Further information on some of the conditions treated at the clinic

ACHILLES TENDINITIS

This is an over-use injury affecting the Achilles tendon which runs down the back of the lower leg to the heel. Athletes, joggers, runners and other sports people are most commonly affected. It may be aggravated by a high heel tab on running shoes as well as improper training/ insufficient warming-up. Athletes over 35 are more prone to this injury due to impaired blood-flow to this tendon.

Symptoms: Initially, pain is experienced first thing in the morning or after activity. Symptoms may progress to unrelenting pain. The area will be hot and inflamed and may be swollen. Pain will increase when standing on tip-toe.

Treatment: It is important to rest from sporting activity and an ice pack should be applied to the area for 10 minutes, four times a day. Underlying biomechanical abnormalities must be corrected and a heel raise, to rest the Achilles tendon, is often useful. After the injury has resolved, which may take several months, a rehabilitation programme involving stretching exercises should be begun.


ATHLETES FOOT

This is a fungal infection of the foot called Tinea pedis and is more common in adults than in children. Footwear creates the ideal conditions of moisture and warmth and communal areas, such as swimming pools and changing rooms, allow it to spread.

Symptoms: The skin between the toes can become 'soggy' and white and often sore and/or itchy. Another form can cause blisters on the sole of the foot (often only one foot is affected with this type) and a third form, known as the moccasin type, causes dry redness and scaling over the soles.

Treatment: It is important not to share towels, bath mats, socks etc and not to go barefoot in communal areas such as changing rooms. There are various treatments available, in the form of creams, sprays, powders and ointments, depending on the type of Tinea causing the infection. In general, it is advisable to use a spray or powder between the toes rather than a cream. Antifungal powders may be used inside the shoes as a preventative measure.


BUNIONS

This is a deformity of the big toe (hallux) known as Hallux Abductovalgus. A prominent bump develops around the big toe joint as the toe moves towards the smaller toes, sometimes crossing over or under them. Another type of bunion, called a Tailor's bunion or bunionette, affects the little toe as it moves inwards towards the other toes.
Bunions can be aggravated by tight, narrow shoes with a pointed toe box but are usually caused by an abnormality in foot function, arthritis or a genetic predisposition to the disorder.

Symptoms: The early stages of a bunion formation usually cause aching in the big toe joint (this is a good time to seek treatment). As the condition progresses the aching usually subsides but is replaced with inflammation, swelling and soreness. Sometimes a corn can develop at the most prominent point of the bunion. The discomfort usually causes the patient to walk improperly which can cause other problems to develop.

Treatment: Early symptoms can be relieved by soaking the feet in warm water or applying an anti-inflammatory gel (for example, Ibuprofen). Shoes with a wide toe area are recommended and bunion shields are useful in protecting the prominent joint.
It is important to establish whether there is an underlying biomechanical disorder causing the problem. If there is, the use of prescription made orthotics (shoe inserts) will restore correct foot function, thereby relieving the symptoms and preventing the condition from worsening.


CHILBLAINS

Chilblains, or erythema pernio, are the result of an abnormal vascular reaction to cold but may occur on rewarming after exposure to cold. They tend to be most common amongst children and young people (mainly young women) but can occur at any age. Areas most affected are the ends of the toes, the heels, the lower legs, the fingers, nose and ears.

Symptoms: The first, or cyanotic, stage tends to pass unnoticed. Later stages cause the skin to be red, hot, burning, itchy or painful. Scratching of the area can cause a break in the skin which can lead to infection.

Treatment: If prone to chilblains, prevention by wearing warm clothing, avoiding cold and damp, taking adequate exercise and a good diet, is more effective than treatment. Once the chilblains have appeared, however, dressings soaked in witch hazel are useful as are topical creams and ointments designed to increase circulation. If the skin is broken and/or infected it is important to seek professional advice.


CORNS and CALLUSES

Hyperkeratosis is the name given to an area of the skin when it becomes thickened. A larger but shallower area of thickening is known as a callus whereas a more localised, but deeper area with a nucleus is called a corn, or heloma. The nucleus presses on the nerves in the underlying layer of skin, which causes pain.
Both conditions arise as a result of pressure and/or friction. Under these conditions the skin cells become stimulated to over-produce, ie. new skin cells are produced more rapidly than old cells are being worn away. This is a normal protective response of the skin and if a callus is not painful it does not usually need to be removed. A corn, however, often develops where there is friction as well as pressure, for example, when shoes which are too tight are worn. There are several types of corn, including soft corns (heloma molle) which develop between the toes, hard corns (heloma durum) which tend to develop over or under a prominent joint, and seed corns (heloma miliare) which tend to cover a larger area, usually on the sole of the foot .

Treatment: Areas of callus are best treated by gently rubbing them with a foot-file, preferably when the skin is dry (ie. before bathing). After bathing the skin should be moisturised, ideally with a foot cream containing urea (urea is a naturally occurring substance found in the skin which restores elasticity - a quality lacking in callused skin). A corn needs to be removed by a chiropodist/podiatrist.
In order to prevent a recurrence, properly fitting footwear is important, as is the use of prescription orthotics to correct any underlying mechanical dysfunction.


FLAT FOOT

Flat foot, or pes plano valgus, is an umbrella term for a range of conditions which tend to lower the medial longitudinal arch of the foot. Flat foot is often painless in itself but, if left untreated, can lead to a wide range of conditions including hallux valgus/bunions, Achilles tendinitis, plantar fasciitis, shin splints and knee, hip and lower back pain.
The vast majority of feet described as flat respond to treatment with orthotics.


FUNGAL NAIL INFECTION

Onychomycosis is a fungal infection of the nail bed and of the nail itself. It can be caused by several different fungal organisms, one of which is Tinea which is also responsible for athletes foot, and so the two conditions can occur together. Communal changing rooms, showers etc can be sources of the infection and failing to dry the feet after bathing, or having feet which tend to be naturally moist, tends to encourage it.

Symptoms: An infected nail becomes thickened, quite brittle and porous and takes on a yellowish-brown colour. The infection usually starts at the free edge or sides of the nail and gradually spreads down over the entire nail.

Treatment: To establish what type of organism is infecting the nail and, therefore, to select the correct treatment, nail clippings are first taken for analysis at the Podiatry clinic.
There are various topical remedies available without prescription, usually in the form of drops or 'paint'. In order for these to work effectively, the nail is first thinned down as much as possible. This also has the benefit of making the nail easier to cut and of improving its appearance.
Nail infections are extremely difficult to cure and, at best, will often involve many months of diligent treatment. Even when the nail finally appears free of infection, it is important to continue the treatment for several months in order to prevent re-infection.


INGROWING/INVOLUTED TOENAIL

An ingrowing toenail, or onychocryptosis, is often caused by trauma to the nail, either by faulty nail cutting or poor-fitting footwear. It is also common in hot, moist feet as the skin is less resistant to pressure from the nail. This makes adolescent boys quite prone to the condition.
The condition occurs when a small section of nail or spike of nail pierces the skin and, as the nail grows forward, the spike penetrates further causing pain and inflammation.
An involuted nail differs from an ingrowing one in that the sides of the nail curve round under the surface of the nail and start to pinch the nail bed beneath, sometimes actually penetrating the skin. The cause is often unknown although it can be associated with tight footwear and is sometimes hereditary.

Symptoms: Both conditions can be extremely painful and an involuted nail is sometimes mistaken for an ingrowing nail due to the pain. Generally, however, the swelling and inflammation tends to be more localised with an ingrowing toenail and, if treatment is delayed, this gets worse, often with the production of pus and extra skin tissue (hypergranulation).

Conservative treatment: The ingrowing part of the nail is removed and the side filed smooth. The area is washed with sterile solution, dried and the side of the nail packed with clean cotton wool to encourage normal growth.
There are various methods of relieving the discomfort of an involuted nail. However, as this condition is often permanent, severe cases are best treated surgically.
Obviously, with both conditions, correct nail cutting and properly fitting footwear are vitally important.

Surgical treatment: When a nail edge becomes repeatedly infected and the usual efforts to re-educate its growth and proper cutting have failed, then a minor surgical procedure under local anaesthetic may become appropriate. The procedure itself takes around 10 minutes. However, you should allow an hour for the medical paperwork and a rest afterwards with your foot raised.

Having taken your medical history and written consent, local anaesthetic is first used to numb the four nerves supplying the toe. The area is cleansed using a strong iodine solution. Once I am sure that you cannot detect any pain or discomfort, I then remove the troublesome side of the nail (a partial nail avulsion) or more rarely the whole nail (if both sides are troublesome and the nail is particularly narrow). To prevent re-growth of the nail a couple of drops of a strong caustic called Phenol are applied. This has the advantage of killing any deep infection and also of deadening the local nerves - hence less post-operative pain. However, being a strong acid, the superficial skin is sloughed-off over the following couple of weeks (as with a severe burn from a cooker). For this reason, tepid salt water bathing is recommended every other day at home, followed by application of clean dry dressings.

After the procedure you should go home and rest with your feet up, to help with the blood clotting. You may retire to bed for a normal night's rest, taking a couple of your usual pain killers if necessary (NOT aspirin). You may continue with light duties, your normal schooling or work activities on the following day. Strong physical exertion, swimming or strenuous sports activities are not recommended until the toe has stopped weeping. Ignoring this advice is likely to damage the delicate, regenerating tissues, to slow your healing and to encourage an infection. There is the possibility that the troublesome nail will re-grow as before, particularly if you bleed more than is normal during the procedure, neutralising the Phenol before it has had its effect. You are not insured to drive with an anaesthetised toe, since your reaction times and emergency braking may be affected. Hence you must be accompanied and then driven home after the surgery. You will also need to bring some open-toe sandals on the day of the surgery, since initially you will have a rather large toe bandage!

I will usually ask you to return to the clinic on the day following the procedure to receive further instruction on salt water bathing and how to apply dressings, so as to keep the toe as clean and dry as possible. You will be expected to purchase dressings and apply them yourself at home in between appointments. I will review your progress at fortnightly intervals, until all weeping of the toe has ceased. The initial procedure and all follow up appointments are sold as a single course for a fixed fee.




PLANTAR FASCIITIS

This is often referred to as heel pain syndrome. The plantar fascia is a thin layer of tough tissue covering the muscles of the sole of the foot and supporting the arch. Inflammation of the plantar fascia is relatively common but it is more frequently seen in the 40-60 year age group and in runners. It tends to occur in just one foot, both feet being affected in about 10-20% of cases.
There are a number of possible causes of plantar fasciitis including tightness of the foot and calf muscles, improper or excessive athletic training (eg. running too far, too fast, too soon), obesity, poor-fitting footwear, arthritis and biomechanical disorders. People with low arches, flat feet or high arches are at increased risk of developing the condition.

Symptoms: Onset of pain is usually gradual, often appearing for no obvious reason and without history of injury. Pain on weight-bearing is described as sharp, usually worse first thing in the morning then gradually easing off. With exercise the pain diminishes, then recurs after rest and at the end of the working day.

Treatment: Plantar fasciitis will often resolve without treatment after a few months. However, during the painful phase the application of ice and/or ibuprofen gel can be helpful as can the use of gel heel cups in the shoes. Stretching exercises, which work on the Achilles tendon, are recommended as is weight loss if the patient is obese. If there is an underlying biomechanical cause the use of orthotics will relieve the problem and prevent it from recurring.


SESAMOIDITIS

The sesamoids are two tiny round bones situated under the base of the big toe and embedded in a tendon leading to it. Their function is to allow the big toe to move up and down during walking and to absorb impact as the foot strikes the ground.
Sesamoiditis is usually caused by repetitive, excessive pressure on the forefoot which leads to the surrounding tissues becoming irritated and inflamed. It is a common problem among ballet dancers and in people who have a rigid, highly arched foot. Any activity which places constant pressure on the ball of the foot can cause sesamoiditis.
Occasionally the cause of pain could be due to fracture of the sesamoids but this is rare.

Symptoms: Sesamoiditis causes pain in the ball of the foot, especially on the inner (medial) side, usually with a gradual onset. The pain may be constant or just occur during weight-bearing activity and may be accompanied by swelling around the big toe joint.
A fracture of one or both sesamoid bones is usually the result of an injury involving a sudden and heavy impact to the ball of the foot and pain is immediate.

Treatment: It is important to off-load pressure from the ball of the foot around the sesamoids. This can usually be achieved with a specially designed pad or modified shoe. Inflammation and swelling can be treated with ibuprofen or a similar anti-inflammatory.
Treatment for a fractured sesamoid involves rest and immobilisation for 6-8 weeks.


VERRUCAE

Verrucae, or plantar warts, are caused by infection with the human papilloma virus and are one of the most common viral infections of the skin. They are commonly found on the soles of the feet where pressure causes them to grow into the dermis. Swimmers are particularly prone to infection partly because the skin tends to be more porous when wet, so allowing the virus to gain access.

Symptoms: In appearance verrucae can look similar to corns. However, there are several differences; usually verrucae develop more rapidly than corns, corns develop only where there is pressure and friction, verrucae tend not to be painful and verrucae bleed quite readily whereas corns do not.

Treatment: Sometimes verrucae will disappear without treatment but, if they do not, or if they are painful or spreading there are various options. A special verruca cream incorporating, amongst other ingredients, tea tree oil, which is available from the clinic, has been found to be very effective against verrucae. It has the advantage of being painless and does not damage the surrounding skin, which makes it ideal for children and diabetics.
Other treatments available include solutions containing caustics, usually salicylic acid or glutaraldehyde, which are painted on to the verrucae and which the patient must continue to do on a daily basis at home. Another option is cryotherapy - destroying the wart tissue by freezing. This can be a more painful method but tends to be more effective and does not require any further treatment by the patient at home.