How diabetes can affect your feet?

Your feet are supplied with blood to keep them healthy and have a large number of nerves to detect pain and act as an early warning system for potential injury. For example, if you have a stone in your shoe, nerves will send a message to your brain to remove the stone and hence prevent injury to the feet. However, if your diabetes is poorly controlled for a long period of time it may result in:

Nerve damage, termed peripheral neuropathy, which reduced sensation to the feet and /or reduced blood supply as damage to the blood vessels occurs.

Nerve damage may mean that you no longer notice small objects like a stone in your shoe, due to loss of sensation to your feet. This could then lead to a wound or injury that you can’t feel, and a possible infection. If you have poor circulation, any injuries or infections to your feet, even seemingly minor, will take longer to heal as there is less blood flowing into the arteries in your feet. Blood provides energy to working muscles and aids in healing damaged or injured tissue. If you have poor circulation, you will need to take extra care to protect your feet from injury. Most foot problems in people who have diabetes occur when injuries, and often infections, go unnoticed and untreated, and when healing is delayed due to poor circulation.

What can your Podiatrist do to help?

Having your feet checked every six months will help detect changes early to minimise the chances of problems occuring. A diabetic foot assessment involves:

Examining the circulation by feeling foot pulses and sometimes listening with a small hand held machine called a doppler.

Examining the nerves supplying your feet by testing your ability to detect vibration and light pressure as well as testing your reflexes

Checking for any problems with foot posture that may be creating areas of excessive pressure in the form of corns and callous that may have the potential to develop into an ulcer

Examining your footwear to ensure thay are suitable

Ensuring that there are no other problems with nail

Determining what level of risk (high, moderate or low) you may be for developing foot problems related to diabetes and whether you need to be reviewed at closer intervals.

Diabetic Foot Care is a post from: Lefort Podiatry - Melbourne Podiatrist

Warts

Are growths on the skin caused by a virus called human papillomavirus (HPV). Plantar warts are the term for those found on the foot and they may be either single warts or a collection of warts covering a large area termed mosaic warts.They are not always painful but may be if they’re underneath an area subjected to high pressure such as the ball of the foot and the heel. The virus causes thickening of the top layer of skin and are often mistaken for a corn or callous. Warts are usually aquired from person-to-person contact. The virus is not highky contagious but may cause an infection by entering though a small break in the skin.

Warts are known for being difficult to eradicate as they live in essentially dead layers of skin where there are no cells that detect infection to start the immune response and fight the virus.

Treatment Options

The choice will depend on how painful the warts is, the location and size of the wart/warts and the age of the patient. Below are the treatment options offered at Lefort Podiatry:

Liquid Nitrogen: is a very cold liquid applied to the wart to freeze the fluid inside the cells so that the wart virus can’t survive. It usually requires several treatment sessions to destroy the wart.

Acid preparations: is applied in a paste or paint form made up of 2/3 different acids that aims to erode the wart in a slow and controlled fashion and is usually applied under waterproof tape and left alone until it’s changed every 2-3 days. This a slow process and the acid is usually well tolerated but is better for small areas only.

Formalin 10%: is used mainly for children when the wart is not causing a great amount of discomfort as it is painless and easy to apply using a piece of cotton or gauze soaked in the Formalin. The Formalin acts to dehydrate the cells makiing it more difficult for the virus to survive in the cells. it also irritates the skin making it more likely for the body to detect initiate an immune response.

Silver Nitrate: silver nitrate is again painless but is only a temprary treatment in the majority of cases as it forms a cap or ‘eschar’ over the top of the wart that prevents further growth and spread of the wart to other areas. The body sheds the cap in about 2-3 weeks just like it does with a scab and some of the wart tissue may come of with the cap but is usually not enough to kill the wart completely.

Efudix cream: is a prescription medicine that comes in a paste form. It needs to be applied twice daily under a waterproof tape and is usually used for approximately 10 weeks. It is a newer treatment option and works by killing cells that divide and ‘reproduce’ at a rapid rate such as wart cells and for this reason it is known as an antimetabolite medication.

Deep Needling: is a more aggressive means of treating warts but has been used with higher success rates than some other treatments. The disadvantge is that is requires an injection of local anaesthetic around the wart but the advantage is that usually only 1-2 treatments are required and if there are mutliple warts treating only one will often result in eradication of others. This is because the idea of the needling is to push the wart deeper into the 2nd layer of skin, called the dermis, where the immune mediating cells live and initiate an immune response against the virus.

Surgery: if all else fails and the wart is very painful then surgery or curretage may be considered. This is the surgical removal of the wart under local aneasthetic done in the clinic room.

Wart Treatment is a post from: Lefort Podiatry - Melbourne Podiatrist

Is a treatment in which a very fine acupuncture needle is inserted into the skin and muscle directly at a myofascial trigger point. A myofascial trigger point is a painful knot within a tight band of muscle. Pain frequently radiates from these points of local tenderness to broader areas, sometimes distant from the trigger point itself. Trigger points usually occur in muscles that have been overworked, often through overuse or due to abnormal foot posture.

Is dry needling similar to acupuncture?

Although there are many simillarities and differences between dry needling and traditional acupuncture, dry needling is strictly based on Western medicine principles and research.

How does dry needling work?

The exact mechanisms of dry needling are not known. Recent studies have shown that inserting a needle into trigger points can cause complicated changes to both the tension of the muscle and the chemicals in the blood around the trigger points, resulting in breaking up of the knots, increased blood flow and reduced pain.

What type of problems can be treated with dry needling?

There are many conditions causing musculoskeletal pain of the lower limb, ankle and foot that could potentially be treated with dry needling. A common example is trigger points within the calf and foot muscles referring pain to the heel that are often overlooked in those presenting with plantar fasciitis/heel spur syndrome. Other conditions may be related to the achilles tendon, calf spasms/tightness or any other muscles below the knee.

Is dry needling painful?

The majority of patients feel very little on insertion of the needle. Sometimes a small muscle twitch may occur that elicits a very brief (less than a second) painful response that some describe as a very little electric shock. The needles generally stay in for 10-15 minutes and during that time patients describe the sensation as feeling nearly nothing to a mild deep but comfortably tolerable aching sensation.

Can I expect any side effects after the treatment?

Although there are very few side effects some patients report being mildly sore after the procedure. The soreness is described as muscle soreness over the area treated and occasionally into the areas of referred symptoms. Typically, the soreness lasts between a few hours and two days. Patients are always advised to apply heat at home after the treatment over the area of needling as this significantly reduces post needling muscle soreness. Ice is not advised as this is likely to rapidly cause the redevelopment of trigger points.

How many treatments will it take for the treatment to work?

Typically, it takes several visits (usually between 4-6) for a positive reaction to take place. The aim is to basically reprogram the muscle. This is often done in conjunaction with other therapies, such as joint mobilisation/manipulation and orthotics, to address the underlying cause of the trigger points.

Dry Needling is a post from: Lefort Podiatry - Melbourne Podiatrist

An ingrown nail (called onychocryptosis) is a painful condition where the nail is growing in either an excessivley curved or an excessively flared direction into the skin at the nail edges. This causes a significant amount of pain and often associated infection requiring the nail edge to be removed. If the problem is recurrent, the most appropriate definitive procedure is to remove the nail edge and the cells where the nail starts its growth, called matrix cells, as it’s either damage or a congenital problem with these cells that dictates the pattern of nail growth.

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An infected ingrown nail.

What happens on the day?

The procedure is undertaken under local anaesthetic. A small and quick injection of local anaesthetic is administered into either side of the nominated toe to completely numb the entire toe.

The foot is then prepared under sterile conditions for the procedure.

The procedure involves removing the offending nail edge inculding the matrix cells with sterile instruments.

A chemical called Phenol is then applied down the side of the toe into the small pocket where the matrix cells were to kill any remaining cells, should they exist, which reduces the chances of regrowth to a very low percentage.

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You will need to bring open-toed shoes as you will have a dressing on the toe for 2 days that will not fit into closed shoes.

What happens after the nail surgery?

The area is initially dressed with an antiseptic, non-adherent dressing and tubi gauze to hold the dressing in place.

The area is an open wound and must be treated with care, therefore the initial dressing must be left on and kept dry until you next see your podiatrist as it ensures the area is kept completely sterile and clean, reducing the chance of infection.

What happens when I go home?

You will be able to walk and function normally
You will be advised to keep your feet elevated and rested on the day as much as possible. There will be some discomfort so it is adviseable to take simple analgesia such as panadol or panadeine before the local anaesthetic wears off, your podiatrist will advise you of appropriate pain relief.
You shall receive a handout infroming you of postoperative care and it is esential that you follow these instructions to ensure healing takes place problem free.

Are there follow up appointments?

You shall generally see you podiatrist for the 1st dressing change where he will remove the bulky dressing, clean the wound and ensure no infection is occuring. You will then continue redressing the wound yourself as per the postoperative handout.
You shall then be reviewed in approximately 10 days to ensure healing is occuring as expected and you will be required to continue dressing the until heaking is complete.

Ingrown Nail Surgery is a post from: Lefort Podiatry - Melbourne Podiatrist

What are foot orthotics?

Foot orthoses are shoe inserts designed to support, align, or improve the function of the foot.

There are many different kinds of orthotics. Those recommended by your podiatrist are often prescription devices, custom-made to suit your individual needs and biomechanics (the way your body moves). However depending on your situation, non-presription refabricated or semi-custiomised devcies may be adequate.

Who wears orthotics?

People of all ages with a variety of foot or related lower leg or back problems wear orthotics. Sports people are often prescribed orthotics to help maximise their performance, as well as to address mechanical problems. Children may also be given orthotics to improve foot posture whilst their skeleton develops. Anyone suffering from a chronic foot or lower limb condition, which is limiting their mobility or independence, may benefit from wearing orthoses.

When are orthotics used?

Orthotics may be advised for your particular foot problem after a comprehensive assessment, taking into account your own biomechanics, footwear, and occupational and lifestyle factors.

Orthotics provide valuable long-term solutions in the treatment, prevention and rehabilitation of acute and chronic foot conditions such as heel pain, tendon and muscle pain, recurrent ankle sprain and stress fractures, by providing consistent postural control. Orthotics may also help reduce the occurence of corns, callous and ulceration by redistributing the pressure of the body’s weight on the feet

What can I expect when being prescribed orthotics?
A full clinical assessment of your foot problem prior to prescription
Prescription orthotics tailored to your individual needs
Provision of any additional treatment as required
Advice regarding exercises, footwear and training methods where relevant
Fine-tuning or correction of any problems experienced in wearing your orthotics

Orthotics is a post from: Lefort Podiatry - Melbourne Podiatrist

Is the injection of small volumes of a local anaesthetic/glucose solution done with very fine short needles just underneath the skin to repair damaged nerves that are responsible for chronic pain and associated problems such as Achilles tendon injuries and shin splints.

Often pain is due to injury to the nerves themselves. The injury to the nerve is often thought to be a kinking or constriction in the nerve as it penetrates muscle or fascia. This results in abnormalities if the nerve function that begins to develop all along its length. If there is restriction of the fibres of a nerve, the nutrients can’t flow down the fibres, so the ends of the nerve can’t repair themselves and they become pain generators themselves. These points are extremely tender. There is a principle called “Hilton’s Law” that says that the nerve supplying sensation to a joint also supplies sensation to the skin over that joint and the muscles that move that joint. This law suggests that if a nerve is irritated that supplies skin over a joint it may affect (cause pain and change function) the ligaments, tendons or muscles around that joint and indeed the joint itself. Inflammation in the nerve (neurogenic inflammation) causes inflammation in those soft tissues and joints, preventing healing.

The solution used to treat the injured nerves consists of a glucose and lignocaine mixture that suppresses inflammation and if done often enough, allows healing in the nerve itself and the tissues it supplies. The solution is safe for those with diabetes as it is given in such small volumes that it has no measurable effect blood sugar levels. This new technique was developed by Dr John Lyftogt in New Zealand and is called Neural Prolotherapy. He has published many reports of his results with this technique, with excellent results, particularly reagrding the Achilles tendon and shin splints.

Two recent studies have now been published, all consecutive patient type.

Lyftogt J. Subcutaneous prolotherapy for Achilles tendinopathy Australas Musculoskeletal Med Nov 2007;12(11):107-109.
Different dextrose concentrations were clinically trialed over a four-year period with long-term follow up of 132 Achilles tendons. Results are broken down by year and cannot be looked at in total with information given. A representative year was 2006 in which 30% glucose was use in 0.1% ropivacaine and 0.1% lidocoane. In that year 34 tendons in 31 subjecdts were treated with mean age 47 (28-69) years, and mean symptom duration of 14 months (1-60). The mean length of treatment was 7.6 weeks (3-15 weeks) 84% were available for long term followup at mean of 12 months with mean VAS change from 6.7 to 1.1 and 88% of those that were contactable at 12 months satisfied with treatment.

Lyftogt J. Subcutaneous prolotherapy treatment of refractory knee, shoulder and lateral elbow pain. Australas Musculoskeletal Med 2007;12(2):110-112.
In 2005, 127 painful knees (74), shoulders (33) and lateral elbows (20) were treated with subcutaneous prolotherapy. . The treatment was well tolerated and safe. The treatment protocol consisted of weekly treatments where possible. All active TPs were identified by palpation and injected subcutaneously with 0.5-1 ml of a Glucose 20%/Lignocaine 0.1% solution. The objective at the time of each treatment was to achieve complete local anesthetic pain relief. Treatments were continued until VAS 0-1 and/or after consultation with the patient. The combined outcome statistics for the treatment of the 2005 knee, shoulder and lateral elbow pain showed a mean length of symptoms of 23.9 months and a mean treatment length of 7 weeks. The mean initial VAS 6.7 reduced at follow up of mean 21.4 months to VAS 0.76. The combined satisfaction rate at follow up was 91.7%. However, the follow-up success was an average of about 75% so approximately 25% were lost to long term follow.

Prolotherapy is a post from: Lefort Podiatry - Melbourne Podiatrist

Is a manual therapy consisting of rhythmic stretching and deep pressure to the soft tissue of the lower leg, ankle and foot. Soft tissue includes muscles, tendons, ligaments, nerves and fascia (a fibrous sheet or band of tissue enveloping, separating, or binding together muscles, organs, and other soft structures of the body). A number of factors such as foot posture, activity levels and body weight can overload the soft tissue resuting in pain and injury. The soft tissue can become inflammed, develop adhesions (the tissue basically sticks together) and scar tissue and the fascia can become thickened reducing the range of motion of the joints and increasing pain.

How does Soft tissue mobilisation help?

The goal of these techniques is to restore normal texture to the tissue and reduce associated pain.

This is achieved by:

Restoring range of motion to stiff joints and improve flexibility of muscles.

Relieving muscle tightness, spasms or restriction which reduces pain.

Improving muscle tone and balance.

Reducing stress on bones and joints.

Assisting in the removal of toxins and waste products to reduce muscle fatigue and soreness.

Increasing healing rate by promoting increased blood flow to the soft tissue.

What conditions does deep tissue mobilisation address?

Deep tissue mobilisation is effective for any conditions involving lack of mobility and/or pain within the soft tissue.

Common examples include heel pain, chronic ankle pain, shin splints and calf/achilles pain.

Soft tissue mobilisation is also recommended to help the feet adapt when adjusting foot posture with prescription orthotics.

Soft Tissue Mobilisation is a post from: Lefort Podiatry - Melbourne Podiatrist

The feet of young children are soft and pliable, so abnormal pressures can easily cause the foot to deform. The foot of a child grows rapidly during the first year, reaching almost half their adult foot size. That first year can be very important in the development of the feet.

Although foot and ankle pain in children is not as common as in the adult population, there are certainly problems that arise in growing bones and muscles that are more common in particular age groups. For example, non-specific growing pains is common in the age groups 3-5 and again at 7-9. Also heel and knee pain frequently occurs in both boys and girls between the ages of 9-15.

What are some of the common conditions treated by Podiatrists?

Flat feet

Toe walking

In-toe (feet point inwards) and out-toe (feet point outwards) walking

Limping both painful and painless

Ingrown toenails

Curly toes

‘Growing Pains”

Heel pain termed Sever’s’ disease

Knee pain called Osgood Schlatter’s disease

What can a Podiatrist do to help?

Assess your child’s lower limb skeletal development and gait (walking pattern) to determine whether intervention is required.

Recommend exercises to help balance muscles and reduce foot defomities

Prescribe orthotics to help correct abnormal foot posture

Provide advice regarding footwear and expectations of normal skeletal development

Refer your child to an appropriate specialist as required

Children’s Feet is a post from: Lefort Podiatry - Melbourne Podiatrist

Problems with the Achilles tendon usually presents as a dull ache in the Achilles region (the back of the heel) typically about 5cm above the heel bone but may also occur as the tendon attaches onto the bone.

The pain may be due to tendonitis which is inflammation of the tendon, or more commonly tendinosis, which is an accumulation of tiny tears (microtears) as a result of overuse of the tendon. Less commonly a significant tear or complete rupture of the Achilles tendon may occur that requires surgical repair.

Causes

Achilles tendon problems are most often caused by overuse or repetitive movements that may happen during sports, work, or other activities. Foot posture can increase the risk of injury when the foot over pronates (excessively roll inwards) increasing the amount of strain on the Achilles tendon. Being out of shape and poorly conditioned, or not warming up before exercising may contribute to Achilles tendon problems. Inappropriate shoes for particular activities with poor arch supports or rigid heels may also predispose to injury.

Treatment

Orthotics
Joint and soft tissue mobilisation
Prolotherapy
Dry needling

Click on treatments to read more.

Achilles Tendon Pain is a post from: Lefort Podiatry - Melbourne Podiatrist