Louise King

Good evening, everyone. Welcome to our webinar on treatments for lower leg and feet injuries. My name is Louise and I’ll be your host this evening. Our expert presenter is Sports Medicine Podiatrist, Mr Liam Stapleton. This presentation will be followed by Q&A session. If you'd like to ask a question during or after the presentation, please do so by using the Q&A icon at the bottom of your screen. This can be done with or without giving your name but please note this session is being recorded so if you do provide your name that will be in the recording. If you'd like to book your consultation we'll provide contact details at the end of this session, and I’ll now hand over to Mr Liam Stapleton and you'll hear from me again shortly. Over to you Liam.

Mr Liam Stapleton

Thank you. Thank you, Benenden Hospital, for giving the opportunity to speak to you all today, please ask any questions you've got, and I’ll do my best to answer all of them. As said, I’m Liam Stapleton I’m a specialist in podiatric sports medicine here at Benenden Hospital. A few things, I am the vice chair of our special advisory groups the Royal College of Podiatry, my fellowship from the Faculty of Podiatric Medicine on the Royal College of Physicians and Surgeons in Glasgow. I have postgraduate qualifications in podiatric sports medicine and podiatric surgery and go back and do some guest lecturing from my university Queen Mary university of London, I have an interesting past scanning and injection therapies.

We're going to talk about a few a kind of broad range of problems today hopefully touch on things that might might mean something to some of you at home we talk a little bit about the thoughts and how it's the structure of it and how it's made up but with some common injuries and some sports injuries and how we might treat some of those problems. Some ankle problems with some ankle treatments and then talk about my surgical colleagues and how they might also better help and then I’ll hopefully in about half an hour so we'll be answering all your questions, so please ping them through, that might well be the most interesting part of the whole presentation.

So, the foot broadly speaking most people have about 26 bones, not including the excess and sesamoids also you have muscles, tendons, ligaments in your feet alongside the the bones and joints help to support your whole body when you're walking and running and jumping. Injuries can be caused by several different factors, obviously trauma being one and then regular repetitive stress is obviously one of the other most common reasons someone might get injured.

So the hind foot or the rear foot predominantly has the two bones the talus and the calcaneum, it's ankle bone and your heel bone and that connects with your bottom of your leg or your ankle and and this part of your foot is responsible for the first initial contact heel strike when you walk and it's responsibility to adapt to the the terrain you're walking or running on and absorbing shock. The fractures in the heel are relatively uncommon but can be caused by extreme force and a calcaneum fracture is often called a lovers fracture as it was its commonly seen when the lover jumps out of the window when the husband comes home and I have the obviously the other side going on the point from the previous slide recently I saw a good a lady who had some some osteoporosis and she had a stress fracture from running in her heel bones and that's obviously always a possibility as well.

Your midfoot at least predominantly the middle of the arch portion of your foot made up of your navicular your cuboid and your three cuneiform bones these are little square bones inside your foot the the joint where your rear foot and your mid foot to connect it's called the show path joint that made up of four different bones it's an unusual type of joint made of more than just two bones, made up of the calcaneum cuboids so the the joint between the calcaneum and the cuboid and the navicular or the talonavicular bones.

Forefoot is mainly your toes and your metatarsal, and this joins your midfoot at the Lisfranc joint which is also called the metatarsal metatarsal joint again another joint in the foot that's made up of lots of different bones so the five metatarsals and your cuboid.

So obviously different strains and sprains of foot injury is and how these are separated into different categories so we are obviously you can get a mild strain or sprain, and this can be graded both on symptoms and also radiologically and broadly speaking they follow the same three-step pattern. So very slight damage this is normally impossible to see under under ultrasound or or an MRI and and generally resolves very quickly. So mild tenderness, minimal swelling, sometimes you get some ligaments take a stretch a bit more than they did before. Normally probably resolves itself within a week or two. A grade two strain or sprain this is where it becomes a little bit more a bit more moderate so we're getting little tears of the fibres and those can stretch from everything from slight tears to a very slight tears to something that's a bit more visible on the scan and these can be picked up and there's probably something to do with a between a two week and a six week recovery and then obviously you've got your really severe strains and sprains and this is where you've got significant tears and rupture and obviously this is where surgical correction from my surgical colleagues would potentially come in, so if you have a a rupture that wasn't healing by itself then there were procedures that can be done to help with that, speed up that process and we're looking at probably a six to twelve week recovery for someone with anything severe.

So common foot conditions we're going to talk about quite a few of these as we're moving forward today and these are probably some of the things we see most commonly I see most commonly in kind of sports medicine of the foot and ankle, hallux limitus this is stiffening of the big toe joint very often as a result of arthritis Morton’s neuroma which is a trap nerve essentially in the forefoot gives you burning sensations to the forefoot sometimes neuromas and capsulitis the next thing on this list are together. I saw one of these ladies I saw ladies’ day with both of these things. Capsulitis is where the the joint, that connect metatarsals to your toes becomes swollen and inflamed capsulitis can often become a plantar plate tear or rupture if they're left over time, so this is kind of it does progress onto that. Hallux valgus, this is where you get this is a proper name for a bunion. Ingrown toenails, I think we see a lot of and and this is a minor procedure we do in our patients takes about three or four minutes to cure you of an ingrown toenail that's obviously something well worth seeing and is a common problem in different age groups. Arthritis in any of the joints the feet is seen, arthritis can be both wear and tear and inflammatory into the different types of arthritis and and they have different telltale signs and might well affect different joints. A ligament injury, so lots of ligaments in the foot and ankle, obviously most people are commonly aware of an ankle ligament injury they twist your ankle but there are other ligaments too and plantar fasciitis is a type of that type of ligament and that's really commonly injured and obviously can cause quite significant ongoing discomfort. So now I see quite a lot of is an adult quite flat foot that's not to be confused with flat feet in general, but someone who didn't always have a flat foot and the foot becomes flat and that becomes a pathological process in its own right there are different reasons for that, we'll talk about that in a bit and and the main causes for it and then obviously one of my again most common things I see in clinic is is Achilles tendon problems, there are lots of varieties or sub categories of Achilles tendon problem and we'll talk about some of the most common ones later on and how we might go about treating some of those.

So, arthritis. So, we see a lot of this in rear foot and midfoot so the ankle and subtalar joints mid foot the arch joint and a combination of all, which is quite common. We think that about 60% of the arthritis in these joints is caused by historic trauma, now that's not necessarily last week's twisted ankle, but often the trauma 10 or 15 years ago you know and that can be and it was always thought for a long time that road traffic accidents accounted for a really high percentage. We think that the safety features in cars now make that less so but it's still a very popular thing and certainly one of the things one of the most common problems I see in clinic. We think the hyper mobility so joints that move more than they should also contributes to the making up most of the other 40% of reasons for this, you see a lot of overlap between the the injury trauma and the hypermobility and that's a bit of a recipe for an arthritic midfoot all right. Generally, like any arthritis we're looking at pain stiffness it tends to be sorer and stiffer after after periods of rest can be caused by and obviously made worse by activity, often whilst you're moving for people when they're not too badly not too severely afflicted but they're moving they are mostly okay. Obviously can cause pain at night and that's where the that you start to get bone marrow Dema in the in those joints as the cartilage starts to wear away so you might pull that bone on bones as your GP might call it.

Midfoot arthritis, this is probably the most common, I’ve seen this at least three times today in my clinic. Normally affecting the tarsal metatarsal joints this is the joints between your calcaneum and your metatarsals there's and and this tends to cause some flattening of the foot, real difficulty towing off pushing off when you're walking so as your body won't move over your foot it makes it really difficult people limp a lot with this problem. This should be very treatable okay, it's very common and probably massively under diagnosed so I see this often misdiagnosed as tendonitis, I joke with people when I see them sometimes that is almost never tendonitis in the top of the foot, and this is by by far more common. Easily diagnosed and clinic, we see it we see this telltale signs on ultrasound scan and and should be very treatable. Protocol for it is pretty proven and I'd normally say that the patient's that I see only maybe one or two a year get referred for surgery, so most people make a near full recovery, and it'll normally consider it to be management of that arthritis rather than cure. The surgery is also very successful for this but rather involved and most the surgeons I work with here prefer we do the conservative stuff first before they get the screws and plates out because if if they don't have to do the surgery then obviously that's a better way to go. We tend to find that the same pattern of pain, stiffness swelling that you see with commonly with arthritis you notice that there's bone growth on the top of the foot so it becomes bumping on the top and certainly painful to the top, that makes footwear fitting difficult because it tends to compress the tendons and the blood vessels and the nerves onto those bony prominences. Can you give you some strange sensations too and predominantly because of these nerves running across the very surface of these bones there's not a lot of extra padding to protect them from the spiky bits of bone that grow underneath them and that's why it's often misdiagnosed because the symptoms are thought to be that of the nerve or that of of the tendon are really secondary if we didn't have midfoot arthritis, the tendons and the nerves wouldn't be impinged and you'd have you wouldn't have those sensations at all.

You see a lot of this sort of problem in clinic and sometimes symptomatic and sometimes not, so toe deformities, claw toes, hammer toes and mallet toes and basically to just describe different types of deformity to the lesser toast you can get hammered big toe it is rarer but you see a lot of second third fourth. Obviously the difficulty with these is that you can like rub on shoes and make footwear difficult fitting and and and can alternate in certainly the diabetic population and that's also something we want to avoid these are can be called for different reasons so we know that song with a high arch foot is more prone to this sort of problem but we often see I would often see these clawing of the toes once the plantar plate is ruptured. So years ago that was something that wasn't particularly well known because imaging wasn't there for us to be able to see it and and now we know have a better idea of what's going on causing this under toes to go like this plantar plate tears or ruptures, total sub Luxes or dislocates and you tend to get the claw that goes with it often there are different ways of treating this conservative and surgical and probably kind of seeing how badly affected it is and having the system is probably the best way to go to inform that.

This leads nicely on to the next the next slide here where we're looking at forefoot pain. So this is you see the the diagram there and we're looking at a tear to the plantar plate I don't know if you can see my cursor but the plantar plate is just down here and this is a ligament that holds your toes straight essentially once that starts to tear the toe starts to curl up and starts to retract and this is it's commonly caused by too much load on that joint, so there are some reasons why you can have that long metatarsals so your long metatarsals are compared to the ones around it that can cause it you have a a stiff big toe or hallux valgus or bunion that can cause it to and and the wear and tear on the on the on the plantar plate that cause it eventually to begin to tear. We think of this as a spectrum between capsulitis the capsule gets inflamed and then you'll see a plantar plate tears and then also the rupture and then you end up with this stiff retracted claw toe. Morton’s neuroma, this is the other most common reason we get a forefoot pain that I see, certainly less a toe forefoot pain and I probably must have seen at least three people with more the drama at least today as well it's one of the other most common things I see you often get an overlap between the capsule the capsulitis or the plantar plate tears and the Morton’s so sometimes they can they can be confused easily the Morton’s neuroma essentially is a trap nerve in the forefoot tends to give you nerve symptoms so numbness pins needles burning shooting pains normally from the ball you'll put into the toes normally make worse wearing footwear so if I normally put the way to relieve it for most people would be take a shoe off. The nerve tends to thicken up with scar tissue which then causes it to take up more space be trapped between the bones even more so it makes the symptoms worse and and and that's something that we know is if you catch early enough is very treatable in outpatients and as a conservative treatment we know that as long as the neuroma is less than five millimetres in diameter on that put that into context is five times the size it should be then you've got a really good chance of responding to a course of conservative treatment and about 85% I would say in my clinic and then about the final 15% is a surgical intervention if you wait till that thickening is beyond five millimetres the chances are that's a surgical intervention and very often at that point is we would consider we'd talk about sending you straight for a surgical opinion for a decompression because it's probably beyond what we can manage conservatively but that is more than five times the size it should be. Get these things checked out sooner probably is the models that models that story.

So, we know that the gap between the third and fourth toes is the most common, but we see a lot of it in the second and third as well. Very rarely do we ever see between between the big tone the second and the fifth toe and the fourth that's a much rarer once a year, once every two years we might see that in a patient. So, there are different risk factors shoes and the types of shoes you wear are a big risk factor we know that narrow shoes and any shoe or foot type that puts a little weight on the ball of the foot is provocative we there is a common gate pattern I see with almost everyone who has a neuroma with this I call it an abductory twists which you when you stand and you your foot twists and flip your foot up almost everyone I’ve seen with them all this room and I’ve done a gate analysis on they've all walk the same and I believe that this coupled with that gate pan is probably what causes the thickening of the nerve the the patients often describe these electric shock pains neurological symptoms but walking on a pebble is something you would read in almost every website in about Morton’s neuroma and is probably a little bit false most of them don't feel like walking on a pebble but that's normally how capsulitis feels but that would be when you read up about tomorrow's job that tends to be one of the things that's that's said and because there's such an overlap between these symptoms that is something we would often think of being a a a swollen capsule rather than the nerve.

I mean certainly my protocol for Morton’s neuroma we do injection guides and injection and ultrasound that we know if it's for less than five millimetres that's got 50% chance of working, we know that's 75 based on two injections so that means for 75 percent of people.

With two injections will get complete symptom relief and biomechanics plays a part and putting an insole in also helps to we mention that a little bit a bit higher and more importantly prevents recurrence in my experience, we know that surgery is also an important important tool in this. Hallux rigidus so this is something we see very commonly challenges arthritis the big toe put in context is the most common incidental finding on playing film x-rays all right that will have x-rays for any reason or they thought this is the most common finding the majority of people don't have symptoms so that's puts into some context most people can live with some stiffening of their big toe about and how inflamed that is and normally denotes whether or not you need treatment people come in because of pain in their big toe probably I suppose maybe only five or ten percent of people with Hallux rigidus end up presenting the clinic for the characteristics you tend to have this knock-on overload of lesser metatarsals with the problems we've just seen as a result of secondary to this so it might not be this doesn't hurt but you end up using other parts of your foot more which puts more of a strain on them and so this might be the underlying cause but causes something else. Essentially what this would be is in lay terms is the joint becomes more arthritic and you can't bend a big tiny one they will always bend it down and they'll show you and collect they can bend the toe down as you climb trees you don't need to bend your toe down so how much it bends up is more important and the test will be to ranger to up and if it doesn't bend you probably you probably tick the box.

Hallux valgus now this is known as bunions to almost everybody and this essentially is a is a deformity that is is progressive so it tends to get worse, tends to cause pain on the imminent so that the lump but also tends to cause a lot of knock-on effects of that rest of the foot dislocation of the lesser toes overload of the lesser metatarsals other parts you're having to work harder because your big toe doesn't point straight anymore this is a surgical problem, you can't make hallux valgus straight again no matter what you do to it unless you have pins and screws and this is what my surgical colleagues do every day the problem we have a list of these every single day of their working life and and probably taking 20 minutes to fix really are that skilled of it. If it's not hurting we wouldn't always necessarily say you need to have it done if it is hurting then also there's a there's a reason to treat, the braces and toe straighteners that you see online you see on social media they don't work, we know that the studies have been done and the the potential correction they offer was less than the error in reading the angle so it's so small that when you read the angle that was less short on the width of the line that they really angle with and so pads if it hurts to rub on shoes straighteners you can see on the right hand side save your money.

So as we mentioned this already hallux valgus the final part of this that affects your big toe and you have two little pea-sized bones underneath your big toe they're called sesamoids and and these all commonly become injured this is a very common sports injury you see a lot of football players anyone who has a stud under that part of the foot and and dancers the other the other group we see a lot of this in. It can get inflamed, you can get stress fractures to them and in severe cases and maybe a couple of times of years we see this where the you lose the circulation to the bone and often that's where stress fracture has not been treated and then you end up having the cuts off some of the circulation of the bone.

Adult acquired flat foot so this is someone who hasn't always had a flat foot but the foot has become flat so often there's a big asymmetry between left and right before there is a spectrum to this so this is commonly caused by the weakening of them one of the main structures that holds the arch up in your foot most commonly tibialis posterior tendon the spring ligament plant pressure also somewhat involved. So, you start normally there's a spectrum of this it starts with some pain up inside of your ankle bone where the tendon is inflamed and the second stage this is where the tendon stops hurting because your brain stops pulling on it so it switches that off and the foot flattens, then third stage that flat foot becomes arthritic and then the four stages where the arthritis becomes bad enough that you can't really use the foot anymore and and you want to come in when you're stage one I normally say safe from a common stage two stage four and we're limited really limited and and it might well be that a surgical fix.

So treatments wise that we offer here so certainly myself obviously consultations diagnosis image guidance injections and ultrasound scanning so we have a scanner with me in clinic all the time we do some nail surgeries to ingrown toenails that I can say we can fix that in three or four or five minutes completely pain-free do some shop wave therapy and this is really good for certain Achilles problems and plantar problems custom insoles a couple of custom authorities and we make the latest 3d printed custom orthosis and and kind of the anyone who's had orthoses before and can't fit me shoes that's probably the answer the 3d printed ones we can fit an insole into an into a six inch stiletto if you wanted me to so really are we have so much more range that we can make insoles for now gate analysis that's an important part of any podiatrist's job looking at how you move look at how you walk spotting weaknesses asymmetries and obviously then physiotherapy and surgical opinion leading into and playing a part of that multi-disciplinary team. Physiotherapy is really good for high exercise rehabilitation, we've spent a lot of time setting our patients with physio and then obviously the surgery so many patients who aren't getting better with a conservative treatment well often say to them have a chat with the surgeon find out what's involved and we come back to carry on the conservative stuff if we need to but at least you're informed or can make educated informed decisions.

So shockwave therapy is a type of treatment that stimulates your body to repair itself and is commonly seen as an alternative to corticosteroid injections and and really good like I say for plantar fascia and and Achilles problems within the kind of meta-analysis the analysis shows that about 80% of Achilles problems resolve within three sessions or so of shopping therapy and something like 75 to 80% of a plantar fascia problems so certainly they're the two most common things I would use it on that best indicated from that from the evidence base and the studies that have been done.

Okay so now it says let's skip that because we want to get a time not going to get told off. Injections got a whole range of different injections from local anaesthetics for doing simple nail ops pain-free corticosterone injections very good for certain problems we do a lot of them for in combination with the sodium hyaluronate below it's basically like a lubricant for for a bit like WD-40 for rusty joints all right combination of the two works really really well for some arthritic joints high volume Achilles injections is one we do we're being we use that as a type of water injection that that cures mid portion Achilles tendinopathy because that's a really really useful one again with the 80 to 85% success very high success rate.

Insoles where we spoke a little bit about that so flick beyond.

Ankle problems there's a whole range of different kind of rear foot and ankle problems that you can have we spoke about some sprained ankles already Achilles tendon problems so that's a week probably one of the most common things I might see in clinic here but bursitis and there's a there's an overlap between bursitis and Achilles tendon broken ankles I mean that we do pick them up unusually a lot considering you'd imagine especially people have been x-rayed by only already which is always reassuring if you're with ankle if you if you if you've twisted your ankle you've got an ankle trauma if you can't take three steps either of your your ankle bones hurt when you press it or the the bone lump on the side of the midfoot if any of those hurt we imagine that's standard okay or if you can't take three steps so if you if you have to twist your ankle you've already broken it you've been told by anything you haven't then then that's kind of pretty standard approach come in for x-ray. Ankle and arthritis so obviously we we obviously the conservative treatments for this and and and surgical treatments obviously it can be osteoarthritic and we spoke about that being primarily as a result of trauma and you can't get ankle impingements as well and these are common both from bony overgrowth and from accessory hospitals these are little floating bones that get caught so a young girl this morning with one of those at the back of her ankle which we injected this morning we're hoping thanks ballet dancer very common in ballet dancers posting with ankle impingement that which will make a full recovery.

So exercise is really important with ankle arthritis injections really important as well something we use a lot of both because we know it reduces pain but when we combine them with the hyaluronic acid part we know it slows down the worsening of the arthritis the arthritis it slows down the degenerative process and and we know that that slows it down by years so it's a really powerful tool depending where the other is and obviously your standard painkillers and and then obviously in surgery you saw the picture previously a nice couple of screws through there and and obviously there are certain different procedures that can be done ankle fusion which is where those screws are that's got a good so we've got the best outcomes but they kind of replace them too.

Ankle injection so a bit like I just said that mix of steroids and hydric acid is my approach that normally gives you symptom relief for about a year nine months to a year and I have quite a few patients that come back regularly to have that done I’ve got repeated on a yearly basis. My colleague here also Mr Dhinsa who we did this presentation together with last time about six months ago he tends to go with a more steroid approach and a slightly different way of a different way of of approaching the same thing.

Plantar fasciitis is again probably one of the most common things we see in clinic heel pain the banks the heel tends to be very sore on first step and normally resolves within 10 or 15 minutes of getting up generally we expect fragile onset and and it's somewhat over diagnosed something that's simply diagnosed in clinic with ultrasound scan we can judge how bad it is plantar fasciitis is a broad term and and we might use a term called plantar fasciopathy plantar fasciitis is an inflamed plantar fascia and that accounts range of quite a small percentage of plantar problems plantar fasciitis and plant fibromas are also part of that and then plus or minus calcific changes so we've judged those that categorize it and then we can I think that dictates I think what we think is going to work best.

One of my favourite things to treat and clinic that's a lovely picture here of a mid-portion Achilles tendinopathy if you can see my cursor which I don't know if you can but that's the mid portion of your Achilles there and see that's a lot thicker than it should be should be about this thick all right really common problem and one of those problems that tends to ramble on for years I see a lot of patients like this been going for years, had a guy flew in from Dubai at the beginning of the year have one of these injections done for this ex-professional sportsman and yes eight weeks later he was completely back to playing sport game brilliant essentially we use a high volume of steroids and aesthetic high volume of water anaesthetic and a touch of steroids and it's got a hydro dissection injection it mimics the surgery you can have done for it without all the surgical risks through one through an injection guide to by ultrasound that is certainly for this sort of problem hello 80 85 or more success the rupture is always the possibility, it's very rare but that is something we see kind of on a once a year basis so then probably one too many exercise rehab really important it's kind of mainstay of both getting better and staying better more importantly so one thing we'd always do is get you some some rehab and you complete the daily. Shockwave is another important part for this is sometimes we shock wave more when they're down the insertional when they attach to the bone that tends to be we do a lot more shot by for that but also works well in this mid portion.

Something we sometimes see with GP sometimes older GPs we inject right into the Achilles tendon if you've got where the key standing injections if it's not guided don't risk having an injection at it it's not an injection to be done on guided you make sure the image guided and ideally ultrasound guided otherwise you don't know what to put it in through.

And obviously one of the things we see a lot of is a combination of Achilles problems this is with plantarsity they'll tend to the runs alongside your Achilles bursitis bone deformity and obviously calcification of the insertion it's obviously part of scanning these is that is to work out how we categorize this and give us an idea of what we think is going to work best.

My orthopaedic colleagues here so we've got the three of them Mr Southgate Mr Dhinsa and Mr Dunning, all consultant foot and ankle specialty surgeons obviously treat a whole range of of foot and ankle problems surgically and real experts in the in their field there's a whole range of different things that they they would see and would regularly treat and there's obviously a lot of overlap broadly speaking their job is to pick up the ones that don't respond to conservative treatment and and and obviously you have brilliant success rates doing so.

Obviously the different types of surgery involved and a lot of that is depending on the surgeon one of the things I say to a lot of people would be to have that consultation with a surgeon if conservative stuff has failed have a chat with the surgeon find out what's involved because obviously those reading from a textbook and applying those principles to everyone is not how this works they normally run some x-rays of you see exactly what's going on so the structure of your foot through x-rays this is how surgeons see people and and with the bit like we always joke with the you watch the matrix and the guys are watching all those numbers flying off the screen film matrix the foot surgeons look see people with x-ray eyes and and do you look in here there's a couple of Mr Dhinsa’s pictures I believe and and they're called intriguing the same problem midfield arthritis two different approaches depending on depending on what works best for that person that's us. Probably what is 8 minutes late, sorry.

Louise King

You're not late that was really interesting, I said I said a minute a slide.

There's so much that is involved with the threat and ankle so yes, it's really interesting hopefully everyone else found it interesting too.

We have some questions just go through them. This one says they've had people comment that they have flat feet or their feet lean inwards but this has never caused them any issues so they haven't seen a podiatrist as of yet should they book an appointment if it doesn't affect them and there could be could there be any long-term problems?

Mr Liam Stapleton

So look we think that the joints are probably is probably no so but we we think that certainly in depending on ethnic origin that it's normal for a lot of people to have flat feet so we're looking at people from south Asia and of African origin that flat feet would be the norm and it would be unusual to have art feet some of the some of the focus on arts height is based on some work done in the 60s and 70s in California by some really early surgical podiatrists who the three of them did cadaveric studies so studies on on dead people's feet and all of the those basic biomechanics principles that that we see a lot of still run through today or until are spoken about commonly today it's about flat feet and arms feet come from those studies which were based on 10 individuals and some of that normative data that's been probably banded around for a long time is based on 10 individuals and that it probably isn't that a good cross-section of you know of of the norm I would say if if I’ve got a lovely photograph somewhere with Usain bolt who's got the flattest feet and was the fastest man alive all right if they don't hurt prop cause a problem then they're probably fine and if they've never caused a problem they're probably fine part of what we'd do normally if you're worried would be to assess their function how good are they functioning because just because it's flat doesn't mean it's not functionally very good we know that people with flat feet are more likely to have certain problems we also know that people got high arch feet are also prone to having certain problems whole different list of other problems but but they're equally as likely to have problems and so it's not a it's not a given so functionally it's all about function for me all right if they function well flat then great and if they don't function well then might well start with something simple like some exercises to improve that function it wouldn't necessarily mean it's a pathological problem in its own.

Louise King

Okay this person says they've had in ankle fusion due to injury and they're looking for help with gait and footwear is there something with which you can help?

Mr Liam Stapleton

Yes so look certainly a couple of things that kind of simple stuff we think something we've had ankle fusion that obviously has a limited range of of dorsiflexion between foot doesn't move up and down as well as what is used to and it predominantly doesn't get rid of all of that but there's normally a fair portion is reduced there's a bit compensation at some of the other joints some depends on what type of angle fusion you've had as to how bad that gets we tend to feel like a rocker sole shoe works best and right this does mean you have to be kind of a bit stronger through your core to start right because obviously cause work a bit harder to stabilize yourself on a rocker silver soled shoe but that sort of shoe works really really well there's a brand of training shield called a hawker which is one of the ones I recommend a lot of patients wear or or an mbt soul shoe they work really well for people who've had ankle fusion or who have really severe ankle arthritis would always have that severe arthritis will give you the same almost as the same limited ankle movement as you would get with a fusion of not normally a great little difference between movement pre and post-surgery when that when the ankle's bad enough. That's what rocker soul shoe is probably one thing I would would start with we can't obviously obviously probably more we could do specifically if you know we'll see you see your x-rays and see what kind of sort of surgeries you've had and how restricted you are assessing function but the best way to help yourself is get the kind of a kind of that sort of rocker soled shoe, yes.

Louise King

Okay, this person has numbness in both feet writers they believe this is irreversible but aren't any medical and surgical interventions that might help alleviate symptoms?

Mr Liam Stapleton

This opens up more questions as to where she has arthritis and we're guessing probably lower back if it's both feet but maybe if she wants to come back on and let us know if that's if that's like lumbar spine arthritis rather than foot and ankle arthritis it's be rare to have bilateral numbness or no symptoms like equal on both sides if it wasn't from your back.

Louise King

Okay is it possible to have ankle injections after recent knee surgery?

Mr Liam Stapleton

Yes, so I would say print out recent it was, the surgeon often injects the joint after whatever these have you had but if you're like a a knee resurfacing surgery they often inject into the joint they've just operated on that's really commonly done normally what what's your stitches are out the wounds healed that should be relatively safe to do yes.

Louise King

Okay thank you this person has severe lower leg pain apparently caused by the way they walk, and they have fallen arches are now notice dents appearing in the legs.

Mr Liam Stapleton

Okay yes so is that maybe more than one thing going on there so but particularly the dents are from swelling I presume and and the kind of demo you get perhaps look so obviously when we spoke with flicked across the flat foot problem really quickly it's very involved so the the main tendon and muscle that's responsible for holding the arch up and your foot is in your leg so so when that starts to when the art starts to fall or normally because that tendon is either being overworked or as torn or is tendinopathic there's a whole range of things indoor with that that will give you pain both in your leg your ankle and potentially your foot as well once that arch falls once it starts to collapse you become a propulsive so you your thought struggles to push you forward when you walk which puts a lot more strain on Achilles and your calf muscles the main customer the ones responsible for pushing you forward when you walk so is that putting more strain on those too so there's obviously reasons why that would happen with that pattern probably that would be one you have to be assessed for that I think we'd have to have a look at you and actually see what's going on, see what stage you're at what the underlying causes were and obviously tackle each of them in in order that sounds sensible.

Louise King

Okay, this person asks should they be worried about thickening skin on the outside of the big toes is not hurting presently?

Mr Liam Stapleton

So normally when you get thickening skin it normally a sign that that part of your foot is up bearing more pressure or more weight than the other part so for different reasons why someone might get an increased skin on the outside so hallux limitus will do that to you so if your big toe doesn't bend up like you should do you tend to roll off that side knuckle of your big toe and so like this rather than toeing off straight you tend to come off the side and that would be one of the reasons why you'd get that if you have the palette developers deviation to the bung in deviation with a big toe deviates inward again it's already pointing in so it becomes very difficult for you to top off the end of your toe because it no longer points straight to the point over there somewhere so you're going to roll off that inside double too so there are two reasons why that might be the case it might well be that it might not the hard skin in itself might not be a problem it might be suggestive of something going on under the surface perhaps one of these things we know that a lot of people have hallux limitus or how it's ridges arthritis and the big toe joint if it doesn't hurt we don't always do a little critical to it I wouldn't necessarily think we always do something to it but it's very common and and most people if we live long enough we'll probably end up with it one of your feet at least so it wouldn't all and for most people it's not painful so wouldn’t always do something to it but if she's worried about it probably worth having looked at  yes.

Louise King

Okay this person has had multiple stress fractures in both feet the last two years and now has permanently has pain in both feet and finds walking extremely painful could you help?

Mr Liam Stapleton

Yes, well presumably presumably she's had been been screened by rheumatology for osteoporosis that would be kind of first thing you had more than one stress fracture in a short period of time then yes definitely screen with I’d say rheumatological colleagues to make sure that you had your bone density assessed and relevant medication given to straighten the bones back up if that's if that's a possibility yes then obviously looking at which bones were the stress fractures were in and and looking at at how we might reasons why that might be so we think of say well one of the most common second stress fracture normally because of bending force that's doing too much work that would be a type of insole and shoe would would resolve that problem in a similar way that a you know a mid-foot bone stress fracture would be caused by compression this is the top of the arch if there's compression there that can cause stress fractures all that too and again that might be a different type of insert we might look to to offload that with we're going to try and look at the bone see if we can see if we work out what the contributing reasons are for that and then tackle those reasons obviously bone health would be if it's multiple stress fractures bone health is a big big question mark there and that would be something we definitely want Dr Saha to have a look at with with regards to bone density testing I think. We can help with the pain.

Louise King

Just going to come off a couple more questions so this person says the car door blew back on their foot a year ago and the foot swells every time they walk on it and below the little toe and the two adjoining toes what could be wrong? Sometimes they get numbness too at night.

Mr Liam Stapleton

Couple of things there really just perhaps stress fractures that's always a possibility so if it's hurting getting worse as she walks that's possibility that would give you numbness across that region Morton’s neuroma that would also be a possibility too so if the swelling of the nerve that's there arthritis so post traumatic arthritis that's a possibility to probably yes well look but not all of those things most of those things people are seeing without a scanning clinic so that might be the first point of call have it assessed have it looked at and then obviously and then obviously once you've got diagnosed the treatment is easy the treatment follows itself once you know what we're treating.

Louise King

Okay after steroid injections how long is recovery and when could this person get back to cycling?

Mr Liam Stapleton

So it depends what what you've injected I guess and and I mean broadly speaking why my my broad protocol and I probably follow whoever's injected you would be follow their protocol rather than mine because I don't know what they've rejected how I might have injected what they've injected and what sort of conditions so but my protocol is normally no running and jumping for about seven to ten days after injections and then a graduated return and so normally I’m happy for cycling fairly straightforward for most of them I would say but that obviously I’d follow whoever injected you it's their advice is king because also I don't even know which people for the foot they’ve injected but you know my project was broadly seven to ten days.

Louise King

And our final question this person has some ripping pains towards the back of their foot and ankle after exercise particularly running, is it reasonably common or should they say a podiatrist?

Mr Liam Stapleton

So there are different reasons why you might get pain at the back of the ankle and obviously Achillies problems that would give you often gives you pain 24 to 48 hours after after exertion obviously very commonly runners there's always one possibility positive ankle impingement is another one so again that would be where you're getting some pinching off the back of the joint capsule sometimes of the tender that runs through there the big toe tenders have run through there all extra little bone but there that pinching of that through their region that would also give you a similar pattern of pain often these kind of inflammatory pains don't hurt when you're actually running but would often hurt after you know after you've been well after you've got cold somebody stopped and rested. Yes, probably I would yes if any aches and pains I definitely recommend seeing someone who deals with that part of your body that would be kind of simple I think the simple answer so yes come on and see us and look at it.

Louise King

Thank you. Yes, that's all of our questions and if not then we can get back to you if you've provided your name. If you'd like to discuss or book a consultation our Private Patients team is available between 8 am and 6 pm Monday to Friday, you'll see on the screen we're offering a discount for joining the session this is applicable for the next seven days with the terms on the screen. At the end of this you receive a short survey we'd really appreciate if you could spare a few minutes to feedback, so it really helps improve our future webinars. Our next events are on hip and then on knee surgery separately, we're also doing a webinar on an enlarged prostate treatment and one on varicose vein treatment, you can visit our website to sign up to those.

So, on behalf of myself, Mr Liam Stapleton, and our expert team at Benenden Hospital, I’d like to say thank you for joining us today and we hope to hear from you very soon and have a nice evening and goodbye.

Mr Liam Stapleton

Many thanks everyone, thank you, bye.