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.

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.

Traction Apophysitis-feedback

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