Web viewOf course the word bunion is misconceived and in ... inflammation inside the joint, ... the...

Clinician Portal. December 2016

Conflicting ideas about the human foot are considered for critical discussion. The objective to consider the knowns and confront the facts, as we know them, comparing current and past publications. Clearly while there is no substitution for attending talks, the ethos behind this presentation is hopefully captured.

For those attended either the Birmingham, UK or Tel Aviv, Israel lectures in 2016, the order and material may be different. The material in this article has not been peer reviewed and is solely intended as a website medium. While the author works independently for Spire Little Aston Hospital, the content and views are entirely that of the author.

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Level: simple to moderate. Prior anatomy valuable. Intended audience health professional / students / interested members of the public.

Myths, Facts, Fables. Musings on the Foot Tollafield D R. November 2016 - Busypencilcase Communications Ltd

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Myths, Facts and Fables. Musing on the foot - David R Tollafield

General

We all love stories, whether housewife tales or fables; like burying a piece of steak in the garden used to get rid of warts, or preventing chilblains by keeping a horse’s tooth in a pocket. Eighty per cent of people are supposed to have a foot complaint once in their life… or do we really walk 80,000 miles in a lifetime?

Well, what about walking around the world in a lifetime. True or false? If we walk 10,000 steps a day, and that can be a big ask for a westerner with a car, then we walk around 3.31 miles per day. If we walk 80,000 miles that comes to 1142 miles per year, and provided we live to three score and ten. This could mean walking around the globe, measured at the equator as 24,900 miles distance, completing twice or more circuits.

The most common problems facing the patients are ingrowing toe nails, corns, hammer toes, bunions, neuroma (Morton’s) and swellings such as ganglia – plural of ganglion. These conditions, together with chilblains, nail fungi, heel bump pain and fasciitis (central heel pain), represent frequent complaints presented to the family doctor or podiatrist. The less healthy patients are at greatest risk and there are no myths covering problems associated with nerve damage (neuropathy) and diabetes. The reader is directed elsewhere for matters associated with the ‘at risk foot’.

Damaging the body

With the upsurge in Musculoskeletal (MSK) Sciences, many professions holding a strong interest in biomechanics find their skills overlap. The promotion of gyms and desire to loose weight has driven generations into fun runs. The picture of two fit people running on a treadmill illustrates the target audience; the message - young people stay healthy if they exercise. However, people would do better if they walked all the time rather than subject their bodies to the madness of running, and crashing against the treadmill. It is not just feet, but knees but the remaining structures of musculoskeletal system – hips, pelvis and lower spine, that take the brunt of impact. Perhaps the message is not so much keep running, but use the expertise of professionals to design how we exercise, based on the pre-existing condition of our bodies. A fifteen-minute assessment by a fitness instructor cannot, however well intentioned, assess the human body with sufficient knowledge if weaknesses exist.


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The power of the graph is made here.

Injuries lie low for years; the visual picture expresses an assumed history based on my own experience. Weight gain went up from ½ Kg to 19 Kg (around 3 stones). Male born in 1955-

1965

Activities start at school age then follow into college and peaks off when the career escalation hits 25 years upwards. These are approximate guides as some people do have an exercise ethic even at work.

Recovery from injury when young is fast but the traumatic effect lags behind, re-emerging later because of potential inactivity during mid-life. After retirement, and in some cases mid-life crises for males, the effect of early injury becomes more relevant. The graph is not a generalisation; variables exist, but it illustrates why some injuries are ignored only to be recognised as a pattern of pathology later on in life.

Foot Bones

Feet are designed to walk without pain and should function over variable terrain; the design of the ankle, which in fact breaks down into three joints functions around one key bone, the talus. This is the foot’s steering wheel in many ways and I mention this as it is key to management of flat foot, and also dealing with midfoot pain, plantar fasciitis and metatarsalgia, the generic name for pain under the ball of the foot. How many bones are in a foot?

Patients often say, the foot is complex because there are so many bones. The usual figure is 26 with 28 for the two sesamoids, but 25 can be possible as the fifth toe


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may only have two, if the distal two are fused. Of course there can be numerous accessory bones and the percentages vary between populations and race. Of the true consistent additional bones, sesamoids, number two so 26 or 28 is correct. The sesamoids of the first metatarsal are often left out of the count.

1The Lost Souls of Ushaia and the sesamoid bone

One of the strangest notions to be advanced by rabbinic Judaism—and of relevance to the evolution of the concept of death—was that of the “bone called Luz or Lus”. Luz means Almond tree from the Hebrew and associated with a Canaanite city. The bone was associated with everlasting life. The ‘bone called Lus’ was considered important and held in high esteem as a mystic in religion.

Rabbi Ushaia AD 210 describes the bone in his book Bereschit Rabbi or Glossa Magna In Pentateuchium, [great tongue of the five first books of the old testament – Genesis, Exodus, Leviticus, Numbers & Deuteronomy]- that there was a bone in the human body, just below the 18th vertebra, that never died. He suggested this bone was the repository of the soul after death, ‘should never be burned or corrupted in all eternity for its substance is of celestial origin and watered with heavenly dew, wherewith God shall make the dead rise as with yeast in a mass of dough.’ There is some lack of clarity as to whether this was another part of the skeleton such as the sacrum or coccyx, or elsewhere, the fable caught on but the sesamoid was not a likely candidate.

The emperor Hadrian once asked Rabbi Joshua between the first and second centuries, how God would resurrect people in the world to come. The rabbi, who was a distinguished Rabbinic teacher answered “from the bone Luz in the spinal column.” He had then produced a specimen of such a bone, which could not be softened in water or destroyed by fire. When struck with a hammer, the bone had remained intact while the anvil upon which it lay had been shattered. Vesalius later showed, in 1543, that the bone did not exist.

The sesamoid bones are as important as any of the bones associated with the great toe. The sesamoids are like the knee cap, a vital functional lever for the halluces tendons. The toe is maintained in a stable position during propulsion, being the last phase of stance. We will meet the sesamoid later when discussing hallux valgus

Metatarsalgia

Is Morton’s neuroma more common in the 3-4th interspace over the 2-3rd interspace?

There is an assumption that we know nerves can be traumatised and can cause foot pain and Morton’s neuroma the best known. First described by Lewis Durlacher2 in 1845, Thomas G Morton reported this in 18763 and so took the name. Lorimer and

1 Lost Souls Helal, B The Great toe sesamoid bones: The Lus or Lost Souls of Ushaia. Clin. Orthopaedics & Related Research 1981 157;83-872 Durlacher, L 1945 A treatise on corns, bunions, the diseases of nails and the general management of feet. Simpkin, Marshall and Co, London3 Morton T 1976 A peculiar and painful affection of the fourth metatarso-phalangeal articulation. Amer. J. Med. Sci 71:37-45 http://dx.doi.org/10.1097/00000441-18760100-0002


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Neale reported a 5:1 ratio between males and females in 20024,5 and this was confirmed in later sources. This in fact is true – the author can report 6.2 (65 cases) and nationally 5.8 using a data base of 4138 cases where incidence in gender is biased toward females5.

While footwear is incriminated, we need to be open for many complain of muscle spasm of the smaller interossei and lumbrical muscles. While 3/4rd interspace is considered common, the actual incidence of interspace representation includes 2/3 where it is common to find a bursa. Evidence from audit suggests 2/3 space = 9 versus 3/4 space = 8, for 17 cases.

Histology reports no evidence of a bursa in the sample6 from my own centre. The conclusion is that the location of what was a Morton’s neuroma may arise in either interspace with equal frequency. This is not agreed with from previous studies (1976,1986) where the 3-4th interspace is considered more frequent. Dual interspace neuromata can arise and as recorded 1 out of 19 (5.2%) from randomised histology samples.

Shape of the foot and Morton’s neuroma

The shape of feet is recorded by statues from the ancient world; by toe length. The Egyptians suggest a second toe that is similar in length to the first, while the Greek foot represents a longer second toe. This appears to relate to a short first metatarsal that influences toe length. Modern diagnosis favours ultrasound to confirm diagnosis. Audit shows the value of ultrasound, but the specificity can vary between bursa and neuroma. Sixteen cases were reviewed; 25% were reported as bursa formation where histology contradicted this finding5.

Dudley Morton in 1927 paid great interest toward the genealogy of the first toe, considering the Greek foot predominated in the occurrence of Morton’s neuroma. Jump repeated the study with 184 patients in a retrospective study. In 133 cases taken from his cohort A; patients selected as a control- 20% had Greek foot and were asymptomatic. In cohort B, the group with foot pain and suspected neuroma, 63% had symptomatic Greek feet but also 37% had Egyptian feet. While the association suggests a greater likelihood even with attractive statistical significance (p<0.05) there is no conclusive proof. We can therefore see a divergent discrepancy with statistics and factual evidence forming any useful sense of predictability.

In order to test this finding further, known neuroma from histology were reviewed where x-rays were available; two radiographers looked at the x-rays. Each were slightly different but the greater proportion showed the Greek foot style foot was associated with neuroma mean 68.6%. Although a smaller sample this curiously agreed with Jump.

The arch & the army

4 Jump, C, Rice, M, Gheorghui, Sanchez-Ballester, J 2014 Does the Greek Foot Predispose to Morton’s Neuroma. Open Journal of Orth. 4,176-1825 Tollafield D R 2016 National Database Survey Neuroma Surgery. WWW.PASCOM-10 6 Tollafield D R 2016 Clinical Histology Audit of 17 cases of plantar neuroma at one centre (unpublished)


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http://WWW.PASCOM-10/

Is walking better with a high arch or low arch foot? We all know the answer – I hope? The low arch foot. Well okay if you did not know that this is because the low arch foot has more flexibility.

One of the first ways to manage a flat foot was considered stimulation of the small muscles. Scientists from the eighteenth century had pioneered the advent of electricity used in animals, such as Galvani in Italy (1791). The use of electricity to stimulate muscles became an important development in medicine, and not just for feet. The small muscles of the foot are unable to respond to any significant stimulus, and certainly not for the long arch, which is derived from the external post and anterior leg muscles.

The obsession with arches has led to a mega industry of many different professionals and commercial outlets issuing insoles and arch supports, and making a good living. So do they do any good?

During the first part of the 20th century in Britain a flat foot excluded you from the army. This of course was a travesty. Many athletes perform with flat feet and yet a large industry of speculators make spurious claims. Is this good sales pitch? In fact, it was not until the end of the second world war (1939-45), that Harris and Beath in Canada (1947) set up a large study looking at 3619 Canadian soldier’s feet. They developed an ink mat to study pressure and arches, formed an arch index measurement as well as contributed to some of the x-ray shots of the hindfoot -subtalar joint.

"It is a useless waste of time, effort and money to enlist men whose feet will not permit them to undertake the duties of a soldier even though they may have succeeded in finding themselves a niche in civil life in which they can compete on equal terms with their fellows."

This authoritative quotation comes from the classic and oft-quoted Army Foot Survey7

“It is evident that we cannot be content merely to recognize the deformity of flat foot. Our concern is with function. If this is good it matters little whether the longitudinal arch is depressed”

An army depended on the foot soldier when lack of transport ran and then forced them to depend on their feet. The army doctor focused on the arch for this reason. Stories like the hunter "who tramped 200 miles out of the bush in order that he might reach Edmonton to enlist, and then tramped back again the 200 miles to his trapping ground after he had been rejected because of his flat feet,” made the exclusion somewhat fallacious.8 Fellner9 used e-talk to discuss the flat foot and Harris and Beath’s work. He stated that,

“the flexible, or hypermobile, flatfoot accounted for most of the flatfeet that they identified in their study population. This type was determined to be the normal contour of a strong and stable foot, and

7 Harris, Beath 1947 An Investigation of Foot Ailments in Canadian Soldiers, published in 19478 Seiden, H 1992 Flat feet don't automatically mean bad feet. The Gazette (Montreal) 17 Oct 1992: J6.9 Fellner D, 2012 E-talk Flat feet, kids, the military and orthopedists – what the literature tells us


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not the cause of pain and disability. No one before nor since then has provided scientific evidence to refute their claim, yet the controversy continues.”

The foot is designed to cope with terrain variation and is divided into three arches, the medial long arch, the mid transverse arch and the lateral arch. Morton Altman (1968)10 reviewed lateral weight bearing x-rays of 138 subjects between 1-18 years and plotted the sagittal plane position. He noted that the talus and calcaneus varies in pitch increasing as we reach teens. The pitch of the calcaneus varies, from 1 year, 10-27 degrees but from the age of 6 it reaches 14-26 degrees. The talus decreases with age so starts at 1 year around 23-40 degrees and by six was down to 20-30 degrees. Their study was large and unfettered by strict ethical committee approval, as no doubt radiation was used without therapeutic intention. The importance of the work cannot be underestimated and shows that the foot changes from birth and the wide variation arises so that no-one arch position exists. What is important is the flexibility to undertake the appropriate foot function. What the report did not show was the variation that existed between measurements; today expressions such as standard deviation would be represented on a graph. Attempting to identify single number values as applied to pitch of thee calcaneus and talus was erroneous.

Transverse arch

The transverse arch is made up of the midfoot bones; the 3 cuneiforms and cuboid. These neatly fit the concept of the hump back bridge in cross section. Their small facet like joints allow for little reciprocal movement. It has been suggested

10 Altman, M 1968 sagittal Plane angles of the Talus and Calcaneus in the Developing Foot. JAMA 58; 11:463-470


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that removal of tendons would still maintain a theoretical arch because the bones act like cuboid bricks so that upward forces push the bricks together. As the load increases the bones become more stable as with bridge based on equal forces. Downward force and upward reaction force create stability.

Flexible foot

Of course, some feet look very flat. McPoil (2009) showed that longitudinal arch drops, on weight bearing, 14 degrees, and Nilsson (2012) by 13mm11. The length changes, as does the width with full contact. This provides shock absorption. Shock absorption comes from the talo-navicular joint, created by movement on contact and from the fascial band, which braces the heel to toes. The foot drops down then comes up like a bobbing float on water as we move to toe off.

During normal active life there is no reason why the flexible flat foot cannot cope, but added undue stress in situations where the tissues are exposed to larger forces cause symptoms. This is where orthoses do play a significant part in helping patients. Do we need to ‘jack up the arch’?

A flat foot will not necessarily tolerate a high arch as established in a recent study by Sheykhi-Dolah (2015).

Orthoses and the arch

The type of orthosis comes down to what a patient can wear and tolerate. Females are troubled more by the limitations of designs than males and so there is a gender gap. Twenty people with flat feet aged 20-26 were selected. The three types of orthosis included; rigid (UCBL12), semi-rigid in prefabricated formed plastic and softer polyurethane orthosis. The functional orthotic (b) was tolerated best.

Foot mobility magnitude is expressed as the square root of the difference between the (arch height index)2 and difference in the (forefoot width)2, which provide overall changes seen in height of arch, length and width of foot. Comfort was measures on a 1-10 scale, where 10 was most comfortable. The UCBL scored 3 and the semi-rigid orthosis scored 8. The softer PU orthosis scored 6. This suggests that

11 Shekyhi-Dolagh 2015 (International prosthetics and orthotics international Vol 39(3): 190-9612 U.C.B.L stands for University California Biomechanics Lab. The design is a high rearfoot component and the arch usually raised high on the medial and lateral side affording almost rigid control.


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soft materials alone do not account for the best outcome. The key point to make is that some control is better than no control and soft materials do not make the best orthosis just because they are soft. Hard, rigid orthoses may control the foot as the arch indices changed less in the research, but could not be tolerated.

Anterior (transverse) arch

It is important to say something about the dropped anterior arch. There is no such thing as an anterior arch, although much has been made of it. The three middle metatarsals work independently to the first and fifth metatarsals, which can rise up, exposing the middle three metatarsals. These lateral metatarsals, or rays show different positions of dorsi or plantar flexed. A fixed position is easy to spot. An x-ray shows the heads are relatively even. It is the soft tissue that suggests a metatarsal is dropped. These are difficult to capture by x-ray although the CT views of the foot are achieving considerable visual accuracy. Radiographic studies were made in 100 feet, 59 with hallux valgus, compared to a controlled group.13 While the load may be maintained under the second metatarsal, the heads of the central metatarsals were not significantly different to each other.

Footwear clues

When it comes to treating flat feet it is important to differentiate flexible from fixed. The patient in constant pain needs investigating before using orthoses, and footwear should be evaluated and the turnaround replacement of footwear checked. The shoe illustrated needed to be replaced every 6 weeks. All tred on the medial side had been worn. Because of replacement frequency cheap shoe purchases were used which then needed replacing often.

Bunion from hallux valgus? Conflicting opinions!

13 Suzuki, J, Tanaka, Y, Takaoka, T, Kadano, K, Takaura, Y 2004 Axial radiographic evaluation in hallux valgus: evaluation of the transverse arch in the forefoot. J.Orthop Sci. 9:446-451


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One of the most frequent complaints that can come into the podiatrist’s office is the bunion. One of the first myths is that shoes cause a bunion. Is this true, or not? A picture of a tribesman who has never worn shoes is shown in Root, Weed and Orien, 1977. The deformity is large and the forefoot is wide.

Of course the word bunion is misconceived and in layman’s lexicon it has various connotations. The reasons given in terms of seeking help “Should I wait until it hurts?” “...don’t like the look of it!” “Want to stop it getting like my mother’s” “Can’t get shoes on I want”. The family doctor often sees a bunion differently; not being ripe enough for surgery!

Footwear design and branding

The footballer David Beckham and his pop singer wife Victoria are brand names14. He inadvertently promoted the AircastTM boot after experiencing a second metatarsal fracture, while his wife was photographed by a tabloid newspaper with her bunions.

Many shoes derive from the past for different purposes. The front shape is curious and dates back to the 14th

century in footwear style known as Poulains from the French, although the origins came from Poland. Henry VIII the much revered and hated anti papal English King, wore wide shoes because of his gout. Fashions often take off from courtesans, but today pop stars and sport idols can make a difference to fashion trends. Mrs B’s foot shape does not look too bad. So what is the difference between a bunion and the proper name; hallux valgus.

The bump or exostosis is often considered a bunion, or the soft swelling associated with a ganglion. This causes misshapen shoes. It is perfectly

14 Sara Nathan 2009 Victoria Beckham shows off her pedicure (and bunion) as she loses a shoe11 December 2009 http://www.dailymail.co.uk/tvshowbiz/article-1234900/Victoria-Beckham-shows-pedicure-bunion-loses-shoe.html#ixzz4HFlyi390


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possible to have a straight toe and just a bump. The hallux valgus or H.V. is most commonly referred to as the big toe but it can be associated with more complex deformities. We have to divorce ourselves from appearance and concentrate more on scientific aspects – pain, function, and secondary features leading to morbidity. Pain is often caused by spasm due to inflammation inside the joint, while pain outside is associated with skin pressure, or bump pressure, and poorly fitting shoes. Men suffer HV less than women, however, their symptoms are usually associated with the combination hallux valgo rigidus.

In Japan, Kato and Wantanabe (1981) blamed HV on shoes. Few bunion operations were performed before 1979 and it was recognised that since 1975 western style shoes had increased six fold15. The use of the Geta (socks) and Tabi (wooden sandal) were used up to this point. The incidence in bunions were more notable in women and before 1972 no surgery had been performed; the authors associate the rise in hallux valgus, and moreover need for surgery with changing footwear customs.

Do we need toes?

How important is the big toe for balance? For that matter what about any toe? The toes provide a spring to the step and offsets the load (pressure) across the forefoot. I am often asked when I amputate toes will it affect my balance? Of course it will, but the toe in this scenario is already dysfunctional and the risks of correction minimal. The use of such surgery though is reserved for patients where the toe cannot be salvaged.

Management with surgery depends on patient’s health, home support, mobility and how well they are likely to heal. Later in life, such surgery is often safer with amputations allowing fast healing and removal of the course of pain. Importantly patients can mobilise faster, offsetting problems from longer recuperation. However, there are less common cases where osteomyelitis arises and failed healing arises for many months even with antibiotic treatment. The risk imposed by maintaining unsuccessful conservative care allows surgery to actually become conservative. In the main such surgery tends to be offered to patients where such correction is too complex and risks too high.

Arthropathy - Damage inside the foot!

In 2008 I presented a lecture called ‘sexing up bunions’, of course using the layman’s term for hallux valgus. The lecture is posted on Clinician Portal. The primary reason

15 Kato, T, Watanabe, S 1981 The Etiology of Hallux Valgus in Japan Clin. Orth Rel. Res. 157:78-81


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for the lecture was to reveal the damage that arises with failed diagnosis and management. When it comes to risk from failure to act, then the consequences, while not life threatening, can lead to a form of disability that affects quality of life. We need to go inside the joint to consider the effects.

X-rays are valuable. They show deformity, dislocation, bone density, reduced joint spaces, as well as myriad of affectations with medical diseases or trauma. It is difficult to make a decision off an x-ray because the image can only provide collaborative information. It is not until we go inside the joint that we see the effects of damage. The effect of hallux valgus on cartilage degeneration using the international cartilage repair society grades 0-416 has been studied. Bock et al correlated radiographic observation with intra-operative observation with 196 patients. Seventy-four percent of feet showed damage within the first toe joint. Majority (144 /265 feet) were underestimated by radiologists, validated against intra-operative findings using International Cartilage Repair Society (ICRS) and Kellgren-Lawrence, a separate rating scale for degeneration seen on x-rays. The reliability of the ICRS in HV was evaluated 7 years later by Smith, but this deviates from the flow of this article17 and is not considered here.

International cartilage repair society

Kellgren-Lawrence

0 Normal Normal

1 Superficial lesions / indentation, cracks & fissures

Mild osteophytic lipping, no sclerosis

2 Abnormal lesions extending down to 50%

Moderate osteophytic lipping

3 Severely abnormal, cartilage defect through subchondral bone

Multiple osteophytic lipping, some sclerosis, possible deformity of bone contour

4 Severely abnormal, cartilage defect extending through subchondral bone

Geode’s body is a cyst, forming a myxoid lining due to the traction on the internal capsular ligament. This is easily packed with patient bone chips and after aligning the bone. Cartilage is one of the most spectacular tissues in the body. Patients often suggests arthritis is the cause and that they have aged prematurely with a condition of the old. We talk now talk about arthropathy where the suffix ‘itis’ is being dropped. This is also the case with fasciopathy, instead of fasciitis.

Ganglia - Can a heavy book provide effective treatment?

16 Bock, P, Kristen, Kh, Kroner, A, Engel, A 2004 Hallux valgus and cartilage degeneration in the first metatarsophalangeal joint J Bone joint Surg (Br) 86-B:669-7317 Smith, S, Landorf, KB, Gilheany, MF, Hylton, B M 2011 Development and reliability of an interoperative first metatarsophalangeal joint cartilage evaluation tool for use in Hallux valgus surgery. J Foot Ankle Surg. 50:31-36


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One of the most interesting myths through time is the hitting a ganglion with a heavy book. The bible was cited because it was one of the heavier books kept in most households. In truth this could be effective, that is if additional trauma did not lead to fractures. Ganglia and bursae are often discussed together. Histologically they vary although present similarly, that is they show up as swellings. Even the histology has similar features, but bursae are anatomically normal while ganglia are not. We have seen the ganglion related to a bunion, but the ganglion is not uncommon over the midfoot and ankle.

The thin gossamer lining has a thick clear fluid like gel. The lining is often hard to preserve in the initial incision. Fibrin and myxoid degeneration are present. Bursae are more chronic, they have fibrous components within an organised cystic structure. It is possible to draw fluid off a ganglion but it is short lived. A heavy book will cause the outer membrane to burst. This is then is absorbed only to grow again if the derivative tissue is well organised, as from joint linings or tendon sheaths. Some even grow within the tendon itself. During my research a similar case18 arose in 2009 written up as a case history. If you hit the ganglion it will disperse but the lining does not disappear and can regenerate within weeks.

Dancers - Going on Pointe!

If we stick with the theme of arthropathy, no one can remain unaffected at the beautiful spectacle dancers put on. The foot is beautifully held on the toes. But what of damage? Look at any popular chick flics covering dancing, some hunk will be on hand to nurse blisters and sprains but perhaps not fractures. Pointe dancing (dancing on the extreme ends of the toes with the aid of a toe shoe) as performed by the advanced female

18 Kono, M, Miyamoto, W, Imade, S, Uchio, Y 2009 Intratendinous ganglion in the extensor digitorum brevis tendon. J Orth Science Japan. 14:666-668


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ballet dancer, causes unnatural loading of the foot19. This leads to conditions such as skin problems, soft tissue damage and degenerative joint disease.

To determine the effectiveness of the current shoe, the authors measured the normal pressure distribution on the foot en pointe. Sampling the entire forefoot in the toebox of a pointe shoe showed that pressures are localized at the bony prominences and at the ends of the toes. About 5% of total force is found at the heel and ball of the foot. The pressures on the forefoot could reach 500 kPa and account for about 80% of the total axial force; the remaining 15% being supported by shear forces on the skin.

Lubricating the foot and shoe causes peak pressures to increase by as much as 43% causes difficulty because the foot slips about in the shoe. Further study may result in a shoe design that distributes pressure more evenly over the entire foot, eliminating peak pressures and thus reducing injury.

The great toe receives considerable body force not just going onto ‘point’ but due to constant impact. The square toe box helps but the foot takes a battering. Inside these joints a slow process emerges over time to leave a dancer with a high chance of arthropathy later on in life as cartilage does not repair. The rule in not going onto pointe until 12 years of age20 is universally appreciated because of the growth centres (plates) at this critical time are easily injured. According to the International Association of Dance Medicine & Science the type of dance is important, not the age. In the case of girls, 12 is not the maturation age. Moving onto to adulthood the effects of impact trauma to the great toe are all too easy to see. Small bleeds lead to fibrinous attachment which tear the cartilage and lay new bone down. If this happens at the great toe, the midfoot and hindfoot, let alone more proximal joints, each will bear the pain and pleasure of this specialised pastime. It is for the dedicated alone to survive the rigours and effects later on in life.

The high heel shoe

The high heel shoe is the bane of every podiatrist’s life, or should it be? There are two views. The arch is elevated and can relieve some of the pain brought about by tibialis posterior overuse; this is because the foot is often fully supinated, which does not need extra tendon pull. The heel cord tightens with excessive use and of course lower shoes may not be as comfortable. The forces acting on the forefoot increase, so conditions such as Morton’s neuroma, a nipped off nerve between the 3/4th toes may be created. The ball of the foot is exposed to shear and friction; many women place small siliconised pads into the shoes to help. Risks of injuries to the ankle and higher up the frame, can arise. The compromise is to assess the risk, come

19 R. G. Torba and D. A. Rice, "Pressure analysis of the ballet foot while en pointe," Biomedical Engineering Conference, 1993., Proceedings of the Twelfth Southern, New Orleans, LA, USA, 1993, pp. 48-50.doi: 10.1109/SBEC.1993.24735020 Guidelines for initiating Pointe training J. Dance Medicine & Science 13,(3)90-92


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to an agreement on occasions but do not argue or force a patient. It is better to negotiate a deal; any reduction is better than nothing.

The heel Spur (plantar fasciitis PF)

Nothing has been so maligned than the heel spur in causing heel pain. This is something no doubt many professionals dealing with MSK have to consider. To radiology professionals it seems pretty clear as indicated in this x-ray21. First of all let us be clear. This is NOT a spur but a ledge of bone which goes all the way across. As Johal et al state, the band of fascia sits below the so called spur and does not in fact pull on the calcaneus. Johal looked at 22 patients with a diagnosis of PF22 and relied on lateral x-rays alone and cases were selected that has come to Accident and Emergency with a diagnosis of ankle sprain rather than heel pain.

The fascial band is shown in an MRI confirms there is a co-association with fibres of the Tendo–achilles (TA) but not with the bone causing a spur (not shown, see heel

pain in clinical portal). This makes sense because at 12 weeks of intrauterine life, the TA and fascia are as one and then diverge into two different planes. The main portion of the fascial band inserts into the medial tubercle and this is often associated with greatest frequency of symptoms.

Consider this; the separate body of the calcaneus arises around 6-8

years and joins the main body at 12-14 years. The gap is obvious in the juvenile and the MRI shows the incomplete ossification at this point. The figure above shows the apophysis where the ledge or spur is in its’ primacy.

Conclusion: yes, you can have heel pain with a so-called spur but it is just happenstance. Johal’s study is compelling but the size of the cohort perhaps does not have the appropriate sampling. The use of CT scanning may be more appropriate when conducting such research to provide a 3D picture.

Do corn plasters really work?

21 Johal, KS, Milner SA 2012 Plantar Fasciitis and the calcaneal spur: Fact or fiction? Foot and Ankle Surgery 18;39-4122 PF or plantar fasciopathy is now considered fasciopathy or fasciosis


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Podiatrists are probably more engaged with corns and callus than any other professional. The intractable plantar keratoma is the most painful kind of keratin based lesion and can be confusing. The toe corn is often submitted to a round felt pad, often filled with salicylic acid (40%), which breaks down the epidermal cells and bonds called desmosomes. So, if the skin is hard and it needs softening, then the keratolytic paste can work.

A scalpel in the right hands can reduce surface skin faster without the lengthy wait or risks of pastes causing unwarranted damage. However not all corns are that simple. Cross sections through corns often highlight inflammatory changes. These types of corn are unlikely to clear because a) the changes are too chronic, b) there is a pre-existing fixed toe deformity. The sole of the foot can throw up even more concerns as to what lies below the skin and can be poorly appreciated from clinical examination alone. Hard skin with a crusty centre can be associated with cystic bursae deep in the tissue of the foot. The fallacy that surface management alone can provide effective treatment is misleading.

In work carried out by a number of authors reported by Timpson (2005)23, the effectiveness of debridement is short lived. In reality most debridement is effective between 2 days and one month.

Conclusion

This small range of foot problems is easier to appreciate once we sweep away the myths and hypotheses and replace the argument with better science. The requirement of the clinician to retain a valid reflection of his work remains ever important. Of course there are many foot conditions that need closer scrutiny, and no doubt could fill a book, but then I had to fit this all into the constraints of a short lecture.

23 Timpson, S, Spooner, S K (2005) A comparison of the efficacy of scalpel debridement and insole therapy in relieving the pain of plantar callus. British Journal of Podiatry. 8(2):53-59


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David R TollafieldDecember 2016

David writes regularly for Podiatry Now, has a blog called Footlocker on his website consultingfootpain.co.uk and posts on LinkedIn. You can follow him on LinkedIn and Twitter


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