Podiatry Review January February 2013

Podiatry Review

39537 Chiropody Jan 2013 19/12/2012 10:59 Page 1

ISSN 1756-3291

Volume 70 No.1. Published by the Institute of Chiropodists and Podiatrists as a Peer Review Journal January/February 2013

• 2013 Conference Information • Diabetic Foot Assessment

• Treating Achilles Tendinosis

INSTITUTE OF CHIROPODISTS AND PODIATRISTS

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JANUARY/FEBRUARY 2013 VOl 70 No.1

Editor Ms B. Hawthorn H.M.Inst.Ch.P.

Academic Editor Robert Sullivan BSc.(Hons) Podiatry, MSc. Pod Surg., PgDip M.Acu., FSSChP. FIChPA. M.Inst.Ch.P.

Editorial Committee Mr. D. Collett M.Inst.Ch.P. Mrs. J. Casey B.Sc., M.Inst.Ch.P. Mrs. J. A. Drane M.Inst.Ch.P.

Advertising Please contact Julie Aspinwall secretary@iocp.org.uk

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

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PODIATRY REVIEW

The Institute of Chiropodists and Podiatrists

Contents

Editorial .............................................................................2 Diabetic Foot Assessment Michelle Taylor, M.Inst.Ch.P., BSc..........................................3 An interview with Justin Hall, fifth-generation sock-maker at the HJ Hall sock group: Nathan Rous .....................................................................6 Treating Achilles Tendinosis with Eccentric Exercises Iain B. McIntosh, BA(Hons) MBChB., Former Chiropody Schools Inspector ..........................................7 Volunteering in Hong Kong Cosyfeet Podiatry Award winner Alia Sohail .................10 Footmedics Press Release ...............................................16 2013 Annual Conference Information .............................17

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ISSN 1756-3291

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© The Institute of Chiropodists and Podiatrists.

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.

Diabetes Information Diabetes UK.....................................................................21 Cosyfeet Award Information ...........................................23 Arthritis Research UK Information ..................................24 Awareness Week Cervical Cancer Prevention .............................................26 Branch News ...................................................................27 Raynaud’s Awareness Month ..........................................30 Back to Base Article.........................................................32 Classified Adverts.......................................................34-35 Diary ................................................................................36 National Officers ............................................................IBC

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EDITORIAl Dear Readers,

A very happy New Year to all our readers! By now the Christmas festivities will, no doubt, seem a distant memory but hopefully enjoyed by one and all.

We now look forward to the year ahead and in this issue we are focussing on our Conference – see pages 17-20.

Once again our annual Conference and A.G.M. are to be held here in Southport. The main reason is that this purpose built conference centre is perfect for traders and delegates alike. Some of you may remember past conferences where space for trade has been limited and in some instances, split into different rooms. This was always frustrating for everyone, with some companies feeling they had been relegated to an ante room! Other venues had extremely difficult access routes. In Southport it is large and airy with access on ground level. There is also plenty of car parking space.

The venue is adjacent to the 4 star Ramada Hotel with internal access. Anybody staying at the Ramada has free underground car parking facilities. However, there is also a wide choice of other hotels and bed and breakfast establishments within walking distance. Do look at our website www.iocp.org.uk There is a link on there for accommodation to suit all tastes and budgets.

Also in this issue we have some very interesting technical and information articles. We thank Michelle Taylor BSc., MInstChP, for an excellent article on

Diabetic Foot Assessment. Michelle is one of our Western Branch Members who took up the invitation to write for Podiatry Review in our last issue and found she enjoyed it. Her articles are peer reviewed and will count towards her CPD profile for HCPC audit requirements. If anybody else would like to write but is not sure how to get started, Michelle will be happy to assist you (email Head Office in first instance).

We also have an article on Treating Achilles Tendinosis with Eccentric Exercises from Iain McIntosh BA(Hons) MBChB. Iain is a former inspector of chiropody schools and has written several articles of Podiatry Review over the years – all of which, give different perspectives on familiar topics. Thank you Iain – keep them coming in!

Once again we are happy to include another article from one of the Cosyfeet winners who travelled to Hong Kong. These articles are always informative, sometimes disturbing but always interesting.

Anybody can enter the competition offered by Cosyfeet and details are on page 23 as well as our website. Closing date is the 19th April 2013. Past winners have utilised their winnings by helping where it is needed most.

These are just a taster of what is inside your January-February 2013 issue of Podiatry Review.

Happy reading!

Bernadette Hawthorn, Editor

Southport Chiropody Clinic

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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 binging 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 atherosclerosis 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, distribution, and texture

quality,

thickness,

• Colour; cyanosis (bluish discolouration), 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 page | 03

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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 04 | page

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 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.

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ARTIClE 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 practioneers “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 blockage’s 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 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/Understandi ng_the_ankle_brachial_index.23.aspx[accessed 27th October 2012]

Oxford Medical Dictionary 2002 3rd ed.

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/Doppler -assessment-and-ABPI.html[accessed 27th October 2012]

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An interview with Justin Hall, fifth-generation sock-maker at the HJ Hall sock group: Nathan Rous

After an Olympic summer where legacy has become the buzzword of a golden generation, nowhere does legacy exist more than in the countless family businesses across the country which continue to make Britain great.

HJ Hall has been making socks in Hinckley since 1882, ever since ‘Honest John’ Hall asked his bank for a £1,200 overdraft at the age of 28 and built a factory in the small Leicestershire village of Stoke Golding.

Five generations later, his great-great-grandson, Justin Hall, continues to uphold the same traditions – manufacturing quality socks for the masses. With a range now that encompasses classic day socks, to technical outdoor socks and a customer base of over 2,000 stockist worldwide the HJ Sock Group is undoubtedly the leading sock manufacturer in the UK. HJ is also the only sock manufacturer to have two socks endorsed by the Institute of Chiropodists and Podiatrists Softop, the original non-elastic sock and a new style specifically designed for diabetics).

Of course, being born into a family business can be as claustrophobic as it can be empowering. Here Justin explains what it was like growing up in such a dynasty and how he plans to leave his own legacy.

“My first memory of the business was a nine or 10-year-old, popping into the factory with my older sister and playing on the phones. I knew my dad and my grandpa ran a sock business but I had no idea of the size or scale of it until I was older.

“We had boxes of socks around the house and a few brochures, and then every so often you’d see an advert on the telly for our socks, but it all felt completely normal. Home was obviously a nice cut-off from the factory, especially as so many family members worked there.

“The older I got the more involved I got. In my early and midteens I’d come down here for a week or so, trying to earn some money in the holidays by counting socks or making up boxes or helping out in the warehouse.

“It was then that HJ Hall was enjoying its heyday and my grandpa was quite a showman. We had a double-decker bus emblazoned with our logo that used to do the shows and he also had a plane which would do trips around the country.

There were some pretty big celebrity names involved with the brand too, from Big Daddy to Larry Grayson. It was quite an exciting time for the business and I became increasingly aware of its presence.

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“But while it was very much a family business – and always had been – there was never a time when my dad,

who’s still chairman of the company, sat me down and told me where I was going to slot in. He didn’t want to shove it down my throat and it was left to me to show interest.

“Naturally the question of whether I’d get involved was always at the back of my mind. I knew I wanted to get involved in running a business but I didn’t feel any pressure from my dad. I think if I hadn’t have been remotely bothered by following in his footsteps he would have sold it, but even so he didn’t stand over me wondering when I was going to join.

“As it was, I didn’t get involved in the firm until I was 30. I’d been away to school and then did a Masters in mechanical engineering at Bristol University. After I finished that I joined a graduate scheme at BAE Systems and set out to do management accountancy. I figured that I wanted to get a good grasp of business and finance before working out exactly what I wanted to do.

“From there I went to work for a carbon origination company in London which was extremely interesting but fullon. I imagine this was a pretty frustrating time for my dad because he was in his 60s and spending two or three days in the office but without a natural successor.

“Fortunately 2009 was a landmark year and everything fell into place on a number of different levels. I asked my longterm girlfriend, Karen, to marry me and I also moved back to Leicester to get involved in the business.

“By that time HJ Hall had acquired Pantherella and I was brought in as commercial director to oversee that business.”

Now chief executive of Pantherella and sitting on the board of the HJ sock group, Justin is determined to leave his mark, much in the way his forefathers have.

“I feel very much free to do what I wanted but I am very aware that I am fortunate to be part of this legacy and I want it to continue,” he explains.

“Naturally I want to pass the baton on to the next generation but I’ll take a leaf out of my dad’s book when it comes to that and let them make their own decisions.”

With a daughter, Martha, two in October and another baby on the way, the Hall sock-making dynasty has every chance of carrying on to a sixth generation.

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Treating Achilles Tendinosis with Eccentric Exercises Iain B. McIntosh, BA(Hons)MBChB., Former Chiropody Schools Inspector As noted in Podiatry Review in a recent issue, Achilles Tendonitis or Achilles tendinosis is a common cause of pain at the back of the ankle usually caused by acute Achilles tendon injury which can present as gradual onset of pain at the back of the ankle, just above the heel bone. developing over a period of days. This results in tendon pain at the onset of exercise which fades as exercise progresses and eases with rest with rest. On examination there is tenderness on palpation. If the injury has been mild the symptoms will disappear over a short time, but are likely to appear in a more severe form if the ankle is subjected again to the same trauma. The condition can be alleviated and its duration attenuated by application of eccentric exercises.

Achilles tendonitis accounts for about 11% of all running injuries. The tendon connects the large calf muscles to the heel bone and provides the power in the push off phase of the gait cycle in walking and running. It is a form of tendinopathy. and not thought to be an inflammatory condition. Pathologically the main finding is degenerated tissue with a loss of normal fibre. The condition can be either at the attachment point to the heel or in the midportion of the tendon (typically around 4cm above the heel).

Healing is often slow, due to poor blood supply. Chronic Achilles tendonitis may follow on from acute tendonitis if it goes untreated or is not allowed sufficient rest. This is a difficult condition to treat, particularly in athletes and elderly people who have a slower healing process.

Achilles Tendinitis Inflamed Tendon

Symptoms

Usually there is:-

• gradual onset of Achilles sited pain over weeks, or months and constant pain with all exercise.Pain occurs in the tendon when walking especially up hill or up stairs and pain and stiffness are patent in the Achilles tendon especially in the morning or after rest.

• a nodule or lump in the Achilles tendon, 2-4cm above the heel.

• tenderness on palpation.

• swelling and thickening over the Achilles tendon.

• redness over overlying tendon skin.

• creaking feeling when fingers is pressed into the tendon with movement of the ankle.

Differential diagnoses • Ankle Sprain

• Achilles Tendon Rupture • Ankle Fracture

• Calcaneofibular and talofibular ligament Landry • Retrocaecal Bursitis • Harlands deformity

Case History

A fit, forty two year old male hill walker presented with pain in the left heel which he related to wearing too tight mountaineering boots and a 24 mile mountaineering trip.

He was very tender over the Achilles tendon about 5 cm above the low edge of the calcaneum. He had chosen to take aspirin tablets and rub in anti-inflammatory skin ointment and continue despite pain with his hill climbing.

Six weeks after injury he found he could not move the ankle in the mornings because of stiffness and severe pain. The stiffness diminished with exercising but a nagging chronic pain persisted and was interfering with sleep. Enforced rest from exercise over the next few months, with ingestion of anti-inflammatory medication brought little relief. He endeavoured to return to exercise and within a short time represented with a lesser swelling of the right Achilles tendon and pain. He had developed a bilateral Para tendinitis involving the Achilles tendon, the sheath and surrounding tissues. page | 07

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ARTIClE Despite physiotherapy, heat therapy and a series of medications, the condition continued to immobilise him with pain, even interfering with swimming, for many months. Ultimately over a period of 2 years the swelling, which at its most severe involved the lower 12 inches of the left leg, gradually became less painful and chronic swelling settled although he was left with some thickening of the tendon sheath. He returned to hill walking using a built up heel boot insertion and low rise heel backs.

Twenty years later unmindful of the previous heel problem, while indulging in ski touring the boots again rekindled the former condition. The left heel was severely swollen between 4-6 inches of the lower heel with a 2cm nodule apparent in the tendon and clicking feeling was elicited when he moved the ankle. Once again immobilised, he sought physiotherapy and was given simple tendon massage, and ultrasound stimulation. Anti-inflammatory gels and oral medication did not improve the condition and he had to resort to enforced rest with the prospect of many more months of enforced immobility. Seen by a podiatrist he was introduced to a series of eccentric ankle stretching exercises over time and six months later was sufficiently improved to indulge again in his sport.

Podiatrist treatment and advice

This condition can be appropriately treated buy the podiatrist. In the acute phase the important factor is to exclude tendon rupture but history and clinical presentation confirm the diagnosis of tendinosis. A rehabilitative programme will often save the athlete from long waits to consult an NHS GP, physiotherapist or orthopaedic specialist and return the patient more quickly to active sport.

Traditional treatments of icing, stretching, and use of a heel lift insertion during the acute phase are conventional and progressive eccentric loading exercises will often allow the athlete to return to sport

Stretching Exercises for Achilles Tendinitis

Active stretching This type of stretching will be the safest to use in the early stages of rehabilitation. It involves pulling the foot and toes up gently to stretch the muscles at the back of the leg Hold for 5 seconds, repeat 5 times. Stretch if pain allows throughout the day.

Gastrocnemius muscle stretch

Instruction to patient:• If pain allows, this stretch should be used at least 3 times a day.

• Stand in a wide stance position with the leg to be stretched at the back.

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• Keep the back heel firmly on the ground as you lean forwards and push against the wall in front Hold for 15-20 seconds and repeat three times.

• Gradually hold the stretch for longer (up to 45 seconds).

Soleus muscle stretch

• Used in addition to the above stretch

• This takes the Gastrocnemius muscle) out of the stretch but will stretch the Soleus muscle lower down in the back of the leg. It is important to bend the stretching leg at the knee hold for 15-20 seconds and repeat 3 times. Do this at least 3 times a day.

These strengthening exercises use gravity, and encourage the muscle to lengthe.

Chronic Achilles Tendinitis

The programme of treatment should be based around eccentric exercises for the tendon. A paper in an American Journal. supports the use. 2

It prospectively studied the effect of heavy-load eccentric calf muscle training in 15 recreational athletes (12 men and 3 women; mean age, 44.3 +/-7.0 years) who had the diagnosis of chronic Achilles tendinosis with a long duration of symptoms despite conventional nonsurgical treatment.

Calf muscle strength and the amount of pain during activity (recorded on a visual analogue scale) were measured before onset of training and after 12 weeks of eccentric training. At week 0, all patients had Achilles tendon pain not allowing running activity, and there was significantly lower eccentric and concentric calf muscle strength on the injured compared with the non-injured side. After the 12week training period, all 15 patients were back at their preinjury levels with full running activity. There was a significant decrease in pain during activity, and the calf muscle strength on the injured side had increased significantly and did not differ significantly from that of the non-injured side. A comparison group of 15 recreational athletes with the same diagnosis and a long duration of symptoms had been treated conventionally, i.e., rest, nonsteroidal anti-inflammatory drugs, changes of shoes or orthoses, physical therapy, and in all cases also with ordinary training programs. In no case was the conventional treatment successful. The treatment model with heavy-load eccentric calf muscle training has a very good short-term effect on athletes in their early forties.

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ARTIClE Concentric exercise is done by toe raises with progressive weights.

Warm up exercise consist of moderately vigorous exercise such as on the exercise bike.

Stretching Exercise and Icing Standard stretches are performed by leaning against a wall with the heel on the floor.

Eccentric Exercise 3 sets of 10 repetitions of eccentric exercise on the ankle with the forefoot on a step are done. Severity of initial symptoms dictates the starting resistance of the program.

Increasing speed of movement or increasing resistance allows for progression: • Weight is supported on both feet initially during the exercise • Increase the shift of weight to the involved side • Weight is supported on the involved side only • Increase the speed of dropping the heel • Add weight to the shoulders eg a loaded rucksack and repeat

The heel is dropped below the level of the step with use of an ice pack during and immediately after this exercise to control pain and swelling.

Week 1

Day 1-3

2

1-3

3

1-3

4

1-3

5

1-3

6

1-3 7

Exercise Slow drop, bilateral weight support Moderate speed, bilateral support Fast drop, bilateral support

Slow increase in weight on symptomatic leg Moderate increased weight Fast, increased weight Slow weight supported on symptomatic leg moderate weight on one leg Fast speed

Slow add 10% body weight Moderate, same weight fast speed

Activity No Sports

limited sport vigorous activity

slow, increase by 5-10# Pain during exertion moderate speed fast speed slow, increase by 5-10 moderate speed fast speed

References

1 Hooper M Podiatry Review 2012. 69.3 29

2 H, Pietila T, Jonsson P, Lorentzon R Heavy-load eccentric calf muscle training for the treatment of chronic Achilles tendinosis.Am J Sports Med 1998 May;26(3):360-366 3 Alfredson H, Pietila T, Jonsson P, Lorentzon R Effects of Low-Level Laser Therapy and Eccentric Exercises in the Treatment of Recreational Athletes With Chronic Achilles Tendinopathy Am J Sports Med; online Feb 13, 2008,

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Volunteering in Hong Kong

Cosyfeet Podiatry Award winner Alia Sohail was awarded £500 to assist with her travel and living expenses during her voluntary work in Hong Kong. Here she reports on her experiences

I am presently studying a 4-year Podiatry BSc (Hons) course at Glasgow Caledonian. At the end of our 3rd year we are given the opportunity to volunteer in either India or Hong Kong. Due to my interest in Chinese culture I chose to go to Hong Kong.

I hoped that by volunteering I would become a broader thinking clinician, capable of utilising the clinical skills and academic knowledge I had gained in my three years of undergraduate study, and applying it to patients to help deliver excellent foot care. I also wanted to learn about what foot care is available in Asian countries, and to learn about the Chinese culture, which I have always been fascinated by.

Diabetes Mellitus is continually increasing globally according to the World Health Organisation (WHO, 2011).

Hong Kong is no exception and I felt that by volunteering, I could educate patients there about their diabetes control and about how to lower their risk of ulcer formation.

Volunteering in Hong Kong would also give me the opportunity to treat patients with certain conditions that I would not see here in the UK, such as Leprosy and Chinese foot binding, therefore increasing my podiatric knowledge.

I arrived in Hong Kong in May and instantly felt the hot, humid weather hit me as I stepped off the plane. Not being able to speak the native languages Mandarin or Cantonese, I had to rely on speaking clearly in English. This was the moment I realised how difficult it could be to communicate with patients in the hospitals.

Museum at Kwong Wah hospital

Western Cluster, as well as the first ever community centre in Hong Kong, which provides foot care for locals.

Hong Kong is a beautiful city which has a wonderful transport system. You can use the Metro, Trams, Buses, or ferries travelling from one end of the island to the other for as little as 40p. This made travelling from one clinic to another relatively easy.

It was really exciting trying to find my way to the Kwong Wah Hospital relying on directions from the hospital’s podiatrist, Peter Chan, my tourist map, and lots of help

Fortunately for me, the podiatrists I was to work alongside had studied either in the UK or in Australia, and could speak good English as well as Mandarin and Cantonese. The Chinese government, having recognised a need for better foot health in China, had sponsored their studies abroad on condition that they work for the state for a minimum of 5 years after qualifying.

Jane Lee is the Hong Kong podiatrist who would take me under her wing for the next couple of weeks. Jane, who is British, originally trained in London but now lives permanently in Hong Kong. She arranged for me to stay in nurse’s accommodation, took me out for dim sum (which I’d never had before) and generally helped me to settle in.

Jane is the Cluster Coordinator for Western Kowloon. She arranged for me to volunteer in four hospitals within the

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The old hospital building

39537 Chiropody Jan 2013 19/12/2012 10:59 Page 13

ARTIClE

Ulcerative lesions present on both knees as a result of acupuncture

from locals, some of whom spoke broken English. Once there I quickly realised how busy the Podiatry clinic was as two rooms were occupied and a patient was also being treated in the corridor, which also doubled up as a treatment area. The Podiatry team consisted of Peter Chan and two other members of staff, assisted by two health care assistants. The health care assistants were equivalent to the podiatry assistants that we have in the UK.

Peter Chan, who had studied at Salford, gave me a tour of the hospital and also showed me the hospital’s museum. This fascinating area is part of what was once the original hospital on the site, where patients were treated according to traditional Chinese medicine. It is now a peaceful sanctuary where incense is burned and visitors are not permitted to take pictures.

I saw a wide range of patients at Kwong Wah including those with diabetic ulceration and venous ulceration, as well as those with biomechanics complaints. The clinic was set up as it would be in the UK and there were foot care leaflets available for patients. A particular case I found interesting was a man in his sixties with Type 2 diabetes who attended the clinic with burn marks on both knees.

After questioning the patient I found that he had sought the help of a traditional Chinese medical practitioner.

(Traditional Chinese medicine is still very prevalent in Chinese culture, and many people have more faith in it than in Western medicine.) The patient was in denial about his diabetes and felt that the practitioner could ‘cure’ him with acupuncture. Unfortunately, in this case the acupuncture had led to tissue breakdown, resulting in ulceration. The patient’s glycaemic control was not at

7mmol as recommended by the SIGN (2010) and NICE (2004) guidelines and therefore he was at risk of neuropathy, which was already evident in the lower limbs.

It was explained to the patient that his diabetes would never be cured, however it could be controlled, which would prevent further complications arising. I told him to check his feet daily for any wounds and to continue his medication. It can be difficult to persuade those who have faith in traditional Chinese medicine to accept that Western medicine can be helpful to them, especially, as in this case, the patient did not want to accept his diagnosis. It was interesting for me to see the psychosocial effects that diabetes can have on patients who cannot accept their condition.

Venous ulceration on left leg

Ulcerative lesion present lateral aspect right leg

Venous ulcer present lateral malleolus and lower leg

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39537 Chiropody Jan 2013 19/12/2012 11:00 Page 14

ARTIClE Another patient I saw that day was a man in his fifties.

He was a cook and would stand for 1213 hours every day.

He felt he could not cut down his hours otherwise his business would suffer as he was the head chef of two restaurants. He had been attending the clinic for years due to the venous ulceration on both legs healing and then re-ulcerating.

Whilst at the clinic the patient was strapped to a 3M compression machine. This machine worked by contracting and relaxing specific parts of the lower limb to encourage venous return. Peter Chan does not know how effective this treatment is yet, however there has been an improvement in the presenting ulcers.

Compression apparatus 3M

This gentleman Patient during treatment presented with severe venous ulceration as a result of Peripheral Vascular disease. He was not diabetic, however he was obese and had been tested for diabetes.

The patient was compliant in that he would attend the clinic for treatment and re apply the compressional bandaging at home. However, he would not cut down his work at the restaurants he owned as he provided for his family. His son attended clinic that day and when I spoke to him he said that he is beginning to take more responsibility at the restaurant so his father can rest a little. The patient’s treatment had to be tailored to his personal circumstance. Whilst at the clinic the wounds would be debrided and dressed and in between appointments his son would redress his bandages at home. However, the patient’s ulceration was chronic and bandaging alone was not effective.

Presentation of neuropathic ulcer on styloid process

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The next hospital I visited was the Princess Margaret Hospital near Mei Foo, which was only a 30-minute journey from the nurses’ accommodation I was staying in.

Eric Kwan was the only podiatrist based at this hospital, along with a health care assistant. The clinic was busy and I noticed the patients were similar to those at Kwong Wah hospital, where the patients treated were mainly high risk.

Eric was kind enough to give me a tour of the hospital, and I saw the infectious disease building which was built specifically for the SARS break out in 2003.Within the hospital was also one of the best renal clinics in Hong Kong.

Whilst there I saw a man in his late forties with Type 2 diabetes who presented with a neuropathic ulcer on his styloid process due to the equino varus position of his foot.

Eric explained that treatment for this patient would consist of debridement of the wound and application of dressings, but there was no mention of off-loading the foot. Eric said in Hong Kong the patient has to pay for any kind of pressure relieving footwear and it is very expensive. The government are reluctant to pay for it even though the patient cannot afford it. The patient therefore has no choice to but to keep walking on his wound or become wheel chair bound. The patient suffered from neuropathy so chose the option of continuing to walk on the ulcer. I felt a bit upset that there would be no help for this gentleman in terms of pressure relief as Reiber et al (2002) believe that pressure relief is vital for wound healing.

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ARTIClE The Caritas Medical Centre is the hospital where Jane Lee is based, and she is also the cluster coordinator for West Kowloon. Along with Jane there are two other podiatrists and two health care assistants. I found this clinic very exciting as patients could walk through the door with anything from diabetes to leprosy.

Eric using the beaver bay to do a partial nail avulsion

Another patient came into the clinic complaining of pain from his big toe. I could see he had an ingrown toenail even with his sandals on.

Eric explained there would be no time for anaesthetic or phenol as the clinics are very busy and it would take time to prepare for nail surgery. A beaver bay is used to cut a section of the nail instead. The wound is dressed and would be redressed in the community by a health care assistant under the podiatrist’s instruction. It amazed me how the patient could keep still while in so much pain. This demonstrates a clear difference in UK practice compared to Hong Kong, as in the UK nail surgery would be carried out with anaesthesia and on most occasions phenol would be used to destroy the nail matrix. Total nail avulsions are very rarely carried out in Hong Kong. In most cases only the spike of the nail is removed.

The next day I was to volunteer in the East Kowloon Health Care clinic. I was getting more confident with my map skills in trying to find the various clinics. The locals were very friendly and would give good directions despite the language barrier.

The East Kowloon Health centre is the very first community clinic provided as a government service. Carol Tong is the podiatrist who works there three days a week with a health care assistant. The other two days a week she works at the Caritas Medical Centre, which is an acute hospital. The clinic at Kowloon is similar to those in the UK regarding its clinical set up and computer system. The computer system is similar to SCI-DC in Scotland where all the health care professionals can add and see patient notes. This clinic is a routine one for nails, callous and corns, but Carol also treats wounds there, and if necessary refers onward to the hospital.

This patient was an elderly man who attended the clinic regularly. When I saw his foot I thought it was Charcot, but after questioning the patient I soon realised his foot was a result of leprosy. Leprosy is caused by the bacteria called Mycobacterium leprae (WHO, 2012). This condition is treatable but if left untreated can have an impact on the central nervous system and ultimately cause neuropathy, skin damage and affect the eyes (WHO, 2012). The patient had been diagnosed and treated, but in spite of this he had unfortunately been left the with irreversible skin damage in certain areas, as well as neuropathy.

The patient was at first unwilling to talk about his condition, but eventually he told me that he used to live in mainland China, and that is where he believes he contracted Leprosy. When he arrived in Hong Kong he lived on an island with other leprosy sufferers, but the government no longer keeps them isolated and so they now live in the community.

This patient had bilateral ulnar deviation at his wrists consistent with leprosy, as well as glove and stocking neuropathy. It was an eye-opener for me to realise the psychosocial implications of treating patients such as this.

I would never have thought that a patient who once suffered from leprosy would feel embarrassed about it and be reluctant to tell me his history.

Normally in the UK podiatrists do not treat sacral sores, however in Hong Kong Podiatrists treat sacral sores and skin grafts. This patient attended clinic due to having a skin graft which had become infected on his thigh.

Neuropathic ulcer present on first metatarsal head

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39537 Chiropody Jan 2013 19/12/2012 11:00 Page 16

ARTIClE Jane believed the patient had a fungal infection as the presentation looked like ring worm. An antifungal cream was therefore prescribed. Fungal infections were common at this time of the year due to the humid weather. Jane informed me that patients have to pay for every single item of medication. The government does not contribute towards medication at all.

Infected skin graft on patient’s thigh

The last hospital I volunteered in was Yan Chai Hospital which was located in Tsuen Wan. This hospital had one podiatrist, Eunice Wong, and a health care assistant.

Eunice specialised in biomechanics and had and an orthotics lab where insoles are manufactured for patients in the West Kowloon cluster. Eunice prefers not to cast, but to adapt off the shelf insoles as it saves time and seems to work for most patients, but would cast if the patients’ insoles were not alleviating their presenting symptoms.

This patient was a gentleman in his late forties suffering from uncontrolled type 2 diabetes. He presented with gangrenous digits and a necrotic ulcer on his knee. Eunice explained the patient had an infection and so was admitted for IV antibiotics. The patient did not really seem to care that he might loose his digits, and it had been explained to him on different occasions how to keep his sugar levels under control, but he was non-compliant.

Necrotic digits

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Ulcer present on the left knee

One of the reasons that I wanted to volunteer in Hong Kong was to promote health education. Once there I realised just how large and diverse the population is. It seems that every ethnic group can be found there, and due to people’s cultures and beliefs, some patients do not want to follow advice given. The first patient, with ulceration on his knees, had felt that his diabetes could be cured with acupuncture, whereas in fact, this treatment had created further problems. It is difficult to change people’s beliefs as Podiatry is still a relatively new discipline in Hong Kong, and people’s beliefs can be very entrenched.

Podiatrists in Hong Kong are understaffed and their caseload is continuing to rise with the increase in Diabetes. Both Eunice and Eric are, however, the only podiatrists at their respective hospitals. The hospitals and the community centre I volunteered in demonstrated that a multi-faceted approach is essential to promote good quality health care to patients. This was achieved with informative posters, leaflets and foot care advice (figures 17 and 18).

39537 Chiropody Jan 2013 19/12/2012 11:00 Page 17

ARTIClE The exposure to certain conditions and witnessing a variety of wound types allowed my clinical thinking to be challenged. I gained a lot of confidence in dealing with patients and it really allowed me to put into practice all the theory from university lectures and clinical sessions.

Through volunteering I have come to appreciate the Chinese culture more, and have gained insight into lower limb conditions, such as leprosy, which I had never seen before. I never did get the opportunity to see a patient with Chinese foot binding though. Jane explained that it is now rare to see Chinese foot binding as it was outlawed in 1948, however a few elderly patients do present with it at Caritas Medical Centre.

Back in the UK I hope to utilise the knowledge I have gained in my 4th year at university. I found going to Hong Kong a really enjoyable experience. The trip has felt like an adventure, and has motivated me to embark on a similar journey again, perhaps elsewhere in Asia.

Finally, I would like to express my thanks to the university tutors at Glasgow Caledonian University who encouraged me to volunteer abroad. I would also like to thank Jane Lee and her Podiatry team for allowing me to volunteer in Hong Kong. Lastly, a big thanks to Cosyfeet for helping me to develop my clinical thinking.

References

National Institute of Clinical Excellence, 2004 Type 2 diabetes: prevention and management of foot problems’, NICE clinical guideline No. 10 [online]. National Collaborating Centre for Primary Care, UK. Available at: http://www.nice.org.uk/nicemedia/live/10934/29241/29241.pdf [Accessed 3rd July 2012]

Reiber, G.E., Smith, D.G., Wallace, C., Sullivan, K., Hayes, S., Vath, C., Macicjeweski, M.I., Yu, O., Heagerty, P.E., & LeMaster, J, 2002, “Effect of therapeutic footwear on foot reulceration in patients with diabetes: A Randomised Control Trial”, JAMA: The journal of the American medical association, Vol. 287, no. 19, pp. 2552-2558.

Scottish Intercollegiate Guidelines Network, 2010, Management of diabetes A national clinical guideline, SIGN clinical guideline no.

116 [online]. Health care improvement Scotland, Edinburgh.

Available at: http://www.sign.ac.uk/pdf/sign116.pdf [Accessed 3rd April 2012] World Health Organization, 2011, Diabetes Fact sheet no. 321 [online]. Media Centre, UK. Available at: http://www.who.int/mediacentre/factsheets/fs312/en/[Accessed 3rd July 2012] World Health Organization, 2012, Leprosy Fact Sheet no. 101 [online]. Media Centre, UK. Available at: http://www.who.int/mediacentre/factsheets/fs101/en/[Accessed 1st September 2012]

Demonstrating health promotion in clinics

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39537 Chiropody Jan 2013 19/12/2012 11:00 Page 18

PRESS RElEASE

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The range is now supplied in high gloss retail friendly re-sealable packaging along with patient friendly usage instructions.

For more information or if you have any questions or require a copy of the new Footmedics product codes please contact 01246 268456, info@talarmade.com or visit www.TalarMade.com

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39537 Chiropody Jan 2013 19/12/2012 11:00 Page 19

CONFERENCE

7th - 8th June 2013 Southport Theatre and Convention Centre The Promenade, Southport, Merseyside PR9 0DZ

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39537 Chiropody Jan 2013 19/12/2012 11:00 Page 20

A.G.M. Booking Form

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39537 Chiropody Jan 2013 19/12/2012 11:00 Page 21

A.G.M. Booking Form

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39537 Chiropody Jan 2013 19/12/2012 11:00 Page 22

CONFERENCE

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39537 Chiropody Jan 2013 19/12/2012 11:00 Page 23

INFORMATION

Nine out of 10 parents unaware of Type 1 diabetes symptoms Nine out of 10 parents do not know the four main symptoms of Type 1 diabetes, according to a new survey commissioned by Diabetes UK.

“Make it your business to know”

This lack of understanding is one of the reasons that a quarter of children with Type 1 diabetes are only diagnosed once they are already seriously ill with diabetic ketoacidosis (DKA), a life threatening condition which needs immediate specialist treatment in hospital.

Get tested straight away

The IPSOS Mori survey of 1,170 parents found that just nine per cent were able to correctly identify that frequently urinating, excessive thirst, extreme tiredness, and unexplained weight loss are all symptoms of the condition.

The 4 Ts

To address this lack of awareness, Diabetes UK launched their campaign to highlight the "4 Ts" of Type 1 diabetes symptoms: Toilet, Thirsty, Tired, and Thinner. The campaign posters use children’s fridge magnets to spell out the 4 Ts, with the aim being to help ensure parents, carers and anyone who works with children knows the symptoms and understands that a child who has any of them urgently needs to visit a doctor immediately and get a test.

The campaign will also raise awareness among healthcare professionals that they need to test for Type 1 diabetes as soon as a child presents with any symptoms. This is because onset can be extremely quick.

“End this appalling situation”

Barbara Young, Chief Executive for Diabetes UK, said, "The symptoms of Type 1 diabetes are so obvious and pronounced that there is no reason why every child with the condition cannot be diagnosed straight away.

"But the stark reality is that a quarter of children with Type 1 diabetes become seriously unwell before being diagnosed and we need to bring this appalling situation to an end. I fear that unless there is a big increase in awareness of symptoms, we will continue to see hundreds of children a year become seriously ill completely needlessly.

"We need to get the message across that if you have a child or if you work with children, you need to make it your business to know the symptoms of Type 1 diabetes. We hope the 4 Ts will make them easier to remember and so help ensure children with the condition get diagnosed at the right time.

"As well as making parents and those who look after and work with children aware of the symptoms, we need to increase understanding that a child who has any of the 4 Ts needs to be tested straight away. This is because onset can be so quick that a delay of a matter of hours can be the difference between being diagnosed at the right time and being diagnosed too late.

Generalist healthcare staff

"This is why we will also be targeting our 4 Ts campaign at generalist staff such as GPs, practice nurses and those working in accident and emergency. While many of these healthcare professionals already do excellent work in correctly identifying the 4 Ts and ensuring children are tested quickly, we hear about some awful cases where parents are told their child has a virus or a urine infection and are told to come back for a test if the symptoms persist.

We need to stop this kind of thing happening and the only way to do this is to make sure every healthcare professional understands that a child with any of the 4 Ts needs to be tested for Type 1 diabetes immediately."

New blood test for Type 2 diabetes?

A blood test could identify those at risk of developing Type 2 diabetes up to ten years in advance, a new study claims.

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39537 Chiropody Jan 2013 19/12/2012 11:00 Page 24

INFORMATION Researchers at the Lund University Diabetes Centre (LUDC) have for the first time established a link between a protein called SFRP4 and the risk of developing Type 2 diabetes. The study, which is published in the journal Cell Metabolism, found that those with above-average levels of the protein in their blood were significantly more likely to develop the condition – irrespective of other risk factors such as age and waist size.

Increased risk of Type 2 diabetes

Levels of SFRP4 in the blood of people without diabetes were measured three times at intervals of three years.

Thirty-seven per cent of those who had higher-thanaverage levels went on to develop Type 2 diabetes. Among those with a lower-than-average level, only nine per cent developed the condition.

SFRP4 is associated with inflammatory processes within the body. Taman Mahdi, main author of the study, said, "The theory has been that low-grade chronic inflammation weakens the beta cells so that they are no longer able to secrete sufficient insulin. There are no doubt multiple reasons for the weakness, but the SFRP4 protein is one of them."

lifestyle improvements

Anders Rosengren of the LUDC said, "If we can point to an increased risk of diabetes in a middle-aged individual of normal weight using a simple blood test, up to ten years before the disease develops, this could provide strong motivation to them to improve their lifestyle to reduce the risk.

Work necessary for a complete understanding

Dr Matthew Hobbs, Head of Research at Diabetes UK, said, "The researchers behind this work have gone further than just identifying a new gene that affects the risk of developing Type 2 diabetes – they have also performed a number of experiments to try to understand the processes that are controlled by it. This is the kind of work that is needed to help us get a complete understanding of what causes Type 2 diabetes and, further down the line, to develop new treatments. The researchers also claim that this work may lead to a new test for Type 2 diabetes. We would welcome any new methods for identifying people at high risk of Type 2 diabetes, but further research is needed to assess how effective this new method is compared to current methods. For now, people can assess their risk using our Diabetes Risk Score test."

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INFORMATION

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39537 Chiropody Jan 2013 19/12/2012 11:00 Page 26

ARTHRITIS RESEARCH UK

Vitamin D deficiency linked with pain levels in Knee Osteoarthritis Lack of vitamin D contributes to the pain endured by people with knee osteoarthritis, according to new research, which suggests that varying levels of the vitamin may explain why black adults feel more pain from the condition than their white counterparts.

A long-term study by researchers from the Universities of Florida and Alabama at Birmingham in the US, published in the journal Arthritis & Rheumatism, sought to identify why there are variations in the amount of pain associated with knee osteoarthritis between different races.

As a starting point, they considered previous studies showing that vitamin D plays an important role in several bodily functions and that deficiencies of the vitamin have been linked with poorer immunity and susceptibility to diseases such as cancer and diabetes.

They also looked at evidence indicating that people with a dark skin pigment absorb less vitamin D from the sun and, as this is the main source of the vitamin for humans, are more likely to have low levels of it as a result.

The team recruited 94 volunteers with symptomatic knee osteoarthritis, 45 of whom were black and 49 of whom were white. The volunteers had an average age of 56 and the group was three-quarters female.

Testing their vitamin D levels, the severity of pain associated with knee OA and their susceptibility to heat and mechanical pain, the researchers concluded that 84 per cent of black participants low vitamin D levels (less than 30ng/mL) compared to 51 per cent of white subjects.

The average vitamin D level for the black participants was 19.9ng/mL, a figure that represents deficiency of the vitamin.

For the white contingent, this figure stood at 28.2 ng/mL, which was low but not deficient. It did not surprise the team to discover, therefore, that black volunteers reported greater knee osteoarthritis pain, with those who had lower vitamin D levels also displaying greater sensitivity during the heat and mechanical (experimental) pain tests.

“Our data demonstrate that differences in experimental pain sensitivity between the two races are mediated at least in part by variations in vitamin D levels,” concluded Toni Glover, research nurse practitioner and doctoral candidate at the University of Florida, who led the study.

“However, further studies are needed to fully understand the link between low vitamin D levels and racial disparities in pain. Although rare, vitamin D toxicity is possible and older adults should consult with their primary care provider regarding supplementation.”

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Arthritis Research UK is currently funding a £500,000 clinical trial to find out of if taking vitamin D can stop the deterioration of the knee joint due to osteoarthritis. Researchers are investigating whether adding vitamin D to the diet through a tablet or supplement prevents the destruction of cartilage, and reduces pain. Results are due next year.

Anti-TNF drugs ‘reduce heart disease risk factors in people with rheumatoid arthritis’.

Anti-tumour necrosis factor (anti-TNF) therapy can help to reduce the risk of cardiovascular disease in patients with rheumatoid arthritis, research has found.

The autoimmune disease is known to be associated with an increased risk of cardiovascular disease, but scientists at the University of Cambridge’s Addenbrooke’s Hospital have found that anti-TNF drugs - which were pioneered by Arthritis Research UK - reduce risk factors associated with poor heart health.

Researchers measured levels of inflammation in the aortas of 17 patients with rheumatoid arthritis, as well as 34 patients with known cardiovascular disease.

Participants were assessed both before commencing treatment with anti-TNFs and after eight weeks on medication.

The researchers found that rheumatoid arthritis patients had high levels of inflammation prior to taking anti-TNF drugs.

However, anti-TNF therapy reduced their aortic inflammation and arterial stiffness, thereby reducing their risk of heart disease.

Publishing their findings in Circulation journal, the study authors concluded: “Anti-TNF therapy reduces aortic inflammation in patients with rheumatoid arthritis, and this effect correlates with the fall in aortic stiffness.”

“These results suggest that rheumatoid arthritis patients exhibit a sub-clinical vasculitis, which provides a mechanism for the increased cardiovascular disease risk seen in rheumatoid arthritis.”

A spokesman for Arthritis Research UK welcomed the findings.

“Anti-TNF therapies have transformed the lives of millions of people with inflammatory arthritis worldwide and, although the number of patients in this study was small, the resulting reduction in risk of cardiovascular disease in rheumatoid arthritis is further evidence of their effectiveness in treating inflammation,” he added.

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ARTHRITIS RESEARCH UK

New research hope for teenagers with arthritis

The charity Arthritis Research UK today launches the world’s first research centre dedicated to understanding how and why arthritis affects teenagers.

Researchers at the £2.5 million Centre, which is a collaboration between UCL, University College Hospital and Great Ormond Street Hospital, aim to understand why rheumatic diseases such as juvenile idiopathic arthritis (JIA) or juvenile systemic lupus erythematosus (JSLE) can be more severe in teenagers and why specific types of arthritis are more likely to occur in this age group. It is hoped that the research carried out at the Arthritis Research UK Centre for Adolescent Rheumatology will lead to better treatments for teenagers and young people with the condition.

There are approximately 15,000 children and young people in the UK living with arthritis. It causes disability, pain, fatigue and irreversible joint damage.

Having arthritis as a teenager makes the physical, psychological and sexual changes teenagers go through more difficult. Side effects of drug treatments can be debilitating and can increase the risk of infections. Steroid use is common and often leads to a change in face and body shape and weight gain.

The condition impacts on all aspects of life, including education, social life and work. Research has shown that people who develop arthritis in childhood and adolescence often face educational difficulties that affect their employability in later life.

Professor David Isenberg, Professor of Rheumatology at University College London, said, “As well as dealing with the challenges of being a teenager, young people with arthritis have to come to terms with having a disease that they may have to live with for the rest of their lives and affects every aspect of their life including appearance, education and job prospects.”

Professor Alan Silman, medical director of Arthritis Research UK, said, “Having arthritis at any time in your life is difficult but having arthritis as a teenager is particularly challenging.”

“At the moment, we know too little about this disease.

Research into how arthritis affects teenagers has been underfunded and we need to do more to develop life-changing treatments. The Arthritis Research UK Centre for Adolescent Rheumatology will help to give hope to young people currently living with arthritis, helping them to grow up free from pain and disability.”

Professor Wedderburn, Head of Rheumatology at the UCL Institute of Child Health and a Consultant at Great Ormond Street Hospital, said, “This is the world’s first centre dedicated to understanding the very specific needs of young people who are growing up with arthritis. By focusing our attention on understanding why and how arthritis is different in adolescence, and what happens as they enter adult life, we

hope to dramatically improve treatment and care for young people living with this painful disease.”

The centre aims to: • Improve our understanding of the long-term effects of arthritis in adolescents and the drugs used to treat it. The inclusion of teenagers in these studies will enable monitoring of young patients taking specific drugs and their disease progression • Improve the number of young people included in clinical trials and increase access to therapeutic drugs. To date, teenagers with arthritis have had limited access to clinical trials, therefore the treatments used to treat young people with arthritis have been based on research carried out on adults and children • Improve care by creating a group of world class experts in adolescent rheumatology • Establish a UK-wide, national network of researchers working with teenagers with arthritis and related conditions to extend the benefits of the centre across the UK and internationally • The centre officially began work on the 1st October 2012 and research is due to start in early 2013 • The centre will have twelve staff from across the three participating institutions The work of the Centre will help young people like Emily, aged 17, from Cardiff. Emily was 15 when she first started to feel pain and swelling in her knee, hands and feet. Three months later she was diagnosed with JIA. Over the past two years, Emily has lived with the pain and fatigue caused by arthritis and the drugs that she has taken to try and manage the condition have caused her debilitating side effects such as sickness and headaches.

Emily said, “I’ve found it really hard over the last two years, especially dealing with medication side effects and joint pain whilst taking my GCSEs. I was too ill to sit most of my exams, I managed to pass my art exam but the pain I felt in my hands nearly stopped me from holding the paint brush.

“Arthritis is unpredictable, sudden flare ups and problems with my medication are really difficult to manage. Most of all, it’s hard to explain to my friends why I can’t do something, despite the fact that I look normal and could do it a week ago.” www.arthritisresearchuk.org Find out more about the Arthritis Research UK Centre for Adolescent Rheumatology 1. Malviva A., Rushton S., Foster H, Ferris C, Hanson H. , Muthamayandi K., and

Deehan D., The relationships between adult juvenile idiopathic arthritis and

employment, Arthritis & Rheumatism Volume 64, Issue 9, pages 3016–3024, September 2012.Cervical Cancer Prevention Week.

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INFORMATION

Cervical Cancer Prevention Week 21-27 January 2013

This January the European Cervical Cancer Association (ECCA) runs Cervical Cancer Prevention Week. Over six days, the organisation wants to draw awareness to cervical cancer by providing information on the development of the disease and prevention.

Every year in the UK, over 2,900 women will be diagnosed with cervical cancer and nearly 1,000 women will die from the disease. After breast cancer, cervical cancer is the second most common cancer in women aged 35 and under.

Cervical cancer is not thought to be hereditary.

Cervical cancer, in 99.7% of cases, is caused by persistent infection with a virus called human papillomavirus (HPV). HPV is a very common virus transmitted through skin to skin contact in the genital area. Around 4 out of 5 people (80%) will be infected with HPV at some point in their lives. However, for the majority of women this will not result in cervical cancer. Cervical cancer is rare while HPV infection is common.

Human papillomavirus (HPV) is an extremely common virus. At some point in our life most of us will catch the virus. The world over, HPV is the most widespread sexually transmitted virus; 80% (four out of five) [1] of the world’s population will contract some type of the virus once. If you catch HPV, in the majority of cases the body’s immune system will clear or get rid

of the virus without the need for further treatment. In fact you may not even know that you had contracted the virus.

There are over one hundred identified strains of HPV; each different type has been assigned a number. HPV infects the skin and mucosa (any moist membranes such as the lining of the mouth and throat, the cervix and the anus). Different strains affect different parts of the body and cause different types of lesions. The majority of HPV types infect skin on external areas of the body including the hands and feet. For example, HPV strains 1 and 2 cause verrucas on the feet [2].

Around forty of the HPV strains affect the genital areas of men and women, including the skin of the penis, vulva (area outside the vagina), and anus, and the linings of the vagina, cervix, and rectum [3]. In women, around 20 of these strains are oncogenic (cancer causing) and associated with the development of cervical cancer, the so called high-risk HPV types [4]. A person infected with high-risk genital HPV will show no symptoms so they may never even know they have it.

The remaining genital HPV types have been designated low-risk as they do not cause cervical cancer but they cause other problems such as genital warts.

Human papillomavirus (HPV)

References

1. Koutsky L (1997) Epidemiology of genital human papillomavirus infection. The American Journal of Medicine, 102 (5A), 3-8.

2. Lacey CJ, Lowndes CM and Shah KV (2006) Chapter 4: Burden and management of non-cancerous HPV-related conditions: HPV-6/11 disease. Vaccine, 24 (3), S3/35-41.

3. Giuliano AR et al. (2008) Epidemiology of human papillomavirus infection in men, cancers other than cervical and benign conditions. Vaccine, 26 (10), K1728.

4. Walboomers JMM et al. (1999) Human papillomavirus is a necessary cause of invasive cancer worldwide. Journal of Pathology, 189 (1), 12–19. http://www.jostrust.org.uk/about-cervical-cancer

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39537 Chiropody Jan 2013 19/12/2012 11:00 Page 29

BRANCH NEWS

West of Scotland Branch First Aid Training Day on 4th November 2012 Christina Millard-Barnes

M Inst.Ch.P.

We convened at 0930 at the Holiday Inn, Stirling for a full day of First Aid at Work Course run by Amega First Aid Training. The two professional trainers were Ian Wilson and Bob Clark.

The whole course was very well run by two men who had, obviously, an enormous amount of experience and knowledge both of running training days and of ‘hands on’ First Aid At Work. In the morning they guided us through all the situations which might occur and need First Aid, in depth. They were very willing to answer questions – indeed they encouraged questions from us – and their answers were simple and clear to understand. Only true professionals can simplify complicated questions and put their answers into laymen’s language.

In the afternoon they conducted an extremely useful ‘hands on’ session and guided us through bandaging and slinging each other with humour and expertise. No-one was made to feel stupid, but all the minor mistakes were kindly corrected.

I, personally, thought the whole day was extremely successful and extremely professionally managed. It was good to have my rusty knowledge revised and updated. We were a typically friendly crowd and a very good day was had by all.

london Branch Meeting 14th November 2012 Flavia Tenywa M Inst.Ch.P.

London Branch held their last branch meeting on 14th November.

Their hands-on workshop with otoform, making interdigital wedges was a huge success.

The next London branch meeting will be their A.G.M. on 16th January 2013.

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39537 Chiropody Jan 2013 19/12/2012 11:00 Page 30

BRANCH NEWS

d

Sheffield is a busy and active branch with 69 members and 18+ regular attendees at our Meetings which are held in a sports and social club in Sheffield on Thursday evenings.

Our meetings are very informal and friendly with lots of networking opportunities for members, our branch is very much member led and lively discussions often ensue!

Our AGM is in January, with meetings spaced through the year in March, May and September. In recent years our September meeting has evolved into an extremely successful study day with speakers, trade stand and lunch provided at an extremely low cost. Last year we donated a hundred pounds each to Bluebell Wood Childrens Hospice and to St Luke’s Hospice in Sheffield from profits made.

At Sheffield branch we try to offer a broad and varied selection of CPD and recent lectures have included care services available to cancer patients and stress and its management. A first aid course was also organized for members.

We currently send information to members by either email or letter however due to the costs involved in mailings we actively encourage members to register their email address with Head Office and with Branch.

For further information on Sheffield branch please contact Penni Hardy (Branch Chair) or Debbie Straw (Branch Secretary), we are always happy to chat!

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39537 Chiropody Jan 2013 19/12/2012 11:00 Page 31

INFORMATION

!!Medical Device Alert!!

The MHRA has issued an alert for all medical devices and medicinal products containing chlorhexidine following numerous reports of anaphylactic reactions after the use of these products.

The MHRA does not hold a comprehensive list of products containing chlorhexidine. However, examples of products which contain chlorhexidine are: antiseptic creams, wipes, cleansers and skin preparations; antiseptic mouthwashes, toothpastes and dental implants; eye drops and contact lens solutions; antiseptic lozenges and throat sprays; urinary catheters; central venous catheters; and antimicrobial dressings.

The following advice has been issued:

• Be aware of the potential for an anaphylactic reaction to chlorhexidine.

• Ensure that known allergies are recorded in patient notes.

• Check the labels and instructions for use to establish if products contain chlorhexidine prior to use on patients with a known allergy.

• If a patient experiences an unexplained reaction, check whether chlorhexidine was used or was impregnated in a medical device that was used.

• Report allergic reactions to products containing chlorhexidine to the MHRA.

• Further guidance on anaphylaxis is available from NICE, the Resuscitation Council and the AAGBI. Dear Editor,

With great sadness I read of the death of Jim Kirkham.

I still remember his entry into the world of Chiropody and the Institute. Bill Airey had just retired and was followed as our accountant by Mr Haigh who soon left the Southport Office. As Chairman of the Executive Committee, I had to discuss with Sidney Shipper and others whether to move our accountants from Southport or appoint Jim Kirkham. We made the right choice! A short time later, at an executive meeting, I had the pleasure of proposing Jim as an Honorary Fellow – an unopposed proposal. I later, as President, did the same for Susan.

When it was decided to move to Southport, I was not happy with it as I thought we could not afford to move our H.Q. out of London. I am so glad I was wrong!

During my seven years as president both Jim and Susan were loyal and good friends. Jim held strong views but never pressed then listened and gave good advice.

It will be some comfort to Susan to know how much they were liked and appreciated.

Rest in Peace Jim God Bless You

Stanley Harrison, Past President page | 29

39537 Chiropody Jan 2013 19/12/2012 11:00 Page 32

AWARENESS NEWS

February is Raynaud’s Awareness Month

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39537 Chiropody Jan 2013 19/12/2012 11:00 Page 33

AWARENESS NEWS

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39537 Chiropody Jan 2013 19/12/2012 11:00 Page 34

BACK TO BASE

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39537 Chiropody Jan 2013 19/12/2012 11:00 Page 35

BACK TO BASE

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39537 Chiropody Jan 2013 19/12/2012 11:00 Page 36

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

TORQUAY, DEVON - RETIREMENT SAlE

Surgery and Domiciliary Established 25 years Income £17k over 3 days Plenty of Scope for Expansion Price £15K Telephone 01803 211616

NORTH EAST DERBYSHIRE PRACTICE

A great opportunity has arisen to buy an established podiatry business of 8 years Located in a beautiful stone built shopping centre in a picturesque town. The clinic has good aspect and ample parking, has 2 treatment rooms reception/waiting area, kitchen with storage.

Podiatry business consists of 3 day clinic work and 1 day dom per week. Great potential for expansion. Sale due to relocation. Price negotiable.

Telephone 07979 150308

EQUIPMENT/SUPPlIES FOR SAlE Podospray Work Unit for sale incorporating air/water spray and spray drill, three storage drawers and instrument tray with ultra violet light. Cost £3600. Will accept offers around £950.

Can arrange delivery anywhere in the UK. Also Daray examination mobile light. Cost £950. Will accept £350. In new condition.

Sale due to retirement.

Telephone: 07736 814281 for further details.

Classified Section SOUTH lINCOlNSHIRE

Three bedroom detached house with integral surgery for sale - London - 55 Minutes by rail - will consider selling separately. Lovely historic market town in one of the best areas of the country. Lots of benefits including one of the best Grammar schools in the country. Established over 30 years. 20,000 population unopposed.

Sale to include all equipment (if required) - ready to walk in and start! Wonderful opportunity - Further details.

01778 426101 - Sale due to retirement

West Midlands Area

Business for Sale - Wolverhampton, West Midlands.

Attractive practice, with contents, on-going.

Turnover in excess of £40,000 per annum.

Reasonable offers considered.

Please contact Thomas on the following email: hypernano21@gmail.com.

Please leave your name, telephone number and personal circumstances and we will contact you.

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

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

Business Cards 1 sided; 1,000 - £49 /10,000 - £99 Record Cards/Continuations/Sleeves (8” x 5”) 1,000 - £99 Appointment Cards 2 sided; 10,000 - £99 Small Receipts 2,000 - £48; 4,000 - £68 Flyers 10,000 - £80 + type setting + carriage FOR All YOUR STATIONERY NEEDS

34 | page

39537 Chiropody Jan 2013 19/12/2012 11:00 Page 37

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

PRACTICES FOR SAlE ISLE OF MAN

Busy practice established c30 years. Excellent turnover for current 3 day week as retirement approaches.

Great scope for expansion/development.

Two treatment rooms with shared (dental surgery) waiting area in flexible leasehold property in service precinct (GPs, dentists, optometrist, audiologist) etc., with large free car park. Phased hand-over considered.

Genuine enquiries only 01624 816901 after 7:00pm

Classified Section Sale of Chiropody Practice in Dartmouth, Devon an area of outstanding natural beauty T/O £38,000-£40,000, and state of the art equipment sale negotiable. Total change of life style, with good schools in the local area. Dartmouth lies in the South Hams, in close proximity to the sea, Moors, Exeter, Plymouth, Torquay, Cornwall all within 2 hours journey. please call me on: 01803 839562, or e-mail me to: roger@rogerchilcott.plus.com

Retirement Sale Practice North East Essex

Fully Equipped Clinic Turnover £30,000 based on 3 days Scope for expansion – Transitional help if required Initial enquiries to Richard Sexton and Co., Accountants Tel: 01206 578421 (Ref: JM)

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39537 Chiropody Jan 2013 19/12/2012 11:00 Page 38

DIARY

What’s on in your area?

January 2013

12 Surrey and Berkshire Branch A.G.M. & Meeting 7:30 p.m.

Reading Tel: 0208 660 2822 13 Chester North Wales Staffs and Shropshire Branch A.G.M. and meeting. The Dene Hotel, Hoole Road, Chester Presentation – Treatment of Fungal Nails Tel: 0151 327 6113 13 Western Branch A.G.M. 12:15 p.m. Liverpool Womens Hospital, Blair Bell Education Centre, Crown Street, L8 7SS Tel: 01745 331827 13 Wolverhampton Branch A.G.M. 10:00 a.m. start Please telephone for details Tel: 0121 378 2888 15 North West Branch A.G.M. 7:00 p.m.

St. Joseph’s Parish Club, Harpers Lane, Chorley PR6 0HR Tel: 0161 486 9234 16 Hants and Dorset Branch A.G.M. 7:45 p.m.

Crosfield Hall, Broadwater Road, Romsey, SO51 8GL Tel: ß01202 425568 16 london Branch Meeting and A.G.M. 63-79 Seymour Street W2 2HF

Tel: 0208 586 9542

17 Birmingham and the Shires Branch A.G.M. and meeting 7:30 p.m.

Red Cross Centre, Evesham, Worcs Tel: 01905 454116 17 Sheffield Branch A.G.M. and Meeting 7:30 p.m.

SWD Sports Club, Heeley Bank Road, Sheffield S2 3GL Tel: 01623 452711 20 East Anglia Branch A.G.M. Barrow Village Hall, Nr. Bury St. Edmunds IP29 5AP Tel: 01473 830217 20 Nottingham Branch A.G.M. 10:00 a.m.

Feet & Co, 85 Melton Road, West Bridgford, Nottingham NG2 6EN Tel: 0115 9313492 20 West of Scotland Branch A.G.M. 11:00 a.m.

Express By Holiday Inn, Springkerse Business Park, Stirling FK7 7XH Tel: 0141 632 3283 36 | page

20 leicester and Northants Branch A.G.M. 10:00 a.m.

Lutterworth Cricket Club or Kilsby Village Hall Please phone for details Tel: 01234 851182 26 Southern Area Council A.G.M. at 1:00 p.m.

Victory Services Club, 63-79 Seymour Street London W2 2HF Tel: 01992 589063 27 Essex Branch A.G.M. 2:00 p.m.

Southend University Hospital Education Centre Carlingford Drive, Southend on Sea SS0 0RY Tel: 01702 460890 27 Midland Area Council A.G.M. Tel: 07790 350109 for more information

March 2013

21 Sheffield Branch Meeting 7:30 p.m.

SWD Sports Club, Heeley Bank Road, Sheffield S2 3GL Tel: 01623 452711

June 2013

7th - 9th National Podiatry Conference Southport Theatre and Convention Centre, The Promenade, Southport.

For further details Tel: 01704 546141

39537 Chiropody Jan 2013 19/12/2012 11:00 Page 39

NATIONAl OFFICERS

National Officers Acting President

Mr. R. Sullivan, BSc.(Hons) Podiatry, MSc. Pod Surg,. Pg,Dip., M.Acu,.FSSChP. FIChPA. M.Inst.Ch.P

Acting Chairman Executive Committee Mrs. C. Johnston, M.Inst.Ch.P., BSc.(Hons)

Acting Vice-Chairman Executive Committee Mr. M. J. Holmes, BSc. (Hons) M.Inst.Ch.P.

Chairman Board of Ethics

Mrs. C. Johnston, M.Inst.Ch.P., BSc.(Hons)

Chairman Board of Education

Mr. R. Sullivan, BSc.(Hons) Podiatry, MSc. Pod Surg,. Pg,Dip.,

National Officers Area Council Executive Delegates Branch Secretaries

Branch Secretaries Birmingham

Mrs. J. Cowley

01905 454116

Cheshire North Wales

Mrs. D. Willis

0151 327 6113

Devon & Cornwall

Mrs. M. Reay

01805 603297

East Anglia

Mrs. Z. Sharman

01473 830217

Essex

Mrs. B. Wright

01702460890

Hants and Dorset

Mrs. J. Doble

01202 425568

Leeds/Bradford

Mr. N. Hodge

01924 475338

Leicester & Northants

Mrs. S. J. Foster

01234 851182

London

Mrs. F. Tenywa

0208 586 9542

North East

Mrs. E. Barwick

0191 490 1234

North of Scotland

Mrs. S. Gray

01382 532247

North West

Mr. B. Massey

0161 486 9234

Midland Area Council

Northern Ireland Central

Mrs. P. McDonnell

028 9062 7414

North West Area Council

Nottingham

Mrs. V. Dunsworth

0115 931 3492

Sheffield

Mrs. D. Straw

01623 452711

South Wales & Monmouth

Mrs. J. Nute

02920 331 927

Surrey and Berkshire

Mrs. M. Macdonald

0208 660 2822

Sussex

Mrs. V. Probert-Broster

01273 890570

Teesside

Mr. J. Olivier

01287 639042

Western

Mrs. L. Pearson

01745 331827

West Middlesex

Mrs. H. Tyrrell

0208 903 6544

West of Scotland

Mr. S. Gourlay

0141 632 3283

Wolverhampton

Mr. D. Collett

0121 378 2888

M.Acu,.FSSChP. FIChPA. M.Inst.Ch.P

Acting Vice-Chairman Board of Education Miss Joanne Casey, M.InstCh.P., BSc.

Honorary Treasurer Mrs. J. Drane, M.Inst.Ch.P.

Standing Orders Committee

Mr. M. Hogarth, M.Inst.Ch.P. Mrs L. Pearson, M.Inst.Ch.P., BSc., Pod Med

Secretary

Area Council Executive Delegates Miss A. J. Burnett-Hurst

Mrs. V. Dunsworth, M.Inst.Ch.P., DChM

Mrs. M. Allison, M.Inst.Ch.P.

Republic of Ireland Area Council Mrs. J. Casey, M.Inst.Ch.P. BSc.

Scottish Area Council Mr. A. Reid, M.Inst.Ch.P

Southern Area Council

Mr. D. Crew, OStJ, F.Inst.Ch.P., DChM, CertEd

Yorkshire Area Council Mrs. J. Dillon, M.Inst.Ch.P.

39537 Chiropody Jan 2013 19/12/2012 11:00 Page 40

A step forward in managing INGROWING TOENAILS GENTLY CUSHIONS AND PROTECTS

INGROWING TOENAILS CAN BE MANAGED IN THE EARLY STAGES BY OFFSETTING PRESSURE AWAY FROM THE AFFECTED AREA. The design of the Carnation Ingrowing Toenail Protector is based on the measurements and 3D images of the big toes of a representative sample of the UK population. These have been used to mould a specially formulated high performance gel which creates a secondary layer of protection around the toe while leaving the painful area clear from any additional pressure which would exacerbate the condition.

BENEFITS INCLUDE: CUSHIONS AND PROTECTS INSTANT RELIEF WASHABLE AND REUSABLE EXTRA SOFT GEL ONE SIZE FITS ALL

IN A USER TRIAL: 84% said the product gently cushioned and protected the nail 66% of users stated they had instant relief from the product “An innovative and useful product - I wish this had been invented years ago. I’ve noticed a substantial improvement during use as shoes are no longer rubbing”.

PODIATRIST DESIGNED

“The product was fantastic, it prevented my shoes from pressing on the delicate area of my ingrowing toenail and reduced discomfort”.

Reference Cliniresearch on behalf of Cuxson Gerrard & Co Ltd amongst 68 patients with ingrowing toenails.

Cuxson Gerrard & Co. Ltd., 125 Broadwell Road, Oldbury, West Midlands B69 4BF

www.cuxsongerrard.com