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.  

The perils of self treatment

If you have a sore tooth you see the dentist, if you have an eye problem you make an appointment with your optician. So why is it that when it comes to our feet we often neglect or treat them ourselves. 

It's often said we take our feet for granted. Let’s face it, without our feet in good shape just think about how miserable daily life could be. Unfortunately, this message still struggles to get through to a large proportion of society. There are a number of reasons why patients don't seek professional help sooner. Some people think the problem will get better by itself, some people don't even know they have a problem. Occasionally, some people feel that they can manage problems by themselves. 

This image is of a patient who self treated plantar warts using vinegar, garlic and duct tape. The result was a nasty irritant contact dermatitis. Given that plantar warts are generally painless I know in this instance which one I would choose- self treat or see my podiatrist. Podiatrists are lower limb and foot experts and as far as health care goes, private podiatry consultations are some of the lowest costing and best value for money consults available. Typically, appointments can last for up to 30 minutes and more in some cases. The cost of treatment remains relatively low so we would urge anyone with a foot or lower limb problem to speak to your podiatrist in the first instance and not to self medicate or treat without getting the right advice first. Whether its a typical skin or nail problem or a pain inside your foot or limb, they really are the experts with the deepest level of understanding when it comes to injury, diseases affecting the feet and anatomy of the lower limb. 

Pick up the phone and make your appointment with your expert today.

Leg cramps or something more?

Peripheral vascular disease

With peripheral arterial disease (PAD), also called peripheral vascular disease (PVD), deposits of fat build-up in the arteries restricting the blood supply to the leg muscles. This process is called atherosclerosis.

PAD is more common with age and affects around 1 in 5 over 70s. Men tend to develop PAD earlier than women.

AD may not cause any symptoms, but can cause pain in the legs when walking over a distance.

Complications of PAD include heart attack, stroke, or critical limb ischaemia (CLI) where blood flow to the limbs is severely restricted. In these cases patients may have breakdown of tissue, wounds which won’t heal or ultimately gangrene and tissue death. In some cases this can result in amputations. That’s why its really important not to ignore symptoms in the leg and foot. Your podiatrist is best placed to advise you if you have concerns.

Other PAD symptoms

• PAD pain can often be mistaken for something else.
• Other signs and symptoms of peripheral artery disease include:
• Wounds that heal poorly
• Legs are cooler than the arms
• Shiny or ‘waxy’ skin on the legs
• Some say loss of hair on the legs
• Decreased pulses in the feet or pulses which sound abnormal under doppler examination
• Leg ulcers
• Brittle toenails

PAD diagnosis

Your podiatrist should ask about PAD symptoms, carry out a physical examination and may measure the ankle brachial index (ABPI). This is done using a handheld ultrasound probe to measure the blood pressure at the ankle and upper arm. A difference in the readings may suggest PAD.

In some cases a referral to hospital may be needed for further testing. Tests include ultrasound scans or angiograms of the legs to pinpoint blockages in the arteries.
Causes of peripheral vascular disease

The most common type of peripheral vascular disease is peripheral artery disease.
Peripheral artery disease is due to atherosclerosis. This is a gradual process in which a fatty material builds up inside the arteries. The fatty material mixes with calcium, scar tissues, and other substances and hardens slightly, forming atherosclerotic plaques. These plaques block, narrow, or weaken the vessel walls. Blood flow through the arteries can be restricted or blocked totally.


Other causes of peripheral vascular disease include:

• Blood clot: A blood clot can block a blood vessel (thrombus/emboli).
• Diabetes; Over the long term, the elevated blood sugar level of those with diabetes can damage blood vessels. This makes the blood vessels more likely to become narrowed or weakened. Additionally, people with diabetes frequently also have hypertension/ high blood pressure and often hypercholestrolaemia (high fats in the blood), which accelerates the development of atherosclerosis.
• Inflammation of the arteries: This condition is called arteritis and can cause narrowing or weakening of the arteries. Several autoimmune conditions can develop vasculitis, and, as well as the arteries, other organ systems may also be affected.

• Infection: The inflammation and scarring caused by infection can block, narrow, or weaken blood vessels. Both salmonellosis and syphilis have been two infections traditionally known to infect and damage blood vessels.
• Structural defects: Defects in the structure of a blood vessel can cause narrowing. Most of these cases are acquired at birth, and the cause remains unknown. Takayasu disease is a vascular disease affecting the upper vessels of the body and affects (usually Asian) females.
• Injury: Blood vessels can be injured in an accident such as a car crash or a bad fall.

People who have coronary heart disease or a history of heart attacks or strokes generally also have an increased frequency of having peripheral vascular disease. It’s important to remember that only about half of the people with peripheral vascular disease have symptoms. Almost always, symptoms are caused by the leg muscles not getting enough blood. Thats the cramp like pain people get in the calf muscles when walking, or as we call it, intermittent claudication. Whether you have symptoms depends partly on which artery is affected and to what extent blood flow is restricted.

The most common symptom of peripheral vascular disease in the legs is pain in one or both calves, thighs or hips. If you have cramp like pain in your legs when you walk and feel the need to rest frequently to get the pain to subside you may have a blood supply problem.

If you are concerned about any of the points we’ve talked about you should have this assessed by someone who is suitably qualified. Certain podiatrists or your GP should be able to help. We use doppler and blood pressure measuring equipment at our clinic and can advise and assess your vascular status if you are worried.

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.

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.

Hitting the nail on the head

So many people are horrified at the thought of toe nail removal. Well they shouldn't be! Nail removal is not the horrible thing people imagine it to be. Some people still describe and worry about an old fashioned procedure called the zadek's procedure. This involved cutting the toe to access and destroy the nail growth source. This procedure is not commonly used today and having nail surgery is not how it used to be.



Suitably qualified podiatrists are experts in nail surgery and can remove problem nails with minimum discomfort to the patient.

These days nail surgery is carried out under local anesthetic. If you haven't had this before, at the dentist for example, it means that the area where the podiatrist will work will have no feeling while the drug is having an effect meaning you feel no pain - whatsoever! Importantly, it may not always be necessary to remove all of the nail, and your podiatrist would only remove the minimum possible to give you permanent relief from the problem.

Once the nail has been removed, a chemical called phenol is applied. This helps to destroy the nail matrix to ensure the chances of your problem nail growing back are kept to a minimum. 

Please don't worry about nail surgery. It's quick and  relatively painless. If you have nails which have repeatedly ingrown speak to us today to see if you and your nail could benefit from nail surgery. If you have any questions about nail surgery, like who can do it, what’s involved and how long it will take to heal, call us today so we can advise you and if appropriate arrange an assessment for you.

Diabetes and your Feet

A busy week at the clinic!

We see our fair share of diabetic patients at the clinic most weeks. Sometimes the patients we see are not so sure about just how diabetes affects their feet or just how important it is to have regular foot checks.

So we've put together a few points that everyone should know about diabetes, in plain english so that everyone reading it can understand.

The first thing to note is that diabetes is generally split into two groups called type 1 and type 2 diabetes. Treatment guidelines have changed of late and many people who would have been considered type 2 diabetic now use insulin as part of their treatment plan.

Diabetes is a condition resulting from either, the absence of insulin in the body to help break down and use glucose from the blood, or having some insulin but having too little or poor quality.

Diabetes can have serious implications for your feet and legs. If you have poorly controlled blood glucose particularly over a long period of time changes can happen to the nerve and blood vessel tissues in your lower limbs. So what! you might say.

Well, if the nerve tissue changes and becomes less conductive, this is called peripheral neuropathy. Having peripheral neuropathy increases the risk of injury. Because the feeling can be absent in the foot injuries are common, although often the sufferer is unaware of injury to the foot. The result of this can lead to breakdown of the tissue, or as we call it, ulceration.

Ulceration is complicated because of the hardening of the arteries which is also caused by prolonged poor glucose control. Sufferers will lack the ability to supply damaged tissue with a sufficient blood supply. This prolongs healing, increasing the risk of infection and ultimately leads to gangrene and amputation.

Now heres the scary part...statistically, the mortality rate (chances of death related to the disease) is greatly increased if an amputation has been required. What we find is that, in general, because diabetes is a 'silent' disease', often without any outward signs, people either dismiss it, deny it, or just don't understand enough about it. It is that serious. Diabetes, if poorly controlled or neglected for periods of time can seriously impact on your foot health and ultimately lead to your premature departure.

Finally, the best way that you can prevent these changes happening for as long as possible is to maintain good blood glucose levels. What we mean by that is your average blood sugar levels. Daily readings will fluctuate, this is normal even in a person who doesn't have diabetes. The average blood sugar is measured by HbA1c. Because the recommended level can change sometimes there's little point in writing it down here, but we would encourage all patients we come across in the clinic to discuss their blood glucose levels with the GP. Ask the GP for your HbA1c levels, learn about getting it to the best levels you can, and finally, own your disease, take control of it, don't allow diabetes to control you, or to destroy your quality of life.

If you have diabetes and are worried about your feet, or if you have any other questions about your feet please contact the clinic to arrange your assessment today. We will be happy to advise you and to carry out your diabetic foot check.

For more information about diabetes visit http://www.diabetes.org.uk/