and site of the pain described, plus the fact that the Tibial nerve runs in the area where the thorn penetrated the foot. For the time being the treatment is local ice and continue with the anti-inflammatory.

Heel Pain and Plantar Fasciitis

Over the past few weeks, I have seen an increasing number of patients of all ages  complaining of  Heel Pain – usually diagnosed as Plantar Fasciitis (PF).

The pain is usually persistent and occurs under the heel pad and around the heel. Often it only affects one foot, but after questioning and examination, they admit to “a bit of discomfort in the other foot.”

This extremely painful condition also called Plantar Fasciitis (PF), but strictly speaking PF causes pain into the arches and soles too, rather than just the heel.

In 1979, one of the founders of Podiatric Sports Medicine, Dr Steve Subnotnick, devoted an entire chapter to heel injuries, in his book Cures for Common Running Injuries. He was probably the original ‘running foot doctor’ when the surge in road running began to take off worldwide.

Tell me where it hurts!

The pain is usually worse in the morning when taking the first few steps and then gets less with continued movement. This pattern is repeated if you sit for a while later in the day – say in a meeting, classroom, lecture or tea-break – and stand up to walk again.

Patients always point to the exact site of pain. This is right in the middle under the heel pad. On the inside (very common) or outside of the heel and at the back.

Why does Plantar Fasciitis hurt?

Overuse is the phrase we use to explain PF! It’s a bit like saying stress. The basic cause is the malfunctioning of the person’s foot and lower limb structure, what we call your Biomechanics. The normal -for you – rocking and rolling movements are exceeded and the tissues get strained and inflamed at the very point where the plantar fascia is attached to the heel bone.

This can be caused by too much exercise such as increasing your distance and not getting enough rest. Changing the surface you run on; for example: running on a treadmill, starting running without the correct preparation, suddenly running more quickly.

Another common cause as we get older is being overweight.  Or a change of occupation where more walking or standing is required. Old worn shoes for day wear or exercise. Arthritis, a pinched nerve. All these and many more causes need to be identified.

How do you treat Plantar Fasciitis?

With difficulty to be honest! You must let your podiatrist see a good selection of your shoes. Frequently we can provide relief from the symptoms by padding, taping and some anti-inflammatories.

The basis of treatment is the biomechanical assessment to identify what goes on as you walk/run. Orthotics may be necessary, but current therapy is team-based,  so I might send you to a Physiotherapist or Biokineticist for strengthening of other muscle groups in your body.

We talk of core strengthening, to improve posture and alignment above the lower limb. If the pain is at the back of the heel gentle stretching plus raising the heeel helps. Nearly always lifting and cushioning the heel gives some relief. Wearing a higher heeled shoe also helps sometimes.

Can I avoid  it?

Yes, but not always. If you can diagnose the problem yourself then stop doing what caused the PF. We often get heel pain on holiday after a day of sightseeing or playing on the beach or more likely shopping!

Never let your trainers get badly worn, especially if they bulge on the inner side. Keep your weight under control. If you know you are going to have to do a lot of standing or walking, consider wearing your more comfortable shoes and change into your fashionable ones later.

At the first sign of pain seek professional help and advice – a proper biomechanical examnation will identify whether plantar fasciitis is the problem. Remember the basic First Aid of treating any inflammation of the soft tissues of your feet.

• Rest;
• Ice;
• Compression;
• Elevation.

Holiday Foot Problems?

Foot problems can spoil our holidays, because they are so unexpected. If you click on Foot Health Articles on this site, you can get some tips on holiday care for people with diabetes, I also wrote about a patient who suffered a holiday foot injury when he fractured his metatarsal as a result of a swimming pool fall!  Also, check out the post on Holidays: Sore feet and sun back on 13 December 2008.

If you have been spending lot’s of time in the pool you might have felt your feet burning. Watch out for the surface of the pool – if it is a bit rough -rubbing the skin on your soles away. [This happened to a little girl I know recently]. You get red-raw skin because the protective outer layer is worn away. Just  treat the area with antiseptic and a plaster, to keep the ‘bugs’ out and avoid an infection.

You can get a similar effect after that first, long-awaited barefoot walk along your stretch of beach! Our feet are usually protected in shoes and the skin is quite soft; our soft city-dwellers’ feet  need a gentle introduction to the great outdoors!

Even regular runners can get burning soles after that early morning barefoot  ‘quick 5 kays’ along beach! So don’t be afraid to wear your tekkies on the beach.

Sunburn on the foot

Sunburn is probably the most obvious holiday foot problem. Mostly to the tops of our feet and the front of the ankles. Use a high SPF cream or spray and re-apply during the day and if you go in the water.

Shoe rubbing is very common on holiday, as we spend more time in sandals. So look out for pressure or friction points that cause blisters – often made worse when there is sea sand added to the mix.

If you are somewhere exotic this New Year, try not to let sea anemone spines, puffer fish or jelly fish spoil your fun – but  who really sees them coming anyway?

Then there are always the snakes! Whenever you go into potential ‘snake- country’, think ahead and be prepared. Make sure at least one person in your group is equipped to deal with a snake bite.

Unfortunately, this time year produces a number of common injuries like cuts from hidden glass and metal, plus aches and pains from too much walking, golf or frisbee! So don’t worry too much about that new heel pain, achilles tenderness or arch pain. It should settle down – if not – see a podiatrist.

The same goes for that itchy rash – could be fungus!

However you celebrate the New Year – from where I am, I’ll get a free fireworks show on Kleinleeuwkoppie at Hout Bay, courtesy of Sol Kerzner – I wish you and your families all the best for 2010.

After A Fall, Don’t Ignore The Pain

At the end of last week, a 60-something lady was brought to me complaining of a very painful ankle, three weeks after she tripped and fell whilst walking in the Bush.

She was uncertain which way her ankle had bent when she fell, but said there was a lot of swelling and bruising, which was only now starting to go down. Whilst in the Bush she had managed only basic First Aid with a bandage, to keep the swelling down so that she could get her foot into her trainers, but walking was extremely painful.

During my examination I isolated a point of severe pain over the tip of the lateral malleolus. [That’s the bit of your fibula that sticks out on the outside of your ankle joint]. The area was also swollen and hot to touch. Moving the ankle caused pain and the lady walked with a stiff-legged limp. The provisional diagnosis was to eliminate a fracture as the ankle joint is very stable and usually the injury in these situations is of severe ligament damage. However, because of the local symptoms I was thinking fracture. The obvious thing to do was send for X-ray.

The X-ray report confirmed a fracture of the tip of the fibula bone, only slightly displaced, fortunately. However, perhaps more importantly, the radiologist reported the appearance of ‘low bone density’ and therefore the possibility of osteoporosis.

The lady is now wearing a “Moonboot” below knee walker – with some difficulty – and was referred to her GP for investigation into the low bone density, which is now underway.

Now I know this isn’t really podiatry, but when questioned further, before I referred her, the lady revealed that she had never had a mammogram or bone density test. These tests are as important for older women as the prostrate examination is for men.

So if you have a fall or trip, don’t just put it down to a sprained ankle and put up with pain; monitor the pain, bruising and swelling. Also, ladies, don’t wait for the next time you need an X-ray to check your bone density.

Remember:  podiatrists don’t just treat feet, we treat people.

You may also find these articles interesting linked to osteoporosis and bone density loss.

• Women not getting bone treatment (news.bbc.co.uk)
• Coeliac bone loss link uncovered (news.bbc.co.uk)

Interesting cause of Heel Pain

Heel pain can be a really crippling  problem at all ages and especially for adult males. I have recently had an email from a 60 year old man complaining of heel pain. 

He described “sharp shooting pains in the left heel area. Usually when it comes under tension – even slightly, say from bending at the waist – or on impact – even the slightest.”

He went on to explain the pain as “odd, insignificant, but very sharp when it occurs.” He had only become aware of the pain in the past few days and said that the only change of habits was that he had started doing quite a lot of swimming. He didn’t indicate that he had had any injury.

My first thoughts were a series of questions:

 – “Do you have any lower back pain?

 – “How strong are your abdominal muscles?”

– “Does it come on spontaneously when sitting in the car or at the computer?”

– “Do you have any residual joint damage from sports injuries or osteo-arthritis?”

Shooting pains like this are usually associated with nerve entrapment,  pinching, or tight muscles like the hamstrings. At this age, osteoarthritis of the spine is a common cause. However, in this case, I suggested that the pain could be associated with the new range of movement since he started swimming.

Treatment for heel pain, begins with trying to find the cause, including the possible underlying cause at this age of being overweight, with a protruding belly! Not so in this case. Bearing in mind that this was an email communication and the symptoms were clearly described, I suggested the following:

• Start by gently stretching your lower back when lying on your back on the floor
• In this position, with knees bent and feet flat, roll gently side to side, all the time pressing your lower stomach into the ground
• In the same position, curl your knees up to your chest
• Another fun exercise is to kneel on all fours; extend your left arm out in front and your right leg out behind you; hold this for 10 seconds and change sides!
• A Physiotherapy consult is advisable at the same time

A few days later, the gentleman diagnosed the problem as tension-related. He actually tried a rather risky move – “I can provoke sustained pain by crouching and then arching my back to put the whole back, rear leg muscles under tension.”

 Luckily he was able to get up from this position, not call the Fire Brigade to lift him up and take him to hospital!

There is no apparent foot problem of pronation or flat feet, so it does sound like a nerve – related problem.

Then out of the blue, another man of similar age visited the practice with similar symptoms. By me moving the foot into certain positions that stretched his lower back, I was able to reproduce the burning, shooting and tingling pains he complained of.

Doing some research on heel pain reveals many causes; nerve entrapment is one of the more difficult to diagnose.

Undiagnosed Achilles Tendon Tear

When an Achilles tendon ruptures, the patient may tell you they heard a sound like a gunshot and they cannot walk, but with an Achilles tendon tear it is still possible to walk around without knowing your injury.

This week a lady consulted me complaining of pains at the back of both heels and into the calves, which had been there for more 6 weeks. She experienced aching, throbbing and a stretching sensation, especially in the evening. She felt less pain wearing higher heeled shoes. In addition, the pain was worse when she got up after sitting for some time.

There was a history of a right ankle fracture and some persisitent left knee pain. She  also told me that she had been diagnosed with calcaneal spurs many years ago. The lady was overweight and of short height.

During my examination, I could see and feel that both Achilles tendons were swollen and had nodules in them. Her walking stride was short and stamping. There were other significant biomechanical problems too.

Temporary treatment consisted of  in-shoe wedging. I also referred the lady for an ultrasound scan of the Achilles tendons.

Two days later the scan reported the left tendon as having “….an almost full thickness intra-tendon tear ……approximately 2.8mm thick, extending 30mm longitudinally.” On the right “……loss of fibrillar pattern, consistent with fraying.”

There were other features, but this was one lucky lady, because there could have been a rupture at any time. This time she was referred to an orthopaedic foot surgeon.

So whether you are a patient or podiatrist, when managing chronic pain at the back of the heel, consider the benefits of ultrasound scanning to assist in diagnosis and always act quickly, you might discover an Achilles tendon tear.

Prevent a fall-visit your podiatrist

Many older people suffer a fall with consequent injury such as a fractured  shoulder, wrist, hip, ankle or foot. In the UK there is an active falls prevention initiative, promoted by the National Health Service.  Not so in South Africa, although we are aware of the problem.

Have you ever thought how the state of your feet could contribute to a fall? Podiatrists should be  involved in preventing falls and your visit to one could help to prevent one.

Hazel Tomkins, a British podiatrist, writing in Podiatry Now has detailed how your feet can cause a fall.

So, if you want to stand on your own two feet here’s what to look out for.

Any corn, callus, ulceration, painful nail condition alters the way your foot hits the ground. This usually makes walking uncomfortable and unsteady. With age, the cushioning fatty pad on the soles  of the feet thins out – giving less protection to the bones and joints underneath.

Changes to the basic shape of the feet alters the ability to walk evenly. Often the cause of these changes is reduced muscle strength. On the other hand, any change in posture – quite common as we age – is associated with weakening of our muscles, so there is the potential for loss of balance or unsteadiness.

Watch out for changes to the length of your legs after hip or knee replacement surgery. The pain has gone but you really do need to do all the physiotherapy to restore muscle strength and balance.

At the same time there are many changes to hearing and eyesight which affect the ability to balance and see clearly what is going on around us.

If you have any nerve changes associated with diabetes (neuropathy), you are disadvantaged, because you have a reduced ability to respond to the sensory stimuli around you. On the other hand, arthritis can cause deformity as well as stiffness, making movement difficult, slower or unsteady.

Research into barefoot walking showed a 19% worse performance when barefoot compared with even a least unstable shoe. Going barefoot or stocking feet dramatically increases the falls risk.

Simple you might think, I’ll wear slippers or shoes. Well this is an area of some dispute. There is good scientific evidence that if you change to a lower or flat heel after a lifetime of wearing high heels, you have a greater risk of falling! At the same time there is research which suggests that the most important feature of footwear in preventing falls is the grip of the sole on the ground. Added to that is the need for good fit and thicker soles.

So what to do?

Keep mobile – exercise regularly – start walking, even if you use a walking aid. Maybe you need to start using one? Make sure that you can see and hear as well as possible.

A visit to a podiatrist for a biomechanical assessment is an important way to identify any underlying structural and functional problems. Treatment of any painful foot condition, such as corns and calluses, is essential and  information on the best shoes for you, will be provided.

Avoid higher heels, barefoot walking and slippers. Consider wearing trainers with a rippled sole. A word of warning though, some trainers have really ‘grippy’ soles and that can cause a fall!

Try to remove all loose carpet runners and potential hazards that you could trip over. Make sure the lighting in your home is adequate (most falls occur at home!).

It takes team work to prevent falls, so get any advice that you can, or share it with those who you know are at most risk of a fall.

Chilblains

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.

Traction Apophysitis and Heel Pain

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.

MAY IS WORLD FOOT HEALTH AWARENESS MONTH

Bunion Surgery – A Painful Choice

Deciding to have bunion surgery can be one of the most difficult health decisions to make. ‘Bunions’ are a cause of distress to many thousands of people -mostly women -worldwide. Last year, I wrote about bunions and my opinion was and still is – “avoid bunion surgery if at possible, unless it is ruining your life and crippling you with pain”.

The ‘bunion’ referred to here is the bony deformity characterized by a big toe that deviates towards the rest of the toes, possibly accompanied by a second toe which is bent and overlies it.

When any surgical intervention is considered, be it the podiatrist enucleating a corn, removing part of a toe-nail or the orthopaedic surgeon realigning the foot in bunion surgery, all of us strive to do our best to achieve a satisfactory outcome, by exercising our skills to the utmost.

So you can imagine my concern to have two patients recently complaining bitterly about their unhappiness with the result of their bunion surgery. Add to this my surprise at the ‘twenty-something’ who wants surgery because she doesn’t like the look of her feet and her bunion (this one is the small thickening of the metatarsal bone with no deformity), prevents her from wearing the high fashion shoes she needs for work.

What can you say to a middle-aged, active woman who decided to have her bunion (deformed type) corrected, but after three months can only wear trainers with the toe cut out, has a swollen foot, pain and discomfort, difficulty driving, plus all the associated emotional stress? Or how do you respond to a similar woman who is now in constant pain and has had altered her walking style because the foot is rigid at the big toe joint?

To the best of my knowledge the procedures were technically successful and there is no deformity anymore. In addition we all react differently to a surgical “assault” and time does allow better healing. Also, there are numerous variations of operations and techniques available for bunion correction surgery.

Firstly – go back to the surgeon and discuss your options.
Secondly – see if a podiatrist can assist with biomechanical correction or alignment and footwear advice.

With my 2 patients, one has had orthotics made and the other I referred to the surgeon, who has recommended further physiotherapy, with the possibility of another operation to remove the steel plate that is in the foot.

I will still refer patients who meet my criteria outlined above for consideration for surgery, because the final decision to undergo sugery is always taken by the patient. Unfortunately, there can be no absolute guarantees since the structure of each foot is so complicated.

So what to do about ‘bunions’? Is there an underlying systemic disease such as rheumatoid arthritis?

We must consider the patient’s age. Is the patient overweight? What is the biomechanical structure and function, not only of the feet but lower limbs and body? Have all possible conservative measures such as night splints, orthotics, insoles, appropriate footwear, been exhausted?

Be guided by the severity of loss of function, pain, discomfort and limitation of daily activities. Will the patient be able to adhere to all the post-operative requirements, expected by the surgeon?

Eventually, all these factors (plus others), must be seriously thought about before undergoing bunion surgery.