Mirella Falcone

Good evening, everyone. I hope you're well and welcome to our webinar on foot and ankle treatment my name is Mirella and I'll be your host for this evening our expert presenters our Consultant Orthopaedic Surgeon, Mr Bal Dhinsa and Sports Medicine Podiatrist, Mr Liam Stapleton the presentation will be followed by a Q&A session so if you'd like to ask a question during or after the presentation please do so via the Q&A icon which is on the bottom of your screen this can be done with or without giving your name if you would like to book your consultation we'll provide contact details at the end of this session please note the webinar is being recorded I'll hand over now to Mr Liam Stapleton and you'll hear from me again shortly.

Liam Stapleton

Hello everybody and welcome to our webinar me and Bal will take you through a little whistle stop tour of foot and ankle pathology and some of the treatments are available for some common conditions. I am a specialist in podiatric sports medicine I've been a consultant at Benenden for about five or six years now registered with all the appropriate bodies we're all College of Podiatry and Royal College of Physicians and surgeons of Glasgow postgraduate qualifications in sports medicine and foot and ankle surgery my specialty is conservative treatment of foot and ankle of foot and ankle injury primarily musculoskeletal and sports injuries through some guests lecturing different universities primary Queen Mary University of London and I have a special interest in ultrasound scanning diagnostic ultrasound and injection therapies so podiatry services available at Benenden so for myself clinical consultation and treatment we do ultrasound scanning which is where we can diagnose complaints in in the clinic during your consultation which speeds up that consultation and diagnosis process, do a variety of image guided injections, minor nail surgery and growing toenail surgeries, done in outpatients we do shockwave therapy, orthosis, gait analysis, and obviously referral for things like foot and ankle surgery with Mr Dhinsa here. So, some common conditions we are going to discuss problems with your big toe hallux, Morton’s neuroma which is trapping over in the forefoot, capsulitis planter plate injuries, valgus ingrown toenails some real foot pathologies like arthritis are very common ankle ligament injury problems plantar fasciitis flat foot problems and Achilles tendon problems. So in the forefoot one of the most common problems we see is problems with the old big toe or hallux or limitus or registers normally caused by arthritic changes in the joint causes limitation in movement so basically that can cause pain in the joint or commonly it can cause pain as you compensate for the lack of movement and the Hallux valgus is where the big toe deviates and there's no longer in a straight position again it's very common and really this is that's something about Mr Dhinsa is going to talk about in detail in his part of this presentation sesamoiditis and sesamoid injuries are also two little bones under your big toe and they're easy to be injured and generally you'll find pain at the ball of the foot normally during exercise or immediately after exercise and pain on first step. The metatarsalgia is something you hear a lot about and there are different causes of it methodology itself being a descriptive term of the pain that you feel a bit like headache or back pain a couple of common reasons for this a Morton’s neuroma essentially is a trapped nerve in the forefoot this is a really common problem as it progresses the nerve gets thicker it gets more compressed and it tends to give a burning numbness pins needles electric shock pains both in the ball of the foot and extending into the toes. Now often there is an overlap with this with capsulitis and plantar plate injury often caused by biomechanical overload so when normally your second metatarsal joint, the second toe joint is overworking this tends to feel a bit more like a stone on a shoe bruise kind of feeling inflammatory pai. It can feel swollen as well there is an overlap between the overload of that joint and the neuroma and often you get both existing together, which makes it slightly more complicated to treat. If the capsule to the swollen joint caption is left and not treated it can cause damage to the ligament that is underneath you get plantar plate tears and rupture, and this is when you start to notice the toe starts to hammer and can dislocate.

Rear foot, one of the most common things I'm going to see in clinic is plantar fasciitis, essentially that's pain in the centre of the heel normally most people describe pain on the first step when they get out of bed in the morning eases off after 10 minutes of walking around and then build through the day as they've been active we estimate that about 10 of the UK population has this during their lifetime normally we have a gradual onset of symptoms although it can come on suddenly and sometimes you can tear your planter fascia if we think that is the case then definitely we will need to perform an ultrasound scan it's commonly misdiagnosed so I see a lot of referrals in clinic for plantar fasciitis for pretty much anything that hurts on the bottom of your foot but most of them a lot of things I see that are referred because they think of that are not plantar fasciitis can self-resolve if you're suffering with it after two years you probably know it run away that. Arthritis, so ankle arthritis subtalar joint arthritis are really common can be the result of injury and certainly injury historic injury that goes back you know can be 10 or 15 years earlier or more mood for arthritis is also something I see a lot of again caused by trauma or caused by collapse in the arch hard mobility can cause it as well because it destabilizes the joint. Arthritic pain generally stiffness loss of range of movement, mild inflammatory pain and the mechanical pain it's a pain when it moves pain after you've been resting for a while so when you've been asleep and you get up in the more get up first of the morning tends to hurt occasionally if it's very bad it can cause night pain to pain that wakes you up in the night getting that you've probably waited a bit too long to get seen so make a make a note to definitely make it priority to get that scene so something we see a lot of both me and Mr Dhinsa here is an adult acquired flat foot so this isn't a normal flat foot people normally naturally some people are naturally flat-footed and then normal if they function well with a flatter foot that's fine if you didn't always have a flat foot and one of your feet becomes flat or one and then the other becomes flat as you all can see that and then that isn't normal and certainly when you get pain and you get a difficulty when you're actually walking, struggling to stand on one leg these are the sorts of things you should look out for with a flat foot. One of the tests we have for this being a problem is whether you can stand on tiptoes, if you can raise easily up on tiptoes with no pain and very little difficulty, especially on one foot, it's probably not a problem. If you cannot then it may well be worth having this seen, so the most common reason for this starts as a problem with one of your tendons the tendons that holds the arch up in your foot called your tibialis posterior tendon, this could be degenerate and get weak it can be torn you are ruptured. Hypermobility is another it is a predictive factor for this essentially more mobile more flexible your foot is the harder the soft tissues have to work to maintain the arch and maintain function. You tend to notice a gate pattern it is a one foot if one foot's affected one foot really isn't doing pushing it’s very much a propulsive, so you'll see some walk along and foot kicked out to the side like the photograph here, one foot's doing all the work the other foot's doing very little at all. This can lead to deformity arthritis if not seen early and that's often when they get into Mr Dhinsa hands and he has to perform magic to get you back, literal magic to get you back to normal we're better off catching these early I think he'd agree there are things he could do to fix these, I don't know if that's including your talk yet well but to set you up for that. There’s something I see a lot of in in our clinic we do treat our patients for is ingrown toenails, so we can go internal surgery is will we remove a small piece normally a small piece of ingrown piece of your nail sometimes that can also be include some of the soft tissue of the skin can include the whole nail, depending how bad it is but normally, it's a small piece of nail. We do this under local anaesthetic where we have numbed the toe, it is almost completely painless I would say, yes, and it stings a little bit but with the actual procedure itself is painless. Normally for recovering two three weeks, if you are fit and healthy and a permanent solution so something we would I treat with a 97% success rate. Low risk of low risks associated with it the and obviously it's something that if left can cause some serious problems you know and there was a story when I was training of a young professional footballer who lost his toe because it wasn't treated early enough and then obviously subsequently went on to not fulfil his career  because the infection that he got, so worth having that treated. Achilles tendinitis, Achilles tendinopathy, again something I see most clinics to be honest there are lots of sub types of Achilles tendonitis or tendinopathy Achilles tendonitis tends to be that the older name for this and now is strictly speaking used for Achilles problems associated with inflammatory arthropathy and so all your sports injuries musculoskeletal injuries and the stuff that mostly falls into minor Mr Dhinsa's hands are now called Achilles tendinopathy subtypes of this acute or chronic so acute tend to be more inflamed or feel more inflamed and chronic tends to be some tender degeneration and weakening there's also subtypes amongst that as well with calcic changes the tendon which make it more difficult Hagler’s deformity which again probably Falls more under Mr Dhinsas hands plantaris is a small tender that lives with inside your Achilles and that can cause problems too and commonly bursitis you see symptoms along with the insertional Achilles types and obviously we separated between insertional and mid-portion Achilles problems. All of these should be very treatable so that people often live with years and years and years of chronic pain with Achilles problems, and it shouldn't be the case we have enough tools in our box between us for the almost 100 percent of these to be resolved so that's something well worth noting if you're suffering for a long time. So treatments wise, I'm going to talk about some of the conservative stuff so this is the stuff that I do in our patients at Benenden Hospital most every clinic so injections not all injections and steroid injections that's the first thing to say a steroid is used synonymous with what people might know whether it's cortisone or corticosteroid essentially these are painkilling injections or anti-inflammatory injections really useful, certainly when picked for the right patient. There doesn't always have to be a limitation on them depending on how well you tolerate them they've been used for 70 plus years and we know more about them than we probably almost do anything else we do in clinic call the trigger that corticosterone injection is picking the right diagnosis picking the right patient and then guiding the injection so we do image guides and injections in outpatients. All the injections I will do will be misguided, we know that something like half of blind injections miss what they are actually trying to try to inject and if you have a scattering click it'd be slightly remiss not to use it. I think a different type of injection so sometimes we get a lot of questions about injections of everyone always thinks that they're all the same they're all steroid a sodium highlight injection or sometimes called hyaluronic acid injection essentially WD-40 for rusty joints so if you have a mild to moderate arthritic joint these can be useful in relieving some of the mechanical pain. We do not tend to change much of the inflammatory symptoms you might get and that is sometimes why I mix them with a corticosteroid and do both but certainly for the grinding you might associate with an arthritic joint that can be really useful.  In the knee they have been shown to reduce the need for knee replacement surgery in in-page station in end stage patients who need a knee replacement by years, so they have there they have the uses. A different type of injections that I do regularly is high volume Achilles injection now this is called a hydro dissection injection it's an it's a way of freeing off adhesions onto Achilles tendon with water and logs anaesthetic primarily we do it under guidance needle never goes into the body of the Achilles but separates adhesions and you can see the inflammatory caloradoper signal on your ultrasound scan and reduce as you do the if you do the injection it doesn't negate the need to do the rehab afterwards that certainly gives you a break from the pain you've been having most patients walk out pain-free and local anaesthetic injection suggestions that numb pain and are useful for doing injections and it's useful for doing minor operations and so it's a it's a good it's a good adage to have to enable us to do other procedures in clinic. I will say as well sometimes we a bit of an old-fashioned way but sometimes we use a local anaesthetic injection if you have two or three diagnoses that come up on a scan you're not sure which one is the one that hurts so say you've got three arthritis joints and you want to work out which one hurts the most we can actually put a small amount of local anaesthetic into each joint at the time and don't have you walk away and test it, it's really good for working out which joint is the one that's really causing your pain if you've got several joints causing a problem. Now something I do in clinic and you don't see it's not around that much is shock wave therapy shock wave has now been proven although I'm I've been claiming that it does that for a few years now to stimulate the body to repair itself that's interesting generally I use it on Achilles problems and plant pressure problems what it's been shown to do is it stimulates tenositis to excite tenositis these are little cells that live within your Achilles tendon for example to produce the collagen fibres that that make up the kidneys tendon if you're going to repair injury you're going to need to produce these collagen fibres. It also it also numbs some of the pain for a short period of time as well which does help with you doing some of your rehab exercises we know for Achilles problems that that used in isolation with sessions three sessions spaced a week apart that that should improve 80 percent of patients with Achilles problems and about 75 to 80 percent of plantar fascial problems. I think when that is coupled with the right rehab program that is greater if it the right patient pick the right rehab program, we get a greater positive outcome and I would probably say it's something closer to 85 90 percent in in my practice. It works the opposite to having a steroid injection so instead of it being anti-inflammatory it is pro-inflammatory, so you get some inflammatory side effects from it for a short period, but it does stimulate the repair of the tissue. You can't have tissue repair without having some inflammation so that's every patient I see with it and that's a temporary thing but the repair is permanent, we know that with shockwave patients that they continue to improve up to a year beyond having the treatment done so patients who are 70 percent better to 30 after three sessions at three months are improved again at six months and approved again at a year it also has the lowest recurrence rate for these injuries so if you get better with it you're less likely to suffer recurrence than any other treatments we have.

Something I do a lot of is orthotics this is orthotic to have evidence to support their use for certain conditions and do not have any evidence to support the use for other conditions, sometimes they're overused and there's criticism might have probably of my profession that everyone gets a pair and we know they work for certain things so when we talk about wide flat foot stimulus posterior tender dysfunction mid for arthritis these are nailed on things that have been shown in studies that they work and things like plantar fasciitis and Achilles tendonitis, not so much and you're probably not going to get one from me unless you really want one and you talk me into it and you've tried everything else that I think for certain things we know they work and when we know they were brilliantly and when you know and certainly when they're prescribed for the problem you have. One of the things with Orthotics, there are four I would say to everyone there are four things we have to consider all right when you're actually making a custom orthotic, so the foot that they're made for so we take a cast of your foot and there's a bespoke for your foot they're specific to the injury so custom orthotic you had for a plantar fasciitis maybe you might have from somewhere else that won't be the same as we'd use for a different condition they're specific to your footwear so some Footwear you might be a chains between similar footwear one trading shoe to another one running shoe to another but you can't take a an orthotic design for a for a running shoe and put them in a court shoe for instance that now with 3D printing what we can make is we can make separate orthotics for your courses and make orthotics for a four inch stiletto if you want me to, I'm not saying that's what you should be wearing but we can we can make almost any size almost any shoe. The other thing they're specific for is specific for the sport so something I do my specialties and my sub specialism being sports medicine is that if you play golf what you'll get from your orthotic will be different to what you run marathons in and what you play football in and if you do five different sports it is possible you might need more than one orthotic. So, we can try and make hybrid pairs and with a bit of compromise, but that's obviously something we have to take into account because the movements are different movement you have running in a straight line down the road running a marathon is different to what you'd have playing tennis mainly side to side so yes we have to consider these things. Imaging, so something I do as mentioned already ultrasound imaging in clinic I think we can diagnose 60 to 70 percent of conditions with an ultrasound scan in clinic.

Obviously MRI we need because ultrasound doesn't really look at bone pathology very well and plain film x-ray again something probably about Mr Dhinsa here uses almost every day or for you know 20 patients a day brilliant for looking at bone anatomy but not so much soft tissues, and then obviously I'll sound really good for image guided injections where we know we can increase the accuracy of the injection to the point where I can I know that I've hit the spot, I know what I've injecting you and where I've put it we'd be very accurate with that. Something I do as well these leads into some of the orthotics but also into rehab prescription physiotherapy referral is biomechanics gate analysis something I do a lot this kind of highlights what some of the underlying causes of precipitating factors to whatever injury. This can be quite simple so someone who has a short first metatarsal compared to a second is more likely to have a second metatarsal overload more like have a bunion more likely to have osteoarthritis the first toe joint there is a whole ream of different things it is much more likely to have. This can be quite simple sometimes it can be watching someone walk with a slow-motion video analysis or pressure plate analysis shows us peak pain peak pressure time exposed to this peak pressure torsional forces. Yes it kind of this both tells us maybe why what maybe the underlying causes for injury are and also gives us the clues we need in in writing a prescription for an orthotic or for a running shoe or writing a rehab program highlighting weak muscles weak movement patterns so it gives us gives us all the clues and all the clues some of the clues we need once we have a diagnosis that that is that is solid.

So, that's a bit of an overview on everything about me and what I do in clinic, now we're over to Bal he's going to talk about some of the magic he does he's a bit of a magician and so sometimes you see some of these patients they look completely different once they come they come back out of out of his hands and I'll let him, I'm looking forward to him talking through this next bit. Hopefully I haven't overrun so long that he can't catch up for us.

Bal Dhinsa

Cheers thank you Liam and thank you for a great talk, that was really good and thorough and pretty much like my practice Liam's helped me with my talk because he's covered most of the my talk regards in an octave management and I think about my practice the non-opt management is the key part just when you see when you see me doesn't mean you're going to get a surgery I think the surgery is the last resort for most these conditions and therefore often seek Liam's help to manage these my patients and it's when the non-operative measures have failed to remain consider surgery just a little bit of background about myself I stated that guys in St Thomas's I trained in the Southeast have a sports interest very similar to Liam and I think that helps the management of our patients because when we see the patients that are sporting and want to get back to those activities it helps us understand the rehabilitation and the expectations are currently work in the southeast of Kent and London and there. Also going to apologize now I am not being bossy or thinking of above myself but Liam's controlling the PowerPoints, I am going to have to say change side please every now and again there can you change the slides Liam?

Right, okay it is a bit slow. Sorry everyone, sorry. Bunions as Liam did go through bunions so let me tell me to talk about that which is great. Bunions as Liam said is when the toes point towards the second toe there's normally the eminence on the medial side so the bump you can see on the inner aspect of the foot that causes problems and most of this is due to footwear issues and now it's commonly thought that people that have Helix viruses due to the foot footwear they were whilst I think that's a contributing fact I don't think it's the main one because often patients I see are wearing sensible shoes their whole life and they still develop a bunion so I think there is a genetic component to it which causes soft tissue laxity which causes the big toe to turn and as a result getting imbalance or the soft tissues. change side please. So options included a little commercially available are things like splints in my opinion whilst they may relieve the symptoms while they're being worn they're not particularly a long-term solution as soon as they're off they go back into their normal position of a hallux valgus position and get the same pain again so unless you're willing to wear these sort of supports continuously, they're not going to provide much benefit and most the patients subjectively that I've spoken to who have tried these have found them not particularly helpful, but they are an option to avoid surgery. The important thing, this is where Liam particularly will get involved in, is when someone has a bunion you also need to look at their hind foot and often it might be related to a flat foot and a tibialis posterior deficiency and that can make the bunion look worse because the toe starts turning so you shouldn't just address the value need to look at the flat foot as well let's see if that will resolve the issues. Now if it is a hallux valves clear hallux valgus about this and it is not getting better it is causing problems with Footwear adoption is surgery. Now I did have some x-rays but we can't show them on the presentation because it won't be allowed to be because it makes it over 18 it can't be published online, but the way to correct this is you make an incision on the inside of the foot and you literally you have to break the bone and the metatarsal bone to shift it and realign it, then you hold it with a screw and then you do a similar sort of incision just above the joint and then you hold out with a staple and the idea is to correct the alignment in the deviation between the first and second toes and this is called a scarf and aching osteotomy. There's a new modern techniques called minimally invasive surgery and this is where it's done through keyhole surgery where there's small little five millimetre incisions are made and the bones cut with a burn rather than opening it up and it's held in slightly larger screws for the benefit being that it's a smaller incision but the recovery is similar with both options and it'd be six weeks in a surgical slipper which they can weight bear on and at six weeks we get x-rays if all looks good to get back into their normal shoes. It is important to be wary of the fact that there is swelling which will go on for at least six months to a year, particularly in the evenings and get better with elevation by the morning okay thank you Liam.

Liam mentioned a lot nicely about capsulitis metatarsalgia. The patients often see you often present with either Amato which you can see here a clot which involves hyper flexion of both interplanetary joints and the hyper extension at the metatarsal phalangeal joint or a malate and it's important as Liam described to look at the cuts or the metatarsal flounder joint and see how that affects because the deformities tends to be from the metatarsal flounder joint and then it causes problems in the interferential joint. So, in the early stages this can be managed non-operatively with toe slings or support to prevent dorsal ulceration or irritation that has occurred in these pictures, when it becomes more rigid and then you're looking at doing more comfortable shoes, wider fitting shoes to make it more manageable. New slide please. Such as these options, I often when it becomes a rigid deformity and the shoes become more uncomfortable you may then need to consider surgical options and as I said you need to start a bit further away from the tips of the toe and then move towards the tip toe slowly so we tend to find that our plantar clusters underneath the balls of their feet and this is due to the metatarsals coming hitting the ground on the plantar aspect so we often have to start with shortening of the plantar the Lesser metatarsals which is a vials orthodoxy once we shorten them we then assess the interphalangeal joints and if they're still rigid and they're not straightening out we may need to fuse those joints that often requires putting a wire into your toe and the wire hangs out the tip of the toe for about six weeks and then we pull that wire out at six weeks in clinic and this will lead to a nice flattened toe straight and toe which will stop the irritation. The obvious risks of this being that it is a rigid toe for that so they will lose the flexion extension of interfangible joints, which means their shoes their foot's more comfortable in shoes which makes them aim to get back to activities. Thank you, Liam.

Oh, also we mentioned earlier, Liam did mention that planter rupture if it's noticed that there is a plantar rupture we can obviously consider a plant or plate repair as well which is a surgical technique to improve the position to return and to allow the toes to sit down but this would be done as an additional procedure to what I've mentioned previously as well thank you.

The hallux rigidus, as Liam said, this is a painful metatarsal joint at the hallux it can vary from early after changes to spurs with small spurs to global arthritic changes and a fairly rigid joint as you can see in this x-ray in the early stages it can be seemed to relief where the mortars type splint you can try injections steroid injections which I tend to do and if I do am I doing theatre but I find that's a bit of a hassle for patients I try to do immediate image guided so someone like Liam who's a perfectly skilled can do an ultrasound guided injection this ensures it's in the right place and that tends to be with steroid and local anaesthetic if it's more of a mechanical problem and there's a clear spur formation which is restricting the range of motion then the early steps could be what we call a colectomy where we make an incision over the top of the toe and when we move dispersed to increase the range of motion. Then this is beneficial in the early stages but not in the later stages because if you increase the range of motion and it's different arthritis you increase the movement of bone and there's more bone on bone rubbing which can then lead to conversely more pain so therefore removing the spurs and someone that's got stiffness arthritis isn't a good option because it can lead to more pain. When it's progressive like this x-ray I think we're really looking at the fusion or replacement and the gold standard is a fusion where we join the both bones together we move all movement from the joint then therefore the pain is relieved and when people think of fusion they often feel that this is affects their gait it and it reflects their ability to do their activities and whilst it does have an impact on gate and Liam will say it affects their gate analysis and I think we both agree with that most people can leave a fairly active life with a fusion and we do it in young people. In a slightly older more sedentary people we can consider replacement which is with a silastic implant and this is what we sort of do for the more elder century patients that allows work some movement and preserves some of the other joints so you can do things because they won't be able to cope as well with a rigid joint as well as younger people. Thank you, Liam. Normally one of the things I find on the getting us is improves their gait post fusion than it than it was before they had it done to affect the gate positively and normally the gate's so bad with a painful arthritic first MTP with limited movement that it proves things normally you know. Is that because they're offloading and using the lateral collar more? yes normally you set the angle of the of the toe up at like five degrees of that don't you enables them to toe off through your big toe whereas when it's painful they're just not they don't it doesn't touch the ground and pressure plate analysis where it doesn't even touch the ground before surgery so that's good to know. Brilliant thank you and Liam just made an interesting point there about the five degrees of positioning of a hyper extension, we can adjust that and with the plates we use you can adjust it so I have done a fusion in a dancer you need to go on to point so they weren't too worried about going to normal shoes, so I actually participate in a position where the toe was quite extended so that it could generally do demi point and still teach dance obviously she struggled getting to normal shoes as a result so she was able to carry on being a teacher.

Morton’s neuroma, Liam mentioned the common symptoms and findings when we see the patients. The thing that's interesting is that we say in neuroma but it's not really a neuroma it's a more of a trauma related inflammation around the nerve so then the terminology is slightly incorrect, but as Liam said it is down to it the impact and the inflammation around there and it can be contributory to a very tight calf musculature which leads to four foot overload as well so it's important when you we see some of the Morton’s neuroma where we look at the tender killings and look at the inflammation and impact this can have because just removing the neuroma May resolve that symptom but it may not resolved out of a problem so we need to look at all of that that's one. My first line of treatment is always an ultrasound that is lean can do and in a measuring the size of the Morton’s neuroma confirming his presence and then doing a steroid injection in the same setting that often resolves the problems and dissolves the symptoms. If it doesn't then we consider surgery and the surgery would be an incision over the top of the foot and unfortunately it's quite destructive surgery, it's removing the nerve so they will have numb toes afterwards but it solves their problems and it and as most of the surgery I'm not suggesting is all last resort and it's when the symptoms are being so significant that they'd rather have that surgery to live with their symptoms. Thank you, Liam. Just a picture here there's a picture of needing a blind injection, I used to do this in early in my early years of training I certainly haven't done it as a consultant in the last five years I think it's quite important to really do it with ultrasound guidance to make sure you're getting it in the right place and I've imagined as I mentioned there looking at the biomechanics, looking at adjusting footwear, metatarsal pads, I don't think metatarsal pads, well I always offer it as an option but I think it's more about getting the right footwear and having a firm cushion to the foot area in the metatarsal area. Thank you. Mid foot arthritis this can be a range from the navicular or tibiae extremum in the conicoid area which is where all the pink areas on this picture patients often complain of pain and swelling it can feel like it's coming from the ankle but when you do for examination it's more in the mid foot and it becomes more of a rotational movements. In the early stages often they can feel a bone spare and it's difficulty wearing shoes because when they're wearing shoes the compression on that spur can irritate the nerves as well, then they can lead to altered sensation in the foot so in the first instance once again is non-operative measures changing the footwear doing something which I call a skipper lace technique, so if they wear shoes with laces removing the laces over the prominence because that can relieve the pressure as well and then insoles and even potentially using a rocker bottom type shoe to try and offload that area and prevent pain. If that doesn't work, then we need to look at surgery before that as Liam mentioned I always try guided injections because that can give symptom relief and avoid the need for surgery because surgery can be quite drastic has a long recovery period so I always offer injections in the first instance if it's sensible. If there's clear bone on bone arthritis no, they do not do that but if it is a stage where I think you can get a needle into the joint, I would always offer an injection first. thank you, Liam. surgical sorry non-optimizations we mentioned injections and rocker bottom type shoe and insoles thank you. Then the surgical options I think if it's just a spur and our operating changes aren't too bad on Imaging, I would certainly consider just doing a removal of the spur to remove reduced compression of the nerves and the soft tissues and allow footwear to be well worn comfortably if there's more progressive arthritis then I have to say I tend to get CT scan rather than live purely on x-rays to get a real picture of where the arthritic changes are if injections have failed non-operative measures are failed then we look at fusions and if the fusion, the idea of fusion, just like the big toe is to remove the movement and therefore it reduces the pain the knock-on effect is that they have reduced movement in a fairly important part of the foot which can knock an effect on the other joints in the long term the configuration you can use it's either screws staples or plates as you can see here and the idea is to get an alignment of the metatarsal going into talus in a clear parallel line as you can see here rather than having a break in it which you often see in a midfoot arthritis.

So the key components of this is the risk that the unit doesn't work it goes into non-union and it's a long recovery you're looking at six weeks in a cast none weight bearing and then a period of six weeks in a boot where you can put weight on but it can take up to a year to fully recover from it and so it is a long recovery it's really important to get the right selection of patients and to cancel the patients appropriately for this and hence my reluctance to go straight for this and I certainly think this is optional last resort. Thank you, Liam. ganglions these are fluid collections which can come from either joint or a synovial sheath, once again it is a bit like mid for arthritis a lot of the problem comes from pain from compressional enabling structures or difficulty wearing footwear. They tend to resolve and some of them do go back, and they can fluctuate between sides. I'll get a lot of referrals for aspirations, I personally don't escalate just because of I found that when I've done that as a trainee they tend to come back every week because they reoccurred and so therefore I'm fairly resistant to do it, but I do it in those patients that got other comorbidities and surgical intervention wouldn't be safe for them. I recently saw someone who had a lot of comorbidities they had no benefit from having an anaesthetic to have the surgery and so I did aspirate in that circumstance but as I said I do not do it very often. I tend to get Imaging to confirm as a ganglion and then the surgery is an incision over this area of prominence and you try and remove the ganglion as one that's often very difficult to do it often pops as you try to get it out, but you find the stalk it's a bit like a balloon you have the sack any other stalk of where the fluid's coming from it's important to find that stalk and destroy it with a diaphragm to prevent the risk of the occurrence. I think if you do is a good chance that they don't reoccur always send the sack off to the pathology lab to ensure it is a ganglion and then we cancel it so we do that are quite low a bit of risks of the surgery are you having a scar in an area which can be uncomfortable and if it comes a hypertrophic scar that can be worse than what the ganglion was and there's a risk of nerve damage particularly for this one here is around the separation cranial nerve so they can get some numbness and they're around the top of the foot. Thank you, Liam. and Ankle arthritis, once again were quite conservative of this most of it tends to be post-traumatic unlike the other joints that's your hips and knees, primary arthritis is relatively rare and it tends to be secondary to arthritic changes or sorry to trauma or even if it's not a fracture it may be repetitive sprains and each time there's a bit of cartilage that's been damaged which only leads to post-traumatic arthritis. The next common cause is inflammatory or gout related arthropathy. The other a type of patients you see quite often with pain that frontal angular football players I'm sure Liam sees these and they get a footballer spur and this is just due to the mechanism of kicking the ball and running they're doing the front of the joint and this causes impingement and difficulty in movements and for those patients you can consider doing keyhole surgery arthroscopic shaving of the spur for the arthritic patients I think in the first instance once again is guided injections where this is steroid or hyaluronic acid supplementation viscose supplementation so these are options for early stage arthritis I think furthermore aggressive arthritis and end-stage arthritis you're looking more either fusional replacement and the decision between those two options are dependent on the patient and their history, certainly think in a younger active patients we head to more towards fusions and they're less active and more sedentary patients we tend to do and they're slightly older patients we tend to do replacements and this is just because of the fact that the amount of force is going through the ankle replacements have a lower life expectancy than the hips and knees and therefore you want to be careful in your patient selection before you offer a replacement. The benefit of the replacement being that it protects the sub trailer joint the tailor nuclear joint where the fusion leads to increased pressures in those areas thank you Liam.

Just an example of injections, I'm not sure how Liam does it I often if I inject I do it in medial side it just makes the tibialis anterior but I know if I'm going to some of the ultrasound guided courses people use ultrasound to go anterior lateral both probably I see where the spur is and see where the biggest gap is normally. Through the middle you are probably fine, yeah. Thank you, next slide please. Kind of this is this an extra example of some fusions and replacements, as I said the fusions we can do arthroscopic we can do open once it depends it depends on the type of the arthritis and how much space we can find and also if there's a deformity associated with it which we need to correct and it's often easier than open rather than arthroscopically, but the both options are available. This x-ray is an aggressive X so it is not one of mine, but I tend to use two screws which are coming up from the tibia into their talus that tends to do the job. This x-ray is quite aggressive and shows multiple screens and the people are being taken as well which we tend not to do important in the operative planning is to look at the subtalar joint as well because if that's involved you may need to incorporate that in the fusion as well so often get a CT scan before we go ahead with surgery. Thank you, Liam. We I'll talk very quickly about tender can you come over running as Liam said you can break down includes tendinopathy into mid-substance and non-surgical this example of mid-substance where I say do not I do not inject and why that I mean I do not inject any steroid around there thank you I don't inject any steroids but certainly I do hydro distension and high volume injections to break down adhesions and that often helps with the patient's rehabilitation physiotherapy as a role as does shockwave and I do refer a lot of patients for shock waves I think this has a role and subjectively like Liam I feel that it gets good results and we're operating on less and less of these patients and night splints I'm not a great fan of I find patients find this a struggle and they don't really they're not really compliant with it and surgery for the mid-substance tendinopathy isn't great but we do it and it's literally you make an incision over the tendon Achilles and we open up the tendon and we scrape our away the dead and healthy tissue and then re-tubulise it make it nice and circumferential close it up and the obvious problem being with creating scar tissue once again but it reduces the bulk and that's why patients get some benefit from that but certainly by increasing the scar tissue there can cause problems and therefore the importance is the rehab and getting going with activities as soon as possible and not restricting movements. You can do next slide please Liam. This is still more mid substance but we do get in surgical technology which is more towards the calcaneal insertion and certainly with the insertional Achilles tendinopathy it's slightly harder recovery surgically but we get good results and the reason it's harder is we tend to have to take the tender Achilles off the calcaneum, we shave off any caglins deformity that is present which is a prominence of cocaine we need to provide any unhealthy part of the Achilles tendon and then we reattach it to the heal using the suture anchors. Then the patients have to go into a boot for six weeks with keeping their foot in the quietness and we slowly bring the foot up to a plant to break position over a six week period so it's slightly longer recovery but we get good results on this and I think we get better results on this than we do from the mid-substance surgery. This is because we are clearing off and it creates less scar tissue within the tendon area and obviously like I said we would avoid doing this if possible and we tried the hydro distension shock wave and tried basic rehab beforehand, thank you.

That is it, that's quite a quick whistle stop tour, so I hope that was okay.

Liam Stapleton

So let me say, some of those Achilles patients Bal, they when they have the Achilles deformity, it is very difficult to manage them conservatively, so because they're the haglands causes compression on the on the Achilles and they get better for a while and then come back again so sometimes that that it's a difficult surgery but I can see why you'd get positive results from it because it's a common recurrence with the insertional technology because the tendon is not really the issue it's the bone, the shape of the bone, so you don't want to do it but it sometimes it's needed. yes, exactly and is that when you do the haglands you take away that whole inflammatory fatty tissue that you see at the back of the metro canal area and once you get that out up in that often there is a pain generator as well. Yes, it is cool to have the most nerve endings of anything in that area so it is a bit if that's if that's causing problems that's the bit that hurts. yes, we tend to respect that is what helps.

Bal Dhinsa

You did mention flat feet in your talk which I didn't go over, certainly the surgical options for that, if it's flexible and it hasn't managed non-operatively then it is it's quite significant, you have to break the heel and shift it and you take the disease tibialis posterior tendon out and take the FDO tendon to put that into the navicular. It is a long recovery and whilst the pain goes away, the flat foot normally reoccurs but the benefit is that the pain goes away. If there's arthritic changes, there's rigid you are looking at fusion type surgery, so I agree with Liam that we try and avoid that surgery if at all possible and try to use insoles and supports and particularly strengthening up intrinsic muscles I think help as well. I think some of the tendon transport and Orthotics as a couple work better you know because you you're maintaining the Integrity of the of the shape of the foot long term and taking away the pain yes. I agree combination if it is good yes.

Sorry Mirella, we overrun a bit there.

Mirella Falcone

Yes, okay it is no problem, it is a really interesting presentation. So, we have a couple of questions that have come in, so we will just take those.

So, first question is, I have been suffering with heel pain for a while now I have booked in a holiday early next year which involves quite a lot of walking if I had surgery before would I be restricted to how far I could walk?

Bal Dhinsa

Because you mentioned surgery I'll answer that it depends what the cause of the heel pain is nothing now that's what we need to determine because it could be a stress fracture it could be incident at least a idiopathic or could be plantar fasciitis and so you really need to identify the cause if it's plantar fasciitis surgery really isn't an answer I don't think and I think it is non-surgical options, which may include needling but before needing I'll try shockwave the first line treatment and rehab probably.

Liam Stapleton

Yes, you know it's yes I like Bal said it depends entirely on all the things we do depend on diagnosis the diagnosis right it all starts falling into place.

Mirella Falcone

Okay thank you very much. Next question is I find that many shoes especially sandals cause pain for flat feet do you have any recommendations for sensible footwear aside from chunky trainers or would your custom orthotics be best?

Liam Stapleton

It's a customer thinks they're difficult to fit in sandals there are companies that produce sandals that that you can take the footbed out of and replace it with your custom orthotic the lab we use on occasion will also you can send in a sand of your choosing and they will replace they'll cut the footbed out of it and replace it with a custom orthotic the limitation is with that is you can't move the orthotic from shoe to shoe when that sound will finish their life that's always the orthotic they're permanently in there so it can be done but you know set you back a few hundred pounds probably.

Mirella Falcone

Okay thank you, next one is the main purpose of Shockwave therapy to relieve pain, or does it improve symptoms in the long term?

Liam Stapleton

So yes that was part I guess partly covered in that in my in my thing we know it has the symptoms continues to improve for up to a year and the studies that have been the longitudinal studies that have been done have been a year in length because no one studied it beyond that we know it's got the lowest recurrence rate so if you get better with it you're less likely to for it to come back than with any of the other treatment options available, so yes it does do that it's both it's not that it both numbs some of the pains it reduces the pain and stimulates your body to repair itself.

Bal Dhinsa

I don't know if you agree Liam but I think the problem with tendinopathy as well no one knows if it's a degenerative or an inflammatory repetitive problem and so no one no one that's why you're getting a variety between shock wave and you get people that want to have a phone plan which you people don't want to deal with a degenerative the degenerative people tend to want to do surgery yeah. I found it because we do not know it is more of a mixed picture that's why Shockwave works because it sort of manages a bit of both options.

Liam Stapleton

Yes, so it takes away some of the planes you can do your rehab you know and stimulate a bit of repair see them on ultrasound scan that you certainly am reducing the thickness of Achilles tendon both before and then you can measure it again after that yes you normally reduce the thickness of the tendon and improves the fibre alignment the appearance of the hyper echogenicity of the tendon so yeah.

Mirella Falcone

Okay thank you. Next question is I am sixty-five and enjoy being active however I have noticed minor symptoms of arthritis in my foot how would I prevent this getting worse with age?

Liam Stapleton

Some of that depends on where it is sometimes it might not be the end of the world if it got worse so but sometimes you your foot does compensate quite well with some quite significant arthritis we know and Bal will tell you that authorizing the big toe is the single most common incidental finding in the asymptomatic population or foot and ankle for so you go for an extra for something else and big to arthritis shows up so that that's common and most people don't get any symptoms of it so it's going to treat the ones with symptoms depends where it is we know broadly that living an active lifestyle, those living active lifestyle are less likely to suffer to generation a cartilage of their joints than those who are sedentary. The theory is that regular activity does stimulate some of the cartilage to repair itself some of that has been some of those things are taken from knee problems, which is commonly believed to be made worse by things like running um, but regular runners have knee cartilage fifty thicker than sedentary people of their own age group. So yes, I would not we would not stop you from doing being active but maybe support you depending on depending on where it was.

Bal Dhinsa

Yes I think it's very important I think like you said that loading is important you need to load it and keep it out keep it up and the joint subtle because the lubrication comes from movement and your ankle so much load going through it if you're suddenly rest it it's not going to make it better it's going to make it worse because it loses normal structure architecture so I think loading is important and that's where our rehabs change significantly game hasn't it before it used to be about stretching when we have tendinography and things now it's more about loading.

Liam Stapleton

Yes, so it's about symptom relief so if you're going for a long walk and you're not going for the maybe take some painkillers just to help you get through it but it's important to still do the activities.

Mirella Falcone

Okay, thank you. Next question is from Dee, has anyone but myself used LLTD for inflammation infection or wound healing properties also deep oscillation therapy for drainage?

Liam Stapleton

So low level laser there's low level laser therapy, is that what she means towards the acronym LLTD? Obviously it's difficult because it would I think she's talking about like light therapy or laser therapy as far as far as the evidence base goes there's no evidence to support it so it's not something I do in clinical practice it's not something I generally refer for subjectively I've heard a lot of my colleagues that say good things about it I would like them to collect data on it and publish it and then we could all give a give her an educated opinion on it oscillated what was the other thing that sounds like ultrasound therapy is that right yep so deep oscillation therapy for drainage I'm not sure I haven't had any experience no.

Mirella Falcone

Okay, thank you. 

Liam Stapleton

Tell her to pick us through emails through some information about both that's probably the best thing, okay I think Dee is on the webinar so she should be able to through.

Mirella Falcone

Yes so the next question is at what point would you recommend surgery for pain and loss of movement in the big toe, I feel like I need treatment but I'm afraid of surgical procedures?

Bal Dhinsa

Yes that’s reasonable my answer to that is when things are bad enough it's affecting on a day-to-day basis it's talking to doing the things you want to do they're the stocking activities and having to think about them because of the toe I think that's when you need to consider a surgical opinion then depending on the examination and the findings you've discussed options are management whether it be removing the Spurs or are you refusing the joints as I said fusions doesn't affect your activity too much Liam pointed out that actually the gate analysis improves after a fusion of the big toe so certainly that factor and fear of fusions is something we can explain and and get around but we if the key question is is the symptoms bad enough and has any management unopen measures fully and then that would be the decision when to operate.

Fusion one of the what are the success rates because one of the things I get a lot yes one of the things like and I I quote from the literature as far as I know the most well worried about it because they've had a great arm who had it done in the 80s who had a bad reaction to it and they kind of socalifragon surgery and fusion surgery I've been success rate for that is pretty high yes you’re going to quote the quote the figures yes the literature is up there over 90 if you range between 88 and 95. in my cohort I've been a consultant five years I've had to revise one because the screw was backing out and I've changed now to a plate and screw so I'm not any problems with that all mine have united today the only one didn't actually sorry to tell about one didn't you know it and that was a rheumatoid patient and that was where the screw backed out so I then changed it to a plate and they've all fused and they're deformed here the toes have changed now because the plates have the angulation built into it the idea getting the position of toe wrong is completely gone which is a historic problem and as you mentioned about our aunties having problems the same with had bunion surgery historically when you said you had a bad name but actually we did blocks and the surgery would do now the pain is a lot less the majority of my patients do say that wasn't as bad as we thought it would be is really high for that as well isn't it because that's yes that’s one of the worries yes and I think because in the old days it used to be just a shaving of the bone and tightening all the tissue now we're actually quick in alignment and the actual mechanical problem and that's why we're getting less recurrence and better success rates.

Mirella Falcone

Okay thank you very much. So just two more questions. So where do you send people for Orthotics?

Bal Dhinsa

To Liam!

Liam Stapleton

Yes, but normally I either take a physical cast of your feet normally weight bearing cast of your foot in clinic or I take a 3D scan non-white bearing cast your foot I send that scan away so I take a physical cast I 3D scan the cast I've taken and that actually because you can't really scan a physical weight-bearing impression of your foot that's in a way to a lab in Spain actually who I write prescription so that prescription incorporates the injury that you have your foot type your activity and I thought we wanted to go into and that takes about two weeks that returns to the clinic in about two weeks’ time probably nearly closing time here I actually got off that they want me out of here and so yes about two weeks’ time that comes back my secretary normally gives them a call books them in for a follow-up and then and then we might fit them so yes we do it it's all done in-house about the all the all the measurement prescription everything and fitting is all done in-house and that with a lab that make what I want. Things can come back not how I want I will have them made again so if people you know I always say sometimes people get feel like they're getting left high and dry with when I feel like that's not comfortable like that shouldn't happen under any circumstances if it's uncomfortable I'll have it taken back and remade so that shouldn't be that shouldn't be a problem.

Bal Dhinsa

I'd say what Liam does offer as well he does a gate analysis as well as another service and then that is quite good because a lot of times we say can we have an insole we don't really know what we want and so it's a way we don't want surgery but we need something done and Liam actually assesses the hole in assesses the mechanical access again and then it works out what's best for the patient yes and so therefore I think it's very good in active young patients as well because he doesn't treat everyone the same and so he's really good with it off the shelf insoles are one size fits-all yesso tend not to like Off the Shelf at all and I use the analogy if you've had a problem with your eyes you wouldn't go to the optician and he rustles around the cupboard and says he's the whole pair of phone sitting around here for a couple of years see if you can see out of those you have a pair of glasses made for you and that's kind of the same the same thinking often with the gate analysis as well I like to couple that with some rehab so often you'll get an insult and you'll get rehab because you highlights some of the asymmetry or weakness muscle weakness that contributes to the poor movement patterns if you couple both of those two things together certainly the sporting population you get a really good result.

Mirella Falcone

Okay thank you last question. Do you accept referrals from osteopaths or does it have to be from a GP?

Liam Stapleton

Certainly, private referrals you don't need a referral at all so you can rock up from anywhere. If you're self-funding through your health insurance you need I think it's a GP referral or something or online consultation and I think they do use an online GP service what about you Bal?

Bal Dhinsa

Yes, it tends to come from all angles mainly from GPs I have to say or physiotherapists but I'm not sure about private healthcare, I'm sure I'm not sure the pathway how to get into it. I think best bet it has to be through your GP. Unless if you’re a Benenden Health member or if you're self-funding yes. I think you can just I think insurance would cause a doctor to review before the phone as well yes.

Mirella Falcone

Thank you very much. So, that's all the questions we have. Thank you to everyone that has asked a question this evening. If you would like to book your consultation please do contact us on the number on the screen between 8 and 6pm Monday to Friday. You will receive a short survey and I would be grateful if you could spare a few minutes to let me have your feedback on today's webinar. Our next webinar is on the 31st of October with consultant gynaecologist Mr Gupta and our nurse specialist Jan Chaseley who will be discussing continence care for women. So on behalf of Mr Bal Dhinsa, Mr Liam Stapleton, myself and the team at Benenden Hospital, I would like to say thank you very much for joining us this evening and we look forward to you joining us again for another webinar very soon and wish you all a very good evening, many thanks bye-bye.