Podiatry Review March/April 2010

March/April 2010 Vol. 67 No. 2 ISSN 1756-3291

Management of Elderly Foot Disorders Case Study Malignant Melanoma 2010 A.G.M. Information

The Institute of Chiropodists and Podiatrists Abductor digiti minimi

Cuboid

Metatarsals

Phalanges

2010 Annual General Meeting Nominations for National Office President - One Nomination

Chairman, Executive Committee - One Nomination

Mrs. Heather Bailey East Anglia Branch

Vice-Chairman, Executive Committee One Nominations

Mr. Robert Beattie North of Scotland Branch

Chairman, Board of Ethics - Two Nomination Mrs. Colette Johnston Northern Ireland Branch

Mr. David Crew Surrey & Berkshire Branch

Chairman, Board of Education One Nomination

Mr. Charles Goldman London Branch

Vice-Chairman, Board of Education - Two Nomination

Mr. William Liggins Birmingham Branch

Mr. John Patterson Cheshire, N. Wales Branch

Mr. Martin Harvey Birmingham Branch

Honorary Treasurer - Two Nominations Mr. Stephen Gardiner Nottingham Branch

Mr. Roger Henry Devon and Cornwall Branch

Standing Orders Committee - Four Nominations. Two persons to be elected Mrs. Linda Pearson Western Branch

Mrs. Rita Duck Surrey and Berkshire Branch

Mr. David Elliott Nottingham Branch

Mr. Martin Hogarth Leeds Branch

Contacts Editor: Mr. R. H. S. Henry Email: editor@iocp.org.uk Editorial Assistant: Mrs. B. K. Willey Email: bernie@iocp.org.uk Published by: The Institute of Chiropodists and Podiatrists 27 Wright Street, Southport, Merseyside PR9 0TL Telephone: 01704 546141 or 08700 110305 Fax: 01704 500477 Email: secretary@iocp.org.uk Web: www.iocp.org.uk

Contents 1. Editorial 2. Diabetes News 3. HPC Information 4. Obituary 6. Article - Management of Elderly Foot Disorders 10. Article - High Heeled Footwear 13. Case Study - Malignant Melanoma 15. Personal Profile

Dear Reader

March/April 2010

How did you get on in the snow and ice? My wife and I have a friend who is a nurse. She slipped, fell and broke a bone in her wrist. She was telling us that the hospital authorities did not grit the nurses’ car park which was a sheet of ice. The result was that five nurses slipped and fell and injured themselves just when they were so short of staff at the hospital.

commentary article entitled “High Heeled Footwear: Uses, Abuses and Reality Invited Commentary”. The full article will appear in later issue(s).

Ivan Bristow and Katharine Ackland of Southampton University have contributed an article on ‘Acral Lentiginous Melanoma of the Foot and Ankle.’ A case series and review of the literature for our Continuing Professional Development centre fold pull out.

Our 2010 A.G.M. and CPD lectures, Dinner Dance and Trade Show is getting closer. It will be held at Eastwood Hall Nottingham on the 7th-9th May 2010. Even if you can only spare a day it would be worth your while attending lectures or workshops as well as the Trade Show (Booking Form on page 21).

What is there of interest and note in this issue of Podiatry Review?

To tie in with this, Valerie Dannourah M.Inst.Ch.P has contributed a case study of a lady with Malignant Melanoma on her right lower leg.

Sarah A. Curran, PhD BSc(Hons) Senior Lecturer, Wales Centre for Podiatric Studies, University of Wales Institute, Cardiff has contributed a preliminary

Finally we have an article from our old friend, Iain B. McIntosh, BA(Hons) MBChB DGMRCP, entitled Management of Elderly Foot Disorders.

To all our contributors we say a heartfelt thank you.

The Institute appreciates your involvement.

Don’t forget to attend the Barbeque and Medieval evening with games and archery (Medieval fancy dress is optional). It all promises to be educational, informative and fun. I look forward to seeing old friends and new.

Roger Henry, Editor Podiatry Review

17. 2010 A.G.M. Information 19. President’s Page 21. 2010 A.G.M. Booking Form 26. CPD 32. Diary of Events 34. The XXth World Congress on Podiatry 35. Classified Adverts 36. National Officers Annual Subscription: £25.00 Single Copy: £5.00 Including Postage & Packing ISSN 1756-3291

L-R Colette Johnston (Irish Area Executive Delegate), Malcolm Holmes (North West Area Executive Delegate), Ann Yorke (Scottish Area Executive Delegate), Robert Beattie (Chairman Executive Committee), Stephen Willey (Chairman Board of Ethics), Heather Bailey (President), Roger Henry (Honorary Treasurer), Bill Liggins (Chairman Board of Education), David Elliott (Midland Area Council Delegate), David Crew (Vice-Chairman Executive Committee), Mary Newnham (Southern Area Executive Delegate), Judith Kelly (acting Yorkshire Area Executive Delegate) © 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 News

A deafening silence - children and young people with diabetes feel they are being ignored

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housands of children and teenagers with diabetes in the UK are left disenfranchised and at risk of developing serious health complications, because they feel healthcare professionals and schools don’t always listen to their needs and help them control their diabetes. This is the finding of a report by Diabetes UK. We are now calling for improved provision of and access to educational and psychological support for children and young people with diabetes.

Last year 61 per cent of children and young people with diabetes aged up to 17 years said that they rarely felt able to talk about their needs or only able to talk about them “some of the time” when trying to discuss their diabetes care goals with their healthcare team.

For example, many children and young people wanted to have better access to advice on food choices and to psychological support but last year only 16 per cent of children and young people always had access to a dietitian and only 0.5 per cent to a psychologist.

The Diabetes UK’s Survey of people with diabetes and access to healthcare services 2009 report also shows that 56 per cent of children and young people wanted to see better communication between their diabetes care team and schools so that they could receive the necessary joined-up support to manage their diabetes better.

Diabetes UK calls for all young people and children with diabetes to have a care plan developed in collaboration with their school and their healthcare team: at the moment 46 per cent of children and young people do not have a plan in place.

Managing diabetes often more complex for younger people.

The management of diabetes in children and young people can be more complex compared with adults. Adolescence is a notoriously difficult time to achieve good diabetes control as hormonal changes can affect blood glucose levels. Having poor diabetes control makes children and young people more at risk of developing the serious complications of diabetes in the future, including stroke, heart disease, amputation, kidney disease and blindness.

“Coping with a condition like diabetes as a child or a young person is a great challenge and many struggle with their diabetes management,” said Douglas Smallwood, Chief Executive of Diabetes UK. “We must provide children and young people with diabetes with all the necessary help and support so they can manage their condition effectively and avoid developing the serious complications of diabetes in the future.

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“The majority of diabetes management is self-care, so it is crucial that children and young people feel that they are being listened to and can take control of their condition. If they feel their views are not taken into account, we run the risk that they will become disenfranchised and become less likely to attend their healthcare appointments as adults.”

Dr. Deborah Christie, Consultant Clinical Psychologist at University College London Hospital (UCLH) said “We must understand that managing diabetes within a full and active life is challenging for children, young people and families. This is why it is vital to offer them the type of support and advice they need. Psychological support for instance is an area where more provision is urgently needed.”

In the UK there are 25,000 children and young people under the age of 25 with Type 1 diabetes and it is estimated that as many as 1,400 children may have Type 2 diabetes.

1 in 5 hospital patients in the UK has diabetes The first ever diabetes audit of 200 NHS hospitals has found that 20 per cent of patients on hospital wards have diabetes – twice the proportion previously estimated. In addition, the audit, which is due to be published later this year, will also show that people with diabetes stay in hospital longer than other patients.

Access to specialist advice The Government’s diabetes tsar Dr. Rowan Hillson, who is leading the audit, wants to see all patients admitted to hospital with diabetes be given access to specialist advice and believes that having diabetes specialist nurses on wards can reduce re-admissions of patients with diabetes, as well as drug errors, and length of stay.

“When they are in hospital it is crucial that people with diabetes have access to the right advice and support from healthcare professionals who have a specialist knowledge of the condition to ensure the best possible health outcomes,” said Cathy Moulton, Care Advisor at Diabetes UK. “In addition, as more and more people are diagnosed with Type 2 diabetes and put more pressure on NHS spending, we must do all we can to raise awareness of Type 2 diabetes and its risk factors in the general public by encouraging people to make lifestyle changes enabling them to reduce the risk of developing the condition.”

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News News News

Anna van der Gaag lands role as Public Appointments Ambassador

nna van der Gaag has landed a role as a Public Appointments Ambassador in a new Government programme led by the Government Equalities Office and Cabinet Office to encourage more people to apply for public appointments. The Public Appointments Ambassadors programme was launched at a high profile event in Whitehall on 14th January by Government Equalities Office Minister of State Maria Eagle MP.

Anna van der Gaag said: "it’s an honour to be selected as an ambassador for this campaign. I have found being a public appointee a hugely rewarding experience.

Public Bodies make decisions that affect our day to day lives, but too few women, people from ethnic minorities and disabled people sit on boards like the Arts Council, the governing bodies of local hospitals and the Competition Commission.

Two new public appointment mentoring schemes were also launched at the event. To find out more about public appointments, current vacancies and how to apply for new mentoring programmes, visit http://www.direct.gov.uk/publicappointments

Anna is a speech and language therapist by background.

She was the first of only two women to be appointed Chair of a health regulator under the new reforms to regulation brought in by the government in 2008/9. She is proud of the fact that the new Council at the Health Professions Council has a 50 50 split of women and men and has a strong equality and diversity culture throughout the organisation.

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n Wednesday 3rd February 2010, I went to a Health Professions listening event.

News News News Council The HPC held four meetings, two in Exeter at the Thistle Hotel and two meetings at Truro at the Alverton Manor Hotel. They were quite well attended, approximately 120 people at the listening event that I attended. Those present on behalf of the HPC were Marc Seale (Chief Executive) Michael Guthrie (Policy and Standards Officer), Kelly Johnson (Director of Fitness to Practice) and Jonathan Jones (Publications Manager). Marc Seale gave a brief background and described the work of the HPC. He outlined developments in regulation and the context in which they work, pointing out that the regulation department had up to 19,000 telephone calls per month! The HPC also had 78,000 visits to its web site www.hpc-uk .org each month.

Marc also pointed out that in 2008-09 allegations regarding Fitness to Practise were received concerning 0.26% of all registrants and only 66 people were struck off (0.03% of all registrants ) He said that there were far fewer cases involving HPC members, 1.8 per 1,000 registrants, than the General Dental Council, 21 per 1,000 registrants, or the General Medical Council, 24 per 1,000 registrants (Source CHPE annual report 2007).

I hope my experience will inspire others from different backgrounds with skills to bring to public boards to come forward.”

Anna joins over 180 ambassadors, who are current public appointees from across the UK, including playwright and Deputy Chair of the British Museum, Bonnie Greer, and Peter Cooke, Vice-Chair of the Independent Living Fund.

As an ambassador Anna will show why it’s vital to have people with a wide range of skills and experience involved in the important decisions public boards make, playing a key role in highlighting the benefits of serving on a board and encouraging more people from under - represented groups to apply.

Following this Jonathan Jones spoke regarding Continuous Professional Development and the HPC audit.

Two years ago, 5% of all Chiropodists/Podiatrists were audited. This year it will be 2.5%. If you are called for audit this year, you must show a list of CPD activities (for the last 2 years). You must produce a summary in no more than 500 words of recent work (for the last 2 years) and a statement of how standards have been met (no more than 1,500 words with supporting evidence). 325 (2.5%) of all Chiropodists Podiatrists will be called for audit.

The registrant must:1) Maintain a continuous up to date and accurate record of their CPD activities.

2) Demonstrate that their CPD activities are a mixture of learning activities relevant to current or future practice.

3) Seek to ensure that their CPD has contributed to the quality of their practice and service delivery.

4) Seek to ensure that their CPD benefits the service user.

5) Upon request present a written profile (which must be their own work and supported by evidence) explaining how they have met the standards for CPD. We then went onto questions asked by Chiropodists Podiatrists/Physiotherapists, Occupational therapists and Radiographers. The meeting was very interesting and lasted from 5.45pm until after 8.00pm.

Roger Henry, Editor, Podiatry Review

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OBITUARY

John Francis Webster

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16.04.31 - 16.12.09

ohn Francis Webster died, aged 78, on 16 December 2009 and will be sadly missed by many colleagues in our profession.

He was an Honorary Fellow of the Institute and a Life Member of Nottingham Branch and when he joined the Branch, some thirty-five years ago, he was in charge of the second largest NHS Chiropody Service in England and Wales, a position that he held for twenty-seven years until retirement.

John viewed that a successful manager should know, and understand, the differing jobs of employees and he was well qualified to hold such a post because he had been in private practice for eleven years and had undertaken the practice of local anaesthesia and skin surgery working in various hospitals and with a particular interest in diabetology.

He advanced and became a very well respected figure within the chiropodial and podiatric world and, for twelve years, held the position of Chair of the Health Service Chiropodists' Association. He was also one of the Department of Health's professional advisors for the appointment of senior chiropody and podiatry management posts in the NHS and, until he retired, was on the Department of Health's list of Professional Witnesses.

As a member of over fifty years of the Institute of Chiropodists & Podiatrists he served and held positions at Branch, Area Council and national level and for nine years, [not held consecutively], he was Chair of the Executive Committee.

John represented the Institute on the Joint Steering Group for Review of the Professions Supplementary to Medicine Act and until the last two and half years before the new Act came into force was the Institute’s Chief Negotiator and also its Professional Advisor.

He also represented the Institute on the Committee of the Association Europeene Des Podologues in Brussels and was on the Education Sub-committee of that organisation and was the Institute's representative to the Industrial Relations Committee of the Society of Chiropodists. He was one of the authors/designers of the Scholl Chiropody Course and later, when that ceased, of the Institute's revised and up-dated course, having written the module on anatomy and was an Institute tutor.

Despite the weight of responsibility John was not a gloomy man and had a good sense of humour and was

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very well-read with eclectic and esoteric interests which made him a lively conversationalist.

He was never lost for words in speech or prose because he had an academic knowledge of vocabulary, syntax and grammatical construction and was precise and very much to the point. He held to high expectations and expected them from others.

In retirement he still engaged in his particular forte of chiro-politics at national level, although in a much reduced role, and continued to, willingly, offer professional and ethical knowledge to those who sought it until the very end.

Among John's professional achievements, and particularly in the field of chiro-politics, he had a prescience of mind coupled with his long experience, understanding and knowledge of his chosen profession and many years ago he voiced to the Branch of the need for unity within the profession, as it faced impending legislation, as the lack of it would divide the profession and we could be, "stuck with the Act", for the next twenty five years or so!

John was a monumental figure in his profession and to us his colleagues and his experience, knowledge, support and friendship will be sadly missed.

John leaves behind his wife Helen, just two weeks after celebrating their Golden Wedding Anniversary, and his children, Simon, Mark, Ruth and Rachel.

Valerie Dunsworth, Nottingham Branch Dear Sir, It is with great sadness that we learnt of the death of John Webster, a great friend and colleague. John worked tirelessly for many years within the Institute for the unregistered Chiropodists. He always gave advice to his fellow members which was much appreciated. It was a shame that John did not see Nottingham branch host A.G.M. 2010 at Eastwood Hall.

Our thoughts go out to Helen and family. It was our privilege to have known John for the past thirty years.

Anne Rockley and Heather McCance, Nottingham Branch

Dear Editor, Before Christmas I had the sad task of ringing Head Office to inform them of the death of John Webster. John was one of the Institute’s greats. He was an academic (and the most knowledgeable and educated man the Institute had in his time) During his fifty years with the organisation including nine as chairman, he always guided us along the right path. Two of his successes were our first web site and our own school (with the help of the rest of the executive committee). He also chaired the merger of the Association of Chiropodists and Podiatrists.

Before training as a Chiropodist John had trained to be a priest at Oxford theological college but decided his future lay in chiropody.

John had many hobbies, Scottish dancing and gardening to name two. After he retired he studied art and painted some lovely paintings.

He also loved to write and has written his autobiography which the family hope to have printed in the future.

Another ‘love’ of his life was the Freemasons. He was a member of six orders and Master of various lodges ten times. This was an incredible amount of work that he carried out with dedication and enthusiasm. They will certainly miss him.

The passion of his life though was his beloved Institute. I first met John at the Midlands Area Council meeting, along with Albert Smith. Their exuberance for the members and their respective branches carried everyone else along with them. I can picture John now at A.G.M.’s standing up, waving his paperwork about and pressing his point forward for any resolutions for Nottingham branch. He always had his facts and figures right and even if you did not vote for the motion, you had to admire the man himself. He was a joy to behold.

We were lucky to have him in our organisation. He was very well respected by other bodies also, including the Society and he knew how to talk to them on our behalf both politically and professionally. During his illness he kept up to date with all things new in the chiropody field and while he was in hospital for the last time, Institute members were still contacting him on his mobile phone, such was his knowledge of the chiropody profession and the constitution and by-laws of our organisation.

Teresa White It was with great sadness that I learned of the death of Teresa White who passed away on September 16th 2009.

Teresa was a regular attendee at all our Irish branch meetings. She had a heart of gold and was always a source of enlightenment and laughter. She was fondly remembered at our last Institute meeting in Dublin on September 26th and will remain in our hearts, thoughts and prayers.

Our condolences are with her family now and in the future. May she rest in peace.

Joan Flannery, Republic of Ireland Branch

How did he manage to fit it all in you may well ask?

Because he had the love and support of a wonderful family.

Our prayers today are with his wife Helen and his children and grandchildren.

God bless you, my friend and colleague Vivienne Jobber, Wolverhampton Branch

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Management of

Elderly Foot Disorders Iain B. McIntosh, BA(Hons) MBChB DGMRCP.

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Former chiropody schools inspector

he ageing process affects the foot just as it does every other part of the body. The effect may be minor or severe enough to disturb walking and may even result in immobility due to inflammation and pain. Loss of muscle mass and tendon tone causes dropping of the longitudinal and transverse arches of the foot resulting in flattening of the foot in elderly people and in some loss of flexibility. The ageing skin is less able to cope with trauma and infection when this occurs in the feet. Diseases associated with old age, such as diabetes and osteoarthritis can have a debilitating effect, on the circulation to these areas and on joints, which can seriously disturb mobility.

There can be knock-on effects on foot shape, skin quality and joint movement. Relatively minor afflictions of toes, nails and foot can lead to major loss of function and are aggravated by the older person’s loss of ability to reach feet to wash and treat them. Prompt podiatry attention can keep many elderly people on their feet and mobile.

The ageing failing heart and the onset of atherosclerotic disease, which affect many of advanced years, results in a defective blood circulation to the periphery of the body which can cause swelling of the feet and lower legs and in cold extremities in old people This causes poor nutrition and impaired removal of waste products from the affected areas and interferes with the healing process in foot disease. The tendency for senior citizens to sit about with limited physical exercise also results in pooling of the blood in the lower limbs, with foot swelling and slower healing of sores and foot disorders.

A life times use of the feet may have brought deformity, callosities, corns and chronic infection to toes and toe spaces all requiring personal attention and hygiene which old people are often unable to provide as they can no longer reach the offending parts because of obesity, generalised arthritis or senile loss of spinal function. The feet may no longer be accessible or visible to the individual, who will be dependent on the nurse or podiatrist for appropriate attention. Regular nail cutting and good foot hygiene is vital to avoid the overgrowth of nails, skin injury and infection. Deformed in- growing nails digging into the skin, distorted toes, infected web spaces and inflamed toe and foot joints can cripple otherwise healthy elderly person. Fortunately most of these conditions may be prevented, alleviated or avoided and prompt and appropriate treatments can maintain mobility.

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Structure of the foot

The foot consists the 14 phalanges, (the toes) the 5 metatarsals (the fore foot) which create an arch across and along the foot, with intervening joints providing the ‘spring ‘ in the step with the 7 tarsals. Tendons form the leg with some fatty padding, a blood supply and overlying skin to complete the anatomy. The toenails are specialized, thickened skin. Their lifetime growth demands regular trimming or overgrowth brings skin damage and infection. Addiction to cigarettes makes vascular disease of the feet in smokers more likely, as does immobility, hypothermia and diabetes mellitus.

Foot disorders Affecting the skin Local

Due to trauma Bacterial infection Fungal infection.

Systemic Arteriosclerotic disease

Affecting joints

Due to joint disorder such as gout osteo and rheumatoid arthritis.

Affecting soft tissues

Due to pressure of nails, shoes and distorted toes and joints on the surrounding skin Corns Callosities,

Affecting nails

Usually due to damage of the nail plate where the nail is growing.

Onychogryphosis-thickening of the nail In-growing toe nail

Affecting bones

Usually due to trauma, but sometimes in elderly people the end result of generalised thinning of the bones (osteoporosis)

Affecting tendons

Often the result of repetitive strain injury, with strains and sprains of the small muscles and tendons of the foot. The most common afflictions of the foot are corns, callosities, and fungal infections and in-growing toenails which can be avoided and when present are within the podiatrist realm.

Corns and callosities

Heloma, These are the end result of constant or repetitive pressure from ill fitting shoes or friction from toes rubbing together. The hard and the soft corn can result in pain, which can interfere with walking. Hard corns are usually found on dry areas of skin whereas the soft corn tends to inhabit moist interdigital clefts. Treatment requires paring of the accumulated hard skin using a scalpel.

Soft corns, these are often more painful, more difficult to access and poor treatment may lead to infection. They have developed an infected centre and hard skin has to be removed then diligent paring of overlying skin will open up a cavity of serous fluid, which when drained can dry out and seal naturally. Occasionally purulence will be found when infection has occurred and the cavity will have to be cleaned with an antiseptic, an antibiotic may be needed and a dressing applied to promote healing. Treated dry and wet corns (when dried out) need protection from further pressure to avoid recurrence. This usually involves chiropody felt or foam pads. These are best cut from rolls and the pad shape individualised to the patient’s requirements, rather than custommade. The latter rarely meet specific needs and if too large or too small, create a new area of pressure Often a small interdigital roll of felt at the base of the toe will suffice to keep the pressure off the affected area and allow healing. The relief from pain and discomfort is often disproportionate to the treatment involved.

A simple procedure in the young, in older people there is a risk of infection if sterile instruments and antiseptic procedures are not used in treatment. Diabetic patients are exposed to serious health risk if cuts and sores of the feet are not treated correctly and hygienically, as poor healing ability may allow the spread of infection with gangrene developing in the foot.

Callosities

These develop over points on the foot where shoes pinch or toes override. A thickening of the skin from constant pressure brings more thickening and roughening of the skin, which creates more pressure and pain. Removal of the offending skin with a scalpel will do much to alleviate the problem. Steps must also be taken to remove the source of the unwanted pressure with advice on comfortable non-pinching footwear.

Nail Disorders

Damage to the nail plate, often the end point of repeated hitting of the large toenail on an obstruction, can result in the overgrowth of the nail which much thickening. The nail is difficult for older people to clip and is often left to elongate and overgrow the toe. In time it may even grow under the toe or sideways into other toes with much pain and deformity. A nail rasp can be used to thin down the offending nail and professional nail cutters can shorten it closer to the end of the toe. Once the thickening has occurred constant foot care is required to keep the overgrowth within toe limits.

Damage to the nails and the surrounding skin and deeper tissue often arises when people inadequately groom nails and this is particularly true with older people struggling to reach their toes. Nails should be cut transversely across the nail just behind the border of the toe. The angles should be rounded, with great care taken to ensure that the sharp edge of a growing nail does not embed in the nail border. When the sharp edge of a nail impacts into the flesh an infection usually arises resulting in formation of a paronychia which can be very painful and resistant to treatment sometimes requiring removal of the nail before the infection can be eradicated. In-growing toenails and onychogryphosis require attention with heavy duty files and cutters – a mechanical exercise which can bring immediate relief of pain. A Black’s file is an essential tool to slip down the side of an ingrowing nail and pare away the nail border. It is essential to reveal and remove the growing point to alleviate the problem.

There may be associated toe infection requiring attention.

Achilles paratendonitis will settle in time, if a raised heel insert is placed in the shoe. Metatarsal felt or foam bars also prove valuable when arthritis is dropping the transverse arch and causing metatarsalgia.

Nail and Web Infections

The hot humid area between the toes – the web – is very attractive to organisms and bacteria and funguses thrive here. The funguses especially can cause chronic infection-onychomycosis resistant to treatment. Poor foot hygiene encourages their growth and failure to dry the webs of the toes after washing helps them to maintain their presence and sometimes to spread over the rest of the foot. 10-15% of the population suffer from these infections. Tinea pedis is the culprit and persistent treatment with antifungal ointments obtainable on doctor prescription can eradicate this pest although treatment is often prolonged. The fungus will spread to the nail and gradually discolour and destroy it. Affected nails often become brown and crumbly and just erode away. A process called onycholysis. It is not uncommon to find very elderly people with all their toe nails infected. Oral medicines are available to treat fungal nail infections but side effects often contraindicate their use in the old. Scrapings from nail and infected skin should be taken for culture of the organism in the laboratory to confirm the diagnosis in resistant infections.

Tineal infections respond to antifungal ointments. Only rarely is an oral preparation required, a consideration in patients with systems failures and on many drugs.

Toe deformities

Hallux valgus –usually the result of wearing high-heeled shoes earlier in life results in the big toe being displaced inwards and overriding the nearby toes with marked deformity. This results in callosities, corns, skin abrasions and ulcers. Appropriate foam padding to take pressure of the deformity and wide fronted shoes may alleviate this problem. This condition is often associated with a bunion. Bunions are swellings of the joint between the great toe and the first metatarsal bone caused by ill fitting shoes. Appropriate shoe wear and foam padding may help to diminish pain and upset to walking but sometimes only surgery can improve symptoms.

Hallux rigidis is a painful stiffness of the joint between the big toe and the first metatarsal bone which often causes disability. It is related to arthritis and may benefit from antiarthritic medication.

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The effects of systemic disease

Gouty, osteo and rheumatoid arthritis can all affect the feet with gout causing very painful swelling of the great toe.

Antiarthritic drugs are helpful in treating these conditions and simple painkillers may alleviate the pain which causes upset to normal walking. Psoriasis sometimes affects the nails causing a pitting of the nail. People with diabetes mellitus are particularly likely to have monilial (Yeast) infections affecting the feet and the toe webs. These infections often respond to treatment with antibiotic creams. Scratching and skin breakdown can make affected areas become sores and ulcers however, which heal very slowly and are a serious problem. Poorly controlled diabetics may develop neuropathic ulcers of toes which are usually painless but are dangerous and need prompt medical attention. The risk of gangrene developing in the diabetic foot means that all diabetics should have regular chiropody care from a skilled and qualified chiropodist. The poor blood supply to the lower limbs and delayed healing in diabetes brings a constant threat to the well-being of the feet and good foot care is very important in those with this disease. Diabetic foot ulcer healing can be improved by treatment with platelet derived growth factor and is now licensed for use in Britain.

Prevention of foot disorders in old people

The use of sensible, well fitting foot wear in youth and middle age will minimise foot problems in later life.

Meticulous foot hygiene is important in older people. Feet and

toe webs especially should be properly dried after washing.

Great care should be taken by individuals and health professionals when cutting toe nails or paring corns. Toe nails should be properly cut and not left with edges which are unseen and sharp to grow into surrounding skin. Friction points from bunions and displaced toes should be protected from trauma with padding. Debris should be removed regularly from nailborders, with regular grooming of nails.

Any sore or infection of the toes or foot skin should be taken seriously and dealt with by a professional. Diabetics should be particularly careful to avoid injury and infection of the feet.

Diabetics should have regular foot care by a health professional with expertise in diabetic care. Diabetics should seek professional help for any infection or injury affecting the feet.

Elderly diabetics should check their feet or have someone check their feet are healthy daily. Diabetics should not use a hot water bottle to warm up the feet. Examination, identification of disorder and disease and application of simple remedies by doctors and nurses can alleviate and cure many of the simple but painful maladies, which affect toes and feet. This neglected field of management demands greater attention by health professionals to eliminate simple foot problems as a cause of gait disturbance and loss of mobility in the old.

The Institute thanks Iain McIntosh for this contribution to Podiatry Review

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High Heeled Footwear:

Uses, Abuses and Reality Invited Commentary

Sarah A. Curran, PhD BSc(Hons) - Senior Lecturer, Wales Centre for Podiatric Studies, University of Wales Institute, Cardiff, Western Avenue, Cardiff, CF5 2YB – (email: scurran@uwic.ac.uk)

Introduction

In Western modern society, footwear is considered as a natural and important part of an individual’s attire, and is often expressed as indicator of class and gender1. Footwear can be viewed as an ‘extension’ of the foot which can influence function, and in certain designs contribute to dysfunction of the lower extremity. Whilst there appears to be a wide range of footwear designs such as trainers, boot and lace-ups, high heeled footwear appear to produce the most controversy and discussion. The purpose of this commentary is to provide a clear overview of high heels and how they contribute to pathology of the lower extremity. It will also consider how ‘reality’ may require compromises in the clinical environment.

High heels are worn across the world and come in various styles that are labelled according to the height and shape of the heel, and include the cone, kitten, prism, spool, stiletto and wedge heel. The influence of fashion and an increase in confidence are often believed to be a dominant factor for wearing high heels. In a recent survey of 1,095 adult British women, 78% admitted to wearing high heels on a daily basis2. On a night out, 63% of women commented that they feel more glamorous. Of the regional variations, 79% of women from Wales felt the most glamorous and sexy on a night out. At work, 48% of women stated that they felt more confident, although a higher percentage was noted in women under the age of 45 years. Although high heels are part of the standard professional uniform for many women, 47% of the respondents stated that their high heels hindered them and complained of discomfort, fatigue and pain following a day’s work. In September, 2009 the Trade Union Congress (TUC) of Britain proposed that risk assessments should be undertaken on women who wear high heels at work. Whilst the proposal can be considered as ‘reasonable’ in terms of potential injury, working days lost and cost to the economy each year, TUC members were branded as ‘killjoys’3.

As well as feeling more confident, glamorous and sexy, the majority of women comment that high heels change their posture which requires an alteration in position of the spine (i.e. increase lumber lordosis/curve). This in turn influences gait style which can be considered as attractive.

In addition, women believe that high heeled footwear gives the appearance of shorter and smaller feet. In an American survey, Frey and colleagues4 noted that 86% of women who wore high heeled footwear wore sizes that were too small for their feet. Whilst the aesthetic appeal of smaller feet may be an obvious one, high heeled footwear is also worn

10

for practical reasons. Since no laces are used to anchor the high heels to the feet, a smaller size is chosen to allow a suction effect of the footwear to the feet. This in turn allows the wearer to walk, albeit uncomfortably.

Dysfunction and Injury

High heeled footwear alters lower extremity and foot function in various ways. In particular, the rear foot is inverted at heel strike which incidentally occurs much earlier due to the increased heel height.5-8 Postural changes are noted at the lumbar spine, hip and knee in response to the ankle which is plantarflexed throughout stance phase6, 911. In particular, high heeled footwear is considered to produce increased muscle activity of rectus femoris12, erector spinae, and tibialis anterior muscles13, 14. Although persistent contraction of the lateral head of the gastrocnemius is noted15, the activity of the vastus lateralis however does not appear to be affected by high heels6.

Pressures and load distribution under the foot are also thought to be altered which can be harmful to the structure of the foot. Studies have shown that forefoot pressures can increase by up to 40%. In particular, higher pressures are noted at the first and central metatarsal heads.5, 12, 16-21 Speksnijder et al.22 used a Pedar (Novel, Munich, Germany, GmbH) in-shoe pressure system to assess forefoot pressures in women wearing high heels and found that the higher the heel, the higher the pressures (correlations of 0.70 for peak pressure and pressure time integrals). These functional alterations within the lower extremity are accompanied by general changes in gait and include a reduction in stride length and velocity, as well as an increased risk of falling.

Whilst heel heights of 6 – 9cm6 are considered to produce pain and discomfort, some individuals will be unable to tolerate heels that are at a lower height (i.e. less than 5cm).

Although, individuals who wear high heels can sustain acute injuries such as ankle sprains, most of the problems associated with high heels can be classified as cumulative micro-traumatic events (i.e. occur overtime). These injuries include lower back pain, hip and knee pain (i.e. tibiofemoral and patellofemoral joints) and Achilles tendinopathy (due to contraction and shortening of the Achilles tendon). Problems predominantly related to the foot include Morton’s neuroma, hammer toes, corns, callus, blisters, hallux valgus, as well as others6, 23-25. Dawson et al.26 noted that foot problems were more common in women (86%) aged 50 – 70 years of age who wore high heels. Whilst no absolute comparisons can be made, these

findings lend some support to the recent British survey2 which showed that women over the age of 45 years, felt less confident in high heels.

Although other factors are likely to be attributed; the lack of confidence could be associated with pain and discomfort experienced by the older age group.

Looks are Deceiving, but does Reality Dictate?

High heeled footwear is considered by some health professionals as completely unacceptable. For example, Professor Casey Kerrigan MD, MS based at the University of Virginia, USA has undertaken a series of studies examining the effects of stiletto heels and wider heels.25, 27, 28. Whilst at first glance you may consider the wider heel variation to be more forgiving since it provides greater stability, Kerrigan25 found that forces at the knee were 26% higher compared to 22% from stiletto heels. She further states that high heeled footwear is a risk factor for osteoarthritis of the knee and strongly advises caution for wearing high heels and states “Heels are bad, whether they are thin or wide. My recommendation is simple and unpopular – don’t wear them”29. This advice will seem harsh to many women who adore their high heels – with pain or without, but it is the correct advice. However, we have all experienced (and will continue to do so) the daily battles and discussions with our patient’s footwear (high heeled or not). As foot health professionals, it is our duty to provide the best care by reducing pain, and improving quality of life. To take this argument further, let us consider a young male tennis player who has persistent lateral ankle pain from repeated sprains. You treat him to the best of your ability to allow him to continue playing in spite of acknowledging the effects of sports injuries in individuals over the age of 45 years. Taking this stance, we all treat the effects of previous sports injuries daily, and whilst doing so it never stops us from treating the young sporting individual. Could the same argument be used for the high heeled wearer? There will always be answers for and against of course, and this discussion and debate is beyond the scope of this article.

In reality, women will always wear high heeled footwear and a critical skill of the foot health professional is learning the art of compromise. This involves establishing a balance between you and your patients. Podiatrists, as well as other health professionals quite correctly have a negative view of high heels because of the associated increased risk to lower extremity dysfunction and pathology. Nevertheless, adopting a dogmatic approach is likely to result in podiatrists and other health professionals to seem ‘out of

touch’ with their female patients. Therefore, the modern day podiatrist (and other health professionals) must understand the concerns of their female patients, and provide feasible resolutions that should include the reduction in symptoms that enables them to remain fashionable. This more realistic approach will make the opinions of podiatrist’s to be well-informed and acceptable from a clinical perspective, and socially responsible from a fashion perspective.

Although it may be acknowledged that women will be required to wear high heels at certain points during the week, the critical factor is to minimise the time spent in this footwear.

Perhaps the way forward for future is to consider a ‘risk factor high heel index’ where algorithms are calculated and applied determining an individual’s weekly time limit of wearing high heels.

This may sound bizarre at first since we know high heels are ‘bad’ for women, however establishing normalised risk thresholds may assist in finding the elusive compromise with women who wear high heels.

Since fashion continuously drives the high heeled footwear market and the desire of women to continue to wear high heels, a number of companies have attempted to establish methods of easing the burden and pain associated with high heels. However, whilst the market is saturated with gel insoles such as Party feet (Scholl, UK) and Happy feet (Jump shoe care, UK), their actions are limited to act simply as ‘cushions’ rather than dissipating the increased impact forces generated by high heels. Custom made foot orthoses (i.e. total contact insole) have been used 16 in the past and have shown evidence that impact forces are reduced particularly at the footto-shoe interface. Moreover, in the last couple of years new prefabricated orthoses have become available and include the Vasyli McConnell Extended slim fit (Vasyli International, Australia), Orthaheel slim fit (Scholl, SSL International Plc, Manchester, UK) and Insolia (Insolia, Salem, New Hampshire, USA), the latter of which shifts weight from the forefoot to the heel. Objective evidence on the value of these products however is limited.

Summary

Whilst fashion (good or bad) will always dictate our daily and evening wear, the detrimental effects of high heeled footwear cannot be underestimated. In reality, it is unlikely health professionals (i.e. podiatrists, physiotherapists, osteopaths, orthopaedic surgeons) will be able to stop women from wearing high heels. However, the key will be to obtain a ‘balanced approach’ by adopting management strategies that are clinically viable which acknowledges the dominant role of fashion.

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References 1. Kippen C: The high heeled shoe: an historical survey. British Journal of Podiatry 2001; 4(3): 84 - 89.

2. Society of Podiatrists and Chiropodists: British women's daily battle with high heels. 2007. http://www.feetforlife.org/cgibin/item.cgi?id=1850&d=pnd&h=0&f=0&dateformat=%25o%20%25B%20% 25Y Accessed 15th December, 2009.

3. Society of Podiatrists and Chiropodists: High heels - Falling over could be the least of your problems. TUC congress 2009 motion - high heels. feet for life 2009. http://www.feetforlife.org/cgibin/item.cgi?ap=1&id=2350&d=pnd&dateformat=%25o-%25B Accessed 29th January, 2010.

4. Frey C, Thompson F, Smith J, Sanders M, Horstman H: American Orthopaedic Society women's shoe survey. Foot Ankle 1993; 14(2): 78 - 81.

5. Esenyel M, Walsh K, Walden JG, Gitter A: Kinetics of high-heeled gait.

Journal of American Podiatric Medical Association 2003; 93(1): 27 - 33.

6. Lee CM, EH Jeong, Freivalds A: Biomechanical effects of wearing high-heeled shoes. International Journal of Industrial Ergonomics 2001; 28: 321 - 326.

7. Whittle MW: Generation and attenuation of transient impulsive forces beneath the foot: a review. Gait Posture 1999; 10(3): 264 - 275.

8. Snow RE, Williams KR: High heeled shoes: their effects on center of mass position, posture, three dimensional kinematics, rear foot motion, and ground reaction forces. Archives of Physical Medicine Rehabilitation 1994; 75(5): 568 - 576.

9. Opila-Correia KA: Kinematics of high heeled gait. Archives of Physical Medicine Rehabilitation 1990; 71: 905 - 909.

10. Murray MP, Kory RC, Sepic SB: Walking patterns of normal women. Archives of Physical Medicine Rehabilitation 1970; 51: 637 - 650.

11. Gollnick PG, Tipton CM , Karpovich PV: Electrogoniometric study if walking in high heels. Res Q Exer Sport 1964; 35: 370 - 378.

12. Hwang YT, Pascoe DD, Kim CK, Xu D: Force patterns of heel strike and toe off on different heel heights in normal walking. Foot Ankle International 2001; 22(6): 486 - 492.

13. Joseph J: The pattern of activity of some muscles in women walking on high heels. Ann Phys Med 1968; 9(7): 295 - 299.

14. Hwang SJ, Choi HS, Choi HH, Kim HS, Kim YH: The evaluation of the lower extremity joint moments and muscle force during various high-heel walking.

Key Engineering Materials 2006; 326 - 328: 755 - 758.

15. Basmajian JV, Bentzon JW: An electromyographic study of certain muscles of the leg and foot in the standing position. Surg Gynecol Obstetrics 1954; 98: 662 - 666.

16. Yung-Hui L: Effects of shoe inserts and heel height on foot pressure, impact force, and perceived comfort during walking. Applied Ergonomics 2005; 36: 335 - 362.

17. Mandato MG, Nester E: The effects of increasing heel height on forefoot peak pressure. Journal of American Podiatric Medical Association 1999; 89(2): 75 80.

18. Nyska M, MCCabe C, Linge K, Klenerman L: Plantar foot pressures during treadmill walking with high-heel and low-heel shoes. Foot Ankle International 1996; 17(11): 662 - 666.

19. Eisenhardt JR, Cook D, Pregler I, Foehl HC: Change in temporal characteristics and pressure distribution for barefeet versus various heel heights. Gait Posture 1996; 4(4): 280 - 286.

20. Corrigan JP, Moore DP, Stephens MM: Effect of heel height on forefoot loading. Foot Ankle 1993; 14(3): 148 - 152.

21. McBride ID, Wyss UP, Cooke TD, Murphy L, Phillips J, Olney SJ: First metatarsophalangeal joint reaction forces during high-heel gait. Foot Ankle 1991; 11(5): 282 - 288.

22. Speksnijder CM, vd Munckhof RJH, Moonen SAFCM, Walenkamp GHIM: The higher the heel the higher the forefoot-pressure in ten healthy women. The Foot 2005; 15: 17 - 21.

23. Cowley EE, Chevalier TL, Chockalingham N: The effect of heel height on gait and posture. A review of the literature. Journal of American Podiatric Medical Association 2009; 99(6): 512 - 518.

24. Edwards L, Dixon J, Kent JR, Hodgson D, Whittaker VJ: Effect of shoe heel height on vastus medialis and vastus lateralis electromyographic activity during sit to stand. Journal of Orthopaedic Surgery and Research 2008; 3(2).

25. Kerrigan DC, Johansson J, Bryant M, Boxer J, Della Croce U, Riley P: Moderate-heeled shoes and knee joint torques relevant to the development of the progression of knee osteoarthritis. Archives of Physical Medicine Rehabilitation 2005; 86(5): 871 - 875.

26. Dawson J, Torogood M, Marks SA, et al.: The prevalence of foot problems in older women: a cause for concern. Journal Public Health Medicine 2002; 24(2): 77 - 84.

27. Kerrigan DC, Lelas JL, Karvosky ME: Women’s shoes and knee osteoarthritis.

The Lancet 2001; 357(9262): 1097 - 1098.

28. Kerrigan DC, Todd MK, Riley PO: Knee osteoarthritis and high heeled shoes.

The Lancet 1998; 351(9): 1399 - 1401.

29. Kerrigan CM: Time to heel knee osteoarthritis in women. American Academy of Physical Rehabilitation.

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Case Study of a Lady with Malignant Melanoma on Her Right Lower Leg

By Valerie Dannourah M.Inst.Ch.P

AETIEOLOGY AND EPIDEMIOLOGY

There has been a dramatic increase in the incidence of Malignant Melanoma in the last 40 years among white populations. It is now the most common cancer of young adults in the U.K. although numerically more common in older people.

It is accepted now that much of this increase is due to exposure to sunlight, especially in childhood and sunburn may be important.

There are a number of individual risk factors which may determine a persons chance of developing MM in their lifetime.

1) Family history of Malignant Melanoma 2) Larger than average number of moles 3) Skin colour/type, those with very fair skin especially red hair and freckles. These factors give a higher risk.

DIAGNOSIS

As can be seen from the photo (1) there is asymmetry of the mole, the border is obviously irregular. The colour changes across the mole from pale brown to an area of very dark brown. It measured 3.5cm horizontally by 1.5cm vertically. The changes have occurred over the last 3 years.

MEDICAL HISTORY

When observing moles this fitted almost exactly to the traditional A,B,C,D,E, mnemonic table see below.

She has no family history of MM. She has more than average number of moles on her body and before she was grey she had brown hair. Her skin is fair.

CELLULAR PATHOLOGY REPORT

Mrs. B., 89 years old, she is fully ambulant.

Non Hodgkins lymphoma in 1985 treated successfully.

Essential hypertension 2001.

Ventricular hypertrophy 2004.

Sacroilitis 2006.

SPECIFIC HISTORY AND EXAMINATION

The mole on her right lower limb, shin area showed changes in May 2006. Bowens disease was diagnosed and she was treated by cryosurgery at the dermatology dept in September 2006.

I saw her in January 2009 and the same mole looked suspicious and darkened in an area. I advised her to see her GP about this and she reluctantly agreed, he referred her to the dermatologist. She attended the dermatologist outpatients in June 2009 where a biopsy was taken and she returned for the results which showed melanoma in situ with suspicious features of microinvasion. A multidisciplinary meeting took place on 25th June 2009 which recommended an immediate full excision. He referred her to a plastic surgeon at a specialist centre for full/wide excision and skin graft and he would see her in 3 months when completed. There is no lymphadenopathy or hepatomegaly or further lesions.

A B C D E

Asymmetry Border irregular/unclear Colour not uniform particularly if areas are black Diameter > 7mm Evolution (change over Months)

Punch biopsy Microscopy – section of skin shows a junctional proliferation of atypical melanocytes. There is intraepithelial spread and an occasional single melanocyte within the dermis.

Diagnosis – features amount to at least malignant melanoma in situ with features suspicious of microinvasion. Final diagnosis should await complete excision of the lesion.

Malignant Melanoma

13

REFERRAL

The graft had taken 100%. The site was redressed and double tubigrip applied from toe to knee. The donor site dressing was left intact.

TREATMENT

HISTOPATHOLGY REPORT

She attended OPD to see the plastic surgeon on 16th September 20009.

She was admitted to hospital on 29th September 2009 and had wide excision of the tumor with split skin graft taken from her left thigh carried out under a general anesthetic the next day. The dressing was removed on the 4th day to inspect the graft and skin clips were removed.

Histology shows a superficial spreading malignant melanoma. The tumour has an in situ component and a dermal invasion component. The tumour has a Breslow thickness of 1.0mm. Clark’s level is 3. Excision is complete.

TABLE SHOWING 5 YEAR SURVIVAL VALUES FOR CUTANEOUS MELANOMA WITH LESION THICKNESS Breslow thickness

Approximate 5 year survival In situ

95 – 100%

1 – 2mm

80 – 96%

<1mm

2 – 4mm >4mm

95 – 100% 60 – 75% 30 – 50%

The prognosis of an individual tumour is closely related to its initial cross-sectional area and its level of invasion at first excision. Most pathology laboratories will provide a report indicating the Clark level (which in this case was 3) The scale is 1 to 5 which indicates invasion to the papillary dermis. They also report the Breslow thickness as seen above.

See photograph taken six weeks post operative (2) of excision 4cm x 4cm square.

Mrs. B., came home six days after her operation. District nurses have been checking the dressing on alternate days.

Mrs B has been advised to sit with her feet up when sitting to aid healing.

References: www.dermnetnz.org.nz Graham-Brown 1998 dermatology, naevi and tumours of melanocytes.

PROGRESS

Mrs. B., did receive a letter of apology from the plastic surgery dept as there was a longer than expected delay in her getting called for her operation.

Mrs. B., was told that no further treatment was needed but she would need to attend out patients every three months for one year, four monthly for the second year and then six monthly for years three, four and five.

She has a good prognosis with a better than ninety per cent five year survival rate.

OUT PATIENTS ATTENDANCE TO CONSULTANT PLASTIC SURGEON AND DERMATOLOGIST

Ten days post op the doctor inspected the graft. Progress was satisfactory To continue with the dressing on with the nurses attending to change the dressing as necessary and feet elevated between mobilizing.

Six weeks post op the doctor removed the dressing and the graft left exposed. It was dry and healed with only one tiny moist area centrally treated with Fuciden H. the surrounding dry skin treated with Hydromol lotion.

14

Excision of Malignant Melanoma and Graft

Personal Profile D

Stephen Gardiner PGDip BSc(Hons) M.Inst.Ch.Pod uring my school years - some not too far distance memory ago; I believe I had no real insight as to where my future and chosen career would take me.

Upon leaving school I worked on a surgical ward at my local hospital as a Nursing Auxiliary; which then became the role of Health Care Assistant. I had a variety of roles working within this hospital from Surgical Wards to finishing working in theatres and Accident and Emergency. It was during this time I joined The Royal Navy Reserves – HMS Sherwood in Nottingham as a Medical Assistant. It is this role that would equip me with the skills needed to diagnose and treat injured Military personnel in time of conflict. After initial reservist basic training and undertaking several war-role commitments on HMS Nottingham and Royal Hospital Haslar, I found myself being drawn to The Royal Navy. Four months later, I joined The Royal Navy full time.

After completing basic training, I entered branch training in the medical field. This I embarked upon at RH Haslar – Gosport, Portsmouth, and had an intensive twelve months training in medical care. My role as a Medical Assistant was to be a highly skilled member of The Royal Navy's healthcare team, providing day-to-day medical services and health education both at sea and ashore. Another part of my role was specialist lower limb injury management, where I worked closely with an Orthopaedic Surgeon. This Podiatric experience was to be the catalyst for my future interest and specialism.

During my role in The Royal Navy I provided essential medical care in demanding and often dangerous environments; flood disaster relief in Mozambique, peace keeping in Sierra Leone, and Iraq – Gulf War 2. Within these theatres of operation, my role as the Medic demanded the need to become an expert in the field of life saving techniques and advanced first aid – supporting the medical needs of those on both sides of the conflict or disaster area I was in.

In addition to regular duties of medical care, administration and a full time role as a member of a ship's company; dependant upon my draft, I was often the only Medic on board and dealt with all conditions - in effect the General Practitioner for the entirety of the ship’s complement.

My time as Medical Assistant was short lived as I was bestowed with opportunities for promotion very quickly. I progressed through the ranks to Trauma Officer where I was responsible for the management of medical care of up to 5,000 service personnel ashore and afloat during Gulf War 2.

With promotion came the “offer” of a desk job in Whitehall, London; which I avoided for as long as possible, preferring a hands-on approach in the field. After 10 years service under my belt, I left The Service in 2004.

Directly after The Royal Navy, I took a brief change in career in the role of teaching English as a Foreign Language in Hami, near the Mongolian border of Xinjiang Province, China. Here I was teaching both locals and businessmen the “Queen’s English”. Whilst I was in this post I gained a Master’s Degree in Teaching English. My stay in China gave me a chance to

travel around this vast country and sample a range of foods - something quite different to the Western diet. My existing reticence for boiled rice day after day turned into somewhat of an aversion, which still exists to this day. Apart from eating the usual meats, fish and poultry, I was introduced to donkey, turtle and unfortunately without foreknowledge, dog - to name a few!

As part of the resettlement period into civilian life I undertook a formal civilian qualification in Chiropody and completed this two years before my eventual leaving date – medical treatment that I had been providing for some years in The Royal Navy, prior to receiving the civilian qualification. Service qualifications and training were completely different to those in civilian life and until recently there was no civilian equivalent qualification to those I’d previously obtained.

During my time within The Service, it gave me an insight into a variety of medical conditions, some of which I now see today in private Podiatry practice. I regular uphold my traditions of Navy life, being an active member of the local Royal British Legion. I am also proud to wear my medals - awarded for service to my country: The General Service Medal for duties in the Gulf, Gulf War 2 Medal with rosette (denoting active duty in conflict at the time of war), the Humanitarian Medal for medical services in Mozambique, Sierra Leone Medal and the Queens Golden Jubilee medal.

On returning to the UK I took up the position of Podiatrist with Scholl - working at both their Nottingham and Derby centres. After a short spell at Scholl and domiciliary practice, I felt that Podiatry was the way forward for my future career and “A Foot Above” (Ilkeston) Derbyshire was born.

It’s not all plain sailing (pardon the pun). As many of you will know, setting up a private practice on your own and from scratch is not easy. Adjusting to civilian life can be very difficult after serving many years in an environment where you are protected, have a sense of security, life is disciplined and well sheltered. Jumping into an unprotected civilian life of business meant I learned the hard way - but quickly adapted after realising that life on the outside is not black and white and that in business, not everyone should be trusted… but I got there – I had established a successful, modern and professionally run private practice of my own.

Within two years, in 2007 I opened my second clinic (Beeston) in the neighbouring county of Nottinghamshire. It was during this time I knew the world of Podiatry was changing, and changing at a fast pace. I had to take action. I studied long and hard and it became clear that my interest in biomechanics was to be a passion of mine and still is. After a visit to France to gain some formal training, the conundrum came as how to move forward with this. My efforts paid off and

15

with the investment in some very expensive equipment, I have extended and broadened both my skills and the services offered within my clinics with a Gait Laboratory. The Gait Lab now brings customers to me from further afield than the pure Chiropody service did alone.

Moving forward with my Podiatry career, and thinking of my future and eventual planned retirement (a long way off, but on some long days in the clinics I sometimes feel like it should be very soon), I needed to do more! So, I enrolled at New College Durham and completed my BSc conversion in 2008, followed

by BSc(Hons) in 2009. Since then I have undertaken further development of my skills with a Local Anaesthetics course, Silicone Injection therapy, Steroid Injection therapy and Nail Reconstruction – which I now teach. I’ve also taken the Prescription Only Medicines course; being part of my MSc in Podiatric Surgery which I am currently studying at Glasgow Caledonian and Edinburgh Queen Margaret Universities.

These transferable skills will be taken with me as my practice has now become International recognised for its clinical skills and service, having received awards of accreditation.

In 2010 as part of the “A Foot Above®” brand I launched a new clinic called “Sportsorthotic™” which will be focusing on biomechanical issues with a service that intends to be both UK and internationally based – seeing me working in both the UK and in Dubai UAE.

As you are reading this, you may be thinking “When does he find the time?” I often wonder that myself, but in addition to working in my two busy clinics and expanding the practice, completing my MSc in Podiatric surgery (I have one year to go before hopefully graduating with my MSc), I am now commencing a Surgical placement in Doncaster.

Work aside; I am also an active member of our local Red Cross Branch as a First Aid Trainer and Quality Monitor, Nottingham Branch Secretary and Midland Area Council Delegate. However, amidst all that I do, I still have a social life, as my partner will tell you.

Those that know me, know that my passion is Podiatry and the delivery of foot health care. Fellow members of The Institute often pose questions to me with regards to treatment plans and routines, which I am very happy to provide answers to. This must be the tutor and educator side of me coming out.

In completing my BSc(Hons) and now in the final stages of my MSc, I find that I cannot help myself in thinking about research and investigating research based evidence. I know myself that whilst studying, a lot of the material we all see can sometimes be confusing. Training that I have delivered at Branch level has enabled me to put all that into plain simple language - easily understood and that can be related to in everyday practice.

Our world is ever changing and as someone who was not academically gifted at school and has learnt over the years to develop my skills and knowledge, I have been able to adapt my knowledge into a way I can understand and I feel I have a duty to share that with others as private practice can sometimes seem like an isolated world.

My colleagues within the Podiatry world and in the Institute may have seen me at Conference. This year I have the pleasure of co-hosting The 2010 A.G.M. and Conference at Eastwood Hall, Nottingham. You may choose to read more from me over the coming months, as I will be wearing my other hat and writing to you, providing updates as to the A.G.M. and Conference.

I bid you farewell for now, but if you see me around, please say hello - it will be a pleasure to meet with fellow colleagues of our Podiatric Profession.

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16

2010 Annual General Meeting and Conference - Nottingham

Welcome to this final article prior to the A.G.M. from your conference Hosts, David Elliott and Stephen Gardiner As you all know by now from the past two articles, 2010 will see a change to the A.G.M. format. Firstly you will have all seen in the last journal that we have increased the keynote/plenary speakers to five instead of the usual three. We are also offering you the opportunity to enhance your CPD and get involved in our six different Gregg Quinn workshops, conducted by professionals in the field who are either, podiatrists themselves or from our very supportive Trade Houses, and we thank them in advance.

The A.G.M. will commence on the Friday afternoon with lectures from highly respected people, Professor Wesley Vernon and Mr. Greg Quinn. This is hoped to whet your appetite ready for the evening events and to the event enjoyable and memorable for the rest of the conference.

Friday’s evening entertainment will be consisting of a Medieval Evening and Barbeque with games and archery.

So start thinking about that fancy dress. Along with the usual pub games such as Giant Connect Four, Chess, Jeng and Snakes and Ladders we will have a local archery club attending the venue.

The archery is planned for all and there is no minimum or maximum age as long as you can hold a bow and arrow.

Everyone taking part will be given a formal teaching session before the competition begins. The competition will work as follows: Five members will make up a team and pay a entrance fee of £10, money raised at this event will go towards the Benevolent fund and our nominated charities:- Help for Heroes and The Royal British Legion.

The teams will be battle it out together until we have the final two teams and the team with the highest score will be crowned archery champions of the event, and a prize will be presented by our President.

Friday is hoped to be a fun event, with a variety of games, for all to enjoy. Saturday will see the formal proceedings begin with the opening of the conference and the business meeting and the concurrent workshops. Saturday afternoon will be the two final plenary keynotes speakers of the day prior to the Dinner Dance. Sunday morning will finish the business meeting and our final keynote speaker and rounding off the CPD events for your annual conference.

In the previous journal we gave you information about some of our plenary speakers; we now conclude this with their professional profiles of our other speakers and information about our workshops to help you all in booking your chosen workshop.

We hope that you will wish to visit Nottingham and Nottinghamshire and to meet up with friends and colleagues once again at your Annual General Meeting and Conference.

Gregg Quinn FCPodS – Podiatric Surgeon After graduating in 1994 from Salford School of Podiatry, Greg worked within the NHS in Derbyshire for over 10 years, establishing a podiatric surgery department to work alongside diabetes, orthopaedic and rheumatology support clinics. After his appointment as a Fellow of the Surgical Faculty of the Society of Chiropodists & Podiatrists and serving on the Education and Examinations Committee, he left Chesterfield Royal Hospital to work at Holywell Healthcare and was appointed as a Consultant to the Ministry of Defence Regional Rehabilitation Unit at Aldershot, Tidworth and ATR Pirbright. He is a co-founder of Talar Made Ltd. and a Fellow of the Royal Society of Arts, Manufacturers and Commerce. He has recently taken a break from clinical practice to complete his research into the genetic inheritance of foot morphology and has worked with many University research colleagues outside of the clinical environment to achieve this. His particular interest is the multi-disciplinary approach to foot pathology and the incorporation of new evidence based ideas into patient care.

His lecture - The Foot Shape We Inherit & Why Symptoms Occur Will focus on that we are all trained to recognise an ‘abnormal’ foot shape or posture. To do this we assume that there is one ideal foot structure or position and any deviation from it can be measured and used to quantify ‘deformity’. Simply put, Medicine or any Biological Science does not work like this. Normality is always represented by a range of values. This presentation will address key issues to understanding how and why foot symptoms occur by answering the following questions: 1)

How have human feet evolved?

2)

What key functions must a human foot deliver?

3)

What do we mean by normal anatomy?

4)

What are the implications for examination & treatment?

17

By following this simple explanation of our inherited foot structure and purpose of function, an easier and more evidence based understanding of our patients’ symptoms becomes clear.

Robert Isaacs – Lead Podiatrist Biomechanical Therapies BSc (Hons) MChS Cert. KCHyp Robert has been working as a specialist in biomechanics in the NHS for almost ten years. He lectures in various topics around this area and writes a regular Robert Isaacs monthly column on biomechanics for Podiatry Now. Robert also has an interest in cognitive psychology and various forms of suggestibility, in particular how these things affects everyday clinical decision making and research. Although he works primarily as a Podiatrist he is also a certified clinical hypnotherapist.

Sandy of D L Townend. Including topics such as the Health Technical Memorandum (HTM) basis for change, presenting the new product to patients, and the estimation of potential costs, this workshop will be invaluable to those members worried about the forthcoming guideline changes.

Darren has recently been invited onto the steering group for the Department of Health’s new Podiatry sterilisation document, and has an extensive knowledge of the requirements for NHS, HPC, private practice and domiciliary practitioners.”

Strappings and Paddings: A Guide By Cuxson Gerrard Hapla and Zopla felt has long been the industry standard for strapping and paddings. In this seminar, Cuxson Gerrard will run through the most popular techniques used in Podiatry, including our well known 'Hapla 3D' system.

Lecture summary: It is tempting to think of ourselves as objective and analytical, especially when considering the science of what we do. The truth, however, is somewhat different for most of us. This lecture is an exploration of the cognitive errors which are hard wired into all of us and which can lead to objectively excellent, or disastrously harmful clinical decisions. The depth and scope of these "heuristics" is both fascinating and alarming.

Concurrent Sessions Nail Reconstruction: Step into the world of cosmetic Podiatry Every day in private practice patients present with discoloured, disfigured, thickened, damaged, fungal or psoriatic nails. These unsightly nails cause embarrassment and discomfort, with patients often shying away from wearing open shoes as a result. Up until now the few options to cosmetically disguise them have been somewhat successful. Many patients simply paint the area with polish or stick on a false nail, which often causes more problems than they solve.

Now we can offer a perfect cosmetic procedure to reconstruct the nail using Wilde-Pedique toe correction gel. The gel, when applied to the nail bed is cured under a UV light and provides a natural looking prosthetic nail.

The result is a malleable, yet durable and long lasting “nail”; patients can’t believe their nails look so good.

The treatment is suitable for men and women who are conscious of how their feet look and is perfect for sportsmen and women who loose nails.

During this informative session I hope I can dispel the myths that cosmetic treatments are frivolous and in fact do have a place in a modern private Podiatry practice.

Infection control in your practice – what does the legislation actually mean?

“This introduction is on the latest sterilisation requirements. This workshop is presented by Darren

18

Assessing the Diabetic Foot - Gareth Hicks of Bailey Instruments Limited This workshop presents the tools and techniques with which to correctly assess the risk level of INSTRUMENTS LTD your diabetes patients’ feet. A hands-on session will be followed by patient education strategies.

The workshop will be run by Gareth Hicks, podiatrist, who qualified in 1988 and has worked in NHS and private clinics. Gareth is a director in Bailey Instruments but maintains his clinical interest in diabetic medicine and biomechanics.

Fresco Podologica – A practical demonstration and guide to making silicone orthosis.

Mr. Alberto Fresco and Mr. Aitor Fresco of Fresco Podologica (Spain) have flown in especially as guests of Canonbury Products, to present a live demonstration of how to produce orthoses from scratch using silicone putties.

This is a rare opportunity to see these experts at work.

Mr. Alberto Fresco has over 30 years experience working with silicones and has run educational courses throughout the world. This will be a very hands-on presentation with the opportunity for you to participate and hone your skills under expert guidance.

Fresco Podologica was founded by Alberto Fresco in 1975, they have been dedicated to the production, development and distribution of footcare products.

Fresco Silicones are now used in over 35 countries throughout the world.

Continued ProfessionalDevelopment

Continuing Professional Development The Institute of Chiropodists and Podiatrists

This article is one of a series of educational documents that can be inserted into your portfolio and be a contribution towards your personal CPD learning.

Acral Lentiginous Melanoma of the Foot & Ankle – A case series & review of the literature

By Ivan R Bristow1§ and Katharine Acland2

Abstract

Background

Acral lentiginous melanoma (ALM) is an uncommon, cutaneous malignant tumour which may arise on the foot. Its relative rarity, atypical appearance and late presentation frequently serve as poor prognostic indicators.

Methods

At a tertiary skin tumour centre, a retrospective review was undertaken of all patients diagnosed with the tumour at the level of ankle or below.

Results

Over a six year period, 27 cases (20 female, 7 male) were identified with positive histology confirming the disease. The age ranged from 35-96 years of age (mean 62.7 years). The majority of the cohort were white (59%) with plantar lesions (62%). 33% of patients were initially were diagnosed incorrectly. The average time taken from the point of recognition, by the patient, to the lesion being correctly diagnosed was around 13.5 months.

Conclusions

Earlier diagnosis of ALM requires education at both a patient and practitioner level.

Background

Melanoma is a malignant tumour arising from melanocytes.

The number of cases of the disease worldwide is increasing faster than any other form of cancer amongst Caucasians1.

Although the disease is uncommon in the UK, the incidence of cutaneous melanoma continues to rise and it has been calculated that the lifetime risk for developing the disease is 1:120 for men and 1:95 for women2. Currently there are around 8500 new cases annually in the UK with around 1,800 melanoma related deaths3. Australia has the highest annual incidence of melanoma in the world. The lifetime risk of developing melanoma before the age of 75 is 1: 24 for males and 1:34 for females. In 2003, there were 9,524 new cases of melanoma reported in Australia with an annual death rate of around 1,5004. Cutaneous melanoma can develop at any site.

The lower limb represents around 30% of all primary cutaneous melanomas, particularly in women, with the foot and ankle representing 3-15% of all cutaneous melanomas5.

Sub-types of Melanoma

Malignant melanoma (MM) is the commonest malignancy observed in the foot6. In 1969, Clark et al7 histologically identified three sub-types – superficial spreading melanoma

(SSM), nodular melanoma (NM) and lentigo maligna melanoma (LMM). In 1976, a fourth type, acral lentiginous melanoma (ALM) was added by Reed8. All sub-types of melanoma have been reported to arise on the foot with the exception of the LMM which occurs almost exclusively on the face9.

Acral Lentiginous Melanoma

The term ALM was first described by Reed8 as a subtype of melanoma. It was so named because of its predilection of acral (distal) areas of the body, particularly the palms, soles and the sub-ungual areas, and its distinct radial or “lentiginous” growth phase. ALM represents the rarest of the four sub-types of cutaneous melanoma yet is the most common variety diagnosed on the foot10. Reed described its diagnosis as being based on its histological, intra-dermal features showing a diffuse proliferation of large atypical melanocytes along the epidermal-dermal junction which is dispersed in a lentiginous pattern with marked acanthosis and elongation of the rete ridges8. When reviewing terminology within the literature, confusion often arises with the use of the term “acral” with some papers describing “acral melanoma” which is merely an anatomical term for any sub-type of melanoma located on the palms, soles or sub-ungual region.

ALM (figure 1) is the only sub-type of melanoma that occurs at the same rate in all races11. However, research data have demonstrated that melanomas in acral locations account for only around 1-7% of all cutaneous melanomas in Caucasians but has been shown to be significantly higher in Asian12, 13, Chinese14, 15, Japanese16, Middle Eastern17 and African populations18, 19. This data reflects the low incidence of melanomas elsewhere on the body in the more pigmented skin types.

Aetiology

As ALM occurs equally across all races, predominantly on an area that seldom receives much sun exposure it has been suggested that the aetiology is different to that of other sub-types of melanoma or that sun exposure is a lesser risk factor than melanoma elsewhere.

Green et al20 undertook

Figure 1

Figure 1 - Acral lentiginous melanoma on the plantar surface Acral lentiginous melanoma on the plantar surface

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Continued ProfessionalDevelopment a case control study of 275 melanomas diagnosed on the soles and palms to investigate risk factors. Interestingly, they found that sun exposure was a significant risk factor in the development of ALM despite their plantar and nail bed location. Furthermore, a high mole count on the soles and elsewhere on the body were associated risk factors (RR=6.3 95% CI 2.5-15.6). Reinforcing this belief, other studies have demonstrated that increased sun exposure in an individual leads to the development of higher numbers of moles, especially in children21.

Trauma as a cause has also been proposed as a possible risk factor for the development of ALM20. Penetrative injury of the foot showed significant association (RR= 5.0 CI 3.0-8.6) although the authors could not confirm from the data if the ALM actually developed at the original site of injury. In an earlier study, Briggs et al22 reviewed a number of cases but suggested that incidental injury to the foot merely drew the patients attention to a pre-existing foot problem. Kaskel et al23 suggested that trauma in acral areas such as the foot were to be expected more frequently and could find no evidence to identify trauma as an aetiology.

The prognosis of the disease, as with other sub-types of melanoma, is determined by the Breslow thickness of the lesion at diagnosis24. It has been suggested that ALM itself carries a worse prognosis than other melanoma - often as lesions are recognised later than melanoma on other body sites25.

Following a number of cases late diagnosis occurring at a tertiary care centre, a study was set up to review cases of the disease in an attempt to identify common clinical factors.

Methods

A database search was undertaken to identify all cases of ALM treated at the tertiary care melanoma centre located in a central London district. From these, notes were selected of patients presenting with a ALM (diagnosed by histology) on the ankle or below. In the period 2000 – 2006, twenty seven patients were identified and from their records clinical data including gender, age, ethnicity and diagnostic information were gathered and tabulated for review.

Table 1. Summary of locations of ALM in 27 patients Location

Plantar Surface Plantar Forefoot (4 located under 1st met head.)

Plantar Midfoot Plantar Heel Dorsum of the foot Ankle Nail Bed (2 hallux , 2 fifth toe)

Digit (excluding nail unit) Not Known Total

Results

Number 17 6 5 6 2 2 4 1 1

27

The cohort of patients totalled 27 (20 female and 7 male) with a female ratio of nearly 3:1. The patients’ age at diagnosis ranged from 35 to 96 years. The average age of the patient at was 62.7 with no age difference between men and women (62.5 versus

March/April10CPD

62.8 respectively). The majority of patients reported their ethnicity as white (n=16) in addition there were 7 AfroCaribbean, 1 Chinese/Oriental and 3 unrecorded. Although not always recorded, patients had been reviewed at a number of other clinics with their lesions prior to reaching the dermatology department with a definitive diagnosis. These included a range of specialities - general practice (n=5), podiatry/chiropody (n=9), vascular clinics (n=2), diabetology (n=1) and plastic surgery (n=1).

Nineteen of the lesions were reported on the right foot and eight on the left. All male patients exhibited ALM on their right foot only. The majority of lesions were located on the plantar surface (62%) with 2 on the ankle, 2 on the dorsum of the foot, 1 on the digit and 4 located in the nail bed (with 2 in the hallux and 2 in the fifth toe nail bed). One lesion site was stated simply as being on the “foot” (see table 1). Twenty-one (78%) of the lesions were reported as melanotic, three amelanotic (11%) and three (11%) were unknown.

Data on the time from the patient first recognising something on their foot to diagnosis was available for 19 patients. The average time for women was 12.5 months versus 14.5 months in males. The most reported symptoms from patients were change in size and bleeding. A number of lesions were misdiagnosed as warts (n=4). Lesion thickness at diagnosis ranged from 0.84mm to 13.30mm. The mean thickness for women being 3.68mm (n=16) versus 4.41mm in males (n=6).

Table 2. Reported symptoms/diagnoses (21 patients) Symptoms

Change in Size Bleeding

Change in colour Change in form Pain

Itching

Previous Diagnoses

Number 8 4 2 2 1 1

Wart

4

Haematoma

1

Fungal Infection Ulcer

Discussion

1 1

This set of patients represents a small cohort (n=27) of a population from an urban area with a high ethnic mix.

Interestingly, despite the wide ethnic diversity of the local area, a high proportion of this cohort were white (69%). Despite the wide spread of ages (35 – 96), the average age of the patient in this study was 62.6 years which concurs with similar studies26, 27

Continued ProfessionalDevelopment that ALM is most frequent in the 60-70 age group25. ALM appears to occur in an older age group, other types of melanoma having a peak incidence around 50 years of age, albeit with a wider age spread2. The female preponderance to ALM was 2.8:1 slightly higher than other published data26-28 but still confirms that MM is a disease more common in females3, 10.

Within this study, the prime location for ALM was the plantar surface (65%), with 4 of these occurring under the first metatarsal head. A smaller number were seen in nail beds, ankle and dorsum of the foot. A similar prevalence pattern for the plantar area has been reported by Soon et al27 (61%) and Kuchelmeister25 (65%) with sub-ungual lesions making up a smaller percentage of all cases of ALM. The four sub-ungual tumours in this study were located exclusively on the hallux (50%) and fifth toe (50%). The hallux has been consistently reported to be the most common area for sub-ungual lesions in the foot. Possible reasons for this are two-fold. Firstly, the hallux may be the most prevalent location owing to the larger proportion of nail tissue in this area. Secondly, one could debate the role of trauma. The hallux is typically an area of the forefoot more prone to abuse from footwear and one-off injury.

In one case series from Germany, 6 patients with ALM reported tight footwear as a possible causative agent23. The authors went on to discuss that patients with acral melanoma tended to report a high rate of trauma compared to those with melanoma at other sites but this was not found to be statistically significant.

Furthermore, one could hypothesize, if physical trauma was associated with melanoma, one would expect the foot show a more significant proportion of lesions on the foot as a result of the forces of weight bearing and locomotion.

Early recognition is the key to improving survival rates29. As cutaneous melanoma is a visible disease, both the patient and practitioner play a major role in recognising suspicious lesions.

Initially, the time taken to reach a diagnosis depends on the patient’s ability to recognise and seek professional advice.

Secondly, diagnosis depends on the professional’s capacity to recognise the lesion. Data were available for 19 patients showing that the time from first noticing a lesion to diagnosis ranged from 1 – 36 months, which shows similarities to other studies of patients with ALM26. Reasons for the delay were not examined in this study but have been reviewed by Richard et el30. In a series of 590 patients they examined the reasons for delay in melanoma diagnosis and discovered that male gender, increasing age and a low educational level were all risk factors for a later presentation to physicians. In a second paper31 examining physician delays, acral locations and lack of lesion pigmentation were factors more likely to lead to a delay in diagnosis by a physician, particularly lesions in acral locations without pigmentation.

Within this study, symptoms or initial diagnoses were recorded for 21 patients. The most common reported symptom was a change in the size of the lesion (38%) followed by bleeding (19%), change in colour (9%) and change lesion form (becoming raised/nodular) (9%). Bleeding is a common feature in melanoma which have entered a vertical growth phase and have become ulcerated2 and may represent a feature of advanced disease. The average lesion thickness in patients reporting

bleeding was significantly higher in those not reporting it (mean thickness 6.13mm v 3.8mm) although due to the small numbers involved it was difficult to draw firm conclusions.

Seven of the twenty one lesions (33%) were initially misdiagnosed as other conditions (warts, a fungal infection, haematoma and an ulcer). Numerous papers have highlighted conditions including warts, tinea pedis, ulceration, infection, paronychia, haematoma, onychomycosis, ischaemic necrosis, pyogenic granuloma, ganglions and blisters which have been later discovered to be ALM 27, 28, 32-36. Misdiagnosis is a common feature of melanoma on the foot but ALM in particular has been shown to be more likely mis-diagnosed than other sub-types of the disease37. Delays can in turn lead to a poorer prognosis for the patient. The misdiagnosis rate in this study was 33%, other have reported rates of between 33% - 67%27, 38.

It is appreciated that the results of this study represent a retrospective review of patient case notes which have some inherent bias - in particular that this data was collected at a tertiary centre where possibly only more complex cases are seen.

However, in view of the relative rarity of the condition, twentysix cases represent a sizeable cohort, which has been shown to be concurrent when compared to literature on this topic.

This paper has highlighted an uncommon but serious lesion which may present for the first time to Chiropodists and Podiatrists. One third of the lesions, in the presented cohort, were seen prior to diagnosis by a chiropodist or podiatrist.

Unfortunately, typical features of melanoma as exhibited by the “A,B,C,D,E” rule may not be present in a proportion of ALM and so misdiagnosis remains a significant risk. Therefore it is important to remain vigilant and where there is clinical suspicion, patients should be referred for a prompt dermatological opinion. In suggesting ways to heighten awareness, the typical patient profile should be borne in mind as well as continuing the patient health education message. In addition, dermoscopy has been demonstrated as a useful, noninvasive technique to increase sensitivity in acral lesions39 improving early recognition.

Conclusions

Acral lentigious melanoma is an uncommon malignant tumour which can occur on the foot. This study provided clinical data from 27 cases based on a mainly white, urban population. A third of cases in this series were misdiagnosed before reaching the skin clinic with a proportion of patients having been seen by a number of specialities prior to diagnosis. Lesions were most common on the plantar surface (62%). The average time from patients first noticing something to diagnosis was 13.5 months.

The most common reported symptoms were a enlargement of the lesion (38%) and bleeding (19%). Further studies are required to better understand the aetiology and pathology of this unusual but serious tumour.

School of Health Sciences, University of Southampton, UK St. Johns Institute of Dermatology, St. Thomas’ Hospital, London, UK §Corresponding author Ivan Bristow email: IRB: ib@soton.ac.uk 1 2

Acknowledgements

The authors wish to acknowledge the help of Sally King at St. Thomas’ in identifying patient cases.

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Continued ProfessionalDevelopment References 1. Lens MB, Dawes M: Global perspectives of contemporary epidemiological trends of cutaneous malignant melanoma. British Journal of Dermatology 2004, 150:179-185.

2. Bishop JN, Bataille V, Gavin A, Lens M, Marsden J, Mathews T, Wheelhouse C: The prevention, diagnosis, referral and management of melanoma of the skin: concise guidelines. Clinical Medicine, Journal of the Royal College of Physicians 2007, 7:283-290.

3. UK Skin Cancer mortality statistics [http://info.cancerresearchuk.org/cancerstats/types/skin/mortality/] 4. Australian Institute of Health and Welfare (AIHW) & Australasian Association of Cancer (AACR): Cancer in Australia: an overview 2006. Canberra: AIHW 2007.

5. Soong SJ, Shaw HM, Balch CM, McCarthy WH, Urist MM, Lee JY: Predicting survival and recurrence in localized melanoma: a multivariate approach. World J Surg 1992, 16:191-195.

6. Barnes B, Seigler H, Saxby T, Kocher M, Harrelson J: Melanoma of the foot. J Bone Joint Surg AM 1994, 76:892-898.

7. Clark WH, Jr., From L, Bernardino EA, Mihm MC: The Histogenesis and Biologic Behavior of Primary Human Malignant Melanomas of the Skin. Cancer Res 1969, 29:705-727.

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10. Hudson DA, Krige JEJ, Stubbings H: Plantar melanoma: Results of treatment in three population groups. Surgery 1998, 124:877-882.

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Dermatologic Surgery 2002, 28:1051-1059.

12. Chang JW, Yeh KY, Wang CH, Yang TS, Chiang HF, Wei FC, Kuo TT, Yang CH: Malignant melanoma in Taiwan: a prognostic study of 181 cases. Melanoma Res 2004, 14:537-541.

13. Chen YJ, Wu CY, Chen JT, Shen JL, Chen CC, Wang HC: Clinicopathologic analysis of malignant melanoma in Taiwan. J Am Acad Dermatol 1999, 41:945-949.

14. Collins RJ: Melanoma in the Chinese of Hong Kong. Emphasis on volar and subungual sites. Cancer 1984, 54:1482-1488.

15. Luk NM, Ho LC, Choi CL, Wong KH, Yu KH, Yeung WK: Clinicopathological features and prognostic factors of cutaneous melanoma among Hong Kong Chinese. Clinical and Experimental Dermatology 2004, 29:600-604.

16. Ishihara K, Saida T, Yamamoto A: Updated statistical data for malignant melanoma in Japan. Int J Clin Oncol 2001, 6:109-116.

17. Al-Maghrabi JA, Al-Ghamdi AS, Elhakeem HA: Pattern of skin cancer in Southwestern Saudi Arabia. Saudi Med J 2004, 25:776-779.

18. Muchmore JH, Mizuguchi RS, Lee C: Malignant melanoma in American black females: an unusual distribution of primary sites. J Am Coll Surg 1996, 183:457-465.

19. Bellows CF, Belafsky P, Fortgang IS, Beech DJ: Melanoma in African-Americans: trends in biological behavior and clinical characteristics over two decades. J Surg Oncol 2001, 78:10-16.

20. Green A, McCredie M, MacKie R, Giles G, Young P, Morton C, Jackman L, Thursfield V: A case-control study of melanomas of the soles and palms (Australia and Scotland). Cancer Causes Control 1999, 10:21-25.

21. Wiecker TS, Luther H, Buettner P, Bauer J, Garbe C: Moderate sun exposure and nevus counts in parents are associated with development of melanocytic nevi in childhood.

Cancer 2003, 97:628-638.

22. Briggs JC: The role of trauma in the aetiology of malignant melanoma: a review article.

Br J Plast Surg 1984, 37:514-516.

23. Kaskel P, Kind P, Sander S, Peter RU, Krahn G: Trauma and melanoma formation: a true association? British Journal of Dermatology 2000, 143:749-753.

24. Breslow A: Prognostic Factors in the Treatment of Cutaneous Melanoma. Journal of Cutaneous Pathology 1979, 6:208-212.

25. Kuchelmeister C, Schaumburg-Lever G, Garbe C: Acral cutaneous melanoma in caucasians: clinical features, histopathology and prognosis in 112 patients. vol. 143. pp.

275-280; 2000:275-280.

26. Phan A, Touzet S, Dalle S, Ronger-Savle S, Balme B, Thomas L: Acral lentiginous melanoma: a clinicoprognostic study of 126 cases. British Journal of Dermatology 2006, 155:561-569.

27. Soon SL, Solomon AR, Jr., Papadopoulos D, Murray DR, McAlpine B, Washington CV: Acral lentiginous melanoma mimicking benign disease: the Emory experience. J Am Acad Dermatol 2003, 48:183-188.

28. Fortin PT, Freiberg AA, Rees R, Sondak VK, Johnson TM: Malignant melanoma of the foot and ankle. J Bone Joint Surg Am 1995, 77:1396-1403.

29. Roberts D, Anstey A, Barlow R, Cox N: UK guidelines on the management of cutaneous melanoma. British Journal of Dermatology 2002, 146:7-17.

30. Richard MA, Grob JJ, Avril MF, Delaunay M, Gouvernet J, Wolkenstein P, Souteyrand P, Dreno B, Bonerandi JJ, Dalac S, et al: Delays in diagnosis and melanoma prognosis (I): the role of patients. Int J Cancer 2000, 89:271-279.

31. Richard MA, Grob JJ, Avril MF, Delaunay M, Gouvernet J, Wolkenstein P, Souteyrand P, Dreno B, Bonerandi JJ, Dalac S, et al: Delays in diagnosis and melanoma prognosis (II): the role of doctors. Int J Cancer 2000, 89:280-285.

32. Gregson CL, Allain TJ: Amelanotic malignant melanoma disguised as a diabetic foot ulcer. Diabetic Medicine 2004, 21:924-927.

33. Serarslan G, Akcaly C, Atik E: Acral lentiginous melanoma misdiagnosed as tinea pedis: a case report. Int J Dermatol 2004, 43:37-38.

34. Rosen T: Acral lentigious melanoma misdiagnosed as verruca plantaris: a case report.

Dermatology online journal 2006, 12.

35. Dalmau J, Abellaneda C, Puig S, Zaballos P, Malvehy J: Acral Melanoma Simulating Warts: Dermoscopic Clues to Prevent Missing a Melanoma. Dermatologic Surgery 2006, 32:1072-1078.

36. Valdes A, Kulekowskis A, Curtis L: Case Report: Amelanotic Melanoma Located on the Lower Extremity (letter). Am Fam Physician 2007, 76:1614.

37. Metzger S, Ellwanger U, Stroebel W, Schiebel U, Rassner G, Fierlbeck G: Extent and consequences of physician delay in the diagnosis of acral melanoma. Melanoma Res 1998, 8:181-186.

38. Bennett DR, Wasson D, MacArthur JD, McMillen MA: The effect of misdiagnosis and delay in diagnosis on clinical outcome in melanomas of the foot. J Am Coll Surg 1994, 179:279-284.

39. Bristow I: Dermoscopy - a technique for Podiatrists to assess pigmented lesions of the foot. In World Congress in Podiatry. Denmark; 2007

The Institute of Chiropodists and Podiatrists Training School, Sheffield

March/April10CPD

Letter from the President

A

s 2010 moves into spring we are fast approaching the time of our Annual General Meeting at Nottingham, this year being hosted by the Nottingham Branch. A great deal of work by the A.G.M. Committee is going into restructuring the event, with members and non-members being able to take part in concurrent C.P.D. sessions for the first time.

Please attend and support the occasion. The booking form can be found on the pages following.

Responding to the needs of the membership, the Executive Committee has been working to bring about changes in many areas, some which are now showing; new C.P.D. courses introduced by the Board of Education enable you to swiftly put these newly-learned skills into practice.

Negotiations continue with the planned extension to the Training Centre at Sheffield. Development work on the web site continues, on time and on budget. Members who forward their email address to Head Office will have access to the Members Area in which you are encouraged to use the Members Forum. This is for Institute of Chiropodists and Podiatrists members only so if you want to take part and are not a member already please apply for membership using the forms on our web site at http://www.Institute of Chiropodists and Podiatrists.org.uk/node/344 Comments from members are considered in planning future development of the site, remember that revision of the site will continue, evolving to meet the needs of the membership and market forces, just as the Institute of Chiropodists and Podiatrists does.

March/April 2010

With impending Parliamentary elections and the financial situation with government funds I do not expect more progress to be made towards further regulation of our sector for many months, although we continue dialogue with the H.P.C. and other professional organizations.

“Because you see the swan glide on the surface do not make the mistake of thinking we are not paddling like the devil underneath”, (with thanks to Jacob Braud and Bill Liggins).

The time draws near for members to have their democratic say in the running of the Institute of Chiropodists and Podiatrists, all nationally elected officers are put into office by you to plan on your behalf; this is your opportunity to make your voice heard. Each National Officer is elected every year by you the member. National Officers receive no pay in return and, speaking for myself, I do the work because I care about my profession and its future. I know I can make a difference as a member of the Institute of Chiropodists and Podiatrists, if I were in any other professional body, run for profit, I would not have that privilege. The Institute of Chiropodists and Podiatrists is run by the members, for the members, this makes it unique. The steady flow of new members joining us from other bodies proves this.

Each year at the A.G.M. it is an honour for the President to award the President’s Prize which is given to the person who has made the most outstanding contribution for the benefit of the Institute during the year. The prize is not restricted to Institute of Chiropodists and Podiatrists members and the rules are to be found in “The Articles of Association and Byelaws”. If you wish to nominate someone for the prize please send the nomination to Head Office, closing date is one month prior to the A.G.M. Heather Bailey

Annual ACPU Award

Applications are invited in the form of a dissertation of between 3,000 and 3,500 words on a subject connected with chiropody/podiatry. They will be judged by the ACPU Award Committee and the winner will be awarded a monetary prize at the Annual Dinner of the Institute held coincident with the Annual Conference in Nottingham.

Applications must arrive no later than Friday 9th April 2010 and must include the name and address of the author. The Award is open to all Chiropodists/Podiatrists and is not restricted to Members of the Institute of Chiropodists and Podiatrists.

All entries to be sent to:

IOCP, 27 Wright Street, Southport, PR9 0TL or email secretary@iocp.org.uk 19

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25% Urea

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Footcare Cream

For cracked heels and excessively dry skin.

Applied regularly this will quickly hydrate and moisturise the affected area.

General dry skin conditions can be treated with the 10% version of the cream, continued use will aid skin cell regeneration and dermal hydration.

Tea Tree

Deodorant

Footcare Cream

Footcare Cream

Used to treat tinea and other similar problems.

Also helps to control odour causing bacteria and prevent infection.

Contains both zinc oxide, to eliminate odour, and lavender to help prevent infection.

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ICB Newsletter )#" Orthotic /RTHOTIC Bi-Monthly "I -ONTHLY .EWSLETTER

Issue )SSUE 13

DLT: $,4 0845 230 4411

)NVERSION 3PRAIN ,ATERAL 0AIN

&OREFOOT 6ALGUS $EFORMITY AND /RTHOTIC 4HERAPY "Y !BBIE .AJJARINE "3C 0OD 1-5 5+ $IP 0OD .37 0ODIATRIST !USTRALIA ) OFTEN READ ARTICLES WRITTEN ON LATERAL SPRAIN AND PAIN ASSOCIATED WITH A PES CAVUS FOOT STRUCTURE AND A FOREFOOT VALGUS DEFORMITY )N THIS ARTICLE ) WILL EXPLAIN MY VIEWS AS TO WHY ) BELIEVE PATIENTS PRESENT WITH LATERAL SPRAIN AND STRAIN AND HOW TO USE A VARIETY OF TREATMENT MODALITIES IN COMBINATION WITH ORTHOTIC THERAPY TO TREAT THE PROBLEM EASILY AND SUCCESSFULLY /FTEN A PATIENT WILL PRESENT WITH REPETITIVE LATERAL ANKLE SPRAIN OR KNEE PAIN OR EVEN LATERAL SHIN SPLINTS AND SAY THAT THEY HAVE SUFFERED WITH THESE PROBLEMS FOR ALL OF THEIR LIFE OR THAT UPON COMMENCING A NEW EXERCISE REGIME PROBLEM HAS STARTED TO OCCUR

AND IT IS NOW IMPACTING ON THEIR QUALITY OF LIFE "ECAUSE MY PATIENTS WOULD ASK WHY THIS WAS HAPPENING TO THEM ) NEEDED TO INVESTIGATE AND TRY TO IDENTIFY AN UNDERLYING CAUSATION AS THE PAIN SHOULD NOT BE DEEMED @IDIOPATHIC AND HENCE NOT ADDRESSED 0ES CAVUS FOOT HIGH ARCH STRUCTURES SEE &IGURE ARE VERY INTERESTING BECAUSE IT IS GIVEN THAT THEY ARE A RIGID STRUCTURE AND IN NEARLY EVERY CASE ARE A SUPINATED FOOT STRUCTURE 4HE PATIENT WILL OFTEN INDICATE THAT THEIR JOINTS ARE PAINFUL AND WHEN THEY WALK ON mOOR BOARDS AT HOME WITHOUT SHOES THEY SAY h9OU CAN HEAR ME COMING AS ) THUMP UP AND DOWN THE

HALLWAY v 5SUALLY IN THIS TYPE OF STRUCTURE THE PATIENT WILL EXHIBIT A FOREFOOT VALGUS DEFORMITY WHICH MEANS THAT 4HE PLANTAR PLANE OF THE FOREFOOT REMAINS EVERTED RELATIVE TO THE PLANTAR PLANE OF THE REARFOOT WHEN THE SUBTALAR JOINT IS IN NEUTRAL

&IGURE 0ES #AVUS &OOT 3TRUCTURE

4HIS DEFORMITY WILL HAVE AN IMPACT ON THE PATIENT IN HEEL STRIKE MIDSTANCE AND TOE OFF PHASE OF GAIT 4HE PATIENT WHO EXHIBITS A PES CAVUS FOOT STRUCTURE WILL USUALLY PRESENT WITH A &OREFOOT VALGUS AND WILL OFTEN EXHIBIT A PLANTAR mEXED ST METATARSAL "OYD "OGDAN

ENCOURAGING THE FOOT TO STRIKE LATERALLY AND ELICITING PRESSURE ON THE LATERAL ASPECT OF THE HIP JOINT )F THE &OREFOOT VALGUS DEFORMITY IS

IN MY EXPERIENCE THE FOOT WILL CONTINUE TO SUPINATE THROUGH THE CYCLE HAVING A JARRING EFFECT ON THE UPPER STRUCTURE AND WILL PUT ADDITIONAL STRAIN ON THE ,ATERAL ASPECT OF THE STRUCTURE 7HEN THE FOOT IS SUPINATED IT CAUSES EXTREME STRESS ON THE PERONEALS AND MAY CAUSE ELONGATION OF THE MUSCLES AND TENDONS THUS WEAKENING THE RETINACULUM AND LENGTHENING THE PERONEALS CAUSING THE TENDON TO SUBLUX OFF THE LATERAL ASPECT OF THE MALLEOLAR

4HE &&4 6ALGUS IN GAIT WANTS TO REACH THE GROUND AND PROPULSION IS DELAYED CAUSING LATERAL INSTABILITY !S THE FOOT STRIKES LATERALLY IT THROWS IT INTO SUPINATION RESULTING IN TENSION AND TEARING ON THE PERONEAL MUSCLES

CAUSING INmAMMATION AND TENDERNESS TO TOUCH AND DIFlCULTY WALKING ,ATERAL ANKLE SPRAINS ARE MORE COMMON THAN MEDIAL DUE TO THE FACT THAT LIGAMENTS ARE WEAKER ON THE LATERAL SIDE (ENCE THE LACK OF LATERAL STABILITY CAN BE CAUSED BY UNCOMPENSATED OR PARTIALLY COMPENSATED REARFOOT A mEXIBLE FOREFOOT VALGUS OR OSSEOUS FOREFOOT VALGUS "OYD "OGDAN

(OLLIS ET AL 3HAPIRO ET AL

4HERE ARE ALSO CERTAIN BIOMECHANICAL FOOT DEFORMITIES THAT MAKE SOME PATIENTS MORE SUSCEPTIBLE TO INVERSION SPRAINS SUCH AS NEUROLOGICAL DElCITS AND SUPINATED FOOT TYPES WHICH EXHIBIT OR FUNCTION WITH A SUPINATED CALCANEUS VALMASSY

)T IS IMPORTANT TO ALWAYS ASSESS PATIENTS THAT PRESENT WITH LATERAL STRUCTURAL PAIN

FOR A FOREFOOT VALGUS 7HEN ) ASSESS ) LIKE TO USE THE SUPINE POSITION RATHER THAN PRONE AS IT REQUIRES LESS MOVEMENT OF THE PATIENT ON THE BENCH AND THE PATIENT CAN OBSERVE THE &IGURE A 4ESTING FOR A &OREFOOT 6ALGUS ASSESSMENT PROCEDURE THUS THEY ARE ACTIVELY INVOLVED IN THE EXPLANATION OF THE PROCEDURE !SSESSING IN THE PRONE

POSITION IS HOWEVER .EUTRAL OK IF YOU FEEL MORE COMFORTABLE DOING SO )F THE FOREFOOT VALGUS IS MY OBSERVATION IS THAT &&4 6ALGUS THE PATIENT WILL SUPINATE AT HEEL STRIKE

LATERALLY ROTATE THEIR FOOT TO &IGURE B -EASURING &&4 6ALGUS MAKE GROUND CONTACT AND THEN PRONATE AT MID STANCE TO TOE OFF SEE &IGURE 7HEN THE FOOT IS SUPINATED IT CAUSES EXTREME STRESS ON THE PERONEALS AND MAY CAUSE ELONGATION OF THE MUSCLES AND TENDONS 0ERONEAL TENSION OCCURS )N GAIT THE &&4 6ALGUS INVERTS THE FOOT TO GAIN GROUND CONTACT

IS APPLIED THE PATIENT WILL FEEL THAT THE ADDITION IS TOO MUCH AND THE METATARSAL SHAFTS WILL FEEL THAT THEY ARE JAMMING

WHICH MAY ENCOURAGE PRONATION IN MIDSTANCE TO TOE OFF )F THE FOREFOOT VALGUS IS VERY LARGE SAY A LOWER AMOUNT MAY NEED TO BE APPLIED TO ASSIST THE PATIENT IN BEING ABLE TO GET THE ORTHOTIC INTO THE SHOE 3UGGESTED 4REATMENT /PTIONS FOR ,ATERAL 0AIN s $EEP TISSUE MASSAGE ALONG THE PERONEAL MUSCLES OR SUCTION CUPS TO BREAK DOWN SCARING AND ADHESION s /RTHOTIC DEVICE WITH AN APPROPRIATELY SIZED FOREFOOT VALGUS ADDITION APPLIED SEE &IGURE !LWAYS START WITH A CONSERVATIVE SIZED VALGUS ADDITION AND BUILD UP FROM THERE TO ASSIST COMPLIANCE s !CUPUNCTURE AT THE POINT OF PAIN s ,ATERAL 0ROLOTHERAPY TO STRENGTHEN THE LATERAL ANKLE LIGAMENTS TO ENCOURAGE PROLIFERATION OF THE LATERAL LIGAMENTS FORMATION OF COLLAGEN lBRES s -OBILISATION OF THE CUBOID JOINT AS THIS MAY BECOME SUBLUXED s &OR LATERAL ANKLE SPRAINS USE STABILISING ANKLE STRAPPING

IN COMBINATION WITH THE ORTHOTIC DEVICE

3UPINATES FOOT &IGURE &OREFOOT 6ALGUS DURING GAIT

)N SUMMARY IF A PATIENT PRESENTS WITH LATERAL HIP PAIN

KNEE PAIN ANKLE STRAIN OR REPETITIVE LATERAL INVERSION SPRAIN

ALWAYS CHECK FOR A FOREFOOT VALGUS DEFORMITY AND EMPLOY THE FOLLOWING TREATMENT SUGGESTIONS TO ASSIST IN ALLEVIATING THE PAINFUL SYMPTOMS WHILST MOST IMPORTANTLY TREATING THE UNDERLYING CAUSATION )F THE PATIENT REQUIRES A FOREFOOT VALGUS POSTING TO BE ADDED TO THEIR ORTHOTIC DEVICES REMEMBER THAT THE MEASURED FOREFOOT VALGUS DEFORMITY WHEN APPLIED SHOULD BE REDUCED BY THE AMOUNT OF REARFOOT VARUS CORRECTION WHEN THE FOOT IS CORRECTED TO NEUTRAL &ORMULA &&4 6ALGUS MEASURED AS A VE .#30 MEASURED AS A VE 2ESULTANT 6ALGUS ADDITION &OR EXAMPLE IF THE REARFOOT MEASURES PLUS THE ASSESSED FOREFOOT MEASUREMENT OF RESULTANT VALGUS ADDITION OF )F THIS STEP IS EXCLUDED AND THE FULL VALGUS

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Continuing Professional Development 2010

26

Continuing Professional Development BOOKING FOR M

Please send your booking, together with a cheque or completed Credit/Debit Card Form to:The Institute of Chiropodists and Podiatrists, 27 Wright Street, Southport, Merseyside PR8 0TL Telephone: 01704 546141 Fax: 01704 500477 Email: secretary@iocp.org.uk Website: www.iocp.org.uk PLEASE COMPLETE IN CAPITAL LETTERS

Name: .....................................................................................................................................................................................

Address:...................................................................................................................................................................................... ...............................................................................................................................................

Tel No: ..............................................................................

Seminar

Branch/Organisation:

Date

Postcode: .............................

............................................................

Venue

Cost

Vascular & Neurological Assessment

Saturday, 20th March 2010

Sheffield

Laser Therapy

Saturday, 17th April 2010

Sheffield

Verrucae Treatments

Saturday, 29th May 2010

Sheffield

Skeletal & Muscular Systems

Saturday, 19th June 2010

Sheffield

TOTAL

£

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27

Venue: The Cheshunt Marriott Hotel, Haalfhide Lane, Turnford, Broxbou o rne, Hertfordshire, EN10 6NG

Our sp s eakers for the day: a Judit d h Brown ² now a Teaching Fellow to phase on o e medics at Durham University.

Trained as a podiatrist she now has an extensive, almost encyclopaedic, knowledge of ph p ysiology and pathology g . She has an easy lecture manner and has be een rated high hly by previous seminar attendees.

Essential Podiatry Clinical Knowledge Monday 22nd March 2010 at The Cheshunt Marriott Hotel Part 1. Advances in Rheumatology & related Pharmacology Part 2. Clinical Use of Dermal Fillers

Your Work as a Clinician Enhanced.

Introduce new treatments to your clinics.

Martin Harvey - is truly innovative in his cosmetic practice of enhancing his clinical skills with Dermal fillers. An aesthetic practitioner, he works in advancing clinical skills. Experienced in the use of Botox and Prolotherapy, he is a dynamic and fascinating lecturer.

The HPC continues to randomly audit ou ur profession bi-annually. The process is for you to show attendance and learning on clinically relevant courses that ensure you work effectively for the benefit of the patient. Currently the period for your CPD portfolio is between June 2008 and June 2010. Podiatric Rheumatology and Pharmacology is the topic we all need to have reviewed and this da d y has been de d signed to t br b ing a fresh and innovative approach to t your patients who need a professional and modern approach to their foot problems.

CPD Cycle June 2008 to June 2010 ´'HPRQVWUDWH %HQHILWV WR 3DWLHQWV¾ It will be an opportunity to refresh your knowledge and meet ot o her clinicians. We promise a fact filled day to genuinely enhance your clinical practice, with 5 CPD C p points. Pre -reading for the course allows you to claim an extra CPD D point.

Dear Colleagues , Supplefeet would like to invite you to join us at our next one day seminar which is an Essential Podiatry Clinical Knowledge for your role as a clinician.

The morning session is led by Judith Brown ² Teaching Fellow in Medicine- on advances in Rheumatology & related Pharmacology.

The afternoon session is a detailed clinical look on the use of Dermal fillers by the renowned expert Martin Harvey, aesthetic podiatrist.

Seminar Agenda Mon onday 22nd March The Cheshunt Marriott Hotell

An agenda for the day is included. If you would like to attend pl p ease complete the registration form and return to t our address. You can also register online for any of our semina ars at www.su upple efeet. t com/seminars. Please find attached the seminar agenda and the registration form.

We look forward to seeing you there.

Emma Supple Podiatrist & Podiatric Surgeon

We have received some excellent comments from our delegates: œ(QMR\HG FRXUVH ² JRRG OHQJWK K YHQXH DQG LQWHUHVWLQJ OHFWXUHV¡ œ%ULOOLDQW ² ZH ZLOO EH RQ WKH QH[W RQH¡ œ7RRN ORDGVV RI QRWHV DV DOO VR LQWHUHVWLQJ ² WKDQN \RX YHU\\ PXFK¡

Time Start

Time Finish

Subject/Activity

08.30

09.00

Registration and Refreshments

09.00

09.15

Introduction by Miss Emma Supple

09.15

10.00

The pathology off related disorders, in pa articular Rheumatoid Arthritis.

10.00

10.45

The clinical challenges in managing your patients with effective outcomes - NHS and privately

10.45

11.15

Tea and Co offee (time for questions)

11.15

12:30

New pharmacological approaches ² biologic drugs in particular

12:30

13:30

Hot Lunch served in the Restaurant

13.30

15:30

15:30

16.00

Seminar Roundup Se

16:00

16:30

Evaluation and feedback

The Science of Dermal Fillers; with a practical session.

What filler to choose and why? Advance your clinical knowledge g with these innovative treatments for de ecreased fibrofatty padding, corns and callus.

Price ÂŁ99.00 includes VAT, refreshments available all day and lunch served in th t e Marriot Restaurant.

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œ$OO UHOHYDQW ² JUHDW LQVLJKW¡ œ([ [FHOOOHQW DQG YHU\\ LQWHUHVWLQJ¡ œYHU\\ LQWHUHVWLQJ HQ QMR\DEOH H¡ ¾H[FHOOHQW GD\œ ¾WKLV KDV EHHQ YHU\ LQVSLULQJ ¹ SOHDVH GR RQH DJ D DLLQœ ¾, WKRXJKW WKH RUJ JDQLV VDWWLRQ RI WKH FRXUV VH ZDV H[FHOOHQW SOHQWLIXO UHIUHVK V PHQWV DQG IRRG œ

Bring your swimsuit with you and relax after the seminar.

All hotel leisure facilities including swimming pool are available for the Supplefeet seminar de elegates

13 Genotin Terrace Enfield EN1 2AF Tel: 020 8367 9292 www.supplefeet.com

Seminar Registration Form Monday 22nd March 2010 Essential Podiatry Clinical Knowledge

Seminar: Name:

Address:

Post Code:

Tel:

Fax:

E-mail: Profession: (Please tick) Podiatrist Osteopath

Chiropractor

Physiotherapist

Other

Please advise of any special dietary requirements:

Remittance: £99 per Delegate

(includes lunch and refreshments)

&KHTXH ² made payable to Supplefeet Ltd , ZRXOG OLNH WR SD\ EH &UHGLW 'HELW &DUG 3&7·V FDQ SURYLGH D 32 DQG EH LQYRLFH E\ DJUHHPHQW ² please contact Supplefeet Visa

MasterCard

Issue No (switch only) :

Switch Expiry date: Start Date:

/ /

Card Number:

Email back to info@supplefeet.com or book online or post to: Supplefeet 13 Genotin Terrace, Enfield, Middlesex, EN1 2AF

Any Questions? Tel: 020 8367 9292 or email seminars@supplefeet.com Terms & Conditions: A completed booking form indicating one of the following payment methods will denote acceptance of the cancellation clause below.

Cheque: a cheque drawn on a UK bank is necessary. Cheques should be made payable to Supplefeet Ltd Credit Card: We are happy to accept payment by Mastercard/Visa. Please tick the appropriate box.

Cancellation Terms: Delegates who cancel prior to 14 days before the seminar will have fees refunded in full. No refunds will be made after this date but replacement delegates may be nominated. The seminar has a minimum as well as maximum attendance levels. The seminar may be cancelled if too few reservations are received, in which case you will be notified approximately 5 days prior to the date with a full refund of your fee. If the seminar has to be cancelled at the last moment for reasons outside the control of Supplefeet, we will refun d your fee in total, but cannot be held liable for any other expenses.

Registered Office: 255 GREEN LANES, PALMERS GREEN, LONDON, N13 4XE Registered Number: 04983960 www.supplefeet.com

29

Five pairs of Crocs to Give Away e have five pairs of Crocs Work Specialist shoes to give away courtesy of LookAtMyCrazyShoes.com the web store that stocks a range of top brands for on or off duty, including Crocs, Fitflop and UGG.

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Perfect for treatment rooms or for going out and about, Crocs Work Specialist shoes have a closed toe and heel, plus a thick metatarsal area to protect the top of your foot.

Made from bacteria and odour resistant Croslite™, these comfy clogs conform to your foot shape for a custom fit.

Easy to sterilise in water and bleach, they have a built-in arch support and footbed nubs to stimulate circulation.

Jibbittz shoe charms can be inserted into the straps.

LookAtMyCrazyShoes.com is a sister company to Cosyfeet, the extra-roomy shoe specialists for patients with swollen feet.

To enter the draw, simply visit www.lookatmycrazyshoes.co.uk/PROFFER

The draw will take place on xx.Winners will be notified by email or post.Terms and conditions: only one entry per reader.The prize is as stated and no cash alternative will be offered.The judge’s decision is final and no correspondence will be entered into.

Putting the power back into your step

W

e’ve all noticed how, after a day of walking, our feet can really feel the strain. During a lifetime, we take enough steps to walk around the planet more than four times – approximately 115,000 miles, which means proper foot care is imperative to keep feet healthy.

Powerstep from Carnation Footcare is a unique podiatric support system designed to correct and stabilise foot alignment.

By aiding foot posture and mechanics Powerstep helps to relieve heel and arch pain and protect against injury.

Podiatrist, Dave Wain says, “Hard surfaces and lots of walking can cause more problems for people who excessively pronate (excessive rolling inwards of the feet). Research indicates that up to 90% of the population excessively pronate, which causes arches to flatten, collapse and soft tissue to stretch abnormally, causing the joint surfaces to function at unnatural angles to each other.

“At first this causes fatigue and strain on the arch, heel, ankle, knee and back, often resulting in great pain, but Powerstep can provide great relief.”

Excessive pronation will be diagnosed by a visit to a podiatrist but Dave Wain has some tell tale signs that you can check for yourself: 1) Look at wear patterns on the bottom of your shoes, extreme wear on the balls of the feet especially towards the big toe area is often a sign.

2) Place your shoes on a level surface and look at the heels at eye level, look for heels that tilt the shoes inwards.

3) Stand barefoot with a mirror behind you, the Achilles tendons at the back of your heels should run straight in normal feet. Also look at the bony prominence each side of your ankle. They should look fairly equal, but if one side is more pronounced than the other this can be an indicator.

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Dave Wain says, “By preventing excessive pronation with Powerstep, the likelihood of other related conditions such as bunions, corns and even ingrown toe nails occurring can be reduced.”

Powerstep helps feet withstand the most gruelling of walks with a 4-part design, including: – A heel cradle and platform for stability – A prescription standard arch support – A unique double layer cushion casing – An anti-bacterial top layer to help prevent odours

Powerstep is available from pharmacies in S, M and L, priced £22.99.

For further information about Powerstep contact Carnation Footcare on 0800 018 7117 or visit www.powerstep.co.uk. For more information on the complete Carnation Footcare range, please go to www.carnationfootcare.co.uk Dear Editor I am writing to formally thank John Patterson for the dedication he has given to the Cheshire/N. Wales/Staffordshire and Shropshire Branch. He has kept the members and especially the various position holders of the branch moving forward as Chairperson of this branch since it was formed 12 yrs ago. Oh... Scarry where the time has gone and amazing how none of us look any older (or did our eyes just grow dimmer?)

He is now involved with a lot of training at Sheffield and we wish him all the best with this.

Thanks John!, Michelle Heald

Achilles has a habit of wandering through a multitude of journals, but any additional material is always welcome and should be sent to Institute H.Q. for the attention of Mrs. Bet Willey. Achilles is, and will remain, anonymous.

Abbasi K. Editor of the Journal of The Royal Society of Medicine in the December 2009 volume, notes that Bertrand Russel asked whether a scientific society could exist. Abbasi suggests that the question should be framed as ‘Is it possible to create a scientific society?’ A number of Premier League football clubs have sent their star players to a Serbian housewife/therapist named Mariana for ‘treatment’ of ankle, knee, hamstring and calf injuries. It seems that Mariana can defy the laws of tissue healing by reducing recovery time from 8 weeks to 2 days. Quite how this miraculous cure is effected remains a mystery. She is said to apply or inject a cream or liquid which contains stem cells from human or horse placenta, she then might apply some sort of electrical impulse to ‘stimulate’ regeneration. There has been no testing, there is no evidence and the placebo effect has not been taken into account; as Abbasi states ‘Whether horse placenta is any better than horse dung has not been evaluated.’ It is certainly astonishing that players valued at £50 million are being subjected to totally unresearched procedures. Cynically, it might be thought that Wayne Rooney was sent out to play in the last World Cup only 4 weeks after fracturing a metatarsal. Could this be a similar ‘miracle’?

RA

The British Medical Journal of 9th January carried an interesting article by Aranegui B. et al. entitled ‘Generalised Tetanus in a Patient with a Chronic Ulcerated Skin Lesion’. Such a clinical presentation is rare in developed countries but antibodies to various infections are well known to decrease with increasing age. Both chronic and acute wounds can allow entry to clostridium tetani with resulting complications. In the case discussed, a 67 year old otherwise healthy male presented with two skin lesions on the right lower leg. The lesions were noted to be over the right medial malleolus, were asymptomatic, eroded, scabbed and were violaceous plaques. A biopsy was taken under standard aeseptic conditions for investigation. Three weeks later the patient attended when the wound was necrotic and dirty and he exhibited the classical signs of tetany.

He required intubation and multipharmacy due to complications and was admitted to the Intensive Care Unit for 49 days before discharge. The diagnosis of the original lesions was sarcoidosis with cutaneous and pulmonary involvement and this was treated with cortico-steroids. The moral of the story is that even an apparently simple ulceration can lead to complications and patients who present with such a condition should be instructed to keep the area clean and dressed and gardening should be avoided

MBLIN

Assistive Technologies journal December 09/January 10 issue features research carried out by a team at Teeside University to ascertain whether using a textured insole might assist in avoiding falls in the elderly. Volunteers who are in otherwise good health, but who have fallen at least twice in the previous year are assessed. The tests include eyesight, balance, muscle activation and plantar sensation. Although not stated in the article, presumably the object is to improve proprioceptive feedback from the plantar surfaces of the feet.

RO

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The Proceedings of the National Academy of Sciences, DOI:10.1073/pnas.0908882 reports that patches of synthetic Whilst on the subject of lower limb ulceration, in skin could soon be delivering gene therapies without the The Journal of The Royal Society of Medicine need for injections. A team at the National Institutes of December 2009, Chalmers C.R. and Chaloner E.J. Health in Bethesda USA cultured fibroblasts and discuss King Henry VIII and some of his physical keatinocytes and introduced a gene for atrial nariuretic afflictions. In some circles it has long been thought that peptide, which is released naturally by cells in the his bilateral ulceration was due to the effects of syphilis, heart. It reduces blood pressure by dilating a disease from which he was known to suffer. However, the vessels and decreasing blood volume. authors point out that the physicians of the time were well The synthetic skin was applied versed in the secondary presentation of the disease and did treat to the skin of mice and these with some success using mercury - a treatment which caused a drop in blood continued in use until well into the 20th century. It is well known that pressure, even when Henry was a great (and highly skilled) jouster but suffered severe injuries the creatures were subject in 1536 when his horse fell and crushed both his legs. It is suggested that such to a high salt a crush injury and the king's later obesity would both predispose to deep vein diet. thrombosis and venous insufficiency. In addition, an untreated compound fracture might also result in infection with cellulitis, osteomyelitis and deep abscess formation with a discharging sinus. The treatment carried out on Henry viz. the frequent opening of the fistulae by lancing with re-hot pokers - as the authors observe with admirable understatement - was unlikely to have improved the King's ill temper. The King's diet, replete with high cholesterol foodstuffs is now known to lead to type II diabetes, hypercholesterolaemia and atherosclerosis. Henry suffered from gross swelling of the legs towards the end of his life. It does therefore seem quite plausible that venous ulceration as a complication of the above noted factors is more likely than the effects of syphilis in his case.

A DS

Elizabeth Bathory, the real 16th century 'Countess Dracula' who legend has it bathed in the blood of young virgins in order to preserve her youth was, in fact, correct - perhaps! New Scientist 30-01-2010 reports that in an experiment at the Harvard Stem Institute in Boston, the blood supplies of old and young mice were conjoined.

This apparently resulted in the rejuvenation of the ageing blood stem cells of the older mice. It also revitalised the 'niche' cells in the bone marrow which nourish and support the blood stem cells, although old mice make more blood stem cells and 'niche' cells than young mice. It is hypothesised that older mice have a greater number of faulty and damaged cells as well as too many myeloid cells contributing to inflammation, and conversely too few lymphoid cells for tissue repair. Sadly for Achilles and his ilk, a 'one off' exposure to the relevant blood factors will not reverse ageing, it would need to be constant

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Diary of Events March 2010

April 2010

Cheshire North Wales Branch Meeting and Seminar

Devon and Cornwall Branch Meeting

21st March at 10.00 a.m.

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

Leeds/Bradford Branches 6th March Full Day Seminar Huddersfield University HD1 3DH Tel: 01274 546424 or 01653697389

Leicester & Northants Branch 7th March Emergency First Aid in the Workplace Kilsby Village Hall - 9.30 a.m.

Registration and Refreshment 9.15 a.m.

Cost £45.00 payable in advance Further details Tel: Sue 01530 469816

West Middlesex Branch meeting 8 March at 8.00 p.m.

The Harvester, Watford Road, Croxley Green, Rickmansworth WD3 3RX Tel: 0208 903 6544

plus lecture to topup First Aid Appointed Persons Certificate - 10th April at 10.00 a.m.

The Belmont Chapel, Exeter Tel: 01805 603297

Leeds/Bradford Branch Meeting 11th April - 10.00 a.m. The Oakwell Motel, Birstall, Nr. Leeds WF17 9HD Tel: 01653 697389

Leicester & Northants Branch 11th April Branch Meeting plus lecture, Kilsby Village Hall, Registration and Refreshment 9.45 a.m.

Tel: Sue 01530 469816

London Branch Meeting 7th April at 7.30 p.m. Victory Services Club, 63-79 Seymour Street, London W2 2HF Tel: 01895 252361

North of Scotland Branch Meeting Please phone secretary for date and time The Heugh Hotel, Stonehaven, Aberdeenshire

South Wales and Monmouth Branch Meeting

Nottingham Branch Meeting

25th April Taffs Well Ex Service Mans Club, Taffs Well Tel: 02920 331927

Wednesday 24th March The Red Cross Centre, Nottingham

Surrey & Berkshire Branch Meeting Tel: 0115 932 8832

North West Branch Meeting 21st March

Tel: 0161 486 9234

Oxford Branch Meeting 13th March at 10.00 a.m.

89 Rose Hill, Oxford OX4 4HT

12th April at 7.30 p.m.

Pirbright Village Hall

Tel: 0208 660 2822

Western Branch Meeting 18th April 12.15 p.m. Women’s Hospital, Crown Street, Liverpool Tel: 01745 331827

West of Scotland Branch Meeting Tel: 01993 883397

Sheffield Branch Meeting 18th March at 7.30 p.m.

SWD Sports Club, Heeley Bank Road, Sheffield CPD Presentation - Malignant Melanoma

by Martin Harvey Tel: 01623 452711

Sunday 18th April at 11.00 a.m.

The Express By Holiday Inn, Springkerse Business Park, Stirling FK7 Tel: 01796 473705

May 2010 West Middlesex Branch meeting

Surrey & Berkshire CPD meeting

10th May at 8.00 p.m.

The Harvester, Watford Road, Croxley Green, Rickmansworth WD3 3RX Tel: 0208 903 6544

29th March at 7.30 p.m.

Pirbright Village Hall

Nottingham Branch Meeting

Tel: 0208 660 2822

Sussex Branch Meeting 21st March at 9.30 a.m.

The Bent Arms, High Street, Lindfield, RH16 2HP Tel: 01273 890570

Wolverhampton Branch Meeting Sunday 21st March - 10.00 a.m.

4 Selman’s Parade, Selman’s Hill, Bloxwich WS3 3RN Tel: 0121 378 2888

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Sunday 23rd May at 7.00 p.m.

The Red Cross Centre, Nottingham Tel: 0115 932 8832

Sheffield Branch Meeting May at 7.30 p.m. (date to be confirmed please phone secretary) SWD Sports Club, Heeley Bank Road, Sheffield Tel: 01623 452711

Surrey & Berkshire CPD Meeting 17th May Tilehurst, Reading.

Contact Sue Marchant

Tel: 0208 660 2822

June 2010

Nottingham Branch Meeting

Leeds/Bradford Branch Meeting

Thursday 2nd September at 7.00 p.m.

The Red Cross Centre, Nottingham Tel: 0115 932 8832

6th June - 10.00 a.m.

The Oakwell Motel, Birstall, Nr. Leeds WF17 9HD Tel: 01653 697389

Southern Area Council meeting

Leicester & Northants Branch

South Wales and Monmouth Branch Meeting

11th September at 1.00 p.m. Victory Services Club 63-79 Seymour Street, London W2 2HF

27th June Branch Meeting plus HPC audit guide Kilsby Village Hall Registration and Refreshment 9.15 a.m.

Tel: Sue 01530 469816

5th September Taffs Well Ex Service Mans Club, Taffs Well Tel: 02920 331927

Oxford Branch Meeting

Surrey & Berkshire Branch CPD meeting

5th June at 10.00 a.m.

89 Rose Hill, Oxford OX4 4HT

20th September at 7.30 p.m.

Pirbright Village Hall

Tel: 01993 883397

Western Branch Meeting

Western Branch Meeting 13th June 12.15 p.m. Women’s Hospital, Crown Street, Liverpool Tel: 01745 331827

Southern Area Council Meeting 19th June at 1.00 p.m. Victory Services Club 63-79 Seymour Street, London W2 2HF

West of Scotland Branch Meeting Sunday 6th June at 11.00 a.m.

The Express By Holiday Inn, Springkerse Business Park, Stirling FK7 Tel: 01796 473705

Wolverhampton Branch Meeting Sunday 27th June - 10.00 a.m.

4 Selman’s Parade, Selman’s Hill, Bloxwich WS3 3RN Tel: 0121 378 2888

July 2010 Surrey & Berkshire Branch Meeting 3rd July at 1.30 p.m.

Greyfriars Centre, Reading

Tel: 0208 660 2822

Tel: 0208 660 2822

West Middlesex Branch meeting 12th July at 8.00 p.m.

The Harvester, Watford Road, Croxley Green, Rickmansworth WD3 3RX Tel: 0208 903 6544

5th September Blair Bell Education Centre

Tel: 01745 331827

West of Scotland Branch Meeting Sunday 19th September at 11.00 a.m.

The Express By Holiday Inn, Springkerse Business Park, Stirling FK7 Tel: 01796 473705

October 2010 Devon and Cornwall Branch Meeting Please phone secretary for details The Exeter Court Hotel, Kennford, Exeter Tel: 01805 603297

Leeds/Bradford Branch Meeting 3rd October - 10.00 a.m.

The Oakwell Motel, Birstall, Nr. Leeds WF17 9HD Tel: 01653 697389

North of Scotland Branch Meeting Please phone secretary for date and time The Heugh Hotel, Stonehaven, Aberdeenshire Tel: 01382 532247

Oxford Branch Meeting 9th October at 10.00 a.m.

89 Rose Hill, Oxford OX4 4HT

Tel: 01993 883397

Sheffield Branch Meeting

September 2010

October at 7.30 p.m. (date to be confirmed please phone secretary) SWD Sports Club, Heeley Bank Road, Sheffield Tel: 01623 452711

London Branch Meeting

Surrey & Berkshire Branch meeting

8th September at 7.30 p.m. Victory Services Club, 63-79 Seymour Street, London W2 2HF Tel: 01895 252361

11th October at 7.30 p.m.

Pirbright Village Hall

West Middlesex Branch meeting

24th October at 9.30 a.m.

The Bent Arms, High Street, Lindfield, RH16 2HP Tel: 01273 890570

13th September at 8.00 p.m.

The Harvester, Watford Road, Croxley Green, Rickmansworth WD3 3RX Tel: 0208 903 6544

North West Branch Meeting 26th September

Tel: 0161 486 9234

Tel: 0208 660 2822

Sussex Branch Meeting

Wolverhampton Branch Meeting Sunday 10th October 10.00 a.m.

4 Selman’s Parade, Selman’s Hill, Bloxwich WS3 3RN Tel: 0121 378 2888

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The XXth World Congress on Podiatry, May 13-15 2010 Amsterdam (The Netherlands)

As a Dutchman I may be a little biased with this particular conference but I hope to wet your appetite and greet you at the FIP conference in May. Canonbury have been corporate sponsors of FIP (Federation Internationale de Podologues) for many years together with amongst others, Spenco USA and Canada, Vasyli International and Algeos.

The last international conference was held in Copenhagen in 2007 and this attracted over 1,000 Delegates from the then 22 member countries.

There was a real GLOBAL feel. Since then FIP have had a further 8 countries join. Representatives and podiatrists from those new countries will attend (Spain, Portugal, New Zealand, Morocco and Germany). Amsterdam (I promise the sun will shine) in May will be beautiful and offers dozens of sight seeing opportunities. It is the perfect time to visit “Keukenhof” where you will see flowers you have never seen before. Canonbury are looking to invite all UK based delegates for a drinks reception and I very much hope to see you there.

Hans Bakker, Canonbury Porducts, Simply Feet

ll podiatrists throughout the world are invited to be present in Amsterdam for the XXth FIP World Congress of Podiatry to be held at the RAI Exhibition and Convention Centre in Amsterdam, The Netherlands, May 13-15, 2010. We would like you to enjoy both our congress, the city of Amsterdam and The Netherlands in general. Amsterdam, the capitol of The Netherlands and one of Europe’s most exciting cities, offers a wealth of attractions to its visitors. The city boasts nearly eight hundred years of history. For centuries, Amsterdam has struggled against the water; nowadays water is a source of pleasure. You will feel right at home in the Dutch capital, where English has become a second language.

Live foot clinics

We are planning an interesting and inspiring program for this XXth anniversary of the three yearly FIP congress. Every day will start with 2-3 keynote speakers on several interesting topics, as the rheumatoid foot, the Special Olympics, the diabetic foot and Evidence Based practise in Podiatry. After this every day 6 different sessions, 3 with oral presentations and 3 with practical information and/or hands-on workshops. The practical sessions do have limited space, so you have to be early, as full is full. We are planning to organize the entrance for the practical sessions day by day, so you can’t make any reservations on forehand.

Completely new is the launch of the Academy of Podiatric Medical Educators. All podiatrists involved and interested in teaching are invited to enter this track, to be informed of the latest views on podiatric education. Speakers in this track will be Anthony McNevin, Stuart Baird and Vincent Hetherington.

A

In addition to keynotes on different subjects, interesting case studies and lectures on our profession from all over the world, we would like to present several new elements within this Congress:

Workshops Workshops will give you the opportunity to learn new techniques and practice these under the supervision of renown specialists. You will have the opportunity to practise the AnkleArm Index, get the latest information and practical teaching on screening of the diabetic foot and practise with computerized gait analysis.

Robert van Lith workshop A practical hands-on program on conservative treatment with felt paddings and silicones, in the honor of the late ROBERT VAN LITH, past-president of FIP and one of the most legendary podiatrists in Europe since the introduction of the profession.

The workshop will be opened by Marie-José van Lith, French podiatrist and the wife of the late Robert van Lith.

34

The ‘live foot clinics’ are sessions about the daily practise of the podiatrist. Real patients will be treated on stage and discussed with the audience in an interactive way. You can be part of the discussion and treatment, as everything will be shown on a big screen.

More interactive sessions Several other interactive sessions will be presented as ‘A day at the office’ of a DPM, the Special Olympics and examining a mental disabled athlete and we also offer a session on sport shoes.

The Academy of Podiatric Medical Educators

There will be AWARDS for the most outstanding poster(s) and presentation(s).

Besides the scientific part of the Congress we do invite you all to enjoy Amsterdam. On Thursday directly after the program at the back of the Conference Hall there will be boats waiting for us for a canal ride through Amsterdam. This will be an exciting experience. Also the Conference Dinner, to be held in the middle of old Amsterdam in the beautiful restaurant Beurs van Berlage, will be a great experience. You have to register for both on forehand and you have to pay an extra fee, as mentioned on our website.

For all details, registration and information, but also the special social program please visit: www.fipworldcongress.org. Mind that the early registration fee ends at the 15th of February!

Additionally we have a Special Offer: For those interested in education, there will be an opportunity to visit the Dutch Schools for Podiatry and learn about their programme and facilities. The schools are based in Enschede (Saxion Hogescholen, founded in 2002), Eindhoven (Fontys Hogescholen, founded in 1982) and Amsterdam (Fontys Hogescholen, started September 2007). On your registration form you can make your interest known.

So there are many good reasons for you to spend a few days in The Netherlands in May and we hope to meet you all at the XXth FIP World Congress: you can’t miss this!!

The Institute Strongly advises any applicants seeking employment to obtain a formal “Contract of Employment”

Chiropodist/Podiatrist Required

ESSEX Chiropody/Podiatry Position Vacant. SOUTHEND-ON-SEA Cubicle available within busy physiotherapy clinic (established 20+ years) Ground floor with wheelchair access.

Good local parking. Very close to Thorpe Bay train station.

Buses nearby. Hours to suit individual. Footbath already installed but applicant must be HPC registered and be able to supply all their own equipment.

Please contact 01702 588831 or email kentesclinic@hotmail.co.uk for further details.

ESSEX Part-Time Chiropodist Required Mondays and Saturdays – 9.00 a.m. - 5.00 p.m.

The Walk Chiropodist. Telephone: 01277 633220 CHIROPODIST REQUIRED LONDON Treatment rooms to let in a modern, state-of-the-art chiropractic clinic in NW London. We are looking for a chiropodist/podiatrist to join our friendly team. Rates negotiable.

Contact Danine Irwin 0208 905 4440 or cdi@carlirwin.co.uk PART-TIME SELF-EMPLOYED PODIATRIST POST – WITH OPPORTUNITY TO EXPAND ACTIVE VIII

Henley Physiotherapy, Sports Injury and Biomechanics Centre.

Fantastic opportunity for a highly skilled & enthusiastic podiatrist to work in a dynamic and supportive environment with a multi-disciplinary team of 14. We have excellent facilities including Biomechanics lab (incorporating motion analysis systems, RSScan footscan and thermo-moulding system) and ultrasound scanner.

Join our team and use the very latest facilities. Excellent package for the right person, including regular in-service training.

Contact: Geraldine Watkins on 01491 577129 for a friendly chat or to arrange a visit.Email: gerry@active-viii.org www.active-viii.com

Chiropody Supplies

BUSINESS CARDS printed 1 side: 1,000 = £40, 10,000 = £96.

Appointment Cards printed two sides: 10,000 = £99. Record Cards, Continuations, Sleeves all 8” x 5” x 1,000 = £59. Small Receipts: 2,000 = £48, 4,000 = £68. Des Currie: 01207 505191.

BERGMAN UK – For all your Orthotic Requirements 28 High Street Northallerton, North Yorks DL7 8EE. Telephone: 01609 781397 or 07877 986605.

Practice for Sale CENTRAL SURREY New year, new opportunity? Your chance to acquire this modern profitable practice showing continuing growth. Situated in a good location within a market town. Transferable goodwill with a loyal patient base and great patient feedback with 95% of surveyed patients consistently ‘satisfied with everything’. Owners have a genuine reason for sale. The practice comes fully equipped.

Includes 2 treatment rooms, staffed reception, WC and car parking. Turnover £70,000 approx from mixed caseload including chiropody, biomechanics, orthoses, video gait analysis, and nail surgery. Scope for expansion. All serious enquiries in strictest confidence to e-mail: surreyfootcareclinic@hotmail.co.uk or call 07931 255132.

AMBER CHIROPODY SUPPLIES

Serving the chiropodist/podiatrist with all the essential daily consumable items for a busy practice, including: * Instruments & Equipment * Padding & Appliances * Dressings & Adhesives * Biomechanics

* Domiciliary * Sterilization * Diagnostics * Retail Products

To view our website/online store please visit:

www.ambersupplies.co.uk

Leicester and Northants Branch 28th November 2010 Branch Seminar

Lecture on Dermatology Ivan Bristow, Southampton University Trade support from Canonbury Autoclave servicing (by appointment) Lutterworth Cricket Club Registration and Refreshment 9.45 a.m.

Further details Tel Sue 01530 469816

35

National Officers

Branch Secretaries

President Mrs. F. H. Bailey M.Inst.Ch.P

Birmingham

Mrs. J. Cowley

01905 454116

Bradford

Mrs. S. Keighley

01274 546424

Cheshire North Wales

Mrs. D. Willis

0151 327 6113

Devon & Cornwall

Mrs. M. Reay

01805 603297

East Anglia

Mrs. S. Bennett

01223 881170

Essex

Mrs. B. Wright

01702460890

Hants and Dorset

Mrs. J. Doble

01202 425568

Kent

Mrs. C. Hughes

01303 269186

Leeds

Mr. M. Hogarth

01653 697389

Leicester & Northants

Mrs. R. Rose

01582 668586

London

Mrs. L. Towson-Rodriguez 01895 252361

North East

Mrs. E. Barwick

0191 490 1234

North of Scotland

Mrs. S. Gray

01382 532247

North West

Mr. B. W. Massey

0161 486 9234

Northern Ireland

Mrs. C. Johnston

02893 340589

Nottingham

Mr. S. Gardiner

0115 932 8832

Oxford

Mrs. S. Harper

01993 883397

Republic of Ireland

Mr. R. Sullivan

00353 5856 059

Area Council Executive Delegates Irish Area Council Mr. R. Sullivan M.Inst.Ch.P

Sheffield

Mrs. D. Straw

01623 452711

Sth Wales & Monmouth Mrs. J. Nute

02920 331 927

Midland Area Council Mr. D. Elliott Hon.F.Inst.Ch.P

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

Mrs. J. Drane

01796 473705

Wolverhampton

Mr. D. Collett

0121 378 2888

Yorkshire Library

Mrs. J. Flatt

01909 774989

Chairman Executive Committee Mr. R. Beattie Hon. F.Inst.Ch.P Vice-Chairman Executive Committee Mr. D. A. Crew OstJ, F.Inst.Ch.P., DCh.M Chairman Board of Ethics Mr. S. Willey M.Inst.Ch.P., L.Ch. Chairman Board of Education Mr. W. J. Liggins F.Inst.Ch.P., F.Pod.A., B.Sc(Hons) Vice-Chairman Board of Education Mr. J. W. Patterson B.Sc(Hons)., M.Sc., M.Inst.Ch.P Honorary Treasurer Mr. R. H. Henry F.Inst.Ch.P., D.Ch.M

Standing Orders Committee Mr. C. B. Goldman M.Inst.Ch.P., D.Ch.M Mrs. L. Pearson M.Inst.Ch.P

Secretary Miss A. J. Burnett-Hurst

North West Area Council Mr. M. J. Holmes M.Inst.ChP., D.Ch.M, B.Sc.Pod Scottish Area Council Mrs. A. Yorke M.Inst.Ch.P Southern Area Council Mrs. M. Newnham M.Inst.Ch.P Yorkshire Area Council Mrs. J. Dillon M.Inst.Ch.P

36

Graduation News Congratulations Valerie!

Pictured below is Valerie Probert Broster who recently obtained a BSc (Hons) in Podiatry at the University of Brighton.

Pictured at the awards ceremony are Valerie with her youngest son, Sebastian and husband Godfrey.

Very well done from all at the Institute.

Midland Area Council

The Midland area Council met on Sunday 31st January at the Village Hall Kilsby Nine members attended representing five branches It was agreed to hold the Next MAC Seminar on:

2nd October 2010 at Leicester Subject: Rheumatology Details to follow Make a date in your diary now!

David Elliott Chair MAC

Following on from the success of Foot Health 2009 we are pleased to give details of this yearâ&#x20AC;&#x2122;s CPD lecture programme Foot Health 2010 offers Health Professionals the opportunity to update their practice with first class presentations by key note speakers

Health Care Professionals who would like to attend this event can do so by booking their place online for a booking fee of just ÂŁ5 + vat.

Please visit w

for full details.

Last year this event was sold out to over 600 professionals so please book your place early to avoid disappointment.

June 22nd & 23rd 2010 Kettering Conference Centre CPD EVENT www.professionalevents.co.uk

EXCLUSIVE VIDEO DEMO at www.canonbury.com

Order before 31.3.10 and get 72 Cartridges FREE (worth £224.99)

The icing on the cake There are many tasty reasons to consider the new Cryopen C but we couldn't resist providing just one more!

Book a demonstration before 31st March and not only will we provide a personal Cryopen presentation at your premises but we’ll also bring along a selection of delicious cakes!

Cryopen C – excellence in cryotherapy made affordable Q Low pain application Q Accurate to the millimetre Q Portable Q Quiet and discrete application minimises patient anxiety Q Order before 31.3.10 and get 72 Cartridges worth £224.99 FREE

Book your presentation… presentation…

Call Adrian Adrian Watt on 01280 843872 843872

RealSERVICE Find it

www.canonbury.com

Call 01280 706661