I thought we would dip into a clinic today as some interesting points emerged. Is this you?
Clinic was busy as usual but the common denomenator came from patients having metatarsalgia. This condition is akin to rheumatism as I tell patients – meaningless unless defined! Pain under the ball of the foot is not only common but complicated to diagnose. In a recent audit covering 6 years, metatarsalgia accounted for 1.9% of a podiatric surgeons workload. If this is specified to say one type, it jumps to 5.4%. This is not the only cause. Ben (53 years) was an ironman challenger and Mary (72 years) a part time fitness dance instructor. Both had metatarsalgia and seemed surprised that their foot problems had suddenly started to incapacitate them. Both were medically fit. It was time to have a philosophical discussion at the consultation.
So, consider a car in the garage, one that is taken out to the shops to make the weekly purchases and perhaps undertake a few other journeys. The car, no doubt well made, will go on for a long time, although doubtless will need a service and the odd part replacing. The metaphor for a car plays well to the analogy of the human body; the power house of people movement.
Jean, a third patient aged 42 said that she was told she had arthritis!
As medical disease had been ruled out arthritis was not the case. Her big toe joint was stiff and clearly suffered wear and tear. Back to the car. So is the car broken? No, it might be dented or scratched, but it can be fixed and go on for a few more years. I pointed out I do not like labelling people with arthritis for a single joint; one that is inevitably exposed to wear and tear over many years. The car as indeed the foot will go on but might not work as efficiently if pushed hard.
One day we might ask the car to do more than it usually does. At this point there is always a risk it may resent being pushed harder up the motorway than usual, or around a tight bend, or carry one too many sacs of cement. Ben was lean, Mary was just sensibly active. Tears in the fine lining of tendons and joint covering (capsules) leak out and cause swelling and pain. Ben was the Ferrari; highly tuned and but perhaps as an older model performed less well. Mary wanted a Ferrari for its extra performance. Her usually highly reliable car regaled at the continuous treatment.
Forgive the analogies but brand new cars age as much as we do. We have high expectations and for those of us 40-70 we believe we can pick up where we left off. I am not critical as I am the same. At 45 I pushed myself, became lean and dropped off pounds. My blood pressure was impressively low and my pulse a fantastic 60 beats per minute. Then – I popped my knee! At 57 I was on my third surgery (same knee) and can no longer run. My Ferrari is truly knackered ( a non medical term) and so when James came to clinic, on the same day as Ben and Mary, his tendo-achilles had popped up as a swelling. At 52 he was mortified as he wanted to keep up with his young daughter. As a professional comedian he had the right attitude and we went about fixing his problem, but I talked about the car again. Keep it there for high days and holidays and just cruise. Make sure you go out on safe roads and potter along letting the 25 year olds speed past. Tomorrow those same youngsters will be in clinic as weight gain arises and they seek youth once again. Sure we can fix things but do not have expectations that we clinicians can save you from age. Our connective tissue, that is the stuff that holds us together, is genetically programmed. Some parts will wear out sooner than others. So do please come to clinic and let us talk and be optimistic. Much can be done, but DO have realistic expectations.
All names used are anonymised.
In March this year I talked about shock wave treatment and the benefit for heel pain relief. This short case from Judith highlights that sometimes steroid injections fail and shock wave can indeed be successful. We certainly cannot promise any one treatment will benefit heel pain symptoms but it is encouraging that a non invasive option may make all the difference. Judith is a keen golfer and was desperate to return to her sport as quickly as possible. These are her own words…
“I suffered with dreadful Plantar fasciitis for around three months until the pain was so unbearable I could hardly walk.
After my first consultation with Mr Tollafield he suggested a cortisone injection unfortunately this was not successful.
He then suggested Extracorporeal Shock Wave Therapy (ESWT) which obviously is less intrusive than surgery.
After the first session there was a significant improvement, by the third treatment the pain was 3 out of 10 and it continues to improve. I cannot thank Mr Tollafield enough. I am now back playing 18 holes of golf three times a week.”
Judith – Lichfield (27th June 2016)
Other tips and personal views:
Sustained improvement can be helped considerably by stretching the heel cord tendon regularly and using orthoses. Please select Self Treatment for further information using the password provided at your first consultation.
Occupations that involve 8 hours standing or heavy use of the foot are at greatest risk in the 40-65 age group. Males and females are equally exposed. Although overweight patients suffer from heel pain, they are not exposed anymore than patients of normal weight when it comes to this unpleasant condition. Continuous pain, pain at rest or at night should not be ignored and professional advice sought. Oral ibuprofen or other NSAID (anti-inflammatory) medication should not be used for heel pain for longer than 2 weeks without further advice from a registered health professional.
Painful corns are more debilitating than many realise
When Cheryl had her surgery performed she had reached the end of her tether. I perform skin reconstruction on corns where there is a chance to achieve a good result. The main objective is to try to provide comfort and reduce the need for patients to have frequent podiatry (chiropody) where the skin is reduced often under painful experience. Cutting corns out usually fails but replacing the skin with a new fat pad taken from our patient’s foot can restore the damaged fat. I am grateful to Cheryl for recounting her experience in her own words…
“Okay so before I had this operation my life revolved around my foot as it was causing so much pain to the point of of changing how I walked & what footwear I could actually wear.
I have a physical job so on my feet all day plus 2 dogs that required an hour in the morning & an hour in the afternooon walk plus our holidays are walking holidays.
I had been receiving regular treatment over the past 5 years & although they couldn’t help permanently they did relieve the pain every 6 weeks. It wasn’t till 2015 that I actually found out that surgery was an option. I visited my GP about something else but happened to mention my left foot as by this time my right hip was aching which I believe was due to the way I was walking. My Dr referred me to Mr Tollafield.
Mr Tollafield explained everything to me regarding the surgery, the risks to the operation, the chances of success plus the risk of infection.
Once the operation was over I received great aftercare & clear simple advice to the aftercare that was required by myself once home.
For 2 weeks after operation I stayed in bed completely apart from toilet/shower.
3rd week – I went downstairs just for a few hours but wore the boot provided.
4th week – short walks to the local shop with boot & crutches provided.
5th week – Boot off and was able to drive (phew)
6th week – Back to work
Since my op, which I took 6 weeks off work due to my profession as I do think if I had an office job I would have been back sooner but my foot has healed well, no infections & its comfortable. Every night I put bio oil on my foot & I wear a gel metatarsal strap whilst I’m at work.
So…was it worth 6 weeks of no income?…it so was….I can wear high heals again (yay) so my outfits do not work around what simple shoes I can wear but more importantly my day to day working life is pain free & on a happy note my dog walks are not confined to fields now ..the canal tow path is no longer my enemy but an enjoyment once more.
So if your reading this …GO FOR THIS OPERATION …”
Ask for my brochure by contacting Spire Little Aston Hospital; Geraldine 0121 580 7302 or e-mail firstname.lastname@example.org
Most of us are unaware that even when we sustain a small skin injury, the skin around the wound alters in many ways. After surgery it is not unusual to experience such colour changes. Bruising arises from escaped blood content which can migrate to the heel, arch, and may appear well away from the site of surgery. There is no need for concern, bruising will soon disappear. What may not disappear so quickly is the general redness, or even purple colours. This can vary during the day, after rest, or even after having a warm shower or bath. The healing process is complex as there is mass disturbance at all levels. The colour reflects the state of the small vessels (capillaries), the larger conducting blood vessels – arterioles or arteries, which change diameter through reflex controls. While cold makes the skin pale or blue, and heat makes the skin darker or red, after surgery the circulatory status is temporarily altered for months, not just weeks. It is a reflex because we have no control. The reason is associated with a need to carry nutrients (good) and waste products (bad) to and away from the surgical site.
Much can be done to improve the colour, which on occasion appears alarming. Drop the foot down and the colour will change dramatically. Elevate the limb, and ‘bingo!’ the foot colour improves. Rest and elevation are important during the first week after surgery, but as comfort returns, exercises in the form of muscle pumping are valuable, and not just to prevent a venous blood clot (DVT). Once the wound heals we can then start massaging the foot, compressing the soft tissue forcing the fluid back toward the ankle to be carried away by the lymphatics and veins. The use of regular (three times a day) massage with a suitable cream or Bio oil will help the scar and the foot return to normal faster. I had to become a patient to learn this trick from a good physiotherapy colleague. Massage and careful exercise following surgeries will not only improve the colour but discourage the unwanted reflex causing uncomfortable sensations after foot surgery.
Val writes this month about a useful disability aid where complex foot surgery might impede early mobility. We are reminded mobility is important to reduce stasis induced types of deep vein thrombosis, prevent muscle atrophy and bone wasting, but above all keep the patient psychologically stable. Immobility and lack of engagement soon leads to low esteem and of course puts those pounds on. Crutches and Aircasts (T.M) are valuable, but with larger surgeries, where aids are essential for the first few weeks, a different system is recommended. For hire, to buy or go second hand. The patient has complete control with brakes, a basket to carry necessary items and uses the normal leg and foot to propel the small buggy, carrying the body weight safely and preventing unnecessary loading of the healing foot. Anyway, here are Val’s words…
“Hi, I am Val
I recently had a major foot operation carried out by Mr Tollafield. He recommended The ‘Stride-On’ to get around on. It is like a scooter but you put your knee on. It is very easy to use and was a life line. Highly recommended. Thanks Mr Tollafield.”
V.F 5th May 2016
Tel No. Stride-On 01823-216202 Croydon, United Kingdom (Website – Strideon.co.uk)
This month I wanted to feature a little more about heel pain. Previously in March, I discussed common heel pain known as fasciitis. Heel pain can become more resilient to treatment and if an injection fails it does not mean that all injections are bad, or should not be attempted. Outside the specialty of foot experts, the so called Triad Heel Pain is not well understood, so here is a brief but important overview.
On the inside of the ankle, that is the point under the ankle bones (tibiae) a thick nerve is routed into the foot where it divides. Close to this run two sets of veins which network with a strong artery. Just to complicate matters three major tendons run down the same anatomical space. We call this space the Tarsal Tunnel. As with any major road, many roads branch off. The nerve has branches and these run through muscles where they are both protected, but also supply muscles. So we now have a picture of many different anatomical parts, nerves, veins, arteries, tendons and muscles. If the nerve (tibial) is trapped pain can shoot not just into the foot, but also the heel. If the tendon lining is torn inflammation pressure builds up in the tarsal tunnel. This causes pressure on the nerve. In some cases veins strangle the nerve causing pain especially on activity. As activity increases so does the fluid and with this comes increased pressure. I refer to this as a Triad (threesome) until I know exactly what the problem is. Some types of imaging tests like MRI and ultrasound can be helpful, sometimes I use a nerve conduction test. A carefully placed an injection of steroid into the region which can help reduce the inflammation, but, sometimes surgery is necessary to release the pressure. This is known as decompression.
If the tendon alone is affected this may lead to Post Tibial Tendon Dysfunction. This can cause TTS, but in most cases this can be managed conservatively. What you need to do is ask someone to undertake a careful tarsal tunnel examination exclusion test.
What to look out for?
If you have a foot which burns, feels tight and toes tingle, with or without heel pain. If the front of the feels as though it will explode with pressure then be sure to have a consultation with someone who knows feet. You will know because the more you exercise, the worse it becomes. At the end of the day it probably is not TTS, it could be post tibial tendon dysfunction, but that is another story.
This month I consider an excellent forum debate in the March 2016 edition of Podiatry Now. I know for the patient that this is not accessible but it is worth focusing on the subject of heel pain, often attributed to fash-eee-eytis and sounds confusing. Four podiatrists were asked 10 questions. With such an expert body, this provides a great piece of information for patients. I thought it worth summarising and putting in my own 2p.
Heel pain is represented by a wide range of symptoms as colleagues suggest. Fasciitis is key to heel pain although we are trending away from the term, even though it had a happy following. The fascial band runs from the heel to the toes and acts as a strut. A strut is a support but it is also an important method to absorb shock when the foot contacts the ground. By the time we reach 40 years of age we are susceptible to tiny tears in this band which project into the heel and arch of the foot. This inflames the heel pad which in turn becomes congested. I call it repetitive heel pad strain, but fasciosis is an alternative name. There are others but I won’t list them all. The curious fact pointed out by the experts was that although much research exists, there are still many things we do not know about the condition. The early morning heel pain and the pain after a long day’s work, especially after rest, is classic. I took a look at our data base with 70,ooo patients and was able to review my own data and those of my colleagues. For the most part these were actually podiatric surgeons and not generalist podiatrists. We have 354,491 different contact events recorded so this gives good numbers, many connected to conservative treatment. Nationally for heel pain we record 489 cases since 2010 which broadly represents 1.3% of foot pain. So, in the big scheme – small. My data shows 191 representing 7% of my case load who present with heel pain. It is good to know your own figures and this is why many, but not all, audit their work.
Are we any good at treating fasciitis? (Experts were asked). Well as it happens yes pretty good. All experts reported success by various methods, many without surgery. There was one niggling point though. It was clear most had not had experience with surgery or even some newer methods so one expert panel member was right, we do need more information. Academic discussion was inconsistent across this panel probably as each had their own approach and felt this worked. However, and here’s the rub, not all mentioned the period of time when action is most successful. So, the baseline is if it is treated early, success is better. Injections have a mixed view and I liked comments about the shock wave treatment. I use this at Spire and suggest 55% success to patients. If we are going more scientific the range is around 33-90% which means some better than others. Call me a cynic but when we talk about foot mechanics we need to be specific. I don’t buy into flat foot (pronation) as the key to the cause, but I do believe the nature of the band which is integral with the delicate heel fat pad, and easily damaged. This means soft structures are exposed to forces which cause deterioration. Think very broadly of a rope that looses some strands and stretches and eventually weakens. These bands actually do snap occasionally, often with a resounding thump. Steroids give a very good chance of full recovery but should not be repeated in the same location if the first fails.
What about diagnostics? Imaging is helpful. X-rays are limited unless there is a known injury. Forget the spur, it is usually irrelevant. My last spur surgery was carried out sometime in the early nineties! Don’t go there. Ultrasound currently is the favourite diagnostic and my colleague in our radiology department at Spire, Dr Ali Mehr, is a big proponent of this when managing heel pain because it shows the band and the thickness measured. Once the band is shown to be 4mm above, I can usually not only determine the correct foot which hurts but justify treatment. MRI is okay and has a place. Blood tests are pointless and who wants a needle and Dracula to have a go when standard tests are unreliable. Of course a medical picture might suggest an inflammatory musculo-skeletal disease; that’s joints and muscles to most of us. I usually get my rheumatology colleagues to take a look here if I am concerned. If you have heel pain look for fascial pain associated with chronic repetitive heel pad pain first.
What about surgery? I realised the experts were more into conservative care and hence may have not been so clued up about surgery. I do around 20 cases a year I thought, but even I do not do as many as that. Since 2010 = 38. If I didn’t audit I would have been wildly out. This means I do not carry out surgery routinely – but it has a place. Since 2010 our national audit shows 176 surgeries performed in our field (not orthopaedics). So given this represents some 30 podiatric surgeons, I do more surgery than most maybe?
The small incision which on the side is hardly visible. The band is released then has to be stretched by exercise. Our physios at Perform help the rehab brilliantly. You can walk after surgery, but I recommend resting for 4 days. Risks – these are minimal, although I have seen someone with some numbness in the toes afterwards. I can only account for one patient not doing well after surgery so on the whole, where heel pain is 1) unresponsive to treatment 2) has been present for more than six months and meets criteria from (1) then surgery is an acceptable choice and viable option.
When you had heel pain, what did you do? Yep I too have had heel pain. I was 45 and decided to loose weight and hit the dreaded treadmill! Bad idea before I had become accustomed to exercise. The 22 year old who played rugby forgot how age creeps up. I used a heel cup called a Tuli heel cup, and a 3/4 length orthosis (cheap over the counter type) and it went. Bear in mind I started treatment at a week and experienced great success. The experts are right – go for mechanical devices aimed to help reduce foot strain. When you hit six weeks and the GPs approach…yes ibuprofen, fails, OR your stomach bloats and gives you acid reflux, so go to someone who knows how to give a steroid injection. I mean someone who does this all the time and uses the right needles, AND dare I say, knows the foot intimately. Pain killers work for around 48 hours; NO improvement, move on. Local anti-inflammatory gels, try them but you probably won’t experience much improvement.
In rare instances heel pain is part of another problem. I will deal with this another time, but heel pain triad syndrome is not so well recognised by many people who should know this. I will cover this another time. Look out for posterior tibial tendon syndrome and tarsal tunnel.
If you want to know more or read more, go to Clinician’s Portal on this website and check out my 2008 lecture. You will be amazed what the professionals do not know about heel pain. For the time being, your heel pain is most likely the common garden “fasheetus” as many patients call it. Who cares what it’s called, it just hurts! DONT LEAVE IT TO BE BECOME CHRONIC.
Decision making before bunion surgery
To most people in the street, the bunion is a single entity. This means it is a deformity and thus follows the same pattern of treatment that all corrective bunion follows. Nothing can be further from the truth. When we wrote about mild and severe forms of bunion in the 1997 book, Clinical Skills, we were expressing a fact that some people suffered differently. So, what does it mean to a patient after surgery? Well put simplistically some patients can expect to have different size surgeries and that means recovery will vary. There are 2 major questions a patient should ask about before admission. A: How does surgery affect my recovery B: From a medical perspective, what complications should I be concerned about? A small concern may not mean that in the event of a problem occurring that it won’t have a major impact your life. Serious pain may only affect 0.25% of a clinician’s case load, but, if you are the person with that problem it may affect your life. Perhaps one should ask; if this happens can you fix it, or is it easy to fix? Don’t have surgery before a big holiday or event as you may have to cancel. Low or high risk? Don’t expect the surgeon treating you to answer this as he has no crystal ball. As we are talking about elective surgery it is important to weigh up a decision whether to embark on this course of management. A good consultant will never press you into an instant decision but hopefully will offer you all available or realistic options.
As I tallied up my own foot complaints I started to wonder if rather than providing patients with lists of qualifications, which let’s be frank means little to the average man on the street, we should qualify our own experience in light of diseases and syndromes!
I suppose one has to balance the effect of looking a little poor in shape against a positive experience. How easy it is to discuss with patients common conditions with better empathy? I come from an era when we injected each other with local anaesthetic. Today it is just an orange or some type of fruit that receives the benefit to maintain good ethical karma. Mind you maybe there is some rule that says we should be kind to fruit but at least we do not need to take consent! I confess it is easier to tell a patient just when it might hurt and what benefit will soon be experienced. So here goes;
Tollafield D R Sesamoiditis, Haglunds deformity, Mortons Neuroma, Post tibial tendonosis, Ingrowing toe nail, extensor tendon callus. Maybe I can claim I know more than the text books now!
Heel pain is a common problem and my blog this month looks at this briefly. There appears to be no gender variation here, and the age group hovers around 40-65 but peaks at any age where rejuvenation at exercise is attempted. There is a more sinister side to constant heel pain, especially if it grips the patient for more than 4 months. For those who like to see the full dimension of heel pain you can look at my Clinician Portal which can be found under EDUCATION INFORMATION. Over the last year GP practices have been sending more patients with heel pain and some fall into pretty tough categories to fix.
The first sign may be pain on activity or first thing in the morning when rising. If left this worsens. However the patient who works long hours on their feet may experience chronic pain. Jobs requiring over 8 hours standing can turn this into an occupational disorder. Traffic wardens, postal workers, nurses and health care workers, factory workers all fall into this occupational grey zone. Early attention and management can arrest the problem but I am being asked to help people who have had the condition for over a year or more.
Heel pads, insoles and cushioned outersole materials of shoes or boots are helpful but may be short lived. You should use painkillers for no more than 7 days without guidance. Four to six weeks is often the golden window for positive, swift help; beyond this period it can be downhill.
Steroid injections are worthwhile but do go to someone who is experienced and above all qualified with a passion for this condition because treatment can run into months. If you have needle phobia then consider seeking someone who can provide sedation to avoid becoming overly agitated at the time of treatment. If you are offered lots of repeat injections beware – steroid over use will thin out the fat pad. ‘Fat in feet is our friend.’
Stretching – is a good idea to keep the Achilles tendon from tightening. Night splints and simple aids to stretch the fibres can help. Chronic heel pain can become expensive to manage. Our latest approach to long standing heel pain, often called fash-ee-eytis (fasciitis) is ultrasound diagnostics where we measure the thickness of the band as a predictor of outcome.
Injections cost around £50 – £70 in my practise depending upon the complexity and can be done in clinic. Spire Hospital charges around £22 for the drug itself so you are looking at a combined fee of around £72-£92. We are looking at remaining competitive with our non-invasive treatment called extracorporeal shock wave (ECSWT) but success does vary from 45 – 75% with an average of around 58% successful. The hospital will give you an idea of the all-in cost of a course covering three treatments, but ECWST is used after injection treatment. I believe it offers at least another non-operative option.
I find myself using surgery now in 25-30% of the heel pain group as more long-term cases come to seek out solutions.
No longer do we talk about the heel spurs and I certainly do not like the idea of cutting heel spurs out, as it is generally unnecessary. Fasciotomies are small operations that only create a small incision and allow you to walk after a few days. Physiotherapy is important and I work closely with Perform, our own physio brand at Spire, as they understand feet and foot surgery very well and have worked with me for 15 years.
It can take around three months for all pain to settle. There are a plethora of people willing to treat the heel pain and as usual some may promise the earth – ‘We can treat all heel pain,’ Or ‘100% success with such and such a treatment.’ The commercial approach can often over emphasise the success. I might think I am good, and have been in this business for 37 years, but even I don’t achieve a 100%! Of my surgeries I achieve around 88% good satisfaction. Complications are rare but we do audit cases. In a recent audit I found 1 infection, 1 wound that suffered delayed healing, 1 haematoma (localised blood clot) and 3 patients with small sensory loss. This came from a small study cohort of 26 patients. Fifteen had their aims met completely, 1 in part and 2 patients aims were not met. Data was not collected in the remainder of this quick audit over a five year period
Those who return to occupations with a high percentage of standing can deteriorate and the reality is that if this happens your job may need to be considered before embarking on any treatment. I love to help my patients but I cannot compete with the plus 8-hour occupational heel pain problems. The only solution left sometimes is to change or alter the nature of one’s occupation; never an easy task, but then who wants chronic debilitating heel pain forever? There is one hope. For those coming up to retirement, heel pain may clear up so you may want to put off having some types of treatment until you have hung up your office coat and hat. Watch out though, golfers form another group of heel pain sufferers!