Podiatry Review November/December 2012

Podiatry Review

38780 Chiropody Nov/Dec 12 19/10/2012 10:00 Page 1

ISSN 1756-3291

Volume 69 No.6. Published by the Institute of Chiropodists and Podiatrists as a Peer Review Journal November/December 2012

• Plantar Fasciitis

• Lymphoedema Patients in India • Osteomyelitis

INSTITUTE OF CHIROPODISTS AND PODIATRISTS

38780 Chiropody Nov/Dec 12 19/10/2012 10:00 Page 2

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38780 Chiropody Nov/Dec 12 19/10/2012 10:00 Page 3

NOVEMBER/DECEMBER 2012 VOL 69 No.6

Editor Ms B. Hawthorn H.M.Inst.Ch.P.

Academic Editor Robert Sullivan BSc.(Hons) Podiatry, MSc. Pod Surg., PgDip M.Acu., FSSChP. FIChPA. M.Inst.Ch.P.

Editorial Committee Mr. D. Collett M.Inst.Ch.P. Mrs. J. Casey B.Sc., M.Inst.Ch.P. Mrs. J. A. Drane M.Inst.Ch.P.

Advertising Please contact Julie Aspinwall secretary@iocp.org.uk

Published by The Institute of Chiropodists and Podiatrists 150 Lord Street, Southport Merseyside PR9 0NP 01704 546141 www.iocp.org.uk

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PODIATRY REVIEW

The Institute of Chiropodists and Podiatrists

Contents

Head Office News..............................................................2 Editorial .............................................................................3

Plantar Fasciitis: A new Treatment Protocol Robert Sullivan, BSc.(Hons) Podiatry, MSc. Pod Surg., PgDip M.Acu., FSSChP. FIChPA. M.Inst.Ch.P. .........................................4

Helping Lymphoedema in India Tim Maiden.......................................................................9

Osteomyelitis Michelle Taylor BSc., M.Inst.Ch.P. .......................................13

Conditions Corner - Metatarsalgia Mr. Michael Hooper........................................................17 Obituary - James Arthur Kirkham....................................18

2013 A.G.M. News...........................................................20

Post Bag...........................................................................23 Diabetes News.................................................................24

Branch News ...................................................................27 Printed by Mitchell & Wright Printers Ltd, The Print Works, Banastre Road, Southport PR8 5AL 01704 535529

ISSN 1756-3291

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© The Institute of Chiropodists and Podiatrists.

The Editor and the Institute of Chiropodists and Podiatrists accept no responsibility for any opinions expressed in the articles published in the Journal; and they do not accept responsibility for any discrepancies in the information published. No part of this publication may be reproduced, stored in a retrieval system or transmitted in any form or by any means, electronic, mechanical, photocopying or otherwise, without the prior written permission of the publishers.

Arthritis Research UK Adolescents’ weight linked to severe knee pain ...........30 BBC West Midlands Radio Interview Somuz Miah BSc PodM, DipBMec, DipsP.1, M.Inst.Ch.P. ...........34

Classified Adverts ............................................................35

Diary of Events ................................................................36 National Officers ............................................................IBC Happy Christmas to all our readers From the Editor, Executive Committee and Secretariat

150 Lord Street

Seasons Greetings

2

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38780 Chiropody Nov/Dec 12 19/10/2012 10:00 Page 4

EDITORIAL

Your New Head Office 150 Lord Street, Southport, PR9 0NP

Telephone: 01704 546141 (office) 01704 541495 (clinic) www.iocp.org.uk secretary@iocp.org.uk Following months of hard work and negotiations the Institute of Chiropodists and Podiatrists is proud to announce that we moved into our new premises on Friday 28th September and the clinic opened its doors on Monday 15th October.

We now hope to have a new centre of excellence with the top floor being utilised for administration and training purposes together with the board room for executive meetings.

The ground floor will be concentrated on the clinics with three operational clinical cubicles in situ and space for expansion of clinics either additional podiatry or for renting out to other disciplines.

In addition, we also have plenty of parking space and disabled access and facilities.

All in all, we are proud of our new centre and we are already saving money by combining Southport and Sheffield together.

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38780 Chiropody Nov/Dec 12 19/10/2012 10:00 Page 5

Editorial

As you are all aware there have been some changes in the management of the Institute which have in turn lead to the departure of the Editor and Chairperson Mr. Bill Liggins. Bill was the editor of this publication for a short time but managed to bring about some productive changes. As academic editor, on behalf of the entire editorial team and its reviewers we wish him well and every success in his future choices.

A publication without a general editor is like a ship without a rudder. For many years the Review has been supported by our staff in Head Office. Most of this work has fallen on the head of Ms Bernie Hawthorn. Bernie has compiled the articles, read them, contacted the writers with any possible changes suggested by the review team, proof read and co-opted others to proof read. Her job did not finish there as she would talk to the publishers and decide any last minute changes.

My role as academic editor is to source articles of academic interest to the membership, review them and have them reviewed by other leading academics in the

Dear Readers Firstly, I would like to recognise the previous two Editors of Podiatry Review, Mr. Roger Henry and Mr. William Liggins who both played a huge part in guiding both myself and Podiatry Review to where we are today. I have been editorial assistant since 2005 and the changes during that period have been immense! I would like to remind YOU, however that this is YOUR journal and I would like to see many more members participating in its production. Please remember that all comments (good and bad) are valued and that we do listen to what our members would like to read. We already have several branches writing regularly with details of seminars that have taken place complete with photographs, but we would like to see all branches sending in regular news bulletins regarding their meetings/activities or just general interest articles.

Please do not worry about layout or style. We can help with this if we get the general information.

In this issue of Podiatry Review, we are featuring our new combined office and clinic. This has followed months of hard work and negotiations and we thank all who worked so hard to achieve this ambition. We are planning an official opening when all the final tweaking has been done but every member is very welcome to

EDITORIAL

field and then pass them to Bernie. The Editor of the Review has for many years been an honorary role, supported by Ms Hawthorn.

It is with great pleasure that I introduce to you Our New Editor, the slave in the background, Ms Bernie Hawthorn. This woman has managed to produce a good publication in very trying conditions consistently for many years, it is now time to recognise her and her role. I have no doubt that there will be interesting times ahead and she will face them in her usual style. She and I will continue to work closely together to develop and grow the Review for you Our Members. Talk to us, tell us what you like and what you don’t. Change is lead by the Membership.

I have every confidence in Bernie and congratulate her, on her official appointment.

Robert Sullivan, Academic Editor and Interim President, Institute of Chiropodists and Podiatrists.

‘pop’ in to see the clinic and the team in the office if they are in the area. It is very central on Lord Street and we have our own car park (a huge bonus for Southport with its over zealous traffic wardens!).

We also have next year’s A.G.M. booking form complete with most of the workshops. Yes, it is early but remember; how many of you were disappointed last year when your chosen workshops were fully booked? They were hugely successful so please… book early!

This issue’s technical articles are by Robert Sullivan on Plantar Fasciitis - this article combines ancient acupuncture with modern myofascial pain therapy and Michelle Taylor on Osteomyelitis. We thank Michelle for writing about this interesting issue. Please remember, all published academic articles count towards your CPD profile. We also feature a very interesting article by Tim Maiden on his experiences in Kerala in Southern India, plus lots more interesting news and views.

Finally, it is hard to believe that we are now into the final issue before Christmas and the editorial team would like to wish each and every one of you season’s greetings.

Bernie Hawthorn, Editor page | 03

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ARTICLE

Plantar Fasciitis: A New Treatment Protocol Using Myofascial Acupuncture in Podiatry Practice

By Robert Sullivan, BSc.(Hons) Podiatry, MSc. Pod Surg., PgDip M.Acu., FSSChP. FIChPA. M.Inst.Ch.P.

Correspondence to robert.sullivan@iocp.org.uk

Background: It is believed in acupuncture that Principal Meridians flow through the myofascial layer of the body and that these meridians send branches to one another and to the organs that they influence. Recent literature has described the concept of ‘myofascial meridians’ as anatomical pathways that transmit strain and movement through the body’s muscles and fascia (Dorsher 2009).

Senelar (1979) reported that pathological studies show the anatomical presence of small myelinated nerve fibers, lymphatic, arterioles, and venules at acupuncture points (Seneler 1979).

FIG. 1. Lateral line cadaveric dissection Myers 1979.

These anatomical dissections of the bodies fascia clearly show the relationship between the body and what is termed ‘traditional Chinese Acupuncture Meridians’, and clearly, in the author’s opinion, demonstrate the relationships between the bodies fascia and their possible influence on myofascial pain.

Plantar Fasciitis is a common conditions seen in podiatry practice and is often associated with a calcaneal heel spur. However clinical analysis shows that this spur is often non symptomatic in the presentation of true plantar fasciitis (Dutton 2008).

FIG. 2. From file, shows a heel spur that was a non symptomatic incidental finding on x-ray.

According to Garrick (2004), plantar fasciitis accounts for as much as 10% of all running injuries. Dutton (2008) states that 40% of males and 90% of female with plantar fasciitis are overweight and whilst this condition is usually an overuse injury, it can be the result of acute trauma caused by strenuous lower extremity activities.

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Presentation: l Pain at the plantar aspect of the heel. l Symptoms often extend along the arch of the foot towards the toes. l There may be tenderness in the achilles tendon and gastrocnemius l Pain and stiffness in the morning when taking the first steps. l Symptoms go as the patient warms up and the fascia stretches. l Pain returns after periods of rest or prolonged sitting. l Runners find no pain while running only to have the pain return as they cool down. l Symptoms become worse towards the end of the day. l The patient can report pain or throbbing of the affected foot in bed at night.

With all diagnosis is it necessary to consider the possible differentials such as: l l l l

Achilles tendonopathy.

Periosteal bruising.

Soleus referred pain or ‘joggers heel’.

Tarsal tunnel syndrome.

and other conditions with similar presentations.

Examination: Palpate the centre of the plantar heel and also the medial tubercle of the calcaneus, as this is also often a pain point. Pain felt by the patient with modest examination pressure of the thumb and forefinger strongly suggests plantar fasciitis. It is advisable to test sensitivity with the unaffected side as some patients are more sensitive than others and testing the other side with the same pressure, in the author’s view, enables a more objective examination.

Things to remember: Plantar fasciitis is often the result of increases in activity levels and changes in footwear especially exercise shoes. Exercise surfaces can also contribute to the condition. It is also advisable to assess, or have the patient assessed for biomechanical imbalances, as research suggests that up to 80% of plantar fasciitis type injuries are due to excessive foot pronation (Dutton 2008). Other contributory conditions are atrophy of the fat pad, leg length discrepancy, pes cavus, and pes planovalgus.

Acupuncture and plantar fasciitis: In traditional Chinese acupuncture this condition is diagnosed under the category of accident/trauma (Smith 2011). As previously stated plantar fasciitis is usually a repetitive strain condition resultant of the accumulation of micro-trauma (Reaves 2011). Inflammation is at the level of the tendons, ligaments and bone (Garrick 2004).

38780 Chiropody Nov/Dec 12 19/10/2012 10:00 Page 7

ARTICLE A literature search using Chablis, Pub. Med and Cochrane harvested only one paper by Reaves (2011) between 2002 and 2012 that stood up to academic scrutiny (Higgins and Green 2006) and this paper is relevant to the development of this new protocol.

Keywords: acupuncture, myofascial acupuncture, plantar fasciitis.

Reaves states ‘There is qi and blood stagnation in the channels and collaterals. Internal organ imbalances may also possibly contribute. It is recommended to treat twice a week for three weeks, and then re-evaluate. Most uncomplicated cases will show improvement within six treatments. In chronic cases, continue treatment at least once weekly after the first three-week period’ (Reaves 2011).

The aim of any intervention in the treatment of plantar fasciitis is to reduce pain and increase the range of movement as soon as possible.

It is not the remit of this essay to discuss the points used in traditional Chinese acupuncture, but it is beneficial to mention them. After a review of the literature, the following acupuncture points, among others, are repeatedly mentioned and also favored in the reviewed article by Reaves (2011): l l

Fuliu KID-7 plus Jiaoxin KID-8 or Dazhong KID-4 plus Shuiquan KID-5

Either of these two paired-point combinations, advises Reaves (2011), may be helpful to activate the Kidney channel and treat symptoms of heel pain. Needle on the affected side, using palpation to assist in point selection (Reaves 2011). l

Taichong LIV-3 plus Yongquan KID-1

Taichong LIV-3 benefits the tendons and ligaments. Yongquan KID-1 is an adjacent point located directly in the plantar fascia where it separates into bands attaching toward the digits. Use of electrical stimulation between Taichong LIV-3 and Yongquan KIDl frequently benefits the condition (Reaves 2011).

Reaves (2011) goes on to say that the calf muscles should be palpated from the popliteal fossa as this may present with ashi points (points not based on the maridian), which are added to the treatment. These point include: l l

Sanyinjiao SP-6 Yanglingquan GB-34

In the protocol described by Reaves (2011) the needle is inserted at the Shimian M-LE-5 and directed towards the center of the heel to a depth of about 0.5 inches. This insertion can be paired with medial Shimian in region of the medial tubercle of the calcaneus (Zhaohai KID-6). The needle at this point should be inserted at the medial and directed towards the centre of the heel to a depth of about 1 inch. (Reaves 2011).

From a podiatrists perspective insertion of a needle at the point described as Shinian M-LE-5 would cause considerable discomfort to the patient, this discomfort is further heightened by the associated swelling and plantar fascial dysfunction. In clinical practice, as podiatrists, it is common practice to use a local analgesic agent to the posterior tibial nerve up to 20 minutes prior to any needle being introduced into the plantar heel. This is not to say that the above mentioned acupuncture procedure is wrong merely just another clinical approach.

A new treatment protocol for Plantar Fasciitis using Myofascial Acupuncture in Podiatry.

Having received ethical approval to conduct a clinical trial using myofascial acupuncture the author conducted the following trial using some of the method described in the work carried out by Reaves (2011). The points chosen to work with were, Zhaohai KID6 and Shimian M-LE-5, the later using an internal approach.

Rationale: Plantar fasciitis as discussed is an inflammatory process cause mostly by overuse in one form or another. The Shiniam M-LE5 serves us well from a podiatry perspective as it is the attachment point of the plantar fascia and any stimulation of this point may cause irrigation and depletion of toxins and aid recovery process by assisting in the inflammation cycle and deplete the buildup of acetycholine (Longbottom 2012). Zhaohai KID-6 is chosen, as this is most often a trigger point in plantar fasciitis and a good point for nourishment of the kidneys that aid in fluid processing.

Prior to the commencement of the intervention stretches of the bulk muscles of the lower led are carried out as these are often stressed in plantar fasciitis (Hodge et al 1999).

Reaves (2011) recommends the needling of the Shimian M-LE-5 in the centre of the plantar heel surface over the point that is most tender, this is the place where the plantar fascia attaches to the calcaneus. All local needling is in relation to the M-LE-5 point as in Fig. 3. left.

FIG. 3. Shows the M-LE-5 (red dot) and a number of possible local ashi points (blue dots).

FIG. 4. From file, shows manual plantar stretching. This can be achieved by the practitioner applying good force to the forefoot in the direction of the arrow.

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38780 Chiropody Nov/Dec 12 19/10/2012 10:00 Page 8

ARTICLE The anatomy of the ankle 1

6

2

5

Highest prominence of the medial malleolus

FIG. 7. From file, showing location of KID-6.

3 4

Pathways, that are not the result of trigger point pain, then the needle, in the author’s opinion, should be repositioned.

Description of treatment FIG. 5. From file, shows a superficial medial ankle Dissection 1. Medial Malleolus. 2. Tibialis Anterior Tendon. 3. Tibialis Posterior Tendon. 4.

Flexor Hallusis Longus Tendon. 5. Susyentaculum Tali. 6. Flexor Digitorum Longus Tendon.

The green dot in Fig. 5 represent the KID-6 acupuncture point and the red dot represents the M-LE-5 point.

A Ă˜ 22 x 75mm sterile single use acupuncture needle is introduced through the Zhaohai KID-6 acupuncture point in the direction of Shimian M-LE-5. The needle is advance through a series of decreasing guide tubes until the skin at Shimian M-LE-5 blanches. The needle is then slowly withdrawn until the patient experiences the discomfort in the plantar fascia that they experience upon first load bearing in the morning, the needle is then pistoned until the patient feels considerably less or no pain.

On average, based on the 83 patients treated in this way by the author, it takes 14 seconds for the quality of the pain experience on a VAS scale to decrease by up to 80%.

1

5

4

3

2

FIG. 6. From file, shows structures to be aware of whilst carrying out this treatment. 1. Tibial nerve (medial calcaneal branch) 2. Postireor tibial artery (Medial branch). 3. Calcaneus. 4. Plantar aponeurous. 5.

Abductor hallucis.

With any invasive practice, knowledge of the underlying structure is imperative, as one can see from the above dissections there are a number of delicate structures that are best avoided. The patient is your best advisor as far as this is concerned especially where nerves are involved. Should the patient experience nerve pain radiating to the toes or along other nerve.

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FIG. 8. From file, shows 75mm needle in the guide tube being inserted.

The guide tube and needle is placed against the skin with the safety tab removed. The needle is then tapped in using the forefinger.

38780 Chiropody Nov/Dec 12 19/10/2012 10:00 Page 9

ARTICLE

FIG. 11. From file shows blanched area over needle at the M-LE-5 acupuncture point.

FIG. 9. From file, shows the needle inserted into the KID-6 acupuncture point.

Reaves (2011) specifies up to 6 treatment over a three week period, with the needle progressively inserted till it come to its final position at the plantar aspect of the calcaneus. Reaves (2011) also recommends electro stimulation between the two points. The author finds that of the 83 patients treated only 24 required a second treatment, 9 required a third treatment, this could have been due to noncompliance with the given exercises.

Of these 83 patients 61 had received steroidal injections over a year prior to the acupuncture intervention, 59 found the injection unsuccessful and extremely painful. Appendix 1 shows a more detailed breakdown of the study.

Discussion

The work of Reaves (2011), presents an alternative approach to the treatment of plantar fasciitis using acupuncture from the perspective of a clinical professional skilled in acupuncture.

What this author has presented is another approach, presented from a podiatrist viewpoint. Both approaches are valid and both demand more study. The author finds this new myofascial acupuncture method well tolerated by the patient and a viable alternative to other injection therapies.

FIG. 10. From file, shows needle inserted 35mm into foot towards the M-LE-5 acupuncture point.

Figure 11 opposite shows the needle fully inserted to the point where the skin blanches behind the M-LE-5 acupuncture point (internal approach). It is not necessary to advance this far as the fascia itself will move with the needle when the needle is sufficiently imbedded.

At this point the needle is then slowly withdrawn until the needle feels held or stuck. This is where the patient will feel the pain as intensely as they do when they first weight bear. The needle is then pistoned until the underlying tissues no longer grasp it. Again the needle is slowly withdrawn further and the pistoning process repeated each time the needle is grasped, until it is fully withdrawn.

The patient is discharged with plantar stretches as in FIG. 4. above and is requested to revisit in one week.

The author preformed the approach described by Reaves (2011) on 10 patients to generate a base line to compare treatments. 6 patients found the treatment to be extremely painful and 4 fainted. This (the 10 patients) may be due to lack of skills by the author in relation to the Reaves (2011) method. At the time of presenting this paper, limited follow-ups have be carried out, as the study to date has been over 8 weeks. Followups are planed for 12, 24 and 36 weeks with a final follow up in 12 months.

Conclusion

It would appear, that from a clinical point of view, the treatment of plantar fasciitis, using myofascial acupuncture, is a good alternative to other methods of treatment. Further study is necessary however. Any treatment that causes relief from pain without the introduction of complex medicines is welcome, once it is proved to be safe and clinically effective.

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38780 Chiropody Nov/Dec 12 19/10/2012 10:00 Page 10

ARTICLE

Appendix 1 – Study data to-date The pie chart shows the number of patients involved in the study. l Represents the of patients who had no prior intervention. l Shows the number who received a steroid injection more that 12 months prior to the study. l Presents the number of patients who report benefit from the steroid injection.

The pie chart represents the patients treated using the myofascial technique as presented in this essay. l Represents the patients who received only 1 treatment. l Shows the number of patients who received a 2nd treatment. l Presents the number of patients who received a 3rd treatment.

The pie chart below shows the response of patients after the second treatment. l Patients with total relief 1 week after 2nd treatment. l Patients with 3 points of pain remaining, 1 week after 2nd treatment, as described in the VAS mentioned above. l Patients with 4 to 6 points on VAS, 1 week after the 2nd treatment.

The pie chart below represents the outcomes for the patients who received a 3rd treatment.

l

l

The pie chart below shows the number of patients treated and the amount of relief they experienced after 1 treatment. l l

l

Patients with total relief 1 week post treatment.

Patients 1 week after treatment with 3 points of pain remaining on a VAS of 0 to 10, with 10 being the pain the presented with.

Patients with 4to 6 point on the above mentioned scale 1 week after treatment.

Patients that had no pain 1 week after the 3rd treatment.

Patients with 4 to 6 points of pain on VAS after the 3rd treatment.

Final Note.

After a 3rd treatment on 2 patients failed to have a total remission from pain this represents only 2% of the total patients treated. The short-term result of this study appear very exciting, however at this time no long-term follow up have been taken.

Patients on this study are encouraged to continue plantar fascial stretched.

References

Dorsher, P. T. 2009. Myofascial Meridians as Anatomical Evidence of Acupuncture Channels. Medical Acupuncture, 21 (2), pp. 1-7.

Dutton, M. 2008. Orthopaedic Examination, Evaluation and Intervention. 2nd ed. Pp. 1139. New York: McGraw-Hill.

Garrick, J, G. 2004. Orthopaedic Knowledge Update: Sports Medicine 3. North American Academy of Orthopaedic Surgeons. Illinois.

Higgins, J. P. T. and Green, S. 2006. Cochrane Handbook for Systematic Reviews of Interventions.

Hodge, M. C. Bach, T. M. and Carter, G. M. 1999. Orthotic management of plantar pressure and pain n rheumatoid arthritis. Clinical Biomechanics, (14), pp.567--575.

Longbottom, J. 2012. Foundation course in Myofascial Acupuncture. Parks Physiotherapy Center, St. Neots, Camb.

Senelar, R. 1979. Caractéristiques des points chinois. Nouveau Traité d’Acupuncture. pp. 247-277.

Smith, S. 2011. The importance of muscle region clearing in the acupuncture treatment of foot disorders. Journal of Chinese Medicine, (97), pp.41-45 Reaves, W. 2011. Plantar Fasciitis: the acupuncture treatment of heel pain. Journal of Chinese Medicine. (96), pp.22-25.

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38780 Chiropody Nov/Dec 12 19/10/2012 10:00 Page 11

An Indian Approach to Helping Lymphoedema Patients

ARTICLE

Tim Maiden, a former Cosyfeet Podiatry Award Winner, describes his recent trip to Kerala in South India, where he studied local methods of treating lymphoedema patients and assisted in their treatment.

Podiatry has given me a great opportunity to work in countries that many people will only visit as tourists, and has allowed me to integrate a little more, and get a sense of the raw issues that the people cope with every day.

lymphoedema, whilst exploring one of the most diverse places in the world. The experience from start to finish was daunting but almost every step was exhilarating.

I have recently arrived back from India after a period of time working in several medical clinics there. For me India remains a place of mystery and intrigue, while I accept that it has been demystified a little in recent years following increased international media coverage of its domestic news. Terrorist attacks, call centre complaints and sports all form prominent issues in the nation’s media profile and have given a very negative slant to a country with so much diversity.

Dr. Kaajal (ayurvedic doctor), Patient, Tim Maiden. Home visit to a traditional Indian house in Gulbarga. A success story.

Patient recovered sufficiently to work and provide for his family.

View of a rural village

India is a country with a population of over 1.3 billion people, where there is a huge chasm between rich and poor. It is the largest democracy in the world and yet countless people die there on a daily basis for the lack of the basic needs to survive. Millions wake up on the streets on a daily basis unable to attain work due to the social stigmas associated with many diseases that only the poorest seem to acquire.

Podiatry in India is a relatively new concept although schemes have been running to educate a new workforce of podiatrists at dedicated training camps. I saw this trip as an opportunity to learn and to help with education, advice and treatment of

IAD is a not-for-profit organisation that has seen over 2000 patients for treatment of Filariasis at Kasaragod, and educated many more at its clinics in Kerala, Kanartaka and Andhra Pradesh.

It conducts rigorous data collection in a broad range of areas enabling it to double up as a research clinic, regularly upgrading protocols effectively and investigating new treatments. Each site location is vastly different from the others, whether these are

With time seemingly more precious I have found it difficult to visit any country without having a ‘meaningful’ purpose there. I found the perfect excuse to visit India following a conference last year, where I attended a lecture by Professor Terence J. Ryan, Emeritus Professor of Dermatology at Oxford University.

Professor Ryan asserted that podiatry should be playing a more proactive role in the treatment of lymphoedema. Professor Ryan is the overseeing consultant working with an organisation called the Institute of Applied Dermatology (www.IAD.com.in). The group is based in Kerala, Southern India with links in other states and provinces.

India is a country that people seem to love or hate. For me, I love it. I find the bright, vivid colours, the deep fragrant spices of the market places, the rich tapestry of social dynamics and the mix of fauna on most streets absolutely enthralling. I have had a mild obsession with the country since childhood, and have admired heroes, both real and fictional, including Ghandi and Tendulkar as well as characters from Kipling’s books. So it was with passion, excitement and some fear that I boarded a flight and headed to IAD in Kerala.

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38780 Chiropody Nov/Dec 12 19/10/2012 10:00 Page 12

ARTICLE differences with the species of mosquito and disease, socioeconomical, educational, geographical or of climatic conditions.

Despite theses huge differences the treatment protocol remains the same. In addition, all IAD patients have joined the scheme to improve their health, and are united in their desire to help themselves to end their chronic and often desperate suffering.

Long term effect of LF

The focus of IAD is to help reduce swelling, treat and educate on reducing the swelling of lymphoedema and the causes of this.

More specifically IAD is working to reduce the morbidity factors associated with Fliariasis. The treatment takes place over several weeks and includes counselling of the patient to help educate and manage expectation, followed by consultations from doctors specialising in Allopathy, Ayurveda and Homeopathy, with physical treatment and ongoing education after this. Furthermore there is a 6-week follow up when the staff will visit patients in their homes to confirm that no complications have been witnessed.

The WHO defines Lymphatic Filariasis (LF) as follows: “Commonly known as elephantiasis, this is a disfiguring, disabling disease, usually acquired in childhood. In the early stages there are either no symptoms or non-specific symptoms.

Although there are no outward symptoms, the lymphatic system is damaged. This stage can last for several years. Infected persons sustain the transmission of the disease. The long term physical consequences are painful, swollen limbs (lymphoedema or elephantiasis). Everyday work becomes difficult due to frequent infections. Hydrocele in males is also common in endemic areas.�

Nodule formations on the foot from long term lymphoedema

Grossly enlarged LF infection. Picture shows problems patients face when trying to address intertrigo issues.

Many of the practitioners working with IAD have been patients themselves and have the additional understanding of what patients are experiencing. IAD hosts weekly study days, plus weekly lessons following treatments, where staff are often educated about new ideas or given practical explanations of what can be achieved in certain cases.

All of the staff at IAD are so grateful for outside interest in what they are doing, and get such a kick out of educating others and doing something of such benefit to society. IAD has esteemed visitors, predominantly from Europe and the US, who attend to treat, learn and teach. As the targets are the healing of patients and data collection, results are achieved quickly and effectively, with an atmosphere of progressive easy freedom and meticulous note taking. There is a refreshing sense of optimism in each of the staff and patients. With the rigorous audits and assessments, the treatments are especially concise, clear and coherent. Limited funding is available, so staff have learned to turn a car tyre into a shoe, for instance, or use locally sourced or natural products.

Such practices instil you with a fresh zest in podiatry practice.

During my time at IAD I met and treated a wide range of patients. The following three stand out in my mind.

Case study 1 This 36-year-old gentleman had suffered from LF since his early teens and had no other known medical conditions. The limb of the patient was not grossly enlarged, however, there were signs of swelling in relation to the contralateral limb. Several days a month the patient was too ill and incapacitated by his sickness and cellulitis to work, causing a reduction in income and trouble maintaining a household.

Long term effect of LF with ulceration 10 | page

Initially, when the patient presented, he had several open lesions on his legs, following self-treatment using the heated Neem seed.

The patient also had scarring from a failed lymphoedema liposuction which would often break open through dryness.

38780 Chiropody Nov/Dec 12 19/10/2012 10:00 Page 13

ARTICLE The Neem tree is a plant seen to have ‘mystical’ properties and is regarded as the ‘go to’ treatment for most conditions. With limited education about their condition, lack of medical assistance and consequent frustration, sufferers frequently listen to any suggestion that may help. In this instance the patient was told by a neighbour to heat up the Neem seed and lacerate the leg to drain the lymph, but in this case further infection ensued without any benefit.

The liposuction highlights the importance that health care professionals understand the condition before commencing treatments, while good firm education could have assisted in reducing incidence of infection.

Despite a general widespread campaign for taking medication, the patient was previously unaware of the medical significance due to a lack of understanding and an inability to miss work to attend the clinics at the requested appointment times.

(The helpers employed to distribute medications in the villages are usually paid such low salaries that many are forced to work other jobs, and thus frequently no one is present to hand out the medications. So long journeys are not always met with reward, leading to disillusionment and lack of immunity.)

The patient was suffering from major gaps in levels of knowledge and education of the condition (In the majority of cases education turned out to be the best treatment.) Following education and counselling, the patient learnt the importance of taking the medications and ceased to suffer from illness associated with his LF. He also understood how to reduce the risk of infection.

In addition, it was of benefit for his family to understand the clinical situation, both to enable them accept it, and to educate others in the neighbourhood, leading to a reduction in stigma. The patient also benefited from the compassion shown by the staff at the centre, and he reported a much higher quality of life in the review at the end of the two-week period.

Case study 2 This 52-year old gentleman had suffered from LF since his 20s, however it was suspected that he had contracted the disease far younger. He was an agricultural worker in the paddy fields of southern Kerala and as such spent long hours in the breeding grounds of the mosquito. Under such circumstances it is very difficult for workers to prevent infection without taking medication. Unlike other cases we saw, the patient has a bilateral infection which has caused swelling in both legs.

He had sought treatment previously, taking western medication in the form of antibiotics each time he contracted an infection, however this was not sustainable as he had to travel over an hour on public transport, or walk several hours to attend a local government hospital to collect antibiotic medication. The legs continued to increase in size with more and more recurring infections. He had ultimately become unable to work due to weekly infections leading to bed rest for three days, which had in turn made the limb increase in size still further, reducing his mobility.

The patient was unable to afford regular medical attention as no one else within the household worked. His three children were all of school age. His diet was very low in calories and he lived near water systems of stagnant water in a hut without glass windows or much more than a wooden plank for the door. So even if the patient were to use smoke to deter future mosquito attacks on the family, the chances of total prevention are fairly slim. Using expensive repellent was not an option.

The patient heard about the scheme set up by IAD from a friend who had undertaken the treatment previously. (A group of fellow sufferers have now formed a close relationship and spend many days and evenings each week together. They also work actively in the community to raise awareness among others. This is a far cry from the experience of many others living several hours’ walk from the centres.) Patients are required to travel in on a daily basis for two weeks until treatment is completed. They then continue self-treatment at home with their caregiver or solo.

We visited the patient at the review stage following a successful treatment during which the limb had reduced by several litres since his initial visit to the IAD. The leg was weighed for size using the (picture) method of measuring the displacement of water in the water-filled bin. No infection has presented since following the routine instigated by IAD and the skin integrity and discolouration has continued improving.

The issues that the patient faces are the cost of the bandaging and of the Ayurvedic treatments. The costs seem low to us, but not to the patients. European produced bandaging is much better in quality than that produced locally. This imported bandage is only available via IAD, and the organisation has significant costs in the distribution of supplies to the patients in some of the more distant villages. (We discussed the use of places of worship as meeting places for distribution of medicinal supplies, but found out that both IAD and the villagers would have to pay for this benefit, irrespective of religious beliefs).

The quality of life for this patient has improved considerably in the six weeks since treatment began, and with the education he has received, the likelihood of a relapse is greatly reduced. Yet with his potential inability to afford the ongoing costs of treatment, the future for him is unclear. The patient has subsequently had each of his children immunized against the condition, allowing them to have a better future ahead.

Case study 3 In complete contrast to the other two case studies, the subject of this study is an 18 year old boy from a wealthy business family in Mumbai. Sufferers of LF do not usually come from such an economic group, and this boy suffered the additional stigma of having a condition normally associated with poverty, and therefore being very unusual within his social and family circle.

The patient had been hoping to attend university but was achieving poor grades due to absenteeism for fear of attending school. He visited the Kasaragod clinic for two weeks following years of different treatments and a worsening condition. He had no other medical conditions but his LF had led him to struggle with walking and finding footwear. In addition, he could only wear shorts or specially tailored trousers. The patient had suffered from LF since the age of three and the condition had been misdiagnosed many times as he did not fit the usual demographic.

The boy’s life had been affected dramatically due to the social stigma surrounding the condition. His understandable and natural fear of rejection had led to this boy being marginalized by society.

Even the boy’s mother appeared unable to see her son as a fully functioning human being. The boy’s mother appeared apathetic toward him, perhaps as a result of self-shame. I became involved with the case during the second week of treatment, and the difference in him was remarkable. Following conversations with caregivers they noted that both the mood of the boy and of his family had improved substantially. Upon further conversations with the teen, he appeared optimistic about returning to his home town for university. The patient was fortunate enough to page | 11

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ARTICLE have enough money to have specially customised footwear made: a situation we attempted to rectify with limited success.

(Any ideas for low cost footwear would be very welcome.)

My time with IAD was refreshing, stimulating and fun. It was especially rewarding to see work that was being done to reduce stigma through education, and also the remarkably successful outcomes of treatments for patients with LF using a combination of Allopathy, Ayurveda, Yoga and Homeopathy.

Although IAD is one of the three internationally recognised centres with a thorough treatment protocol, we were constantly forced into thinking outside the box due to the huge financial constraints of being a non-profit organisation (NPO). Working with enthusiastic practitioners, many of whom have suffered from the conditions we were treating, made the whole process fun, and at times challenging.

Very happy patient, still unable to reduce ankle oedema

Treating people who lack the benefits of health education or income, whilst making a positive impact to the lives of sufferers, is very rewarding. Filariasis affects approximately 120 million people worldwide in 81 countries. It is a disease that poses a risk to over 1 billion people, with 20 million people last year being diagnosed with the condition in India.

My fears about going to many developing countries surround the possibility of catching a disease through living in communities of sufferers, but these cases are very rare and the benefit that we can provide to people with debilitating chronic conditions is huge. I hope to return to IAD this year to volunteer my skills and experience again. There are so many issues that podiatrists can help with there, especially those with a few years’ experience in Concordant patient but problems the NHS, as the structure from low quality bandaging and management skills acquired would be of benefit. Private podiatrists with an inquisitive mind would also be of great value, as they would have to think outside the box on an hourly basis there. I would implore all podiatrists to experience voluntary work of this nature. It would help you remember why you became a podiatrist in the first place, and breath fresh life into your practice.

Oil massage taking place

Bilateral bandaging

Patient made bandage protection

family life for stigmatized ladies 6-week home visit follow-up.

Although improved, this patient could not afford to comply with our recommendation to wear shoes.

I would like to thank the people who had visited IAD before me for their assistance and advice, Dr. Cross for tolerating my erratic emails, Professor Ryan for his introductions and advice, Bailey’s Instruments and Cambridge CCS. A heartfelt thank you also to IAD, who made my nine week stay so wonderful, stimulating and thought provoking.

If you have questions for Tim Maiden, he can be contacted at tim.maiden@gmail.com.

Cosyfeet’s annual Podiatry Award assists one person each year to further their professional knowledge and skills. The £1000 award is open to any podiatrist or podiatry student who is planning voluntary work, a work placement or research, whether in the UK or abroad. It is designed to assist with travel and living expenses. To find out more about the Cosyfeet Podiatry Award see www.cosyfeet.com/award or email prof@cosyfeet.com.

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38780 Chiropody Nov/Dec 12 19/10/2012 10:00 Page 15

ARTICLE

Osteomyelitis

Michelle Taylor, BSc. M.Inst.Ch.P Osteomyelitis is either a localised or generalised inflammation of the bone, due to a pyogenic infection. It can lead to destruction of the bone, stiffening of the joints. The long bones of the arms and legs are usually affected. (Weller, B, F. 2005). Inflammation of the bone and its marrow is caused by pyogenic bacteria, mycobacteria or fungi. Infection may present initially as a diffuse or local swelling (Newman, L, G. 1995). This unresolved infection may lead to the bone becoming involved resulting in osteomyelitis. Initially just the periosteum – where the muscles or ligaments attach or adhere to the bone – spreading to the cortical (surface area of bone) and medulla (inner area of the bone) is affected (Lorimer, D. et al 2006).

Traditionally osteomyelitis is based on aetiological considerations classed as haematogenous, secondary to a contiguous – area adjacent of infection or those associated with peripheral vascular disease (PVD). Predominately osteomyelitis is caused by the bacteria Staphylococcus Aureus with hematogens osteomyelitis reaching the bone from a remote portal via the blood. Secondary osteomyelitis infection results from a direct trauma, surgical reduction or internal fixation of fractures, along with adjacent focus – decubitus ulcer or soft tissue trauma (Conterno, L, O. et al 2009).

Once the infection is established it transverses acute, sub-acute and chronic phases. Within the first 10 to 14 days of the acute infection phase there is very little evidence of infection other than some soft tissue swelling, blurring of the fascial planes and possible periostitis (inflammation of the membrane of the bone). Clinical symptoms include pain, raised temperature and malaise. Bone needs to show at least 50% demineralisation before a correct diagnosis is made (Lorimer, D. et al 2006).

Bone infections are classified by either the Walduogel or the Cierny – Mader system. Both systems can be used simultaneously as Walduogel is an etiologic system where as the Cierny – Mader is descriptive. Cierny – Mader is based on the anatomy of the bone infection and the physiology of the host. This classification system allows for the development of comprehensive treatment guidelines for each stage (Mader, J, T. et al 1996). The Cierny – Mader (CM) classification system uses 4 anatomic types (1 – IV) with 3 host’s types – normal, immuno compromised or untreatable.

Acute l Acute haematogenous osteomyelitis (CM stage 1) v Infection in the metaphysis of a long bone. Localised slow blood flow. v Usually Staph. Aurous. Can be streptococci or gram – negative rods. 5 clinical settings neonates, adult’s children, sickle cell anaemia, injecting drug users. v Hallmarks fever, severe deep “bone” pain, acute bony tenderness, limited movement. Swelling late onset. Blood cultures. As x – rays are usually negative initially. Elevated white cell count (WCC) neutrophil count, erythrocyte sedimentation rate (ESR), C – reactive proteins. Ultrasound detects fluid in soft tissue/joints. Aspirated pus from bone is diagnosis. Surface swabs usually misleading.

v Initially empirical with flucloxacillin, plus gentamicin if gram

– negative rod is suspected. Ceftriaxone in children over 6 months. Specific therapy given once positive culture and sensitivity testing. Surgical removal of pus and sequestra (dead bone). v Early diagnosis and treatment of primary sources of bacteraemia. Education of injecting drug users of safe equipment and techniques.

l Acute contiguous focus osteomyelitis

Initial ostietis infection of the cortical bone only – CM Stage 11.

May lead to CM111 localised Osteomyelitis. v Acute contiguous infection spread from adjacent focus.

Four causes: a) Ineffective arthritis. b) Post trauma infections (open fractures, bone surgery). c) Soft tissue (skin wounds, pressure ulcers etc.). d) Puncture wounds (feet, animal bites.). Often mixed infections. v Post operatively Staph. Aurous. Gram – negative rods.

Especially in mandible, pelvis and small bones. Pseudomonas aeruginosa via punctures to the calcaneum. P. multocida due to animal bites. Anaerobes with facial, pelvic or sacral osteomyelitis and bite infections. v Symptoms are acute with fever, pain, soft tissue swelling, redness and tenderness. Pus will form in any wound. Features may be subacute in sacral or skill infections, or in deep postoperative infections with less virulent pathogens – coagulase staphylococci. Culture of the adjacent focus with blood, bone scans and x-ray, more likely to be positive due to longer history. Surface swabs usually misleading. Successful treatment is dependent on adequate deep cultures; antibiotics according to sensitivity tests are required for at least 4 weeks. v Surgical removal of pus and sequestra. Depends on early diagnosis and treatment of infections adjacent to the bone.

l Acute ischaemic – neuropathic osteomyelitis

v Occurs with arterial or nerve disease or in diabetic foot

v v

v

v

v

infection. Due to impaired host response, neuropathic damage and vascular disease.

Usually mixed with staphylococci, and anaerobes enteric Gram – negative rod colonisation.

Predominately local, with pain, swelling, redness, cellulitis, ulceration and pus. Impaired sensation and circulation are common hence gangrene and offensive odour.

Cultures of pus and available tissue, surface swabs are usually misleading. Bacteraemia is uncommon, x-rays and technetium bone scans are difficult to interpret due to ischaemia, neuropathy, trauma and cellulitis. Indium and gallium scans can be more helpful.

Chemotherapy is directed by sensitivity tests on deep specimens. Conservative surgery where possible, pus drained and necrotic tissue and sequestra removed.

Control and prevention depends on education the at risk patient with diabetes, neuropathy and/or ischaemia, plus early treatment of infections.

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38780 Chiropody Nov/Dec 12 19/10/2012 10:00 Page 16

ARTICLE Subacute l Device related osteomyelitis v Infection around fixators, nails, pins, plates, screws and other temporary devices. Or around prosthetic joints, intended to be permanent. v S. aureus or coagulase – negative: either can be methicillin sensitive or resistant. Streptococci, Gram negative rods or other bacteria are less common. v Mainly wound breakdown and purulent discharge. Fever is not common with pain or loosening is late. Early signs of wound discharge for microscopy and culture are reliable but can be misleading due to time factors of secondary colonising bacteria, thus requiring deep swaps at bone level. X-ray changes are late; bone scans are unhelpful due to the recent procedure. Erythrocyte sedimentation rate ESR is elevated. v Chemotherapy depends on the organism isolated. Mixed infections are rare. Surgery to drain pus and remove necrotic tissue. Infection around temporary devices require the device to be removed antibiotics are required for 6 weeks or longer. v Infected prosthetic joints require removal and either replaced or arthroplasty or arthrodesis done. Rigorous operative asepsis and appropriate chemoprophylaxis are required. l Vertebral body osteomyelitis

v Infection occurs in one or more vertebral bodies. The route

v

v

v v

is usually blood borne occasionally directly from operation or procedure.

S.aureus rarely with Gram – negative rods. Salmonella or Pseudomonas spp. Candida spp can affect drug addicts.

Persistent back pain, muscle spasm referred pain – sciatica or hip pain – later spinal cord compression. Fever common with S.aureus less so with other organisms.

CT or MRI identifies the extent of disease. Microscopy and culture of vertebral samples taken by needle aspiration or open operation define the pathogen and exclude other diagnosis including tumours.

Chemotherapy depends on the pathogen and sensitivity results.

Control and prevention is dependent on treatment of potential primary source and procedural asepsis.

l Fungal osteomyelitis (rare)

v Chronicity, osteolytic – bone dissolving – lesions with

v

v

v v

eventual overlying “cold” abscess. Usually blood borne during disseminated fugal disease rarely by inoculation in sporotrichosis. Immunosuppression by drugs or disease and injecting drug users are predisposing factors. Candida spp but osteomyelitis occurs in systemic mycoses, aspergillosis, sporotrichosis and zygomycosis.

Those of the underlying disease, plus fever, chronic bone pain, bony tenderness and failure to respond to antibacterial drugs. A cold abscess overlying superficial bones is a valuable clue. Infection can spread to adjacent joints.

Fugal blood cultures, bone scan, x – ray, CT scan with diagnostic aspiration for microscopy, special stains and fungal culture. Serology assists with systemic mycoses.

Chemotherapy is classically with amphotericin B, but newer potent azoles are less toxic and effective.

Control and prevention depends on early treatment of both local and systematic fugal disease.

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Chronic l Pyogenic (bacterial) osteomyelitis v Chronic osteomyelitis is characterised by bone infection lasting months or years. v Chronic pyogenic osteomyelitis presents as late localised Brodies abscess, with no history of acute osteomyelitis, or more commonly as chronic osteomyelitis following unresolved acute osteomyelitis or any of the above 3. v Usually caused by one of the pyogenic bacteria particular staphylococci. Symptoms are mild pain with swelling, which may be scarlet. Sinuses, scaring and stiffness if infection spreads to adjunct joint. Bone biopsy for defining organisms due to secondary colonising organisms from sinus and surface swabs. X-ray and CT scan define both the extent and destruction, sequestrum formation cloaca (hole in bone leading to skin sinus) periosteal new bone formation and overall thickening with sclerosis. Stage 1V is diffuse, circumference and or permeative. ESR and CRP help assess progress during treatment. v Flucloxacillin often with rifampicin for at least 6 months at times years. Surgery to drain pus, remove devitalised and dead bone, and stabilise both onset and during chemotherapy. Hyperbaric oxygen therapy and vascularised muscle flaps can improve modest cure rates. v Control and prevention depends on cure of acute osteomyelitis. l Actinomycosis (rare)

v A very chronic bone infection from dental, sinus or lung

Actinomycosis.

v A israelii.

v Sinus formation, sulphur granules in pus, scarring and slow

progression across tissue planes. Pain and fever are not prominent. X-ray, bone scan or CT scan. Sulphur granules are required from the pus and bone specimens for branching Gram positive filaments. Anaerobic cultures are taken for 10 days. Mixed associate bacteria are not uncommon. v Chemotherapy is high dose, long term penicillin, initially intravenous for 4 – 6 weeks, then orally for up to 12 months.

Rarely other antibiotics are required. v Control and prevention depends on treatment of potential primary sources. l Brucellosis (rare)

v A very rare infection of the bone, as vertebral osteomyelitis

v v

v v v

following disc space infection during chronic localised brucellosis.

B.melitensis Back pain, fever, malaise and lethargy. Splenomegaly and hepatomegaly if present are useful clues. Bone scan, CT scan and aspiration, prolonged culture of CO2.

Serology is helpful if present but can be negative during one infection.

Chemotherapy with rifampicin plus doxycline for 6 weeks.

Surgery is rarely needed.

Eradication of animal brucellosis and prompt treatment effective treatment of acute brucellosis.

38780 Chiropody Nov/Dec 12 19/10/2012 10:00 Page 17

ARTICLE l Tuberculous osteomyelitis

v Chronicity, bone and joint destruction, spread with adjacent v

v

v

v

“cold “abscesses. TB elsewhere often pulmonary or renal.

M.tuberculosis occasionally M.Bovis from unpasteurised milk rarely and an “atypical” mycobacterium can be involved.

Relatively late symptoms pain, deformity or swelling. Sinus development from superficial bones. Spinal TB spreads from the disc to adjacent vertebra causing flexion deformity, referred pain, later spinal cord compression with paraparesis paraplegia.

Mantoux and FBE. Bone or tissue sputum or urine mycobacterial stains and specific culture and sensitivity tests.

Chest X-rays often show primary source, which now be inactive. Bone X-rays show destruction and collapse, adjacent abscesses. Ct shows further detail, MRI shows disc, bone and CHS involvement.

Chemotherapy is a triple therapy including isoniazid and rifampicin for 9 – 12 months. Surgery to drain pus, remove necrotic tissue and correct deformity.

Depends on BCG and effective treatment of all active early TB.

(Spicer, W, J. 2008).

References

Conterno, L, O. Rodrigues da Silva Filho, C (2009) Antibiotics for treating chronic osteomyelitis in adults. Cochrane database of Systematic Reviews Issue 3. Art. No: CD004439.

DOI: 10.1002/14651858.CD004439.pub2

Lorimer, D. French, G. O`Donnell, M. Burrow, J, G. Wall, B. (2006). Neale’s Disorders of the Foot. 7th ed. Churchill Livingstone Elsevier, p.584 Mader, J.T. Ortiz, M. Calhoun, J.H. (1996). Update on the diagnosis and management of Osteomyelitis. Clinical Podiatric Surgery, Oct 13 (4), p.701 - 724.

Newman, L, G. (1995) Imaging techniques in the diabetic foot. Clinics in Podiatric Medicine and Surgery. 12 (4): 75 86 Spicer, W. (2008) Clinical Microbiology and Infectious Diseases. 2nd ed. Churchill Livingstone Elsevier, p.206.

Weller, B.F. (2005) Nurses Dictionary, for nurses and healthcare workers. 24th ed. Elserver, p.283

Chronic osteomyelitis can present as a recurrent or intermittent disease with periods of variable duration. Relapses even with apparent successful treatment can have a major impact on the quality of life of the patient and health services. Long term recurrence rates are approximately 20 to 30% of all cases of osteomyelitis (Conterno, L, O et al 2009).

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38780 Chiropody Nov/Dec 12 19/10/2012 10:00 Page 18

38780 Chiropody Nov/Dec 12 19/10/2012 10:00 Page 19

Metatarsalgia

CONDITIONS CORNER

By Mr. Michael Hooper In House Podiatrist, The Langer Group Metatarsalgia is a generic term for pain under the forefoot. The general consensus is that the pain occurs in or around the Metatarsal heads, the Metatarsophalangeal joints (MPJ’s) or is caused by soft tissue injuries.

Metatarsalgia can be a difficult problem due to the vast amount of conditions it could encompass.

Below is a list of conditions which could be included: • Mortons Neuroma.

• Stress Fractures.

• Capsulitis.

• Rheumatic Pain.

• Plantarflexed Metatarsal.

• Bursitis.

• Freiberg’s Disease.

• Calluses.

Causes: Excessive loading due to a number of reasons can lead to metatarsalgia.

• Increased pressure on the metatarsal heads through a poorly functioning 1 MTPJ. • Atrophy of the plantar fat pad, resulting in generalised metatarsalgia.

• Clawed toes that dorsiflex on the metatarsal head can pull the fat pad forward causing the metatarsal head to be exposed.

• High levels of callus can lead to increased pressure over the metatarsal heads.

• Tight calf muscles can lead to prolonged forefoot loading.

• Hallux Limitus or Rigidus causing greater loading on the lesser digits.

• Long 2nd metatarsal or short 1st metatarsal.

Symptoms: • Pain under the ball of foot when weight bearing.

• Well cushioned shoes can reduce pain.

• Hard skin building up underneath the area.

• Tenderness under the metatarsal heads on palpation.

• Callus under symptomatic heads.

Investigations and tests • Plain X-rays will demonstrate any inflammation and changes in the joint.

• Pressure plate analysis can demonstrate any excessive loading of the joint.

• Ankle joint dorsiflexion test to assess calf muscle tightness.

Treatment options

Orthotic adaptions: A Metatarsal pad could be an effective orthotic adaption to use. The purpose of a Metatarsal Pad is to transfer the weight to the Metatarsal Shafts, or in the case of Neuromas, to separate the Metatarsal heads. A Metatarsal Pad should support the second, third and fourth Metatarsal heads and avoid the fourth and fifth.

You can use a Kinetic Wedge on the device to help with the timing of the patients gait in terms of time spent loading on the forefoot. This usually made from EVA which leaves a space for the 1st met head sit in. It has EVA across the metatarsal heads and under the IPJ of the Hallux. This is often used in conjunction with a 1st metatarsal and 1st ray cut out which helps with Hallux dorsiflexion and functioning of the first ray essential for normal gait function.

It may also be applicable to add a PPT or Plastazote top cover to Sulcus or Toes.

Alternate treatment options:

This depends upon the cause of the pain • If the patient has a Functional Hallux Limitus a corrective orthotic can increase movement in the Hallux whilst offloading pressure.

• Potential surgery on a later stage HAV. • Greater cushioned shoe.

• Shoe with a distal rocker (e.g. Running shoe).

• Removal of any callosity in the area.

The Langer Group Emerald Way Stone, Staffordshire ST15 0SR 0845 678 0182 www.langergrp.com

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38780 Chiropody Nov/Dec 12 19/10/2012 10:00 Page 20

OBITUARY

James Arthur Kirkham 1935 - 2012

Friends, I am writing this today to commemorate the life of James Arthur Kirkham – Jim!

Jim was born on 24th March 1935 and went to St. John’s school then to King George V Grammar School where he was in the ‘Trans’ form which consisted of the top 30 brightest boys. He didn’t disappoint. Jim did his national service in the RAF and went on to qualify as a chartered accountant.

My wife and I first met Jim and Susan in 1972 – forty years ago - where have the years gone? Jim had just taken over as accountant to the Institute of Chiropodists and I had just taken over as treasurer. It was an arrangement that suited me fine; Jim did all the work and I took all the glory! I soon found out there was a lot more to Jim than on first acquaintance. He was a very shrewd, switched on chartered accountant but he was also a kind, caring, considerate person with a great sense of justice.

Jim stoically put up with kidney dialysis and soldiered on through a kidney transplant, supported by Susan’s love and devotion. I asked some of my friends who knew Jim for their abiding recollections of him; they all said “a true gentleman” – so there you have it “Gentleman Jim” – not a bad epitaph?

Goodbye old friend, I shall miss you. I shall miss your wise counsel but most of all I shall miss you as a friend.

Roger Henry, Ex-Treasurer and Editor, Podiatry Review

Dear Editor, It was with great sadness that I received a phone call from the Company Secretary to tell me of the passing of Jim Kirkham. Jim’s contribution to the Institute both as Secretary and then Accountant was greatly appreciated by all who knew him. Hid dedication and commitment was evident to all who knew him.

He was held in high regard and continued to show a great interest in the Institute long after retirement.

He was also a great friend, and someone who was always willing to listen and offer sound advice. In spite of failing health in recent years, he was never one to complain. When asked how he was, he inevitably replied “I’m feeling fine”.

Our thoughts go out to Susan and the family at this sad time. I would like to personally express my thanks to both Susan and Jim for the tremendous help and support they gave me during my time as Chairman of the Institute. I owe both of them. Debit I can never repay.

Robert Beattie, Ex-Chairman, Executive Committee

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Dear Editor, I was extremely saddened to learn of the recent passing of Jim Kirkham, especially as I had only seen him a few days prior whilst attending a friend’s wedding. We were all having such a lovely time catching up on things that had happened since we last met and quizzing one another on the trivia questions which had been placed on each table. He was telling me of his two sons, Simon and David and then of his grandchildren – he was bursting with pride! Photographs were aplenty and I managed to capture one of Jim with the ‘bride’ balloon – he just loved it. I have some lovely memories of that evening.

I first met Jim 19 years ago when I went to work for his firm of Chartered Accountants. I loved working for Jim as he was such a gentleman. He was always very professional, fair and understanding and someone that I had a lot of time and respect for. More importantly, he was also a very good friend whom I shall miss dearly.

My love and prayers go to Susan and the family at this very sad time. Good night and God Bless Jim Jill Burnett-Hurst, Company Secretary

Dear Editor, It was with great sadness that I learned of the death of Jim Kirkham. I had worked with Jim on the Executive Committee for over 12 years. I think the best way of describing Jim in one word “Gentleman”. Underneath this gentle demeanour lay a very intelligent and analytic mind! Jim was never pushy or opinionated, but if you asked for his advice he would give it willingly. On more than one occasion I have asked Jim a question and within a couple of seconds he would give me the answer. I always came away thinking “why didn’t I think of that!”

38780 Chiropody Nov/Dec 12 19/10/2012 10:00 Page 21

OBITUARY As well as being our Accountant, he had also been the Company Secretary. He knew our Association inside out and back to front.

What a lot of people probably don’t know is when we had to give up our London headquarters, Jim offered us the use of his Southport Office and I think that sums up how kind Jim was.

Jim was not born into a privileged life or with the proverbial silver spoon. He achieved everything through hard work. His friends and family travelled the length and breadth of the country to attend his funeral and I think that sums up the love, respect and admiration that people had for him.

To Susan, David and Simon; you were so privileged to have had him as a husband and father and his devotion to his family always shone through.

Goodnight, God Bless Stephen Willey, Sheffield Branch

Dear Editor, Jim Kirkham was one of the nicest men I have ever had the privilege to number amongst my friends. I first knew him when he succeeded Sidney Shipper as the General Secretary of The Institute, a post he carried with dedication and expertise second to none. When he relinquished the post, his wife Susan took over the challenging task with equal devotion as many of you know. I had the honour to serve on the executive committee for many years and Jim's advice and guidance, particularly in his capacity as a management consultant and accountant was always welcome and indeed invaluable.

Dear Editor, It is with great sadness and loss that I have heard of the death of my dear friend, James Kirkham. I have known Jim and his wife, Susan, for a very long time. Jim became the Institute’s secretary in 1988 taking over from Sydney Shipper after the move of head office up to Southport, so we indeed go back pre 1988.

Jim was always a gentleman, quiet and refined. He always had time to talk even if he had a busy schedule at any level of Institute meeting. He gave a lot of support to Western branch in our bad days, when branch meetings were so small and he encouraged us to keep going. In fact Susan and Jim would attend our meetings just to keep the numbers up! What a way to spend a Friday night or Sunday afternoon. Thankfully, things have improved a lot since then!

The Institute and the world have lost a lovely, lovely man, God bless.

Helen Lloyd, Western Branch

Dear Editor, I was saddened to hear that Mr. Jim Kirkham, past Accountant of the IOCP had passed away. I had first met Jim fifteen years ago at my first A.G.M. in Southampton. During the time I have known him, Jim was always very pleasant, professional in his work and a polite gentleman.

Our thoughts and prayers go out to his wife, Susan and family.

Linda Pearson, Western Branch

My condolences and I am sure, that of the Birmingham and Shires Branch go to Susan and the family. I will miss Jim dearly, rest in peace my friend Carl Burrows - Chairman Birmingham and Shires Branch

Dear Members, It was such a shock to receive the news of Jim’s death as we had all attended a wedding reception the week before and had a good laugh. Jim was in great spirits. I first met Jim Kirkham around 1999. At that time he was waiting for a kidney transplant and was undergoing dialysis daily. He never complained about anything and rarely missed a day’s work. At the time, certain foods were ‘off limits’ but Jim would cheekily ask me to sneak him a chocolate biscuit when I took him a cup of tea with instructions ‘not to tell Susan’. It was all in fun of course. I am not sure how Jim did manage to stay so optimistic and cheerful but that was typical.

He was a very quiet, gentle, man but a perfectionist when it came to his work. I met many of his clients who all thought the world of him.

Jim was lucky enough to receive a kidney transplant and it was a great success. He was back at work in next to no time.

Jim looked after the Institute’s accounts until his retirement.

We all missed him when he stopped coming to the office everyday.

God Bless Jim, Bernie Hawthorn

Taken at the wedding of David and Jane Crew on Friday August 31st 2012

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38780 Chiropody Nov/Dec 12 19/10/2012 10:01 Page 22

A.G.M. NEWS

National Podiatry Conference 7th – 9th June 2013

Southport Theatre and Convention Centre, Merseyside

Following the very successful 2012 Conference and A.G.M., the Institute has arranged to hold both the 2013 and 2014 events in the same prestigious Conference Centre in Southport.

For 2013 the very popular workshops and lectures will be expanded and we are hoping to attract many more traders to the trade exhibition where new equipment will be available for both viewing and testing. You will also get the opportunity to get your autoclave calibrated at a discounted cost. Please notify Head Office 01704 546141 to book your autoclave in!

The Conference is open to any member of any organisation which represents the profession, as well as members of the medical and AHP professions.

The 4* Ramada Hotel is attached to the Centre and overlooks the attractive Southport Waterfront. As a cost-effective alternative there are dozens of hotels and Bed and Breakfast establishments – see our website for details www.iocp.org. Why not make a weekend of it away with the family?

Southport is a sophisticated, cosmopolitan and vibrant destination with a classic feel. The stretch of coastline is renowned for its beautiful beaches and is ideal for coastal walks. The pinewoods at nearby Formby are home to the increasingly rare red squirrel and the dunes are home to Natterjack toads and sand lizards. The Pier was first opened in 1860. It is the oldest surviving iron Pier in the country and is the second longest. Thanks to a £7 million restoration in 2002, the Pier is now back to its Victorian splendour. The Pier Pavilion reflects a modern seafront theme. Inside can be found an exhibition on the history of the pier, a coastal wildlife display, café and bar.

The stunning Marine Way Bridge links the seafront to the town centre and provides a direct route to Ocean Plaza where there are shops, restaurants, cinemas and bowling alley.

Hop on the Pier Tram which runs up and down the Pier every half an hour. Southport’s Marine Lake is one of the largest artificial boating lakes in the country. In the warmer months there are the Southport Belle Mississippi style paddle steamer, speedboats and smaller pleasure craft on the lake. Nearby is The Lakeside Inn, the smallest pub in Britain.

Lord Street ranks among the finest boulevards in Europe. It features a 67 foot war memorial monument and municipal gardens. Southport is well-known for its fabulous covered shopping arcades. The Ocean Plaza retail & leisure complex offers visitors plenty of choice – shopping, restaurants, a cinema and bowling alley, within easy walking distance of the town centre. There are 1,200 free parking spaces on site Southport is widely recognised as ‘England’s Golfing Capital’. There are six championship standard golf courses, including Royal Birkdale Golf Club, a regular venue for ‘The Open’.

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38780 Chiropody Nov/Dec 12 19/10/2012 10:01 Page 23

A.G.M. Booking Form

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38780 Chiropody Nov/Dec 12 19/10/2012 10:01 Page 24

A.G.M. Booking Form

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38780 Chiropody Nov/Dec 12 19/10/2012 10:01 Page 25

POST BAG Dear Editor, May I sincerely thank the many Members, Branches and Area Councils of the Institute for their letters, cards and phone calls received on the sudden death of my dear husband Jim, who served the Institute for nearly 40 years as Accountant and Secretary.

Special thanks to Roger Henry, Carl Burrows, David Crew, Jill Burnett-Hurst and the girls in the office, who have been extremely supportive.

My family and I appreciate the comfort at this time.

Thank you, Susan Kirkham Dear Miss Burnett-Hurst, It is with sadness I write this letter which I have been dreading doing for quite some time. However, after sixty-four years membership of the Joint Council of Chiropodists and now our present Institute of Chiropodists and Podiatrists, I am compelled to give up my practice and retire from the profession I treasure.

I have so many happy memories, receiving my first certificate as an Associate Member in 1948. The sitting for the L.Ch, and later the H.Ch.D. in 1951. The Secretary in those days was Mr. Tertis; the President, Mr. Pezarro, then Mr. Morgan and later Mr. Douglas Stewart-Forbes. Harold Laskey, Ron Hale, Jack Semmens, Bill Lewis, Tom Jefferson, Kathleen Batho, Myra Boddington and so many others were such good friends and colleagues.

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My wife, Mrs. Doris Eccles, and I have been in practice in Knotty Ash, Liverpool for over sixty-two years. Later with my podiatrist son-in-law and two assistants on the staff have enjoyed operating in a very busy surgery. It is now a wrench to leave and I don’t find retirement as attractive.

I enjoyed being the Secretary of Western Branch for fourteen years. We had a very happy time having monthly meetings at Walton Hospital, Liverpool where Consultants of the hospital almost vied with each other to deliver an abundance of interesting lectures. The classy substantial refreshments they provided all free of charge were a treat and members travelled widely and regularly from Liverpool areas, Manchester, Lake District, Isle of Man and North Wales etc etc often carrying chains and ice shovels to dig their cars out of the snow during our winter meetings, which they wouldn’t miss. We were, in those earlier days, enjoying professional, chiro-political and valued “get togethers”. All so much pleasant history. I still have some minute books of those days if they are of any interest.

However advancing years and declining health oblige me to take this step and with regret must submit my resignation to take effect from 31st December 2012, together with fond good wishes for the future prosperity of our special Institute.

Yours sincerely Haldane R. Eccles, Western Branch (We wish Haldane a very happy retirement from the editor and team.)

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38780 Chiropody Nov/Dec 12 19/10/2012 10:01 Page 26

DIABETES NEWS

Flaws in NHS Health Check have “dire consequences” for Type 2 diabetes Thousands of people with Type 2 diabetes in England are missing out on being diagnosed because of the failure to properly implement the NHS Health Check programme, according to a new report by Diabetes UK.

During the last financial year, less than half (40 per cent) of people who could have benefitted from an NHS Health Check, which tests people aged 40 to 74 for risk of Type 2 diabetes, heart disease, stroke and kidney failure, actually had one.

According to the new report, called Let’s Get it Right, about 9,500 people with undiagnosed Type 2 diabetes could have been diagnosed in 2011/12 if the programme had been properly implemented. This missed opportunity has potentially devastating implications because early diagnosis reduces risk of diabetes-related complications such as amputation, blindness, kidney failure and stroke. This is in addition to the many cases of Type 2 diabetes that could have been prevented through identifying people at high risk and giving them support to reduce their risk.

The report has highlighted that while the NHS Health Check is supposed to be given to all people in the target age group, in practice it has become a postcode lottery. During the last financial year, for example, there were three primary care trusts (PAT) areas where not a single person got a check. But in Liverpool and Greenwich, areas that face significant health challenges, thousands of people were checked during the same period.

Diabetes UK has used the launch of the report to call for the Government to ensure the NHS Health Check is properly implemented and to demand a public awareness campaign so that people aged 40 to 74 know they are entitled to a check and understand how important it can be for future health.

Barbara Young, Chief Executive of Diabetes UK, said: “The failure to deliver the NHS Health Check has potentially dire consequences for the state of diabetes care in this country. It is vital that people with Type 2 diabetes are diagnosed as early as possible to reduce their risk of developing complications and we are concerned that the estimated 9,500 people who missed being diagnosed last year are at increased risk of amputation, blindness, kidney failure and stroke.

“The NHS Health Check is also important for making people aware they are at high risk and helping them get the information and support to encourage lifestyle changes to help prevent it.

“Put together, this means the poor implementation of the NHS Health Check is a tragic failure. In particular, the fact that there are some places where not a single person has been

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offered a check is appalling and in these areas the NHS Health Check and signposting to services are not being given the priority they deserve.

“So while it is good news that the Government has made it mandatory to deliver the NHS Health Check, it now needs to go a step further by monitoring how well this is being done and holding poor performing areas to account. This is the only way we can begin to turn back the rising tide of Type 2 diabetes and ensure that those who already have the condition are identified early enough to give them the best possible chance of living a long and healthy life.

“The alternative – watching idly as the human and financial cost of Type 2 diabetes continues to soar – is too awful to contemplate. The situation has reached crisis point and urgent action is needed now.” Diabetes UK is urging people aged 40 to 74 who have not had an NHS Health Check to contact their GP to ask for one.

More than half of people with diabetes have poor cholesterol control

Almost 60 per cent of people with diabetes are not meeting their cholesterol targets despite the vast majority of them now getting it checked at least once a year, according to a new analysis by Diabetes UK.

While we welcome the news that 91.6 per cent of people with diabetes in England are now getting the annual check, according to National Diabetes Audit data, we are concerned that the large numbers of people missing their cholesterol targets means that these checks are not leading to improved outcomes for many people.

Increased risk of heart disease

This is a concern because people with both Type 1 and Type 2 diabetes are more likely to develop heart disease than the rest of the population, with cardiovascular disease accounting for 44 per cent of deaths in people with Type 1 diabetes and 52 per cent in people with Type 2. People with Type 2 diabetes also have twice the risk of stroke within the first five years of diagnosis compared with the general population.

38780 Chiropody Nov/Dec 12 19/10/2012 10:01 Page 27

DIABETES NEWS 15 healthcare essentials

We have warned healthcare professionals and their patients not to be complacent about the annual cholesterol check, which is one of the 15 healthcare essentials that everyone with diabetes should receive.

We are using the one-year anniversary of the launch of the healthcare essentials to highlight the danger of them becoming a ‘box-ticking exercise’ and emphasising that any problems they identify – including poor cholesterol control – should be acted on.

With poor cholesterol control, for example, the increase in use of statins over the last decade means that making improvements should now be relatively straightforward in most cases, but it is unclear why this has not happened.

Both healthcare professionals and people with diabetes should make sure that the annual health check leads to meaningful action to bring high cholesterol under control.

Worrying findings

Barbara Young, Chief Executive of Diabetes UK, said, "If people with diabetes have poor cholesterol control then they are at far higher risk of heart disease and stroke than someone who has poor cholesterol control but does not have diabetes.

This is why these findings are so worrying.

"The first step in the journey"

"It is not clear why the high number of people having their annual cholesterol check is not translating into better cholesterol control, but it is an issue that is putting the health of hundreds of thousands of people at risk. We need to emphasise that annual cholesterol checks have to be the start of a process of improving unhealthy levels.

"As with all our 15 healthcare essentials, which are based on official NICE guidance, taking a measurement is only the first step in the journey. Once poor cholesterol control is identified, the healthcare professional and the patient should work together to bring it under control. This should involve a personal target that will significantly reduce their risk of developing cardiovascular disease; it is also important to explain exactly why unhealthy cholesterol levels are so dangerous for someone with diabetes.

"Devastating consequences"

"It will often be appropriate to prescribe medication such as statins, but it is no good doing this without explaining both the importance of taking the medication regularly, and the potentially devastating consequences of not doing so.

"Other ways people can help improve their cholesterol levels include losing weight, exercising daily, reducing alcohol consumption, stopping smoking and eating a healthy diet, low in fat. We want to urge people to get the support they need to self-manage and enable them to live long and healthy lives."

Statins

We recognise that some people do suffer from side effects such as muscle cramps if they take statins, but the vast majority of the population tolerate them well, and the benefits are well established. There is also other medication available.

Study reveals extent of Type 2 diabetes risk for people of South Asian, African and African Caribbean descent

New research findings have shown that approximately half of all South Asian, Black African and African Caribbean people in the UK will develop Type 2 diabetes by the age of 80, compared to only one in five people of European descent.

The findings, published in the journal Diabetes Care are the first to reveal the full extent of ethnic differences in the risk of developing Type 2 diabetes.

The new information comes from the Southall and Brent Revisited (SABRE) study, a large-scale population-based investigation which has followed 4,200 middle-aged Londoners of European, South Asian and African Caribbean descent for over 20 years.

South Asian men diagnosed with diabetes 5 years younger

The study revealed that by age 80, twice as many British South Asian, Black African and African Caribbean men and women had developed diabetes compared with Europeans of the same age.

The researchers, from Imperial College London, found that Black Africans, African Caribbeans and White Europeans tend to be diagnosed at around the same age (66-67 years), whereas South Asian men were 5 years younger on average when diabetes was diagnosed at an even greater risk of related complications.

Risk factors in ethnic women: large waists and insulin resistance

The study also revealed that higher body fat levels (especially around the waist) and resistance to insulin explained the increased risk of Type 2 diabetes in South Asian and African Caribbean women. However, this explained only part of the risk in South Asian and African Caribbean men, suggesting that other risk factors, which are as yet unknown, may also play a part.

Risk assessment and screening for South Asian, Black African and African Caribbean people should happen from the age of 25 (as recommended by NICE), enabling those with the condition to be diagnosed, and those at risk – to make lifestyle changes to reduce their risk. This is something Diabetes UK has been doing through its Community Champions programme for over 2 years.

Awareness levels are low among black and minority ethnic communities and more needs to be done. With the right action early on, people can reduce their risk of diabetes and their risk of related complications.

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38780 Chiropody Nov/Dec 12 19/10/2012 10:02 Page 28

DIABETES NEWS Avoid being overweight to reduce risk of Type 2 diabetes

Iain Frame, Director of Research at Diabetes UK, said, “These findings show us how serious the risk of developing Type 2 diabetes is for people from South Asian, African and African Caribbean backgrounds. This is why people from these communities should be screened earlier than the general population - from the age of 25 rather than 40. While it is important for everyone to maintain a healthy weight, for people at high risk of developing Type 2 diabetes – such as these groups – it is even more important to avoid being overweight and reduce their risk.

“We know that awareness of the condition is particularly low in these groups so more needs to be done so that people know about of the risk factors associated with Type 2 diabetes.

Living with undiagnosed Type 2 diabetes for 10 years increases risk of complications

“People need to know their risk of developing Type 2 diabetes and get diagnosed as early as possible. We know that

people from South Asian backgrounds can often be living with the condition for around ten years before they are diagnosed, which increases the risk of complications such as heart disease, stroke, kidney failure, blindness and amputation.

We will continue to fund studies looking into risk factors for Type 2 diabetes

“In-depth cohort studies like the SABRE study are useful because they help us to visualise the long-term picture of diabetes. We will continue to fund and monitor studies that examine the complex interaction of genes and other factors and their influence on the risk of developing Type 2 diabetes. We look forward to seeing further evidence to determine where support and change is needed.”

SABRE study

The SABRE study that produced these findings was funded by the Welcome Trust and British Heart Foundation and the preliminary research was funded by the Medical Research Council, British Heart Foundation and Diabetes UK.

Sir Peter Dixon announced as new Diabetes UK Chairman

Diabetes UK has announced Sir Peter Dixon as its new Chairman. He has been appointed following a formal interview process and will take up the position on 1 January 2013.

Sir Peter has previously fulfilled a range of senior public sector roles, including Council Member and Trustee for the NHS Confederation and Chairman of University College London Hospitals NHS Foundation Trust. He has also been a board member in registered social landlords for over 25 years and was Chairman of the Housing Corporation. He was knighted for services to housing in 2009.

He will take over from Professor Sir George Alberti, the internationally renowned diabetes expert who has been Chair of Diabetes UK since 2009.

Julian Bast, Vice-Chair of Diabetes UK, said: “We are delighted Sir Peter has agreed to become Chair of Diabetes UK. Peter’s wealth of experience in senior public sector roles and in-depth knowledge of the NHS will be a huge asset.

I look forward to working closely with him to ensure Diabetes UK continues to campaign for those with

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diabetes, or at high risk of developing it, provides the care and support to make life better for people with the condition and works towards a World without Diabetes.

On behalf of the charity, I would like to thank Professor Sir George Alberti for his work as Chair over the last four years. His knowledge and judgement have been invaluable and we are extremely grateful for everything he has done.”

Sir Peter said: “Diabetes UK is widely respected for its work on behalf of people with diabetes and this is why I am delighted and humbled to be asked to become Chairman. I look forward to working with the rest of the Board, the staff and volunteers to address the challenge of diabetes.

“The number of people with the condition is expected to rise dramatically over the next decade and this is why I am pleased to be able to play a role in helping Diabetes UK contribute to turning back the rising tide of Type 2 diabetes and campaign for people with Type 1 and Type 2 and other types of diabetes to get the support and healthcare they need to manage their condition and so have the best possible chance of a long and healthy life.”

38780 Chiropody Nov/Dec 12 19/10/2012 10:02 Page 29

West of Scotland Branch

West of Scotland Branch held their seminar on Sunday 9th September on a beautiful sunny day in Stirling. The meeting which was open to members from all over Scotland was well attended, with two members travelling all the way from Wigtownshire in the South and several from Sutherland in the North, a glance at a map will show the distances our members cover in order to take part in branch events and I personally would like to thank all for their commitment.

Our topic for the day was diabetes and several talks and demonstrations were organised.... however the representative from Diabetes UK, who was to deliver two presentations, unfortunately cancelled at the last minute due to ill health.

Despite the best efforts of the charity, they were unable to find a replacement speaker at such short notice so I found myself with little option but to take his place. Therefore it was with enormous gratitude that I accepted the offer made by our branch secretary Stephen Gourlay to step up and deliver one of the talks with me.

The Media and Communications Officer at Diabetes UK agreed to send me the power point presentations and accompanying notes by email and Stephen and I arranged a hasty "rehearsal" (over a pint !) on the afternoon before the seminar. Stephen delivered the first talk "Diabetes Awareness" and I delivered the second "Putting Feet First" both of which were well received given the circumstances.

BRANCH NEWS

After a short break for teas & coffees, Miss Vicky Connolly who is a diabetic dietician with Forth Valley Health Board, gave a very informative lecture entitled "The Role of the Dietician in the Diabetes Team" A good selection of leaflets accompanied all the morning’s talks and they were distributed to all who attended.

After a most enjoyable buffet lunch the afternoon was handed over to Algeos Ltd. Their representative Miss Michelle Weddell gave an excellent lecture on diabetic assessments; this included the use of foot screening forms and a ‘hands-on’ session on the use of Dopplers and monofilaments. Her presentation was second to none and was enthusiastically enjoyed, it prompted much discussion within the group and can be highly recommended to other branches.

West of Scotland was delighted to welcome along as their guest, Mrs Anna Duncan, an honours student at Queen Margaret's University Edinburgh who recently became a student member. She is a vocal supporter of the Institute and we hope she will do much to encourage her fellow students to follow suit.

Our next branch event will be a First Aid Course to be held in Stirling on Sunday 4th November 2012 - further details will be posted soon.

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38780 Chiropody Nov/Dec 12 19/10/2012 10:02 Page 30

BRANCH NEWS

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38780 Chiropody Nov/Dec 12 19/10/2012 10:02 Page 31

BRANCH PROFILE

A message from our Secretary Linda Pearson Our branch is very friendly and approachable, with a current total of 68 members, including 2 National Officers.

We meet at Liverpool Women’s Hospital four times a year January, April, June and eptember. wide range of topics including “Plantar fasciitis, exercise and prevention”and “Nail onstruction” have been offered to members to enhance their CPD portfolios. We ot confine CPD to branch meetings as we have visited the Hotter shoe factory on wo occasions and the Algeos factory.

Many members like to see new and current products that are available, therefore we have invited several trade houses e.g Canonbury, Chiropody Express and Algeos to attend branch gatherings throughout the year. Other companies for example MDS Medical have attended for the calibration of members autoclaves. First Aid courses have also been organised for members.

Western Branch is a modern, democratic and forward thinking branch. For this reason we have been awarded the Branch Endeavour award for two consecutive years running , 2010 and 2011. Long service Awards have also been celebrated within the branch.

The Presidents Award has been awarded to two of our branch members ; Mr Malcom Holmes (2011) and Mrs Linda Pearson (2012) which is a great honour to receive.

Last year saw our first branch Christmas get-together at the Chaoprya Thai restaurant in Liverpool One. Our committee consist of Margaret Coleman, Malcom Holmes, Linda Pendleton, Linda Pearson, Michelle Taylor, David Topping , Gary Munro and many other who work to keep things on track.

The Western Branch committee members work hard to keep the branch running smoothly, trying new innovations and ideas to move the branch forward in a positiivve an nd d beneficial way for its members.

We also like ke to keep in to ou uch with other brancch hes by informing them about fortth hcoming CPD opportunities and inviting them to attand. We all keep meem mbers iin nformed regarding fu utture events from other branches.

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38780 Chiropody Nov/Dec 12 19/10/2012 10:02 Page 32

ARTHRITIS RESEARCH UK

Adolescents’ weight linked to severe knee pain Adolescents with a body mass index (BMI) rating of obese experience knee pain more often and to a greater severity than adolescents with a healthy weight, a new study shows.

The Arthritis Research UK funded study explored the relationship between obesity and pain around the body in young adults.

Although previous epidemiological studies have identified obesity as a risk factor for general musculoskeletal pain in adults, this is the first study to investigate the link in adolescents.

Researchers at the University of Bristol surveyed 3,376 seventeen year olds, all from the ‘Children of the 90s Study Group’. They answered a pain assessment questionnaire and their BMI was calculated based on measurements of their height and weight.

New osteoarthritis of the hand trial

People in Yorkshire with painful osteoarthritis of the hand are set to benefit from a major new clinical trial about to be launched at the University of Leeds.

The £900,000 Arthritis Research UK-funded clinical trial could offer welcome relief to the eight per cent of the population affected by hand osteoarthritis.

Up to 250 people are to be offered the chance to take part in the study which aims to find out if a drug more commonly used to treat rheumatoid arthritis might reduce inflammation and pain in osteoarthritis.

Current treatments for hand osteoarthritis such as splinting, pain killers and physiotherapy provide only limited relief. And, painkillers, although effective, can have side-effects and do nothing to slow or halt the progression of disease.

Of the 7 per cent of participants with a BMI rating of obese, 33 per cent were more likely to report musculoskeletal pain at any site around the body compared to non-obese participants.

They were also more likely to report knee pain (87 per cent) and more severe average pain, with pain scores 11 per cent and 20 per cent higher.

But Philip Conaghan, Professor of Musculoskeletal Medicine at the University of Leeds believes that as well as providing long-term pain relief, his study testing a drug called hydroxychloroquine could also slow down progression of the condition.

Professor Jon Tobias, from the Musculoskeletal Research Unit at the University of Bristol, who led the investigation, said: “This study suggests that obesity is an important risk factor for pain in young adults, particularly knee pain. More research is needed to determine cause and effect, but if it is the case that obesity causes knee pain, these findings imply that obesity adversely affects joints relatively early in life, and may contribute to persisting symptoms and reduced function in later life”.

“Recent imaging studies have shown that osteoarthritis is not just ‘wear and tear’ but that inflammation is important too, so we think that by reducing inflammation, pain will also be reduced.”

Lower back pain was the most common pain reported by the study group overall, followed by shoulder and upper back pain.

Arthritis Research UK medical director, Professor Alan Silman said: “This study adds to the evidence that keeping to a healthy weight is important for everyone’s joints, including young adults.

“More importantly this study also shows that obesity, the strongest risk factor for osteoarthritis in older adults, may start to damage the knees at this crucial period of life.

“Being overweight puts an extra burden on the weightbearing joints like your knees and back. Because of the way joints work, the pressure in your knee is 5-6 times your body weight, so even a small weight loss can make a big difference and help keep joints pain free”.

The study was published in the Journal ‘Pain’.

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“Osteoarthritis of the hand is generally considered to be less important and less disabling than hip or knee osteoarthritis but a large proportion of those affected report that they have significant difficulties with everyday tasks which have a great impact on their quality of life and general health,” explained Professor Conaghan of the university’s Leeds Institute of Molecular Medicine, based at Chapel Allerton Hospital.

Hydroxychloroquine is already used on an anecdotal basis by some doctors to treat osteoarthritic pain, but there’s been no big randomised controlled trial to test its effectiveness.

In Yorkshire patients will be recruited in Leeds, York and Harrogate. Up to 250 people from up to 20 rheumatology departments in hospitals and some GP surgeries around the UK will be recruited onto the trial for one year. Half will take hydroxychloroquine; the other half will take a placebo drug, and both groups will be allowed to continue with their existing painkillers. Their condition will then be assessed at six and 12 months.

Hydroxychloroquine is derivation of an anti-malarial drug and is considered to be the least toxic of the diseasemodifying drugs used to treat rheumatoid arthritis. It is also cheap and well-tolerated.

Recruitment will start shortly.

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ARTHRITIS RESEARCH UK

Charity survey reveals poor public understanding of arthritis in Great Britain A national survey commissioned by the medical research charity Arthritis Research UK has revealed that nearly a quarter (22 per cent) of the population of Great Britain admit they have a poor understanding of arthritis, the biggest cause of pain and disability in the UK. Of the 78 per cent who think they have a good or average understanding of arthritis, many actually believe common arthritis myths.

10 million people in the UK, including over 15,000 children, are affected by arthritis and musculoskeletal conditions, yet over two thirds (68 per cent) of the public are unaware that children under the age of ten can be affected.

The National Arthritis Week survey also revealed that while 78 per cent of people in Great Britain consider arthritis a serious condition, nearly half (45 per cent) believe that arthritis simply means ‘aches and pains when you get old’. In fact, the term ‘arthritis’ is used to describe around two hundred conditions affecting the bones, joints and muscles, some of which can also cause the immune system to attack and seriously damage internal organs.

The research results were announced to launch the charity’s National Arthritis Week which runs from 8th - 14th October 2012 and aims to bust common myths around arthritis and musculoskeletal conditions.

Alan Silman, Arthritis Research UK medical director, said:

“One in six people in the UK are affected by arthritis, and anyone at any age can be affected. Our National Arthritis Week survey reveals that while most people think they have a good understanding of arthritis, for many people this understanding is actually unfounded as they believe common arthritis myths.

It is particularly concerning that 3 in 10 (29 per cent) of people in Great Britain believe that nothing much can be done to treat arthritis and that people affected just have to live with joint pain, and that the same proportion (32 per cent) would wait a few weeks before consulting a healthcare professional about pain in their joints.

Early diagnosis and treatment can make a huge difference to the prognosis and outcome of inflammatory arthritis.

There may be many people in the UK living with painful joints

and reduced quality of life who have not consulted their GP and are not aware of the many treatments and self-help measures that could drastically relieve their pain.”

The survey also revealed that: • Nearly half (48 per cent) of the population of Great Britain believe or are unsure whether cracking your knuckles can cause arthritis. Research has shown that it may be linked to ligament damage, but it does not cause arthritis.

• 1 in 5 people in Great Britain do not believe being overweight makes you more likely to get arthritis, when in fact it is the strongest risk factor involved in the development of osteoarthritis.

• 25 per cent believe that if you have neck, back or joint pain you should not exercise. The truth however, is that at the right level exercise can ease stiffness, improve joint movement and strengthen muscles.

• Nearly a quarter (22 per cent) believed arthritis is inevitable when you get old. In fact you can develop it at any age and many older people do not develop it at all. A combination of risk factors influences the development of arthritis, including genetics and obesity.

Three-year-old Rosie Jupp from Leigh-on-Sea, Essex, was recently diagnosed with juvenile idiopathic arthritis (JIA) after her parents Peter and Louise noticed that she began to wince in pain when they encouraged her to walk around as normal.

Peter Jupp says, “Rosie’s symptoms rapidly got worse and within a matter of weeks she would begin most mornings crying in what seemed like pain, and refusing to get up from the sofa after she’d had her milk.

“We have had to watch Rosie go through so much and as parents it has been heartbreaking so see her undergo the constant hospital visits and tests to get a diagnosis.

“There needs to be a greater social awareness of the disease. There is currently no cure for the chronic condition but without the pioneering research by Arthritis Research UK my little girl - and many other children like her - would undoubtedly be wheelchair-bound.”For more information visit www.nationalarthritisweek.org.uk

page | 31

38780 Chiropody Nov/Dec 12 19/10/2012 10:02 Page 34

www.qmu.ac.uk

INFORMATION

QMU is offering the following short course for November 2012:

Local anaesthesia for HPC registered podiatrists The aim of the programme is to provide the theoretical underpinning and practical skills required for podiatrists to safely and effectively administer local anaesthesia.

The course is approved by the HPC and successful completion will result in annotation on the HPC register.

Our course consists of two study blocks: 1st block:

Four full days of study at QMU on 2,3,4,5 November 2012.

2nd block:

In conjunction with the Institute of Chiropodists and Podiatrists, a practical component will be offered at their training centre in Southport (other venues on approval from QMU) over two weekends.

If you are interested in finding out more about this course contact Lois McKinnon, course administrator, by email: lmckinnon@qmu.ac.uk or telephone 0131 474 0000 (voice-activated system: ask for Lois McKinnon when prompted).

Scottish Charity No. SC002750

32 | page

38780 Chiropody Nov/Dec 12 19/10/2012 10:02 Page 35

PRESS RELEASE

Popular elastane styles now feature hardwearing sole for active, misshapen feet The Cosyfeet footwear range now includes shoes to meet the needs of active men and women with swollen or misshapen feet. Karen and Ken feature the ever-popular stretchy, elastane uppers but in response to customer feedback, also have flexible yet hardwearing soles.

The styles provide outstanding comfort as the elastane uppers mould to practically any foot shape, without putting pressure on swelling, hammer toes or bunions. In addition, the cushioned lining and seam-free toe area won’t rub against sensitive toes or joints. The lightweight, shockabsorbing sole is hardwearing and a coating of Teflon® fabric protector over the elastane makes these shoes ideal for outdoor use.

“Many of our customers who need the made-to-measure feel of our elastane shoes lead very active lifestyles,” says Cosyfeet Managing Director, Andrew Peirce. “We’re delighted to be able to offer footwear for men and women with the benefits of both elastane uppers and PU soles, which are hardwearing, lightweight and shock-absorbing.”

The Karen is priced at £64.00, or £55.33 if wearers qualify for VAT relief. It comes in Black, Latte or Loganberry, in sizes 4 to 9.

The Ken is priced at £72.00, or £60.00 if wearers qualify for VAT relief. It comes in Black or Brown, in sizes 6 to 13.

For more information see www.cosyfeet.com/karen or www.cosyfeet.com/ken or call 01458 447275.

page | 33

38780 Chiropody Nov/Dec 12 19/10/2012 10:02 Page 36

RADIO INTERVIEW

BBC WEST MIDLANDS RADIO INTERVIEW

Somuz Miah, BSc(PodM), DipBMec, DipSp.I, M.Inst.Ch.P. The recent announcement by Lord Howe (Health Minister) on the issue of Podiatrists to be permitted to prescribe independently caused shock waves throughout the media. I was fortunate to be invited by BBC WM Radio (midlands region) to give a talk on this matter and about podiatric medicine in general, which was aired live on Sunday 29th July 2012 at 8.25pm. The programme was called Midlands Masala.

Initially nervousness followed, not because this was my first; I had been on BBC radio previously. This time because it was on a hot topic. However, eventually, I eased the tension by further research and help. It was a great opportunity for me to spread the word of what the podiatry profession is all about. Once the conformation from the programme producer arrived, I immediately asked for help on the Institute website forum. What can I say; the support from Institute was unbelievable with so many hints and tips. My sincere thanks to Martin Harvey and Bill Liggins, input from them made a huge difference.

I had planned well for the interview by writing down essential elements, and was ready with my latest gadget (iPad) in case any difficult questions were asked as well as over 14 years of knowledge in this field stored in my head!

Please be aware when you are approached by the media get good advice; if not you may regret it.

The following is some of the highlights. The show began by the presenter saying:

"Now do you know what a Podiatrist is? Well that's what you and I would call a foot doctor. This week Health Minister Lord Howe announced that from now on foot doctors will be the first in the world to be independently prescribe medicines".

Q. Now, Somuz, what on earth made you want to look at people's feet?

A. Firstly thanks for having me on your show, I was always interested in studying medicine. But in early life due to family commitments, I worked in a restaurant. I later decided to go back to education, and I looked into the possibility of dentistry. Working in a restaurant you meet people from all backgrounds and there I met a podiatrist who invited me see what he did. I was immediately 34 | page

fascinated with what the podiatrist could do and the benefit patients receive from the treatment. I thought that also this is a very different unique health profession.

Q. So this week’s news allowing foot doctors like yourself to prescribe medication, why is that significant?

A. There are many important benefits for patients, service commissioners and other health care providers. Extending independent prescribing to Podiatrists will substantially enhance patient safety because patients will get appropriate medicines without delay which can be vital in treating such dangerous conditions as infections or severe ulceration.

In today’s busy medical world, it will also reduce the burden on GP’s by allowing Podiatrists to diagnose and prescribe at the same time without having to refer back to a GP. As Lord Howe, the Health Minister said: “Podiatrists are highly trained clinicians who play a vital role in ensuring patients receive integrated care that helps them recover after treatment or manage a long-term condition successfully”.

Q. If there are people out there suffering with foot problems what can they do?

A. The average person takes 8,000 to 10,000 steps in a day.

Therefore we are all bound to have foot trouble. Children's feet undergo many changes as they grow. Screening at an early age by a podiatrist is essential.

If you are suffering from any skin/nails disorders it is important to have these properly treated. Make sure your podiatrist is registered and insured; most podiatrists belong to professional bodies of which there are several, one of the most well-known is The Institute of Chiropodists and Podiatrists. It is illegal to use titles Chiropodist or Podiatrist or provide chiropody podiatry treatments; unless the practitioner is registered with Health Professions Council soon to be renamed Health and Care Professions Council.

Finally there were many questions unanswered, due to the insufficient airtime. The presenter was so amazed and thirsty for more information, I was asked to return in the near future for a further interview.

38780 Chiropody Nov/Dec 12 19/10/2012 10:02 Page 37

CLASSIFIED

Chiropody Supplies

Practices For Sale ISLE OF MAN

Busy practice established c30 years. Excellent turnover for current 3 day week as retirement approaches.

Great scope for expansion/development.

Two treatment rooms with shared (dental surgery) waiting area in flexible leasehold property in service precinct (GPs, dentists, optometrist, audiologist) etc., with large free car park. Phased hand-over considered.

Genuine enquiries only 01624 816901 after 7:00pm

NORTH EAST DERBYSHIRE PRACTICE A great opportunity has arisen to buy an established podiatry business of 8 years Located in a beautiful stone built shopping centre in a picturesque town. The clinic has good aspect and ample parking, has 2 treatment rooms reception/waiting area, kitchen with storage. Podiatry business consists of 3 day clinic work and 1 day domiciliary per week. Great potential for expansion. Sale due to relocation. Price negotiable

hanics FREE biomecse ! u e-learning cour

Retirement Sale Practice North East Essex

Visit www.biomechanics-education.com www.biomechanics-education.com to to take take your your free free e-learning e-learning course course now! now!

RECEIVE CPD POINTS ON THIS COURSE

Classified Advertisements 80p per word - minimum £8.00

Box Number & sending replies: £4.00 extra

Classified Advertisements placed by Members: 45p per word minimum £4.50

Trade Classified Advertisements Eighth page (minimum) £85.00 + VAT.

The closing date for receipt of Classified Advertisements is the 1st day of the month preceding publication i.e. Jan-Feb issue - 1st Dec.

All Classified Advertisements must be prepaid and sent to:-

Bernie, Podiatry Review,

THE ADVERTISING DEPARTMENT, PODIATRY REVIEW 27 Wright Street, Southport, Merseyside. PR9 0TL.

Tel: 08700 110 305 or 01704 546141

Fax 01704 500477

Email: bernie@iocp.org.uk

Fully Equipped Clinic Turnover £30,000 based on 3 days Scope for expansion – Transitional help if required Initial enquiries to Richard Sexton and Co., Accountants Tel: 01206 578421 (Ref: JM)

Sale of Chiropody Practice in Dartmouth, Devon an area of outstanding natural beauty

T/O £38,000-£40,000, and state of the art equipment sale negotiable. Total change of life style, with good schools in the local area.

Dartmouth lies in the South Hams, in close proximity to the sea, Moors, Exeter, Plymouth, Torquay, Cornwall all within 2 hours journey. please call me on: 01803 839562, or e-mail me to: roger@rogerchilcott.plus.com

Chiromart UK ‘WHY PAY MORE?’ Suppliers of Autoclaves and Chiropody Surgery Equipment. Single items to full surgery set ups. Quality used and new. Also your equipment wanted, surgery clearances, trade- ins and part exchange CASH WAITING.... www.chiromart.co.uk Tel: 01424 731432 (please quote ref: iocp)

page | 35

38780 Chiropody Nov/Dec 12 19/10/2012 10:02 Page 38

DIARY

November 2012 !

4 4

SouthOakwell WalesMotel, and Monmouth Branch meeting 2:00 p.m.

Low Lane, Birstall Village Hall, Cardiff Tel: 0292 033 1927 Tel: 01924 475338

West of Scotland Branch meeting8 11:00 p.m. a.m.

Express

By Holiday Inn, Springkerse Business Park Harvester, Watford Road, Rickmansworth WO3 3RX Tel:FK7 0208 903 6544 Stirling 7XH Emergency First Aid Course 9:30 a.m. – 4:00 p.m.

Tel: 0141 632 3283

12 West Middlesex Branch meeting 8:00 p.m.

Harvester, Watford Road, Rickmansworth WO3 3RX Tel: 0208 903 6544

22 Birmingham and the Shires Branch meeting 8:00 p.m.

Red Cross Centre, Evesham, Worcs Tel: 01905 454116

23 Hants and Dorset Branch Meeting and Social Event 7:45 p.m.

The Sir Walter Tyrrell, Lower Canterton, Nr. Lyndhurst SO43 7HD Tel: 01202 425568

25 Essex Branch meeting 2:00 p.m.

Southend University Hospital Education Centre Carlingford Drive, Southend-on-Sea SS0 0RY Tel: 01702 460890

Tel: 01924 25 Leicester and 475338 Northants Branch meeting 10:00 a.m.

Lutterworth Cricket Club or Kilsby Village Hall 11.00 a.m.

Please phone for details Tel: 01234 851182 Oakwell Motel, Low Lane, Birstall

January 2013 6

Algeos T North Wales, Staffs and Algeos, Chester B Shropshire Branch A.G.M. and meeting

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

12 Surrey and Berkshire Branch 01202 425568 A.G.M. and meeting 7:30 p.m.

A potpourri of dermatology – Paula Oliver Reading Tel: 0208 660 2822

!!

16 Hants and Dorset Branch A.G.M. 7:45 p.m.

Crossfield Hall, Broadwater Road, Romsey, SO51 8GL Tel: 01202 425568 17 Birmingham and the Shires Branch A.G.M. and meeting 7:30 p.m.

Red Cross Centre, Evesham, Worcs.

Tel: 01905 454116 9

17

West Middlesex Branch Meeting 8 p.m.

Harvester, Watford Road, Rickmansworth WO3 3RX Sheffield Branch A.G.M. and meeting 7:30 p.m.

Tel: 0208 903 6544

SWD Sports Club, Heeley Bank Road, Sheffield, S2 3GL Tel: 01623 452711 20 East Anglia Branch A.G.M. Barrow Village Hall, Nr. Bury St. Edmunds, IP29 5AP Tel: 01473 830217 20 Nottingham Branch A.G.M. 10:00 a.m.

Feet & Co., 85 Melton Road, West Bridgford, Nottingham, NG2 6EN Tel: 0115 9313492 20 West of Scotland Branch A.G.M. 11:00 a.m.

Express By Holiday Inn, Springkerse Business Park, 02927XH 033 1927 Stirling, FK7 Tel: 0141 632 3283 20 Leicester and Northants Branch A.G.M. 10:00 a.m.

Lutterworth Cricket Club or Kilsby Village Hall Please phone for details Tel: 01234 851182 11.00 a.m.

10 Southern W p.m. p.m.

26 Area Council A.G.M. at81:00 Harvester, Watford Road, Rickmansworth WO3 3RX Victory Club, 63-79 Seymour Street, Tel: Services 0208 903 6544 London, W2 2HF Tel: 01992 589063

27 Essex Branch A.G.M. 2:00 p.m.

01202 425568 Southend University Hospital Education Centre, Carlingford Drive, Southend-on-Sea, SS0 0RY Womens Hospital, Blair Bell Education Tel: Liverpool 01702 460890 C

13 Western Branch A.G.M. 12:15 p.m.

Red Cross Centre, Evesham, Worcs Liverpool Women’s Hospital, Blair Bell Education Centre, Crown Street, L8 7SS Tel: 01745 331827

27 Midland Area Council A.G.M. Tel: 07790 350109 for more information

15 North West Branch A.G.M. 7:00 p.m.

St. Joseph’s Parish Club, Harpers Lane, Chorley, PR6 Tel: 0161 486 9234 02920HR 033 1927

21 Sheffield Branch meeting 7:30 p.m.

Tel: 01702 460890 noteClub, there Heeley will be a Bank first aid courseSheffield, preceding S2 3GL SWDPlease Sports Road, Tel: 01623 452711

The Dene Hotel,10:00 Hoole Road 13 Wolverhampton Branch A.G.M. a.m. start Please telephone for details Tel: 0121 378 2888

36 | page

March 2013

01473 830217

38780 Chiropody Nov/Dec 12 19/10/2012 10:02 Page 39

NATIONAL OFFICERS

National OďŹƒcers

National Officers

Acting President Mr. R. Sullivan BSc.(Hons) Podiatry, MSc. Pod Surg,. Pg,Dip., M.Acu,.

Area Council Executive Delegates

FSSChP. FIChPA. M.Inst.Ch.P

Acting Chairman Executive Committee Mrs. C. Johnston BSc.(Hons) M.Inst.Ch.P

Acting Vice-Chairman Executive Committee Mr. M. J. Holmes BSc.(Pod) M.Inst.Ch.P.

Branch Secretaries

Chairman Board of Ethics Mrs. C. Johnston BSc.(Hons) M.Inst.Ch.P

Chairman Board of Education Mr. R. Sullivan BSc.(Hons) Podiatry, MSc. Pod Surg,. Pg,Dip., M.Acu,.

FSSChP. FIChPA. M.Inst.Ch.P

Acting Vice-Chairman Board of Education Miss Joanne Casey BSc.(Hons) M.Inst.ChP Honorary Treasurer Mrs. J. Drane MInstChP

Standing Orders Committee Mr. M. Hogarth MInstChP Mrs. L. Pearson MInstChP BSc Pod Med Secretary Miss A. J. Burnett-Hurst

Area Council Executive Delegates Midland Area Council Mr. D. Collett M.Inst.Ch.P

North West Area Council Mrs. M. Allison MInstChP

Republic of Ireland Area Council Mrs. J. Casey MInstChP BSc Scottish Area Council Mr. A. Reid MInstChP

Southern Area Council Mr. D. Crew OStJ, FInstChP, DChM, CertEd Yorkshire Area Council Mrs. J. Dillon MInstChP

Branch Secretaries Birmingham

Mrs. J. Cowley

01905 454116

Cheshire North Wales

Mrs. D. Willis

0151 327 6113

Devon & Cornwall

Mrs. M. Reay

01805 603297

East Anglia

Mrs. Z. Sharman

01473 830217

Essex

Mrs. B. Wright

01702460890

Hants and Dorset

Mrs. J. Doble

01202 425568

Leeds/Bradford

Mr. N. Hodge

01924 475338

Leicester & Northants

Mrs. S. J. Foster

01234 851182

London

Mrs. F. Tenywa

0208 586 9542

North East

Mrs. E. Barwick

0191 490 1234

North of Scotland

Mrs. S. Gray

01382 532247

North West

Mr. B. Massey

0161 486 9234

Northern Ireland Central

Mrs. P. McDonnell

028 9062 7414

Nottingham

Mrs. V. Dunsworth

0115 931 3492

Sheffield

Mrs. D. Straw

01623 452711

South Wales & Monmouth

Mrs. J. Nute

02920 331 927

Surrey and Berkshire

Mrs. M. Macdonald

0208 660 2822

Sussex

Mrs. V. Probert-Broster

01273 890570

Teesside

Mr. J. Olivier

01287 639042

Western

Mrs. L. Pearson

01745 331827

West Middlesex

Mrs. H. Tyrrell

0208 903 6544

West of Scotland

Mr. S. Gourlay

0141 632 3283

Wolverhampton

Mr. D. Collett

0121 378 2888

38780 Chiropody Nov/Dec 12 19/10/2012 10:02 Page 40

A step forward in managing INGROWING TOENAILS GENTLY CUSHIONS AND PROTECTS

INGROWING TOENAILS CAN BE MANAGED IN THE EARLY STAGES BY OFFSETTING PRESSURE AWAY FROM THE AFFECTED AREA. The design of the Carnation Ingrowing Toenail Protector is based on the measurements and 3D images of the big toes of a representative sample of the UK population. These have been used to mould a specially formulated high performance gel which creates a secondary layer of protection around the toe while leaving the painful area clear from any additional pressure which would exacerbate the condition.

BENEFITS INCLUDE: CUSHIONS AND PROTECTS INSTANT RELIEF WASHABLE AND REUSABLE EXTRA SOFT GEL ONE SIZE FITS ALL

IN A USER TRIAL: 84% said the product gently cushioned and protected the nail 66% of users stated they had instant relief from the product “An innovative and useful product - I wish this had been invented years ago. I’ve noticed a substantial improvement during use as shoes are no longer rubbing”.

PODIATRIST DESIGNED

“The product was fantastic, it prevented my shoes from pressing on the delicate area of my ingrowing toenail and reduced discomfort”.

Reference Cliniresearch on behalf of Cuxson Gerrard & Co Ltd amongst 68 patients with ingrowing toenails.

Cuxson Gerrard & Co. Ltd., 125 Broadwell Road, Oldbury, West Midlands B69 4BF

www.cuxsongerrard.com