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BRITISH BROADCASTING CORPORATION
RADIO SCIENCE UNIT
CASE NOTES
Programme 2. - Feet
RADIO 4
THURSDAY 09/08/07 1500-1530
PRESENTER:
BARBARA MYERS
CONTRIBUTORS:
BARRY FRANCIS
PRODUCER:
DEBORAH COHEN
NOT CHECKED AS BROADCAST
MYERS
Hello. Hammer toes and bunions and ingrowing toenails can be corrected by surgery. Athlete's foot can be treated with anti-fungal drugs. So does it really matter if we mistreat our feet - cramming them into sweaty nylon socks and tight fashionable shoes?
Well those poor aching feet can lead to pain right up into the knees, hips and back and neglecting foot hygiene is simply unpleasant and may lead to infections, which we can then pass on to others. We do tend to take our feet for granted a lot of the time but there are some simple things that we can do to make sure that they hold up well into older age. If you want to know how to look after your feet or have a question about treatment then get your check up here. Joining me with the answers today is foot expert Barry Francis, he's a consultant podiatric surgeon at Herts and Essex Hospital.
And our first caller is waiting on the line, she's Alice, she's phoning in North London and she says she's got hard skin. A lot of hard skin Alice?
ALICE
Yes and actually primarily on the three centre toes of both feet. If you can imagine if you're sort of curling your toes over the little areas where the toes curl if you like, extremely hard skin but seems to grow, literally almost as much as I can cut it off every two weeks and it will grow again.
MYERS
Okay, well I'm sure Barry's seen plenty of hard skin on toes and feet generally in his practice, what are you going to suggest for Alice, she keeps cutting it off and it keeps coming back?
FRANCIS
Hello Alice. This is obviously a common problem but for all that it's a very uncomfortable one and as you say can be difficult to deal with. I think the important thing to remember about hard skin is that it's really a symptom of an underlying mechanical or structural problem. So in your case you seem to have some kind of clawing of the toes, this would encourage friction against the shoe and that's why you're getting the hard skin. There are - there could be other reasons for this as well and if left these areas of hard skin could turn into corns, which are even more uncomfortable. So I think you need to look, first of all, at whether the toes themselves are flexible or fixed and you probably need to go along and see a podiatrist or chiropodist and have that checked out. Sometimes I'm afraid there's the harder issues of do I need a deeper shoe to accommodate these types of toes? Well it depends on what you do and what you like to wear and how old you are and sometimes it can be a hard decision if you're younger and want to wear a nicer shoe. In those cases you may be looking at having the underlying deformity corrected by surgery if that was appropriate.
MYERS
So Barry are you saying it's not quite good enough just to kind of keep shaving the skin off, in fact that might be a quite dangerous thing to do, you've got to be really looking at what's causing that to build up because there's obviously something mechanical there to do with the shoe and the way it rubs against the foot?
FRANCIS
That's exactly what I'm saying and whereas the problem might start now with some hard skin, later on when the joints become perhaps more fixed and there's some soft tissue contraction then this may affect the way your foot is working and the way you walk in fact and things may become much worse. So I think early intervention but particularly to get a good diagnosis because it's not always surgery that's required, sometimes you can deal with this by way of exercises, I've already mentioned shoe adaptation as well and things of that sort can be helpful.
MYERS
Alice I hope that has been helpful, there will be more helpful advice I'm sure as we go through the programme, so please stay listening. But we'll go to another caller on corns because Stuart's got painful corns. He thinks it's caused by the way he's walking and that would probably tie in with what you've just been saying Barry, but Stuart over to you what are you hoping for, have a quick word with Barry and see what he can do for you.
STUART
Yes, hello Barry Francis. I've just been told from the chiropodist that it is the way I am walking. My footwear seems to be okay, according to her, and I even get it in open toed shoes - sandals - which I'm wearing at the moment even though with this weather. It seems to occur as I lift one foot - just put the weight down on one foot and take the weight off the other foot, it's the other foot - it happens on both feet, I've had this condition for some years but it's just as I take the weight off the foot it really is painful.
MYERS
Any thoughts on this?
STUART
And it's on the outside of the toe, the outside edge.
MYERS
Okay I think we're getting a fair picture on that ...
FRANCIS
Off the big toe?
MYERS
... of the big toe is it?
STUART
Yes, oh yes, just the big toe, I don't seem to have any problems with any of the others.
FRANCIS
Well Stuart it's always difficult to judge without seeing but what this sounds to me is happening - to be happening is that as you're putting your foot to the ground the foot is rolling over, this tends to pinch the skin and over a long period of time what can happen is you form a corn there but it's a special type of corn which has little nerves and blood vessels in it and this can be exquisitely painful, it's called a neuro-vascular corn. Now that type of corn, if indeed that is what it was, would need professional assistance, not only to actually get rid of the corn which can be done by either paring it away or treating it with electro-surgical...
STUART
Which is what the chiropodist does yes.
FRANCIS
Yeah all of those things but in addition to that you would need to look at the way you're walking and the posture of your foot and perhaps having something in your shoe to assist in that regard.
MYERS
Can I just ask Barry, do you think that perhaps a lot of these problems, which seem superficial although painful in this case, are actually to do with the way we walk, the way we stand, our posture and sometimes we don't really know about that, we haven't had that checked out?
FRANCIS
Well I think - I think it's true, the science of biomechanics is a relatively recent one, as far as the foot and lower limb are concerned, and we've made - if I can use a pun - great strides in the last 10 years or so regarding this. But now there's much more accurate assessment, there's even a video analysis - there's a machine on the market which can actually photographically scan the movements of your foot and assess the problems that are occurring - and this makes it much easier, not only for us to diagnosis the problem but to actually supply you with an accurate insole or orthotic and this is something which goes inside the shoe and holds your foot in a better position.
MYERS
And where would Stuart and others then go if they wanted to have this kind of gait analysis, to help them really get to grips with this at a really fundamental level?
FRANCIS
Well fortunately many of the local PCTs are able to supply this service via the podiatry department and that should be your first port of call. When that's not available then you can approach somebody perhaps who's in private practice offering this service and you need to be sure that they - that is an area of expertise that they can offer you. And in some instances it may be possible to go to a sport's shop, if you're particularly sports orientated, where they can make you up an orthotic virtually whilst you wait.
MYERS
Thanks for that call Stuart. We've got Sylvia waiting, she's in Northern Ireland, and I think is concerned about flat feet, is this a personal problem? Sylvia are you with us?
SYLVIA
Hello.
MYERS
Yes hello, I believe you're concerned about flat feet?
SYLVIA
Yes my arches have collapsed completely.
MYERS
Oh dear.
SYLVIA
Yes and the bone is now touching the ground and causing extreme pain, as you can imagine. I have had - been to the NHS podiatry clinic who gave me a foam insole but it did nothing to help at all. I have now gone private and hopefully that this Monday I may get an orthotic that's being specially made and adapted for my feet to go into my shoes and that's another difficulty - finding - because I rarely wear trousers, I'm 76 years of age, so I sort of wear skirts and dresses, always have done I suppose. And trying to get something that looks - that'll go well with your clothes is another nightmare.
MYERS
Alright, well let's deal with the physical condition, the dropped arches, it does sound very dramatic and let me ask Barry, I mean what would cause this?
FRANCIS
One of the commonest causes of this condition is a weakness or stretching of a tendon that runs down the inside of the leg and foot. This is called the posterior tibial tendon and when it dysfunctions or stretches, and it commonly does, then it can cause the arch to sag or even to drop completely. Now I quite agree with you Sylvia this is a very disabling condition. Fortunately there are a few ways in which we can actually deal with it. I would certainly feel that the first approach would be orthotics, now it may be that you need something more substantial than a foam - a piece of foam inside your shoe and certainly there are devices these days which would hold your arch in a good position and take the pressure off the tendon. Now in some cases it may be that the tendon itself is amenable to repair and this can either be repaired in isolation and occasionally it can be combined with bunion - sorry with bone surgery to actually restore the arch again.
MYERS
So is that an operation that you yourself have done, do?
FRANCIS
Yes it's one that's commonly done by podiatric surgeons and orthopaedic surgeons of course and this has really quite good results. But obviously, as in most of these things, conservative approaches should be tried first before getting there.
MYERS
And as to that further question about shoes that will perhaps incorporate these inserts, these orthotic devices, and look half decent for a woman who wants to not necessarily trousers and clumpy shoes, is there any option?
FRANCIS
There are some options. I have to say that I think you're in a tight corner Sylvia because in terms of wearing fashion shoes, you might be able to wear them for an hour or two in the evening for a special function but on the whole you're going to be restricted to a shoe that actually supports your foot and even if you're wearing an orthotic it's going to need to actually augment or add to the effectiveness of the orthotic itself. So it is difficult. However, there are a number of makes of shoe on the market today that are relatively good looking and light, moreover, and if you're not too dextrous some of these will incorporate Velcro fastenings instead of laces. There's also a number of catalogue shoe companies which offer a range of shoes for the difficult foot, many of these - one or two of these at least - can offer a service where they can modify the shoe at quite a modest price. So there are things out there if you look for them.
MYERS
Okay Sylvia thank you for your call. I'd like to go to Manchester because Sandra is on the line and she's concerned about flat feet. Her three-year-old son, I think it is, with flat feet. What's the story Sandra?
SANDRA
Hello. We noticed Patrick's flat feet last time he had his shoes fitted, the lady pointed it out, and his feet look completely flat to the extent they sort of tilt inwards. So we've mentioned it to the health visitor and we've been referred to a podiatrist but I'd just like to know whether that's rectifiable because he's so young, is that something that they can correct and what they actually do?
MYERS
Barry, is this the same as the problem we were talking about just now with Sylvia about fallen arches or is this a different condition given that it's a three year old child?
FRANCIS
I don't think this is really a condition at all, I think this is just a stage of child's development. Of course you can't just take things for granted but if Sandra you imagine your child's foot is a bag full of bones, which are not necessarily at the age of three connected up, they gradually grow to connection as the child's foot develops, then you can see that there would be a great deal of instability. So the fact that you see a child with a foot that rolls in or where the arches collapse is not necessarily an omen that his or her life will be blighted by bad feet. Nevertheless, I do think you're right to seek professional advice on having it assessed but in many cases this type of foot can be addressed well with a good fitting shoe, perhaps incorporating some simple type of insole to give the foot support. Now it may be that that type of device is actually intended to deal with an arch problem, which your podiatrist or orthopaedic surgeon or paediatrician may diagnose, but equally there may be a value in wearing this type of device in order to reduce shoe wear - excessive shoe wear - and to produce joint damage - reduce joint damage. And we do know, for example, that in a young person - not at the age of three admittedly - but in a young person perhaps around the age of 8 to 10 years old, if the foot rolls in excessively one of the things they can develop is a painful bump under their knee and this is often associated with posture, it's called Osgood-Schlatters Disease, and other types of painful knee problem, commonly occurring in young people because of the posture of their feet.
MYERS
Sandra, I hope that's been helpful, thank you for that question. And just thinking more generally about children and feet and shoes and getting them fitted, do you think that we know just how to fit children's shoes well enough these days, certainly you don't get them x-rayed anymore which I think is a very good thing, but how good are shops, how good are parents at getting the right size and the right shape of shoes for children?
FRANCIS
Well I'm on fairly dangerous ground here, you'll appreciate, because obviously I'm not monitoring these kinds of things but I've been in practice long enough to feel the changes and to see the changes and certainly it's my impression at least that there is a reduction in the number of independent shoe retailers dealing with children. And indeed in my own area recently one of our long established shops has actually given up selling children's shoes. And with that of course goes an enormous amount of experience, which has been built up over the years by people who can actually fit the shoes properly. That's not to say that the good shoes aren't around, they are, and that's not to say that the good shoe shops aren't around. But I think perhaps there are fewer of them, maintaining a stock of children's shoes is very difficult because of the large number of sizes and designs, they probably don't move as quickly as adult shoes. So I do think as a responsible parent you're going to have to look a bit harder. Fortunately a lot of the chains are providing better footwear now, so perhaps there is a balance there as well.
MYERS
But do you say then that some of the problems that you see in feet in later life really do go back to perhaps bad shoe fitting for growing feet?
FRANCIS
I think that many of the problems that occur in life may well be related to poorly fitting shoes in childhood, although that perhaps is getting better addressed now. But it's also my impression that untreated conditions in childhood, postural conditions of the foot and lower limb, which are not addressed, as that child grows into adulthood they develop other problems, they may be problems such as hammer toes or bunions, but equally they may be knee or low back problems. And as a personal view only, unfortunately I won't live long enough to actually be sure of this, but my feeling is if every child was assessed early in life and dealt with appropriately by way of orthotics and by exercises or other kinds of treatment, we would see far fewer hip and knee replacements in lower life, although of course I have to concede that there can be genetic predispositions towards arthritis and those things.
MYERS
We'll go to the phones again, in Staffordshire Gwyneth Jones is calling and she's concerned about bunions. Gwyneth, you've got a bunion, more than one bunion causing you trouble?
JONES
Hello. I have several bunions. I've had - it's been interesting listening to the thoughts about history of foot care. I had a lot of problems in my teens with my feet and lower arches and like Sylvia I don't think my arches have dropped to the floor but they're certainly low and have caused me a lot of problems. And I think that now I've reached 50 I think that this is affecting my knees and my hips, particularly. But the reason for my call is that I've developed a bunion under my second toe and - which I was - well - shocked about really because I just thought bunions affected the big toe. But now I've got this lump underneath my second toe which has caused a lump on the top of my toe which is preventing me from wearing all kinds of shoes and really all I can wear are old trainers.
MYERS
Okay well let's put this question to our expert Barry, who's looking a little bit quizzical at the idea of bunion on the second toe?
FRANCIS
I was - it's a - if we look at this Gwyneth one thing I would say, first of all, is that I think there's a popular view now, professionally, that bunions certainly start much further back in the foot than the big toe joint itself. So that would mean that not only would be the big toe joint be affected but also the arch itself. And indeed one of the reasons for considering bunion surgery would be in some cases to stabilise the actual arch. But very often what will happen is that not only can the bunion - the big toe move from side to side, as a deformity, but it can actually move upwards. Now when it moves upwards like that you could see that the weight that it should be taking is then transferred to the second toe and to the second joint. And this will cause - this can cause that joint to become inflamed, sometimes called a capsulitis.
MYERS
And just before you go on for those who are lucky enough not to have ever seen a bunion, I mean by a bunion we're talking about an inflamed joint are we?
FRANCIS
Very often an inflamed joint but certainly a joint where the joint appears to be buckled, so that the metatarsal bone, which is the lone bone that attaches to it, points outwards and the big toe points inwards. You then get this reddened inflamed area which can or may not be painful - not all bunions are painful.
MYERS
So that's describing something that's very familiar to Gwyneth I dare say but is there an answer then to just quite what she should do next, I mean I guess if you really can't wear any shoes and can't get around so easily then this is quite serious.
FRANCIS
Yes it's a very big subject and it deserves more than a few words but I'll make it as brief as I can. By the way the word bunion comes from the Latin turnip, so that perhaps gives you an idea of what your joint could look like when it's really bad. Very often if this big toe is going upwards, as it seems to be with you Gwyneth, it may be that you have a degree of a condition called hyper mobility, which means excessive flexibility. And this would be one of the factors that your clinician will take into account when he's determining what type of surgery or treatment will be appropriate for you. Now in some cases orthotics can be very helpful in this kind of condition and I'm afraid in other cases you are looking at surgery. That may be surgery just to correct the alignment of the metatarsal bone and the big toe joint itself or it may be that you need to go a little further back on the same area, back to the base of that metatarsal bone and fuse that where the hyper mobility is really bad and stabilise not only the joint but the arch itself.
MYERS
Okay, so a specialist podiatrist treatment by the sounds of it. But I wonder if I could just take another e-mail here from Jess. She's saying she has bunions, she's had them since she was a teenager, she doesn't get pain from her bunions but she's wondering if she should have an operation to remove them because she would like to be able to wear shoes with a fashionable heel. Would you wish to remove her bunions on that basis Barry?
FRANCIS
Well the surgery to bunions has greatly improved over the last 10 or 12 years. At one time foot surgery or the foot itself was regarded as a Cinderella of the body. I think it's been much more professionally addressed now. But nevertheless, in spite of the considerable improvements in bunion surgery, where really excellent results are often or usually obtained now, you still do need to consider that balance between risk and benefit. Now clearly one of the factors that you need to consider is does my foot hurt because on rare occasions you may have a foot that doesn't hurt and you have surgery and it does.
MYERS
Okay, I can't resist this final quick e-mail, which comes from Louise, who wants to know what her boyfriend can do about his smelly feet. In a word what can he do Barry?
FRANCIS
He needs to ventilate his feet, he needs to wear more open shoes, he needs to wear natural materials - cotton, wool - he needs to wear leather shoes without synthetic insides and he needs to use a foot powder, not talcum powder, which is astringent and will cut down the sweating.
MYERS
Good advice for everyone at this time of the year. Thank you very much indeed to Barry Francis for his expertise and thank you all very much for all your questions today. You can listen to the programme again if you go to our website at bbc.co.uk/radio4. You can get more information by calling our free and confidential help line, that's 0800 044 044.
And join me again if you will next Thursday at 3.00 for your questions on how to enjoy the sunshine while it lasts without causing sun damage to your skin.
ENDS
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