Podiatry Review March/April

INSIDE THIS ISSUE: • NAIL PROBLEMS • ORTHOTICS - VALUABLE OR USELESS DEVICES IN PODIATRIC CARE? • DIABETIC FOOT ASSESSMENTS • KEEPING FIT THE EASY WAY - BORROW A DOG!

Podiatry Review Supporting the Private Practitioner

A step in the right direction

ISSN 1756-3291 Volume 72 No. 2

March/April 2015

The Institute of Chiropodists and Podiatrists 150 Lord Street, Southport, PR9 0NP 01704 546141 www.iocp.org.uk

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ŵĂŝů ƌƵƚŚǁŝůůŵŽƩΛďƟŶƚĞƌŶĞƚ͘ĐŽŵ

Podiatry Review Volume 72 No. 2

March/April 2015 ISSN 1756-3291

Published by The Institute of Chiropodists and Podiatrists 150 Lord Street, Southport, Merseyside, PR9 0NP Tel: 01704 546141 Email: bernie@iocp.org.uk Web: www.iocp.org.uk Editor: Mrs B Hawthorn HMInstChP

National Officers

President Mrs L. Pearson MInstChP BSc Pod Med Vice-Chairman Executive Committee Mr A. Reid MInstChP Chairman Board of Ethics Mrs J. Dillon MInstChP Honorary Treasurer Mrs J. Drane MInstChP

Academic Review Team: Mrs J Barbaro-Brown

Standing Orders Committee Mr M. Hogarth MInstChP

Ms B Wright

Secretary Miss A. J. Burnett-Hurst Hon FInstChP

MSc PGDip PGCE BSc (Hons) BA (Hons) DPodM MChS HonFInstChP MSc BSc (Hons) PGCE PGDip MInstChP

Mr S Miah BSc(PodM) MInstChP

Area Council Executive Delegates: Midland Area Council Mr S. Miah BSc (Pod M) MInstChP North West Area Council Mrs M. Allison MInstChP

© The Institute of Chiropodists and Podiatrists Disclaimer: The Editor and the Institute of Chiropodists and Podiatrists accept no responsibility for any opinions expressed in the articles published in the Journal, and they do not accept responsibility for any discrepancies in the information published. No part of this publication may be reproduced, stored in a retrieval system or transmitted in any form or by any means, electronic, mechanical, photocopying or otherwise, without the prior written permission of the publishers.

Published by Mitchell & Wright Printers Ltd, The Print Works, Banastre Road, Southport, PR8 5AL 01704 535529 Annual Subscription £30 UK/£45 Overseas

Republic of Ireland Area Council Mrs C Tindall MInstChP BSc (PodMed) LCh Scottish Area Council Mrs H. Jephcote MInstChP Southern Area Council Mr D. Crew OStJ FInstChP DChM CertEd Yorkshire Area Council Mr N. Hodge MInstChP

CONTENTS Contents 2

Editorial and President’s letter

3

International Aid News

4

Orthotics – Valuable or Useless Devices in Podiatric Care?

Iain B McIntosh MBChB

6

A slight problem with my nail Martin Harvey MInstChP, BSc

9

Diabetic Foot Assessment Michelle Taylor MInstChP, BSc

13 Record Cards and Record Keeping 15 CPD – Hyperkeratosis of the Foot Part 2 Julia Potter, Senior Lecturer, School of Health Sciences, University of Southampton 23 Diabetes UK – latest information 26 Volunteering with Crisis – an account by Linda Scantlebury 28 Keep Fit – Walk a dog 30 Branch Information 31 Conference Booking Form 33 Classified Adverts 34 Officers for Election 35 Forthcoming Events

http://twitter.com/iocp_chiropody The Institute of Chiropodists and Podiatrists-Southport

Podiatry Review Vol 72:2

page 1

EDITORIAL

Dear Readers,

Welcome to the March-April issue of Podiatry Review. It will be good to see some longer, sunnier days.

This issue is focussed on our forthcoming conference at Southport Theatre and Convention Centre on Friday 29th and Saturday 30th May. In the centre of the journal you will find information supplied by our traders with special conference offers. Pull out the section and bring it along with you!

On page 31 you will find a booking form with details of lectures and workshops. It’s a perfect opportunity to fulfil your CPD requirements as well as picking up some great bargains and socialising with your peers. If you have never been to conference why not make 2015 the year to try it? Nonmembers and members of other organisations are more than welcome to come along. The trade show is free to wander round. It is a really enjoyable and productive weekend.

You can either complete the form or telephone Julie Aspinwall on 01704 546141 who will book you in and

answer any questions you may have.

Full details are also on our website http://www.iocp.org.uk/ DiamondAnniversary-Conference-2015.php.

Remember too that Southport is a holiday resort suitable for all the family so bring everyone along! Check out our website for family offers. There is an abundance of hotels and guest houses to suit all ages as well as many shops, restaurants and entertainment.

We even have a few golf courses!

Of course it is not all conference!

We have articles from Martin Harvey, Consultant Podiatrist Independent Prescriber, “A slight problem with my nail” As you would deduce Martin is speaking about dysfunctional nails often encountered in practice and underlying threats that could possibly be overlooked (starts page 6). Iain B McIntosh discusses the advantages, or otherwise, of foot orthotics (see page 4) and we have part 2 of Hyperkeratosis of the foot written by Julia Potter, Senior Lecturer, School of Health Sciences, University of Southampton.

In the office we have taken several calls of late enquiring about diabetic foot examinations and Michelle Taylor of Cheshire North Wales branch has kindly put together a refresher article and a check form. In addition to diabetic foot examinations we have also had a request to include the article on patient record cards. Accordingly you will find all this starting from page 9. Never let it be said we do not comply with requests wherever possible!

Our cover photo was sent in by a member and is taken on the Leeds/Liverpool canal at Parbold. It compliments our health article; “Dog Walking – The Health Benefits” (page 28). Most experts tend to agree that owning (or borrowing?) a dog has great health rewards in terms of motivation, stress reduction and self esteem issues.

Please keep the photographs coming.

Enjoy reading this issue of Podiatry Review.

Bernadette Hawthorn, Editor

Dear Colleagues,

I hope this letter finds you all well as this year’s AGM rapidly approaches. I am happy to advise that members I have met so far are very proactive with ideas and some have volunteered their time to raise the profile of the IOCP at local meetings, colleges and universities, trying to encourage new members, which will help to ensure the continuation of our Institute.

The executive committee are meeting in February to finalise arrangements for our 60th anniversary conference.

Branch voting will be taking place; it is a very important part of our democracy to be able to have the freedom to vote for whoever you think will serve you and the IOCP well for the next year, whilst bringing our organisation into the 21st century.

As you will have read in the last journal Hilary Supplies are planning a trip to Meinerzhagen, Germany for a visit to Franz Lutticke, manufacturers of the Mykored and Laufwunder range of creams and invite us to join them. I have booked my place already. If you are interested please contact Sonia on 0116 230 1900 (SoniaK@hilaryspplies.co.uk) who will confirm availability and price. The dates are Thursday 10th September to Saturday 12th September. kind regards,

Linda

Linda Pearson President

page 2

Podiatry Review Vol 72:2

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ϯͿ >ĂƚĞƐƚ ŶĞǁƐ͗ ƌĞŐƵůĂƌ ƵƉĚĂƚĞƐ ĨƌŽŵ ƚŚĞ , W ϰͿ ^ŽĐŝĂů ŵĞĚŝĂ͗ ŬĞĞƉ ƵƉ-ƚŽ-ĚĂƚĞ ǀŝĂ dǁŝƩĞƌ͕ &ĂĐĞŬ ĂŶĚ zŽƵdƵďĞ ϱͿ 'Ğƚ ŝŶǀŽůǀĞĚ͗ ĞǀĞŶƚ ŚŝŐŚůŝŐŚƚƐ ĂŶĚ ŵŽƌĞ dŽ ĮŶĚ ŽƵƚ ŵŽƌĞ ĂďŽƵƚ ƚŚĞ ŬĞLJ ĨĞĂƚƵƌĞƐ ŽĨ ŵLJ, W ĂŶĚ ŚŽǁ LJŽƵ ĐĂŶ ďĞŶĞĮƚ ĨƌŽŵ ƵƐŝŶŐ ƚŚĞ ĂƉƉ͕ ƐĞĂƌĐŚ ηŵLJ, W ǀŝĂ dǁŝƩĞƌ ĂŶĚ &ĂĐĞŬ͘ ďƌĂŶĚ ŶĞǁ zŽƵdƵďĞ ǀŝĚĞŽ ĚĞŵŽŶƐƚƌĂƟŶŐ ƚŚĞ ĮǀĞ ŬĞLJ ĨĞĂƚƵƌĞƐ ŽĨ ŵLJ, W ŝƐ ŶŽǁ ĂǀĂŝůĂďůĞ ƚŽ ǁĂƚĐŚ ĂŶĚ ƐŚĂƌĞ͗ ŚƩƉ͗ͬ​ͬ LJŽƵƚƵďĞ͘ĐŽŵͬǁĂƚĐŚ͍ǀс^ǁh<Őƌϲ Ě/ ŽůůĞŐĞ Žƌ >ĞĂƌŶĞƌ WƌŽǀŝĚĞƌ ʹ ϭϬϬϭϯϭϮϮ zŽƵƌ /ŶĚŝǀŝĚƵĂů >ĞĂƌŶĞƌ EƵŵďĞƌ͗ ϰϰϯϭϮϬϵϮϬϯ

ϭͿ 'ƵŝĚĂŶĐĞ͗ ĂĚǀŝĐĞ ĂŶĚ ƌĞƐŽƵƌĐĞƐ Ăƚ LJŽƵƌ

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INFORMATION ARTICLE

Orthotics - valuable or useless devices in podiatric care?

Iain B. McIntosh MBChB Former Schools Inspector

Orthosis is concerned with the design and fitting of devices in the treatment of podiatric disorders. Orthotics are devices used to alter or modify foot function and are designed to treat, adjust, and support various biomechanical foot disorders.

Orthotics include dynamic insoles, heel cushions, arch supports, insoles and can be prefabricated or custom made. They can provide support, increase shock absorption or influence foot position, but may have a negative effect on proprioception.

Foot, ankle, knee biomechanics are extremely complex. Gait analysis is an art as well as a science. Orthotics can be expensive pieces of carbon graphite, neoprene or plastic polymer and their benefits and disadvantages are controversial. Epidemiological studies provide some support for the clinical advantages of orthotics, but numerous studies document poor clinical reliability and validity and explanations of foot orthotic mechanisms remain elusive.1. 2 The orthotic should provide support, stability, cushioning, and alignment necessary to keep feet, ankles, and lower body comfortable, healthy, and pain-free.

Shoe inserts or orthotics may be helpful as a short-term solution, preventing injuries in some athletes but their ability to correct mechanicalalignment problems remains debatable.

Anecdotally, orthotics can help alleviate acute pain and discomfort and aid cure, but the evidence base encouraging their use is limited by research trial quality.

Orthotic Types

Functional orthotics -designed to support abnormal foot biomechanics. Often made of supportive plastic polymer materials they are intended to prevent abnormal foot pronation (flattening of the arch) and reduce the impact load from the ground (shock absorption) while walking or running. The intent is to support the rear foot or sub-taylar joints as well as mid-foot or mid-tarsal joints, stabilising the foot and helping prevent repetitive,overuse injuries.

Accommodative orthotics are soft supportive devices designed to relieve mild foot pain and correct minor foot problems. They often are used to correct biomechanical walking problems in young children.

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Custom-made devices are crafted to specific individual needs, and created from a cast impression of the foot, which duplicates misalignments in foot structure. Device design is intended to balance out deformities and correct misalignments. Foot orthotics are made from basic measurements and captured images of the foot (plaster casting, foam box impressions, or three-dimensional computer images). A custom-made orthotic can be fabricated from a negative plaster impression of the patient’s foot. It is composed of the shell, a layer of material next to the foot and the posting, the material that fills in the space between the shell and the shoe.

Materials such as metatarsal pads can be added to the device to customize it further. Dynamic insole orthotics, can be constructed from closed-cell neoprene impregnated with nitrogen bubbles.

Prefabricated foot orthoses are commercially available in a wide variety of styles. Pre-made appliances are adequate for treating athletes with plantar fasciitis and are significantly less expensive than custom-made ones.

These techniques are not very accurate (<80%), especially measuring the peak arch height.3 Orthotics are often used in:• Flatfeet • Bunions • Chronic heel conditions (e.g., plantar fasciitis) • Frequent ankle sprains • Gait abnormalities (e.g., feet point inward or excessively outward during walking) • Shin pain (e.g., shin splints) • Plantar calcaneal bursitis

Flatfoot

People wear “arch supports” because they have either flat feet or pain in the arch. To properly support the arch of the foot, either end of the open space should be supported. The heel and forefoot should be supported, not the space inbetween the ends of the arch. Paediatric flat foot frequently presents as a common parental concern. Foot orthotics are often used, yet benefits are uncertain and disputed in some investigations.4 A Cochrane review cites limited evidence for nonsurgical interventions. A critical and structured review evaluated the

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effect of paediatric foot orthotics from assessment of current peer-reviewed literature. The low quality of the studies negated definitive conclusions. Thirteen articles, from an initial 429, met the criteria for quality evaluation. The mean Quality Index score was 35% (range: 13% to 81%), indicative of generally poor and varying methodological quality. Only 3/13 quality evaluations scored > 50%; hence, evidence for efficacy of nonsurgical interventions for flexible paediatric flat feet is very limited.5 Clinicians need to consider the lack of good-quality evidence in decision-making for management of the condition.

Plantar fasciitis

This is a common painful inflammation of the foot with insidious onset of sharp pain at the fascial insertion. The irritation is the result of biomechanical deformities, such as limb length discrepancy, gastrocsoleus equinus, and excessive foot or leg varus, producing mid-tarsal and subtalar hyper-pronation and over-stretching of plantar fascia pulling on the origin of the fascia (the medial calcaneal tubercle). An ankle equinus deformity is basically one in which the Achilles tendon is shorter than needed to allow adequate dorsiflexion during the gait cycle.

Orthotic devices can play a key role in treating the biomechanical imbalance and long term use of heel cushions and in my experience can be effective in reducing pain.3 They and taping are recommended for Achilles tendinopathy (AT). A systematic review was conducted to review current evidence for their effectiveness in treatment of mid-portion or insertional AT. Twelve studies satisfied the inclusion criteria. Weak evidence showed that foot orthotics were equivalent to physical therapy, and equivalent to no treatment. Very weak evidence supported the use of adhesive taping alone or when combined with foot orthotics. These findings may aid clinical decision making in the context of AT, however further high-quality studies are required.6

Plantar calcaneal bursitis

Soft heel cups cushion and contain the fat pad. They are effective for a plantar calcaneal bursitis or plantar heel-spur

syndrome. Ringed heel cushions, designed to disperse weight around the plantar medial tubercle of the calcaneus, constructed of polyvinyl chloride, silicone, leather, polyethylene foams and thermoplastics, provide extra shock absorption in the heel area and take pressure off the bursa. A heel lift in the shoe should be no thicker than onequarter inch.

Chronic foot and ankle injuries are a common complaint in recreational runners. Foot orthotics have been shown to be effective for the treatment of running injuries but their mechanical effects are still poorly understood.7 Rheumatoid arthritis, often affects joints of the foot A meta-analysis examined the effects of foot orthotics (FO) on pain and disability in rheumatoid arthritis (RA) patients. Conclusion: FO may improve pain in RA patients, but impact on disability remains undetermined. There is no consensus among rehabilitation professionals regarding the efficacy of FO improved pain and disability in patients with RA. The results suggest that the use of the FO improves pain but has no impact on disability.8 Metatarsalgia, a painful foot disorder affecting bones and joints at the ball of the foot. Metatarsalgia describes pain localized to the fore foot with localized or more diffuse tenderness beneath the metatarsal heads.Pathological changes affecting the positional relationship of the metatarsals in the sagittal plane can cause increased pressure and friction forces during weight bearing. Forefoot pain may be caused by conditions of the lesser toes themselves (eg, hammertoes, mallet toes, claw toes). The pathophysiology of lesser toe deformities is complex and is affected by the function of intrinsic and extrinsic muscle units. In addition to lesser toe and metatarsal abnormality, forefoot pain can be attributed to interdigital neuritis, disorders of the plantar skin, and gastrocsoleus contracture. In the adult it often alters mobility and has a negative impact on quality of life. Treatment of these conditions may include shoe modifications and the increased load, which is transferred to the central metatarsals, can be treated successfully with orthotic devices.9 Lesser toe deformities are caused by alterations in normal anatomy that create an imbalance between the intrinsic and extrinsic muscles. Causes include improper shoe wear, trauma,

inflammatory arthritis, and neuromuscular and metabolic diseases. Typical deformities include mallet toe, hammer toe, claw toe, curly toe, and crossover toe. Abnormalities associated with the metatarsophalangeal (MTP) joints include hallux valgus of the first MTP joint and instability of the lesser MTP joints, especially the second toe. Midfoot and hindfoot deformities (eg, cavus foot, varus hindfoot, valgus hindfoot with forefoot pronation) may be present, as well. Nonsurgical management focuses on relieving pressure and correcting deformity with various orthotic devices.10 Chronic ankle instability (CAI) is a condition commonly experienced by physically active individuals. It has been suggested that foot orthotics may increase a CAI patient's postural control.

The literature was searched for studies of level 2 evidence or higher that investigated the effects of foot orthotics on postural control in patients with CAI. Foot orthotics appear to be effective at improving postural control in patients with CAI. Clinical Bottom Line: There is moderate evidence to support the use of foot orthotics in the treatment of CAI to help improve postural control.11

Osteoarthritis

Studies on the use of lateral wedge orthotics in the conservative management of medial compartment osteoarthritis and foot and ankle dysfunction are widely quoted. This comprehensive, systematic review was therefore undertaken to evaluate all available literature to determine whether evidence exists to support their use. results of this review suggest that, based on current evidence there are no major or long-term beneficial effects with the use of lateral wedges.12 Bunions can be protected by individualised orthotic applications thick enough to fill in the space round the bunion and protect the lesion from further external pressure. They are absolutely vital to protect a bunion with an added bursa complication. The device keeps shoe pressure off the bursa and allows the surrounding fluid to be absorbed and prevents the condition worsening.

Conclusion.

The benefits of orthotics are not conclusively supported by evidence in their many traditional uses. They are of benefit in plantar fasciitis and with

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bunions and bring pain relief in chronic arthritis conditions. Many athletes find bubbled neoprene insoles valuable as shock absorbers and podiatrists have long found them of practically acceptable in daily practice.13

References

1. Ball KA, Afheldt MJ. KA, Afheldt M. Evolution of foot orthotics - part 1: coherent theory or coherent practice? J Manipulative Physiol Ther. 2002 Feb;25(2):116-24.

2 Ball KA, Afheldt MJ. KA, Afheldt M. Evolution of foot orthotics - part 2: research reshapes long-standing theory. J Manipulative Physiol Ther. 2002 Feb;25(2):125-34.

3 Elfer et al. Computer-aided design of customized foot orthoses: reproducibility and effect of method used to obtain foot shape.

Archives of Physical Medicine & Rehabilitation. 2012. PubMed #22541310.

4 MacKenzie JA, Rome K, Evans AM. The efficacy of nonsurgical interventions for pediatric flexible flat foot: a critical review J Pediatr Orthop. 2012 Dec;32(8):830-4 5 Overview Of Custom And Prefabricated Foot Orthoses Mark A. Caselli, DPM and Ellen Sobel, DPM, PhD Issue Number: podiatry today Volume 14 - Issue 12 - December 2001 6 Scott LA1, Munteanu SE, Menz HB. Effectiveness of Orthotic Devices in the Treatment of Achilles Tendinopathy: A Systematic Review. Sports Med. 2014 Aug 10.

[Epub ahead of print] 7 Sinclair J1, Isherwood J, Taylor PJ. Appl Biomech. 2014 Sep 30. The Effects of Orthotic Intervention on Multi-Segment Foot Kinematics and Plantar Fascia Strain in Recreational Runners.

8 Conceição CS1, Gomes Neto M, Mendes SM, Sá KN, Baptista AF. Systematic review and meta-analysis of effects of foot orthoses on pain and disability in rheumatoid arthritis patients. Disabil Rehabil. 2014 Sep 23:1-5.

9 DiPreta JA Metatarsalgia, lesser toe deformities, and associated disorders of the forefoot. J Am Acad Orthop Surg. 2011 Aug;19(8):505-14.Med Clin North Am. 2014 Mar;98(2):233-51. doi: 10.1016/j.mcna.2013.10.003. Epub 2013 Dec 10.

10 Shirzad K1, Kiesau CD, DeOrio JK, Parekh SG Lesser toe deformities Prosthet Orthot Int. 2014 Oct 21. pii: 0309364614550263. [Epub ahead of print] 11 Gabriner ML1, Braun BA, Houston MN, Hoch MC. The Effectiveness of Foot Orthotics on Improving Postural Control in Individuals With Chronic Ankle Instability: A Critically Appraised Topic. J Sport Rehabil. 2013 Aug 12. Epub 2006 Apr 24.

12 Knee. 2006 A systematic review of lateral wedge orthotics - how useful are they in the management of medial compartment osteoarthritis? Jun;13(3):177-83 13 Reilly KA1, Barker KL, Shamley D. Orthopade.

2005 Aug;34(8):767-8, 769-72, 774-5.

14 Hawke F1, Burns J. Brief report: custom foot orthoses for foot pain: what does the evidence say? Foot Ankle Int. 2012 Dec;33(12):1161-3.DOI: 10.3113/FAI.2012.1161.

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TECHNICAL ARTICLE

A slight problem with my nail

Martin Harvey PGCert BSc AEdT MCPodS MInstChP. Consultant Podiatrist Independent Prescriber We often encounter severely dysfunctional nails in podiatry, sometimes to the extent that one privately wonders how the possessor of such items manages to get them into shoes or indeed sometimes even how they manage to walk at all with them.

In this current new case, a pleasant lady of some 81 years of age came to the surgery to discuss “a slight problem” with her nail that she reported having had for “a few years”. She was otherwise fit and healthy with no allergies and was not on any significant medicine. She walked in with a limp and said that the nail had become steadily more painful over the last 12 months, on her consulting her GP they had suggested she buy some ‘over the counter fungal nail paint’ which the lady had been using once a week for approximately three months – unsurprisingly it had no measurable effect.

On examination, the “problem nail” turned out to be on her right Hallux, and it protruded vertically by some 15mm.

The slightest downward pressure on it caused obviously extreme pain. A careful combination of a very judiciously applied abrasive drill, and sharp debridement of the nail plate, produced the results shown here without causing too much discomfort .

The two protruding neoplasms now visible at the lower right corner of the nail were seemingly growing from the nail bed, and it appeared that the nail plate had grown around them as well as growing over them. With the release of the encompassing and overlaying dystrophic nail, the lady reported that the pain had “reduced to virtually nothing” when pressure was now applied to the surface of the nail.

A sample of the nail that had been debrided was retained to be sent to the pathology laboratory for ‘microscopy and culture ?? onychomycosis’. Such analysis

The protruding neoplasms were slightly translucent on examination, when peripherally illuminated with a Dermlite (see photograph and description).

When encountering any unexplained skin lesion it is necessary to consider the range of things that it can be, so that a Dermatoscopes are useful tools for giving magnified images of the skin and its ‘lumps and bumps’. They come in a variety of shapes, sizes and prices. The author uses a Dermlite ® (Schuco Ltd).

These can be used as a simple illuminated magnifying glass, or by twisting out its optical contact plate it can be pressed against a lesion and with the aid of a contact gel, or oil, it can illuminate the lesion with either direct or polarised light.

An adapter can be screwed into its eyepiece to allow connection of a digital camera. Useful for monitoring suspect lesions over a period of time – and taking pictures to send to their GP if you refer them on.

©Schuco International Ltd 2015. By permission

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results can take a few weeks to come back, as it takes some time for a culture to be effectively grown if initially fungal elements are seen upon microscopic examination. This left the need to devise a suitable management plan for these two protrusions, once a tentative diagnosis had been arrived at.

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provisional diagnosis and provisional management plan can be arrived at.

Sometimes that diagnosis will change with further investigations, such as the results of histopathology tests performed on tissue samples taken from the lesions.

It is wise to first eliminate suspicion of skin cancers because these will require prompt action and should not be routinely dealt with in primary care, except in very rare specific instances, by appropriately qualified specialists.

Factors to consider include the following: • Is it pigmented? if so has it changed in size, shape or colour? in which case a malignant melanoma should be high on the list for consideration and immediate referral to a Dermatologist must be made (this will normally be via the patients GP within 14 days in NHS situations). If you refer to a GP do it immediately and confirm in writing.

• Does it have an indurated (hard and often shiny) rounded edge and an ulcerated centre? In which case a Basal Cell Carcinoma should be considered (these used to be termed ‘rodent ulcers’ because the ulcerated centre looked as though it had been nibbled by a rodent)

• Is it a persistent, thick, rough, scaly patch that can bleed if bumped, scratched or scraped? Often initially looking like a wart. In which case consider a Squamous Cell Carcinoma.

It is worth pointing out however that most things which look like a wart, are in fact a wart.

Further items to consider are then warts, acrochordons, seborrhoeic keratoses, actinic keratoses and cysts, most of which are benign. Podiatrists will need no introduction to warts as they regularly haunt our waking and sleeping in the form of verruca pedis.

Acrochordons are a (usually small) tag of

Actinic keratoses, also known as solar keratoses, are dry scaly patches of skin caused by damage from years of sun exposure. The patches can be pink, red or brown in colour, and can vary in size from a few millimetres to a few centimetres across. The skin in affected areas can sometimes become very thick, and occasionally the patches can look like small horns or spikes.

skin that may have a stalk (a peduncle or pedicle). An acrochordon may appear on skin anywhere although the favourite locales are the eyelids, neck, armpits (axillae), upper chest, and groin. Some however can be surprisingly large, as in the case of the one illustrated in the above photograph which was located below a man’s right knee. This one was easily removed under local anaesthesia using high frequency electrosurgery, which uses a modulated waveform via a thin electrode to cut and also coagulate tissue at the same time.

Seborrhoeic keratoses in the less politically correct past were also called senile warts. They usually look like greasy or crusty spots which seem to be stuck on to the skin. The colour varies but usually they are darkish brown or black. They are usually round although they can also be oval in shape. Some seborrhoeic warts have an irregular shape. Their size can vary from around one centimetre to several centimetres in diameter.

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Cysts are non-cancerous, closed pockets of tissue that can be filled with fluid, pus, or other material, the term cyst is from the Greek kystis meaning a bag or pouch.

Often cysts are relatively superficial and can be palpated under the skin, although some can be in or around internal organs such as the kidneys. A digital myxoid cyst (sometimes called a mucous or mucoid cyst) is an entirely benign swelling that occurs on the fingers or, sometimes, the toes. Mucoid refer to the jelly-like contents. The exact cause is not known but they are most commonly observed in people over 60 years of age. The cyst is often connected to the lining of the finger or toenail joint, and is usually located between the joint and the nail.

On the basis of observation and their location, the neoplasms were tentatively identified as mucoid cysts. The tentative diagnosis was discussed with the patient and she requested that if possible they should be removed. It was explained to her that in all likelihood the nail may not grow back normally after any surgical procedure so close to the matrix and also that any procedure should be planned so as to allow tissue samples to be sent for histopathology to remove any doubt as to their actual diagnosis. She was at this time accompanied by another family member who also participated, with her permission, in the discussion and informed consent was given for the proposed procedure.

In order to preserve as much of the

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TECHNICAL ARTICLE

excised tissue as possible for histological examination, it was decided to use a scalpel to curette the neoplasms instead of full electrosurgery which would probably have destroyed much of the tissue. The resulting wound, which would be essentially a scrape parallel with the surrounding tissue could then be treated to an application of high frequency electrosurgery to give haemostasis, and also to destroy any remaining superficial dysplastic skin cells that may decide to again give rise to a cyst.

It was also decided to lightly dress the surgical site and its surrounding with an application of silver nitrate a few days before the procedure to desiccate the neoplasms somewhat and make them easier to grasp with forceps so that the curettage would be as accurate as possible. Silver nitrate (AgNo3) has long been a favourite modality in dermatology to stop minor bleeding and treat very superficial items. Chiropody also frequently used it in (usually unsuccessful) attempts to treat verrucae.

Silver nitrate was historically often referred to as lunar caustic because of its crescent-shaped crystalline structure, and although undoubtedly caustic it has a very shallow action due to its being inactivated by sodium chloride which is present in normal human soft tissue at a concentration of some 0.9%. Upon that reaction the substance produced is silver

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chloride which reacts with light to turn black, which feature was used in early chemical photography. The resultant jet black apparent ‘burning’ looks very dramatic, but is in fact relatively superficial and the most frequent risk after repeated applications is a condition known as Argyria in which precipitated silver compounds stain the skin a semipermanent dark grey/blue.

©Schuco International Ltd 2015. By permission

The Schuco 120 is an electrosurgical unit for minimally invasive surgical procedures.

This unit gives the flexibility of cut or coagulation, as well as a combined cut and coagulation setting. Single use disposable electrodes are ideal for sterile procedures.

For the procedure itself the patient was seated comfortably in a treatment chair with the leg supported and the digit was anaesthetised by a standard digital block injection using a few millilitres of mepivacaine hydrochloride 3% plain solution (scandonest®). The area was cleansed and a povidone iodine preoperative skin paint used. Sterile drapes were applied and the procedure performed in a couple of minutes. The

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picture shows the immediate result and the simple instruments used for the procedure, including the blue electrode holder covered by a sterile disposable sheath.

The patient tolerated the procedure exceptionally well and pronounced herself well satisfied when, a few days later the dressing were removed and the debrided area was revealed entirely denuded of the offending items.

A further review has shown healing to be complete, and whilst the area will remain discoloured for some little time from the silver nitrate, it is entirely pain free.

Histopathology revealed the neoplasms, as suspected, to be mucoid cysts.

Interestingly, the nail samples came back as a negative result for onychomycosis and whilst it is entirely possible (and not uncommon) for false negatives to come back for apparent nail fungus, the use of an ultra violet diagnostic lamp shone on the nail subsequently also suggested that there was no typical appearance of a fungal infection. One could perhaps speculate that the trauma from the pressure of the cysts on the nail matrix played some part in the dystrophy of the nail but a further sample will be sent at some time in the future, when the lady comes back for the continuing routine foot care that she has now decided to have lest any more lumps or bumps appear on her toes. ©Martin Harvey 2015.

DIABETIC ARTICLE

Diabetic Foot Assessment Michelle Taylor M.Inst.Ch.P BSc

Diabetes is due to poor uptake of glucose by the cells of the body leading to raised blood glucose levels – hyperglycaemia (McIntosh, C. et al 2006) with the main types of diabetes being Type 1 and Type 11. The effect of prolonged hyperglycaemia increases the risks of both vascular and neurological complications especially in the extremities. Prolonged exposure can be irreversible and increases the risk of chronic complications (Oxford Medical Dictionary 2002). Therefore a diabetic foot assessment is an important tool to identify any changes within the lower limb.

Peripheral neuropathy within the feet can lead to both sensory deficit and autonomic dysfunction. Ischaemia (obstruction of the inflow of arterial blood through the artery) results in atherosderosis of the leg vessels effecting bilateral, multisegmental and the distal arteries of the lower leg and feet (Lorimer, D. et al 2006). For practical purposes the diabetic foot is best divided into 2 entities the neuropathic and the neuroischemic foot.

The neuropathic foot generally has good circulation, is warm, numb, and dry and is painless and the pulses are ok. This can lead to 3 complications, neuropathic ulcer – usually found on the sole – neuropathic (Charcot foot) and rarely neuropathic oedema. A neuroischemic foot is both neuropathic with absent foot pulses, therefore is cool. Complications include pain on resting, ulceration on the margins of the foot due to localized pressure necrosis and gangrene (Lorimer, D. et al 2006).

Vascular diseases peripheral vascular disease (PVD) and peripheral artery disease (PAD) are more commonly found in patients with diabetes. The duration of diabetes along with the severity of hyperglycaemia is associated with vascular complications of the lower limb. Arterial disease is a risk factor for ulceration of the foot. Underlying health issues – hypertension, dyslipidemia, coronary heart disease, smoking, hyperglycaemia, renal disease and a sedentary lifestyle are risk factors in the development of foot disease (McIntosh, C. et al 2006).

In order for a diabetic foot assessment to be performed a full and detailed medical history is mandatory. The medical history should include name, address phone number, date of birth. Date of attendance, when diagnosed, what type and how diabetes is controlled is also required. G.P details and other medication the patient is on if any.

The assessment also includes a general inspection of the feet with the patient’s socks and compression hosiery fully removed in order that the whole of the foot and lower leg can be inspected (Boulton, A. et al. 2008). Any plasters or dressings that the patient may have applied require removal. The following assessments are also required dermatological, musculoskeletal, neurological and vascular.

The dermatological assessment allows for a full assessment of the skin of the dorsum, planter, and lateral aspects of the foot along with the web spaces of the toes to be inspected. Clinical symptoms looked for include: • Trauma • Fungus • Callous formation and build up – light, medium or heavy • Ulceration • Infection • Temperature of the foot and leg and the gradient – warm, cold, hot, normal.

• Dry skin and or fissures.

While looking at the skin several symptoms are required to be noted: • Hair, present, absent, quality, thickness, distribution, and texture.

• Colour; cyanosis (bluish discoloration), jaundice, changes in the melanin, pallor (abnormal paleness of the skin), erythema (flushing of the skin – possible signs of inflammation or infection), pigmentation, gangrene.

• Texture; course, fine, dull or shiny, smooth or rough.

• Humidity; moist, dry, oily, areas of maceration, dryness Any swelling noted requires inspecting and palpating: • Tenderness – local or radiating.

• Consistency – hard, firm, soft, fluctuant.

• Adherence to any underlying structures – skin, soft tissue or bone.

Are the nails: • Well kept • Unkempt • Thick damaged • Infected.

• Subungal abnormality – swelling, pigmentation.

(Inlows 2004).

Deformity within the foot especially with diabetes is associated with high mechanical pressures on overlying skin on bony areas.

Combined with poor sensation and unsuitable footwear can lead to ulceration. Deformities to be noted include: • Claw toes/ Mallet toe/ Hammer toe.

• Pes cavus • Hallux rigidus/ valgus • Fibro fatty pad depletion • Charcot foot • Deformities caused by previous surgery or trauma (Edmond M, E.) Peripheral neuropathy within the extremities is closely associated with foot ulceration therefore a number of tests need to be performed in order to detect sensory loss; these include the use of a monofilament, Rydell – Seiffer tuning fork and ankle brachial pressure index tests (ABPI). The use of a 10g monofilament has been proven that this level of pressure provides a protective sensation against foot ulceration. Areas requiring testing include 1st planter dorsal area of the 1st, 3rd and 5th toes. 1st, 2nd, 4th and 5th MPJ areas along with the 1st and 5th side of the MPJ’s. (Colmos P, R. et al 1995). The monofilament is applied perpendicular to the surface of the skin, and pressure applied slowly until the monofilament bends. At this point the patient should be able to feel a sensation of pressure (Lorimer D at al 2006). This test should ideally be performed while the patient’s eyes are closed enabling a truer picture of sensory ability. Areas of callous should be avoided.

Vibratory sensation can be tested using a Rydell Seiffer tuning fork. The Rydell Seiffer tuning fork allows for a quantifiable assessment of vibration perception of the patients feet. 2 triangles appear on the graduated scale of 0 – 8 on the ends of the vibrating forks, which merge together as the amplitude decreases. When the patient says they are unable to feel the vibrations, the scale is read at the apex of the single triangle formed of the merging 2 triangles. Diabetic patients of a score of

Podiatry Review Vol 72:2

page 9

DIABETIC ARTICLE

4 or less are vulnerable to ulceration (Vijay V. et al 2001). Areas suitable for testing include any boney prominence bunion, tailors bunion, medial or lateral malleolus or the tip of the 1st toe. Once an area has been chosen to be tested it is advised that the same area is tested in subsequent assessments in order to gain a true sensory ability. It is advised not to test over areas of callous as this can give a lower vibratory score. In order to start the vibration off the 2 prongs of the tuning fork are squeezed together either manually or tapped against a hard surface. The hand end is placed against the area to be tested.

A vascular assessment includes the palpation of the pulses within the foot and should be noted as either absent or present (Boulton, A, J, M et al 2008). The vessels to be checked with a doppler are the anterior and posterior tibial, along with the dorsal pedis and peroneal pulses (Diagram 1). A doppler can be used on these areas to obtain a more reliable reading than palpation with the fingers, as practioners “feel” their own pulses rather than that of the patients. Low blood pressure, obesity or oedema may also cause the pulses to be hard to find. By recording the doppler sounds enables the status of any vascular disease within the arteries to be noted (Aerden, D. et al 2011).

Detection of PAD during a foot assessment is an important indicator of atherosclerotic disease in diabetics. The use of ankle brachial pressure index (ABPI) compares the systolic blood pressure level at the ankle against the brachial pressure. By measuring the arterial blood flowing towards the foot from the iliac arteries allows for any blockages to be noted. If the systolic and brachial pressure are of a similar yield of ABPI of 1 it can be noted that the blood flow is unobstructed. As atherosclerotic lesions are predominantly found in the arteries of the lower limb, while the arteries above the knee are relatively free of disease (Aerden, D. et al 2011).

The ankle brachial pressure index (ABPI) is obtained by taking the brachial pulse in each arm via a blood pressure cuff and a doppler on the brachial artery in the arm. The cuff is inflated until no sound can be heard from the artery, allow the cuff to slowly deflate until the sound of the artery is heard flowing back through the artery at this point note the pressure on the gauge of the cuff.

This procedure is repeated on the other arm.

The same procedure is used to obtain the brachial pressure within the foot with the cuff being placed around the leg just above the malleoli. The arteries in the foot that are used are the dorsal pedis or the anterior pedial pulses with the pressure noted.

The same procedure is repeated using the posterior tibial artery.

The procedure is repeated for the other leg. The highest reading

page 10

from the pulses in the foot is used to obtain the ABPI. The ABPI is found by dividing the highest pressure obtained from the ankle vessels by the highest brachial pressure of the 2 arms [worldwide wounds accessed 27th October 2012].

The results from the ABPI should fall into the following categories The ABI is interpreted as follows: 1.00 to 1.29: normal 0.91 to 0.99: borderline ischemia 0.41 to 0.90: mild to moderate disease ischemia 0.40 Less than or equal to: severe disease.

[Nursing 2012 accessed 27th October 2012].

Any significant variance in sensory ability, doppler sound or ABPI requires an immediate referral on to the Diabetic Clinic, G.P or Diabetic Nurse for further investigation.

References

Aerden, D. Denecker, N. Keymeulen, B. van der Brande, P. 2011. Ankle – brachial pressure index: A mixed blessing. Diabetic Foot Journal, 14 (4), p. 154.

Boulton, A, J.M. Armstrong, D, G. Albert, S, F. Franberg, R, G. Hellman, R. Kirkland, M,S. Lavery, L,A. LeMaster, J, W. Mills, J, L. Mueller, M,J. Sheeham, P. Wukich, D,K (2008) Comprehensive Foot Examination and Assessment. Diabetes Care, 31 (8).

Colmos, P, R. Cataland, S. O’Dorsio, T, M. (1995) The Semmes – Weinstein monofilaments as a potential predictor of foot ulceration in patients with non – insulin dependent diabetes. American Journal of the Medical Sciences, 309 (2), p. 76 – 82.

Edmound, M, E. Foster, A, V, M. (2005) Managing the Diabetic Foot.

2nd ed. Blackwell Publishing Lorimer, D. French, G. O’Donnell, M. Burrow, J, G. Wall, B. (2006).

Neale’s Disorders of the Foot. 7th ed. Churchill Livingstone Elsevier.

Inlows. (2004) A 60 second foot exam. Diabetic Foot Screen. Wound care Canada, (2), p.10 - 11.

McIntosh, C. and Newton, V. (2006) Managing Diabetic Ulcers: Best Practice. Wound Essentials, vol 1.

Nursing 2012 http://journals.lww.com/nursing/Fulltext/2011/01000/Understanding_the _ankle_brachial_index.23.aspx[accessed 27th October 2012] Oxford Medical Dictionary 2002 3rd ed.

Shutterstock http://www.shutterstock.com/ [accessed 27th October 2012] Vijay, V. Snehalatha, C. Seena, R. Ramachandham, A. (2001) The Rydell Seiffer tuning fork: an inexpensive device for screening diabetic patients with high risk foot. Practical Diabetes International. 18 (5), p. 155 – 156 Worldwide Wounds http://www.worldwidewounds.com/2001/march/Vowden/Dopplerassessment-and-ABPI.html[ac

Podiatry Review Vol 72:2

DIABETIC ASSESSMENT FORM

Foot Exam Form Patient:

D.O.B

Address

Dr

Type of Diabetes Type 1

Control

Diet

Please circle the following

Type 2

Insulin

Medication

Signs and Symptoms

Nephropathy

Tobacco Use: How much: How long

Yes or No

Comments

Yes or No

Comments

Neuropathy

Vascular Disease Hypertension

Heart Disease

Stroke

Amputation Other:

Any change in the foot or feet since the last evaluation?

Current ulcer or history of a foot ulcer?

Is there pain in the calf muscles when walking that is relieved when rested

Dermatologic examination:

Are the nails thick, elongated, or ingrown?

Are there calluses or ďŹ ssures

Is there a maceration or open lesion in the web space?

Is there redness or warmth state whereabouts.

Footwear assessment:

Does the patient wear appropriate shoes?

Foot Wear: Good Fit

Foot Wear: Good Shape Foot Wear: Lace/Velcro

__ No __ Yes

__ Yes __ No (Not too loose/too tight)

__ Yes __ No (Square box toe â&#x20AC;&#x201C; not pointed) __ Yes __ No (Slip on not appropriate)

Podiatry Review Vol 72:2

page 11

DIABETIC ASSESSMENT FORM Inspection Deformities Callus Ulceration Amputation

Right Yes No Yes No Yes No Yes No

Left Yes Yes Yes Yes

Palpable Pulses Dorsalis pedis Tibialis Posterior

Right Yes No Yes No

Left Yes No Yes No

No No No No

Sensory Foot Exam

Label sensory level with a “+” in the five circled areas of the foot if the patient can feel the (10-gram) nylon filament and “-” if the patient cannot feel the filament.

The ankle brachial pressure index (ABPI) Right Left

1.00 to 1.29: normal 0.91 to 0.99: borderline ischemia 0.41 to 0.90: mild to moderate disease ischemia 0.40 Less than or equal to: severe disease.

Vibratory Sensation

Using a Rydell Seiffer tuning fork test the area’s indicated by the 2 boxes mark the score here

Right foot

Left foot

Risk Categorization (Check appropriate item) Low-Risk Patient All of the following: □ Intact protective sensation □ No severe deformity

High-Risk Patient One or more of the following: □ Loss of protective sensation

□ No severe deformity □ No amputation

□ No prior foot ulcer

□ Pedal pulses present

□ Absent pedal pulses

□ Severe foot deformity

□ History of foot ulcer

Education

1. Has the patient had prior foot care education?

2. Can the patient demonstrate appropriate self-care?

Management Plan (Check all that apply.)

□ Yes □ Yes

□ No □ No

□ Provide patient education for preventive foot care. □ Refer to G.P/ Practice Nurse Date: Signature:

Michelle Taylor

page 12

Podiatry Review Vol 72:2

INFORMATION ARTICLE

Record Cards and Record Keeping

A Reminder /ŶƚƌŽĚƵĐƟŽŶ͗

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dĞƐƚƐ

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dŚĞ &ŽƌŵĂƚ E ͘ ĞƚĂŝůƐ ŽĨ ƉĂƟĞŶƚ͛Ɛ ǁĞŝŐŚƚ ĞƚĐ͘ ĂŶĚ ĚƌƵŐ ĚŽƐĂŐĞƐ ƐŚŽƵůĚ ďĞ ƌĞĐŽƌĚĞĚ ŝŶ ƚŚĞ ŵĞƚƌŝĐ ƐLJƐƚĞŵ ŽĨ ŵĞĂƐƵƌĞŵĞŶƚ ƵŶŝƚƐ ĞdžĐĞƉƚ ǁŚĞƌĞ ĐĞƌƚĂŝŶ ĂƩƌŝďƵƚĞƐ ĞŐ͘ ŚĞŝŐŚƚ͕ ĂƌĞ ŐĞŶĞƌĂůůLJ ĞdžƉƌĞƐƐĞĚ ŝŶ ŝŵƉĞƌŝĂů ŵĞĂƐƵƌĞŵĞŶƚƐ͘

^ƵĐŚ ĂƐ ƐĞŶƐŝƟǀŝƚLJ ŝŶ ĚŝĂďĞƚĞƐ ƉĂƟĞŶƚƐ͕ ĞƚĐ͘

KŶ džĂŵŝŶĂƟŽŶ dŚŝƐ ƐŚŽƵůĚ ŝŶŝƟĂůůLJ ƌĞĐŽƌĚ ĮƌƐƚ ŝŵƉƌĞƐƐŝŽŶƐ ŽĨ ƚŚĞ ƉƌĞƐĞŶƟŶŐ ĐŽŵƉůĂŝŶƚ͘ KƚŚĞƌ ĞůĞŵĞŶƚƐ ŵĂLJ ƚŚĞŶ ďĞ ƌĞĐŽƌĚĞĚ͗ ^ŬŝŶ dĞdžƚƵƌĞ͖ ^ŬŝŶ ŽůŽƵƌ͖ EĂŝů dĞdžƚƵƌĞͬ ŽůŽƵƌ͖ ŚĂŝƌ ŐƌŽǁƚŚ͖ ƐŬŝŶ ůĞƐŝŽŶƐ͘ :ŽŝŶƚ ŵŽǀĞŵĞŶƚƐ ŽĨ ƚŚĞ ůŽǁĞƌ ůŝŵď ŝŶ ƚĞƌŵƐ ŽĨ ƌĂŶŐĞ ŽĨ ŵŽƟŽŶ ĂŶĚ ƋƵĂůŝƚLJ ŽĨ ŵŽƟŽŶ ƐŚŽƵůĚ ĂůƐŽ ďĞ ƌĞĐŽƌĚĞĚ ĂƐ ƐŚŽƵůĚ ƐŚŽĞ ǁĞĂƌ ƉĂƩĞƌŶƐ͘ dŚĞ ƉĂƟĞŶƚ ƐŚŽƵůĚ ďĞ ĞdžĂŵŝŶĞĚ ƐƚĂŶĚŝŶŐ ĂŶĚ ǁĂůŬŝŶŐ ǁŚĞŶ ƐŝŐŶƐ ŽĨ ƐĞŶƐŽƌLJ ĂŶĚ ŵŽƚŽƌ ĂĐƟǀŝƚLJ ĐĂŶ ďĞ ŐƌŽƐƐůLJ ĐŚĞĐŬĞĚ͘

/ƚ ŝƐ ŽĨ ŐƌĞĂƚ ŝŵƉŽƌƚĂŶĐĞ ƚŽ ĂĐĐƵƌĂƚĞůLJ ƌĞĐŽƌĚ ƚŚĞ ƉĞƌŝƉŚĞƌĂů ǀĂƐĐƵůĂƌ ƐƚĂƚƵƐ ŽĨ ďŽƚŚ ůŽǁĞƌ ůŝŵďƐ͖ ƚŚĞ ĚŽƌƐĂůŝƐ ƉĞĚŝƐ ĂŶĚ ƉŽƐƚĞƌŝŽƌ ƟďŝĂů ƉƵůƐĞƐ ƐŚŽƵůĚ ďĞ ƉĂůƉĂƚĞĚ ĂŶĚ ƌĞĐŽƌĚĞĚ ŝŶ ƚĞƌŵƐ ŽĨ ƐƚƌĞŶŐƚŚ ;Ă ŽƉƉůĞƌ ŝƐ Ă ǀĞƌLJ ƵƐĞĨƵů ĂĚũƵŶĐƚ ŚĞƌĞͿ ĂŶĚ ǀĂƐĐƵůĂƌ ƌĞƚƵƌŶ ĂŶĚ ĂŶLJ ǀŝƐŝďůĞ ǀĂƌŝĐŽƐŝƟĞƐ ŶŽƚĞĚ͘ dŚĞ ƚĞŵƉĞƌĂƚƵƌĞ ŐƌĂĚŝĞŶƚ ƐŚŽƵůĚ ďĞ ĐŚĞĐŬĞĚ͘

dƌĞĂƚŵĞŶƚ dŚŝƐ ŝƐ ƌĞĐŽƌĚĞĚ ŝŵŵĞĚŝĂƚĞůLJ ĨŽůůŽǁŝŶŐ ƉƌŽǀŝƐŝŽŶ͘ WĂƉĞƌůĞƐƐ ƌĞĐŽƌĚƐ ĂƌĞ ďĞĐŽŵŝŶŐ ŝŶĐƌĞĂƐŝŶŐůLJ ƉŽƉƵůĂƌ ĂŶĚ ŚĂǀĞ ĂĚǀĂŶƚĂŐĞƐ ŽǀĞƌ ƌĞĐŽƌĚ ĐĂƌĚƐ ŝŶ ƚŚĂƚ ƚŚĞLJ ĐĂŶ ďĞ ƐƚŽƌĞĚ ƐĂĨĞůLJ ŽŶ ĐŽŵƉƵƚĞƌ ǁŝƚŚ ĂĐĐĞƐƐ ďLJ ƉĂƐƐǁŽƌĚ ŽŶůLJ͘ dŚĞLJ ĂƌĞ ůĞŐŝďůĞ ĂŶĚ ƐĂǀĞ ŽŶ ƐƚŽƌĂŐĞ ƐƉĂĐĞ͘ ůĞĐƚƌŽŶŝĐ ƌĞĐŽƌĚ ĐĂƌĚƐ ƌĞĚƵĐĞ ƚŚĞ ƌŝƐŬ ŽĨ ůŽƐƚ Žƌ ŵŝƐĮůĞĚ ƌĞĐŽƌĚƐ ĂŶĚ ĂƌĞ ĂĐĐĞƐƐĞĚ ƋƵŝĐŬůLJ͘ dŚĞLJ ĂƌĞ ĂůƐŽ ĞŶǀŝƌŽŶŵĞŶƚĂůůLJ ĨƌŝĞŶĚůLJ ŝŶ ƌĞĚƵĐŝŶŐ ƉĂƉĞƌ ĐŽŶƐƵŵƉƟŽŶ͘ dŚĞ ĚŝƐĂĚǀĂŶƚĂŐĞƐ ĂƌĞ ƚŚĂƚ Ăůů ĞůĞĐƚƌŽŶŝĐ ƌĞĐŽƌĚƐ ŶĞĞĚ ƚŽ ďĞ ƌĞŐŝƐƚĞƌĞĚ ǁŝƚŚ ƚŚĞ ĂƚĂ WƌŽƚĞĐƟŽŶ ŐĞŶĐLJ͘ EŽƚĞƐ ƐƟůů ŶĞĞĚ ƚŽ ďĞ ŵĂĚĞ ŽŶ ƉĂƟĞŶƚƐ ĂŌĞƌ ƌĞĐĞŝǀŝŶŐ ƚƌĞĂƚŵĞŶƚƐ ĞƐƉĞĐŝĂůůLJ ĂŌĞƌ ĚŽŵŝĐŝůŝĂƌLJ ǀŝƐŝƚƐ͕ ǁŚŝĐŚ ŵĂLJ Žƌ ŵĂLJ ŶŽƚ ďĞ ƚƌĂŶƐĨĞƌƌĞĚ ƚŽ ĞůĞĐƚƌŽŶŝĐ ƌĞĐŽƌĚƐ͘

tŚŝĐŚĞǀĞƌ ŵĞƚŚŽĚ ŝƐ ƉƌĞĨĞƌƌĞĚ͕ ƉƌĂĐƟƟŽŶĞƌƐ ĂƌĞ ŶŽǁ ĞŶĐŽƵƌĂŐĞĚ ƚŽ ĂĚŽƉƚ ƚŚĞ ^K W ŵĞƚŚŽĚ

^ ʹ ^ƵďũĞĐƟǀĞ K ʹ KďũĞĐƟǀĞ ʹ ĐƟŽŶ W ʹ WůĂŶ

dŚĞ ƉĞƌŝƉŚĞƌĂů ŶĞƵƌŽůŽŐŝĐĂů ƐŝŐŶƐ ƐŚŽƵůĚ

Podiatry Review Vol 72:2

page 13

INFORMATION ARTICLE

džĂŵƉůĞƐ ŽĨ ^K W ^ƵďũĞĐƟǀĞ

/ ŚĂǀĞ Ă ƉĂŝŶ ŝŶ ŵLJ ďŝŐ ƚŽĞ

KďũĞĐƟǀĞ KŶ ĞdžĂŵŝŶĂƟŽŶ͕ ƚŚĞ ƉĂƟĞŶƚ͛Ɛ ƌŝŐŚƚ ĮƌƐƚ ƚŽĞ ĂƉƉĞĂƌĞĚ ƌĞĚ ĂŶĚ ƐǁŽůůĞŶ͘ ƚ ĐůŽƐĞƌ ĞdžĂŵŝŶĂƟŽŶ ƉĂƟĞŶƚ ĂƉƉĞĂƌĞĚ ƚŽ ŚĂǀĞ ŽŶLJĐŚŽĐƌLJƉƚŽƐŝƐ ŝŶ ŵĞĚŝĂů ƐƵůĐƵƐ ŽĨ ƚŚĞ ĮƌƐƚ ƚŽĞ͘

ĐƟŽŶ ŚůŽƌŚĞdžŝĚŝŶĞ ŐůƵĐŽŶĂƚĞ ƐƉƌĂLJ ĂƉƉůŝĞĚ ƚŽ ďŽƚŚ ĨĞĞƚ͘ EĂŝů ƐƉŝĐƵůĞ ĐƵƚ ĂŶĚ ƌĞŵŽǀĞĚ ĨƌŽŵ ŶĂŝů ƐƵůĐƵƐ͘ KŶLJĐŚŽƉŚŽƐŝƐ ĐůĞĂƌĞĚ ĂǁĂLJ ƵƐŝŶŐ ďůĂĐŬƐ ĮůĞ͘ ^ƚĞƌŝůĞ ĚƌĞƐƐŝŶŐ ŝŶĐůƵĚŝŶŐ ŝŶĂĚŝŶĞ͕ ŵĞůŽŶŝŶ͕ ƚƵďĞŐĂƵnjĞ ĂŶĚ ŵĞĮdž ĂƉƉůŝĞĚ͘ WĂƟĞŶƚ ŐŝǀĞŶ ǁƌŝƩĞŶ ĂŶĚ ǀĞƌďĂů ĂĚǀŝĐĞ ŽŶ ĐůĞĂŶŝŶŐ ŽĨ ƚŽĞ ŝŶ ƐĂůŝŶĞ ĨŽŽƚ ďĂƚŚ ĂŌĞƌ ƌĞŵŽǀĂů ŽĨ ĚƌĞƐƐŝŶŐ ŝŶ Ϯϰ ŚƌƐ͘ ůƐŽ ǁƌŝƩĞŶ ĂŶĚ ǀĞƌďĂů ĂĚǀŝĐĞ ŐŝǀĞŶ ŽŶ ƐŝŐŶƐ ŽĨ ƐƉƌĞĂĚŝŶŐ ŝŶĨĞĐƟŽŶ ĂŶĚ ƚŽůĚ ƚŽ ĐŽŶƚĂĐƚ ŝĨ ĂŶLJ ĨƵƌƚŚĞƌ ƉƌŽďůĞŵƐ͘

WůĂŶ WĂƟĞŶƚ ƚŽ ƌĞƚƵƌŶ ĨŽƌ ĐŚĞĐŬ ƵƉ ŝŶ ϮͬϭϮ͘ WŽƐƐŝďůĞ ĨƵƚƵƌĞ ŶĂŝů ƐƵƌŐĞƌLJ͘

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ZĞĨĞƌĞŶĐĞƐ ƵƌƌŽǁƐ ͘Z͘ ;ϵϵͿ͘ dŚĞ /ŵƉŽƌƚĂŶĐĞ ŽĨ ZĞĐŽƌĚ <ĞĞƉŝŶŐ͘ WŽĚŝĂƚƌLJ ZĞǀŝĞǁ͘ ϱϲ ;ϭͿ͕ ϭϬ͘ ƵƌƌŽǁƐ Z͘ ;ϬϵͿ͘ ZĞĐŽƌĚ ĂƌĚƐ ĂŶĚ ZĞĐŽƌĚ <ĞĞƉŝŶŐ͖ ƌĞ LJŽƵ ĨƵůĮůůŝŶŐ ŵŝŶŝŵƵŵ ƐƚĂŶĚĂƌĚƐ͘ WŽĚŝĂƚƌLJ ZĞǀŝĞǁ͘ ϲϲ ;ϭͿ͕ ϭϮ-ϭϰ͘ ůĂŝƌĞ 'ĂůůĂŐŚĞƌ ^Đ ;,ŽŶƐͿWŽĚ 'ĂůůĂŐŚĞƌ͕ ͘ ;ϮϬϭϰͿ͘ dŚĞ /ŵƉŽƌƚĂŶĐĞ ŽĨ ůŝŶŝĐĂů EŽƚĞ tƌŝƟŶŐ͘ WŽĚŝĂƚƌLJ ZĞǀŝĞǁ͘ ϳϭ ;ϭͿ͕ ϭϮ͘

page 14

Podiatry Review Vol 72:2

Continuing

Professional Development Supported by an educational grant from Galderma UK Limited

Hyperkeratosis of the foot: part 2 Julia Potter, Senior Lecturer, School of Health Sciences, University of Southampton.

Introduction One of the most common conditions seen in podiatry practice is corns and callus, accounting for up to 75% of podiatrists’ workload1,2. They often form painful skin lesions and can be the main reason for seeking treatment. Although, seemingly a trivial condition, it has been shown that older people, in particular, who have plantar calluses have difficulty with walking and using stairs3. Calluses and painful feet have also been associated with an increased risk of falls3,4. Within the diabetic population, plantar callus has been identified as a risk factor for the development of ulceration5 and therefore a considerable amount of research has been carried out in this area. This article will cover the formation, aetiology and potential treatment of mechanically induced callus, corns will be covered in a later article. Non-mechanical causes of callus were presented in ‘Hyperkeratosis of the foot: part 1’ in the June 2008 edition of Podiatry Now.

Key Point: callus may account for up to 75% of a practitioner’s workload

The formation of symptom-free callus is thought to be a normal process which helps protect the foot from trauma7-9, and is known as physiological callus. If the traumatic stimulus causing the callus formation is removed, the skin, in particular the stratum corneum, reverts in time to its original structure9.

However, when the callus accumulates sufficiently to cause discomfort, and persists despite the removal of the stimulus, it is referred to as pathological callus8,10. This may progress to ulceration, particularly when the nutrition of the tissues is impaired, for example in diabetes mellitus5,11-13.

Key Point: callus is a risk factor for developing ulceration in the diabetic foot Incidence and sites of callus formation Within the UK it is estimated that 75-80% of people over 65 present with callus or corns14,15, and, not surprisingly, calluses are more common in women15,16. Within the working population, the estimate of people suffering from calluses is 18%16.

What is a callus?

Callus has been defined by Mackie6 as ‘an excessive formation of the normal keratin for the body site in question’ and may be associated with disorders such as psoriasis, eczema and mycosis, as well as mechanical causes.

The distribution of plantar calluses varies across the metatarsal heads, with the second metatarsal head being the most common site, see Table 1.

Podiatry Review Vol 72:2

page 15

Hyperkeratosis of the foot: part 2

Continuing Professional Development Table 1 Percentage distribution of plantar callus from 3 surveys (rounded values) Site

Springett et al [16] Survey 1 (n=1000)

Springett et al [16] Survey 2 (n=319)

Grouios [20] (n=115)

1st metatarsal head (MTH)

21

27

23

2nd MTH

30

36

32

3rd MTH

12

5.5

10

4th MTH

8

6

7.5

5th MTH

11

13.5

12.5

2nd and 3rd MTH

6.5

6

7.5

2nd, 3rd and 4th MTH

3.5

5.5

5

The incidence and location of calluses differ between men and women. It has been found that men are more likely to have calluses over the first and fifth metatarsal heads and women over the second17. There are a number of potential reasons for this, such as footwear and foot shape and structure, but this is not based on research evidence.

Key Point: up to 80% of individuals over 65 suffer with callus, most commonly located under the second metatarsal head Footedness has been suggested to be an influencing factor in foot pathology18,19 and callus formation20, where footedness has been described as the tendency to prefer the use of a consistent foot in performing voluntary motor acts. The preferred or dominant limb is characterised as the mobilizing or manipulating limb, whereas the non-preferred limb is the stabilizing one. For example, in kicking a football, the preferred limb would be the one that strikes the ball, while the nonpreferred limb stabilizes the body20. There are varying degrees of footedness, which may depend on the individual and the task in question, resulting in a number of methods which have been devised to determine footedness20. So, although Springett et al16 found that calluses formed uni- or bilaterally, regardless of the side of footedness, they did not mention how they determined the preferred side.

Key Point: the presence of callus and foot pain is associated with falls in the elderly How does callus form?

While the formation of callus has been investigated over a number of decades, there is still much that is unknown. To be

page 16

able to appreciate some of the cellular aspects of callus formation, it is useful to start with the normal process of keratinisation. This process ensures a balance of newly generated cells from the basal layer, which pass upward through the spiny and granular layer, arriving in the stratum corneum where the cells spend the remaining half of their life before being desquamated. This process takes 4-6 weeks and is regulated by cytokines and epidermal growth factors9.

However, with calluses, this process is disrupted. The cell proliferation in the basal layer has been found to increase by 2-3 times, but this is not compensated by an increased desquamation rate9. The rate of cell transition through the different layers of the epidermis is more rapid, resulting in immature cells in the stratum corneum, which still have connections (desmosomes) with surrounding cells. These connections increase the cell-to-cell cohesion, which makes it more difficult for the cells to be shed from the stratum corneum9. This culminates in a build up of cells in the stratum corneum, increasing the thickness in this area; hence a callus is formed. The presence of the callus itself causes the release of cytokines and epidermal growth factors, thereby perpetuating the cycle of callus formation.

Due to the thickness of the stratum corneum at the site and the increased levels of linoleic acid (which maintains the barrier function of the stratum corneum)21, the movement of water through the skin is reduced, leading to a rigid structure or plaque22. During normal walking, this plaque moves against the surrounding tissues which become traumatised and release inflammatory mediators and growth factors, which causes more cells to be generated from the basal layer, and the process continues.

Podiatry Review Vol 72:2

Springett22 proposed a model that stated that an excess duration and magnitude of mechanical pressures (that is greater pressures over longer times during the gait cycle) were predominant factors in stimulating the cyclical process of callus formation.

The increase in pressure stimulates the release of cytokines and epidermal growth factors in the epidermis, so more cells are produced and the cycle of callus begins. This suggests that if this excess pressure can be altered or reduced, it may be possible to prevent or limit the formation of callus.

In order for the excess pressure or foot mechanics to be modified or altered, firstly they need to be identified. Several factors have been suggested which may give rise to callus formation and they have been broadly categorised into intrinsic (unique factors of an individual) and extrinsic (arising from the outside world) factors8,23. Intrinsic factors include anatomical variants which can give rise to altered gait and faulty foot mechanics24, for example rear and forefoot abnormalities, digital deformities, bony prominences. It also includes disorders of the spine and skin, and systemic disease23. Extrinsic factors include footwear (poorly fitted, over-worn, inappropriate design), hosiery, and sporadic exercise regimes, which may lead to excessive loading on certain areas of the body23. It is also possible for a combination of intrinsic and extrinsic factors to be responsible for callus formation.

Key Point: there are many proposed aetiologies for callus but so far there is no clear evidence to support one theory Two studies have investigated plantar foot pressures in people with and without callus, who were otherwise healthy25,26. Both studies found that those people with callus had higher pressures than those without (by 25% and 12% respectively), Potter and Potter25 went on to remove the callus in the callus group and found that there was no difference in the pressures before or after callus removal, concluding that although people with callus have higher foot pressures than those without, these pressures do not reduce when the callus is removed. This suggests that, in otherwise healthy individuals, the callus has formed due to an alteration in foot pressures. This would indicate treatment targeted at altering foot mechanics, which will be addressed later.

The picture is different again for those people with rheumatoid arthritis. Due to the nature of the disease, the metatarsal heads become prominent, with reduced fatty padding and callus formation. Two studies have investigated the effect of callus debridement on plantar pressures30,31; both found no significant alteration in pressure after debridement.

Despite the fact that high plantar pressures have been shown to be associated with calluses, it is not possible for clinicians to estimate reliably where these high pressure are occurring32.

Guldemond and colleagues32 investigated the ability of podiatrists, pedorthotists and orthotists to reliably distinguish areas of the foot with elevated plantar pressures in participants with metatarsalgia. In general, plantar pressures under the hallux were underestimated and those under the metatarsals were over estimated, across and within all professions.

Therefore the only way of establishing areas of high pressure reliably is with appropriate foot pressure measuring systems, which are expensive and beyond the reach of many practitioners.

The studies on foot pressures have only considered vertical pressure, although undoubtedly, shear has a part to play in callus formation33, but as yet no robust foot pressure system is able to measure shear and reliably quantify and identify where it is occurring on the foot.

Classification of callus Although callus is usually considered as an homogenous entity, it has been recognised that different forms exist. From a cellular point of view, Thomas et al9 described all calluses as having superficial strippable layers (loosely held together), with deeper cohesive underlying layers (firmly held together). But from a clinical point of view calluses can be seen to be different shapes (from well circumscribed to diffuse), sizes and textures (dry, glassy, moist)34 and this can be more noticeable in the diabetic foot33. Sgarlato35 attempted to classify callus into 7 categories, concentrating on â&#x20AC;&#x2DC;shearingâ&#x20AC;&#x2122; callus. While this was comprehensive, it would be difficult to categorize commonly occurring plantar calluses into more than three of the descriptions. More recently Potter and Aitken36 conducted a study to gain consensus on 10 typical types of callus. Although consensus was reached for heel and digital callus, plantar callus did not reach consensus.

Callus and foot pressures In individuals without any underlying systemic condition, it has been found that removing callus did not change the plantar pressures. However, it people with diabetes, this does not seem to be the case. A number of studies have found that following callus debridement plantar pressures have reduced by 26%13, 32%27 and 58%28, which given the associated risk of developing an ulcer5,29, indicates that callus in people with diabetes should be debrided.

Callus debridement It has been demonstrated that calluses re-grow at different rates; fast types make 80% re-growth three weeks following debridement, and slow types make 18% re-growth over the same period34. Although it was not easy to identify clinically which callus would exhibit a fast or slow type, it was found that 89% of fast type calluses were either over the first or fifth metatarsal head and 55% of slow type calluses were over the second metatarsal head. While this is a relatively new finding, it

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Hyperkeratosis of the foot: part 2

Why does callus form?

Hyperkeratosis of the foot: part 2

Continuing Professional Development does not help in determining the optimum time for callus debridement. Pitei et al27 investigated two time frames for callus debridement in a diabetic population, 3-4 weeks and 6-8 weeks.

They measured the amount of callus debrided and found no significant difference. They concluded that the longer interval would be safe regarding ulceration, but only in those with a slower rate of callus formation.

A common reason for debriding callus is pain. Redmond et al37 investigated the pain scores pre and post callus debridement in 79 participants (using a Visual Analogue Scale). Although they found a significant reduction in the foot pain after debridement, they acknowledged that this only assessed the immediate effect of callus debridement and not the pain management over a typical interval of 6-12 weeks. Timson and Spooner38 took this a stage further. They investigated two groups of participants, one group receiving scalpel debridement alone and the other, insole therapy alone. The immediate post-intervention scores in both groups were significantly reduced. After 6 weeks pain scores were taken again. The debridement groupâ&#x20AC;&#x2122;s pain scores were similar to their original pre-treatment score, with 32% reporting increased pain scores. However, for the insole group, their scores were significantly lower than either of their original scores, which demonstrated their continued pain relief with insoles 6 weeks after issue. This is still a short time frame and a combination of scalpel debridement and insole therapy needs to be investigated.

Within the rheumatoid population, pain relief from callus debridement has also been investigated. Although debridement provides immediate relief, it has been found to last only for 2-7 days30,31.

If the causes are found to be extrinsic, for example footwear, then appropriate, tailored advice should be given.

Once the cause of the callus has been addressed, it is now possible to consider relieving the symptoms. Several studies have looked at scalpel reduction and found that it provides immediate pain relief37-39, although not necessarily long lasting.

Other options for reducing the pain caused by calluses include topical preparations which encompass emollients, urea creams and hydrocolloid dressings. All these will hydrate the callus, making it more pliable and therefore more comfortable41. There is a variety of over-the-counter products available, some containing urea or salicylic acid, which have been discussed in an earlier CPD article42. Springett et al43 investigated using hydrocolloid dressings, which were found to improve corns, callus and heel callus.

Filing or pumicing has been advocated over a number of years, although there is no research evidence to support or refute its practice. If this is going to be advised, then specific instructions should be issued, for example only file or pumice once a week or once a fortnight, using a wet file or pumice and for up to 3 minutes. However, a note of caution; callus is thought to be stimulated by excess mechanical stress and filing or pumicing could replicate this stress and therefore contribute to the callus formation, rather than reduce it.

Foot surgery is an option when conservative measures fail44, although the details are beyond the scope of this article.

Management of calluses Given the background to the current research in callus, it is now possible to explore how this impacts on clinical practice.

In order to be able to treat a person who presents with painful callus (it is suggested that painless calluses should not be removed, unless the individual has diabetes), it is necessary to determine the cause. This returns the discussion to the intrinsic and extrinsic factors which may cause the callus and taking a detailed medical history followed by a musculoskeletal assessment of the lower limb. Once the potential cause has been identified, management will revolve around removing or altering the excess pressure.

This is usually achieved by the use of either chairside appliances, deflective or cushioning padding, simple or casted insoles. Caselli et al39 found that using a Poron insole in conjunction with callus debridement reduced pain more than debridement alone up to 4 weeks after issue, while Timson and Spooner38 found that pain was reduced up to 6 weeks after issue of an insole only, with callus debridement. Colagiuri et al40 investigated the use of scalpel debridement and functional orthoses in a group of people with

page 18

diabetes and found that more calluses improved in the orthoses group. It would seem, therefore that insole therapy is the way forward in managing calluses.

Whatever treatment is carried out, it is essential to evaluate it. A number of studies have used simple pain scales, using the Visual Analogue Scale (VAS), which measures pain intensity only37,38.

However, there are more sophisticated podiatry specific outcome measures now available, which consider quality of life measures, foot function and type of pain45-47, and these should start being the mainstay of our treatment evaluations. The details of these will be covered in a future article.

Key Point: evaluation of outcomes are an important step in establishing effectiveness of treatments provided by practitioners Summary The treatment of calluses should: 1 identify the cause, remove or alter if possible 2 provide symptomatic relief, either by scalpel debridement or encouraging self-help in the form of using creams 3 evaluate the outcome of the treatment, in conjunction with the patient and amend if necessary

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Hyperkeratosis of the foot: part 2

Two typical calluses

Figure 1a

Figure 1b

References

11 Duckworth, T., Boulton, A.J.M., Betts, R.P., Franks, C.I., Ward, J. D. (1985) Plantar pressure measurements and the prevention of ulceration in the diabetic foot. J Bone Joint Surg [Br], 67B:79-85.

12 Cavanagh, P.R., Sims Jr, D.S., Sanders, L. J. (1991) Body mass is a poor predictor of peak plantar pressure in diabetic men. Diabetes Care, 14(8):750-755.

13 Young, M., Cavanagh, P.R., Thomas, G., Johnson, M.M., Murray, M., Boulton, A.J.M. (1992) The effect of callus removal on dynamic plantar foot pressures in diabetic patients. Diabet. Med. 9:55-57.

14 Cartwright, A., Henderson, G. (1986) More Trouble with Fee: a survey of the foot problems and chiropody need of the elderly. HMSO, London, p15-31.

15 Elton, P.J., Sanderson, S.P. (1987) A chiropodial survey of elderly persons over 65 years in the community. The Chiropodist, 5:175-178.

16 Springett, K.P., Whiting, M.F., Marriott, C. (2003) Epidemiology of plantar forefoot corns and callus and the influence of dominant side. The Foot, 13:5-9.

17 Daw, J. (1995) Mechanically Induced Plantar Hyperkeratosis. University of Brighton, PhD Thesis.

18 Manna, I., Pradhan, D., Ghosh, S., Kar, S.K., Dhara, P.A. (2001) A comparative study of foot dimension between adult male and female and evaluation of foot hazards due to using footwear. J Physiol Anthrop Appl Hum Sci, 20:241-246.

19 Radin, E., Rose R. Role of the subchondral bone in the initiative and progression of cartilage damage. (1986) Clin Orthop Rel Res, 213:34-40.

20 Grouios, G. (2005) Footedness as a potential factor that contributes to the causation of corn and callus formation in lower extremities of physically active individuals. The Foot, 15:154-162.

1

Dobby, J.L. (1991) An evaluation of courses of education training which leads to State Registration as a chiropodist.

Chiropodists Board of the Council for Professions Supplementary to Medicine, London (unpublished version).

2 Farndon, L., Vernon, W., Potter, J., Parry, A. (2002) The professional role of the podiatrist in the new Millenium: an anlysis of current practice Paper 1. British Journal of Podiatry, 5 (3):68-72.

3 Menz, H.B., Morris, M.E., Lord, S.R. (2001b) The contribution of foot problems to mobility impairment and falls in community-dwelling older people. J American Geriatrics Soc. 49:1651-1656.

4 Campbell, J.A., Bradley, A., Milns, D., White, D., Turner, W., Luxton, D.E.A. (2000) Do â&#x20AC;&#x2DC;low-riskâ&#x20AC;&#x2122; older people need podiatry care? British Journal of Podiatry, 3(2):39-45.

5 Leymarie, F., Richard, J.L., Malgrange, D. (2005) Factors associated with diabetic patients at high risk for foot ulceration. Diabetes Metab, 31:603-605.

6 Mackie, R.M. (1986) Clinical Dermatology: an illustrated textbook, 2nd ed. Oxford, Oxford University Press, p15.

7 Adams, I., Whiting, M., Savin, J., Branford, W. (1989) Skin and subcutaneous conditions. In: Neale, D., Adams, I., editors. Common Foot Disorders, 2nd ed. Edinburgh, Churchill Livingstone, p85-90.

8 Singh, D., Bentley, G., Trevino, S.G. (1996) Callosities, corns and calluses. BMJ, 312:1403-1406.

9 Thomas, S.E., Dykes, P.J., Marks, R. (1985) Plantar hyperkeratosis: a study of callosities and normal plantar skin. J Invest Dermatol, 85:394-397.

10 Hanby, J.H., Walker, H.E. (1960) The Principles and Practice of Chiropody. London, Bailliere Tindall and Cox, p68.

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Hyperkeratosis of the foot: part 2

Continuing Professional Development 21 McCourt, F.J. (1998) Normal plantar stratum corneum and callus: an analysis of fatty acids. BJP, 1(3):98-101.

22 Springett, K. (1993) The influence of forces generated during gait on the clinical appearance and physical properties of skin callus. University of Brighton, PhD Thesis.

23 Grouios, G. (2004) Corns and calluses in athletesâ&#x20AC;&#x2122; feet: a cause for concern. The Foot, 14:175-184.

24 Bevans, J.S., Bowker, P. (1999) Foot structure and function: aetiological risk factors for callus formation in diabetic and non-diabetic subjects. The Foot, 9:120-127.

25 Potter, J., Potter, M. (2000) The effect of callus removal on plantar pressures. The Foot, 10 (1):23-26.

26 Menz, H.B., Zammit, G.V., Munteanu, S.E. (2007) Plantar pressures are higher under callused regions of the foot in older people. Clinical and Experimental Dermatology, 32:375-380.

27 Pitei, D., Foster, A., Edmonds, M. (1999) The effect of regular callus removal on foot pressures. J Foot & Ankle Surg., 38 (4):251-255.

28 Pataky, Z., Golay, A., Faravel, L., Da Silva, J., Makoundou, V., Peter-Riesch, B., Assal, J.P. (2002) The impact of callosities on the magnitude and duration of plantar pressure in patients with diabetes mellitus. Diabetes Metab, 28:356-361.

29 Murray, H.J., Young, M.J., Hollis, S., Boulton, A.J. (1996) The association between callus formation, high pressures and neuropathy in diabetic foot ulceration. Diabet Med, 13:979-982.

30 Woodburn, J., Stableford, Z., Helliwell, P.S. (2000) Preliminary investigation of debridement of plantar callosities in rheumatoid arthritis. Rheumatology, 39:652654.

31 Davys, H.J., Turner, D.E., Helliwell, P.S., Conaghan, P.G., Emery, P., Woodburn, J. (2004) Debridement of plantar callosities in rheumatoid arthritis: a randomized controlled trial. Rheumatology, 44(2):207-210.

32 Guldemond, N.A., Leffers, P., Nieman, F.H.M., Sanders, A.P., Schaper, N.C., Walenkamp, G.H.I.M. (2006) Testing the proficiency to distinguisy locations with elevated plantar pressure within and between professional groups of foot therapists. BMC Musculoskeletal Disorders, www.biomedcentral.com/1471-2474/7/93.

33 Hashmi, F. (2000) Non-enzymatic glycation and the development of plantar callus. British Journal of Podiatry, 3(4):91-94.

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34 Potter, J., Potter, M. (2000) Regrowth patterns of callus.

The Foot, 10 (3):144-148.

35 Sgarlato, T.E. (1971) Ed. Compendium of Podiatric Biomechanics. California College of Pod Med, San Francisco, p376-379.

36 Potter, J, Aiken, B (2007) Classification of callus: a consensus, 19th World Podiatry Congress, Copenhagen.

37 Redmond, A., Allen, N., Vernon, W. (1999) Effect of scalpel debridement on the pain associated with plantar hyperkeratosis. J Am Podiatric Med Assoc., 89(10):515519.

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

39 Caselli, M.A., Levitz, S.J., Clark, N., Lazarus, S., Venegas, L. (1997) Comparison of Viscoped and Poron for painful submetatarsal hyperkeratotic lesions. J Am Podiatric Med Assoc., 87(1):6-10.

40 Colagiuri, S., Marsden, L.L, Naidu, V., Taylor, L. (1995) The use of orthotic devices to correct plantar callus in people with diabetes. Diab Res Clin Pract, 28:29-34.

41 Booth, J., McInnes, A. (1997) The etiology and management of plantar callus formation. J Wound Care, 6 (9):427-430.

42 Penzer, R. (2005) Emollients: selection and application.

CPD Supplement, Podiatry Now, September.

43 Springett, K., Deane, M., Dancaster, P. (1997) treatment of corns, calluses and heel fissures with a hydrocolloid dressing. J British Pod Med, 52:102-104.

44 Freeman, D.B., (2002) Corns and calluses resulting from mechanical hyperkeratosis. Am Fam Physician, 65:22772280.

45 Bennet, P.J., Patterson, C., Wearing, S., Baglioni, T. (1998) Development and validation of a questionnaire designed to measure foot-health status. J Am Podiatric Med Assoc., 88:419-428.

46 Landorf, K.B., Keenan, A-M (2002) An evaluation of two foot-specific, health-related quality-of-life measuring instruments. Foot & Ankle Int., 23 (6):538-546.

47 Evans AM et al (2003) Reliability of the foot posture index and traditional measures of foot position. J Am Podiatr Med Assoc. 93(3):203-13.

Podiatry Review Vol 72:2

Reflection After reading this CPD article spend some time reflecting on its content, using the sub-headings as prompts. Keep the reflections, notes and key points in your CPD portfolio 1. How would you define hyperkeratosis?

2. What are the main causes of hyperkeratosis on the feet?

3. What percentage of my own caseload may have hyperkeratosis attributable to causes other than mechanical?

4. Will this article change my practice at all? If so how?

5. How will this impact on the care of my patients / service users?

6. After reading this, have I identified any new CPD needs (for example revision of specific topics, acquisition of new skills etc).

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Hyperkeratosis of the foot: part 1

Post-reading activity

Hyperkeratosis of the foot: part 2

Continuing Professional Development Notes

Key Keypoints points

Learning Learning outcomesoutcomes

CPD Series No. 3 Title: Hyperkeratosis: Part 2.

Author: Julia Potter

Editorial Board: Professor Kate Springett (Canterbury Christ Church University, UK), Ian Reilly (Podiatric Surgeon, Northamptonshire, UK), Ivan Bristow (University of Southampton, UK), Mike Potter (University of Southampton, UK).

Published in association with the Society of Chiropodists and Podiatrists.

This work is supported by an unrestricted educational grant from Galderma (UK) Ltd. The opinions, statements, assertions and data which are presented in this article are those of the author(s). The author(s), the Society of Chiropodists and Podiatrists, the editorial board, sponsors and their respective employers, officers and agents accept no liability for the consequences of inaccurate, misleading, incorrect statements, opinions, assertions or data. As new knowledge and research evidence is made available there will be changes to treatment, management, advice provided, procedures and equipment used. Readers of this article are advised Acknowledgements to check and confirm that information they are utilising conforms to the latest standards of practice and legislation.

Original article published in Podiatry Now September 2008 The Institute would like to thank Julia Potter, Ivan Bristow and the Society of Chiropodists and Podiatrists for permission to If readers have any feedback, comments or suggestions for future articles please contact the Editorial board at the Offices of the Society of reproduce the article in its entirety. Š 2008

Chiropodists and Podiatrists.

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Podiatry Review Vol 72:2

Biosimilars Update

Simon O’Neill, Director of Health Intelligence, at Diabetes UK, explains why people with diabetes need to be aware of biosimilar insulins, biological copies of insulins which are no longer in patent.

“Biosimilar insulins are about to make their way onto the UK market. That means people with diabetes and their healthcare professionals need to be better informed about them so that they can make the right choices.

New drugs are normally protected by patent and also have to get marketing authorisation from the European Medicines Agency (EMA). Eight years after the original marketing authorisation of the original drug has elapsed, other manufacturers are allowed to make generic versions and submit them for approval by the EMA, and, if approved, these can be marketed in the EU. Generic versions of drugs are commonly used within the NHS as they tend to be much cheaper than the original patented drug. Generic drugs are virtually exact chemical copies of the original drug

*

DIABETES NEWS and therefore don’t need to go through lengthy trials before being licensed.

Although most of the patents on existing insulins have expired or are due to expire in the next few years, there are currently no “generic” versions available on the UK market. This is because, with biological drugs, such as insulin, it is impossible to make an exact copy which can be guaranteed to react in exactly the same way as the originally approved drug. A biological copy, called a biosimilar rather than a generic version, can’t be said to be identical to the original. This is because tiny changes in the structure of the product and in the manufacturing process can change the way the drug works.

Biosimilars therefore require further testing and further EMA approval.

However that is all set to change. Abrasia - Lilly's version of Sanofi’s Lantus - has got EMA approval so once Sanofi’s patent runs out early in 2015 then Lilly can go to market.

Many biosimilar insulins already exist and are licensed in other countries where

they do not need FDA or EMA approval.

Our advice is that people who are already established on an insulin and achieving good control should continue with that treatment and not be made to change to a biosimilar.

However, if people with diabetes choose to switch to a biosimilar insulin they should be encouraged to monitor their blood glucose more closely to ensure that good control is achieved.

Choosing what insulin is right for you needs to be a decision made jointly between the person with diabetes and their healthcare professional.

The first biosimilar on the market will be Abrasia, sometime in 2015, but many are likely to follow. As with all insulins, biosimilar insulins should be prescribed by their trade name rather than the generic insulin name to ensure the correct insulin is dispensed. This is essential for biosimilar insulins to avoid substitution of an unfamiliar insulin without discussion and warning at each prescription.

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Podiatry Review Vol 72:2

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DIABETES NEWS ĂƌďĂƌĂ zŽƵŶŐ͕ ŚŝĞĨ džĞĐƵƟǀĞ ŽĨ ŝĂďĞƚĞƐ h<͕ ƐĂŝĚ͗ ͞dŚĞ ĐŽŵŵŝƐƐŝŽŶŝŶŐ ĂŶĚ ĚĞůŝǀĞƌLJ ŽĨ ĚŝĂďĞƚĞƐ ĐĂƌĞ ŝƐ ŽŌĞŶ ĨƌĂŐŵĞŶƚĞĚ ďĞƚǁĞĞŶ ĚŝīĞƌĞŶƚ ƉĂƌƚƐ ŽĨ ƚŚĞ E,^͘ dŚŝƐ ŵĞĂŶƐ ƚŚĂƚ ŝĂďĞƚĞƐ h< ŚĂƐ ƉƌŽĚƵĐĞĚ Ă ŶĞǁ ƌĞƉŽƌƚ͕ ƉĞŽƉůĞ ǁŝƚŚ ĚŝĂďĞƚĞƐ ĨĂĐĞ ĚĞůĂLJƐ ƚŽ ƐĞĞ ǁŚŝĐŚ ƐŚŽǁƐ ŚŽǁ ŚĞĂůƚŚ ůĞĂĚĞƌƐ ĂŶĚ ƐƉĞĐŝĂůŝƐƚƐ͕ ƵŶĚĞƌŐŽ ƌĞƉĞĂƚĞĚ ƚĞƐƚƐ͕ ĂŶĚ ĂƌĞ ĐŽŵŵŝƐƐŝŽŶĞƌƐ ĐĂŶ ŝŵƉƌŽǀĞ ƚŚĞ ĚĞůŝǀĞƌLJ ŽĨ ůĞŌ ŶŽƚ ŬŶŽǁŝŶŐ ǁŚŝĐŚ ƉĂƌƚ ŽĨ ƚŚĞ ƐLJƐƚĞŵ ĚŝĂďĞƚĞƐ ĐĂƌĞ ďLJ ŝŶƚĞŐƌĂƟŶŐ ƐĞƌǀŝĐĞƐ ĂƐ ŚĂƐ ƌĞƐƉŽŶƐŝďŝůŝƚLJ ĨŽƌ ĚĞůŝǀĞƌŝŶŐ Ă ƉĂƌƟĐƵůĂƌ x īĞĐƟǀĞ ĐĂƌĞ ƉůĂŶŶŝŶŐ ǁŚĞƌĞ ƌĞĐŽŵŵĞŶĚĞĚ ŝŶ ƚŚĞ &ŝǀĞ zĞĂƌ &ŽƌǁĂƌĚ ƉĂƌƚ ŽĨ ƚŚĞŝƌ ĐĂƌĞ͘ dŚŝƐ ŚĂƐ Ă ŚƵŐĞ ŝŵƉĂĐƚ ŽŶ ĐůŝŶŝĐŝĂŶƐ ĂŶĚ ƉĞŽƉůĞ ǁŝƚŚ ĚŝĂďĞƚĞƐ sŝĞǁ͘ ƚŚĞ ĐĂƌĞ ƚŚĞLJ ƌĞĐĞŝǀĞ ĂŶĚ ŽŶ ƚŚĞŝƌ ĂďŝůŝƚLJ ƚŽ ǁŽƌŬ ƚŽŐĞƚŚĞƌ ƚŽ ĂŐƌĞĞ ŐŽĂůƐ ĂŶĚ ĞīĞĐƟǀĞůLJ ŵĂŶĂŐĞ ƚŚĞŝƌ ĐŽŶĚŝƟŽŶ͘ ŝĚĞŶƟĨLJ ŶĞĞĚƐ ŝƐ ǀŝƚĂů ĨŽƌ ĞŶĂďůŝŶŐ dŚĞ ŶĞǁ ƌĞƉŽƌƚ͕ ĐĂůůĞĚ /ŵƉƌŽǀŝŶŐ ƚŚĞ ƉĞŽƉůĞ ƚŽ ŵĂŶĂŐĞ ƚŚĞ ĐŽŶĚŝƟŽŶ͘ Ƶƚ hůƟŵĂƚĞůLJ͕ ƉŽŽƌ ƉƌĂĐƟĐĞƐ ƐƵĐŚ ĂƐ ƚŚĞƐĞ ĂƌĞ ĞůŝǀĞƌLJ ŽĨ ĚƵůƚ ŝĂďĞƚĞƐ ĂƌĞ dŚƌŽƵŐŚ Ăƚ ƚŚĞ ŵŽŵĞŶƚ ĂůŵŽƐƚ ƚǁŽ ƚŚŝƌĚƐ ŽĨ ĐŽŶƚƌŝďƵƟŶŐ ƚŽ ƚŚĞ Ăůů ƚŽŽ ĨƌĞƋƵĞŶƚ /ŶƚĞŐƌĂƟŽŶ͕ ĐĂůůƐ ĨŽƌ ƌŽƵƟŶĞ ĐĂƌĞ ƚŽ ďĞ ĚĞǀĞůŽƉŵĞŶƚ ŽĨ ƚŚĞ ƐĞƌŝŽƵƐ ďƵƚ ĂǀŽŝĚĂďůĞ ƉĞŽƉůĞ ǁŝƚŚ ĚŝĂďĞƚĞƐ ĚŽ ŶŽƚ ŚĂǀĞ Ă ĚĞůŝǀĞƌĞĚ ŝŶ Ă ũŽŝŶĞĚ ƵƉ ǁĂLJ ĨƌŽŵ 'W ĐŽŵƉůŝĐĂƟŽŶƐ ƚŚĂƚ ĂƌĞ ŶŽƚ ŽŶůLJ ƉĞƌƐŽŶĂůůLJ ƉĞƌƐŽŶĂů ĐĂƌĞ ƉůĂŶ͘ ƐƵƌŐĞƌŝĞƐ ƚŽ ŚŽƐƉŝƚĂůƐ͕ ƚŽ ĞŶƐƵƌĞ ƉĞŽƉůĞ ŐĞƚ ĚĞǀĂƐƚĂƟŶŐ ĨŽƌ Ăůů ƚŚŽƐĞ ĂīĞĐƚĞĚ ďƵƚ ĂůƐŽ ƐǁŝŌ ĂĐĐĞƐƐ ƚŽ ĐĂƌĞ ĨƌŽŵ ƚŚĞ ƌŝŐŚƚ ƉĂƌƚ ŽĨ ƚŚĞ ƵƐĞ ƵƉ Ă ďŝŐ ƉƌŽƉŽƌƟŽŶ ŽĨ ƚŚĞ E,^ ďƵĚŐĞƚ͘ x ,ĞĂůƚŚ ůĞĂĚĞƌƐ ƐŚŽƵůĚ ŽǀĞƌĐŽŵĞ ƚŚĞ ŚĞĂůƚŚĐĂƌĞ ƐLJƐƚĞŵ Ăƚ ƚŚĞ ƌŝŐŚƚ ƟŵĞ ĂƐ ƐĞƚ ƌŝŐŝĚ ĮŶĂŶĐŝĂů ĚŝǀŝĚĞ ďĞƚǁĞĞŶ ŽƵƚ ŝŶ ƚŚĞ &ŝǀĞ zĞĂƌ &ŽƌǁĂƌĚ sŝĞǁ͘ ƉƌŝŵĂƌLJ͕ ĐŽŵŵƵŶŝƚLJ ĂŶĚ ƐĞĐŽŶĚĂƌLJ ͞dŚŝƐ ŝƐ ǁŚLJ ŝƚ ŝƐ ŐŽŽĚ ŶĞǁƐ ƚŚĂƚ ^ŝŵŽŶ ĐĂƌĞ ďLJ ƉŽŽůŝŶŐ ďƵĚŐĞƚƐ ĂŶĚ ĂŐƌĞĞŝŶŐ ^ƚĞǀĞŶƐ͛ ŚĂƐ ƌĞĐŽŐŶŝƐĞĚ ƚŚĂƚ ƚŚĞ ĐƵƌƌĞŶƚ ŝĂďĞƚĞƐ h<͛Ɛ ƌĞƉŽƌƚ ƐŚŽǁƐ ŚŽǁ ƚŚŝƐ ĂƉƉƌŽĂĐŚ ƚŽ ĚŝĂďĞƚĞƐ ĐĂƌĞ ĐĂŶ ďĞ ŝŵƉƌŽǀĞĚ Ă ƉƌŽƚŽĐŽů ŽŶ ŚŽǁ ƉĞŽƉůĞ ǁŝƚŚ ĂƉƉƌŽĂĐŚ ĐĂŶ ĞŶƐƵƌĞ ƚŚĂƚ ƉĞŽƉůĞ ǁŝƚŚ ƚŚƌŽƵŐŚ ďĞƩĞƌ ŝŶƚĞŐƌĂƚĞĚ ƐĞƌǀŝĐĞƐ ĂƐ ƐĞƚ ŽƵƚ ĚŝĂďĞƚĞƐ ǁŝůů ďĞ ƚƌĞĂƚĞĚ ĂĐƌŽƐƐ Ăůů ĚŝĂďĞƚĞƐ ŚĂǀĞ ƋƵŝĐŬ ĂĐĐĞƐƐ ƚŽ ƐƉĞĐŝĂůŝƐƚƐ ŝŶ ƚŚĞ &ŝǀĞ zĞĂƌ &ŽƌǁĂƌĚ sŝĞǁ͘ KƵƌ ƌĞƉŽƌƚ ĐĂƌĞ ƐĞƫŶŐƐ͘ dŚŝƐ ŵĞĂŶƐ ƚŚĂƚ ǁŚĞŶ ƚŚĞLJ ŶĞĞĚ ŝƚ ƚŽ ŝĚĞŶƟĨLJ ƉƌŽďůĞŵƐ͘ dŚŝƐ͕ ƵƐĞƐ ĞdžĂŵƉůĞƐ ŽĨ ŚŽǁ ŚĞĂůƚŚ ůĞĂĚĞƌƐ ĐĂŶ ĮŶĂŶĐĞƐ ĂƌĞ ůĞƐƐ ůŝŬĞůLJ ƚŽ ŐĞƚ ŝŶ ƚŚĞ ŝŶ ƚƵƌŶ͕ ĐĂŶ ŚĞůƉ ƚŽ ƌĞĚƵĐĞ ƚŚĞŝƌ ƌŝƐŬ ŽĨ ŝŵƉůĞŵĞŶƚ ^ƚĞǀĞŶƐ͛ ǀŝƐŝŽŶ ĂŶĚ ĚĞůŝǀĞƌ ďĞƩĞƌ ǁĂLJ ŽĨ ƉĞŽƉůĞ ƌĞĐĞŝǀŝŶŐ ƚŚĞ ƌŝŐŚƚ ĂǀŽŝĚĂďůĞ ďƵƚ ƐĞƌŝŽƵƐ ĐŽŵƉůŝĐĂƟŽŶƐ ƐƵĐŚ ĂƐ ĚŝĂďĞƚĞƐ ĐĂƌĞ ƚŚĂƚ ŵĞĞƚƐ ƚŚĞ ŶĞĞĚƐ ŽĨ Ăůů ĐĂƌĞ ǁŚĞŶ ƚŚĞLJ ŶĞĞĚ ŝƚ͘ ďůŝŶĚŶĞƐƐ͕ ĂŵƉƵƚĂƟŽŶƐ ĂŶĚ ƐƚƌŽŬĞ͘ ƉĞŽƉůĞ ǁŝƚŚ ĚŝĂďĞƚĞƐ͘ /ƚ ƐŚŽǁƐ ƚŚĂƚ ďLJ

ƉůĂĐŝŶŐ ƉĞŽƉůĞ ǁŝƚŚ ĚŝĂďĞƚĞƐ Ăƚ ƚŚĞ ĐĞŶƚƌĞ ŽĨ Ɛ ǁĞůů ĂƐ ďĞŝŶŐ ĚĞǀĂƐƚĂƟŶŐ ĨŽƌ ƚŚĞ ƉĞƌƐŽŶ͕ ƚŚĞŝƌ ĐĂƌĞ͕ ƉŽŽůŝŶŐ ƐĞƌǀŝĐĞƐ ĂŶĚ ďƵĚŐĞƚƐ ĂŶĚ ŝĂďĞƚĞƐ h< ƌĞĐŽŐŶŝƐĞƐ ƚŚĂƚ ƚŚĞ ǁŽƌŬ ŽĨ ƚŚĞƐĞ ĐŽŵƉůŝĐĂƟŽŶƐ ĂƌĞ ĐŽƐƚůLJ ƚŽ ƚƌĞĂƚ ĂŶĚ ŐŝǀŝŶŐ ƉĞŽƉůĞ ǁŝƚŚ ĚŝĂďĞƚĞƐ ŵŽƌĞ ũŽŝŶŝŶŐ ƵƉ ŚĞĂůƚŚ ƐĞƌǀŝĐĞƐ ŝƐ ŶŽƚ ĞĂƐLJ ŝŶ ƚŚĞ ƚŚĞLJ ĂĐĐŽƵŶƚ ĨŽƌ ƚŚĞ ŵĂũŽƌ ƉĂƌƚ ŽĨ ƚŚĞ άϭϬ ŽƉƉŽƌƚƵŶŝƚLJ ƚŽ ŚĂǀĞ Ă ƐĂLJ ĂďŽƵƚ ŚŽǁ ƚŚĞŝƌ ĐƵƌƌĞŶƚ ƐLJƐƚĞŵ ǁŚĞƌĞ͕ ĨŽƌ ĞdžĂŵƉůĞ͕ ďŝůůŝŽŶ ƚŚĞ E,^ ƐƉĞŶĚƐ ŽŶ ĚŝĂďĞƚĞƐ ĞǀĞƌLJ ĐĂƌĞ ŝƐ ĚĞůŝǀĞƌĞĚ͕ ǁĞ ĐĂŶ ŚĂǀĞ ĂŶ ĞīĞĐƟǀĞ ĨƌĂŐŵĞŶƚĞĚ ĐŽŵŵŝƐƐŝŽŶŝŶŐ ĂŶĚ ĮŶĂŶĐŝĂů LJĞĂƌ͘ dƌĞĂƚŵĞŶƚ ŽĨ ĐŽŵƉůŝĐĂƟŽŶƐ ĂůƐŽ ĂĚĚƐ ƐĞƌǀŝĐĞ ƚŚĂƚ ƉƌŽǀŝĚĞƐ ďĞƩĞƌ ŽƵƚĐŽŵĞ ĨŽƌ ĂƌƌĂŶŐĞŵĞŶƚƐ ĐĂŶ ŵĂŬĞ ŝŶƚĞŐƌĂƟŽŶ ďĞƚǁĞĞŶ ĐŽŶƐŝĚĞƌĂďůĞ ƉƌĞƐƐƵƌĞ ƚŽ ĂĐƵƚĞ ŚŽƐƉŝƚĂůƐ ŝŶ ƉĂƟĞŶƚƐ ĂŶĚ ďĞƩĞƌ ǀĂůƵĞ ĨŽƌ ŵŽŶĞLJ ĨŽƌ ƚŚĞ ĚŝīĞƌĞŶƚ ƐĞƌǀŝĐĞƐ ŚĂƌĚ͘ dŚĞ ĐŚĂƌŝƚLJ ƐĂLJƐ ƚŚŝƐ ƚĞƌŵƐ ŽĨ ďĞĚƐ ĂŶĚ ĞŵĞƌŐĞŶĐLJ ĂĚŵŝƐƐŝŽŶƐ͘ ƚĂdžƉĂLJĞƌ͘ ŝƐ ǁŚLJ ŶĂƟŽŶĂů ƉŽůŝĐLJ ŝƐ ŶĞĞĚĞĚ ƚŽ ƐƵƉƉŽƌƚ

/ŶƚĞŐƌĂƟŽŶ ĐĂŶ ŝŵƉƌŽǀĞ ĚŝĂďĞƚĞƐ ĐĂƌĞ ĂŶĚ ƌĞĚƵĐĞ ĐŽƐƚƐ

dŚĞ ƌĞƉŽƌƚ ĚĞƚĂŝůƐ Ă ƐĞƌŝĞƐ ŽĨ ŵĞĂƐƵƌĞƐ ƚŚĂƚ ĐŽŵŵŝƐƐŝŽŶĞƌƐ ĂŶĚ ŚĞĂůƚŚ ůĞĂĚĞƌƐ ĐĂŶ ŝŵƉůĞŵĞŶƚ ƚŽ Įƚ ǁŝƚŚ ƚŚĞ ŵŽĚĞů ŽĨ ĐĂƌĞ ŝŶ ƚŚĞ &ŝǀĞ zĞĂƌ &ŽƌǁĂƌĚ sŝĞǁ ĂŶĚ ƐŽ ŚĞůƉ ĞŶƐƵƌĞ ƚŚĂƚ ƚŚĞ ϯ͘Ϯ ŵŝůůŝŽŶ ƉĞŽƉůĞ ǁŝƚŚ ĚŝĂŐŶŽƐĞĚ ĚŝĂďĞƚĞƐ ŐĞƚ ƚŚĞ ŚĞĂůƚŚĐĂƌĞ ƚŚĂƚ ŵĞĞƚƐ ƚŚĞŝƌ ŶĞĞĚƐ ĂƐ ǁĞůů ĂƐ ŚĞůƉ ƚŚĞ E,^ ƚŽ ƐĂǀĞ ŵŽŶĞLJ͘ džĂŵƉůĞƐ ŝŶĐůƵĚĞ͗

x

ŝĚĞŶƟĮĞĚ͘ ǀŝĚĞŶĐĞ ƐŚŽǁƐ ƚŚĂƚ ƚŚŝƐ ĐĂŶ ŚĞůƉ ƚŽ ŝŵƉƌŽǀĞ ƚŚĞ ĐŽŽƌĚŝŶĂƟŽŶ ŽĨ ĐĂƌĞ ƚŚƌŽƵŐŚŽƵƚ ƚŚĞ ƐLJƐƚĞŵ͕ ĂƐ ǁĞůů ĂƐ ƉĂƟĞŶƚ ƐĂƟƐĨĂĐƟŽŶ ĂŶĚ ĞŶŐĂŐĞŵĞŶƚ ŝŶ ƚŚĞ ĐĂƌĞ ƚŚĞLJ ƌĞĐĞŝǀĞ͘

ůŽĐĂů ĂĐƟŽŶ ďLJ ĚĞǀĞůŽƉŝŶŐ ǁĂLJƐ ĨŽƌ ĮŶĂŶĐŝĂů ƐLJƐƚĞŵƐ ƚŽ ƐƵƉƉŽƌƚ ŝŶƚĞŐƌĂƚĞĚ ǁŽƌŬŝŶŐ ĂŶĚ ŵƵůƟĚŝƐĐŝƉůŝŶĂƌLJ ĐůŝŶŝĐĂů ŶĞƚǁŽƌŬƐ͕ ǁŚŝĐŚ ĐĂŶ ŵĂŶĂŐĞ ĐŚĂŶŐĞ ĂŶĚ ŝŵƉƌŽǀĞŵĞŶƚƐ ĂĐƌŽƐƐ Ăůů ƉĂƌƚƐ ŽĨ ƚŚĞ E,^͘

͞tĞ ƌĞĐŽŐŶŝƐĞ ƚŚĂƚ ƚŚĞ ĐƵƌƌĞŶƚ ŚĞĂůƚŚ ƐLJƐƚĞŵ ŽŌĞŶ ŵĂŬĞƐ ŝƚ ŚĂƌĚ ĨŽƌ ĐŽŵŵŝƐƐŝŽŶĞƌƐ ƚŽ ŵĂŬĞ ƚŚĞƐĞ ĐŚĂŶŐĞƐ ďƵƚ ƚŚĞ ĨĂĐƚ ƚŚĂƚ ƐŽŵĞ ŚĞĂůƚŚ ƉƌŽǀŝĚĞƌƐ ŚĂǀĞ ŵĂĚĞ ŐƌĞĂƚ ƐƚƌŝĚĞƐ ŝŶ ƚŚĞ ĚĞůŝǀĞƌLJ ŽĨ ĚŝĂďĞƚĞƐ ĐĂƌĞ ƐŚŽǁƐ ƚŚĂƚ ŝŵƉƌŽǀĞŵĞŶƚƐ ĐĂŶ ďĞ ŵĂĚĞ͘ tŝƚŚ ƚŚĞ ŶƵŵďĞƌ ŽĨ ƉĞŽƉůĞ ǁŝƚŚ ĚŝĂďĞƚĞƐ tŝƚŚ ŝŶĐƌĞĂƐŝŶŐ ŶƵŵďĞƌƐ ŽĨ ƉĞŽƉůĞ ďĞŝŶŐ ƉƌŽũĞĐƚĞĚ ƚŽ ƌŝƐĞ ƚŽ ϱ ŵŝůůŝŽŶ ďLJ ϮϬϮϱ ĂŶĚ ĐŽƐƚƐ ĞdžƉĞĐƚĞĚ ƚŽ ƌŝƐĞ ƐŚĂƌƉůLJ ƚŽ άϭϳ ďŝůůŝŽŶ ĚŝĂŐŶŽƐĞĚ ǁŝƚŚ ĚŝĂďĞƚĞƐ ĂŶĚ ĚŝĂďĞƚĞƐ ĐŽƐƚƐ ǁŝƚŚŝŶ ϮϬ LJĞĂƌƐ͕ ŝĂďĞƚĞƐ h< ŝƐ ƵƌŐŝŶŐ ŚĞĂůƚŚ ƚŚƌĞĂƚĞŶŝŶŐ ƚŽ ďĂŶŬƌƵƉƚ ƚŚĞ ŚĞĂůƚŚ ƐĞƌǀŝĐĞ Ŷ ŝŶƚĞŐƌĂƚĞĚ /d ƐLJƐƚĞŵ ŵĞĂŶƐ ƚŚĂƚ ǁĞ ŶĞĞĚ ƚŚĞ ŐŽŽĚ ƉƌĂĐƟĐĞ ĚĞƐĐƌŝďĞĚ ŝŶ ŽƵƌ ůĞĂĚĞƌƐ ƚŽ ŝŵƉůĞŵĞŶƚ ƚŚĞŝƌ 'WƐ ĂŶĚ ƐƉĞĐŝĂůŝƐƚƐ ĐĂŶ ƐĞĞ ƚŚĞ ƐĂŵĞ ƌĞƉŽƌƚ ƚŽ ďĞ ĂĚŽƉƚĞĚ ďLJ ƚŚĞ ƌĞƐƚ ŽĨ ƚŚĞ ƌĞĐŽŵŵĞŶĚĂƟŽŶƐ ĂƐ Ă ŵĂƩĞƌ ŽĨ ƉƌŝŽƌŝƚLJ͘ ƌĞĐŽƌĚ ĂŶĚ ͚Ăƚ ƌŝƐŬ͛ ƉĂƟĞŶƚƐ ĐĂŶ ďĞ ŚĞĂůƚŚ ƐLJƐƚĞŵ͘͟

KŶĞ ŝŶ ĮǀĞ ƉĞŽƉůĞ ĂĚŵŝƩĞĚ ƚŽ ŚŽƐƉŝƚĂů ĨŽƌ ĂŶŐŝŶĂ͕ ƐƚƌŽŬĞ͕ ŚĞĂƌƚ ĂƩĂĐŬ Žƌ ŚĞĂƌƚ ĨĂŝůƵƌĞ ŚĂǀĞ ĚŝĂďĞƚĞƐ͕ ĂĐĐŽƌĚŝŶŐ ƚŽ Ă ŶĞǁ ƌĞƉŽƌƚ ƉƵďůŝƐŚĞĚ ƚŽĚĂLJ͘

- ϭϯϵ ƉĞƌ ĐĞŶƚ ŵŽƌĞ ůŝŬĞůLJ ƚŽ ďĞ ĂĚŵŝƩĞĚ ƚŽ ŚŽƐƉŝƚĂů ǁŝƚŚ ĂŶŐŝŶĂ - ϵϰ ƉĞƌ ĐĞŶƚ ŵŽƌĞ ůŝŬĞůLJ ƚŽ ďĞ ĂĚŵŝƩĞĚ ƚŽ ŚŽƐƉŝƚĂů ǁŝƚŚ ŵLJŽĐĂƌĚŝĂů ŝŶĨĂƌĐƟŽŶ - ϭϮϲ ƉĞƌ ĐĞŶƚ ŵŽƌĞ ůŝŬĞůLJ ƚŽ ďĞ ĂĚŵŝƩĞĚ ƚŽ ŚŽƐƉŝƚĂů ǁŝƚŚ ŚĞĂƌƚ ĨĂŝůƵƌĞ - ϲϯ ƉĞƌ ĐĞŶƚ ŵŽƌĞ ůŝŬĞůLJ ƚŽ ďĞ ĂĚŵŝƩĞĚ ƚŽ ŚŽƐƉŝƚĂů ǁŝƚŚ Ă ƐƚƌŽŬĞ dŚĞ EĂƟŽŶĂů ŝĂďĞƚĞƐ ƵĚŝƚ ƌĞƉŽƌƚ͕ ƉƵďůŝƐŚĞĚ - ϰϬϬ ƉĞƌ ĐĞŶƚ ŵŽƌĞ ůŝŬĞůLJ ƚŽ ďĞ ĂĚŵŝƩĞĚ ƚŽ ƚŽĚĂLJ ďLJ ƚŚĞ ,ĞĂůƚŚ ĂŶĚ ^ŽĐŝĂů ĂƌĞ /ŶĨŽƌŵĂƟŽŶ ŚŽƐƉŝƚĂů ĨŽƌ Ă ŵĂũŽƌ ĂŵƉƵƚĂƟŽŶ ĂŶĚ ϴϭϳ ƉĞƌ ĐĞŶƚ ĞŶƚƌĞ ;,^ / Ϳ͕ ƌĞǀĞĂůƐ ƚŚĂƚ ƚŚĞƌĞ ǁĞƌĞ Ϯϯ͕ϵϴϲ ŵŽƌĞ ůŝŬĞůLJ ƚŽ ďĞ - ĂĚŵŝƩĞĚ ǁŝƚŚ Ă ŵŝŶŽƌ ΗĞdžĐĞƐƐΗ ĚĞĂƚŚƐ ŝŶ ƉĞŽƉůĞ ǁŝƚŚ ĚŝĂďĞƚĞƐ ŝŶ ŶŐůĂŶĚ ĂŵƉƵƚĂƟŽŶ ĂŶĚ tĂůĞƐ ŝŶ ϮϬϭϯ͘ dŚŝƐ ŵĞĂŶƐ ƚŚĂƚ ƚŚĞLJ ĚŝĞĚ - ϮϳϮ ƉĞƌ ĐĞŶƚ ŵŽƌĞ ůŝŬĞůLJ ƚŽ ďĞ ĂĚŵŝƩĞĚ ƚŽ ĞĂƌůŝĞƌ ƚŚĂŶ ǁŽƵůĚ ŚĂǀĞ ďĞĞŶ ĞdžƉĞĐƚĞĚ ŝĨ ŚŽƐƉŝƚĂů ĨŽƌ ƌĞŶĂů ƌĞƉůĂĐĞŵĞŶƚ ƚŚĞƌĂƉLJ ĐŽŵƉĂƌĞĚ ƚŽ ƉĞŽƉůĞ ǁŝƚŚŽƵƚ ƚŚĞ ĐŽŶĚŝƟŽŶ͘ ^ŝŵŽŶ KΖEĞŝůů͕ ŝƌĞĐƚŽƌ ŽĨ ,ĞĂůƚŚ /ŶƚĞůůŝŐĞŶĐĞ Ăƚ dŚŽƐĞ ǁŝƚŚ dLJƉĞ ϭ ĚŝĂďĞƚĞƐ ǁĞƌĞ ϭϯϭ ƉĞƌ ĐĞŶƚ ŝĂďĞƚĞƐ h<͕ ƐĂŝĚ͗ ΗdŚĞ ĮŶĚŝŶŐ ƚŚĂƚ ĞǀĞƌLJ ĮŌŚ ŵŽƌĞ ůŝŬĞůLJ ƚŽ ĚŝĞ ŝŶ ϮϬϭϯ ƚŚĂŶ ƚŚĞŝƌ ƉĞĞƌƐ ŽĨ ƚŚĞŝƌ ƉĞƌƐŽŶ ĂĚŵŝƩĞĚ ƚŽ ŚŽƐƉŝƚĂů ĨŽƌ ĂŶŐŝŶĂ͕ ƐƚƌŽŬĞ͕ ĂŐĞ ǁŝƚŚŽƵƚ ƚŚĞ ĐŽŶĚŝƟŽŶ ĂŶĚ ƚŚŽƐĞ ǁŝƚŚ dLJƉĞ Ϯ ŚĞĂƌƚ ĂƩĂĐŬ ĂŶĚ ŚĞĂƌƚ ĨĂŝůƵƌĞ ŚĂƐ ĚŝĂďĞƚĞƐ ƐŚŽǁƐ ĚŝĂďĞƚĞƐ ǁĞƌĞ ϯϮ ƉĞƌ ĐĞŶƚ ŵŽƌĞ ůŝŬĞůLJ ƚŽ ĚŝĞ͘ ƚŚĞ ĞdžƚĞŶƚ ŽĨ ƚŚĞ ďƵƌĚĞŶ ŽĨ ĚŝĂďĞƚĞƐ-ƌĞůĂƚĞĚ dŚĞ ĂŶĂůLJƐŝƐ ƐŚŽǁĞĚ ƚŚĂƚ ƉĞŽƉůĞ ǁŝƚŚ ĚŝĂďĞƚĞƐ ĐŽŵƉůŝĐĂƟŽŶƐ ŽŶ ŽƵƌ ŚŽƐƉŝƚĂůƐ͘ ůĞĂƌůLJ͕ ǁŝƚŚ ƚŚĞ ǁĞƌĞ͗ ƌŝƐŝŶŐ ŶƵŵďĞƌ ŽĨ ƉĞŽƉůĞ ǁŝƚŚ ĚŝĂďĞƚĞƐ ƚŚŝƐ ŝƐ ůŝŬĞůLJ

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Podiatry Review Vol 72:2

ƚŽ ŚĂǀĞ ĂŶ ĞīĞĐƚ ŽŶ ĂůƌĞĂĚLJ-ƐƚƌĞƚĐŚĞĚ Θ ĚĞƉĂƌƚŵĞŶƚƐ͘ Η Ƶƚ ĂďŽǀĞ Ăůů͕ ƚŚĞƐĞ ĮŐƵƌĞƐ ƐŚŽǁ ƚŚĂƚ ƉĞŽƉůĞ ǁŝƚŚ ĚŝĂďĞƚĞƐ ĂƌĞ ĚĞǀĞůŽƉŝŶŐ ƐĞƌŝŽƵƐ ĐŽŵƉůŝĐĂƟŽŶƐ Ăƚ Ă ŚŝŐŚ ƌĂƚĞ ĂŶĚ ĚLJŝŶŐ ďĞĨŽƌĞ ƚŚĞŝƌ ƟŵĞ͘ tŚŝůĞ ƚŚĞƌĞ ĂƌĞ ƐŽŵĞ ĞŶĐŽƵƌĂŐŝŶŐ ĮŶĚŝŶŐƐ ǁŝƚŚ ƌĂƚĞƐ ŽĨ ŵŽƐƚ ĐŽŵƉůŝĐĂƟŽŶƐ ĂŶĚ ĞĂƌůLJ ĚĞĂƚŚ ĨĂůůŝŶŐ͕ ƚŚĞ ƌĞƉŽƌƚ ŵĂŬĞƐ ĐůĞĂƌ ƚŚĂƚ ǁĞ ĂƌĞ ŽŶůLJ ůŝŬĞůLJ ƚŽ ƐĞĞ ĨƵƌƚŚĞƌ ŝŵƉƌŽǀĞŵĞŶƚƐ ŝĨ ǁĞ Įůů ƚŚĞ ŐĂƉŝŶŐ ŚŽůĞƐ ŝŶ ƚŚĞ ƐƵƉƉŽƌƚ ƉĞŽƉůĞ ƌĞĐĞŝǀĞ ƚŽ ŵĂŶĂŐĞ ƚŚĞŝƌ ĐŽŶĚŝƟŽŶ͘ Η/Ŷ ƉĂƌƟĐƵůĂƌ͕ ǁĞ ŶĞĞĚ ƚŽ ďƌŝŶŐ ĂŶ ĞŶĚ ƚŽ ƚŚĞ ƉŽƐƚĐŽĚĞ ůŽƩĞƌLJ ŽĨ ĚŝĂďĞƚĞƐ ĐĂƌĞ͘ WĞŽƉůĞ ǁŝƚŚ ĚŝĂďĞƚĞƐ ƐŚŽƵůĚ ŚĂǀĞ Ă ƌŝŐŚƚ ƚŽ ĞdžƉĞĐƚ ŐŽŽĚ ƋƵĂůŝƚLJ ŚĞĂůƚŚĐĂƌĞ ǁŚĞƌĞǀĞƌ ƚŚĞLJ ůŝǀĞ ďƵƚ ƚŚŝƐ ŝƐ ŶŽƚ ŚĂƉƉĞŶŝŶŐ Ăƚ ƚŚĞ ŵŽŵĞŶƚ͘ ΗdŚŝƐ ƌĞƉŽƌƚ ŚŝŐŚůŝŐŚƚƐ ƚŚĞ ŶĞĞĚ ĨŽƌ ďĞƩĞƌ ĐĂƌĞ͕ ƐƵƉƉŽƌƚ ĂŶĚ ĂĐĐĞƐƐ ƚŽ ĚŝĂďĞƚĞƐ ĞĚƵĐĂƟŽŶ͘ hŶůĞƐƐ ƚŚŝƐ ŚĂƉƉĞŶƐ ƵƌŐĞŶƚůLJ͕ ǁĞ ǁŝůů ĐŽŶƟŶƵĞ ƚŽ ƐĞĞ ŵŽƌĞ ƉĞŽƉůĞ ĚLJŝŶŐ ƵŶŶĞĐĞƐƐĂƌŝůLJ ĞĂƌůLJ͘Η

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ƉƌŝŵĂƌLJ ĐĂƌĞ ƚŽ ŚĞůƉ ƉĞŽƉůĞ ǁŝƚŚ ĚŝĂďĞƚĞƐ

ĂƌďĂƌĂ zŽƵŶŐ͕ ŚŝĞĨ džĞĐƵƟǀĞ ŽĨ ŝĂďĞƚĞƐ ďĞƩĞƌ ƵŶĚĞƌƐƚĂŶĚ ĂŶĚ ƚĂŬĞ ŽǁŶĞƌƐŚŝƉ ŽĨ

h<͕ ƐĂŝĚ͗ ͞dŚĞ ƌĞĂƐŽŶ ŝŶĨŽƌŵĂƟŽŶ ƚŚĞŝƌ ĚŝĂďĞƚĞƐ͕ ĂŶĚ ƐŽ ĞŵƉŽǁĞƌ ƉĞŽƉůĞ ƚŽ

ƉƌĞƐĐƌŝƉƟŽŶƐ ĂƌĞ ƐŽ ĞdžĐŝƟŶŐ ŝƐ ƚŚĂƚ ƚŚĞLJ ǁŝůů ĂǀŽŝĚ ĚĞǀĞůŽƉŝŶŐ ĐŽŵƉůŝĐĂƟŽŶƐ ŝŶ ƚŚĞ ůŽŶŐ

ŐŝǀĞ ƉĞŽƉůĞ Ă ĐŚĂŶĐĞ ƚŽ ĚĞǀĞůŽƉ Ă ƉĞƌƐŽŶĂů ƚĞƌŵ͘ tĞ ŬŶŽǁ ƚŚĂƚ ƉƌŝŵĂƌLJ ĐĂƌĞ ŝƐ ƵŶĚĞƌ Ă

ƉůĂŶ ǁŝƚŚ ƚŚĞŝƌ ĚŽĐƚŽƌ Žƌ ŶƵƌƐĞ ǁŚŝĐŚ ŝƐ ůŽƚ ŽĨ ƟŵĞ ƉƌĞƐƐƵƌĞ͕ ďƵƚ ƚŚĞ ĚĞƐŝŐŶ ŽĨ ƚŚĞƐĞ

ƚĂŝůŽƌĞĚ ƚŽ ƚŚĞŝƌ ŶĞĞĚƐ͘͟ ĂůůŽǁƐ ďĞƐƚ ƉƌĂĐƟĐĞ ĂƌŽƵŶĚ ĐĂƌĞ ƉůĂŶŶŝŶŐ

ĂŶĚ ŐŽĂů ƐĞƫŶŐ ƚŽ ďĞ ĚŽŶĞ ĚƵƌŝŶŐ ƌŽƵƟŶĞ

͞dŚĞƐĞ ƉůĂŶƐ ĐĂŶ ƉůĂLJ ĂŶ ŝŵƉŽƌƚĂŶƚ ƌŽůĞ ŝŶ ĐĂƌĞ͘͟

ĞŵƉŽǁĞƌŝŶŐ ƉĞŽƉůĞ ƚŽ ƚĂŬĞ ĐŽŶƚƌŽů ŽĨ ƚŚĞŝƌ

ĐŽŶĚŝƟŽŶ͕ ǁŚŝĐŚ ŝƐ ƌĞĂůůLJ ǀŝƚĂů ďĞĐĂƵƐĞ

ƉĞŽƉůĞ ǁŝƚŚ ĚŝĂďĞƚĞƐ ŽŶůLJ ƐĞĞ Ă ŚĞĂůƚŚĐĂƌĞ ŝĂďĞƚĞƐ h< ŚĂƐ ǁŽƌŬĞĚ ǁŝƚŚ ƉƌŝŵĂƌLJ ĐĂƌĞ /d

ƉƌŽĨĞƐƐŝŽŶĂů ĨŽƌ Ă ĨĞǁ ŚŽƵƌƐ Ă LJĞĂƌ͕ ǁŚŝůĞ ƚŚĞ ƐLJƐƚĞŵƐ͕ ŝŶĐůƵĚŝŶŐ D/^ tĞď͕ sŝƐŝŽŶ ĂŶĚ

^LJƐƚŵKŶĞ ƚŽ ŵĂŬĞ ŝƚ ĂƐ ĞĂƐLJ ĂƐ ƉŽƐƐŝďůĞ ĨŽƌ

ƌĞƐƚ ŽĨ ƚŚĞ ƟŵĞ ŝƚ ŝƐ ƚŚĞŵ ǁŚŽ ŝƐ ƌĞƐƉŽŶƐŝďůĞ

ĨŽƌ ŵĂŶĂŐŝŶŐ ŝƚ͘ ŚĞĂůƚŚĐĂƌĞ ƉƌŽĨĞƐƐŝŽŶĂůƐ ƚŽ ŝŶĐŽƌƉŽƌĂƚĞ

ŝŶĨŽƌŵĂƟŽŶ ƉƌĞƐĐƌŝƉƟŽŶƐ ŝŶƚŽ ƚŚĞŝƌ

ĐŽŶƐƵůƚĂƟŽŶƐ ǁŝƚŚ ƉĂƟĞŶƚƐ͘ dŚĞ ĐƵƚ Žī

͞tĞ ŚĂǀĞ ŚĂĚ ĂŶ ŝŶĐƌĞĚŝďůLJ ƉŽƐŝƟǀĞ ƉŽŝŶƚƐ ĨŽƌ ƉƌŽŵƉƚƐ ŝŶ ƚŚĞ /d ƐLJƐƚĞŵ ĂƌĞ

ďĂƐĞĚ ŽŶ EĂƟŽŶĂů /ŶƐƟƚƵƚĞ ĨŽƌ ,ĞĂůƚŚ ĂŶĚ

ƌĞƐƉŽŶƐĞ ĨƌŽŵ ŽƵƌ ƉŝůŽƚ ƉƌŽũĞĐƚƐ͕ ďŽƚŚ ĨƌŽŵ

ŚĞĂůƚŚĐĂƌĞ ƉƌŽĨĞƐƐŝŽŶĂůƐ ĂŶĚ ƉĞŽƉůĞ ǁŝƚŚ ĂƌĞ džĐĞůůĞŶĐĞ ŐƵŝĚĂŶĐĞ ǁŚŝĐŚ ƐĞƚƐ ŽƵƚ

ǁŚĂƚ ƚĂƌŐĞƚƐ ƉĂƟĞŶƚƐ ƐŚŽƵůĚ ďĞ ĂĐŚŝĞǀŝŶŐ ƚŽ

ĚŝĂďĞƚĞƐ͕ ĂŶĚ ƐŽ ŝƚ ŝƐ ŐƌĞĂƚ ƚŚĂƚ ƉĞŽƉůĞ ĂĐƌŽƐƐ

ƚŚĞ h< ǁŝůů ŶŽǁ ŐĞƚ ƚŽ ďĞŶĞĮƚ ĨƌŽŵ ŝƚ͘ KƵƌ ƌĞĚƵĐĞ ƚŚĞŝƌ ƌŝƐŬ ŽĨ ĐŽŵƉůŝĐĂƟŽŶƐ͘

ƵůƟŵĂƚĞ ŐŽĂů ŝƐ ĨŽƌ ƉĞŽƉůĞ ǁŝƚŚ ĚŝĂďĞƚĞƐ ƚŽ

ůŝǀĞ ĂƐ ůŽŶŐ ĂŶĚ ĂƐ ŚĞĂůƚŚLJ ůŝǀĞƐ ĂƐ ƉŽƐƐŝďůĞ͕

ĂŶĚ ŝŶĨŽƌŵĂƟŽŶ ƉƌĞƐĐƌŝƉƟŽŶƐ ǁŝůů ďĞ ĂŶ ǁǁǁ͘ĚŝĂďĞƚĞƐ͘ŽƌŐ͘ƵŬ

ĂŶ Ă ͚ƉƌŽďŝŽƟĐ Ɖŝůů͛ ĐƵƌĞ

ĚŝĂďĞƚĞƐ͍

ŶĞĞĚĞĚ ďĞĨŽƌĞ ǁĞ ǁŝůů ŬŶŽǁ ŝĨ ƚŚŝƐ

ƚƌĞĂƚŵĞŶƚ ĐŽƵůĚ ďĞŶĞĮƚ ƉĞŽƉůĞ ůŝǀŝŶŐ ǁŝƚŚ

ĚŝĂďĞƚĞƐ͘

&ƌŽŵ :ĂŶƵĂƌLJ ϮϬϭϱ͕ ƉĞŽƉůĞ ǁŝƚŚ ĚŝĂďĞƚĞƐ

ǁŚŽ ĚŽ ŶŽƚ ŚĂǀĞ ƚŚĞŝƌ ĐŽŶĚŝƟŽŶ ƵŶĚĞƌ

ĐŽŶƚƌŽů ǁŝůů ďĞ ŐŝǀĞŶ ƉĞƌƐŽŶĂů ĂĐƟŽŶ ƉůĂŶƐ

ĨƌŽŵ ƚŚĞŝƌ 'W ƚŽ ŝŵƉƌŽǀĞ ƚŚĞŝƌ ŚĞĂůƚŚ͘

hŶĚĞƌ ƚŚĞ ŶĞǁ ƐĐŚĞŵĞ͕ ůĂƵŶĐŚĞĚ ďLJ

ŝĂďĞƚĞƐ h<͕ ƚŚĞ E,^ ĂŶĚ ƉƌŝǀĂƚĞ ƉƌŽǀŝĚĞƌƐ͕

ŝĨ ƐŽŵĞŽŶĞ ŝƐ ŶŽƚ ŵĞĞƟŶŐ ƚŚĞŝƌ ƚĂƌŐĞƚƐ ĨŽƌ

ďůŽŽĚ ƉƌĞƐƐƵƌĞ͕ ĐŚŽůĞƐƚĞƌŽů Žƌ ďůŽŽĚ ŐůƵĐŽƐĞ

ƚŚĞŶ ĂŶ ĂůĞƌƚ ǁŝůů ŇĂƐŚ ƵƉ ŽŶ ƚŚĞŝƌ 'W͛Ɛ

ĐŽŵƉƵƚĞƌ ĂĚǀŝƐŝŶŐ ƚŚĞŵ ƚŚĂƚ ƚŚĞŝƌ ƉĂƟĞŶƚ

ĐŽƵůĚ ďĞŶĞĮƚ ĨƌŽŵ ĂŶ ͚ŝŶĨŽƌŵĂƟŽŶ ƉƌĞƐĐƌŝƉƟŽŶ͛͘

dŚĞ ƐŝŵƉůĞ ĂŶĚ ƉƌĂĐƟĐĂů ŽŶĞ ƉĂŐĞ

ĚŽĐƵŵĞŶƚ͕ ǁŚŝĐŚ ǁŝůů ďĞ ƚĂŝůŽƌĞĚ ƚŽ ĞĂĐŚ

ƉĂƟĞŶƚ͕ ǁŝůů ĐŽŶƚĂŝŶ ƚŚĞ ĐƌƵĐŝĂů ŝŶĨŽƌŵĂƟŽŶ

ƚŚĞLJ ŶĞĞĚ ŽŶ ŚŽǁ ƚŽ ďĞƩĞƌ ŵĂŶĂŐĞ ƚŚĞŝƌ

ŚĞĂůƚŚ ĂŶĚ ĂŶ ĂĐƟŽŶ ƉůĂŶ ĨŽƌ ŝŵƉƌŽǀŝŶŐ ƚŚĞŝƌ

ŚĞĂůƚŚ ƚŚĂƚ ƚŚĞLJ ĂŐƌĞĞ ǁŝƚŚ ƚŚĞŝƌ 'W͘ dŚĞ

ĚŽĐƵŵĞŶƚ ĐĂŶ ďĞ ƉƌŝŶƚĞĚ Žī ĂŶĚ ƚĂŬĞŶ ĂǁĂLJ

ďLJ ƚŚĞ ƉĂƟĞŶƚ͘

KŶ dƵĞƐĚĂLJ ϯ &ĞďƌƵĂƌLJ͕ ŶĞǁƐ ƐƚŽƌŝĞƐ

ƌĞƉŽƌƚĞĚ ƚŚĂƚ Ă ŶĞǁ ͚ďƌĞĂŬƚŚƌŽƵŐŚ ƉƌŽďŝŽƟĐ

Ɖŝůů͛ ĐŽƵůĚ ͚ƌĞǁŝƌĞ͛ ƚŚĞ ďŽĚLJ ĂŶĚ ͚ĐƵƌĞ͛ ďŽƚŚ

dLJƉĞ ϭ ĂŶĚ dLJƉĞ Ϯ ĚŝĂďĞƚĞƐ͘ dŚĞ ƐƚŽƌŝĞƐ

ĨŽĐƵƐĞĚ ŽŶ ƌĞƐĞĂƌĐŚ ĨƌŽŵ ŽƌŶĞůů hŶŝǀĞƌƐŝƚLJ

ŝŶ ƚŚĞ hŶŝƚĞĚ ^ƚĂƚĞƐ ĂŶĚ ƉƵďůŝƐŚĞĚ ŝŶ ƚŚĞ

ũŽƵƌŶĂů ŝĂďĞƚĞƐ͘ Ƶƚ ŝƐ ƚŚĞƌĞ ĂŶLJ ƚƌƵƚŚ

ďĞŚŝŶĚ ƚŚĞƐĞ ĐůĂŝŵƐ͍

ƌĞƉƌŽŐƌĂŵŵĞĚ ŐƵƚ ĐĞůůƐ ƌĞůĞĂƐĞĚ ƵƉ ƚŽ Ă

ƚŚŝƌĚ ŽĨ ƚŚĞ ŝŶƐƵůŝŶ ƉƌŽĚƵĐĞĚ ďLJ Ă ƌĂƚ

ǁŝƚŚŽƵƚ ĚŝĂďĞƚĞƐ͕ ŚĞůƉŝŶŐ ƚŚĞ ƌĂƚƐ ƚŽ

ŵĂŶĂŐĞ ƚŚĞŝƌ ďůŽŽĚ ŐůƵĐŽƐĞ ůĞǀĞůƐ͘

/ƚ ŝƐ ĞƐƉĞĐŝĂůůLJ ŝŵƉŽƌƚĂŶƚ ƚŽ ŶŽƚĞ ƚŚĂƚ ƚŚĞ

͚ƉƌŽďŝŽƟĐ Ɖŝůů͛ ƵƐĞĚ ŝŶ ƚŚĞ ƐƚƵĚLJ ŝƐ ĚŝīĞƌĞŶƚ

ƚŽ ƚŚĞ ƉƌŽďŝŽƟĐ ĚĂŝƌLJ ƉƌŽĚƵĐƚƐ ƚŚĂƚ ĂƌĞ

ĂůƌĞĂĚLJ ǁŝĚĞůLJ ĂǀĂŝůĂďůĞ͘ dŚĞ Ɖŝůů ŝŶĐůƵĚĞĚ Ă

ƐƚƌĂŝŶ ŽĨ ůŝǀĞ ďĂĐƚĞƌŝĂ ƚŚĂƚ ŝƐ ĐŽŵŵŽŶůLJ

ĨŽƵŶĚ ŝŶ ƚŚĞ ŚƵŵĂŶ ŐƵƚ͕ ďƵƚ ǁŚŝĐŚ ŚĂĚ ďĞĞŶ

ŐĞŶĞƟĐĂůůLJ ĞŶŐŝŶĞĞƌĞĚ ƚŽ ƉƌŽĚƵĐĞ ƚŚĞ

ŚŽƌŵŽŶĞ '>W-ϭ͘

tŝƚŚŽƵƚ ĨƵƌƚŚĞƌ ƌĞƐĞĂƌĐŚ͕ ǁĞ ĚŽ ŶŽƚ ŬŶŽǁ ŝĨ

ƚŚŝƐ ĂƉƉƌŽĂĐŚ ĐŽƵůĚ ƉŽƚĞŶƟĂůůLJ ƌĞƉůĂĐĞ Žƌ

ǁŽƌŬ ŝŶ ĐŽŵďŝŶĂƟŽŶ ǁŝƚŚ ĞdžŝƐƟŶŐ ƚŚĞƌĂƉŝĞƐ

ĨŽƌ ƉĞŽƉůĞ ůŝǀŝŶŐ ǁŝƚŚ ĚŝĂďĞƚĞƐ͘ /ƚ ŝƐ

ŝŵƉŽƌƚĂŶƚ ƚŽ ŶŽƚĞ ƚŚĂƚ͕ ŝŶ ƉĞŽƉůĞ ǁŝƚŚ dLJƉĞ

ϭ ĚŝĂďĞƚĞƐ͕ ŝŶƐƵůŝŶ-ƉƌŽĚƵĐŝŶŐ ĐĞůůƐ ŝŶ ƚŚĞ

ƉĂŶĐƌĞĂƐ ĂƌĞ ƚĂƌŐĞƚĞĚ ĂŶĚ ĚĞƐƚƌŽLJĞĚ ďLJ ĂŶ

ŝŵŵƵŶĞ ĂƩĂĐŬ͘ /Ĩ ƚŚŝƐ ĂƉƉƌŽĂĐŚ ǁĞƌĞ ƵƐĞĚ

'>W-ϭ ĂŶĚ ƐŝŵŝůĂƌ ĚƌƵŐƐ ƚƌŝŐŐĞƌ ƚŚĞ ƌĞůĞĂƐĞ ƚŽ ĞŶŐŝŶĞĞƌ ŶĞǁ ŝŶƐƵůŝŶ-ƉƌŽĚƵĐŝŶŐ ŐƵƚ ĐĞůůƐ

dŚĞ ƌĞƐĞĂƌĐŚ ŚŝŐŚůŝŐŚƚĞĚ ǁŝůů ŶŽƚ ƉƌŽǀŝĚĞ ĂŶ

ŽĨ ŝŶƐƵůŝŶ ĂŶĚ ďůŽĐŬ ƚŚĞ ƌĞůĞĂƐĞ ŽĨ ŐůƵĐĂŐŽŶ ŝŶ ƉĞŽƉůĞ ǁŝƚŚ dLJƉĞ ϭ͕ ƚŚĞƐĞ ĐĞůůƐ ĐŽƵůĚ ĂůƐŽ

ŝŵŵĞĚŝĂƚĞ ĐƵƌĞ ĨŽƌ ƉĞŽƉůĞ ůŝǀŝŶŐ ǁŝƚŚ dLJƉĞ ϭ

ĨƌŽŵ ƚŚĞ ƉĂŶĐƌĞĂƐ͕ ŚĞůƉŝŶŐ ƚŽ ƌĞĚƵĐĞ ďůŽŽĚ ďĞ ƚĂƌŐĞƚĞĚ ďLJ ƚŚĞ ŝŵŵƵŶĞ ƐLJƐƚĞŵ ʹ ƐŽ ƚŚŝƐ

Žƌ dLJƉĞ Ϯ ĚŝĂďĞƚĞƐ͕ ďƵƚ ŝƐ ǀĞƌLJ ŝŶƚĞƌĞƐƟŶŐ

ŐůƵĐŽƐĞ ůĞǀĞůƐ͘ dŚĞLJ ĂƌĞ ĂůƌĞĂĚLJ ƵƐĞĚ ĨŽƌ ƚŚĞ

ǁŽƵůĚ ŶĞĞĚ ƚŽ ďĞ ŵŽŶŝƚŽƌĞĚ ĐůŽƐĞůLJ͘

ƚƌĞĂƚŵĞŶƚ ŽĨ dLJƉĞ Ϯ ĚŝĂďĞƚĞƐ͘ tŚĞŶ ŶĞǀĞƌƚŚĞůĞƐƐ͘ dŚĞ ƐƚƵĚLJ ĨŽĐƵƐĞĚ ŽŶ ƌĂƚƐ͕ ĂŶĚ

Ăƚ ƚŚŝƐ ƐƚĂŐĞ ŝƚ ŝƐ ƚŽŽ ĞĂƌůLJ ƚŽ ƐĂLJ ŝĨ ƚŚĞ

ƌĞƐĞĂƌĐŚĞƌƐ ŝŶ ƚŚŝƐ ƐƚƵĚLJ ŐĂǀĞ '>W-ϭ hŶƟů ĨƵƌƚŚĞƌ ƌĞƐĞĂƌĐŚ ŚĂƐ ďĞĞŶ ĐŽŵƉůĞƚĞĚ͕

ƉƌŽďŝŽƟĐ ƵƐĞĚ ǁŽƵůĚ ŚĂǀĞ ƚŚĞ ƐĂŵĞ

ƉƌŽĚƵĐŝŶŐ ďĂĐƚĞƌŝĂ ƚŽ ƌĂƚƐ ǁŝƚŚ ĚŝĂďĞƚĞƐ͕ ƚŚĞ ďĞƐƚ ǁĂLJ ƚŽ ŵĂŶĂŐĞ ĚŝĂďĞƚĞƐ ŝƐ ďLJ

ďĞŶĞĮƚƐ ŝŶ ŚƵŵĂŶƐ͕ Žƌ ŝĨ ŝƚ ĐŽƵůĚ ďĞĐŽŵĞ Ă

'>W-ϭ ǁĂƐ ƌĞůĞĂƐĞĚ ŝŶƚŽ ƚŚĞ ŐƵƚ ĂŶĚ ƚĂŬŝŶŐ ĞdžŝƐƟŶŐ ŵĞĚŝĐĂƟŽŶƐ ƉƌĞƐĐƌŝďĞĚ ďLJ

ƌŽƵƟŶĞ ƚƌĞĂƚŵĞŶƚ ĨŽƌ ĚŝĂďĞƚĞƐ ŝŶ ŚƵŵĂŶƐ͘

͚ƌĞƉƌŽŐƌĂŵŵĞĚ͛ ƐŽŵĞ ŽĨ ƚŚĞ ŐƵƚ ĐĞůůƐ͕ LJŽƵƌ ĚŽĐƚŽƌ͕ ĂŶĚ ŵĂŝŶƚĂŝŶŝŶŐ Ă ŚĞĂůƚŚLJ

zĞĂƌƐ ŽĨ ĨƵƌƚŚĞƌ ƌĞƐĞĂƌĐŚ ƵƐŝŶŐ ĂŶŝŵĂů ĐĂƵƐŝŶŐ ƚŚĞŵ ƚŽ ďĞĐŽŵĞ ŝŶƐƵůŝŶ-ƉƌŽĚƵĐŝŶŐ ǁĞŝŐŚƚ ďLJ ĨŽůůŽǁŝŶŐ Ă ŚĞĂůƚŚLJ ďĂůĂŶĐĞĚ ĚŝĞƚ

ŵŽĚĞůƐ ĂŶĚ ĐůŝŶŝĐĂů ƚƌŝĂůƐ ŝŶ ŚƵŵĂŶƐ ǁŝůů ďĞ ĐĞůůƐ͘ dŚĞ ƌĞƐĞĂƌĐŚĞƌƐ ĨŽƵŶĚ ƚŚĂƚ ƚŚĞ ĂŶĚ ƚĂŬŝŶŐ ƌĞŐƵůĂƌ ĞdžĞƌĐŝƐĞ͘

Podiatry Review Vol 72:2

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COSYFEET ARTICLE

Volunteering with Crisis

Podiatry student Linda Scantlebury responded to a Cosyfeet appeal for Crisis at Christmas volunteers willing to recount their experiences in the media, in the hope of attracting more podiatry volunteers in the future.

As part of my BSc degree in Podiatry at Brighton University, I was tasked to undertake some volunteering work and reflect on this experience. I was excited about this at the outset, and looked forward to being involved in new experiences from which I could learn. I was proud that my university had chosen to take this route, and hoped that there would be those who would so enjoy the experience that they would continue to contribute in this manner in their professional life. Personally, I feel that the charitable work to which so many in Britain contributes is a real strength of our society.

I was not disappointed and I found it thoroughly enjoyable – even the tricky customers, who each had a story to tell, and left me with something to ponder. I realise that not every experience and patient is positive, but there is certainly always a lot to learn from each encounter.

I chose to volunteer with ‘Crisis at Christmas’, a charity that reaches out to the homeless for a week over the festive period; providing a place to stay, meals, new clothing, bedding and access to healthcare as well as information regarding housing, job seeking and essential services.

My shifts were divided into seven hour slots at one of the ten venues across London. On my first shift I was allocated to assist a team of three qualified podiatrists.

As I had expected, the “clinic” was set up in very basic facilities; a classroom with a kitchenette adjoining. When the patient arrived, they were given a basin of warm soapy water to soak their feet in, and a clean towel to dry their feet off afterwards.

The podiatrists set up with two chairs facing each other, plus a footstool.

Instruments were put on a small tray which was either kept on the podiatrist’s lap or on the floor (which was covered with a small piece of couch roll). All instruments were considered single use and disposed of post treatment. The patient was then treated by the podiatrist, and I gave them two pairs of socks, two emollient sachets and a foot file. Some were in need of orthotics, and following an assessment were provided with off the shelf devices.

Eleven patients were treated on my first shift, two of which I will discuss which were

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particularly notable to my learning experience.

Patient X was in his thirties and had multiple sclerosis. He came from a European country where good social care is provided, but said that he chooses to remain in England in order to maintain contact with his children. He seemed to suffer from low self-esteem and was embarrassed, evidenced by his soft spoken voice and numerous apologies about the state of his feet. His clothes were stained and dirty, and he smelt of stale urine. His finger and toe nails were excessively long and unkempt and he had a large, pierced and painful blister on the plantar aspect of the 1st metatarsal on his right foot. The podiatrist wiped his feet with patient wipes, cut and filed his toe nails and dressed his injuries. He was advised to retain the dressing for two days, and to try to stay off his feet to allow the remaining fluid in the blister to be reabsorbed. He expressed the desire to use the shower facilities available at the venue, and was given a glove to cover his foot to enable him to do so. After his treatment he asked to borrow the nail nippers and cut his finger nails.

Patient Y was a 42 year old woman who suffered from mental health problems.

She was subdued and soft-spoken and mentioned pain in her left foot. She had previously attended hospital where an xray revealed a fracture of the fourth metatarsal. She was given a foot orthoses boot to wear for six weeks. However, the boot had been removed with no assessment following, and her foot was again painful, swollen and had erythema.

The podiatrist wiped her feet with Clinell patient wipes, cut and filed her nails, (which were long,) and did a muscular skeletal assessment. She referred her to the doctor who was next door, for a letter to take with her to the hospital requesting a further x-ray, having suspected that the fracture had not yet healed properly.

I was eager to begin my shift and start helping. I anticipated that we would encounter a myriad of serious foot problems that had gone untreated for a lengthy period. I was pleasantly surprised to discover that the majority of patients we

Podiatry Review Vol 72:2

saw were in fact aware of the various drop in centres located around London which operate year round and provide a free podiatry service to the homeless. This meant that the severity of most conditions, had been kept in abeyance.

I was tasked with giving out the socks, emollient and emery boards which were all gratefully received and it was a pleasurable task.

The seating arrangement seemed to work reasonably well, but on reflection I felt it could have been improved by having a small table to that could have been cleaned and lined with couch paper to provide a clean fiend to lay out the instruments. There were plenty of tables available, and there were at least two occasions when instruments fell off the podiatrist’s lap onto the dirty carpet and it was necessary to open a new pack.

This was a good opportunity to learn to make do with what resources were available, and although I only thought of it retrospectively, next time I would make the suggestion.

At first I wanted to help wash the patient’s feet but it soon became apparent that many were embarrassed and preferred to be left to soak and dry off their own feet. None of the patients were very elderly, and clearly felt quite capable of carrying out this task.

I found it difficult to comprehend that the instruments would be discarded and not cleaned and sterilised for use the following year. This prompted me to question the lead Podiatrist who explained that in previous years they had struggled to clean and sterilise the equipment in time to treat the next tranche of patients, and single use and disposal was much easier for the podiatrist. I have pondered this practice and question whether it would not be possible in future to collect up all the dirty instruments and rather than try and have them cleaned and sterilised for use that same day, if enough were purchased, to have them ready for the following year. Bearing in mind that sterilisation has a time limit, perhaps they could be re-autoclaved in time for Christmas. It would still save on purchasing

new ones each year if enough stock were available for treatment for the week that Crisis is open.

Patient X requesting the use of nail nippers to cut his finger nails highlighted another issue for consideration. The compassionate side of me wanted to give him the nippers. This prompted a discussion with the lead podiatrist who explained that in the past, when effects (eg new trainers) had been given out, it prompted other patients to demand to receive the same and when there was no more stock, those who did not receive anything became violent and aggressive which put the podiatrists safety in jeopardy. Accordingly it had become policy never to give anything away except when the items were in abundance eg socks.

Despite the disappointment I still felt at being unable to give the nippers away, the rationale behind the decision made sense to me, and I could not think of another prudent way to circumvent the issue.

Patient X, for example, kept apologising about the state of his feet, which I did not consider to be bad at all. They were relatively clean and well kept. I found it interesting to observe the podiatrist reassuring Patient X, and joking with him that although some may think it crazy she

had willingly chosen this career because she enjoys working with feet, and that it was no burden at all to treat his feet. I felt that the situation was handled in a compassionate and light-hearted manner and I could see the gentleman visibly relax, begin to smile, and talk freer with the podiatrist who had won his confidence.

Her use of humour was undoubtedly helpful to put the patient at ease and I felt that she had approached the situation with professionalism and tact.

It was a new experience for me to work with someone who smelled so bad. I was unsure as to how to react towards him so as not to betray my feelings of disgust. I felt torn because I felt empathy for this young man in such a difficult position who was obviously embarrassed and did not want to be in such a state. I observed the podiatrist who was cheerfully dismissive of his concerns which had the effect of putting the patient at ease. Her humour aided this. I learned from the way the podiatrist reacted to the patient and would strive to react in the same way should I find myself in such a situation in the future; to defuse the situation with professionalism and humour about how much we love feet.

With regards Patient Y, I did not think of it at the time, but the Podiatrist pointed

COSYFEET ARTICLE

out to me that she had not been examined after the boot was removed. On reflection I realised that although her foot had been immobilised for the usual period, it should not be taken for granted that complete healing had occurred. An assessment should have been undertaken, and if any doubts arose a further x-ray should have been ordered to confirm the position. On reflection, it seems possible that because Patient Y’s injury has been left so long without a boot, and taking the increasing age of the fracture into account, that it might now never heal satisfactorily.

If you are inspired by Linda’s account of her volunteering experience with Crisis, look out for more information later in the year about how you can get involved as a volunteer with Crisis at Christmas in 2015.

Linda Scantlebury is a student of the University of Brighton and wishes to acknowledge the university in facilitating her to undertake this volunteering practice.

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HEALTH ARTICLE

Dog Walking - The Health Benefits

/ƚΖƐ ƵŶĚĞƌƌĂƚĞĚ ĂƐ Ă ĨŽƌŵ ŽĨ ĞdžĞƌĐŝƐĞ ďƵƚ ĚŽŐ ǁĂůŬŝŶŐ ŝƐ Ă ƉĞƌĨĞĐƚ ĂĐƟǀŝƚLJ ĨŽƌ ƉĞŽƉůĞ ŽĨ Ăůů ĂŐĞƐ ƚŽ ŝŶĐƌĞĂƐĞ ƚŚĞŝƌ ĮƚŶĞƐƐ ůĞǀĞůƐ͘ &Žƌ ƚŚĞ ŵŽƐƚ ƉĂƌƚ͕ ŝƚ ŝƐ ĨƌĞĞ ĂŶĚ LJŽƵ ĚŽŶ͛ƚ ŚĂǀĞ ƚŽ ůŝǀĞ ŝŶ ƚŚĞ ĐŽƵŶƚƌLJƐŝĚĞ Žƌ ƚƌĂǀĞů ĨĂƌ͘ DŽƐƚ ƚŽǁŶƐ ĂŶĚ ĐŝƟĞƐ ŽīĞƌ ŝŶƚĞƌĞƐƟŶŐ ǁĂůŬƐ ŝŶĐůƵĚŝŶŐ ƉĂƌŬƐ͕ ŚĞƌŝƚĂŐĞ ƚƌĂŝůƐ͕ ĐĂŶĂů ƚŽǁƉĂƚŚƐ͕ ƌŝǀĞƌƐŝĚĞ ƉĂƚŚƐ͕ ĐŽŵŵŽŶƐ ĂŶĚ ǁŽŽĚůĂŶĚƐ͘

ƚŽ ŐĞƚ ƚŚĞ ƌĞĐŽŵŵĞŶĚĞĚ ůĞǀĞů ŽĨ ƉŚLJƐŝĐĂů ĂĐƟǀŝƚLJ ĞĂĐŚ ĚĂLJ͘ ͞ϭ ŽŐ ǁĂůŬŝŶŐ ŝƐ ŐŽŽĚ ĨŽƌ ƐƚƌĞƐƐ ŵĂŶĂŐĞŵĞŶƚ͖ ƌĞƐĞĂƌĐŚ ŚĂƐ ƐŚŽǁŶ ƚŚĂƚ ũƵƐƚ ďĞŝŶŐ ĂƌŽƵŶĚ Ă ĚŽŐ ĐĂŶ ůŽǁĞƌ ůĞǀĞůƐ ŽĨ ƚŚĞ ƐƚƌĞƐƐ ŚŽƌŵŽŶĞ͕ ĐŽƌƟƐŽů ĂŶĚ ĚĂŵƉĞŶ ŽƚŚĞƌ ƉŚLJƐŝŽůŽŐŝĐĂů ƐƚƌĞƐƐ ƌĞƐƉŽŶƐĞƐ͘ dŚĞLJ ĐĂŶ ƌĞĚƵĐĞ ĚĞƉƌĞƐƐŝŽŶ ĂŶĚ ůĞƐƐĞŶ ůŽŶĞůŝŶĞƐƐ͘ dŚĞ ĞīĞĐƚ ŝƐ ƐŽ ƐƚƌŽŶŐ ƚŚĂƚ ƐĞƌǀŝĐĞ ĚŽŐƐ ĂƌĞ ƐŽŵĞƟŵĞƐ ƵƐĞĚ ƚŽ ŚĞůƉ ǁĂƌ ǀĞƚĞƌĂŶƐ ŵĂŶĂŐĞ ƉŽƐƚ ƚƌĂƵŵĂƟĐ ƐƚƌĞƐƐ ĚŝƐŽƌĚĞƌ͘ džĞƌĐŝƐĞ ŝŶ ŐĞŶĞƌĂů ŝƐ Ă ƉƌŽǀĞŶ ƐƚƌĞƐƐ ƌĞůŝĞǀĞƌ ƐŽ ĐŽŵďŝŶĞ ƚŚĞƐĞ ǁŝƚŚ ĐĂƌŝŶŐ ĨŽƌ LJŽƵƌ ĚŽŐ ĂŶĚ ƚŚĞ ďĞŶĞĮƚƐ ĨŽƌ ƐƚƌĞƐƐ ĚŽƵďůĞ͘Ϯ͘ KĨ ĐŽƵƌƐĞ͕ ĞdžƉĞƌƚƐ ĂƌĞŶ͛ƚ ƌĞĐŽŵŵĞŶĚŝŶŐ LJŽƵ ŐĞƚ Ă ƉĞƚ ũƵƐƚ ƚŽ ƌĞĚƵĐĞ LJŽƵƌ ŚĞĂƌƚ ĚŝƐĞĂƐĞ ƌŝƐŬ͊

ĞŝŶŐ ĂĐƟǀĞ͕ ŝŶ ŐĞŶĞƌĂů͕ ŝƐ ŐƌĞĂƚ ĨŽƌ LJŽƵƌ ƉŚLJƐŝĐĂů ŚĞĂůƚŚ ĂŶĚ ĮƚŶĞƐƐ͘ Ƶƚ ĞǀŝĚĞŶĐĞ ƐŚŽǁƐ ƚŚĂƚ ŝƚ ĐĂŶ ĂůƐŽ ŝŵƉƌŽǀĞ LJŽƵƌ ŵĞŶƚĂů ǁĞůůďĞŝŶŐ͘ tĞ ƚŚŝŶŬ ƚŚĂƚ ƚŚĞ ŵŝŶĚ ĂŶĚ ďŽĚLJ ĂƌĞ ƐĞƉĂƌĂƚĞ͕ ďƵƚ ǁŚĂƚ LJŽƵ ĚŽ ǁŝƚŚ LJŽƵƌ ďŽĚLJ ĐĂŶ ŚĂǀĞ Ă ƉŽǁĞƌĨƵů ĞīĞĐƚ ŽŶ LJŽƵƌ ŵĞŶƚĂů ǁĞůůďĞŝŶŐ͘ DĞŶƚĂů ǁĞůůďĞŝŶŐ KďǀŝŽƵƐůLJ Ă ĚŽŐ ŝƐ ŶŽƚ Ă ƌĞƋƵŝƌĞŵĞŶƚ ĨŽƌ ŵĞĂŶƐ ĨĞĞůŝŶŐ ŐŽŽĚ ʹ ďŽƚŚ ĂďŽƵƚ LJŽƵƌƐĞůĨ ǁĂůŬŝŶŐ ƉĞƌ ƐĞ͕ ďƵƚ ƚĂŬŝŶŐ Ă ĚŽŐ ďŽŽƐƚƐ ĂŶĚ ĂďŽƵƚ ƚŚĞ ǁŽƌůĚ ĂƌŽƵŶĚ LJŽƵ͘ /ƚ ŵĞĂŶƐ ŵŽƟǀĂƟŽŶ ǁŚŝĐŚ ŝŶ ƚƵƌŶ ŝŶĐƌĞĂƐĞƐ ĮƚŶĞƐƐ ďĞŝŶŐ ĂďůĞ ƚŽ ŐĞƚ ŽŶ ǁŝƚŚ ůŝĨĞ ŝŶ ƚŚĞ ǁĂLJ ƚŚĂƚ ůĞǀĞůƐ͕ ƌĞĚƵĐĞƐ ƐƚƌĞƐƐ ĂŶĚ ďŽŽƐƚƐ ƐĞůĨ LJŽƵ ǁĂŶƚ͘ ǀŝĚĞŶĐĞ ƐŚŽǁƐ ƚŚĂƚ ƚŚĞƌĞ ŝƐ Ă ĞƐƚĞĞŵ͘ zŽƵ ŵĂLJ ůŽŽŬ Ăƚ ƚŚĞ ǁĞĂƚŚĞƌ ĂŶĚ ƐŚƵĚĚĞƌ Ăƚ ƚŚĞ ƚŚŽƵŐŚƚ ŽĨ Ă ǁĂůŬ ďLJ ƚŚĞ ůŝŶŬ ďĞƚǁĞĞŶ ďĞŝŶŐ ƉŚLJƐŝĐĂůůLJ ĂĐƟǀĞ ĂŶĚ ŐŽŽĚ ŵĞŶƚĂů ǁĞůůďĞŝŶŐ͘ dŚĂƚ ŵĂŬĞƐ ďĞŝŶŐ ĐĂŶĂů ŝŶ ƚŚĞ ƌĂŝŶ͕ ďƵƚ LJŽƵƌ ĐĂŶŝŶĞ ĂĐƟǀĞ ŽŶĞ ŽĨ ƚŚĞ ĮǀĞ ĞǀŝĚĞŶĐĞ-ďĂƐĞĚ ƐƚĞƉƐ ĐŽŵƉĂŶŝŽŶ ŵĂLJ ĨĞĞů ŝƚ ŝƐ ƉĞƌĨĞĐƚ ĂŶĚ ŚŽǁ ĐĂŶ LJŽƵ ŝŐŶŽƌĞ ƚŚĂƚ ƉůĞĂĚŝŶŐ ůŽŽŬ͍ /Ŷ ǁĞ ĐĂŶ Ăůů ƚĂŬĞ ƚŽ ŝŵƉƌŽǀĞ ŽƵƌ ŵĞŶƚĂů ĂĚĚŝƟŽŶ͕ LJŽƵ ĐĂŶ ĐŽƵŶƚ ŽŶ ŚĂǀŝŶŐ ĂŶ ǁĞůůďĞŝŶŐ͘ ϯ ĞŶƚŚƵƐŝĂƐƟĐ ǁĂůŬŝŶŐ ďƵĚĚLJ͕ ǁŚŝĐŚ ƌĞĚƵĐĞƐ ƚŚĞ ƐŽůŝƚĂƌLJ ĨĞĞůŝŶŐ ĂŶĚ ŵĂŬĞƐ ǁĂůŬŝŶŐ ƚŚĂƚ tŚĂƚ Ă ϲϬŬŐ ƉĞƌƐŽŶ ďƵƌŶƐ ŝŶ ϯϬ What a 60kg person burns in 30 ŵƵĐŚ ŵŽƌĞ ĞŶũŽLJĂďůĞ ĨŽƌ ĚŽŐƐ ĂƌĞ ŐƌĞĂƚ minutes ŵŝŶƵƚĞƐ ĨƌŝĞŶĚƐŚŝƉ ƐƚĞƌƐ͖ LJŽƵ ŵĂLJ ǁĂůŬ ƉĂƐƚ (2mph): 75 calories x • strolling ƐƚƌŽůůŝŶŐ ;ϮŵƉŚͿ͗ ϳϱ ĐĂůŽƌŝĞƐ ƚŚĞ ƐĂŵĞ ƉĞƌƐŽŶ ĞǀĞƌLJ ĚĂLJ ǁŝƚŚŽƵƚ ĐŽŵŵƵŶŝĐĂƟŶŐ Žƌ ĂĐŬŶŽǁůĞĚŐŝŶŐ ĞǀĞŶ͘ (3mph): 99 calories x • walking ǁĂůŬŝŶŐ ;ϯŵƉŚͿ͗ ϵϵ ĐĂůŽƌŝĞƐ zŽƵƌ ĚŽŐ ǁŝůů ĐŚĂŶŐĞ Ăůů ƚŚĂƚ͊ ĞǀĞŶ ŝĨ LJŽƵƌ ĨĂƐƚ fastǁĂůŬŝŶŐ ;ϰŵƉŚͿ͗ ϭϱϬ ĐĂůŽƌŝĞƐ walking (4mph): 150 calories ĮƌƐƚ ŝŶƚƌŽĚƵĐƟŽŶƐ ĂƌĞ ƐƉůĂƩĞƌĞĚ ǁŝƚŚ ǁŽƌĚƐ ^ŽƵƌĐĞ͗ ƚ ůĞĂƐƚ ĮǀĞ Ă ǁĞĞŬ͕ ĞƉĂƌƚͲ Source: At least five a week, DepartŽĨ ĂƉŽůŽŐŝĞƐ ĨŽƌ ͙͘ŵƵĚĚLJ ĨŽŽƚƉƌŝŶƚƐ ĚŽǁŶ Ă ment of Health, 2004 ŵĞŶƚ ŽĨ ,ĞĂůƚŚ͕ ϮϬϬϰ ĐŽĂƚ͕ Ă ƌĂƚŚĞƌ ƚŽŽ ĨĂŵŝůŝĂƌ ĂƉƉƌŽĂĐŚ ƚŽ ƚŚĞŝƌ ĚŽŐ Žƌ ĂŶ ŝŶƋƵŝƐŝƟǀĞ ŶŽƐĞ ŝŶ Ă ďĂŐ͊ ĐŬŶŽǁůĞĚŐĞŵĞŶƚƐ ŶŽƚŚĞƌ ƌĞĂƐŽŶ ǁŚLJ ĚŽŐƐ ĂƌĞ ͚ŵĂŶ͛Ɛ ďĞƐƚ ĨƌŝĞŶĚ͛ ŝƐ ƚŚĂƚ ƚŚĞLJ ĐŽƵůĚ ŚĞůƉ ƌĞĚƵĐĞ LJŽƵƌ ƌŝƐŬ ŽĨ ŚĞĂƌƚ ĚŝƐĞĂƐĞ͊ dŚĞ ŵĞƌŝĐĂŶ ,ĞĂƌƚ ƐƐŽĐŝĂƟŽŶ ƐĂLJƐ ŽǁŶŝŶŐ Ă ƉĞƚ͕ ĞƐƉĞĐŝĂůůLJ Ă ĚŽŐ͕ ŝƐ ůŝŬĞůLJ ĂƐƐŽĐŝĂƚĞĚ ǁŝƚŚ ĚĞĐƌĞĂƐĞĚ ĐĂƌĚŝŽǀĂƐĐƵůĂƌ ĚŝƐĞĂƐĞ ƌŝƐŬ͘ dŚĂƚ ŝŶĐůƵĚĞƐ Ă ůŽǁĞƌ ƌŝƐŬ ĨŽƌ ƐƚƌŽŬĞ͕ Ă ůĞĂĚŝŶŐ ĐĂƵƐĞ ŽĨ ĚŝƐĂďůŝŶŐ ďƌĂŝŶ ŝŶũƵƌLJ͘ ͞,ĂǀŝŶŐ Ă ĚŽŐ ŝƐ ƉĂƌƟĐƵůĂƌůLJ ŚĞůƉĨƵů ďĞĐĂƵƐĞ LJŽƵ ŐĞƚ ŝŶ ƉŚLJƐŝĐĂů ĂĐƟǀŝƚLJ ǁŚĞŶ LJŽƵ ǁĂůŬ LJŽƵƌ ĚŽŐ͘ /Ŷ ĨĂĐƚ͕ ĚŽŐ ŽǁŶĞƌƐ ĂƌĞ ϱϰ ƉĞƌĐĞŶƚ ŵŽƌĞ ůŝŬĞůLJ

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E,^ ŚŽŝĐĞƐ dŚĞ ŵĞƌŝĐĂŶ ,ĞĂƌƚ KƌŐĂŶŝƐĂƟŽŶ >ŝŶĚĂ tĂƐŵĞƌ ŶĚƌĞǁƐ

ZĞĨĞƌĞŶĐĞƐ ϭ͘ ŚƩƉ͗ͬ​ͬǁǁǁ͘ŚĞĂƌƚ͘ŽƌŐͬ, ZdKZ'ͬ EĞǁƐͬEĞǁƐZĞůĞĂƐĞƐͬtĂůŬŝŶŐ-LJŽƵƌĚŽŐ-ŚĞůƉƐ-LJŽƵƌŚĞĂƌƚͺh DͺϰϱϮϯϰϵͺ ƌƟĐůĞ͘ũƐƉ Ϯ͘ ŚƩƉ͗ͬ​ͬǁǁǁ͘ƉƐLJĐŚŽůŽŐLJƚŽĚĂLJ͘ĐŽŵͬ ďůŽŐͬŵŝŶĚŝŶŐ-ƚŚĞ-ďŽĚLJͬϮϬϭϰϬϰͬĚŽŐǁĂůŬŝŶŐ-ŚĂƐ-ƉƐLJĐŚŽůŽŐŝĐĂů-ďĞŶĞĮƚƐ-LJŽƵ ϯ͘ ŚƩƉ͗ͬ​ͬǁǁǁ͘ŶŚƐ͘ƵŬͬ>ŝǀĞǁĞůůͬŐĞƫŶŐƐƚĂƌƚĞĚ-ŐƵŝĚĞƐͬWĂŐĞƐͬŐĞƫŶŐ-ƐƚĂƌƚĞĚǁĂůŬŝŶŐ͘ĂƐƉdž

Podiatry Review Vol 72:2

,ŝŶƚƐ ĂŶĚ dŝƉƐ ŽŶ ǁĂůŬŝŶŐ tĞĂƌ ůŽŽƐĞ-ĮƫŶŐ ĐůŽƚŚŝŶŐ ƚŚĂƚ ĂůůŽǁƐ LJŽƵ ƚŽ ŵŽǀĞ ĨƌĞĞůLJ͘ ŚŽŽƐĞ ƚŚŝŶ ůĂLJĞƌƐ ƌĂƚŚĞƌ ƚŚĂŶ ŚĞĂǀLJ͕ ĐŚƵŶŬLJ ĐůŽƚŚŝŶŐ͘ /Ĩ LJŽƵ͛ƌĞ ǁĂůŬŝŶŐ ƚŽ ǁŽƌŬ͕ LJŽƵ ĐĂŶ ũƵƐƚ ǁĞĂƌ LJŽƵƌ ƵƐƵĂů ǁŽƌŬ ĐůŽƚŚĞƐ ǁŝƚŚ Ă ĐŽŵĨLJ ƉĂŝƌ ŽĨ ƐŚŽĞƐ͘ &Žƌ ůŽŶŐ ǁĂůŬƐ͕ LJŽƵ ŵĂLJ ǁĂŶƚ ƚŽ ƚĂŬĞ ƐŽŵĞ ǁĂƚĞƌ͕ ŚĞĂůƚŚLJ ƐŶĂĐŬƐ͕ Ă ƐƉĂƌĞ ƚŽƉ͕ ƐƵŶƐĐƌĞĞŶ ĂŶĚ Ă ƐƵŶŚĂƚ ŝŶ Ă ƐŵĂůů ďĂĐŬƉĂĐŬ͘ /Ĩ LJŽƵ ƐƚĂƌƚ ƚĂŬŝŶŐ ƌĞŐƵůĂƌ͕ ůŽŶŐĞƌ ǁĂůŬƐ͕ LJŽƵ ŵĂLJ ǁĂŶƚ ƚŽ ŝŶǀĞƐƚ ŝŶ Ă ǁĂƚĞƌƉƌŽŽĨ ũĂĐŬĞƚ ĂŶĚ ƐŽŵĞ ǁĂůŬŝŶŐ ďŽŽƚƐ ĨŽƌ ŵŽƌĞ ĐŚĂůůĞŶŐŝŶŐ ƌŽƵƚĞƐ͘ ^ƚĂƌƚ ƐůŽǁůLJ ĂŶĚ ƚƌLJ ƚŽ ďƵŝůĚ LJŽƵƌ ǁĂůŬŝŶŐ ƌĞŐŝŵĞ ŐƌĂĚƵĂůůLJ͘ dŽ ŐĞƚ ƚŚĞ ŚĞĂůƚŚ ďĞŶĞĮƚƐ ĨƌŽŵ ǁĂůŬŝŶŐ͕ ŝƚ ŶĞĞĚƐ ƚŽ ďĞ ŽĨ ŵŽĚĞƌĂƚĞ-ŝŶƚĞŶƐŝƚLJ ĂĞƌŽďŝĐ ĂĐƟǀŝƚLJ͘ /Ŷ ŽƚŚĞƌ ǁŽƌĚƐ͕ ŝƚ ŶĞĞĚƐ ƚŽ ďĞ ĨĂƐƚĞƌ ƚŚĂŶ Ă ƐƚƌŽůů͘ DŽĚĞƌĂƚĞ-ŝŶƚĞŶƐŝƚLJ ĂĞƌŽďŝĐ ĂĐƟǀŝƚLJ ŵĞĂŶƐ LJŽƵΖƌĞ ǁĂůŬŝŶŐ ĨĂƐƚ ĞŶŽƵŐŚ ƚŽ ƌĂŝƐĞ LJŽƵƌ ŚĞĂƌƚ ƌĂƚĞ ĂŶĚ ďƌĞĂŬ Ă ƐǁĞĂƚ͘ KŶĞ ǁĂLJ ƚŽ ƚĞůů ŝƐ ƚŚĂƚ LJŽƵΖůů ďĞ ĂďůĞ ƚŽ ƚĂůŬ͕ ďƵƚ ŶŽƚ ƐŝŶŐ ƚŚĞ ǁŽƌĚƐ ƚŽ LJŽƵƌ ĨĂǀŽƵƌŝƚĞ ƐŽŶŐ͘ dƌLJ ƚŽ ǁĂůŬ ϭϬ͕ϬϬϬ ƐƚĞƉƐ Ă ĚĂLJ͘ DŽƐƚ ŽĨ ƵƐ ǁĂůŬ ďĞƚǁĞĞŶ ϯ͕ϬϬϬ ĂŶĚ ϰ͕ϬϬϬ ƐƚĞƉƐ Ă ĚĂLJ ĂŶLJǁĂLJ͕ ƐŽ ƌĞĂĐŚŝŶŐ ϭϬ͕ϬϬϬ ŝƐŶΖƚ ĂƐ ĚĂƵŶƟŶŐ ĂƐ ŝƚ ŵŝŐŚƚ ƐŽƵŶĚ͘ /Ĩ͕ ƚŽ ďĞŐŝŶ ǁŝƚŚ͕ LJŽƵ ĐĂŶ ŽŶůLJ ǁĂůŬ ĨĂƐƚ ĨŽƌ Ă ĐŽƵƉůĞ ŽĨ ŵŝŶƵƚĞƐ͕ ƚŚĂƚΖƐ ĮŶĞ͘ ŽŶΖƚ ŽǀĞƌĚŽ ŝƚ ŽŶ LJŽƵƌ ĮƌƐƚ ĚĂLJ͘ zŽƵ ĐĂŶ ďƌĞĂŬ ƵƉ LJŽƵƌ ĂĐƟǀŝƚLJ ŝŶƚŽ ϭϬ-ŵŝŶƵƚĞ ĐŚƵŶŬƐ͕ ĂƐ ůŽŶŐ ĂƐ LJŽƵΖƌĞ ĚŽŝŶŐ LJŽƵƌ ĂĐƟǀŝƚLJ Ăƚ Ă ŵŽĚĞƌĂƚĞ ŝŶƚĞŶƐŝƚLJ͘ ĞŐŝŶ ĞǀĞƌLJ ǁĂůŬ ƐůŽǁůLJ ĂŶĚ ŐƌĂĚƵĂůůLJ ŝŶĐƌĞĂƐĞ LJŽƵƌ ƉĂĐĞ͘ ŌĞƌ Ă ĨĞǁ ŵŝŶƵƚĞƐ͕ ŝĨ LJŽƵ͛ƌĞ ƌĞĂĚLJ͕ ƚƌLJ ǁĂůŬŝŶŐ Ă ůŝƩůĞ ĨĂƐƚĞƌ͘ dŽǁĂƌĚƐ ƚŚĞ ĞŶĚ ŽĨ LJŽƵƌ ǁĂůŬ͕ ŐƌĂĚƵĂůůLJ ƐůŽǁ ĚŽǁŶ LJŽƵƌ ƉĂĐĞ ƚŽ ĐŽŽů ĚŽǁŶ͘ &ŝŶŝƐŚ Žī ǁŝƚŚ Ă ĨĞǁ ŐĞŶƚůĞ ƐƚƌĞƚĐŚĞƐ͕ ǁŚŝĐŚ ǁŝůů ŚĞůƉ ŝŵƉƌŽǀĞ LJŽƵƌ ŇĞdžŝďŝůŝƚLJ͘

NWAC SEMINAR FORM

17th NORTH WEST AREA COUNCIL SEMINAR

Ć&#x161;Ĺ&#x161; K dK Z ĎŽĎŹĎ­Ďą

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The North West Area Council will be their 17th at the holding Annual Seminar of Central Lancashire , Preston

University

on 4th 2015. The conďŹ rmed October

are Deformaties of the lectures this year

feet by Andrea Gledhill

and Autism â&#x20AC;&#x201C; of Autism

Awareness a Podiatry within

by Vicky Bisthall.

Another lecture

Practice

is to be conďŹ rmed shortly.

is superb The lecture theatre with

comfortable seating and space. The trade

on a great show again

stands are putting

this year providing members a good variety

of products and consumables.

There is a

hot two course lunch provided and and tea

coďŹ&#x20AC;ee is available throughout the day.

A

available at Valuable CPD CertiďŹ cate will

be

end the day your The the of for portfolioâ&#x20AC;&#x2122;s.

cost of 3 CPD and lunch lectures,

excellent

and a chance to grab a few bargains from trade is ÂŁ60.00 price stands same as

the

last year. Free parking is available. Book

your now on a very worthwhile place

and

enjoyable day.

Denise Willis

North Wales, StaďŹ&#x20AC;s and Cheshire

Shropshire Branch Secretary

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Podiatry Review Vol 72:2

page 29

BRANCH NEWS

Western Branch

On 11th January 2015, fifteen Institute members of the Western branch attended a meeting at the Women's hospital in Liverpool. First on the agenda was the AGM, discussing the important business from head office, the area council and all other business relevant to our branch. We made decisions about future roles within the Institute.

Our education officer, Dawn Hinton then came up trumps again by organising a talk by Simon Dickinson who arrived with his colleague Emma Cook from "Talar Made", who have made a commitment to improving education. The extremely knowledgeable Simon is clinical director at Talar Made and he spent an hour explaining about a new mobile device "app" that he has developed. The "app" is designed to help all practitioners dealing with problems of the foot and will be available to download shortly. He explained how, from simply talking and asking questions of our patients and then taking the information obtained and comparing it with the "app", the various foot related problems can be diagnosed and then ultimately treated. The self

confessed "geek" Simon has a very down to earth approach and all branch members thoroughly enjoyed the session.

We were then treated to a buffet lunch, served by the absolutely lovely Joyce and the computer genius Martin (we insist a teenager attends to help us oldies get the computer working).

The Western branch meeting then got underway.

We discussed branch business and voted on available roles for the coming year within our branch. The branch treasurer Kevin O'Sullivan explained to us how funds had been distributed and spent last year and how the Western branch is doing financially at the start of this year.

We thanked him on his efficiency since holding the position as treasurer. I would also like to thank all the other wonderful Western branch members who hold office for their continued hard work to make our meetings run smoothly and feel like an afternoon with friends.

with Simon and a very willing guinea pig in Dawn Hinton. Dawn has a few foot and knee related problems due to injury and Simon showed us how he could diagnose the problem with a few simple tests and how he was able to ease the pain Dawn is subjected to when she walks. He chose an orthotic he thought would benefit her and the results were amazing.

We as a branch would like to thank Simon and Emma for giving up their time for the benefit of our branch members and allowing us to gain valuable cpd . The day was a great success.

Hazel Carruthers

Finally, we had a practical workshop

Podiatrist knowledge needed to develop new resource for working with the homeless

People who are homeless are in some of the greatest need of foot care advice, support and treatment, and now a major Nursing organisation is working to support the professionals that work with them.

The Queen’s Nursing Institute (QNI) is working with health professionals across England, Wales and Northern Ireland to improve healthcare for the homeless. As part of this goal The QNI would like to bring the experience of these professionals together, to create resources that Nurses, Podiatrists and Chiropodists can use to support their work with patients who are homeless.

David Parker-Radford, Homeless Health Project Manager at The QNI said “When we visited Podiatrists specialising in homelessness, we found they had few colleagues in the same role nationally. This meant they developed all their own patient

page 30

information leaflets, clinic posters, and recording methods. We also found that the most effective treatment was provided where Nurses and Podiatrists worked together.”

“Using the voice and experience of Podiatrists and Nurses working with the homeless, we aim to create a simple pack of information that can support the practitioner in practice.

As well as patient and practitioner guidance, we want to include a Foot Assessment Tool, to allow Podiatrists to track their impact.”

To make The QNI’s materials and resources as relevant and applicable as possible, they want to hear the views of as many Podiatrists as possible. Podiatrists interested in finding out more and getting involved with this work, should contact david.parker-radford@qni.org.uk or

Podiatry Review Vol 72:2

call 020 7549 1410.

A Specialist Podiatrist for the Homeless will also facilitate a workshop on improving selfmanagement of foot conditions at The QNI’s Self-Care for People Experiencing Homelessness: What’s Possible? Event in Central Manchester on February 26th 2015.

As a Podiatrist you can join the QNI’s Homeless Health Network for free, and get news and event updates by visiting www.qni.org.uk. This helps you link with other Specialist Podiatrists and share practice.

Podiatry Review Vol 72:2

page 31

PRESS RELEASE

Patients with Allergies?

ĂŶĚ ĞŶũŽLJ ŐƌĞĂƚĞƌ ǁĞůůďĞŝŶŐ͘ ^ƉĞĐŝĂůŝƐƚ

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ƚŽ ƌŝƐĞ͘ ĂĐŚ

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dŚĞ ƐŝƚĞ ŝŶĐůƵĚĞƐ ƐƉĞĐŝĮĐ ĂĚǀŝĐĞ ŽŶ

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ƚĞĐŚŶŽůŽŐŝĐĂů ĂĚǀĂŶĐĞŵĞŶƚƐ ŝŶ ŚŽǁ ƚŚĞƐĞ ƐŚŽĞƐ

ĂƌĞ ĚĞƐŝŐŶĞĚ ĂŶĚ ŵĂŶƵĨĂĐƚƵƌĞĚ͘ ůŽŶŐ ǁŝƚŚ

ŝŵƉƌŽǀĞŵĞŶƚƐ ŝŶ ƐĞƌǀŝĐĞ ŽƌŐĂŶŝƐĂƟŽŶ ĂŶĚ

ĐŽŶƐƵůƚĂƟŽŶ ǁŝƚŚ ƉĂƟĞŶƚƐ ǁĞ ĂƌĞ ĂŝŵŝŶŐ ƚŽ ƐĞĞ

ŝŵƉƌŽǀĞŵĞŶƚƐ ŝŶ ĨŽŽƚ ŚĞĂůƚŚ ĨŽƌ ƚŚŽƐĞ ǁŝƚŚ

ĐŽŶĚŝƟŽŶƐ ƐƵĐŚ ĂƐ ĚŝĂďĞƚĞƐ͘͟

,Ğ ƐĂŝĚ͗ ͞/ ŚŽƉĞ ƚŚŝƐ ŝƐ ƚŚĞ ĨŽƌĞƌƵŶŶĞƌ ŽĨ Ă

ĐŽŵƉĂƌĂďůĞ ƉƌŽũĞĐƚ ƚŽ ĚĞǀĞůŽƉ ŽŶůŝŶĞ͕

ŵƵůƟŵĞĚŝĂ ĐŽŶƚĞŶƚ ĨŽƌ ŽƌƚŚŽƟĐ ŝŶƐŽůĞ ƚƌĂŝŶŝŶŐ

ĂĐƌŽƐƐ ƐĞǀĞƌĂů ƐĐŚŽŽůƐ ŽĨ ƉŽĚŝĂƚƌLJ͕ ŽƌƚŚŽƟĐƐ ĂŶĚ

ƉŚLJƐŝĐĂů ƚŚĞƌĂƉLJ ĂĐƌŽƐƐ ƚŚĞ h͘͟

ƌ tŝůůŝĂŵƐ ĂŶĚ WƌŽĨĞƐƐŽƌ EĞƐƚĞƌ ĂŶĚ ĐŽůůĞĂŐƵĞƐ

ĂƌĞ ĂůƐŽ ƉĂƌƚŶĞƌƐ ŝŶ ƚǁŽ ĨƵƌƚŚĞƌ h ƉƌŽũĞĐƚƐ

ĐŽŶĐĞƌŶĞĚ ǁŝƚŚ ĨŽŽƚ ŚĞĂůƚŚ ŝŶƚĞƌǀĞŶƟŽŶƐ ĂŶĚ

dŚĞ ƉƌŽũĞĐƚ ĂŝŵƐ ƚŽ ƐƵƉƉŽƌƚ ŐƌĞĂƚĞƌ ĂĚŽƉƟŽŶ ŽĨ

ĨŽŽƚǁĞĂƌ ŝŶŶŽǀĂƟŽŶƐ - ^Ž,ĞĂůƚŚLJ ĂŶĚ ^D ZdW/&͘

ŶŝƚĂ ŝƐ ĐƵƌƌĞŶƚůLJ ŝŶ ĐŚĂƌŐĞ ŽĨ ĚĞǀĞůŽƉŵĞŶƚ ŽĨ ŽŵƉƵƚĞƌ- ŝĚĞĚ ĞƐŝŐŶ ƚĞĐŚŶŽůŽŐŝĞƐ ƚŽ

dŚĞ /E' ϯ ƉƌŽũĞĐƚ ďƵŝůĚƐ ŽŶ ƚŚĞ ďĂĐŬ ŽĨ ƌ

ƚŚĞ KƌƚŚŽƉĂĞĚŝĐ &ŽŽƚǁĞĂƌ ŵŽĚƵůĞ ǁŚŝĐŚ ŽīĞƌƐ Ă ƵŶĚĞƌƉŝŶ ŝŶŶŽǀĂƟŽŶ ŝŶ ƚŚĞ ĨŽŽƚǁĞĂƌ

tŝůůŝĂŵƐ͛ ƐƵĐĐĞƐƐĨƵů ƚƌĂĐŬ ƌĞĐŽƌĚ ŽĨ ƌĞƐĞĂƌĐŚ ĂŶĚ

ďůĞŶĚĞĚ ůĞĂƌŶŝŶŐ ŵŽĚĞů ĂŶĚ ĚŝƌĞĐƚ ĂĐĐĞƐƐ ƚŽ ŵĂŶƵĨĂĐƚƵƌŝŶŐ ĂĐƟǀŝƟĞƐ ŝŶ ^ƉĂŝŶ͕ WŽƌƚƵŐĂů͕

ƉƵďůŝƐŚŝŶŐ ŝŶ ƚŚŝƐ ĂƌĞĂ ďŽƚŚ ŝŶ ƉĞĞƌ-ƌĞǀŝĞǁĞĚ

ƐŽŵĞ ŽĨ ƚŚĞ ŵŽƐƚ ĂĚǀĂŶĐĞĚ ĨŽŽƚǁĞĂƌ ĚĞƐŝŐŶƐ ZŽŵĂŶŝĂ͕ ƚŚĞ h< ĂŶĚ ŽƚŚĞƌ h ĐŽƵŶƚƌŝĞƐ͘

ũŽƵƌŶĂůƐ ĂŶĚ ďŽŽŬƐ͘ ^ŚĞ ŚĂƐ ĂůƐŽ ĚĞǀĞůŽƉĞĚ ĂŶĚ

ƚŽŽůƐ ĂǀĂŝůĂďůĞ͘ dŚĞ ^ĐŚŽŽů ŝƐ ĂůƐŽ ďĞŶĞĮƫŶŐ ďLJ

ůĞĂĚƐ ƚŚĞ ƉŽƐƚŐƌĂĚƵĂƚĞ ĨŽŽƚǁĞĂƌ ƚƌĂŝŶŝŶŐ ĐŽƵƌƐĞ tŽƌŬŝŶŐ ǁŝƚŚ Ă ƌĂŶŐĞ ŽĨ ĞdžŝƐƟŶŐ h< ĨŽŽƚǁĞĂƌ

ŐĂŝŶŝŶŐ ϭϱ ĨƌĞĞ ůŝĐĞŶƐĞƐ ĨŽƌ ƐƚƵĚĞŶƚƐ ƚŽ ƵƐĞ͘

ƚŚĂƚ ŚĂƐ ƐĞĞŶ ŵŽƌĞ ƚŚĂŶ ϵϬ ƉŽĚŝĂƚƌŝƐƚƐ ŝŶ ƚŚĞ h< ƉĂƌƚŶĞƌƐ͕ ƐŽŵĞ ŽĨ ǁŚŽŵ ƉƌŽĚƵĐĞ ƐƉĞĐŝĂůŝƐƚ

ĂŶĚ ƐŽƵƚŚĞƌŶ /ƌĞůĂŶĚ ĞdžƚĞŶĚ ƚŚĞŝƌ ƐĐŽƉĞ ŽĨ WƌŽĨĞƐƐŽƌ ŚƌŝƐ EĞƐƚĞƌ ŚĞůƉĞĚ ďƌŝŶŐ ƚŚĞ ƉƌŽũĞĐƚ ĨŽŽƚǁĞĂƌ ĨŽƌ ƉĞŽƉůĞ ǁŝƚŚ ŵĂũŽƌ ĨŽŽƚ ƉĂƚŚŽůŽŐLJ͕

ƉƌĂĐƟĐĞ͘ dŚĞ Ăŝŵ ŽĨ ƚŚĞ ĐŽƵƌƐĞ ŝƐ ƚŽ ĞŶŚĂŶĐĞ ƚŚĞ ƌ tŝůůŝĂŵƐ ŚĂƐ ŝĚĞŶƟĮĞĚ ŐĂƉƐ ŝŶ ƚŚĞ ƉƌŽǀŝƐŝŽŶ ŽĨ

ĐŽŶƐŽƌƟĂ ƚŽŐĞƚŚĞƌ ǀŝĂ ƚŚĞ ůŽŶŐ ƐƚĂŶĚŝŶŐ ůŝŶŬ ƚŽ ƉƌŽǀŝƐŝŽŶ ŽĨ ĨŽŽƚ ĐĂƌĞ ƚŚĞ ƉŽĚŝĂƚƌŝƐƚƐ ĚĞůŝǀĞƌ /ŶƐƟƚƵƚŽ ƐƉĂŹŽů ĚĞů ĂůnjĂĚŽ LJ ŽŶĞdžĂƐ ĨŽŽƚǁĞĂƌ ƚƌĂŝŶŝŶŐ ŝŶ ŝŶĚƵƐƚƌLJ ďƵƚ ĂůƐŽ ŝŶ ŚŝŐŚĞƌ

ĂůŽŶŐƐŝĚĞ ƚŚĞŝƌ ŽƌƚŚŽƟƐƚ ĐŽůůĞĂŐƵĞƐ͘ ;/E ^ KWͿ͕ Ă ƐĞƌǀŝĐĞ ŽƌŐĂŶŝƐĂƟŽŶ ĨŽƌ ƚŚĞ ĞĚƵĐĂƟŽŶ ƐĞƫŶŐƐ͘

ĨŽŽƚǁĞĂƌ ĂŶĚ ƌĞůĂƚĞĚ ŝŶĚƵƐƚƌŝĞƐ͕ ŝŶ ^ƉĂŝŶ͘

ƌ tŝůůŝĂŵƐ ƐĂŝĚ͗ ͞/Ŷ ŽƌĚĞƌ ƚŽ ĂĐŚŝĞǀĞ ŐŽŽĚ

page 32

Podiatry Review Vol 72:2

CLASSIFIED

Classified

Situations Vacant

Associate Podiatrist sought South London

Saturday position expanding into weekdays on a fee-sharing basis. With your broad base of skills including PNA and natural aptitude you'll be looking to find a practice you feel is the right place to grow and shine. Own transport would be helpful. For a great opportunity send your CV to podiatryjobapp@gmail.com

Practices For Sale

Mixed practice for sale in Chorley, Lancashire.

Current turn over £25k for three and a half days a week. Plenty of scope for further development.

Surgery equipment included in sale.

Accommodation available on sale or rental basis.

Price to be negotiated.

Any enquiries telephone 01257 411272

Miscellaneous

Chiromart UK “WHY PAY MORE?”

Suppliers of Autoclaves and Chiropody Surgery Equipment.

Single Items to full surgery set-ups. Quality used and new.

Also your equipment wanted. Surgery clearances, trade-ins and part exchange CASH WAITING… www.chiromart.co.uk

Tel: 01424 731432 (please quote ref: iocp)

Specialist in footwear for orthotics and wide feet for men and women with problem feet.

Wide Fit Shoes 33 Kenton Park Parade Kenton, Harrow, Middlesex, HA3 8DN Telephone 0208 9071742

www.widefitshoes.co.uk

Wiltshire Full time Podiatrist

Full time salaried Podiatrist vacancy in established multi-disciplinary private practice. The right candidate will be passionate about Podiatry, be of a caring nature and keen to work alongside other Podiatrists and healthcare professionals.

Excellent remuneration, supportive team and company and a very proactive approach to CPD. To apply, please email your CV and covering letter to amanda@jameshattphysio.co.uk

Wednesbury, West Midlands

Thriving practise in Wednesbury, established over 40 years; excellent reputation.

Two full and three half days, plus Saturday morning. Annual turnover 35K+ All equipment included. OIRO 22K Telephone 0121 556 0891 or 07781 947883 email faithden@hotmail.com

DES CURRIE INTERNATIONAL (+44) (0) 1207 505191

Business Cards 1 sided; ........................1,000 - £40 ............................................................10,000 - £99 Record Cards/Continuations/ Sleeves (8” x 5”) ........................................1,000 - £68 Appointment Cards 2 sided; ................10,000 - £99 Small Receipts ......................................2,000 - £49 ..............................................................4,000 - £71 Flyers ..................................................10,000 - £82 + type setting + carriage

FOR ALL YOUR STATIONERY NEEDS

To advertise in this section and on our website Call: 01704 546141 or email: bernie@iocp.org.uk

Podiatry Review Vol 72:2

page 33

NATIONAL OFFICER NOMINATIONS

2015 Nominations for National Office WZ ^/ Ed ͶdǁŽ EŽŵŝŶĂƟŽŶƐ ΎŽŶĞ ƚŽ ďĞ ĞůĞĐƚĞĚ

, /ZD E͕ y hd/s KDD/dd dŚƌĞĞ EŽŵŝŶĂƟŽŶƐͶ ΎŽŶĞ ƚŽ ďĞ ĞůĞĐƚĞĚ

sŝĐĞ ŚĂŝƌŵĂŶ͕ džĞĐƵƟǀĞ ŽŵŵŝƩĞĞ KŶĞ EŽŵŝŶĂƟŽŶ

ŚĂŝƌŵĂŶ͕ ŽĂƌĚ ŽĨ ĚƵĐĂƟŽŶ KŶĞ EŽŵŝŶĂƟŽŶ

sŝĐĞ ŚĂŝƌŵĂŶ͕ ŽĂƌĚ ŽĨ ĚƵĐĂƟŽŶ KŶĞ EŽŵŝŶĂƟŽŶ

ŚĂŝƌŵĂŶ͕ ŽĂƌĚ ŽĨ ƚŚŝĐƐ KŶĞ EŽŵŝŶĂƟŽŶ

^ƚĂŶĚŝŶŐ KƌĚĞƌƐ ŽŵŵŝƩĞĞͶ &ŽƵƌ EŽŵŝŶĂƟŽŶƐ ŽĨ ǁŚŝĐŚ ƚǁŽ ƚŽ ďĞ ĞůĞĐƚĞĚ

page 34

Podiatry Review Vol 72:2

DIARY OF EVENTS

Forthcoming Events Date

4

Hants and Dorset

8

Leeds/Bradford

15

Southport

19

Sheffield

22

Essex

25

London

26

Birmingham and Shires

30

West Middlesex

Date

To be Arranged North of Scotland

12

Leeds/Bradford

12

Western

26

Cheshire, North Wales, Staffs and Shropshire

6

Devon and Cornwall

26

Wolverhampton

Date

13

West Middlesex

17

Essex

March 2015

Branch Meeting - 7.45 for coffee; Meeting 8-10 pm Crosfield Hall, Broadwater Road, Romsey SO51 8GL Speaker – Dr Catherine Bowen PhD CSci FFPM RCPS(Glasg) – Arthritis – use of ultrasound to help with clinical diagnosis. Tel: 01202 425568 Branch Meeting - 10am The Oakwell Motel, Birstall, Leeds WF17 9HD. Tel: 01423 819547 Therapeutic Ultrasound for Lower Limb, Southport Head Office 01704 546141 Branch Meeting SWD Sports Club, Heeley Bank Road, Sheffield S2 3GL. Tel: 0114 266 4101 Branch Meeting - 2.00 pm Southend Hospital, Essex. Tel: 07947 435114 Branch Meeting - 7.30pm Ozzie Rizzo, 14 Hay Hill, Mayfair W1J 8NR. Tel: 07790 717833 for further details Branch Meeting - 8 pm Red Cross Centre, Briar Close, Evesham WR11 2EU. Tel: 07974 592517 Branch Meeting - 8 pm The Harvester, Watford Road, Croxley Green, Rickmansworth WD3 3RX. Tel: 0208 903 6544

April 2015

Branch Meeting Landmark Hotel, Kingsway East, Dundee or Belvedere Hotel, Evans Street, Stonehaven Please telephone for details 01382 532247 Branch Meeting - 10am The Oakwell Motel, Birstall, Leeds WF17 9HD. Tel: 01423 819547

Branch Meeting Liverpool Women’s Hospital, Crown Street, Liverpool Blair Bell Education Centre, Seminar Room 1. Tel: 01745 331827

Branch Meeting - 10.00 am.

The Dene Hotel, Hoole Road, Chester CH2 3ND. Tel: 0151 327 6113

Branch Meeting - 10.30 am.

The Exeter Court Hotel, Kennford, Exeter EX6 7WC First Aid Lecture by David Knowles followed by branch Meeting.

Tel: 01803 520788 email mrkjoanne@aol.com

Branch Education Meeting - 10am The Reading Rooms, Market Street, Penkridge, Staffs ST19 5DH Lectures: “Posterior Tibia Tendon Dysfunction” and “How to get through an HCPC Audit” Tel: 0121 378 2888

May 2015

Branch Meeting - 8 pm The Harvester, Watford Road, Croxley Green, Rickmansworth WD3 3RX Tel: 0208 903 6544 Branch Meeting - 2.00 p.m Southend Hospital, Essex. Tel: 07947 435114

Podiatry Review Vol 72:2

page 35

DIARY OF EVENTS

Forthcoming Events Date

17

Nottingham

17

West of Scotland

18

Surrey and Berkshire

29-30

Southport

Date

3

Hants and Dorset

4

Birmingham and Shires

7

Western

18

Sheffield

28

Southport

Date

6

Surrey and Berkshire

12

Wolverhampton

13

West Middlesex

Date

16

West of Scotland

Date

May 2015

Branch Meeting Feet and Co, 85 Melton Road, West Bridgford, Nottingham NG2 6EN Tel: 0115 931 3492 (other Meetings during year yet to be arranged)

Branch Meeting - 11.am – 1.30 pm.

Holiday Inn Express, Springkerse Business Park, Stirling FK7 7XH. Tel: 0141 632 3283 Branch Meeting - 7.30 pm.

Pirbright Village Hall, Surrey GU24 0JN. Tel: 01252 514273 IOCP Conference, Trade Show and AGM Southport Theatre and Convention Centre, PR9 0DZ. Tel: 01704 546141

June 2015

Branch Meeting - 7.45 for coffee; Meeting 8-10 pm Crosfield Hall, Broadwater Road, Romsey SO51 8GL Speakers to be confirmed. Tel: 01202 425568

Branch Meeting - 8 pm Red Cross Centre, Briar Close, Evesham WR11 2EU. Tel: 07974 592517 Branch Meeting Liverpool Women’s Hospital, Crown Street, Liverpool Blair Bell Education Centre, Seminar Room 1. Tel: 01745 331827 Branch Meeting SWD Sports Club, Heeley Bank Road, Sheffield S2 3GL Plantar Fasciitis update by Debra Straw. Tel: 0114 266 4101 Musculoskeletal Examination, Southport Head Office 01704 546141

July 2015

Branch Meeting - 7.30 pm.

Pirbright Village Hall, Surrey GU24 0JN. Tel: 01252 514273 Branch Meeting - 10am The Reading Rooms, Market Street, Penkridge, Staffs ST19 5DH. Tel: 0121 378 2888 Branch Meeting - 8 pm The Harvester, Watford Road, Croxley Green, Rickmansworth WD3 3RX. Tel: 0208 903 6544

August 2015

Branch Meeting - 11.am – 1.30 pm.

Holiday Inn Express, Springkerse Business Park, Stirling FK7 7XH. Tel: 0141 632 3283

September 2015

To be Arranged North of Scotland

Branch Meeting Landmark Hotel, Kingsway East, Dundee or Belvedere Hotel, Evans Street, Stonehaven Please telephone for details 01382 532247

London

Branch Meeting - 7.30pm Ozzie Rizzo, 14 Hay Hill, Mayfair W1J 8NR Tel: 07790 717833 for further details

2

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Podiatry Review Vol 72:2

DIARY OF EVENTS

Forthcoming Events Date

13

Cheshire, North Wales, Staffs and Shropshire

September 2015

Branch Meeting - 10.00 am.

The Dene Hotel, Hoole Road, Chester CH2 3ND. Tel: 0151 327 6113

14

Branch Meeting - 8 pm The Harvester, Watford Road, Croxley Green, Rickmansworth WD3 3RX. Tel: 0208 903 6544

20

Branch Meeting - 2.00 pm Southend Hospital, Essex. Tel: 07947 435114

West Middlesex Essex

20

Western

Branch Meeting Liverpool Women’s Hospital, Crown Street, Liverpool Blair Bell Education Centre, Seminar Room 1. Tel: 01745 331827

Birmingham and Shires

Branch Meeting - 8 pm Red Cross Centre, Briar Close, Evesham WR11 2EU. Tel: 07974 592517

24

Date

October 2015

Date to be arranged Devon and Cornwall

Branch Meeting - 11.00 am.

The Exeter Court Hotel, Kennford, Exeter EX6 7WC. Tel: 01803 520788

Hants and Dorset

Branch Meeting - 7.45 for coffee Meeting 8-10 pm Crosfield Hall, Broadwater Road, Romsey SO51 8GL Speakers to be confirmed. Tel: 01202 425568

7

12

Surrey and Berkshire

Branch Meeting - 7.30 pm.

Pirbright Village Hall, Surrey GU24 0JN. Tel: 01252 514273

18

Branch Meeting - 10am The Reading Rooms, Market Street, Penkridge, Staffs ST19 5DH. Tel: 0121 378 2888

25

Branch Seminar - 9.30 am – 4.30pm Holiday Inn Express, Springkerse Business Park, Stirling FK7 7XH. Tel: 0141 632 3283

Wolverhampton West of Scotland

Date

15

Cheshire, North Wales, Staffs and Shropshire

22

Essex

25

London

Date

11

Hants and Dorset

November 2015

Branch Meeting - 10.00 am.

The Dene Hotel, Hoole Road, Chester CH2 3ND. Tel: 0151 327 6113 Branch Meeting - 2.00 pm Southend Hospital, Essex. Tel: 07947 435114 Branch Meeting - 7.30pm Ozzie Rizzo, 14 Hay Hill, Mayfair W1J 8NR Tel: 07790 717833 for further details

December 2015

Branch Social Event from 7.30 pm Crosfield Hall, Broadwater Road, Romsey SO51 8GL Food will be served approx. 8 p.m. Tel: 01202 425568

For January 2016 dates see website Podiatry Review Vol 72:2

page 37