Chris Schafer

Conditions treated

Fallen arches/flat feet

This is medically known as having excessively pronated feet.

Studies have shown that not all flat feet require treatment, for example, in infants whose arches are still developing and in adults where there are no symptoms.

However, research has also shown that some individuals may be prone to future problems even though they may have little symptoms now, and so there is merit in identifying and treating them as a preventative measure.

People with excessively pronated feet particularly at risk of future problems are those who:

regularly participate in impact sports such as running, football, cricket, tennis squash etc.

are in occupations that require spending long periods of time on their feet whether it be standing or walking, especially those who might be involved in heavy lifting such as people in construction.

have joint hypermobility or poor core stability and posture

Treatment for excessively pronated feet may include: stretching exercises; core stability exercises; muscle training or the wearing of an insole/orthotic to improve foot function.


Pain under the ball of the foot

This is medically known as metatarsalgia and can be from a number of causes ranging from a ‘Morton’s neuroma’ (bundle of nerve tissue) which can set off a burning sensation like pins and needles when it is squeezed, to pain from simply too much pressure.

The most common causes of pain under the ball of the foot are mechanical due to overloading i.e. someone who has very limited cushioning (fibro-fatty padding) under the ball of their foot, or a dropped metatarsal head and will result in too much pressure or force on that area.

In the majority of cases, specifically placed padding or an insole is used to deflect pressure and provide cushion. If necessary, specific footwear advice is given.

Specific causes of Metatarsalgia that the podiatrist is able to treat:

Morton's Neuroma

lack of natural padding

overloading of the metatarsals

corns/callous

sesamoiditis

stress fracture/fractured metatarsal

bursitis/capsulitis

tendinitis/muscular strain

chronic conditions such as rheumatoid arthritis


Heel pain

The most common cause of heel pain is plantar fasciitis, which accounts for 10-15% of all podiatry referrals, and can affect any age group from teens upwards. This is due to overuse and inflammation of the tendon of this muscle band that runs under the sole of the foot. Classically, the pain is worst first thing in the morning, or after a period of activity, and is felt as a deep pain under the inside (medial) of the heel.

People most likely to suffer with plantar fasciitis are those with:

a particular foot-type

very tight calf muscles

flat or excessively pronated feet

or those who stand for long periods or who have recently increased their activity

Treatment involves dealing with the mechanical nature of the problem, whilst reducing the swelling and inflammation.

Whilst acute cases respond well to vigorous stretching regimes, anti-inflammatory modalities, and heel cushioning, more long-term sufferers may also need footwear advice and insoles/orthotics to manage their symptoms.

Other causes of heel pain that the Podiatrist can treat:

Sever's heel/apophysitis

plantar fibrosis/fibromatosis

Lederhose's disease

impact injuries to the calcaneum

calcaneal spur



Ankle sprain/ankle instability

Ankle sprains and lateral (outer) ankle instability are one of the more common conditions treated. Ankles by the nature of their design are less stable on the outside (lateral) aspect, and so easier to sprain by going over onto the outside (inversion or lateral ankle sprain). A bad sprain can lead to acute swelling, possible ligament damage, tendon damage, and there may be lasting effects as the ankle may become weaker.

In the event of a bad sprain, it is vital to get the swelling down to an absolute minimum. This is best achieved by getting something from the freezer(frozen peas or gel pack) and compressing it against the area that has been sprained, as soon after the injury as possible. In addition to this, you should raise the ankle and remain off your feet.

This is called the RICE (rest, ice, compression, elevation) protocol. Any delay in doing this immediately will have lasting effects on the time it takes for the swelling to go down and the ankle to rehabilitate. This is because the swelling will have long term effects on important tendons that support the foot.

In the case of a bad ankle sprain, if there is still considerable discomfort on walking one day later, then it is strongly advisable to provide external support for the ankle. This can be done by wearing the most supportive footwear you have e.g. trainers. To complement this, you can have the ankle strapped, or preferably wear a temporary insole adapted to your arch to offload the ankle.

In some cases where the ankle has weakened significantly from the injury due to ligament damage, exercise programmes designed to specifically strengthen the muscle and tendons around the ankle are important, as well as range-of-motion exercises to ensure that the ankle is not left with reduced movement.

For active sports people, or for those who are on their feet all day due to their job or lifestyle, it is important not to injure and weaken the ankle further, so permanent support may be necessary. These can be in the form of special insoles or orthotics.

Other conditions podiatry treatment will help with after an ankle injury:

persistent pain after ankle sprain

ankle impingement syndromes

tendon dysfunction

sinus tarsi syndrome



Ankle pain (where there is no history of injury)

Ankle pain may exist when there is no history of injury but be present due to overuse from particular sports such as football or ballet.

The pain can be at the front, inside (medial) or outside (lateral). The most common cause of medial ankle pain is tendon overuse (eg posterior tibial tendon). Lateral ankle pain is often associated with lateral instability and poor lower limb mechanics, often resulting in tendon problems such as peroneal tendons. Pain in the front of the ankle tends to be tibialis anterior tendonitis, whilst achilles tendonitis is the main cause of pain at the back of the ankle.

There are also less common causes where there can be an impingement or pinching of the soft tissues or a nerve which can give rise to pain.

Treatment for the most common cause of tendon problems include mobilization, therapeutic modalities such as transverse massage, strengthening exercises and insoles to correct any biomechanical abnormalities, and advice on which activities to avoid that may aggravate it.

Other treatable common causes of ankle pain are:

flexor hallucis/digitorum longus tendinopathy

tarsal tunnel syndrome

impingement syndromes

tibialis anterior tendinopathy


Achilles tendonitis

The Achilles tendon is the strongest and thickest tendon in the body and attaches into the heel from the calf muscles (gastrocnemius and soleus). The lower third of the tendon is where the problem tends to occur. This is mostly due to the huge diagonal force placed on the tendon as the heel contacts the ground. This diagonal pull on the tendon known as ‘bowstringing’ can lead to microtears, scar tissue, or loss of tissue (collagen) which will cause pain on activity.

Overuse of the Achilles from sport (particularly running), excessive pronation, very tight calf muscles, poor range of motion of the ankle and footwear are all typical causes.

Treatment is always best started as early as possible because even with intense treatment, rest from aggravating activity, and early diagnosis, complete resolution will still take between three to six months.

Early treatment is best achieved through the RICE (rest, ice, compress and elevate) and other anti-inflammatory modalities, muscle strengthening programmes, and heel raises (in-shoe). Vigorous stretching exercises, correction of any abnormal biomechanics through insoles or orthotics and advice on footwear are important to prevent the problem worsening.



Shin splints

Although shin splints is a term frequently used it is actually an umbrella term referring to pain and discomfort in the leg from overuse of the lower leg muscles due to either poor lower limb biomechanics, or external factors like training on a hard surface.

It mostly refers to tibial stress syndrome, and compartment syndromes. Medial tibial stress syndrome (MTSS) refers to inflammation of the surface of the tibia (periostalgia). Research suggests it follows on from compartment syndrome.

Compartment syndrome refers to a condition that can occur on the front (anterior) of the shin, on the back (posterior) and the outside (lateral). They are generally from overuse and occur when the fascia that surrounds that muscle in its ‘compartment’ becomes too tight from exercise. This occurs when the muscle expands and the pressure on soft tissues, and even nerves, in that compartment causes pain. Classically the pain starts after a period of activity and eases off once activity ceases.

Conservative treatment usually consists of a reduced or alternative exercise regime, physiotherapy to stretch the fascia, and correction of poor lower limb biomechanics with good footwear and insoles/orthotics.


Knee pain, hip pain and back pain resulting form poor foot function

The interrelationships between the foot, leg, hip, back and upper body are important to allow fluid dynamics during walking and gait. Normally during walking, the leg rotates internally bringing about pronation (lowering of the foot’s arch) required for shock absorbtion, and then the leg rotates externally bringing about supination (raising of the foot’s arch) required for the stability of the foot during the propulsive phase of gait.

Different models have been used to best describe how human gait works including an inverse pendulum (Dananberg). In this model the base of the upside down pendulum is the foot and the three points that it pivots on are the heel, the ankle joint and the big toe joint (1st MTPJ).

When assessing a patient’s biomechanics, it is important for us to check there is enough range of motion in these three pivots, otherwise the pendulum will not swing correctly and compensations will occur eventually leading to problems.

The hip, knee, ankle and big toe joint (1st MTPJ) all extend and flex in opposing direction to their adjacent joint. Therefore if the mobility in any one of these is “blocked”, it will affect the others, and be compensated by the other foot or the next joint up the body, if not both.

The compensations podiatrists are most interested in addressing are within the foot and ankle, but as the scissor-jack model demonstrates, if we optimise the function of the feet, we can also play an important part in treating biomechanical problems of the knee, hip and back.

Podiatric biomechanical assessment and treatment works very well with physiotherapy and osteopathy particularly for knee and back problems.


Poor posture and core stability

A person’s ‘core stability ‘ is governed by how stable a person’s posture is, i.e. if a person was asked to stand still for a period of time how much would they sway both left to right and front to back. The more that they sway the less core stable they would be.

Why is it important?

If a person has poor core stability, and they sway a lot around their centre of pressure, then their joints may go through too much movement and be prone to more ‘wear and tear’. For active sports people the effect is magnified and those with poor core stability will be more prone to injury as well.

Some people with joint hypermobility/poor core stability will suffer tiredness and fatigue, as they are literally wasting energy in an effort to stabilise their posture. Back problems and headaches are also common complaints.

To offset this and optimise posture and wellbeing, exercise programmes are followed to create muscle tone particularly in the stomach (to keep the back straight) and the quadriceps (to stabilise the knee). Pilates is the exercise specifically designed to improve core stability.

The feet have an important part to play because if they are unstable the rest of the body will be relatively unstable too. So as well as building muscle tone, the feet must be stabilised through exercises and, where necessary, the wearing of insoles/orthotics, as well as the right footwear.

Joint hypermobility is a leading factor in core stability and your podiatrist can measure where on the spectrum you lie using a specifically designed scale. This will help to gauge the significance of hypermobility to your biomechanics and prevent future problems.


Bunions

Bunions of the big toe are medically known as hallux abducto valgus (HAV) and refer to the deviation of the big toe across the foot whilst exposing the big toe joint to pressure as it becomes more prominent.

What causes bunions (HAV)?

There are a multitude of factors ranging from activity, lifestyle, occupation and footwear which will all contribute to an increase in pressure and force from the side of the big toe (medially). However the most significant factors are a family history, which will determine things like footshape and foot mechanics e.g. a foot is that excessively flattening or pronating, or foot that is very wide at the forepart.

What treatment is there for bunions (HAV)?

When we assess HAV, we take into account the person’s lifestyle, and the level of discomfort. If there is no discomfort and the person’s activities are not affected, then there is little cause for immediate concern.

However, a podiatrist may recommend preventative measures to slow down further progression such as by controlling poor foot mechanics through insoles and footwear when active.

For more severe cases where there is pain or a limited range of motion at the big toe joint (MTPJ), looking at the biomechanical causes and treating them through specially adapted insoles or orthotics would be the best conservative management.

For patients who want to know more about surgical solutions, this can also be assessed and given and the relative merits explained.