The awkward conversation

We need to talk.....about fees.....

 My first blog entry for a year, or over a year and its an awkward one. It's one that we need to discuss and one which I know frustrates a lot of my peers in the profession. 

Every couple of weeks or thereabouts I deliver a short talk to various community groups about podiatry, how it has changed and how it might differ from a pre-existing perception. Its fair to say that the feedback from the talks, which are generally to church guilds and woman institute groups, is good. They find it interesting and educational and perhaps even a little tiny bit entertaining. I demonstrate to them how things have changed and that podiatry has moved on. I show them some of the modalities at our disposal and the investment that a modern, forward thinking podiatrist will make. Shockwave therapy and ultrasound for example represent significant financial investment in order to bring services to the client or patient group. To frame that more clearly, a reasonable diagnostic ultrasound machine will set you back in the region of about £25, 000 and a decent patient chair to sit on.... anywhere between 2 - 5 thousand pounds. 

It wasn't until I read a facebook post a few days ago where someone talked about going to see a podiatrist for her heel pain which was so bad she could 'barely walk'. She went on to say.....'but its £36 for a 30 minute appointment and insoles on top of that at £45......that's pretty expensive". 

Of course 'expense' is a subjective thing. But therein lies the real problem. Its not the price, or the expense of an item or service. Whats is wrong with this statement is that the lady completely misunderstands the difference between 'price' and 'value'. What is the cost of pain relief in any case? What is the limit that a person is prepared to pay? And scratching further beneath the surface, what price do we place on the skill of the clinician. And now, were getting down to brass tax. 

Think for a moment, if you will, about your washing machine at home, just as an example. It breaks down, but you need it! How will you wash your laundry. It's a household essential. You go online and start looking for the engineer in your area. They agree to come out to see it but you have to pay a call out fee. Typically anywhere between £50 - 90. Once he gets there you'll be billed for the parts he needs and the time spent to fix it. So where are we, £120 - 150? 

Fees for podiatry treatment remain among some 

of the most modist private healthcare fees with 

a national average of around £40. 

Now just hold that thought, and add to it the statement ' I can barely walk. I am in so much pain - but the podiatrist is ...well pretty expensive'. 

Podiatry forms one of our greatest yet most unsung allied health professions. I admit we have a massive identity crisis facing us. One which we are desperately trying to move away with the perceptions of old. Having to justify the clinical skills and re-enforce daily, hourly perhaps in some cases our entitlement to charge fees for our skills and the services we deliver. We are often asked or expected to do work for free, albeit mundane, simple foot care tasks. But how insulting is that. Would any other professional person, whose invested time and money in a university education be expected to work for free?  

There are many examples and parallels that can be drawn, much like the washing machine engineer, the hairdresser being another favorite that springs to mind. But I will resist, because this was never supposed to be some kind of rant. It is, however,  important to talk about the difference between 'price' and 'value' and the overall attitude that we have towards our health and well being. When the skills of the tradesmen (no disrespect to them of course they too, are skilled), are valued greater than those of the health care professional who, within their armory can remove pain, prevent falls, educate and ultimately improve the quality of your life, I suppose in much the same way clean clothes do.  

Pain in the Butt? - Piriformis dysfunction for amateur/professional athletes.

Piriformis dysfunction for amateur/professional athletes.

This week Mr Frazer Donaldson gives us the lowdown on an all too common problem, piriformis dysfunction.

Frazer's primary interests within Foot Medic is biomechanics and sports injury. His passion for both functional anatomy and problem solving  make him an outstanding sports podiatrist.
 

Read on to find out what exactly the condition is and how you can prevent and treat it.

The piriformis is a flat, pyramid-shaped muscle that lies parallel to the gluteus medius muscle's back margin and underneath the gluteus maximus muscle in the hip area. The piriformis laterally rotates the femur with hip extension and abducts the femur with hip flexion allowing body weight to shift to the other side when walking in single limb support. However when the hip is fully flexed to 90 degrees or more piriformis does the opposite function and internally rotates the femur. And the function during walking is primarily to externally rotate the leg at late stance to allow the foot to ‘lock’ making it a rigid lever.  

So basically it is an important muscle in how your hip moves when you walk and move!

In terms of activity, ie; Running, the piriformis plays an important role in the various rotations of the hip and can commonly be injured or through weakness/tightness to the area cause knock on effects elsewhere ie over pronation due to a poor ability to externally rotate at late stance phase (weakness) or supination of the foot through stance phase as thee leg is too externally rotated (tightness).

As the muscle runs adjacent to the sciatic nerve the symptoms often include:

1. Shooting pain/electric shock
2. Some numbness/tingling sensation
3. Dull ache across the mid portion of the glutes during or after exercise.
4. ‘Trendelenburg gait’ whereby during walking there is minimal support to the opposing swinging leg causing instability. Julia Roberts has it don’t feel bad!
5. Over pronation of your foot or flat footed-ness (weakness)
6. Supination of the foot (tightness)

Symptoms can be due to tightness or weakness of the muscle or poor stretching before and/or after exercise.

You’re local Podiatrist should be able to assess weakness and tightness, however if these symptoms compute to your own it is important to stretch and strengthen the muscle. RICE therapy (rest, ice, compression and elevate) should be applied post exercise or when most painful) As well as this ask to be assessed for other foot conditions and review footwear and orthotic options.

STRETCHING

Sit on a normal chair and cross your left foot on to your right knee, then slowly lean forward, with a straight back, and hold for up to 60 seconds. Complete stretch daily on each side, repeat more frequently pre and post exercise.

 

INCREASE TONE & STRENGTH

Lie on your side, bend your knees and put your feet together. Keeping your feet in contact, lift your knee, as shown above as high as you can very slowly and hold at the peak for 3 seconds then bring your knees into contact again. Repeat 15 times on each side daily. It is important to maintain strength in the muscle even if there is no weakness especially athletes or runners.

For more information on foot conditions why not try out our fantastic, free new web application by clicking HERE!

Shin Splints - A Runner's Curse

The problem. 

Shin splints are an extremely common problem particularly in runners who are increasing their mileage or those who have just started to run. Shin splints are a soft tissue injury where the muscles that control the slow lowering of you foot at each step  (deceleration) and also help to maintain the longitudinal arch of the foot are under severe pressure from the increased, repetitive strains placed upon them.

The two main muscles involved are tibialis anterior and tibialis posterior. Most soft tissue injuries are caused by the structures either being too weak or too short to do the job you're expecting from them. So by increasing your mileage the likelihood is they're going to start to break down.

Each bone has a covering called periosteum. This lining can become inflamed in relation to the injury, this is called periostitis. Many podiatrists and other healthcare professionals see this as a precursor to higher levels of injury such as tibial stress fractures.

Can you still run if you have shin splints? 

If you MUST run, you should do so on a treadmill with a slight incline. This will work better for you as the forefoot has less distance to travel from the shin on landing and the forces will be reduced through your deceleration. Don't run downhill, this is likely to aggravate the problem. Run for 5 minutes, stop and stretch, always remember to do stretching, not strengthening at this point. Repeat the process 5 or 6 times while you have little or no pain. As you progress you can start skipping your stop intervals and be able to run for extended periods.

If, after following this advice you still experience shin pain, you should consult with your podiatrist. If you have had another from of injury it is important to rule out other causes.


Stretching. 
Assuming your pain is shin splints and hasn't developed from a problem in the bone itself, you should get great results from following these easy stretches for tibialis posterior and tibialis anterior. You should also consider 'foot control' and rule out a biomechanical factor in your symptoms. Prescription orthotics can help in many instances with range of motion limitations and other functional anatomy problems.

Don’t Be Embarrassed About Feet Urge Podiatrists

Feet are one of the hardest working parts of the body and in a lifetime you will walk in excess of 150,000 miles which is about five times around the world. As a result, foot problems are common and if untreated can cause discomfort and wider health problems.

As part of its annual Feet for Life month in June 2013, The College of Podiatry ilooked to raise awareness of common foot complaints. The College is encouraging people to become more foot aware and not be embarrassed about seeking help where needed.

Some of the most common foot problems that can cause embarrassment include foot odour, verrucae, corns and callus, fungal infections, ingrowing toenails, bunions and cracked heels.

“Our feet are one of the most neglected parts of our body, but it’s important to keep an eye on them and to know what’s normal for you so you can spot any problems. Feet are not supposed to hurt so if you do experience ongoing pain then you need to have this investigated. Don’t be embarrassed about seeking professional help, it’s a podiatrist’s job to treat feet so there will be nothing we haven’t seen before. Follow our tips to spot some of the symptoms of common foot problems so you don’t have to suffer in silence or hide your feet away in the summer!”

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Common foot problems

- Foot odour: to keep foot odour at bay, wash feet at least once a day and dry carefully between the toes. Wear clean socks made from at least 70% cotton or wool. Alternate shoes daily to allow them to dry out. If odour persists try an antibacterial soap.

- Verrucae: a verruca is a type of wart that looks like a small, dark puncture mark in the early stages but later turns grey or brown. It’s contagious through direct contact. You can buy over-the-counter remedies from your pharmacy; ask for products with salicylic acid. If at any stage your verruca becomes painful and the surrounding skin goes red, stop treating immediately and see a podiatrist.

- Corns and calluses: corns and calluses occur as a result of pressure on the foot. Corns appear over a bony prominence such as a joint and a callus usually occurs on the sole of the foot. Do not cut corns yourself and don’t use corn plasters or paints which can burn the healthy tissue around the corns. Commercially available cures should only be used following professional advice. Calluses can usually be kept at bay by using a pumice stone or non metal foot file gently in the bath.

- Fungal infections: fungal infections such as athletes foot can lead to intense itching, cracked, blistered or peeling areas of the skin. If left untreated it can spread to the toenails causing thickening and yellowing of the nail. Fungal infections are highly contagious so avoid handling and do not use the same towel for your feet as the rest of your body. You can buy over the counter remedies but nail infections do not often respond to topical treatments so you may need oral medication. See a podiatrist if your infection persists.

- Ingrowing toenails: ingrowing toenails pierce the flesh of the toe and can be extremely painful and lead to further infection. They most commonly affect the big toenail but can affect other toes too. To reduce risk use nail cutters and cut nails straight across and don’t cut too low at the edge or down the side.  If you have an ingrowing toenail, see a podiatrist who can remove the offending spike of nail and cover with an antiseptic dressing. If you have bleeding or discharge, you may require antibiotics.

- Bunions: a bunion is a condition where the big toe is angled excessively towards the second toe and a bony prominence develops on the side of the big toe. Contrary to popular belief, bunions are not solely caused by shoes. They are caused by a defective mechanical structure of the foot which is genetic, although footwear can contribute to a bunion developing. Some treatments can ease the pain of bunions such as padding in the shoes, but only surgery can correct the defect. To avoid exacerbating a bunion, try not to wear narrow shoes with pointed toes. If you experience frequent pain, see a podiatrist.

- Cracked heels: cracked heels can be extremely painful and occur where the skin has become dry or has experienced excessive pressure. To prevent them moisturise regularly and use a pumice stone or non-metal file in the bath or shower. If the problem worsens see a podiatrist as some severe cases can require strapping of the cracks in order to allow the feet to heal.

Shin Splints / Medial Tibial Stress Syndrome

Shin splints are the runners curse. They can strike you down whether you’re a serious runner or an amateur trying to increase your mileage. Hopefully you can find some useful information in our latest blog on this common and painful problem.

Shin splints occur for a number of reasons which include, over use of the muscles, increasing an exercise program too quickly, not cooling down properly after exercise, and in some cases, excessive pronation. The pain is associated with inflammation of the interosseous membrane, the origin of the muscles between the tibia and fibula in the lower leg.

You can help heal shin splints by following this advice;  

     

1.          Rest your body.  It needs time to heal. Unless you provide the conditions and time for the structures to mend you could turn a small problem into a chronic one.

2.         Ice your shin to ease pain and swelling. Do it for 20-30 minutes every 3 to 4 hours for 2 to 3 days, or until the pain is gone. In addition to ice you can also alternate between hot and cold therapies. This way the heat will help the blood flow to the site and aid repair, while the cold therapies will reduce the inflammation. Never apply ice directly to your skin, always wrap it in something to prevent cold burns.

3.         Use Anti-inflammatory painkillers. Non-steroidal anti-inflammatory drugs or NSAIDS like ibuprofen, will help with pain and swelling. These drugs can have side effect so if you have ever had a problem taking these before consult your doctor or podiatrist first. Ibuprofen is not recommended if you have asthma.  Do not use these for prolonged periods.

4.         Orthotic therapies and prescription devices. Orthotics can help support the structures within the foot and correct misalignment problems. Often with shin splints there may be a biomechanical cause. It is important to rule this out in order to provide the best management.

5.         Range-of-motion exercises. Your Podiatrist can advise you on exercises. Remember to do your achilles lengthening and heel raise exercises.

6.         Neoprene sleeve or compressional socks, like those used by runners to support and help keep the muscles around the lower limb warm.

Sharp, shooting pain? do you have a Morton's neuroma?

Sharp, shooting pain, tingling, numbness and dull ache are all typical descriptions of plantar digital neuroma or morton’s neuroma as it is more commonly known. A morton's neuroma is a common pathological condition caused by a benign neoplasm of the interdigital nervous tissue. In other words an inflamed bundle of nerve tissue. This results in the tumorous growth of the perineural tissue,

resulting in fibrous lump. 

As the lump grows it articulates with the metatarsal bones which lie each side of it, this causes a number of painful sensations. Neuroma most commonly occur in the interdigital space of 3 and 4, although not exclusively. 

Medical imaging and in particular ultrasound scan is

by far the most diagnostic test but this is not readily available, however there are a few simple tests a podiatrist can carry out to help establish a cause of pain. 

At foot medic we will formulate short and long term treatment plans for our patients who have neuromas. We will relieve the pain in the short term by using various padding and strapping methods. In the long term we may recommend orthotic therapies.

Steroidal anti-inflammatory injections are useful but not permanent. When conservative management fails surgery is an option, but always as a last resort. If you have foot pain that you can't explain call us today or go online to book your appointment. 

Do you have diabetes?

We are pleased to announce that from today we are now offering a FREE diabetic foot health check service. 

The Service is completely free, with no obligation. If you would like to know more about how diabetes affects your feet please see our earlier posts about diabetes. As part of your FREE assessment we will carry out a full sensory neurological examination of the feet and advise you of our findings. We will also advise on risk to your feet specifically associated with any pathological changes that we find. 

If you're a diabetic sufferer and would like to take advantage of the service, simply call us at the clinic on 

0141 5623082 or pop in if you're passing.

Over pronation

In keeping with the idea that we're going to update you with things we see, we thought this was appropriate.

Some people get very excited when pronation gets mentioned. First of all lets clear up a few things.

Pronation is normal.

There....we said it.

It is a normal movement which allows your foot to adapt and subsequently allows your body to pass over the top of it in order for you to take a step. To clarify, pronation and supination are normal movements which occur around primarily one joint although others are involved. Biomechanics is a complex discipline and this isn't a lesson in biomechanics, but just to clear up some issues we've been asked about over the past few weeks.

While pronation is normal, a person can have an excessive amount of pronation. In lay terms, this is where the foot 'rolls' in too much during gait. The image shows a person with substantial excessive pronation. This places stresses on the tissues of the foot and limb that they were never designed for and in some cases can lead to pain and discomfort. Interestingly though, some people who have excessive pronation report no symptoms at all. The reasons behind this are still unclear.

Biomechanical evaluation will help a podiatrist determine the cause of your pain or discomfort. He/She will assess your foot structure, how it moves and importantly the rest of your leg and body. Podiatrists will look at how you move in general looking for tell-tale signs of a problem such as head tilt and spinal curvature along with hip or knee misalignment. By forming a complete picture of your non-weight baring function combined with a gait analysis they will formulate a clear picture of why you feel the way you do.


In some cases, the use of orthotic devices can help. Sometimes clients think this means they will need to spend lots of money. This isn't always the case. It is true that having something made for you, in the form of a custom or bespoke orthotic device will be more expensive than a mass produced device. Here at the clinic we would only recommend a custom insole if we believed it was the appropriate treatment. Even then, the choice is yours. Various prefabricated devices are available and prices will vary. We always explain the range of options available along with the pro and cons of each device.

Some research shows that in some cases, prefabricated devices work equally well as custom devices. It is important to note however that this doesn't apply to every case and indeed in some cases, the best option will be to have an bespoke orthotic made.

If you have a painful condition such as shin splints, plantar fasciitis or any other foot or limb problem a biomechanical assessment could reveal the causes behind the pain. Treatment with pain killers and anti-inflammatory medication is effective but does not address the cause, they merely treat the symptoms. Orthotic therapy directly influences the cause.