Podiatry webinar transcript

Louise King

Good morning and welcome to our podiatry webinar. My name’s Louise and I’m your host this morning. Our expert presenter is Mr Liam Stapleton, a sports medicine podiatrist.

Today's presentation will be followed by a Q&A session where you can ask questions via the icon on your screen. If you don't want your name to be included, you can tick the anonymous button. Please note today's webinar is recorded, so other attendees won't know you're taking part unless you keep your name with the questions.

If you don't want to be recorded, you know, this is your time to leave if you don't want to be involved in the recording at all.

So now I'll hand over to Liam Stapleton. Thank you.

Mr Liam Stapleton

Hi there, everybody. Just want to say thank you to everyone at Benenden for asking me to do this lecture for you and for organising it all for me. I am Liam Stapleton, as you've just heard, a specialist in podiatric sports medicine.

I’m registered with several governing bodies: The Healthcare Professions Council and, most recently, the Royal College of Physicians and Surgeons of Glasgow.

Today we're going to talk about the podiatry service we have at Benenden Hospital and I’m specifically going to focus a little bit more on what I do which is the sports medicine that we do there.

So we're going to talk today, we're going to give a little overview of what podiatry is and what podiatric sports medicine is as a sub-specialty; talk about my scope of practice (so that's what we what we're allowed to do what we treat and how we can do that) and we'll talk about some common conditions that we see every day in clinic.

And then we're going to field some questions from everybody and hopefully you get a chance to ask something that's relevant.

So, podiatry essentially is - we are - foot and ankle specialists, primarily. So, undergraduate, we all have a base level of training across the board in all foot and ankle problems. We are allied health professions and there are many sub-specialties in that, so - like in medicine - people specialise in areas of personal interest.

What sub-specialties are there? So, my colleague at Benenden, Andrew Mcfarlane, is a Podiatric Surgeon and essentially that is a foot and ankle surgeon.

There is biomechanics - the study of movement of the human body. Musculoskeletal podiatry is a bit like orthopaedics, so the study of muscles, tendons, ligaments and bones.

Vascular podiatry – the study of circulation. Wound care is fairly self-explanatory; there's lots of problems you can get from diabetes and they can affect your feet quite profoundly and that's a sub-specialty of its own. Dermatology - study of skin and nail - and then sports medicine is what I do. We'll talk a little bit more about that

So, sports and exercise medicine is a medical specialty that focuses on sports injuries specifically and we have a slightly different focus to general medicine in that we are focused on a fast return to activity. And so, we very often might well do more than one treatment to speed up that process and usually we use non-surgical techniques if we can.

Now this encompasses musculoskeletal podiatry - which is akin to orthopaedics - and which is the study of muscles, tendons, ligaments and bones. And so, we need to understand that to understand sports injuries. And then biomechanics, which is the study of movement and podiatric biomechanics is the study of the lower limb function.

This includes things like gait analysis; the study of the way people walk and run, the differences in running techniques. And this is where we might intervene with foot orthoses or inserts in your shoes to change those biomechanics.

So, my scope of practice - what I’m allowed to do. So, it goes: the foot and ankle, the lower leg and the knee and there's various modalities I have at my disposal.

So, first and foremost for anything that we do, imaging plays an important role, as it does in any part of medicine, because getting a diagnosis right is the most important bit. Then things like gait analysis and biomechanic analysis - this tells us why someone became injured in the first place. We want to know what the diagnosis is and we need to know why if we're going to treat it and prevent it from coming back.

There are various injection therapies, minor surgical procedures: shockwave therapy (which I'll talk a bit about in a second), foot orthoses and, most importantly, the exercise rehab to strengthen up and make sure people don't return to getting injured. I don't want to see people every six months!

So, imaging. I have an ultrasound scanner that goes everywhere with me - it's like my third arm - and I can scan an image in clinic. This gives us a real rapid availability for diagnosis. Ultrasound imaging is the gold standard for soft tissue injuries, so muscles and tendons - and we can see things dynamically, so I can see muscles and tendons moving under the skin, which also gives us a bit more of an in-depth view of what's going on.

MRI scans and x-rays and CT scans, we have at Benenden Hospital and we can refer for these and that will all be done in-house. And then the injections we do, we use the scanner to make sure we are very accurate with that. So, whereas blind injections may take three injections to get pain under control, very often we can do that in one just by being more accurate.

So, on the right there we have an MRI scan. We can see MRI is the best for looking at bones, as well as the soft tissue. You get a really clear view of all of the structures - and this is an important part of making a diagnosis for some people, certainly the gold standard for things like stress fractures that you see in sports medicine.

And then ultrasound. What I love about ultrasound scanning, it also shows you the inflammation in a tissue. As you can see, the flashing lights there, this is the colour signal or power signal and it actually visualises where the areas of the greatest inflammation are and this aids with diagnosis - and we're looking to be very accurate with treatment.

So, we start to think about: we've got a diagnosis then how do we decide why that person's injured, and this forms part of that. It's not the only reasons, but it does play a part. And so biomechanic analysis is kind of the alignment and strength and control of the way someone moves. And then gait analysis; everyone walks differently and there is a sub-specialty I mentioned before called forensic podiatry and they can actually identify people by their gait pattern, by the way that they walk - it's that unique.

And if we're looking through here, we're seeing different people walking very differently and, as we've seen, some of these very differently left to right and that can also be a really key indicator as to as to why someone's injured. We can do this both walking, like these people here, or we can do it running. Certainly for running injuries, that performs part of an important part of what we do; not just finding out why but also preventing it from coming back.

So, treatment options. So, we know what's wrong with you and we know why. Now how are we going to go about treating it? So probably the thing that podiatry is best known for is foot orthoses. These are in-shoe medical devices that improve the function of the injured foot or injured limb. It is changing the forces and timing through the gait cycle - so we can offload force from one bit to another.

One important thing I say to all my patients is that that their weight stays the same and gravity stays the same so we're just shifting force from an injured tissue onto something else. That can take a little bit of getting used to. The ones we use at Benenden Hospital are casted, so we make prescription insoles only and we can cast you either taking a weight-bearing cast in an impression box - you can see on the left-hand side - or the latest and most technically up-to-date ways is to take a 3D scan and we do that non-weight bearing. And from these it's how they produce their insoles.

Now we have to remember that when we're talking about bespoke custom foot orthoses, they're not all arch supports and they're bespoke to the foot. So very often, a left and a right foot may be different - may feel different. They're also specific to the injury, so we might give someone an insole for plantar fasciitis and that may actually be a very different insole than we would do for a Morton's Neuroma, for instance.

And so, one insert might be right for one problem and not for something else. And it's also specific to your footwear - and we can almost make insoles to fit almost any footwear. We have a lot more a lot more freedom with the way they're made these days; we can make them much smaller but it's also specific to your sport. So, the biggest difference probably is between maybe a running insert and one we might have for cycling - that they're made very different and you probably couldn't walk in a cycling insert.

Now injection therapy forms part of what I do, and it's not just steroid injections - and that's kind of something I’d like to stress to potential patients because it puts a lot of people off - corticosteroids or cortisone injections are well known and safe and have been used for 60 years. We know there are side effects and risks involved and we have to play them off with each other, but that's not the only thing that we use to inject.

Hyaluronic acid injections are a newer type of joint injection and these are brilliant for arthritic complaints and they essentially – I use the analogy of WD-40 for a squeaking door - sodium hyaluronate is the same thing for a rusty joint; it frees up the movement, so we get a better movement. And when you get better movement, you tend to get less pain.

We also use local anaesthesia as well. It's brilliant for numbing areas before we do a procedure. I think obviously nail surgery - something I’m going to talk about later - and that's done under local anaesthesia and sometimes I also numb the area before we do a steroid injection for instance.

And the most noted one is a plantar fascia injection. It's renowned for being very painful. We do it under anaesthesia; it's pretty much painless. And sometimes we might do a combination of these and mix them, depending on the patient and depending on what's wrong with them.

So, steroids, as I say, have been used for years. They have minor risks that have to be taken into account and certainly some people on certain medications should do so with caution.

And then the Ostenil is the brand of hyaluronate acid that that we use at the hospital; not in any small part because they are who Manchester United use for their football players, and I’m a Manchester United supporter! But the brands are much of a muchness.

Another injection I use as well is a high-volume Achilles injection. This injection is predominantly water, mixed with a bit of local anaesthetic, so it's not too painful. And essentially, we do this under ultrasound guidance, so it's an injection. We never inject into the Achilles tendon, and that should have stopped some 20 or 30 years ago, but what we do we actually come in behind the Achilles tendon. So if we look at the picture you see on the left there, the circle is the Achilles tendon and the line is the needle.

And we come in behind the Achilles and essentially use high volume water to break off the adhesions onto the tendon and this is a newer technique and it also frees the tendon up to move freely.

One of the biggest differences with the Achilles tendon to almost every other tendon in the human body is it isn't completely encapsulating the sheath so it's quite exposed to the tissue that lays next to it. And what can happen is you can get adhesions from the fat pad, which is very vascular and very sensitive, onto the Achilles tendon - and this stops the tendon moving freely like it should do. It should glide up and down freely when you move your foot.

And we can break these off, a bit like jet washing your drive, by squirting water at it at high volume

Another thing we use local anaesthetics for actually is diagnostically, and I did one of these last week to a gentleman. We can put it into a certain area and make sure that is the area producing the pain. So what we should expect - if there's a painful joint - we put a small amount of local anaesthetics into the joint and the pain goes for a few hours and returns once the anaesthetic is worn off.

And this is also going to be used for trapped nerves. Sometimes you have a trapped nerve; if you're not sure where the nerve impingement is, we can use this technique as well. It aids with diagnosis.

Now, shockwave therapy. This is relatively new in medicine and I believe we're one of the few places around Kent that actually have this at Benenden Hospital - and that’s why I’ve had patients come from Essex and from Brighton and from Canterbury to the hospital to have to receive this. So, people will go travel a fair journey for it.

It is an alternative to steroid injections for tendon and ligament pain. It works very differently to a steroid injection and that is pro-inflammatory, which basically means it stimulates your body to repair itself, repair the injured tissue and – for things like Achilles problems and plantar fascia problems - this is part of the problem. They never fully repair when you injure them, predominantly because they don't have a very good blood supply.

We can stimulate the little cells to produce new tendon fibres and it has a very high success rate, so I believe in the literature the Achilles has about an 80% success rate from three treatments and the plantar fascia has about 77% from three treatments. And so, this is definitely something worth considering if you suffer with either of those two problems.

One thing I couldn't stress strongly enough is the exercise rehab, and the vast majority of my patients - over 50% - will leave the clinic with some exercises to do.

All the things I’ve spoken about are ways to get pain under control, to improve function, ultimately movement and exercise and strengthening up weak spots; and strengthening muscles around weak joints is paramount to what we do. Otherwise six months or a year or two years down the line, you'll be back in my office having the same thing done again.

I couldn't stress that strongly enough, and anyone who's been in my clinic will probably testify to that.

And then the multidisciplinary team. We have a really great team at Benenden, and we regularly share referrals between rheumatology, neurology, orthopaedics, physiotherapy and - this is a real team approach to what we do - and dermatology should say as well.  And when someone is better placed to treat what you have, we should all have an understanding of what each of us can do and this is something we will do.

Nail surgery. So, this is something that is regularly done and certainly my colleague Andrew does lots of these at the hospital. It's a small outpatient procedure where we permanently remove the piece of ingrowing toenail. It's safe, it's pain-free and you should be back to normal within two or three weeks. Normally, only a few days before you're just in a plaster.

Another thing we do occasionally is minor surgical procedures for things like verrucae. They can be really difficult to get rid of and anyone who's had one knows how difficult they can be to get rid of. There we have a few techniques that we can use to get rid of these and that's something worth considering. Less sports podiatry, more general, but a useful addition to the kind of routine stuff that people use for treating verrucas.

Now, common conditions, kind of the things that I see in clinic all the time. And I’ve kind of separated these into three broad areas really. I’m going to touch on a few things that are that are common.

Forefoot generally split between big toe and smaller toes. I’ve included rear foot and mid foot and things like arthritis are really common and ligament injuries.

Leg pain: probably the most common thing I see is Achilles problems and very often knee injuries as well. I’ll talk about a few of those.

So, in your forefoot there are certainly a few problems that can happen to your big toe. Something I always say is I believe this is the most important joint in your foot - or that might be a bit of conjecture - but that's only what I believe!

Now one of the most common things we see certainly as we age is Hallux limitus, Hallus rigidus; and this is normally caused by arthritis (osteoarthritis). And essentially what happens is that the joint reduces the amount of movement it has in it and it can be painful but very often isn't. Obviously, if it's painful, we can treat it directly but very often we get these overload problems that I'll come on to talk to on the next slide.

Hallux valgus, as we can see, there - deviation of the big toe - makes it very difficult to fit in shoes and generally the only proven thing we can do with this, once it's bad enough, is surgery. And these are normally forwarded onto our orthopaedic colleagues.

There are things we can do conservative on to make you comfortable and that's something for when surgery isn't always the best thing for somebody. That is something that we can consider certainly, because surgery isn't for everyone - so not at every stage of everyone's life.

And then sesamoiditis. This is an inflammation under the big toe. It tends to give you pain in the ball under your big toe and these can be very difficult to treat.

No some of the problems we get - the big toe problems - is they tend to overload the lesser metatarsals and though that might be the only reason someone gets it, that can be.

And a couple of the most common things we're going to see is a Morton's Neuroma, and this is a trapped nerve in the forefoot. Anyone who's ever trapped a nerve anywhere can testify how painful that is and pain can be described anything from burning or numbness, pins and needles and electric shocks. I’ve had people complain they thought they've broken a bone in their foot, it’s that painful.

And then another common one which I will always say that - I see a lot of these concurrently - so the Morton's Neuroma and the capsulitis and the plantar plate degeneration all together in the same patient - I mean you’ve sometimes got to unpick that. It can be complicated.

The capsulitis - a swelling of the of your toe joint in the ball of your foot - and normally this is caused by biomechanic overload where it's doing too much work, and that's very often because your big toe isn't working like it should do or your gait pattern isn't maximizing the use of your big toe. So, it's generally it's a sign of compensation somewhere.

Now this is the one that's more often described as feeling like a stone in your shoe or being bruised or giving an inflammatory pain. This has to be separated, inflammatory pain has to be separated, because it's also a common site for rheumatological conditions to start. And so sometimes that's where the scans come into their own, and a good history taking - and where we can differentiate between the compensation causing an inflamed joint or some systemic cause, a rheumatological cause.

And once this joint swells up and you're using it too much it's very common that you will get tears or rupture to the ligament or the plantar plate that sits underneath the joint. And what happens with this is you start to notice the toes start to hammer or retract. Sometimes it can deviate to one side or the other; very often it's the second toe.

Rearfoot; so plantar fasciitis is the most common - one of the most common - injuries in the UK and they estimate that about ten percent of the population suffer during their lifetime.

Normally anyone who's had this, or knows someone that had it, they'll describe a pain first step in the morning and should take less than 30 minutes to reduce. It is almost always on one side, or started on one side, and we should always be careful if you get plantar fasciitis-type pain that presents on both heels at the same time and certainly if it takes more than 30 minutes to reduce.

Generally speaking we're looking at a gradual onset of symptoms, so normally patients can't remember when it happened and - with this gradual onset - normally it gets worse and, for a lot of people, that would get better by itself.

We should always be very wary if you can remember the time your heel pain started and, very often, (I’ve seen quite a few plantar fascia tears misdiagnosed) and that's the key symptom. I had a lad in here a few months ago and he could actually remember nine years previous the exact moment that his heel pain started. Several cortisone injections later and it was a bit of a mess.

This is commonly misdiagnosed as well so very often everything on the sole of your foot is diagnosed as plantar fasciitis, and certainly I think it's over diagnosed. Ultrasound scan in clinic will tell us within a couple of minutes if this is what you've got and how bad it is - and normally I help use that to help direct which treatment is going to work best.

Now arthritis is a really common problem nearly everywhere, and certainly in the foot and ankle we see it. So ankle, the subtalar joint, the joint just below the ankle, and in the mid foot in the arch. Very often this has a historic cause, historic trauma associated with it.

We see some patients whose joints are a bit more mobile than they should be, certainly when they're younger, can end up with this as well. Pain, stiffness certainly after sleep or rest and - if you're getting pain at night - then we certainly want to be getting some scans done on that

And this is something that is treated reasonably well, I would say conservatively. I would say midfoot arthritis is treated very very well. Ankle arthritis; certainly we should be able to relieve some pain and that's the way we should probably treat this as a first line - as the surgery is still a little bit hit and miss on that site.

One thing we should be careful - be aware of - flat feet are in themselves not a problem, but certainly if you're noticing that when you didn't have flat feet one of your feet becomes flat then that's something you need to get treated.

Very rarely, I’d say, that happens to both feet at the same time when trauma's not involved but certainly that's something to be very aware of. You see on this picture here, you've got a nice normal-ish foot on the right-hand side and the left one is what we call an adult-acquired flat foot.

While hypermobility can play a part, it’s generally caused by dysfunction or an injury to the tibialis posterior tendon. It causes you to have an apropulsive gait pattern; this means you don't really push off when you're walking with that foot and eventually can lead to deformity.

So, one of the most common injuries we see is an Achilles tendinopathy, Achilles injury. And these are separated between mid-portion and insertional injuries, and predominantly because we treat them slightly differently. Characterised by morning pain and stiffness, generally speaking warms up during activity in sports and most people can be relatively pain-free during sports. Pain often comes back once you've stopped and it cools down.

This is an overuse injury which essentially means you've probably done too much, too soon after too long doing too little. In the acute stage we're looking at a slightly inflamed tendon and then we get a vascularisation, which we get blood vessels opening up inside the tendon.

And then in the chronic stage, where we probably see most of them - the pain that they get is predominantly because of weakness in the tendon. And I'll come on a bit and talk about how we treat this in some of the questions we've got at the end.

Now, knee injuries. Cartilage tears are really common, certainly in sport, and generally this can lead to arthritis later on. So, kind of to be viewed as a bit of a spectrum.

Ligament strains and tears and issues with kneecap and the way it moves – we call that patellofemoral pain - and then patellar tendon is a really common one as well. And it's another one that responds well to shockwave therapy.

That's kind of a quick overview of all that. I am on, and the hospital have registered, on the site called Doctify where you can read reviews of the service we provide.

And then we get to some questions. So, we've had some questions in advance and I’m going to run through some of the ones we've already taken and then we can take some questions from the floor once we start.

So, we had a question from a fit, healthy 76-year-old male who has insertional Achilles tendinopathy and he wanted to know the best way to treat it.

Like I said, insertional Achilles tendinopathy is different to midportion and, well, the first thing we do with all these people when they come in and they're painful is we either put them in a slightly heeled shoe (so a training shoe with a positive heel stack - the heel is higher than the forefoot) or we put lifts - heel lifts - inside their shoes.

Strengthening rehab forms the basis of you making a proper, full recovery and this is something that should be undertaken daily and it should be progressive; so it should be get harder the further we go through it.

So, the exercise you're doing from day one should not be the same exercise you're doing three months later and, generally speaking, rehab treatment alone should probably take somewhere in the region for three months before making a recovery.

I mentioned earlier about shockwave therapy and shockwave therapy is a great way of speeding up this process. It's a bit uncomfortable to have it done, whilst it's being done. Most patients will hop off the couch and feel better straight away and – as I said – it’s really good at facilitating that process.

Injections are a bit of an old-fashioned way of treating this, I would say, and are probably a last resort - possibly even after surgery, depending on the case. And certainly, when there's bony deformity under the insertion of the Achilles then surgery is a reasonably good option and should be considered.

Next question - how to treat a fungal nail. So, fungal infections are really, really common. I see a lot of people – I see some people in clinic that think they've got fungal nails and they actually don't and there are different injuries to nails that can make it look thick and discoloured. And so, a nail clipping test is certainly the gold standard, recommended by the NICE guidelines we go by in medicine in this country.

It's not perfect and nail clipping testing has a high false positive rate but it's the best that we have. And treatments-wise, medication is probably safer than it once thought it was and places less stress on the liver than a than it was originally thought. And then a topical nail paint certainly, if the infection isn't too bad.

Surgery is a bit of an old-fashioned option, I will be honest, but for some patients it may well be the best option to have the nail removed. And certainly, if it hasn't responded to other treatments then that's a logical step.

There are a couple of other methods that we don't have at the hospital but, for the sake of completeness, the Lacuna method is where you can have little holes drilled - lots of little holes drilled - into the nail and then you pour the medication into the holes, effectively. I’m not sure but I don't know how much better that is than having the nail removed, but it's an option. And then laser. Again, it's probably not a well-tested method; from what I understand, it's a bit hit and miss but when it works it works well and you can actually have the nails lasered.

So, another question. So, the bones in this walker's feet hurt after long walks. They have a history of gout, for which they've been taking dexamethasone tablets and they're afraid they'll have to give up their walking.

Now, certainly, gout is a type of arthritis - predominantly in men (something like nine times more likely for a man to have it than women) - and it does leave behind damage to the joints - certainly, after repeated attacks.

And oral dexamethasone isn't normally how we treat gout in this country. One of the risks of this is that it can atrophy the fat pad on the bottom of the foot; and this person doesn't describe which of the bones hurt - whether it's the joint that's got the gout in it, or whether or not it's the other metatarsals - but once the big toe is painful, and they're walking on exposed joints in the rest of their foot because they've lost some of the fatty padding.

And that's something we would have to discuss in clinic, but certainly we could do something about.

I think that primarily we've got to get that gout under control and try and find a different way of treating it than with oral steroids.

Next question: a 78-year-old dancer who plays tennis, pounding the ball of the foot, warms up - which is active - and returns after rest and feels like a stone under the foot.

And we mentioned this earlier, and this is most likely capsulitis; a swollen joint capsule. And this can be chronic, or it can be acute. Generally speaking, if it’s a 78-year-old lady who plays tennis, the chances are it's probably been there for a while - it's chronic.

It can be caused by the gait and biomechanics and footwear. The way we try and do this is slight change of footwear perhaps and putting an insert inside the shoe is a really good way of taking the strain off that joint. And you take the strain away from the joint and we can reduce the amount of inflammation.

So, the 35-year-old lady with plantar heel pain, sudden onset four months ago.

The difference between a sudden onset and a gradual onset is the sudden onset we're suspecting something like a tear, something that's a bit more than just an inflammation of the plantar fascia.

And whereas we would start with rehab, and possibly shockwave and injections and things, in a normal inflamed plantar fascia with a tear, we may be looking to intervene with orthoses first to offload the tendon, to encourage repair and then begin - we have a different time and certainly a tear would be contraindicated to be injected, I think. It would certainly make that worse.

A 40-year-old male with non-specific rear foot ankle pain of approximately two years. There is a history of a twisted ankle, an inversion injury, worse on uneven surfaces and pain described like a toothache at night.

Now this is all I see reasonably often, and often missed as a diagnosis elsewhere, and it's a Sinus Tarsi Syndrome, but very often the patient themselves can't reproduce the pain in clinic.

Essentially, we're looking at improving balance and strength around the ankle joint. Orthoses can be helpful in stabilising those joints and, in some cases, injection would be the right thing to do - certainly if we're looking at some of the strength and exercise rehab we might look to do might irritate the inflammations inside the joint and that joy in particular can rumble on for quite some time, before being treated.

So, an 80-year-old lady with gradual onset mid-foot pain, arch pain and their foot worse on standing and walking.

And this is actually something I see a lot in clinic. Not just in 80 year old ladies, I'll say, but this is actually something that I see more than most, I would say.

Midfoot arthritis should be considered. I’ve seen midfoot arthritis being diagnosed as all sorts, and certainly that's something should be more to the forefront of people's minds, I think.

The studies they've done, approximately 60 percent have a history of trauma, including car accidents. The best way of treating this is image-guided injections and custom inserts. We need the insert to be rigid, so very hard, and perfectly follow the contour of the foot. If they do that, they're not uncomfortable. If you have a rigid orthotic that's not custom made then it's going to be particularly uncomfortable, possibly make the arthritis more sore. Surgery is an option and is actually a very good option, although the recovery is quite long.

Normally this is something I would be reasonably confident we would have that this wouldn't go progress to surgery for most patients.

The next question. A 40-year-old male runner. His running pace has slowed, and he notices his right foot is now flatter.

We're probably now thinking of adult-acquired flat foot; probably our posterior tibial tendon disorder or dysfunction. And this can cause the arch of the foot to flatten. This one, again as I mentioned earlier, to catch early to avoid surgery or being in in a boot.

If we catch it early enough then strength rehab and possibly some gait retraining; in a runner would be enough.

Footwear also plays a part in this and we need a lot of support. And this is one of those conditions where your trainers aren't quite right, or they're too old. This is something that that you're a risk at. And foot orthoses also play a really important part for a lot of people. Not everybody, but certainly play an important part in this.

If we can, use strength exercises and rest the tendon when you're not doing the strength exercises, then you can be really active whilst you're recovering.

So, thank you for listening everybody. There's some links there for social media and the Benenden Hospital. We have some information about the podiatry service on the Benenden site and then we're going to see if we can take some live questions.

Louise King

We do have some live questions; we have one from Hosen. Hi Liam, after how many months of conservative treatment for Achilles tendon pain would you consider ESWT?

Mr Liam Stapleton

So, I’m probably a bit different to most in that I would consider it almost immediately as a first line treatment, depending on the presentation.

One of the things I mentioned earlier about sports medicine; sports medicine is, we try and get people back as fast as possible and waiting sometimes for conservative treatment to kick in, sometimes we need to speed that up and I don't think that's unreasonable.

So, I, having a sporting history myself, I wouldn't want to be compromised for longer than I absolutely have to. In acutely inflamed Achilles problems, we're not looking at using it because it's pro-inflammatory - it can make you more sore. But certainly when we're looking at slightly more chronic ones that have been there for a while - and been there for months - then yeah, I would seriously consider it as a first line treatment.

And so, it would be a discussion I would have with the patient at the time, so that we could discuss that as an early intervention.

The reason behind that? It's safe, there's virtually no risks unless you're on really strong blood thinners. There are very few risks. It's a bit uncomfortable for a few minutes whilst it's being done, and the evidence behind it is pretty unanimous that certainly for those particular conditions it's successful.

Louise King

OK, another question, from Janine this time. With arthritic ankles is it still advisable to continue running?

Mr Liam Stapleton

Potentially. Again sometimes might depend on how much pain she's in when she's running, but what we know now in sports medicine that's different to maybe what we knew probably five or ten years ago, is that running itself doesn't damage joints, that you don't wear the cartilage out, so to speak, when we're running on arthritic joints.

They did a study, predominantly on knees, where they measured the thickness of people all the same age. Some had been running - with a 20-year history of running - and those who were sedentary and those with a 20-year history of running had 50 percent thicker cartilage in their knees than the sedentary group.

Some of that depends obviously if you're, you know, in agonising pain with it. It might be sensible maybe not to, but I would try to facilitate everything I could to make sure that person could continue to run. It may be that it's not reasonable to expect you to run marathons, but you know possibly running three kilometres or five kilometres on a regular basis might will be enough for that person.

So, what we would try and do is discuss what they wanted to get out from it - what’s a reasonable expectation - and then kind of implementing steps to best do that. So yeah that certainly just straight off the bat that wouldn't be my advice to stop running, no.

Louise King

Thank you. Another question from Peter. He says: I’ve noticed some of my toenails are starting to curve in at the sides. From one of your photos this looks like to be the beginning of ingrowing toenails. Do you have any tips for how to prevent this from reaching the state of a needing to need correction?

Mr Liam Stapleton

Okay so I think the one thing you can - two things probably - that you can do yourself: don't cut them too short and obviously cut them well but don't be tearing them off. I had one lad that was biting them off; he's obviously quite flexible!

And so, we’re looking at good nail care; not cutting them so they’re too short - so we want the edge of the nail certainly over the fold of the skin and certainly with good nail cutting you should be able to do that.

And the other thing is footwear. So, if you've got shoes that are constantly knocking on the nails, or you've got a job where your nails are continuously being exposed to micro trauma, then that can encourage the nail to begin to change its shape.

Not the only reason. Some medications can do that and some health complaints can do that as well - and that's something that can be looked at, but yeah, certainly I think for the vast majority of people footwear and nail cutting and you should be able to avoid them getting worse.

Louise King

Great, right we have two more questions. One from Laura. How would you go about treating gout?

Mr Liam Stapleton

So, gout, that's really interesting complaint. So generally speaking, the guidelines state that anyone who - if you're having gout very intermittently -  and not often, so your attacks are less frequent than two in six months, then just taking anti-inflammatories when you have an attack or or colcochine which is also a medication you can have from your GP, as long as you're under 65, you can take that just when you have an attack.

And there are some people that get gout and they might only have an attack once every three years and going on long-term medication for that wouldn't be the best thing to do. They're treating people who are having regular attacks of gout so more than two attacks every six months, then going on an anti-gout medication you'd take daily is normally the sort of the gold standard in this country.

Some of the treatments, the Mitrim I mentioned earlier, that that is obviously from abroad. That certainly isn't in this country. And I’d say that that has to be started the anti-gout medication has to be started when you're not actually currently in a gout attack and you have to be aware that they can trigger a gout attack when you start taking it so that is a possibility as well.

But once you start and you get in the routine of that, it actually reduces the crystals in the blood that cause the gout and when you get an acute gout attack - so you're actually in pain - anti-inflammatories can be enough.

Something that that we do occasionally if someone gets desperate; we actually do a very small injection into the joint and normally pain will disappear within a day or two, certainly within two days for the vast majority of people with that sort of presentation.

Normally they're also in the hospital, here referred on to rheumatology for the blood workup and for the right medication to bring it under control. But that's certainly something we can do to get you out of pain really, really quickly.

Louise King

Deborah says: I’m a 58-year-old lady who has started getting pain in a small toe joint area for the last year or so which also moves into the area below my foot like I have a rucked-up sock. I had an x-ray, I’ve been told I have a slipped joint. It feels like a pricking or like there's a piece of cotton pulling against the joint. Can anything be done to make it feel better or do I have to live with it? I like walking around five miles a week split into two sessions.

Mr Liam Stapleton

Yeah that sounds really interesting. There's a few things, a few questions I would want to know and that we want to have a little look at that before probably saying too much.

One thing we know that obviously issues with the small toe joint in women can be an early sign of an inflammatory problem, so that is something to bear in mind. There is a very similar deformity with bunions that I showed you the picture earlier, that you can get on the little toe and that can be the case as well. So, you start to get the deformity of the toes starting to ruck up underneath and that can cause pain.

And the rucked-up sensation under the foot? That's interesting. Certainly, because that's how a lot of people can explain how a trapped nerve or Morton’s Neuroma feels so it could be two things going on at the same time and that's certainly something and we won't have a little look at as well.

Bearing in mind that a lot of those soft tissue injuries can't really be seen on x-ray and certainly the ultrasound is probably, I would say, probably gold standard in that case. If you have an x-ray and that you can see the combination of the bone and the soft tissue so something to have a little look at in clinic, I think.

Louise King

Great, so that's all the questions we have. So, thank you very much for your time, Liam. For everyone watching we do have two lovely ladies working today who can take your calls to book appointments with Liam and their number’s on the screen or you can email them. So, they are working today but also be around next week if you want to book an appointment.

So, I guess it's just to say, on behalf of Liam and myself and the hospital team, thank you very much for joining us today. I hope you found it interesting and please do give us your feedback so we can shape future events and we look forward to seeing you soon. So, thank you very much and have a good Saturday.

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