Diabetes, Dialysis and the Diabetic Foot: a timely reminder

On July 28 2008, on this website I wrote about Dialysis and the diabetic foot, with a description of a foot ulcer patient.

Last week I was invited to speak to patients of the Cape Town Dialysis Clinics about foot care; during my preparation I came across some startling evidence proving that dialysis is an independent risk factor for foot ulceration if you have diabetes and require dialysis.

We already know that impaired kidney function increases the risk of foot ulcers – also referred to in my 2008 Blog – but this 2010 research proves that:

If you have diabetes and are receiving dialysis, you are 5 times more likely to develop foot ulcers, compared to someone with diabetes who is not on dialysis.

Scary but true clear evidence from a study completed at Manchester UK.

The research showed that patients on dialysis have more nerve damage, circulatory problems and a history of foot ulcers and amputations.

There is a 25% lifetime risk of people with diabetes developing foot ulcers so the key issue whatever your status is prevention.

Diabetic foot ulcers have multiple causes, some are: external trauma from footwear, neuropathy, arterial damage, poor self-care, lack of access to care, poor treatment.

However, as with all research you must ask – “so what?” This patient group did not include any people of colour, so it may not apply totally to South African patients.

So what to do? our objective is always to PREVENT complications.

Every person with diabetes must have an ANNUAL FOOT EXAMINATION so that they understand their level of risk for developing foot complications.

in addition individual education on self management of their diabetes. this is a team effort, paying attention to cardio-vascular health, eyesight, footwear selection and fitting, foot biomechanics (and possibly insoles or orthotics), plus probably the most important factor – can you invest in the care being offered?

Always “take care of your pair”.

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.

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.

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.

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.

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.

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

Foot Fit for Voting?

Are you ‘foot fit’ for voting? On Wednesday of this week South Africans go to the polls to elect a new government. Foot fitness could be important since the process can involve many hours of extra standing or walking.

Here are a few tips to help you through the day!

Try to get a lift to the polling station – this reduces the walking you have to do.
Take a folding chair or sit on the ground if your feet start to ache.
Wear comfortable shoes with thicker soles – trainers or lace ups are best, because they can be loosened if your feet and ankles start to swell.
Don’t stand in one position for too long – move from foot to foot, wriggle your ankles up and down to keep the circulation going.
Bend gently from the knees up and down a few times.

If you have diabetes and reduced sensation take extra care that you don’t rub a blister from your shoes.

Start talking to the people around you – it helps to pass the time!
(Try to avoid talking politics!).

Have something to eat before you go to vote. (Voting on an empty stomach is as risky as shopping on an empty stomach!).

Sometime it’s a good idea to go later to the polling station, since everyone wants to get there early!

Above all do vote. Remember that it is a Public Holiday, so rush home and put your feet up.

Traction Apophysitis – progress report

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.