Please use this section for your own questions. Because this page is formatted as a blog not a forum, it will be a little while before it appears (depending on my dilligence!) so please check back later..
Merry Christmas!!
I will be closed on Friday 23rd December in the evening till Thursday 5th January, 8am.
So I look forward to seeing you bright eyed and bushey tailed in 2012.
Olympics year.. Wow, it seemed so far away and now it is nearly upon us..!
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Barefoot Running and What It Might Teach Us
I’ve been barefoot running since 2009. I read an entry on the runnersworld.com (USA version, where they have a BF forum), and immediately set out through the park in the name of “research”. I fell in love with it instantly. Bar niggles in the soles of my feet and in my calf muscles at first, I soon found I was running quite long distances injury-free. Simultaneously, I removed the orthoses from my day shoes and switched to “barefoot” shoes from Vivo and Vibram Five Fingers. To my surprise, I found my lower back ache virtually vanished and my lower back muscles relaxed.
Obviously, I wanted to figure out what was going on, if it can help other poeple, and if you had to actually remove your shoes to achieve the same effect. The conclusions I have right now are that:
1. BFR is slower and involves very short introductory distances during the period where the soles of the feet are adjusting. This can easily, with a little self-awareness, be replicated in any shoe. For recommended reading on this technique, try Slow Burn by Stu Mittleman.
2. BFR involves a shorter stride, and has less weight on heel strike and more on the fore-foot. This seems to provide exceptional shock-absorption, and have a beneficial effect on the stability of the knee flexion. Podiatry researchers are now beginning to explore this possibility. You find it easier in Vivo or Vibram than in cushiony trainers.. Follow the above suggestions on short, slow introductory runs you you will surely injure something…. And check out the link to Core Running for more information on technique.
3. BFR and BF walking also seems to have an effect on pelvic and lower back function. I suggest the lower back rotates in order to to effectively increase stride length, whilst still avoiding a painful heel strike… This encourages the use the muscles and joints of the lower back, and in doing so, nudges towards an improvement in posture. This idea is not yet being researched, to my knowledge. It is currently mine uniquely, and therefore of limited value, until someone does research it. This effect probably couldn’t be replicated in ordinary cushiony shoes.
4. By increasing awareness of the sensations in the sole, and by improving the body’s natural shock-absorbing mechanisms, fine muscle control improves, leading to better balance and coordination. Probably not replicable.
5. BFR has variable cadence and stride which changes depending on the surface temperature and texture being run on, and any obstacles to avoid. This cannot easily be replicated in any shoe.
6. BFR is probably more use to IMPERFECT, frequently injured runners who will learn a gentle, non-impact technique from doing it, rather than to lucky gazelles who run perfectly anyway.
7. It is never recommended for feet which are already damaged in some way, or with any medical condition which would affect the ability to feel foot pain or heal wounds.
This information could be of use to some of my patients. An experiment done successfully on myself cannot be extrapolated to everyone, but the simplicity makes it worth a try for many, at least for a couple of months. An orthotic can be made in addition, if required. After some dilemma of how to introduce these ideas in my practice, I now frequently suggest my patients experiment for a test period with one or some of the points I mentioned above, for a period of time, prior to moving on to more conventional Podiatry therapies.
Diabetic Patient: “Why are you asking me all these questions? I only came to get my feet done..”
People ask me why I attend the Diabetic Foot Conference on a regular basis.. “Is it because you are diabetic?”, they say! “No!”, I say. It is because some of my patients are!
Diabetic feet are an ENORMOUS problem nationally. But forget the national problem… If you are diabetic, and are affected by “Diabetic Feet”, they are an ENORMOUS problem individually.
Quick summery… Diabetic feet are at risk of to ulcers, infections, and in extreme cases, amputations, because diabetic feet are prone to altered sensation, inefficient blood supply and compromised immune system (both in repairing damage and in fighting infection).
When I do an annual Diabetic Foot Check, I am looking for physical clues as regards the sensation and circulation. Clues about compromised immune system are extremely important, and are gathered indirectly via a information about your blood-sugar levels, medical health, any history of foot problems.. and by simply.. Looking.
I use the result to assign your feet into a classification, somewhere on the scale of high to low risk, which informs both me and the patient of the level of vigilance required… a statistic that I recall in principle but did not reference, is that 90%+ of patients correctly measured as being “low risk” remain ulcer free for the following year (as opposed to around 90 % of high risk feet developing some kind of wound.)
I have a number of very high risk patients at this clinic, patients who have a history of ulcers, foot infections and even amputation. They are, in the most part, meticulous about their foot- care and monitoring, and return at the slightest hint of any problems. Mostly, they have remained stable. Were they to become unstable in their foot condition, they would be referred back into an NHS for wound care. (The NHS is the place to go as regards the experience of a dedicated wound-care Podiatrist as well as the range of specialist dressings) and, hopefully, access to the multi-diciplinary team supporting Diabetic Care.
Posted in Chiropody
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I haven’t done a post about Sports Massage..
For the therapist doing the massage, it is almost as healing as for the patient being massaged.. Funny word, that. Healing. It takes us out of the world of science and double blind trials and takes us into the world of intuition and all kinds of wordy-wordy words that can’t be literally defined or conventionally understood. I have some patients who genuinely do believe themselves to be healed by touch.
Sports massage hurts, but it is usually one of those “good” pains that feel “right”, or “just what I need right now”.
It is hard to describe the sensation of what you feel when giving a massage. It seems that the decisions about where to focus, what moves to use and how hard to press come from the hands themselves, responding to some signals that the brain observes but does not understand.
“Knots” are the easiest to find. Like peas or apricot seeds hidden in the muscle. Or there are “cables” that run up and down, or occasionally across. But there are other sensations like blockages, where your hands seem to get stuck, or balloons, where your hands skid over the skin and cannot find purchase. Then there is the strange sensation like a warm cushion which seems to indicate that this part of the body has been massaged enough for now, thank-you.
It seems that a problem in one place can cause a pain elsewhere. The bit being massaged does not always correspond to the bit that the patient complained of. Perhaps this is because a tight muscle in one place pulls a joint out of line and drags on another muscle elsewhere.
Although benefit can be found from a single massage, it normally takes 2-3 massages to know for sure if this benefit is lasting and therefore useful from a therapeutic point of view.
Posted in Sports Massage
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Prescribing Children’s Orthoses
Another personal view..
Opinions on treating flat feet, in-toeing gait and other Biomechanical problems in children vary greatly. Even within the Podiatry profession, and certainly outside of it professional opinions are inconsistent. No definitive, objective, double-blind trial has been conducted to prove what is best, and I doubt it could be just yet, given the complexity of what would be studied and how long the study would take. Therefore, clinicians are largely working with those theories and experiences that make most sense to them, and parents are frequently frustrated that different clinicians can give them completely different advice.
It is a general rule of mine to look for alternatives to the early use of orthoses, and to try instead to develop the natural strength and mechanics of a child’s foot. It may be that in some circumstances, orthoses will be indicated, yet I would still will wish to give thought to the strengthening of the foot.
“We are all an experiment of one.” Dr. George Sheehan. Evidence Based Practice
This is a personal view..
The gold-standard in health-care is statistical evidence based on a double-blind trial. If you were a subject in a double blind trial, you will have been chosen because you fit into a well-defined category of people called a “study group”, and neither you nor the research team members you meet, will know if you are given an active agent or a placebo.
Empirical evidence on the other hand, could be gathered by a clinician who finds through experience, and a kind of clinical natural-selection, that certain treatments survive whilst others do not. Or by a patient who finds that after trying all kinds of more conventional treatment, reflexology was the only thing that sustainably and repeatedly relieved their back pain.
I feel frustrated by the unavoidable limitations statistical evidence, it is impersonal; the statistically significant outcome for the group as a whole matters most, not the individual, and the boundries of what are examined are so narrowly defined that they can seem clinically useless.
Yet it is essential in it’s aspirations to objectivity. In particular, what is vastly superior in this formal setting is the follow-up for the intervention which, it is the responsibility of the research team, so it must get done – otherwise the research paper will not pass peer review.
Empirical evidence is more intuitive, it allows for individual creativity, and it allows for treatment of those individuals who fall outside the “study group”. Were I to rely soley on empirical evidence, therefore, there is a high risk that my own beliefs will interfere with my objectivity. And very importantly, to the detriment of empirical evidence, the follow-up in a clinical setting is generally the initiative of the patient, therefore it may not get done; for any other number of reasons that patients may not come back; including that the treatment worked, that it did not work, that they moved house, etc.
If you have noticed a theme developing in this blog, I hope it seems to you that I wish for each patient to be involved in a mindful way in their own treatments, because at the end of the day, though I have treated many feet, I have never treated your feet. And though this treatment made many of my patients better, it has not yet been shown to make your feet better. And all the statistical and empirical evidence in the world doesn’t mean a hoot if you fall into that portion of the group whose feet followed the other set of rules!
Student Visit!
Last week a really nice lady came to spend the afternoon at my practice. She has been thinking for years about this profession, and she now thinks the time might be right.
If she looks at this blog, she will know who she is!
I hope you enjoyed your visit. Good luck and keep in touch! Joanne
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How do you tell the difference between a Verrucca and a Corn?
A verruca is a caused by a virus and a corn is a lump of hard skin caused by stress on the tissues. They sound pretty different, so they should look different, right?
Usually, it is easy. Verrucae often form a perfect ring shape, or mosaic of rings, on the sole of the foot and they sometimes have the little black dots that everyone knows about. If the patient is a child, it is more likely to be a verruca, if they are older, it in more likely to be a corn. If it doesn’t hurt it is more likely to be a verucca, if it does, it is more likely to be a corn.
Like many medical things, even such an easy- sounding thing is not sounding such an exact science!
When I look at the lump, I am looking for a change in the finger print pattern and loops of capillaries. I also look if it bleeds easily and how the callus forms. There is also a way of pressing it that helps me to tell me if I am seeing a verruca or a corn.
Sometimes, despite looking at the two for too many years, I still get it wrong. I am more likely to mistake a verucca for a corn than the other way round. I am more likely to make a mistake with a painful young verucca that has not yet formed the ring and capillary structure, or if the area is covered by a big plaque of callus and the skin structure is altered by that.
Usually in these cases, a good clue is if a patient ends up back at the clinic because the pain is back too quickly. Veruccae replace their callus more quickly than corns. On this visit, the finger-print and capillary patterns are often easier to see.
(Oh, and just in case you are worried, neither veruccae nor corns are fatal !!!!)
So you think I know how orthoses work..?
For those of you considering foot orthoses for treatment to pain inside your foot and leg, plantar fasciities, achilles tendiniitis etc, you may wonder how orthoses are prescribed.
Well despite the casts and all the measurements, at the moment, the process is as much a craft as it is a science. We know, because patients tell us, that foot orthoses work; we just don’t know why. We think that foot orthoses alter foot function, offer support to stressed tissues, and off-load certain areas of the foot. But if you can imagine the weight of the body over the foot, it may seem that a comfortable little orthotic could do little to resist the very large forces from the above.
At the Firefly Conference I attended recently, the Pan-European A-FOOTPRINT project was presented by Professor Jim Woodburn, who is based in Glasgow University. Half way through this four year project, the team already have an accurate working CG model of the foot including all the bones, tendons, ligaments and soft tissues. Using this, they will be able to see what actually happens to foot function if a ligament ruptures, if the heel bone fractures, if an orthosis is used – or even simply if a shoe is worn compared to barefoot.
Quite exciting to witness the introduction of a technology that will take Podiatry from a skill or an art form to one of the most evidence based medical interventions yet available to help patients.
There was loads more information, especially on the construction of orthoses, so if this topic interests you, feel free to post a reply and I can add more information!
