Articles and clinical information from Clinician Portal

Look out for my new series on ‘my foot journey’ available from Amazon

Articles and Clinical Information

Information in this section is available to all, although more academic in nature, this should not dissuade people from reading any articles. Some are topical, others come from older publications. If you wish to publish any articles related to foot foothealth please submit a word document file to



articles, papers and lectures

Latest Publications from Busypencilcase Communications

Article: What’s in a name?

Article: Musing on the foot

Article: The chilled foot

Research: Corns, callus and keratoma

Research: The Effect of Sedation with Midazolam on Daycare Surgery

Article / Transcription lecture: Heel Pain-Advanced Diagnosis

Article: Complex Regional Pain Syndrome

Resource pack: GP Information Pack

Lecture: Wound healing delay following surgery

Research and audit ( and lecture): Hallux Valgus

Research: Prosthetic Implant Surgery for pain first toe

Protocol: Mid-foot Arthrosis

If you wish to become a beta reader or wish to contribute to writing, Busypencilcase Communications will be happy to assist.


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Latest publications from  Busypencil Communications Ltd



Amazon kindle publication. Morton’s Neuroma £2.82. The author describes his experience as a patient having had foot surgery.  Unique description of the nine month journey brings into focus some of the aspects of quality health care. Every one can learn from this book which has had great reviews. See testimonials on home page.

Mortons neuroma 003


*** ARTICLES ***

What’s in a name? The Difference between healthcare professionals.

It is difficult to know who is who in a hospital. When is a doctor a doctor and when is a surgeon called a surgeon. All females are not nurses and some males are nurses. Not all those carrying stethoscopes are doctors. CONFUSED?

I am not a doctor but I am a specialist because I have added to my training substantially and am registered to perform treatment at a higher level. All podiatrists hold a basic three year qualification. All podiatric surgeons in England hold a fellowship; those recently qualified will have a second degree within a post graduate training of a further 10 years. As with many clinicians some have a PhD and so are entitled to use doctor of philosophy even though it may be in science. British podiatrists who practise in foot surgery will explain this to patients if they hold a PhD to avoid confusion with the term ‘medical doctor’.

Many of the websites are very helpful in providing such information. Broadly there are three groups of people in medicine: medically qualified and trained doctors, nurses and allied health professionals (AHPs). Dentists fit somewhere between doctors and AHPs. Some dentists go onto specialise in surgery and medicine i.e reconstruction to the face (maxilla-facial or max-fax surgeons). There has been much consternation about dentists using the term doctor. The Max-fax surgeons became double qualified as medical doctors but use the older historical title Mr that the barber surgeon used. Throughout the world you will find most countries use doctor for surgeon, but not in Britain! We do like to be different…

AHPs include psychologists, physiotherapists, radiolographers, occupational therapists and operating department practitioners as well as podiatrists. There are over 20 professionals which make up a very large group of clinicians who provide a variety of treatment, keeping the nation fitter. Here again some will use the prefix doctor but this will be taken to mean doctor of philosophy, not associated with medicine. As the natural educational standards rise and more responsibility is assumed by many professionals, overlap inevitably arises. Many regulated professionals other then doctors and dentists can provide medicines related to the conditions that they treat. In 2014 Independent Prescribing licenses gave podiatrists an extension to their role in helping to treat appropriate conditions.

All podiatrists study medicine as part of their qualification so that by the time we qualify we know the function at cellular level to macro-level, anatomy of muscles and diseases of the heart for example. To learn more about podiatry please link to

All podiatrists have to be registered in British law to practise podiatry. Unqualified people who use the term ‘podiatry’ are breaking the law. The register is held by the Health Care Professions Council (HCPC) who has similar powers to the General Medical Council in that they protect the public where clinical staff fall below the expected standards of care. Please note that Foot Care Practitioners may be registered but are not Podiatrists.

Regulators in healthcare

In the UK only podiatric surgeons and some orthopaedic surgeons are ‘wholly’ dedicated to elective foot and ankle surgery although orthopaedic surgeons may not practise on the foot and ankle surgery alone. You should check the appropriate websites for further information on orthopaedics. Please note that the orthopaedic profession’s opinions are not necessarily shared by the podiatric profession although members of both professions do try to work closely over a wide range of health concerns. Podiatric surgery is recognised by the Department of Health as providing a valuable contribution to health care in the UK.

The podiatric surgeon works on the foot and associated structures which can include the tendon achilles. We deal with skin trauma due to pressure and fixed deformities as well as diagnose and manage pain.

If confused always ask your consultant what his qualification is and who his regulator is. During 2013 the College of Podiatry and Faculty of Podiatric Surgery have produced a collaborative leaflet on ‘What is a Podiatric Surgeon’ and new code of practice to ensure that patients are clearer about our use of the title  ‘podiatric surgeon’.

Musings on the Foot

Conflicting ideas about the human foot are considered for critical discussion.What are the knowns, and do they stand up to our modern perception of the foot condition? Published December 2016


The Chilled Foot

Written for local GPs around our hospital at Spire Little Aston, the information is designed to help patients combat general chilling of the foot. A DIY self help section is included together with tips . I recommend using the animal wool sock for acute chilling and chilblain. This is an old but inexpensive remedy. Published January 2015. David R Tollafield (C) Busypencilcase Communications.


 Corns,Callus and Keratoma Study  for podiatrists

Definitions have been set out to compare work from 1984 and 2014. The outcome of has been reviewed as data from 165 podiatrists suggests that the understanding of the border and extent of the depth of each lesion from clinical photographs could account for variation in the results. This places the accuracy around 80%. The latest publication came out in November 2017 published in the Journal of Foot & Ankle Research.

Background: The management of plantar corns and callus has a low cost-benefit with reduced prioritisation in healthcare. The distinction between types of keratin lesions that forms corns and callus has attracted limited interest. Observation is imperative to improving diagnostic predictions and a number of studies point to some confusion as to how best to achieve this. The use of photographic observation has been proposed to improve our understanding of intractable keratin lesions.
Methods: Students from a podiatry school reviewed photographs where plantar keratin lesions were divided into four nominal groups; light callus (Grade 1), heavy defined callus (Grade 2), concentric keratin plugs (Grade 3) and callus with deeper density changes under the forefoot (Grade 4). A group of ‘experts’ assigned from qualified podiatrists validated the observer rated responses by the students.
Results: Cohen’s weighted statistic (k) was used to measure inter-observer reliability. First year students (unskilled) performed less well when viewing photographs (k = 0.33) compared to third year students (semi-skilled, k = 0.62). The experts performed better than students (k = 0.88) providing consistency with wound care models in other studies.
Conclusions: Improved clinical annotation of clinical features, supported by classification of keratin- based lesions, combined with patient outcome tools, could improve the scientific rationale to prioritise patient care. Problems associated with photographic assessment involves trying to differentiate similar lesions without the benefit of direct palpation. Direct observation of callus with and without debridement requires further investigation alongside the model proposed in this paper.

Callus classification-preparing new work based on an original study 30 years ago

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David Tollafield reviews corns with clinical pictures in this information sheet based on his 1984/5 work. The original paper is published below as in 1985 in the Journal called The Chiropodist. Such lesions need to be carefully assessed by the professional as many skin excrescences are not suited to pedicure or repeated debridement. Diagnostic techniques are required together with wider professional specialisation to manage this form of foot pain. Research  carried out by the author during 2015-16 included 57 first and third year podiatry students matched against an expert panel. Reliability was analysed using Kappa statistics and considered more useful than percentage evaluation. For the first time the 1985 study could be objectively evaluated and the conclusion suggested that rather than 4 stages (types).


Callus classification-associated with hallux valgus. An original study 30 years ago by Tollafield & Price

Original study 1984. 1700 patients. hallux valgus and callus lesions classified by Tollafield to help students determine lesion severity. Published The Chiropodist (1985)

The effect of sedation with Midazolam on daycare foot surgery

Sedation has a profound effect on the quality of podiatric foot surgery and foot pain treatment. This work has taken four years to bring to the public although represents some 15 years of experience by leading podiatric surgeon David Tollafield. We all know blood pressure can be improved when we are anxious but this is the first podiatric study covering use of Midazolam with senior anaesthetist Dr Nike Akinwale. Articulo is a Spanish Podiatric Journal (English version).


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Heel pain advanced diagnosis

Heel pain is a repetitive stress condition causing foot pain. This presentation by David Tollafield to a West Midlands Podiatric Audience emphasised the fact that some conditions may not be simple.

All clinicians, including medical doctors should be aware that recalcitrant heel pain should be correctly diagnosed and a plan of treatment put into place rather than relying on repeat medications.

Complex Regional Pain Syndrome and foot surgery

This is a condition which is under reported and often misdiagnosed. Burning foot pain was once described by a sufferer as think of pain experienced when putting your hand in a bucket of scalding water without the ability to take it out. Such descriptions must bring home to clinicians and patient alike the potential for this condition to alter one’s way of life. The condition however is not always as severe but early diagnosis is critical. We aim for a diagnosis within three months if not faster but other conditions can mimick the potential symptoms and signs. This makes CRPS a tough condition to judge.


General Practitioner information pack on basic foot health conditions

A handout used for podiatry students, junior GPs and those wanting a quick update. Free download for those with existing medical knowledge. Minor injury, metatardsalogia, flat foot, heel pain, HV and HR deformity, Nail pathology. arthrosis, per-ankle pathology, neoplasia and diabetes.


Delayed wound healing associated with suture foreign body reactions in foot surgery

A complex analysis of wound healing and problems viewed from a more scientific point based on suture reactions following surgery. David Tollafield considers foot surgery and foot pain issues following a lecture given to an international podiatry audience in 2008 in Eire.

Wound healing lecture slide presentation. Case histories

View the slide presentation given by David Tollafield to an international podiatry audience in 2008 in Eire. Wound healing and problems viewed from a more scientific point based on suture reactions following surgery.



Is it possible to sex up bunions by calling it hallux valgus?

A power point slide presentation showing the effects of cartilage degeneration and different bunion deformities. Victoria Beckam’s foot from the Daily Mail was even portrayed!

Can we sex up bunions? Short article for clinicians

The bunion (hallux valgus) is a misunderstood condition causing foot pain is often left too late to be managed effectively. Tollafield discusses why this is the case.

CLINICAL EVIDENCE: Hallux Valgus Surgery. February 2013

A Report from the PASCOM-10 Working Party written and developed by Anthony Maher FCPodS and David Tollafield FCPodS. The purpose of this and subsequent reports is to provide a summary of hallux valgus (bunion) treatment data held on the PASCOM-10 database at a national level. The PASCOM-10 online audit tool was introduced to the profession in May 2010 and represents a considerable leap forward in auditing the outcomes of podiatry treatment. PASCOM-10 replaced the previous software based system (PASCOM 2000). Since its introduction, PASCOM-10 has registered 31190 patients and 29446 episodes of care across 178 centres (system accessed at 16:00 on 24.01.2013). There are 429 registered users ranging from administrative staff to podiatrists of all grades. It is hoped that with time data generated by PASCOM-10 will become a useful tool for monitoring trends and for benchmarking services at a local level.

CLINICAL EVIDENCE:Basal wedge osteotomy v Lapidus fusion for hallux valgus

David Tollafield reviews his base wedge osteotomy for severe bunion pain as part of his reflective practice awareness using PASCOM-10 data


Evidence from David Tollafield on Silastic Implant surgery

This is an abstract of work undertaken in 2000 with Professor Robert Asford and published in The Foot. The silastic implant plays an important contribution in the management of damaged first toe joints without losing movement.

Silastic toe joint information for patients (50)

Click on fact sheet 50 for current patient information.Pain in big toe joints can be significantly improved in a short period.


Midfoot arthropathy Protocol (Walsall Podiatry)

The basis of our approach to foot pain arthropathy is set out in our protocol. Refer to clinical information fact sheet 58 for sheet 53 for podiatric surgery.

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