Flat Feet and activity of Proteolytic Enzymes

Barry Francis the foot surgeon at the Fyfield Clinic London picked out this storie in a recent edition of the Nursing Times, discussed the possibility that adult acquired flat feet may be caused by the activity of proteolytic enzymes.  According to the article put out by the Press Association, researchers at the University of East Anglia found that the increased activity of these enzymes can break down the constituents of the tibialis posterior tendon and weaken it, causing the foot arch to fall.  This condition, which often goes undiagnosed, is most common in women over 30 and occurs when the tibialis posterior tendon gradually stretches out over time.  The researchers say that their study marks an important advance in understanding the causes of adult acquired flat feet and may eventually lead to a new drug for the condition.  The findings may also be useful in developing treatments for other common conditions such as Achilles tendonitis.  However, it is stressed that new treatments could be 10-15 years away.  Further research is needed to find out which proteolytic enzyme should be targeted and whether people could be genetically predisposed to this type of tendon injury.  Lead author Dr Graham Reilly said “our study may have important therapeutic implications since the altered enzyme activity could be a target for the new drug therapies in the future.  If shown that similar changes also take place in other painful tendon conditions such as Achilles tendonitis, this advance may ultimately result in an effective alternative to surgery for many patients”.  I gather that the complete findings are published in the Journal Annals of Rheumatic Diseases.

Barry Francis  “The Foot Surgeon”  Fyfield Clinic London.

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Podiatric Surgeon on UFOs and Aliens

Thought I would share this interesting article with you.

The Friday morning edition of Today (13th January 2012) featured an article on Dr Roger Leir.  Dr Leir is a podiatric surgeon living in California who has a consuming interest in UFOs and has operated on 15 patients removing alien implants from them.  These implants are said to be of a metallic nature but covered with an organic material, and according to Dr Leir, have been sent to eminent research institutions in America for analysis.  Dr Leir is the author of several books including “The Aliens and the Scalpel”, “Alien Implants” and “Chopped Liver”, an anthology written by 52 different authors edited by Dr Leir.  While Dr Leir certainly presents a refreshingly new approach to the use of podiatric surgery, he addresses a theory which is really killed by some, and held in fierce belief by others.

Time will tell.

Barry Francis  “The Foot Surgeon” at the Fyfield Clinic

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Treatment of Verrucare

Mr Francis the foot surgeon thought he would share this recent article appeared in last week’s Mail on Sunday regarding the treatment of verrucae.  This article dealt with some types of treatment, including over the counter products, as well as the application of acids by chiropodists/podiatrists and cryotherapy.  The author, who is a podiatrist, was pessimistic about outcomes and suggested that because verrucae rarely cause difficulty they should probably be left alone.  Other complementary treatments like banana skins were also dismissed.  Unfortunately, I do not totally agree with the ideas put forward.  First of all, many verrucae are treated, not because they are present, but because they are painful and certainly in the adult and quite often in the young person they are present for quite long periods.  In this practice when we feel that verrucae are very resistant to treatment we will often suggest a background homeopathic remedy and also supply a treatment which may be one of the ones mentioned above or possibly excision and cautery which are carried out using local anaesthetic.  The success rate for these treatments is high although there is often quite a large inconvenience factor as well.  However, I would suggest that before any active treatment is started a little time be left to elapse and certainly at the beginning all verrucae should be treated with simple over the counter remedies.  The best ones are probably based on salicylic acid.  We are always happy to discuss treatment options at the Fyfield Clinic.

Until the next time Barry Francis the foot surgeon.

www.thefootsurgeon.co.uk

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Right Foot Update by Joseph Loria

Right foot update by Joseph Loria after his Hyprocure Implant Opperation by Mr Barry Francis the foot surgeon at the Fyfield Clinic

My 3rd & final review appointment took place in November, 2 months following the initial procedure. Mr Francis confirmed everything was going to plan and we discussed possible dates for the left foot. I was keen to have it performed before Christmas, allowing a fresh start to the New Year and to avoid recovery during the colder winter months. Also, I felt the noticeable improvement of my right foot starting to tail off and knew the back/pelvic symptoms wouldn’t be fully resolved until both feet were corrected. I still relied on a crutch at this stage, although it was mainly used for balance rather than to limit any pain. A date was then arranged for early December, roughly 3 months since the 1st operation.

Left foot surgery

The ‘Hyprocure’ surgery was carried out at the same clinic as before and the day’s proceedings followed similar suit to the previous date (please see my ‘day of surgery’ post below for full details). It was slightly quicker this time and felt more relaxing. Having previous experience of the procedure contributed to this as it eliminated any nervousness towards the event. A smaller implant was required for this foot and I left using crutches once Mr Francis and his colleague were happy with the outcome.

As with the surgery itself, the recovery period was smoother due to knowing what to expect; therefore enabling me to prepare myself more efficiently. I eased off the painkillers/anti-inflammatories earlier this time and taking a short course of ‘Arnica’ without delay helped reduce the bruising present. My home was better organised and even though it was certainly frustrating having to remain in bed again, I felt positive I’d recover quicker now both feet were corrected. The 1st review appointment was scheduled for 2 weeks following the operation as it wasn’t necessary to return after a week. Coming from quite a distance away, this was convenient for me.

Returning to the Fyfield clinic involved the removal of the suture and a redressing once the incision area had been checked. I was now ready to progress to wearing the ‘Aircast’ boot until the return to regular footwear could be made. Mr Francis advised a final review for the end of January, 6 weeks away. My foot has improved considerably since setting the date and all alignment issues are gradually being resolved. I sit with better posture and my breathing is deeper/less jagged. I’m confident these factors are directly related to having the surgery and hope the benefits continue steadily into next year.

For more help, information and advice please do not hesitate to contact Mr Barry Francis the foot surgeon and his staff at the Fyfield Clinic, London.

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Sue Knott weeks 8,9 and 10

Following on from Sue Knotts Hyprocure implant opperation the persional thoughts over the past 3 weeks direct from Sue.

Weeks 8 & 9 thankfully saw the pain in the metatarsal joint gradually diminish to the point where it no longer radiated down towards the toe and walking was easier. Once again my foot was a lovely shade of green, having been bruised by the injection, and slightly swollen. Although the wound from the incision has healed nicely and is very neat, there is a lump beneath and it is still sore to touch. I now have full movement in my toes again. Jarring my foot when trying to reach the letterbox to retrieve the mail before Rufus the demented family Cocker Spaniel taught me a salutary lesson in not running before I can walk! Mr Francis rang twice to check on my progress which he is happy with and I have an appointment to see him again in early December.

Week 10 has been the best so far. The bruising and swelling has gone and when pottering about at home I am walking normally without a limp. My routine fitness test has been a trip to the local supermarket for grocery shopping each week. Although this was a painful experience in weeks 8 and 9, I am happy to report that this week it was relatively pain-free. Today (the day after my supermarket trip) the ankle is a little sore so I have been resting it at intervals. Providing the soreness subsides I will continue with short walks from now on as I cannot see how the foot will get back to normal unless it is exercised and becomes used to the stent and new walking position.

For further help and information please do not hesitate to contact “the foot surgeon” Mr Barry Francis and his staff.

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THE SESAMOIDS

Mr Francis was recently asked to contribute to an ebook on foot conditions and surgery being prepared by the Faculty of Podiatric Surgery and College of Podiatry.  He thought that his own contribution might be of interest as problems with the sesamoid bones (two
small bones underneath the big toe joints) are common.  Further information can be obtained direct from Mr Francis or his staff at the Fyfield Clinic.

THE SESAMOIDS

The sesamoids are small bones which are inserted within a tendon and form part of a gliding mechanism and are designed to withstand pressure.  Damage can often occur if there is a variation in directional pull on a tendon, particularly when this is in close contact with bone. The site and number of sesamoids in the foot is variable.  Usually two are found embedded in the tendons of the flexor hallucis brevis (the flexor hallucis longus runs between them).  Others may occur in the plantar plates of the metatarso phalangeal and interphalangeal joints.  Whilst complete absence of the two sesamoids beneath the head of the 1st metatarsal is rare, the author has experienced one case.  The absence of one is more common.  A sesamoid beneath the interphalangeal joint of the great toe is unusual and when found may be associated with hyperextension of the great toe.  The sesamoid metatarso articulation is a complex structure with a number of attachments.
The articular surfaces of the sesamoid bones are concave and lie beneath the head of the 1st metatarsal.

Great toe sesamoids themselves elevate the 1st metatarsal head.  Their displacement can cause considerable biomechanical disturbance of the forefoot.  Normally two sesamoids occur beneath the great toe joint.  One or both of these may be bi partite but the most common bone affected in this way is the medial.  The bi partite bones will normally be much larger than the other sesamoid and will also have smooth edges which may
differentiate it from a fractured sesamoid.  25% of the population have bi partite
sesamoids, and 85% of these are bilateral.

History

The name sesamum is said to have been coined by Gallon in AD180 as the small bones resembled the seeds of the plant sesamum indicum, the oil of which was apparently used as a purgative (Garrison 1910).  The Rabbi Uschia (AD2010) writing in Bereschit Rabbi described a bone called the “luz”.  It was thought this might be the repository of the soul after death.  Vesalius in De Humani Corporos Fabrica 1543 wrote of the sesamoid bones of the great toe as being “another one of those bones is that which the magicians and followers of a cult philosophy so often call to mind as being fashioned like a chick pea,
liable to no decay and if buried in the earth after death will reproduce man like a seed on the day of the last judgment”. Other descriptions and speculations are numerous and are described well by Helal and Wilson.

Pathomechanics

Pain may be experienced around one or other of the sesamoids.  There may be pain associated with the soft tissues structures attached to them.  Inflammatory conditions may also involve the structures surrounding and the involvement of the sesamoidal bursa.  This can cause pain and change in gait.  Change in gait will affect not only the great toe but may affect the foot in general. Subluxation of the sesamoids can occur in connection with problems such as hallux valgus or when there is interference in the “reefing structures
around the sesmoid complex” as in the removal of the base of the proximal phalanx.  They often then are displaced proximally.  Displacement of the sesamoids may cause alteration in the position of the 1st metatarsal head.  This may result in problems with
the lesser metatarsal joints (metatarsalgia). Subluxation of the great toe sesamoids in hallux valgus results in the position of these bones in relation to the underside of the 1st
metatarsal head being altered.  The lateral sesamoid may well end up in the inter metatarsal space and the medial sesamoid on or around the crista, on the underside of the 1st  metatarsal heads.  Malposition will not only accelerate joint wear but will alter the relationship of the structures and thus cause pain.  The function of the sesamoids is to stabilize the hallux in the sagittal plane against ground reactive forces.  Altering the position of them can have substantial effects on the joint apparatus.  The sesamoids absorb shock and if this function is removed then the metatarsal head can become damaged.  The position of the sesamoids is helpful in classifying the extent of the hallux valgus and it should be borne in mind that sesamoids themselves do not move, but rather the overlying bone structure, i.e. the 1st metatarsal.  David et al describes four stages of the loading of the foot in relationship to the functional role of the sesamoids:-

1. Suspension of the 1st metatarsal head.
2. Fixation of the 1st  metatarsal head.
3. Co-ordination.
4. The propulsion stage.

The first stage correlates to heel contact to forefoot load in which the 1st ray plantar flexes and the sesamoid apparatus suspends the 1st metatarsal head, acting much like a harness.  The second stage essentially fixates the sesamoid apparatus to the ground and thus has a stabilizing force.  The third stage allows motion of the proximal attachments of the sesamoid muscles with the hallux fixed firmly against the ground preparing for the fourth stage and this is where energy stored within the flexor hallucis tendon is converted into kinetic energy allowing for propulsion.  David et al concluded that the function of the sesamoid apparatus is to distribute and co-ordinate forces placed upon the forefoot for propulsion and balance.

Radiology

An AP view of the foot will give important information as to whether sesamoids are bi partite or fractured and their position in relation to the 1st metatarsal head can be seen.  The most important view however is probably the forefoot axial radiograph which shows the position of the sesamoids beneath the 1st metatarsal head and will illustrate their relationship to the crista.

Problems of the Sesamoid

Infection – Infection of the sesamoids may be related to trauma or from ulceration connected to neuropathy.  Treatment would involve antibiotic therapy and if indicated debridement of necrotic bone. Early stage treatment would involve offloading from the affected area.

Sesamoiditis – This presents classically with erythema and swelling and is probably due to overuse or enlargement or displacement of other bony structures. Skin callous may be noted beneath one or other of the sesamoids.  This can be complicated by the formation of
neurovascular or deep corns. Conservative treatment of sesamoiditis includes padding to offload pressure from the affected areas, taping, or insoles/orthotics to again reduce
weightbearing of the 1st ray. If pain persists in spite of these conservative measures then partial or total excision of the sesamoid can be considered.  Sesamoid planing can be effective and has the added advantage that the stability of the joint is maintained if the soft
tissue attachments are not released. Excision may provoke hallux valgus, stiffness, or claw toe.  Beacon describes a release of soft tissue structures proximal to the tibial sesamoid to relieve pain which may be associated with tethering often occurring after surgery or trauma.

Sesamoidal bursa – The sesamoidal bursa can on occasion swell and become painful.
First line treatment may involve offloading pressure and injecting cortisone.  Should this not be effective then excision may be indicated.

Osteochondritis – Osteochondritis of the medial sesamoid, described by Ronanda in 1924, can occur in either medial or lateral sesamoids, but rarely bilateral. X-rays will reveal irregularity of the bone resembling AVN.  It is worth trying conservative approaches
first, as already described, but excision may be required.  It should be noted that following the removal of a sesamoid the area may take a considerable time to settle.

Fractures – Fractures of the sesamoids occur commonly in the younger age groups and the acute onset is accompanied by pain and swelling and reluctance to load the area.  X-rays (and occasionally a CT) may be taken to differentiate the fracture from a bi partite sesamoids.  In this respect the lateral weightbearing view may be helpful.  Sesamoids heal
slowly and often poorly.  Conservative care involves insoles or orthotics in this instance and it may take up to a year for resolution of pain.  Total or partial excision of the affected sesamoid may be required.

Summary

The function of the sesamoid apparatus is primarily that of shock absorption and protection of the flexor tendon and distribution of ground reactive force, but also to ensure the greatest mechanical advantage to arguably one of the most important joints within the
foot, subject commonly to damage by trauma. Degenerative changes are common primarily due to alteration of position within the 1st metatarsal joint complex.

Barry Francis Consultant Podiatric Surgeon at the The Fyfield Clinic

References

The Foot edited by Helal & Wilson 1988

David R D et al, Anatomical Study of the
Sesamoid Bones of the 1st Metatarsal

J AM Podiatric Medical Association 79.536
1989

Root M I. Orien et al, Normal and Abnormal
functions of the Foot in Clinical Biomechanics, Volume 2, Page 56-285, Clinical
Biomechanics Corporation, Los Angeles 1977.

Hetherington V, Hallux Valgus and Forefoot
Surgery 1994.

Duke Orthopaedics

Wheeless Textbook of Orthopaedics

J Beacon, unpublished lecture, Royal
Society of Medicine 1981.

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Sue Knott week 5,6 and 7

A personal note from “the foot surgeon” Mr Barry Francis about the unusual complication of Sue’s Hyprocure Implant recovery at the end of week 5,6 and 7 direct from Sue Knott.

“Week 5 was not as good as expected.  The pain I first experienced close to the wound site when wearing the Aircast did not disappear even though I had stopped wearing the boot.  The foot was swollen and tender and I continued to have limited movement in the outer three toes which feel slightly numb.  I discussed this with my local podiatrist who felt that it was early days in the healing process with the swelling possibly pressing on the tendons and nerves in the area and that things would likely improve over time.

I therefore decided to do what I thought my foot was telling me to which was to rest it as much as possible so as not to aggravate things any further.  In addition to taking anti-inflammatory medication again, I used an ice pack on the area regularly and kept it elevated to reduce the swelling.

Week 6 and, although the swelling had reduced, I was still finding it painful to walk on the foot and limping slightly when getting about.  I continued with the treatment regime mentioned in Week 5 but, despite two brief pain-free periods lasting a couple of hours each, the pain refused to go.  It’s hard to know whether the tenderness in the area was caused or simply exacerbated by the Aircast boot, but the fact remains that it did not disappear in the two weeks that I had been boot-free.  I have to say that at this point I felt quite despondent.

Week 7 I travelled to the Enfield clinic to discuss my progress with Mr. Francis.  Examination of the foot showed that the pain is located at the base of the fourth metatarsal and radiates down the foot to the toe.  On a more positive note, an X-ray confirmed that the Hyprocure stent is in the correct position which was good news.  I had laser treatment whilst at the clinic which is used to promote healing and picked up the rigid orthoses which Mr. Francis would like me to use for a few months whilst the ankle gets used to the new position. 

When I returned to the clinic three days later Mr. Francis had, as promised, shown my X-ray results to a colleague who confirmed that the
operation to insert the stent had gone well and that it was in the correct
position.  In addition to a further laser treatment Mr. Francis then
injected the affected area at the base of the fourth metatarsal with local
anaesthetic and asked me to walk around the block to see whether this brought about any improvement in the pain level which would confirm that this was indeed the problem which needed to be resolved.  The pain did improve and I completed my walk slowly, but without limping.  I agreed with Mr. Francis that the best course of action would be to have a cortisone injection placed in the joint which would ease the pain and reduce the
inflammation.  He did point out that relief would not be instant and that
things would get worse before they got better.  How much worse I was to
find out later that night.

I arrived home in the early evening and, although the foot ached, it was certainly bearable.  Unfortunately, as the local anaesthetic wore off over the subsequent hours the pain gradually intensified to a point where at 4 am, despite having taken two lots of painkillers,  it reached a peak and was absolutely excruciating.  I eventually nodded off at 5 am and am writing this blog now after two hours sleep. Happily, the aching and pain has receded and when I’m off the foot there is minimal discomfort.  It does still hurt when I walk so I’ve gone back to using one of the crutches as a support until things settle down further. They say there’s no gain without pain.  Well, I’ve certainly had the pain and am now  looking forward to the gain!”

From Barry Francis, “Sue suffered an unusual complication following the surgery which was probably connected with the use of the boot.  I spoke to her this morning which is now some four days after the injection and, although not completely resolved, things have
improved a lot for her and she is feeling much happier.”

For more help and advice on Hyprocure Implants please do not hesitate to contact Mr Barry Francis and his team at the Fyfield Clinic .

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