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
When bunion surgery does not go right
Maybe around 5% fall below the ideal aims of success. Data is published by the College of Podiatry PASCOM-10.com annually so this is not just a guess. Over the last 7 years, 25000 bunion surgeries have been performed where 93% believed their expectations from surgery had been met. There is a common problem that arises with the best surgery;
pain and stiffness
Julia was keen on tennis and her surgeon selected an osteotomy. An osteotomy is perhaps the gold standard with the aim of retaining joint movement. Sometimes the joint stiffens and can become painful.
Loss of joint quality is not uncommon and can progress as we age. The give away is how much the first toe joint hurts during normal activity. Too much pain and jamming means the toe may have a problem. An injection of steroid might be recommended first before surgery, unless the end stage has been reached, but can be found within the guidelines suggested by the National Institute for Care and Effectivness (N.I.C.E.) as a conservative treatment.
Julia had this type of damage before surgery so she had around a 70% of success of improving even though there was loss of joint quality. While joint movement might be less than ideal, pain on movement is undesirable. When pain on movement arises after surgery, it might be back to the drawing board.
Share your own experience if this has happened to you or a patient and let me know what you did next.
Patients need to be aware of the risk up front as none of us want repeat surgery, but, if we do have to return to the operating theatre, then it is better to be prepared ahead as part of good consent process.
Not always a simple condition to treat
This is a common condition that I have written about before in Footlocker; since 2014 I have blogged the subject 5 times – July 2016, March 2016, October 2015, June 2015 and August 2014.
However my post bag seems to be growing in regard to enquiries. Why is a podiatric surgeon a last resort I ask myself? I see a need for better patient help and yet, given the wide range of specialty clinicians that can become involved, lack of improvement is worrying.
Can I help? Maybe, but it is unlikely that after 11 people: orthopaedics, podiatrists (non surgical), chiropractors, rheumatologists mainly, and a number of interventions this is unlikely.
The longer the problem exists, the more difficult it is to deal with. Do I do anything different? My approach IF it is fasciitis:
rule out medical disease
ensure the problem is localised and not damaged
install conservative treatment for 6 months (cost can limit some patients)
utilise one injection per key area ONLY
counsel occupational related causes
consider percutaneous (key hole surgery) fact sheet 21 under education information.
The typical cost of dealing with fasciitis as a programme of care. From £350 – £5000 (at my facility). Staggering! but then seek 11 clinicians over 4 years, well that adds up to a high cost as well as increasing disability. At Spire we work across a team of professionals and have excellent diagnostic services available.
Pain, stiffness and bumpy ridges!
The big toe is important, a bit like the steering wheel of your car. While movement works with other joints, higher up the body the foot is governed by the big toe and requires just the right amount of movement. When the joint is less effective at moving or pain arises, we twist outwards – causing a ‘duck foot’.
The big problem comes when the joint swells to a point when movement not only fails, but causes pain. Ten to a penny you see your doctor, who will sympathise and suggest a number of things. If it is very swollen, you may be considered to have gout. Off for a blood test maybe! A dose of ibuprofen, pronounced I-BEW-PRO-FEN, not I-BUR-OFEN will be prescribed. If needed, you can purchase this for pennies, by avoiding brand names, which cost pounds. Penny wise starts to make sense. If you have NHS exclusion, then the drug is free. Saving the NHS is worthwhile – remember, it is your NHS.
My last bit of advice – click on my latest information sheet – 109. This can be found under ‘Education Information’ and will help you understand the problem with big toe joints. See what your doctor has to say, but don’t forget, an opinion from a qualified podiatric specialist may provide you with further assistance. With the insurance companies driving costs down, consultations are not so expensive as they might once have been, and you do receive a decent first consultation time. X-rays, if needed are additional.
Look at the information sheet first, and see if it helps you. Don’t suffer in silence.
Happy feet for the New Year 2017…
I am always dubious about making fast decisions when treating the big toe for bunions (Hallux valgus). For that matter, I prefer my patients to observe caution, so all the facts are laid out and understood. Ponder two cases: one patient – C in her sixties and F in her twenties.
C had was recovering from her second operation on her opposite big toe. Like before she developed problems but was not dissuaded from proceeding. Slow healing, a small wound infection, swelling all took time to heal. I was pleased when we finally reached a point when all was mended at 10 weeks. All the rules were followed, but that was just the way it was. Most patients do well, and certainly sixty plus is not a problem for age, as long as medical health is straight forward, and C’s was.
F was a delightfully independent young woman. She wanted both feet managed for a modest deformity but wanted to travel long haul to Australia 8 weeks after surgery. This raised the risk of blood clot. We can minimise this risk by limiting alcohol on the flight, a 75mg aspirin and flight socks, but not Aussie sun on wound. First you must realise, IF 2 feet are operated on together you are DISABLED! This could go on for 2-6 weeks, depending on how well you do. Reoccurrence? Yes, under 30 is more risky but not unrealistic. You can be operated on at any age but 35-45 is still my best age with least risks and optimism .
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