A publication from the new journal: Advanced Research on Foot and Ankle
Advanced notice of my latest academic publication is accessible to all by free download. Do experienced students do better than novices? Do nurses do as well as podiatrists when looking at lesions? Can classification be used as part of teaching OSCE’s?
In this paper I have explored an old classification system and asked experts to make a comparison with unskilled and semi-skilled students.
The key to this new original research questions the use of classification methods without considering reliability and the value of narrative called the ‘Descriptor.’ The sensitivity of the descriptor in the hands of experienced clinicians can make a difference to the most appropriate decision making.
The revised system from the same author came from a number of pilot studies in 2013 and 2014 and was then to put forward through an ethics committee. Fifty-five podiatry students and 20 nurses volunteered to test the system. Contrasting the old paper (above-click the link) maybe useful for educationalists as there has been a gap of 33-years. Much has changed include podiatry and methods. The 1985 demonstrates how far the profession of podiatry has travelled as it is more a historic reference to the old journal style from the Society of Chiropodists.
Podiatry is about foot health and what was seen as cosmetic approach to hard skin management can harbour greater sinister influence in affecting patient mobility, pain and walking comfort.
Although it is only part of the conclusion, consider the value behind classification of skin lesions applied to tele-medicine. The need to speed diagnosis. Obtaining access to the correct clinician is vital for expedient treatment, especially where approval is blocked by a healthcare provider based on lack of evidence or cost effective benefit. This classification can aid assessment and hopefully support clinical triage – and at its bassist, who gets treated first!
When we cry out for more educational models in podiatry or even dermatology, this new system might be worth looking at. Patients who might wish to read the different grades might even attend clinic or ring up and say,
‘I have a grade 2 callus and I think I need an ultrasound?’
Medicine and health is more about sharing healthcare with the client. We are the resource they are our customers.
This paper support my previous paper which considered observation with photography published in October 2017. A further paper is planned on the effects of debridement. Sign up to receive my regular news feed. ‘Subscribe me. I am a podiatrist’ to firstname.lastname@example.org.
Forty years on this July I first embarked on a career in Podiatry, so this year is special to me.
No-one makes a successful career without benevolence from other sources. We owe much to those who gave their time freely for little recompense. This was in part due to a medical profession who transferred their confidence to a disparate group of men and women back in the seventies. The part that USA podiatry played cannot be ignored, and today we see our US cousins still making the same journey to the UK to lecture, only now to see a stronger profession.
Following the successful podiatric surgery conference in March in the West Midlands, I am pleased to pass my second article on for those signed up – In the Shadow of Hippocrates. A book in draft that gathers dust and charts my past, but too effervescent to publish in its original form. Not least it runs to 300,000 words! Maybe one day it will come out, but, in the meantime I pay tribute to colleagues sadly passed and those still working who made a difference to our profession, and not just in foot surgery.
Wishing you all a Happy Easter holiday…
One of the most difficult actions to take is how much to put in and how much to remove when changing from one professional occupation to another. I sat down with my website designer yesterday as Spring heralded a fresh season ahead and discussed the needs of the website consultingfootpain. I am very pro-patient focus for podiatry but also feel it is essential to meet the modern needs of colleagues delivering information. My view takes the angle do a little well than a lot badly.
There is so much development in podiatry and there are pressures to stay ahead of the game, but we must build on what we do well and know works. So, anyone with a view should let me know, write to me as Busypencilcase_rcb@yahoo.com so I can take on board new ideas and areas that podiatrists or patients feel should be represented. You can fill in the box below as well. Patients are more empowered than ever before and the idea of providing edited information is anachronistic.
Podiatry – a profession to be proud of
The College of Podiatry (London) represents the largest group of podiatrists in the U.K. Their database known as PASCOM-10, an audit system originally developed in 1997 (PASCOM-2000), has gathered on-line data for the last 8 years (mainly for podiatric surgeons) but reached an impressive 100,000 patients this week. The database is possibly the largest database held anywhere covering the specialty of podiatric surgeons and is used to capture the benefits of treatment amongst patients with foot health problems. While surgery has been an important component, the high risk foot has equally developed a significant contribution to preventing limb amputations and early loss of life, especially from chronic arthritic vascular conditions and diabetes. The latest Government working party paper on focusing on healthcare manpower recognises that podiatrists within the National Health Service have fallen amongst recruit numbers, and yet their contribution to foot-care in the UK is paramount to maintaining mobility amongst the population for all age groups.
Dealing with pain, skin damage (tissue viability) and deformity rank as the key contributions to the foot health of the UK nation. British podiatry is probably able to provide a wider service than any other podiatry service in Europe. The growth of muscle-skeletal services within the NHS has combined with other groups such as physiotherapy and orthopaedics. Working together with other groups in multi-disciplinary teams has become an important development for British podiatry in the last 10 years.
The top ranking podiatric conditions seen by those centres audited by PASCOM-10 includes hallux valgus (bunion) at 32%, followed by hammer toes (23%) and then arthritic stiff toe joints (11%). Ingrowing toe nail only ranks no.5 at 4% providing a strong suggestion that other conditions are considered more significant and referred to podiatrists by GP practices in the UK. In 1989 majority of surgical management by podiatrists involved ingrowing toe nails and simple skin conditions. The College formed in 1987-8 after an amalgamation took place of the different groups of podiatry professional bodies now has some 10,000 members within the professional body known as The Society of Chiropodists & Podiatrists. The profession continues to develop more treatment programmes for a wide range of groups. The organisation’s website feetforlife.org provides more information about UK Podiatry.
Fascination with typed words
At 9 years-old the fact that my words could be typed up by my Dad’s secretary was a pure delight. The script was a play based on ‘Green Acres’, a new 1965 U.S. sitcom about a farm.
My play was silly, as was ‘Green Acres’, and short, but then it was written as a class project for our drama session with my influential speech and drama teacher, as unlikely as her name was – Paddy Field. She was my inspiration into adulthood. I loved her for boosting my confidence when speaking in public something I was to need in adulthood.
Six pages of neatly spaced script looked impressive on A4 paper. I waved them proudly at the friends I had selected to be in MY play. The only other play that day had been hand written, so mine looked more professional in the eyes of a child.
Today I am still mesmerised by the appearance of my own typed script. Today, typewriters seem destined for museums rather than the slick word processors we all have. Set on pristine 80g white paper, I waste time ogling my words as they appear spurred on by the intermittent drone of my HP printer.
The subject matter is more serious these days. My affection for the sight of printed words has not diminished, but my memories of that wonderful lady never fade. Share thoughts of someone who influenced your early life.
As a child of the late fifties I had my feet measured with loving care. It was an independent shoe outlet called Pomfret’s. As the years went by the father moved on and left it to his son, a smart forty something with tight but neatly creases trousers, and sharp pointed slip on shoes. By the time I finished my education as a podiatrist the grandson has taken over and John, like his father spent more time in the small box office with glass window.
Originally x-rays had been installed for measurement but concerns over radiation exposures were rectified and the standard slide measuring scale was used instead. One recalls the simple actions of the fitter. The foot tickled as the heel hit the back plate. Then a further sensation was noted as the yellow tape enwrapped the foot to achieve the width measurement. The smells of the shop, new leather and busy activities as my mother and I watched John Pomfret climb wooden steps, 12-foot high, to reach a green box imprinted with Clark’s name on the top. Invited to walk around the shop or take home on ‘approval’ was how the final decision was made.
Returning as an adult and now having to pay for my own shoes, plus tax, I selected a pair I thought were ‘podiatrically’ sound. Overconfidence and not a little arrogance allowed me to buy a pair that were too long. I never returned the shoes but decided I was clever enough to adapt these with an insock and tinkering in the orthotics lab at college. That was a big mistake and a serious learning curve.
Podiatrists should have a love affair with shoes and take a broad attitude to their patient’s attitudes toward style and suitability. In reality footwear can and does cause many foot health problems, and like my self-styled fool of an expert, patients and the public will settle on footwear because passion overrides common sense and impetuous decisions ignore practicality. My shoe fitting knowledge came from our trip to Clark’s in Somerset where we were instructed in the practicalities of shoe fitting. This led to a greater understanding about manufacture, while the adaptations needed for shoes came from a senior lecturer with a wealth of knowledge called Mr England.
Wandering into a Clark’s shoe shop in Taunton this year I recalled my love affair with Clark’s shoes over a span of 50 something-years. Ironically Taunton was in Somerset, home county of Clark’s. I have tried many shoe designs during my life and reliability is a hallmark I am prepared to pay for. The anatomy of a shoe is best learned by dissection and our students were given this exercise when I was tasked to teach about footwear as a lecturer in podiatry in the eighties. My post-graduate education at the California College of Podiatric Medicine, San Francisco expanded my knowledge, not least in the market of sports footwear at a time when running had taken off big time.
As I surveyed the shop’s offers during the post winter sales, I found a shoe I liked enormously. The tall shop assistant was very pleasant but gone were the days of the family business and personal touch. Modern shoe shops, and I include most brands, no longer exude the passion I would so much like to see today. Shoes, like glasses are vital pieces of apparel and like tyres on a car bestow comfort, warmth, safety as well as practical style to match daily clothing needs. The skill in fitting has largely disappeared for adults who are expected to say if the shoe is suitable or not. My assistant disappeared to find the right shoe partner. As she returned I looked at her and said,
‘I am sorry to have wasted your efforts. The foot is my larger foot and does not fit comfortably so the left shoe is not required.’
There was no doubt I was taken with the shoe, the colour and sensible design which would become a work horse. Common sense prevailed and I would have to scout around some more. As an experienced foot specialist my expectations are high in a market when shoes are so expensive. That said the cost of work-horse shoes are worth ever penny if they last and do the job.
David writes regularly as a podiatry author. You can read his Footlocker posts by clicking on the link below. Share ideas on foot related subjects and send a message to his e-mail address – email@example.com
Podiatrist on a bike
Podiatrist on a bike
I reflect on my winter experience as I zoom along the lanes near my rural home with the usual awareness of cold feet and safety as a cyclist.
Ben, as ever punctual walked in wearing his customary baggy grey shorts and worn out crocks with bare feet. Dressed for work as a carpenter and fitter, this alone would seem a breach of some kind of health and safety. Having known Ben for three years, he has carried out a number of projects, but those visitations in the winter where it was below 5 degrees amused me in his scantily dressed all-year-round clothing. He was even married in shorts he informed me, although they were a little smarter.
I make it a rule to avoid cycling in icy weather or where rain could cause me to skid. Kitted out with high visibility gear I contrast with Ben in my attitude to safety. Cycling at speeds of over 30 mph (50 kph) is not without its dangers in good weather, but here, in our rural area, products left behind by many four legged creatures build up with rivulets of water running down hilly lands adding to the effects of a skating rink.
Most of us do not need drugs to open up vessels in our legs and arms to cope with cold weather. The seasonal chilblains (perniosis) and chilling is something to be avoided of course no matter how healthy we are. Having had surgery on my left foot over a year ago I seem more sensitive to the effects of cold and again poor fitting shoes. Old wounds and scars are notorious for their sensitivity. As a cyclist, a pair of waterproof insulated socks, correctly fitted cycling shoes which clip into pedals and a neoprene overshoe form my overall foot protection. This keeps my feet dry, comfortable and warm when lower temperatures are recorded on my home digital meteorological box. Living near the sea I have to contend with wind adding to the chill factor so even when temperatures appear warm, the combined effects with cold can still act unpleasantly.
While feet have to be kept toastie during rides; legs, trunk, and head are equally important. Quality fitted helmets with head bands covering the ears or a ski mask are helpful. Goggles or glasses to protect the eyes and layers that are wind proof. Having tried to cycle when the temperature is below 5 0C (41 0F) half gloves leave the fingers exposed. Skin soon turns red with the cold air and the circulation shuts down to preserve the skin. Pain arrives after a few miles and so a quality insulated glove is vital.
Hands are no less important than feet. While I am not a long distance cyclist I will cover 8-20 miles in a single run, more for fitness than competition. Local cycle clubs comprise fit men and women riding in all weathers, their slim bodies and skimpy clothing makes me shiver. They certainly look better in Lycra than I do, but who cares when correct cycle clothing is vital to cut down wind resistance and maintain comfort. Men often wear shorts during the coldest period of the year in the UK and I do wonder how they cope, especially on long rides. Most cyclists that visit my practice do so for reasons other than chilled feet.
Cycle clothing is personal, but the one thing, usually common with all ardent road users is their attention to footgear and keeping warm. Ben appears to be wise about his safety, but then there is his glass eye – how did that happen?
David writes on Linkedin regularly as a podiatrist and for Podiatry Now. You can read his Footlocker posts by clicking on the link below and downloading a free booklet on chilled feet. Share ideas on foot related subjects e-mail address – firstname.lastname@example.org
The Chilled foot
Next month – Footwear can be Tricky
Many patients ask me why I ask questions about other parts of their body and what this has to do with their feet.
‘It’s my bunion, ingrown toe nail, heel I have come for!’
This is where I have to educate my patients to ensure they know as podiatrists that we take regard of their general health and don’t see just them as a pair of feet. It is not possible to isolate the foot from the rest of the body’s functions.
Majority of the time foot pain is relegated to the foot alone and bears little relationship elsewhere. As a foot surgeon who specialised in podiatry I know that medical problems affect joints, skin, bones and if I am to recommend surgery I need to take account of what is going on elsewhere. There are many examples that can be cited, from working out if some type of skin treatment or oral medication is causing a skin allergy in the foot, to whether some undiagnosed problem such as diabetes is likely to result in changes in blood supply to the foot or affect the quality of nerve sensation. I found it hard once to clear an infected wound on the foot as the patient had a bowel problem.
One thing I do know with some sadness is that there is greater pressure on specialists such as myself to consider areas of medicine often not spotted owing to brief GP consultations.
A lady patient in her late sixties presented to clinic and it was only through testing her blood that the true diagnosis behind her rather red face was revealed. She had a rare condition caused by clumping of clotting cells. Had we performed surgery this could have had fatal consequences around the site of her tourniquet ( and of course limb) or to the serious effect the general anaesthetic would have had on her oxygen supply to the brain. One might have found this information in the GP letter. However the greatest surprise was the fact her husband was a medical doctor and had missed the signs.
I have spent most of my career telling patients that I am not a medical doctor but when the chips are down there is no side stepping where responsibilities are starting to lie.
I strongly believe it is not so much the doctors at fault here but a system derived from a political will to make health savings and changes with unforeseen consequences. Mind you, as a podiatrist what do I know about politics let alone medicine!
Neuroma pain can be debilitating
It is tough to decide what to do when you have a medical health problem that you yourself specialise in. Sometimes common sense goes out the window especially when one regards advice to patients as sensible and practical. Of course patients should listen to your very word. So, how was it I failed at every point to deal with my Morton’s neuroma? This is where a particular nerve branch in the foot is trapped between two bones – metatarsals, then thickens. The effect creates abnormal nerve messages. For podiatrists and Podologues, orthotists, orthopaedic surgeons, physiotherapists this would be well known and of course interests a number of groups of health care workers.
Orthoses were my fall back and they certainly helped more than I imagined. One day I was cycling and I could not believe the pain I was experiencing. Something inside snaps and you realise you are now the patient and need to do something.
I deal with heaps of metatarsalgia in practice and now have chalked up forty years, with thirty as a podiatric foot surgeon. If anyone should know what to do it would be me. I arranged a steroid injection and was shocked to see this last 48 hours – if that! I headed up to my radiologist and had an ultrasound. Seriously I was now some five years on with this problem which initially was mild. This was daft, why had I not done something before?
‘Yep, there is is,’ Dr X-ray said.
‘Looks like a bursa, but then it could be a neuroma.’
I knew it was not synovitis and indeed the ultrasound confirmed the joint was unaffected. Ultrasound is the first port of call for a diagnosis and in my clinic used before an injection. The learning curve started again…
“you are never too old to learn and learning should never stop”
An appointment through my GP saw a referral to a good colleague (Mr Footman) 180 miles north of where I lived. Pre-admission checks followed and surgery was scheduled just before Christmas so I could complete my own work load commitment. I came around from the anaesthetic and Mr Footman appeared, plastic container in hand. A white piece of tissue bounced up and down like a shake up ‘snow globe’.
‘Pretty large Dave, one of the largest I have seen!’ he said.
Post-operative blurry eyes could barely make it out as I reclined sleepily back on the bed. So that was it. My neuroma was gone. My experience in the post-operative recovery period had just started and this was one encounter with medicine and surgery that was unpredictable. I broke many rules but made many discoveries. It was then that I decided to write a book – my journey.
‘Prepare to Limp’, was the title. That soon went by the wayside and talking to a good colleague we hit on the title Morton’s Neuroma. Podiatrist Turned Patient: My Own Journey.
The range of material available to the public was poor on this condition, most, dry as dust. Surely I could bring this alive s
omehow? The patient experience or journey needed to be broken down into manageable, bite-size chunks; facts brought together in one place. All specialists, and by that I mean people who offer surgery, will provide information in the form of factsheets. Some are wonderfully presented and, when concise, helpful – but many are woefully brief or too simplistic and omit often needed detail. I believe patients understand more than we give them credit for, and many facts are obscured by medical jargon. Phrases such as ‘informed choice’ are considered modern, but deeper down being informed can only happen when everything is fully comprehended.
My decision to emphasise the ‘impact’ of treatment for Morton’s neuroma is related to a greater demand placed on the treating clinician to clarify aspects of treatment, once taken for granted. Healthcare professionals do not intentionally hide facts, but the downsides of care have to be balanced with the benefits.
I sat down and rattled off the first draft in May 2017, having carefully kept a daily log, now at five months. I deliberately held off trying to write before.
Writing is not a quick pastime if you want to do it well. My last efforts took four years to write 2 textbooks. At the time the internet was not exactly accessible in the way it is today. The 25,000-word marker came up and I stuck there with six chapters. By the time my copy editor came on board and colleagues had an opportunity to hack at it, seven chapters emerged.
Today, as I write this piece for LinkedIn I am pleased to see my book lodged on the wonderful world wide platform – AMAZON – 25th November 2017.
Two learning curves emerged; information for patients by a real patient and foot specialist and secondly, a how to do an e-book publication. A new world appears before me with exciting opportunities. There it was, my book with a professional cover and the customary blurb. I hope it helps patients. For me this was a cathartic experience.
Published as a Kindle publication through Busypencilcase Communications Ltd
A condition called COALITION
A recent enquiry dropped into my post bag. A woman contacted me on behalf of her partner. There seemed to be some frustration as he had received an NHS consultation and wanted to consider private care. It was clear from the information that his health was not tip top but he also had a rarer condition called a coalition. This is far removed from any political group you may have heard of, although the bony bond leaves the foot, and generally the ankle, stiff.
Private or NHS?
There is a pretty straight forward rule as far as I am concerned and that is if you have to pay for something without insurance cover there maybe no endgame; the cheque book might be left open. Coalition can be fixed but like many complex foot conditions there is no assurance all will work well. The NHS may be the better place if you have the right surgeon.
Given that the ankle has two joints (actually three but let’s keep it simple). The foot bone is connected to the leg bone around a joint up and down movement (talus), and the heel bone (calcaneus) being connected to the ankle bone (talus) providing sideways and spiral movements. The two taken together make sure we can walk on even ground safely and smoothly.
A joint should have a space, but with coalition that space is taken up by a bridge of bone crossing the space, preventing movement. The bridge of bone is also called a ‘bar’ and depending where it develops, the joint affected can stop important movement. When the ankle complex is affected it has a knock on effect back up the leg, so the knee, hip and back seem to be affected because the smooth transmission of movement stalls.
There are 2 main types of bar affecting the ankle; talo-calcaneal coalition or the calcaneo-navicular coalition. The first is more difficult of the two coalitions to treat as the ankle won’t move much from side to side, or will be painful during activity. The stiffening effect means the mechanical efficiency around the ankle is reduced. Not all foot surgeons treat this problem as surgery is complex and recovery can be longer than usual.
Diagnosis is important as all ages can be affected from teenage upwards. Computerised scanning is important either by CT or MR scans. Conservative treatment will depend on how stiff the ankle has become and if other problems co-exist.
While I no longer undertake surgery for this problem, I do not mind seeing patients but would not mislead patients that my consultation would lead to direct intervention. Your surgeon should be trained in this type of surgery, have extensive foot and ankle experience and ideally be a member of the British Orthopaedic Foot and Ankle Society. Currently few podiatric surgeons are offering such treatment in England so a specialist foot orthopaedic surgeon is best depending upon the area you work in.
Often the only way to resolve the bar is to remove it as in the calcaneo-navicular bar or coalition, or to make the joint stiff by surgical restriction (fusion) depending how affected the joint is. Ankle injections should probably have been offered before surgery. There is a case for special orthoses to be considered which may help, but examination is important to work out if this has any benefit.
The best aim:
- correct diagnosis – confirmed by special x-ray
- conservative care – injection / orthosis
- Assessment of medical conditions to consider risks
- surgery: talo-calcaneal coalition (better resolution) or the calcaneo-navicular coalition (more complex) because ankle joint stiffens completely and fixation materials can be a problem