Thursday, November 24, 2011

Diabetes and Foot Care

The current incidence of diabetes in Malaysian is about 23 percent – 1 in 5 Malaysian is a diabetic – this does not include the numbers undiagnosed.
Diabetes affects multiple organ systems – even the musculoskeletal system is not spared. The feet in particular are at risk increasing the potential for infection, gangrene and limb loss – amputation. Diabetes may cause nerve damage that takes away the feeling in your feet. Diabetes may also reduce blood flow to the feet, making it harder to heal an injury or resist infection.
Amputations reduce mobility and increase morbidity and mortality rates. To put it simply, having an amputated limb increase the risk of having other problems due to reduced ambulatory capacity and does reduce lifespan.
As always, prevention is better than cure and there are simple preventive measures to reduce chance of diabetic foot infection.
First – Have good sugar control. This has always been a key requirement and will always be so.
Inspect you feet daily – Easy to do but most don’t. Check for cuts or blisters – this may indicate areas suggesting ill-fitting footwear. Skin redness and swelling are also areas for concern particularly if the area of redness does not blanch with pressure. Always give your nail and the spaces between the toes a good look – these are usually the initial sites of infection. Don’t forget the skin of the sole. Using a hand mirror simplifies looking at the bottom of your feet. Get worried and do see your doctor if things don’t look normal.
Clean and wash feet with lukewarm water – Keep in mind that diabetics have reduced sensation over the feet due to nerve damage. Test water temperature either by dipping the points of your elbow in or ask someone else to do this. Keep your feet clean by washing them daily. Be gentle - wash them using a soft cloth or sponge. Ensure that you dry the feet well after wash.
Moisturize your feet – Use a moisturizer daily to keep dry skin from itching or cracking. But DON’T moisturize between the toes – this could cause a fungal infection.
Nail care – Cut nails straight and not in a curve. Never cut them too short. This can cause in growing nails with possible infection and worse. Cut them straight across and file the edges.
Corns and Calluses – Please don’t self treat these conditions. You are not the doctor – I am - ;)
Wear clean, dry socks – I qualify this with this additional important instruction - change your socks daily. Ideally use cotton socks. Synthetic sock usually are less breathable. Avoid tight bands and thicker kinds of socks, which usually fit poorly. An ill fitting sock will cause shear and make your feet prone to injury
Shake out your shoes before wearing them - Diabetics may not be able to feel a pebble or other foreign object, so always inspect your shoes before putting them on.
Avoid walking barefoot – Try practicing this even at home. Wear a soft shoe or slipper. You will be able to avoid unnecessary injury.
Don’t smoke – Duh…. Smoking restricts blood flow and slows healing
Get periodic foot exams - Get regular input from your friendly Orthopaedic Surgeon on foot care with periodic updates and assessment.

Tuesday, October 25, 2011

Children and Sports

Children and Sports - The Bigger Picture - BFM 89.9 - 25/10/2011

... Whether you're dreaming of moulding your child into the next sport superstar or just want to keep them healthy and fit, find out about the do's and don'ts of sport participation and fitness training for children, from Dr. Harjeet Singh, a Consultant Orthopaedic Surgeon.
Dr Harjeet will also advise on ways to optimise the benefits of sport for children, while reducing the risks...

Wednesday, September 7, 2011

Flat Feet in Children - The Basics

I have recently had a number of relatives and patients coming over with their children for an opinion on flat feet and it is interesting that most of them have gleaned a lot of information off the net, from friends and possibly from their friendly neibourhood aunty-patti-makcik too.
The start off this session,  it is necessary to understand how the foot develops in order to have an idea (and possibly worry a teeny weeny bit less)  about flat feet.
At birth, the newborn usually has the foot turned outwards (eversion) and upwards (dorsiflexion). This is due to the natural position in utero. As the child starts standing – usually around the age of one year, the foot nearly always looks flat, particularly because there is a large pad of fat on the inner side of the foot. This is a normal.
As the child grows further, walking makes the child’s foot look particularly flat. This is especially so, as the initially way of walking involves the foot being turned outwards.. The arch of the foot starts developing at the age of 3 onwards. If it doesn’t, and the feet remain flat, it is important to get a consult to check for flexibility of the child in general and the foot in particular. Usually the child is more flexible and these feet are then called flexible flat feet which in principle require no treatment.
Simple tests for flat feet include 1. Great Toe Extension Test - moving the great  toe upwards and seeing if the arch at the inner part of the foot forms. If so,  don’t worry! This means that in function, the arch does develop and biomechanically the foot is sound. 2. The Toe Off - In older children, you could ask them to tip toe while viewing from the back. Forming of an curve in the inner part of the foot with the heel turning inwards denotes good function. 3. If these tests seems complicated (or the way I explain then causes headaches, consider the simple wet tissue test  - this helps determine whether the foot is flat in the first place). Get the child to step on a blotting paper or tissue after stepping into water first. The pattern formed indicates whether the foot is flat (overpronating).

When do you worry? Please consider an early consult if the child complains of pain over the inner and outer part of his feet – flexible flat feet are usually pain free. This is especially so if the foot seems rigid and less flexible. As always, when in doubt, please visit your friendly Orthopod!!

Monday, July 25, 2011

Prevention of Back Pain - Self Care

Dude… My back is killing me. I oft hear this from friends and family.
I know what they mean as this issue plagues me on and off too and trust me back pain can be bloody bad!
Having done the necessary reading and meditation on this common problem, I’ve realized that there is lots that we can do to help prevent and make the pain more manageable. Have perhaps more good days than bad so to speak
It is important when self caring for back pain to remember that you must be able to know when you need to see a doctor.
I have discussed this HERE previously.
Ultimately, the short story is:
1.    Get the pain under control.
2.    Work on flexibility.
3.    Progress to strengthening the muscles and structures which help support the back.
Mind you, the muscles are the key to guarding your back from injury and reinjury. Building up muscle flexibility and strengthening is easier said then done but doing it helps prevent recurrent attacks.
Here are some exercises I gleaned from The Malaysian Low Back Care Management Guidelines. Most of the exercises are self explanatory.

Wednesday, June 22, 2011

Healing of Fractures - Treating Fractures

Fracture healing is both fascinating and complex.  It basicly involves a series of processes designed to remove dead-injured tissue and bone from the fractured site. This is then followed the movement of cartilage and bone forming cells to form the structure necessary for repair.
The steps and process can be broken down basically to include:
               Inflammation – the stage of removal of damaged tissue and bone.
Repair – The process of building the new bone and tissue scaffold
Remodelling – The stage where the newly healed fracture undergoes further modification based on the areas stressed with movement and load. The bone is thickened at points that undergo most pressure during function.
The fracture has to be well aligned in a 3 dimensional plane to enable healing to occur in good position. This can be done using a splint, cast or surgery. As the fracture heals, the amount of support needed reduces and the part can be loaded by bodyweight or its use increased.
Fractures in the upper limb generally require 6 weeks to unite satisfactorily. Lower limb fractures on the other hand require 12 weeks. In children these durations are halved. These figures are only estimates and depend on the serial follow up progress radiographs and examination findings that often change the duration of splintage and care.
Fractures which involve the joint require perfect reduction of fragments as incongruency of the joint will lead to arthritis and pain, especially in the those joints which bear weight – lower limbs. This need in care favours surgical options for these fractures especially when the fragments are displaced.
Fractures that are not involving the joint require techniques that will adequately hold position but allow the patient to be relatively mobile. This is often the reason why surgical option is chosen for fractures of the thigh bone and hip to allow rapid ambulation and avoid the problems of prolonged bed rest.
The need for rapid return to activity and function brings about continued research in fracture treatment techniques and protocols.  Methods to speed up healing are also in frontline research.

Wednesday, June 8, 2011

Ankle Sprain - Ankle Injury

What do roller skating, ice skating, futsal and even high heel use have in common? No takers?
Well, these are all common causes of outer ankle sprain!!
 Ankle ligament injury is common. Almost 25000 people experience it daily! Many of us have found this fact out the more painful way.
These injuries often occur due to a combination of causes,; from poor footwear,  poor foot dynamics to plain bad luck. It happens when the foot twists, rolls or turns beyond its normal limits. The ligaments are effective restraints but with excessive force this may partially or totally tear. Often, an awkwardly placed foot when running, stepping up or down, or even a simple task as getting out of bed may cause an ankle sprain. The injury also occurs during stepping on irregular surfaces especially when this happens unexpectedly, as seen when stepping into a hole. Some athletic events such as basketball and netball involve close body jumps where there is always a risk of planting your foot awkwardly and injuring the ankle.
The foot usually rolls inwards – inversion which is the more common form of ankle sprain seen.
How do you know that you have a sprain?
Firstly the abnormal movement has to be one than can cause a sprain. The most common one would be that of a plantar flexed foot being awkwardly planted with a subsequent movement of the foot.
If you find you ankle swelling up especially the part over the outer part, congratulations you’ve probably sprained it or worse. Movements are usually painful.
When to worry?
Most mild ankle sprains don’t require an immediate trip to the doctor. Please worry (don’t panic) if:
The pain is poorly controlled by the RICE Protocol ( please see RICE and Use of Cold and Hot in Injury) and over the counter medications.
You are unable to comfortably walk for more than 4 steps or you experience severe pain when pressing over the medial or lateral malleolus, the bony bulges on each side of the ankle – this requires an radiograph to rule out a fracture.
You cannot move the injured ankle comfortably.
The foot or ankle is misshapen beyond normal swelling.
You experience loss of feeling in the foot or toes.
You are not fairly improved by a few days.
Why worry?
Most ankle sprains can be treated conservatively but this has to be done right from the word go. The more severe sprains may require the use of a specific ankle brace which allows the injured ligament to heal in its best possible position.
It is also necessary to rule out the more serious injury too.
This will often require the input of your Orthopaedic or Sports Surgeon.
Most important of all…….. Take home message numero uno…….
Please visit your Orthopaedic Surgeon if you are unsure about the severity of your injury.

RICE - Rest - Ice - Compression - Elevation

RICE Protocol
Rest – Ice – Compression – Elevation for Acute Injury.

It is unfortunate that you have sustained an acute injury.  But at least after this you would be getting things right from the start and will be on the road to recovery in no time.

To heal one needs to rest. PERIOD. No buts.
The use of ICE-Cold helps reduce pain and swelling. This is by reducing the metabolic demands of the injured tissue. Please see the section  - Use of Cold and Heat in Injury.
Application of a crepe bandage (apply firmly with gentle stretch) helps reduce pain by a splintage effect apart from reducing the swelling more rapidly. The idea is not to strangulate the injured area – if it is painful – it is too tight!
This helps reduce swelling. The effected part should at least be higher that the more proximal joint. Eg – for injuries of the ankle, elevate the ankle to a higher level than the knee; for injurie to the wrist, elevate to a level higher that the elbow.
Elevate for an long possible for the first 24-48 hours especially when the swelling is significant.

Wednesday, February 23, 2011

Purchasing running shoes......

I started playing hockey recently and to help get fit faster I started running. The first few days were fine. But I noticed that my old pair of shoes weren’t just good enough. I noticed some brusing over my big toe and even a few blisters after a run.
Sigh.....I got to go get a new pair.
Selecting an athletic shoe is important to ensure optimum performance and prevent injury. Selecting the latest version from an establish brand may not be the best thing for you. Buying the most expensive pairs in the market may not also be wise.
What you need to know is what to look for when purchasing your shoes. This is more so if you are going to be using it often. And it doesn’t matter whether you are a man or woman - getting a proper pair is the common sense thing to do – period. Traditionally, the female shoe was a scaled down model of the male version. This is now changing as more and more manufactures realize that female feet are not “small” male feet. The female foot typically has a narrower achilles tendon, a narrower heel in relation to the forefoot, and a foot that is narrower in general than its male counterpart.
Type of feet
Mechanics of the foot. The movement from heel strike to toe off during a stride determines the type of foot. Correct amount of inward movement of the foot (pronation) allows the foot to absorb the force of the stride. Too much pronation will cause buckling over the inner aspect of the foot and is not good. Too little pronation increases pressure over the outer part of the foot.There a three basic type of feet. A rough assessment can be done by the WET TEST.
Wet you feet by stepping into a shallow container of water. Step out onto a piece of absorbent paper and see the tracing made by your foot.
1.    The overpronator – the flat foot – no/mild inner arch.
a.    The foot rotates from heel strike with pressure being concentrated over the inner edge of the foot.
2.    The underpronator – the high arched – exaggerated inner arch
a.    There is under rotation with pressure being concentrated over the outer aspect of the foot.
3.    The neutral
a.    The foot maintains a normal amont of pronation during stride. Approximately half of the mid region is seen

                                               1                         2                      3
Shape of the shoe
Based on the type of feet you have, the shape of the shoe you should choose differs.

Overpronators should use a shoe with a straight shape. This gives the most control of foot motion and are general called – Motion Control Shoes.
Underpronators should use curved shoes (up to a 7 degree curve). This gives most support to the outer part of the foot and are called – Support Shoes.
Neutral foot type should use a semicurved shoe – Stability Shoes – This gives moderate arch support on the inner foot.
Once you understand the type of shoe you need you’ll need to ensure that it fits well.
There are some basic determinations to be made in the fitting of shoes. One must first ascertain that the length is correct. This can be guided by the “rule of thumb” test performed by pressing on the end of the shoe while the wearer is applying full weight. There should be between half and a full width of the examiner's thumb between the end of the longest toe and the end of the shoe.
The next step in the fitting process is to determine proper width. The “pinch” test helps with this. The individual stands in the shoe while the examiner tries to pinch a small amount of material in the upper between the thumb and index finger across the forefoot of the shoe. Make sure that the heel does not slip up and down while walking. This will predispose you to injuries of the achilles tendon.
The final test is a determination of the flex point of the shoe in relation to the metatarsal break (the part of the front of the foot that bends when you step) of the foot. If the shoe does not have the proper degree of flexibility in the appropriate location, one can expect potential injury. This however depends on the sport one plays. Having too flexible a shoe in some sport can be detrimental too – eg – soccer. When in doubt ask the doctor/podiatrist on the best option for you.
Tips while purchasing
  1. Feet tend to swell at the end of the day or after vigorous activity, this should be taken into consideration.
  2. In most individuals, one foot is larger than the other. Size for the larger foot.
  3. Bring along the socks that you are going to use with your shoe.
  4. Shoe size does not remain static over the years. Always measure your size before purchasing.
  5. Bring along your current footwear to allow assessment of wear and foot type by the sales advisor.
  6. Purchase a comfortable size. Don’t purchase one that is too tight expecting it to stretch.
  7. Walk or run in the shoe to assess comfort before purchasing.

Monday, February 21, 2011

Plantar Fasciitis - Heel Pain

‘Hey Doc, I have a spur la’, said my buddy and hockey devil Avtar. ‘What makes you think so huh?’ I asked worried. ‘I have pain over my heel. What else can it be la?’ he retorted.
That started me on a long lecture about how not all heel pain is caused by a spur. Well, I concede that while plantar fasciitis is the most common cause of heel pain, other causes need to be ruled out by the treating doctor for effective and accurate care. These include  stress fractures of the calcaneum, tendonitis of the tendo Achilles or foot flexors, arthritis of the foot joint and nerve irritation being the more common differential diagnoses.
Once other causes have been ruled out, getting rid of that irritating pain of Plantar Fasciitis is a logical end goal!
So… The million-dollar question - How do we do that? To treat plantar fasciitis one must understand the condition well.
What Is Plantar Fasciitis?
The plantar fascia is a band of tissue attached to the heel and extends to the toes - specifically from the medial calcaneal tubercle to the bases of the proximal phalanges. It functions to maintain the longitudinal arch of the foot and is important in the dynamics of proper foot function. In plantar fasciitis, the fascia  becomes inflammed due to repeated injury-irritation resulting in heel pain. This can be as a consequence of a poorly treated acute injury or the end result of overuse.

The most common cause of plantar fasciitis relates to faulty structure of the foot whether congenital or acquired:
1.                   Reduced flexibility at the ankle especially that due to a tight Achilles tendon is a independent risk factor for fasciitis
2.                   Poor footwear especially with hard heel regions place an undue stress to the region of the plantar fascia. This coupled with job descriptions that require prolonged standing and walking predispose to plantar fasciitis.
3.                   Obesity may also contribute to the development of plantar fasciitis.
The symptoms of plantar fasciitis are:
  • Pain on the bottom of the heel. This is worse upon rising in the morning and usually subsides with activity. There may remain  a residual dull ache in the heel. The pain returns or is worsened by long periods of immobilization.
Accurate diagnosis requires a detailed history and clinical examination. Other causes of heel pain should be ruled out systematically. Pain to pressure over the medial part of the heel is pathognomonic. Palpation of the fascial band is essential to not miss a rupture or tear of the fascia. Associated assessment of the tendoachilles for tightness is essential for optimal care.
Although diagnosis is essentially via clinical evaluation, diagnostic imaging studies such as x-rays or other imaging modalities may be used to distinguish the different types of heel pain.
Sometimes heel spurs are found in patients with plantar fasciitis, but these are rarely a source of pain. When they are present, the condition may be diagnosed as plantar fasciitis/heel spur syndrome.
Non-Surgical Treatment
Treatment of plantar fasciitis begins with first-line strategies, which you can begin at home:
  • Stretching exercises. Exercises that stretch out the calf and toe flexor muscles help ease pain and assist with recovery. These concentrate of stretching the Achilles tendon
  • Shoe modifications. Wearing supportive shoes that have good arch support and a slightly raised heel reduces stress on the plantar fascia. This aids in the acute phase. Prevention of recurrence circles around continuance of optimum footwear.
  • Medications. Oral nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen, may be recommended to reduce pain and inflammation.
If these methods fail or if symptoms worsen, it is good to get an expert opinion from your Orthopaedic Surgeon. You may be then advised on these methods:
  • Orthotic devices / Splints. Custom orthotic devices that fit into your shoe help correct the underlying structural abnormalities causing the plantar fasciitis. Splints are usually used as an adjunct to stretching exercises and are usually prescribed for night use.
  • Injection therapy. In some cases, corticosteroid injections are used to help reduce the inflammation and relieve pain. Newer options such as platelet rich plasma to restart the healing process are currently popular in recalcitrant cases.
  • Extracorporeal Short Wave Therapy. The use of ESWT is gaining popularity as a therapy in chronic symptomatic cases.
When Is Surgery Needed?
Although most patients with plantar fasciitis respond to non-surgical treatment, a small percentage of patients may require surgery.  The decision for surgery is usually taken in the group of patients who remain symptomatic in spite of compliance to a structured stretching and rehabilitation programme. Post surgery, rehabilitation has to be continued to obtain optimum benefit.
Long-term Care
It is important to understand that the causative elements of plantar fasciitis may often remain. This underlines the need for continued preventive measures. Appropriate supportive shoes, properly done stretching programmes and using orthotic devices where appropriate are the mainstay of long-term treatment for plantar fasciitis.

Monday, February 14, 2011

Tennis Elbow - Lateral Epicondylitis

My elbow is killing me today! I often hear this from my patients and friends alike.
Most of them are weekend warriors and active at racquet sports. But it is not only them who complain, a fair share are non-sporting and a good number are homemakers.
Pain over the outer part of the elbow has been called several things. Most people call any pain in the region of the outer elbow Tennis Elbow. This is dangerous as not every painful condition over the outer part of the elbow is – Details of these other conditions at some other time.
             Coming back to Tennis Elbow - Mind you, it doesn’t only happen in tennis players! The medical terminology is Lateral Epicondylitis and it is the most common of elbow injuries, typically occurring between the ages of 40 – 60 and affecting up to 3 percent of the population.
What is the Pathological Process?
Tennis elbow occurs when there is damage to the muscle and its tendon over the outer aspect of the elbow. The muscles, which run over the back of the forearm, are mainly attached to the outer part of the elbow. Theses muscles help to extend the wrist and fingers (movements which cause you to curl your wrists upwards and straighten your fingers)
Small tears (micro tears) form in the tendons and muscles, which control the movement of the forearm. These tears happen because the tendons do not stretch. Repeated stress strains the tendon causing it to fray in a similar way that a rope frays. This then causes a restriction of movement, inflammation and pain. As this area is prone to heal poorly with high chance of repeated injury, these micro tears eventually lead to the formation of scar tissue and calcium deposits. This tissue is of poor quality and is prone to further tearing, thus causing persistent pain and dysfunction.
What Causes Tennis Elbow?

The most common cause of tennis elbow is repeated injury due to over use. Any action which places a repetitive and prolonged strain on the forearm muscles, coupled with inadequate rest, will tend to strain and overwork those muscles. Poor technique in sports increases strain on the involved muscles and will contribute to the condition, such as using ill-fitted equipment, like tennis racquets, golf clubs, work tools, etc. It is important to remember that these injuries don’t only occur in those involved in sports. Movements that predisposed to tennis elbow are:
  • Rotation of the elbow with a bent wrist such as using a screwdriver.
  • Gripping something strongly while rotating the wrist.
  • Hitting movements such as usage of a hammer.
  • Throwing movement that is not done smoothly (jerky).
There are also many other causes, like a direct injury - a bump or fall onto the elbow. Understand that poor levels of general fitness and conditioning will also contribute to the development of this condition
Signs and Symptoms

Pain is the most common and obvious symptom associated with tennis elbow. Pain is most often experienced on the outside of the upper forearm, but can also be experienced anywhere from the elbow joint to the wrist. Weakness, stiffness and a general restriction of movement are also quite common in sufferers of tennis elbow. Even tingling and numbness can be experienced.
Preventing Tennis Elbow.

WARM UP: Thorough and correct warm up will help to prepare the muscles and tendons for any activity to come. Without a proper warm up the muscles and tendons will be tight and stiff. There will be limited blood flow to the forearm area, which will result in a lack of oxygen and nutrients for the muscles. This is a sure-fire recipe for a muscle or tendon injury.
STRETCHING: Flexible muscles and tendons are extremely important in the prevention of most strain or sprain injuries. Proper flexibility levels allow muscles to move and perform without being over stretched.  Tight and stiff muscle on the other hand, may be pushed beyond their natural range of movement. This predisposes to injury.
STRENGTHENING:  Strengthening and conditioning the muscles of the forearm and wrist will also help to prevent tennis elbow.
Stretches for Prevention of Lateral Epicondylitis (Tennis Elbow) – These are to be done with controlled movements.  The exercises should not be done if it brings about pain or causes more pain.
·        Lift your arms to about shoulder height and place your hands together in front of your chest, keeping your fingers together. Your fingers should be just under your chin. Lower your hands towards your waist and stop when you feel a mild stretch. Hold for 20 seconds and repeat 4 times.
·        Extend your arm out in front of you, palm down, and push your hand towards you with the other hand until you feel a stretch. Hold for 20 seconds.
·        Extend your arm out in front of you, palm up, and push your hand towards you with the other hand until you feel a stretch. Hold for 20 seconds.
·        Practice squeezing a tennis ball, holding the ball for a few seconds before releasing. Do this twice a day.
·        Place a rubber band around all of your fingers, including thumb, and practice opening your fingers against the rubber band. Do this twice a day.
Treating Tennis Elbow.

The occurrence of acute pain should bring about cessation of the initiating activity.
It is advisable to obtain a consult from an Orthopaedic Surgeon to obtain diagnosis. Not every painful episode over the lateral (outer aspect) of the elbow is due to tennis elbow.
The RICE protocol should be carried out for the first 24-48 hours. This involves R – Rest; I – Ice; C – Compression; E – Elevation.  Usage of ice treatment should be done properly for best benefit (Use of Cold and Heat in Injury)
The next phase of treatment (after the first 48 to 72 hours) involves a number of physiotherapy techniques. This begins with passive methods such as heat and ultrasound therapy and thereafter moves on to the preventive and rehabilitative phase once the pain control is good.
The ultimate aim of this phase is to regain and improve the strength, power, endurance and flexibility of the muscles and tendons that have been compromised.