Gout hurts!

There is an old quote I often use about gout: put your finger in the vice grip and tighten it as hard as you can, that is rheumatism; give it another half turn, that is gout. The message of the quote is that gout really hurts, it is really painful, exquisitely painful. That is the hallmark of gout. Gout most frequently affects the big toe joint of the foot and if you only have minor pain, then its probably not gout.

A red, hot, inflamed, swollen big toe joint is probably gout. However, it could be due to other things as well. The most important of those is an infection in the joint, which is really serious as it needs to be diagnosed and treated urgently to prevent any destruction in the joint from the infection and the inflammation and to prevent the infection spreading.

Gout occurs when uric acids crystals deposit inside the joint because it is the body’s way of getting rid of the higher levels in the blood. It does not work out too well and that uric acid causes the painful inflammatory reaction in the joint. The uric acid comes from purines, so the best way to treat gout over the longer term is to reduce the dietary intake of food that are higher in that (eg alcoholic beverages; some fish, seafood and shellfish, including anchovies, sardines, herring, mussels, codfish, scallops, trout and haddock; some meats, such as bacon, turkey, veal, venison and organ meats like liver) or use drugs that help the body to get rid of the purines (drugs to block uric acid production such as allopurinol and febuxostat or drugs that improve uric acid removal by the kidney such as probenecid and lesinurad).

Other drugs such as colchicine and anti-inflammatory drugs are also used, more in the short term to help with the pain. ICE packs over the joint too can also help.

Gout is not really a condition of overindulgence or lifestyle as is portrayed in the stereotypes, it is mostly a condition of genetics with lifestyle and diet only playing a smaller, but still important part. This historical perception of gout is a barrier to proper care and management. Those with gout have been shown to have a poor adherence to the correct medication routine and this is hampering the management, so please follow the medical advice for the treatment.

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Heel pain that is worse first thing in the morning?

Do you have pain under the heel that is worse in the morning and gets a bit better after you have taken a few steps?

If you do then there is a very high probability that you have plantar fasciitis and that pain is called ‘post static dyskinesia‘. While there are many other causes of heel pain and some other causes that can cause that post static dyskinesia, plantar fasciitis is by far the most common cause of the first step pain in the morning or after prolonged rest. As with all types of problems, getting the diagnosis correct before time, energy and money is spent on a treatment is important.

Plantar fasciitis is the most common musculoskeletal problem that we see at Croydon Total Footcare and it can range from a minor annoyance all the way to quite a severe disability that is so painful that doing things like going to work is difficult.

The plantar fascia is a very strong ligament like structure on the bottom of the foot that is a flat sheet connecting the heel bone to the toes, so its primary function is to support the arch of the foot. Anything that puts too much strain on that plantar fascia, such as being overweight or having high sports activity levels or being on your feet all day on hard concrete floors, can increase the risk for getting it.

Our approach to plantar fasciitis is to get the diagnosis right first and make sure that it is actually plantar fasciitis that we are dealing with. Then there some advice re the initial pain relief with the use of education, ice and maybe strapping to settle it down. Then the longer term strategy is needed. This might involve foot orthotics to prevent the load in the plantar fascia and an exercise or loading program to make the plantar fascia stronger so it can take the loads. Each approach is likely to be different between individuals and that is a discussion that you need to have with one of our podiatrists.

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How to fix ingrown toenails?

Ingrown toenails can become a real problem and they tend not to fix themselves. A true ingrown toenail occurs when a spike, sharp corner or edge of the nail actually penetrates the skin (becomes ingrown) and can become swollen and infected. A lot of people have pain down the edge of the nail that is not technically an ingrown nail but it is a spike, sharp corner or edge of the nail pushing on the skin, but not actually penetrating the skin. In some cases, a corn or callus may even form down the nail sulcus from that pressure from the nail. We see a lot of ingrown nails at Croydon Total Footcare.

What can be done for an ingrown toenail?

This will depend on what exactly is causing the pain, if the nail has penetrated the skin and just how far down the side of the nail the problem is. The podiatrist will meticulously remove the offending piece of nail and smooth the edge of the nail. If it is deep and maybe infected, a local anaesthetic may be needed.

If the nail is very curved and goes deep down the side, this may be an ongoing problem, so a minor surgical procedure may be needed to remove that side of the nail and a chemical used to stop that part of the nail from growing back. This is often the case if the nail progresses to this stage:

If the nail looks like that, the only solution is the removal of the edge or bit of the nail that has penetrated the skin. Not topical cream or antibiotic is going to take that bit of nail away.

What can you do to fix an ingrown nail?

If it looks like the picture just above, then there is not much you can do, so come in and see us before it gets any worse.

If the nail is not infected, the the best thing that you an do for it is to NOT cut down the egde as that can leave a sharp corner or spike and it could become worse. If you are able to use a nail file to keep the edge of the nail smooth, then that may help.

Your best option is to probably come in and let us have a look at it, clear out the edge of the nail to relieve the pain and discuss the different options you have for the long term and what else you could do to manage it yourself.

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Can the ‘bunion correctors’ actually correct a bunion?

These are splints or braces that you are supposed to wear at night and are claimed by those who sell them to correct the bunion (or more appropriately called ‘hallux valgus’). If you look at the pictures of them, it is easy to see how they might do that. The question then becomes, do bunion correctors work?

Thinking about the physics and biomechanics, it is easy to see how the brace could try to correct the position of the toe during the night. The only problem with that thought is that the next day you have all the forces of weightbearing and the footwear pushing the toe back the other way. It is probably likely that those forces easily overcome any correction that may have occurred over night, at least theoretically.

What does the actual evidence say? One study has shown that they do actually work. They showed an improvement of a few degrees after a few months of use, which seems a good outcome. However, what the study did not show (and no other study has looked at) is that if there is any more improvement if it is used for longer or if the improvement is maintained if use of the bunion corrector is stopped. Based on this it is hard to give advice on if the bunion correctors do work at improving the angle of the big toe. That does not stop a lot of people asking if they work in forums and Q & A groups online.

Having said that, that does not mean that they do not have there uses. However, that use often has to be combined with the use of exercises and footwear advice. They can be particularly helpful at increasing the mobility of the joint and that can have a significant impact on the ‘aches and pains’ coming from inside the joint that can be common in those with bunions. We do have these available if you think you would benefit from them and please do not hesitate to contact us if you have any issues with bunions.

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When should running shoes be replaced?

Running shoes are probably the most important piece of ‘kit’ that a runner has. Running shoes can also be expensive and if you are not using the right running shoes, this may increase the risk for an injury and may affect performance. Running shoes can ‘wear out’ and need replacing.

How often should a running shoe be replaced?

There is no hard and fast rule to answer that question. Some runners wear out there shoes a lot quicker than others. You do often see advice that they should be replaced every 350-500 miles or 550-800 kilometers, but that is not based on any actual evidence, but still could be a good guide.

Probably the best way to know when a running shoe should be replaced is to listen to your body. How do the shoes feel? Are they starting to interfere with the way you are running? Do you feel like an injury might be starting? Above all, use your common sense.

When you get your new running shoes

As running shoes wear out, there are going to be very subtle changes in the way that you run. They will be so subtle that you probably will not necessarily notice them, but your body will adapt and be used to those changes. When you get your new pair of shoes, there can be a problem as you will suddenly be changing that way you were running in the older worn out shoes. This can cause an injury if you are not careful. You should only do a few shorter runs in the new shoes initially to allow your body to adapt to the new shoes before using them for most of your runs.

If you have some questions about running shoes

Please do not hesitate to get in touch with us. Craig has had a lot of experience with running shoes and has recently completed the New York Marathon.

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Chilblains Season is Here

As the weather has started to cool for winter we have started to see some chilblains as it is that time of the year. That can also be a bit misleading as chilblains are not technically due to the cold weather, but are due to how the small blood vessels in the foot respond to the changes in temperature from cold to being warmed up.

Chilblains are typically red painful and itchy spots on the toes and other areas of the foot (though they can less commonly also affect the hands, ears and nose). They only appear in the colder climates and are pretty much unheard of in warmer climates. They typically occur when the foot has been cold and is warmed up too quickly for the small blood vessels to react to that change in temperature. This releases chemicals that cause the itch and creates an inflammatory reaction leading to the chilblain. They can become quite painful and break down which might lead to an infection. Repeated exposure to the cold may lead to the chilblain becoming chronic.

The best way to deal with chilblains is to prevent them from happening in the first place. This means making sure the foot does not get cold, so keep on warm socks and closed in shoes. If the foot does get cold, then make sure it is warmed up slowly. Do not put a very cold foot in front of a heat source – warm it up slowly.

If a chilblain does occur, then protect it. Keep it warm. Use some gentle rubbing of it with a cream to stimulate the circulation. Please give us a call and come and see us if you are troubled with chilblains. There is plenty we can do and plenty of advice that we can give.

You can read all the latest research on chilblains at Podiatry Arena, Craigs blog post on beetroot and chilblains as well as an episode of PodChatLive on chilblains.

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Our Response to COVID-19

COVID-19 has certainly been a major upheaval in everyone’s lives and in too many cases having tragic consequences. We have all had to adapt to the short term impacts of this on our lives and there will be long term changes in our lives as a result of this.

We have had a number of calls if we are still open (we are) and we certainly understand people’s reluctance to go anywhere unless they really have to. Our priority is your and our health and safety. We know that people with foot pain need to be treated. At Croydon Total Footcare we have always had a high standard of infection control to protect our patients and us. Since the COVID-19 outbreak, we have implemented new safeguards such as protective screens, adjusted appointment book scheduling to ensure there is no patient to patient contact and the increased use of personal protective equipment. We are also asking people to remain in their cars in the parking area if we already have someone in the clinic.  Our stringent sanitisation of all shared surfaces has also been increased.

For those who just need advice, a second opinion or simple follow-up we now offer a telehealth service, so this can be done over a video call. Most health funds are paying for this, at least in the short term. Please contact us for more on this.

At Croydon Total Footcare we are following all the guidance given by the Victorian Government and the Australian Health Profession Regulatory Authority as well as advice from the Australian Podiatry Association. You can rest assured that we are giving your (and our) safety the highest priority so we can better manage your foot problems. Please give the clinic a ring if you have any questions.

Stay safe.

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Severs Disease or Calcaneal Apophysitis?

Heel pain in kids is something we see a lot of and something that is quite common. Ask a group of, say around Year 6 school kids, about it and you can assume that they have had it or if they have not had it one or some of their friends have had it – it is that common. The most widely used term for this is ‘Sever’s Disease’, named after Dr Sever’s who first described it. The technical or medical name is ‘calcaneal apophysitis’. At the back of the heel there is a growth plate that growth in children takes place at. The condition is a strain or irritation of that growth plate. The growing area of the bone merges with the rest of the heel bone (calcaneus) in the early teenage years, so the condition does not exist after that age.

The issue with the terminology is firstly there is a movement away from naming conditions after people, so the terms ‘Sever’s’ should probably be dropped because of that. Secondly, there is also the issue of calling it a ‘disease’ when it is not a disease. Using the word disease to describe this problem is nocebic and conjures up all sorts of images in the child’s mind so that should not be used also for that reason.

Typically, the symptoms of this condition are at the back of the heel and are worse during activity. They may be reproduced by squeezing at the back of the heel bone. While this is the most common reason for heel pain in children, there are a number of other less common conditions that will need to be ruled out and it is important to get the diagnosis right in case it is something more serious.

The cause of Severs Disease or Calcaneal Apophysitis is most likely just simple overuse; that is too much activity, especially on harder surfaces. A higher bodyweight and tighter calf muscles may also be an issue that increases the risk for this.

The typical approach to treatment after getting the diagnosis right is just reassurance of the child of the self limiting nature of this condition and load modification of activity levels and lifestyle to keep the symptoms under control. Sometime a cushioned heel raise can be used to protect the area. ICE can be used after sport to help the pain.

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What is a plantar plate tear?

The plantar plate is an area on the bottom of the joint capsule that surrounds the joints of the lessor toes. It is a powerful ligamentous structure that provides stability to the joint and serves as an attachment area of other ligaments around the joint. Sometimes that thickened ligament can get strained, which typically gets called plantar plate dysfunction. Sometimes it can progress to a small tear in the structure and can become quite painful to walk on – this is what is known as a plantar plate tear. It is a fairly common musculoskeletal problem seen by podiatrists.

Typically, it is painful under and just in front of the metatarsal head to walk on and to palpate the area. When standing the toe of the affected joint might be slightly elevated. There are some specific tests or movements that a Podiatrist can do to the toe to test the integrity of the plantar plate and to determine just how affected it is. The cause of a plantar plate tear is not that clear but there are a number of factors that do increase the chances of getting it, but mostly is it due to overuse with too much dorsiflexion of the toes (or toes if more than one is affected).

The best way to treat a plantar plate tear is to get the diagnosis right. It is usually fairly obvious clinically, but if it not clear then an ultrasound examination can be used to determine the extent of the tear. The initial treatment approach is to use taping for a plantar plate tear that holds the toe in a plantarflexed position and “rests” the plantar plate by limiting the amount of dorsiflexion of the toe when walking. A metatarsal dome placed just behind the painful area can also be useful to help do the same thing. Stiffer or rigid soled shoes or shoes with a rocker can also be used to help limit the dorsiflexion forces on the toe. If this is done right, the plantar plate tear should generally heal up over a few months. It does not happen quickly and is typically more of a slow and steady improvement over time. We have started using the Fix Toe device lately as it is a more practical approach than having to keep tape or strapping on the toe. If this does not help, and occasionally it dosen’t, then a surgical repair of the tear is indicated.

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Foot Pain in Pregnancy

Pregnancy comes with significant body changes, some of which can actually take place in the feet. The added bodyweight, the fluid retention and the hormonal changes increase swelling in the foot and lower extremities, increasing the chances of foot pain and the ligament laxity may result in structural changes to the feet.

Pregnancy and Foot Swelling
There are several factors that contribute to foot swelling during pregnancy. The body produces more blood and body fluids when you are pregnant and also retains more water during the pregnancy. The venous system is also compressed as the pregnancy progresses which impairs blood flow back up to the heart. All of this leads to an increase in foot volume, leading to footwear fitting issues during the pregnancy.

Almost all of the extra fluid is lost with the birth of the child, so this problem tends to be temporary. During the pregnancy, elevating the feet and using compression/support stockings may help with the symptoms. Also, consider the Archie Thongs.

Pregnancy and Ligament Laxity
When pregnant, the hormone relaxin increases to relax the pelvis which is quite normal and is needed to facilitate the birth process. However, that hormone also affects all ligaments in the body including the foot. Combine that with the weight gain and you can see how the foot can be affected. This can decrease the arch height, increase foot pronation and increase the length of the foot. This means, a flattening foot deformity may result in other problems such as bunions, posterior tibial tendon dysfunction, as well as knee and back problems.

Foot orthotics may help protect and support the feet during pregnancy. The use of good and supportive footwear of the right size is also important. The Archies Thongs are particularly useful.

Pregnancy and Foot Pain
Several studies have shown that 40-50% of women have foot pain during pregnancy. This can range from feet that feel achy, especially while standing for long periods of time to more painful conditions, such as plantar fasciitis. The cause of these problems are mentioned above: weight gain, swollen feet and the hormone, relaxin.

The treatment of the foot pain during pregnancy will depend on the underlying cause of the pain. Please talk to your podiatrist about that.

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