This article was first published in Ryding2Health Magazine in 2011 and is the first time it has been on my blog.  I've made some small edits which I never had the chance to do first time round, so hopefully it reads better!

As always please feel free to comment.

Pronation is a subject close to many a podiatrist’s heart and traditionally the focus of treatment in many biomechanical pathologies.  

Patients regularly tell me that they “pronate too much” or that they “overpronate” and that their feet are “flat”.  In my experience, the main group of patients who consider pronation more than many other groups are runners.  

I suppose the question is; is pronation really a bad thing?

Let’s begin with identifying exactly what pronation is, and when it occurs.

Pronation is a three-dimensional movement occurring at the subtalar joint in the foot.  Sounds simple enough, but don’t be lulled into a false sense of security; podiatrists undertake three years of study to understand it and relate it to an individual’s biomechanics and that’s just the beginning!

Now before I get inundated with corrections, I know that pronation also occurs in the arm too; but I’m a podiatrist and I only really get to play with feet and legs.  For more information on the arm you’ll need to talk to your local physiotherapist.

When pronation occurs, it allows the forefoot to abduct (move away from the midline of the body) upon the rearfoot, dorsiflex (or lift upwards) in relation to the rearfoot, and evert or flatten the arch of the foot.  The overall view of a foot in pronation is that of a “flat foot”.  

The opposite of pronation is supination and when the foot becomes more supinated it takes on a “high arched” profile.

The diagram shown above (taken from Michaud (1997)) shows both pronation and supination movements.

Now, both of these movements are essential and we use both as part of normal “gait".  As a general rule, when walking the foot strikes the ground in it’s supinated form, becomes pronated to shock absorb the body forces upon the ground, and the becomes supinated again prior to lifting of the ground so as to provide a rigid leverage force to move to the next step.

So is pronation bad?

On the whole pronation is not a bad thing; it’s a necessary movement required for normal ambulation, be it walking, running or your activity of choice.  Interestingly there have been many studies examining the link between pronation and injury and most show that there is little relationship between injury and pronation (those which do show a link are pretty weak).   

Pronation is key in providing shock absorption as the foot makes contact with the ground and then body-mass continues in a downward direction.  These movements require a very complex interplay between joints, ligaments, muscles and the forces acting upon these structures.

Often this will become imbalanced when the forces cannot be controlled or opposed by the body, leading to compensation and then injury.

My role is to examine areas of compensation and injury and identify the causative factor.  This involves looking at the forces acting upon the foot from internally (muscles, ligaments, joints, etc) and externally (footwear, the supporting surface, orthotics) to ensure that a balance is struck.   There are a number of tests that we use clinically to look at how easy (or hard) it is to move the foot from a maximally pronated position to a supinated position.

These forces change when different activities are undertaken; running, has much greater forces affecting the foot and leg in comparison to walking.

When it comes to pronation, the movement isn’t such a bad thing, it’s the forces that hurt and cause damage.   My treatment involves the reduction of these pathological forces and this can involve the use of exercises, footwear, orthotics and mobilisation.  

So what about running shoes?  

Okay, you were always going to ask.  Running shoe design, prescription and personal choice is based on the idea of levels of pronation. And while this is flawed it is really all we have.  However, this will change in the future with some interesting and potentially game changing designs coming from Asics and other companies.

A very experienced and knowledgeable Sports Podiatry colleague, Ian Griffiths, wrote an excellent blog regarding running shoe prescription and I would urge you all to go and have a look.  It surmises the issues and research perfectly.  You can find the blog post here http://www.ransacker.co.uk/running-shoes/goings-on/what-running-shoes-should-you-wear-the-myths-busted/.

This article is a designed to be a quick look at a very complex subject and in essence doesn’t cover everything.  Contemporary research is continuing to challenge current and past dogma leading ultimately to a greater understanding of lower limb biomechanics.  Personally, I think it's a very exciting time for anyone working in biomechanics.

References

Michaud, T (1997) Foot Orthoses and other forms of conservative foot care.  Newton, Massachusetts.  

Health Education with the Pound Green Stroke Group

Podiatrist Dave James

Dave James had the pleasure of visiting the Pound Green stroke group today to provide a talk on common foot problems and how they are managed.

The presentation covered a number of subjects including skin and nail problems, diabetes, surgery, verrucae and biomechanics.  The group asked some excellent questions and happily discussed their own issues and experience.  They also enjoyed the pictures of foot problems.

The session finished with the opportunity for group members to have a foot examination and get some advice from Dave.

Many thanks for Brian and the group for inviting Walk to provide a talk.  We look forward to talking to the Bewdley group in the next few weeks.

If you would like a podiatrist from Walk to visit your group to provide education on foot health then please get in touch on 077 666 888 29 or contact@walkfootcare.co.uk.

Pain in the heel and arch: What is plantar fasciitis and how is it treated?

Foot pain is common and of all the locations for foot pain that I see as a podiatrist, the most common has to be pain in the heel and pain in the arch.

Perform a search on the internet for heel pain and the top "hit" will usually be related to a condition called plantar fasciitis.  Much debate exists on exactly what plantar fasciitis is and whether it is truly related to inflammation.  That debate is one which will continue as we continue to understand the condition more but for now let's keep it simple.

Plantar fasciitis can be viewed as an overuse injury to the origin of the plantar fascia related to excessive stress or biomechanics abnormalities of the foot (Healey and Chen, 2010).  

The plantar fascia is a tight band of connective tissue situated on the bottom of the foot running from the calcaneus (heel bone) to the toes.  It is important because it helps to support the structures of the foot during ambulation, helping you to progress from the moment your foot strikes the ground to the moment you bend your big toe and lift your foot.  The pain of plantar fasciitis affects this process, making ambulation less energy efficient and potentially leading to problems elsewhere in the body.

With plantar fasciitis, patients will often report a pain in the heel, present after rest (for example first thing in the morning) which then eases upon walking.  Generally activity is limited and for some it can be a debilitating problem.  A detailed patient history can often identify a traumatic event or a change in shoes which has led to the onset of the symptoms.

Plantar fasciitis is common (Goff and Crawford, 2011) with approximately 10% of the population suffering (Crawford and Thompson, 2008).  So how do we treat it?

Plantar fasciitis is on the whole self limiting - it will go away on its own.  That's the good news, but if it goes on its own, why do people come to the clinic?  How long it takes to resolve will differ between individuals but in some cases it could be upwards of 12 months and that is why treatment it sought.

The mainstay of treatment is stretches to the calf muscles, the muscles on the bottom of the leg below the knee and the plantar fascia itself.  Stretches have been shown to provide symptom reduction and improve function.

There is also evidence for using orthoses or shoe inserts in the early stages of plantar fasciitis to help reduce pathological forces which act upon the foot, reducing compensation from biomechanical problems.

At Walk our podiatrists can fully assess the heel pain examining your biomechanics to provide the best solution for you.  We will provide advice on stretching, footwear and if required issue you with a set of foot orthoses.

To complement this we can also provide foot joint and soft tissue mobilisation techniques to the foot and ankle which helps with the rehabilitation of the area.

There are lots of causes of heel pain with not all of these originating in the foot.  Pain can be referred from other structures such as the lower back which cause pain in the foot.  This is why it is important to see a professional to diagnose the problem and provide an evidence based management plan.

If you have any problems with your feet and legs, or questions and queries regarding your foot health then please contact us on 077 666 888 29 or 01562 51 56 61.  You can also contact us via email - contact@walkfootcare.co.uk.

References:

Healey, K. and Chen, K. 2010. Plantar Faciitis: Current Diagnostic Modalities and Treatments. Clin Podiatr Med Surg 27, pp. 369–380.

Goff, J.D. and Crawford, R. 2011. Diagnosis and treatment of plantar fasciitis. American family physician 84(6), pp. 676–82.

Crawford and Thomson 2010. Interventions for treating plantar heel pain (Review). The Cochrane Library (1).

Walk is now closed for the festive season and will reopen again in the new year.

Thank you to all of our patients and colleagues for your continued support and custom during 2012.  We wish you a Merry Christmas and a happy and prosperous new year!

We look forward to welcoming you in 2013 for all of your foot care needs.

If you need to contact us during the holiday period then please use the mobile number or email, both of which can be found here.

Kind regards,

Walk Specialist Footcare

Tips for looking after winter feet.

Now that the weather is getting colder and each morning generally brings some frost on the ground, it is vitally important that you take good care of your feet.

This time of year brings with it numerous challenges (dark nights, cold weather, slippery ground, christmas shopping, etc) so looking after your feet during these cold months is vitally important.  The tips below will help you to avoid problems.

1. Make sure that your shoes are appropriate for the activity - cold weather means that protecting them from the elements is important.  Also having a good quality grippy sole for those days when there is ice and snow on the ground will stop you slipping over and causing other injuries.  Even if you don't fall, you may tear or damage yourself leading to a long period of recovery.  If your job involves wearing shoes which don't fit the above criteria, consider changing your shoes when you get to work.

2. Don't get cold feet - exposure to the cold weather can cause a variety of symptoms, such as tenderness, pain and even breaks in the skin.  Chilblains,  an inflammatory skin condition related to an abnormal response to the cold, can be problematic and lead to further issues.  They are more common in females, but can affect anyone, especially those with poor circulation such as the elderly where they can become broken and potentially infected.  Ensure that your feet are warm and covered before going outside and when coming inside again, don't remove shoes too quickly.

3. Buy some good quality socks - while it doesn't sound nice, in winter shoes your feet will be more enclosed leading to an increase in sweating.  Socks made from natural fibres, such as cotton, allow your feet to breathe and can wick moisture from the skin.  Also make sure that you wash your socks at high temperature to reduce the chance of athlete's foot.

4. Pamper yourself! - make sure you maintain your daily routine of washing with a moisturising soap, drying well and applying a good quality emollient to keep the skin healthy.  Keep an eye on your nails; pressure from footwear may lead to an ingrowing nail.  

5. Visit a podiatrist for a foot MOT!  Podiatrists can help maintain the health of your feet and treat any problems you may have.  If you are concerned about the health of your feet or just want a foot check to make sure you are ready for the winter period, then please get in touch.

If you have any problems with your feet and legs, or questions and queries regarding your foot health then please contact us on 077 666 888 29 or 01562 51 56 61.  You can also contact us via email - contact@walkfootcare.co.uk.

Diabetes: 10 steps towards healthy feet.

The following hints and tips are adapted from Diabetes UK and while they focus upon diabetic foot health, a number are also pertinent to all patients.

1. Make sure that you attend your annual foot review.  Your bare feet will be examined by an appropriately trained person such as a podiatrist.  They will then be able to inform you of your risk of developing foot problems and whether referral to another health care professional is required.

2. Check your feet every day for any signs of redness, pain, damage to the skin, swelling or build up of hard skin.  If you are unable to examine your feet then ensure that a family member or carer can do this for you.  If problems are found early then the risk of complications can be reduced.  If you find any of the above then it is important to have it checked with an appropriately trained health care professional.

3. Be aware of any loss of sensation in your feet.  Don't go barefoot and avoid extremes of temperature if you think you have lost feeling in any part of your feet.

4. Always wear well fitting shoes that protect and support your feet and whenever possible don't wear shoes with bare feet.  Foot shape changes as you age and it is important to be aware of changes which have occurred.  If you are buying shoes, your feet become more swollen towards the latter part of the day - this is the best time to buy shoes as it represents your feet at their largest.

5. Look after your toenails.  Don't cut down the sides of your nails as this could lead to an ingrowing toenail.  If you have difficulty with your foot care then contact your local podiatrist for advice and assistance.

6. Avoid the use of corn plasters and self treatment of hard skin with blades as these may damage your skin.  Always seek advice and assistance from a podiatrist.

7. Always wash your feet daily with a good quality moisturising soapfollowed by thorough drying, especially between the toes.  This prevents the build up of fungus and bacteria which can lead to further problems.  Use of a good quality moisturising cream afterwards can help to keep the skin healthy.  For advice on moisturising creams ask your podiatrist.

8. Maintain a healthy and consistent blood glucose level.  This ensures that your diabetes is well controlled as studies have shows that poor glucose control leads to complications such as nerve damage and circulatory problems.  Your GP will ensure that you have appropriately spaced blood glucose checks and it is important that you attend for these.

9. Attend an education course to help you understand and manage your diabetes.  Your should be offered and have the opportunity to attend courses in your local area.

10. Visit a podiatrist!  Podiatrists can help to treat and maintain the health of your feet and are a valuable source of support and information.

If you have any problems with your feet and legs, or questions and queries regarding your foot health then please call 077 666 888 29 or 01562 51 56 61.

A focus on verrucas.

Verrucae or plantar warts are a common, infectious and sometimes painful problem.  It is estimated that 4-5% of children and adolescents have warts or verrucas.  They are caused by infection via the Human Papilloma Virus (HPV).  Most verrucae will spontaneously regress within approximately 2 years.  They are commonly found in children, young adults and those with a compromised immune system.

Are warts contagious?

Yes, however the risk of passing them on to others is low.  Skin to skin contact is required and you are more at risk is the skin is damaged, broken or macerated; for example in swimming pools and changing rooms.

Verrucas can be passed to other parts of the body via scratching and picking.  To reduce the chance of passing on verrucae:

•           Do not share towels
•           When swimming cover your verruca with a waterproof plaster
•           Wear flip-flops in communal shower rooms
•           Do not share socks or shoes

What treatments are available?

Your Podiatrist will undertake a full assessment to ensure that you are suitable for treatment.  The aim of any verruca treatment is to stimulate the immune system to fight the infection.

At Walk there are four treatments we use to treat verrucas - which one we advise will be based on your previous management. 

Debridement and filing - removal of excess verruca tissue and stimulation of the immune system.  This is the easiest method and may cause a small amount of bleeding.

Silver Nitrate - application of a caustic after debridement of the verruca.  THis can cause local staining of the skin and requires regular visits to the podiatrist.

Cryotherapy - following debridement of the verruca, liquid nitrogen is applied to the area twice, with a period of thawing in between.  Up to six treatments are provided; however, the verrucas may resolve in less time that this.  This approach can be painful.

Autoimmunisation/needling - local anaesthetic is used to numb the area being treated.  Then the area is cleaned and sterile needle is used to puncture the verrucas multiple times.  The initial injection is often painful; however, with this approach a single treatment is often required and only one area needs to be treated.

If you have any questions about verrucas or any foot and leg problems then please get in touch.

Call us on 01562 515661 or 077 666 888 29 to book your appointment.