Bartholomew Way Clinic

Friday morning clinical meeting

We always try to have fun while working hard at Bartholomew Way. We all got together to go through a few more complex functions of our new practice management software (PPS from Rushcliff software) .

I captured a couple of interesting shots of podiatrists and physios at play.

Heel Pain

The term Plantar Fasciitis is often used as an umbrella diagnosis to cover all sorts of types of heel pain.

The Plantar Fascia is a band of tough fibrous ‘ligament-like’ material that runs from the base of your heel to the underside of all your toes.

The suffix ‘itis’ means a structure is inflammed.

A true plantar fasciitis is an inflammation of the band itself , usually on the tightest side between the heel and the big toe.

Click to enlarge

Heel pain itself can be a complex mixture of injury to different structures around the heel and ankle, involving much more than just the plantar fascia.

When treating heel pain problems it is crucial to carefully examine and test to identify the specific causes of your individual heel pain.

We often see patients who have been diagnosed as suffering with “plantar fasciitis” by practitioners who have not even examined their feet!

It is essential to achieve an accurate picture of what structures are actually causing your pain, to ensure we are using the best treatment for your particular heel pain problem.

Tarsal tunnel syndrome is an entrapment of nerves around the middle side of your ankle, that can mimic plantar fasciitis. This condition needs a different treatment approach to a classic case of plantar fasciitis.

Tarsal tunnel syndrome often occurs to a greater or lesser extent alongside cases of tibialis posterior tenditintis / tendinosis. The tibialis posterior tendon is one of the most important structures the holds up the arch of your foot, and in cases of flatter feet can be overworked and injured.

Plantar nerve entrapment, is a condition where deep nerves within the fatty pad of the heel can become irritated and will also mimic or exacerbate plantar fasciitis.

Good examination technique and the right choice of tests, can help us to better understand your individual injury, getting you on the road to recovery sooner.

Call us now to discuss your problems with one of our podiatrists before making an appointment.

(01403) 276272

Sole of Padders Shore

click on the photo to enlarge

Bunions, Hallux Valgus, HAV

A bunion (or Hallux valgus) is a condition of the big toe joint (or the 1st metatarsophalangeal joint) where it presents as a prominent bump on the side of the foot. There are many factors involved in its development such as pointed or high heeled shoes, foot mechanics (congenital or hereditary in origin) and injury.

The term hallux valgus actually describes the big toe (the hallux) and its position (valgus- meaning the toe points away from the midline of the body). This is a simple term which describes a condition with a variety of complications.
At first the joint may show as an irritated, swollen skin area that is constantly caught between the shoe and the joint beneath. The deformity may become more pronounced (but not always). As time goes by, the pressure may result in a thickening of the joint edge, creating an even larger lump to rub against the shoe.

The problems experienced can include:-

• Discomfort as the side of the foot is rubbed by the shoe.
• The formation of corns and calluses
• The cosmetic appearance can worry its owner.
• Finding appropriate shoes to accommodate the foot comfortably, especially for women who want to wear something more fashionable.
• The toe deformity may push the second toe upward, causing it to then be rubbed by the shoe.

Treatment options include the following:-

• Advice on shoe design.
• Shoe stretching , width or specific dome stretching, over the affected toes to better accommodate the foot shape.
• Clinical reduction of associated callus and corns.
• Padding to protect prominent joints or to improve toe position where possible.
• Orthotics to improve or stabilize foot function and off load the big toe joint.
• Shoe modifications to augment orthotic control.
• Surgery for cases that do not respond to conservative treatment. The aim of which is to improve toe joint function where the surgeon feels it is appropriate.

Adult aquired flat foot deformity & Posterior Tibial Tendon Dysfunction

Adult aquired flat foot deformity (AAFD) can be a painful condition resulting from the collapse of the arch of the foot occurring after the skeleton has fully matured.
There are multiple factors contributing to the development of this problem such as damage to the nerves, ligaments, tendons and bone fractures of the foot that can cause subluxation (partial dislocation of some joints).

Adult-acquired flatfoot deformity has often been linked with dysfunction of the posterior tibial tendon. The loss of active and passive pull and elongation or rupture of the tendon alters the normal biomechanics of the foot and ankle. The reasons for this can be many and varied including; Diabetes , Rheumatoid Arthritis , age , injury and prolonged use of steroids.

The problems experienced can include:-

• Pain and swelling along the medial (big toe) side of the arch and ankle area corresponding to the track of the posterior tibialis tendon which travels from the back of the leg under the medial ankle bone into the foot.
• Pain along the lateral (outside) edge of the foot.
• There may be pain at the end of the day or after long periods of standing.
• It may not be possible to do a one legged heel raise (while keeping the knee straight ).
• It may not be possible to participate fully in their normal activities or sports.

Treatment Options include:-

• Orthotics specifically designed to control the position of the foot, so keeping better foot and ankle alignment.
• Over-the-counter pain relievers or anti-inflammatory drugs may be helpful.
  An off-the-shelf (prefabricated) shoe insert may work well in very mild cases.
• Laced ankle boots ( like walking boots ) can give extra foot and ankle support .
  Ankle support braces.
• Shoe modifications to the sole to stabilize foot function.
• If conservative treatments  are unsuccessful then surgery may be considered.

Pes Cavus & High arched foot types

The opposite end of the spectrum from the flat foot types , characterized by a broad appearance high arch , prominent instep and clawed toes .The forefoot appears dropped relative to the underside of the heel when non weight bearing . Ankle movement may be limited which can then lead to increased forefoot weightbearing .

High arches may be hereditary or acquired, and the underlying cause may be neurological mechanical or neuromuscular .

The problems experienced can include :-

Difficulties fitting shoes , toe rubbing , arch/joint pain , hard skin under the ball of the foot and issues involving the body’s ability to move forward (saggital plane blockade) including back , knee , forefoot joint pains , sesamoiditis and plantar fasciitis.

Treatments include :-

• Advice on footwear design (avoid low /flat heeled shoes) ,
• Shoe stretching to help accommodate for clawed toes and foot width,
• Symptom management ( address biomechanical factors , treatment of corns / calluses / nails) .
• Surgery is only usually considered if there is considerable pain or interference with a patients mobility .

Claw Toes & Hammer Toes

These terms are attempting to describe the altered position sometimes adopted by our toes. In many cases these may be seen but cause no problems
Each toe is made up of three small bones called the phalanges (except for the big toe which has only two).
The toes join the main body of the foot at the metatarsophalangeal joint (or MTP joint). The ball of the foot is formed by these MTP joints.
Each joint is surrounded by a joint capsule made of ligaments that hold the bones together.
Tendons run along the bottom and top of each toe and working in combination allowing us to curl and straighten our toes.
Problems can be the result of shoes (too short , too pointed or with heels that are too high) .The second toe ( and sometimes the third toe) can be longer than the big toe, giving rise to pressure from some shoes , resulting in the toes having to bend to fit into the shoe.
The foot shape, a high arched or flat foot, can result in an abnormal tendon pull on the toes causing them to adopt an abnormal position. Anything that can influence foot position has to be considered.
As time passes the toe joints that are not able to move normally, may stiffen or eventually become fixed so they will not straighten out. As a result pressure may cause calluses or corns to form over the top surface of the toe, at the tip of the toe or under the ball of the foot.

Treatments include:-
Examination of medical history so as to highlight the possible underlying causes and influences (bone fractures, significant injuries, operations, neurological conditions). These will be important in deciding on any strategies for future treatments.
Advice and guidance on shoe design, appropriateness for a particular activity and looking at the fit (this may help reduce the deformity and help return the toes to a more normal condition).
Shoe stretching can help in a lot of cases, with existing and new shoes, to reduce pressure over a prominent joint.
The appropriate stretching of the joint may help if it has just simply become stiffened.
Padding can be used to reduce and control symptoms, and in the long term, can help to manage problem toes.
Orthotics and insoles may be required to redistribute pressure and influence foot function if indicated in certain instances.
If all else fails, referral on for surgery can be discussed.

Tailors Bunion or a Bunionette

This is a similar condition to a bunion (hallux valgus) but affecting the little toe which moves so that it starts pointing towards the big toe (or towards the mid line of the body).

There can be many causes including rubbing on shoes that are too narrow, the foot naturally widening as it ages , the natural mechanics of that particular foot type , trauma or injury . The prominence of that area may produce a callus and a thickening of the skin around the joint .

The problems experienced may include the following:-

• Difficulty fitting shoes comfortably, especially for women who may prefer a more fashionable design.
• Pain or discomfort either due to shoe tightness or as a result of the way the foot mechanics works around that joint.

Treatments include:-

• Stretching the shoe so as to accommodate the prominent joint.
• Reduction of corns and calluses and considering appropriate padding
• Insoles can be used to offload the joint or orthotics to help control abnormal foot function.
• Surgery may be considered if conservative treatments don’t help .

Andrew Jenkins Last Day at BWC

We are very sad to see Andrew leaving the clinic to focus more on his own practice in Storrington.

Gary and Jo suggested that since he is such a fan of biscuits and cookies we should provide a special leaving biscuit for him. Youtube videos of him eating the leaving cake and biscuit may surface later….

Bye Andy we will miss you loads...

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