Q1 Podiatry Review 2023

Podiatry Review

The Institute of Chiropodists and Podiatrists News

A step in the right direction

Editor: Mr W J Liggins, MA,BSc(Hons), FCPS, FPodA

Academic Editor: Ms B Wright, MSc BSc (Hons), PGCE PGDip, FinstChP

Academic Advisor: David M Holland, CSci, CBiol, FFPM-RCPS(Glasg)

Academic Review Team

Ms B Wright, MSc BSc (Hons), PGCE PGDip, FInstChP

Mr S Miah, CFPodM, MInstChP

Mr W J Liggins, MA,BSc(Hons), FCPS, FPodA

Media and Publicity Contact: media@iocp.org.uk

Medicines and Procedures Panel (MaPP)

Chair: Gaynor Wooldridge, MInstChP, CFPodM

Abid Ali, CFPodM, BSc, MInstChP

Somuz Miah, CFPodM, MInstChP

Martin Harvey, PGCert, BSc, MInstChP, MCPodS

The Institute

IoCP Contacts

Executive Committee

President: Mrs C McCartney, MInstChP

Chair Executive Committee: Mr M Harvey, PGCert, BSc, MInstChP, MCPodS

Vice-Chair Executive Committee: Mr A Ali, CFPodM, BSc, MInstChP, BSc

Chair Board of Education: Acting Mr M Harvey, PGCert, BSc, MInstChP, MCPodS

Vice-Chair Board of Education:

Ms B Wright, MSc BSc (Hons), PGCE PGDip, FInstChP

Chair Board of Ethics: Ms B Wright, MSc BSc (Hons), PGCE PGDip, FInstChP

Honorary Treasurer: Mr S Miah, CFPodM, BSc (PodM), MInstChP

Regional Director (Ireland): Mr S Preston, MInstChP

Regional Director (Scotland): Mrs H Jephcote, MInstChP Regional Director (England North): Mrs C McCartney, MInstChP

Regional Director (England Midlands): Mr W J Liggins, MA, BSc(Hons), FCPS, FInstChP Regional Director (England South): Mr J Olivelle, MInstChP, AMCPS

Regional Director (Wales): Mrs L Pearson, FInstChP, BSc Pod Med` Medicines and Procedures Panel (MaPP): Gaynor Wooldridge, MinstChP, CFPodM

Chief Executive Officer: Mr Anthony Hubbard, CSci CChem FRSC Company Secretary: Miss A J Burnett-Hurst, HonFInstChP

Standing Orders Committee: Mr M Franklin, MInstChP

Branch Secretary Telephone Email

January sees not only the end of a year but the end of an era.

OMNIA MUTANTUR, NOS ET MUTAMUR IN ILLIS is the Latin tag denoting ‘all things change, and we change with them.’ Such is certainly the case today when having just recovered from the covid-19 pandemic, we are plunged into a cost-of-living crisis. Members of the profession reacted well to the epidemic with typical resilience and fortitude; many, with the help of government support packages, managed to keep their practices largely intact. New methods of working with PPE (personal protective equipment) and domiciliary visits replacing surgery-based treatments enabled patients to obtain the treatments they so desperately needed. However, sadly, some members were unable to sustain their business due to the cost of maintaining premises together with the expense of replacing equipment and materials which forced some of our members to look elsewhere for employment.

The lesson must be learned if our profession is to move forward. I recall my own father’s reaction during the recession in the late 1970s and early 1980s. His, rather naïve solution, was that if all businesses, including the professions, held their prices and worked harder, the problem would simply disappear. Always a man of actions rather than words and of great moral worth, the inevitable result was that he ended up working a 6-day week, 12 hours per day. Every practice has its pro bono list but, in his case, word spread and he ended with a huge list of gratis or low-fee paying patients and as a result, was unable to replace much needed equipment. Additionally, the necessity to work long hours with a huge list meant that he could not pay a locum and was thus unable to take advantage of CPD to perform new and potentially more lucrative treatments.

The Institute, as has frequently been the case over many years, now leads the profession in providing innovative CPD including such subjects as Laser Therapy, Dermal Fillers, Steroid Injection, Acupuncture, Platelet-Rich Plasma Therapy, Therapeutic (and diagnostic) Ultrasound, Cadaver Local Anaesthetics, Minor Surgery, Orthoses Prescription and many more. The CPD roadshows cover the home countries so that there is one near every member and, of course, our hard-working branch officers provide local CPD.

There is now a plethora of varieties of practice and specialities open to podiatrists: general practice, sports, surgical, musculoskeletal, paediatrics, injection therapies, geriatrics, and legal to mention but a few. Inevitably there is some overlap but each speciality requires particular study and techniques which simply cannot be absorbed by every member of the profession. It seems to be purely common sense to inter-refer, as is the case with the medical profession, and the best way to set up such a system is via your local Branch.

Many challenges lie ahead for the single practitioner and an excellent method to deal with these is via the ‘Step Ahead Business Club’ of the Institute. Help is always available as a membership privilege. Unfortunately, fees must inevitably increase, not only because of the cost of living but also to fund CPD and other, equally inevitable rises such as HCPC registration costs. Patients will understand as long as it is explained to them that their treatment will be enhanced in the long run.

There are no problems – only future challenges, which the Institute is embracing. We are entering a new year and a new era for both the single practitioner, group practices, and the employed member. There are exciting times ahead.

CARPE DIEM - seize the day.

‘The Queen is Dead. Long Live the King’

Guidelines for new and established authors

Content of your article should be Podiatry or foot health-related. Podiatry Review is mostly in easy-to-read format, and articles for submission should reflect this. CPD Certificates are issued for Case Studies and Articles.

Please ensure that your name and title (ie - FHP, Podiatrist, or other) are included with your article. Please proof-read and spell-check your article before submission.

It would be helpful to the Editorial Committee if you could reference any books or Papers mentioned in your article. If you are not sure how to do this we are happy to assist.

Please see ‘Writing for the Journal’ article on page 10 for further detailed information.

‘Goodnight great Lady; And may flights of angels sing thee to thy eternal rest’

Bill Liggins Regional Director (England Midlands)

Executive Officer

Anthony Hubbard CSci CChem FRSC

As I come to the end of my first year with The IoCP, I would like to reflect on a very enjoyable 12 months.

It has been a year of driving change and growth, getting out to meet members at our Primary Care and Public Health Exhibition, at the AGM, attending branch meetings, training and CPD events to engage with the attendees. It is always nice to hear the fantastic feedback that we get for our tutors, presenters, and guest speakers, from our students and to hear of the great support that our members experience in their dealing with our head office team.

We have grown our tutor base significantly in the last 12 months and we will be increasing the number of educational events that we will be running in 2023. We have also introduced new

staff into our head office team, which has helped us to improve the ways of working and put more focus on membership support, both through general enquiries and in liaison with our FHP students, many of whom are just entering into the foot health workspace.

It has really filled me with pride to see our FHP students arrive at our training clinic in our head office facility and leave with their certificates, having grown in knowledge, confidence in carrying out the role and with a new mini-network of colleagues who they can call upon during their working lives to discuss issues with and learn from. We must remember that lots of our members will be working alone and building support networks for them is key to retaining them in the profession and developing them as individual practitioners. To that end, it was great

to see our Business Club launched this year which provides another networking opportunity and a chance to discuss any business issues that you may have with other, more experienced members of the Institute and with our guest speakers that we invite along from time to time.

Our CPD offering has continued to grow, with courses filling up as soon as they are launched. We have partnered with other organisations to improve our offer and will be introducing more partnerships going forwards; keep your eye on the website for the latest information.

I am looking forward to leading The Institute through another year of positive change and growth during 2023 and hope to meet a lot more of you along that journey. Let me sign-off by wishing you all the very best for a happy, healthy and prosperous 2023!

Chief

Minor Surgery anyone?

Martin Harvey FPodM PGC IP BSc

One of the most frequent questions I am asked about minor surgery training for podiatrists is “why?” It is a fair question and one deserving a considered answer. In reflecting on that answer, it may be relevant to take a closer look at ourselves as a profession.

It is a fact that that we are a highly diverse profession in terms of both our individual roles as well as our individual scopes of practice. Role – wise some of us work exclusively in the NHS, others work exclusively in private independent practice, yet others in a mixture of both. That diversity is also displayed in what we do in our clinical lives. In the most recent registrant demographics report available (HCPC 2021); of 12,390 HCPC registered Podiatrists some 51% work full time. Additionally, while some 10,500 of us have access to local anaesthetics (POM-A) just short of 6,500 have access to the specified range of antibiotics and other medicines that POM-S annotations allows. Those of us who can independently prescribe any appropriate prescription-only medicine number just over 500 and there are 88 registered Podiatric Surgeons.

The pictures (left) go some way to suggesting the answer to the question; why learn about minor surgery? We are a profession of varied individuals, arguably perhaps more so than most other registered Health Professions (we certainly have the highest average age – 48 years). Some colleagues will have routine care practices, some will perhaps incorporate basic nail surgery, yet others will concentrate on biomechanics, yet others – such as myself – will include a fair amount of medicines utilisation in our practices as independent prescribers and a few dedicated individuals will follow the long road to becoming an annotated podiatric surgeon. A short minor surgery course will certainly not make you into an annotated podiatric surgeon, so do not revise Kellers excisional arthroplasty and buy a sagittal saw! However, an understanding of minor surgery can add a very interesting dimension to the practice of any podiatrist with both POM-A and POM-S or POM-A and IP, not to mention having the potential to increase your income! and will undoubtedly appeal to some of our very varied workforce.

So, what kind of conditions lend themselves to minor surgery? In fact, a surprisingly large variety; corns that require more than a simple enucleation, acrochordons, cutaneous horns, dermatofibromas, refractory verruca, pyogenic granuloma, epidermoid cysts etc, and the modality utilised on the foregoing may be sharp steel or electrosurgery or cryosurgery.

Additionally, and specifically for us as podiatrists, the wide variety of nail surgical procedures that go well beyond PNA and phenolisation and often necessitate good suturing skills. How is your mattress suturing technique and what type of suture would you utilise? Do you know the difference between a Winograd or a Zadek procedure (or a Frost or a Vandenbos?) How effective is your field block anaesthetic technique? Do you know ALL the anaesthetics we can utilise together with doses, applications and cautions? What type of procedures CAN you do in a podiatry clinic? what procedures need other types of premises? where does CQC regulation fit in? when is it needed?

So, is minor surgery of interest? – You can always find out more by contacting IOCP and arranging to listen in to one of our webinars on “is minor surgery right for me?”. The course is led by Dr Soon Lim, a GP trainer who is president of the Association of Surgeons in Primary Care and it involves online learning modules performed at your own pace, online lectures and a practical day workshop.

HCPC (2021) Diversity Data Report: chiropodists/podiatrists. https://www.hcpc-uk.org/globalassets/resources/reports/hcpc-diversity-data-report (accessed 10.11.2022)

My Care Card - Private Medical Cover with a Difference

Private medical cover can often be seen as a luxury or too expensive to justify the price in this current economic climate. Even though we all value the NHS and are privileged to have access to free healthcare, there is no denying that it is severely under strain. With waiting lists hitting a record high of 7 million and a staffing crisis reaching its peak*, there is no surprise that an increasing amount of people are deciding to have private medical cover in place. Being unwell is already a stressful enough experience and thinking about the cost of your treatment or waiting for treatment will only add to this stress.

Starting at just £9.99 a month, My Care Card is designed to be the affordable introduction to medical cover for those under 50. My Care Card has three different levels of cover to suit your needs and your budget. Each plan provides a cash benefit for each night you spend in a NHS hospital, so time spent in hospital won’t leave you struggling to pay the bills. This benefit is paid directly to you tax free, for you to spend how you wish. All plans also give you access to a 24/7 private helpline and app, so you can speak to a GP anytime you may need to, anywhere in the world. The GP can issue prescriptions that can be posted within the UK and the plan provides a £25 benefit towards this.

By selecting the Gold Plan for just £39.99 a month, you can have access to fixed price in-hospital benefits for acute conditions treated as an inpatient like illness, disease, or injury, alongside the cash benefit. When referred by a GP you will get quick admission into a hospital of your choice at a time and a location that is convenient for you, with the benefits of a private room and en-suite.

My Care Card is available in your mobile phone wallet with just a push of a button for whenever you may need it. If you need to make a claim, you can be assured this will be dealt with smoothly and efficiently by our in-house claims team.

*The Telegraph, 13 October 2022. Joining is easy and your cover will start immediately with no medical required beforehand.

You can join online today by visiting www.mycarecard.co.uk. If you have any questions call 01423 798199 where a member of our UK based helpline team will be happy to answer any questions you may have.

Writing for the Journal

There are as many reasons why practitioners do not write for professional journals, as the reasons for doing so. We are all busy people, most of us with a practice to run and little spare time and perhaps there exists some anxiety concerning putting experience into print. However, it is obvious that the vast majority of patient/practitioner interactions take place in the surgery rather than in the rarefied atmosphere of academia, which spawns most papers. We all see interesting patients and/or interesting pathology from time to time and we all have a responsibility to increase the volume of knowledge available to the profession, lead colleagues toward more formal research papers, and perhaps answer some of the more basic questions of our fellow practitioners.

Recording patient interactions in print is rewarding for the author, is a valuable addition to the individual curriculum vitae, and will enhance the journal and the profession as well as create an excellent teaching format. The Institute of Chiropodists and Podiatrists also provides a valuable Continuing Professional Development (CPD) certificate for every article published in ‘Podiatry Review, which can be presented to the Health and Care Professions Council as important evidence of ongoing CPD. For the purposes of this article, I shall look at three common forms of papers regularly published in professional journals: case notes, essays (as in this araticle), and formal papers.

Case notes, or reports usually originate from outside academia, contain information on the methodology used, and may comment on how further relevant work could be extended. They are essentially objective documentation of practical research. This does not mean that they are academically intimidating! Basically, a patient attends with an interesting condition that is diagnosed and then treated. The practitioner looks up (researches) similar cases and other relevant information, and discusses why their treatment worked (or equally importantly did not).

It is common but not necessary to use charts and illustrations in a report. All the findings are summarised, the report is written, and submitted for publication. In a sense, the report is an extended version of the case notes written at the time of treatment, with the added interest of analysis. There is a vast amount of material available online, just type in the name of the condition being treated into any search engine. Any material used in the report should be suitably referenced.

Bill Liggins

MA, BSc(Hons), FCPS, FInstChP Regional Director (England Midlands)

THE STRUCTURE OF REPORTS (Royal Society 2022)

Most reports use an IMRaD structure: Introduction, Methods, Results and Discussion.

Abstract or Executive summary. This brief summary of the report is usually the last thing you write.

Introduction. Your introduction describes the purpose of the report, explains why it is necessary or useful, and sets out its precise aims and objectives.

Literature review. This describes current research and thinking about the problem or research question, and is often incorporated into the introduction.

Methods or Methodology. This describes and justifies the methods or processes used to collect your data.

Results or Findings

Discussion, Analysis, or Interpretation. This section analyses the results and evaluates the research carried out.

8. Conclusion. The conclusion summarises the report and usually revisits the aim

In contrast, an essay is much more subjective than a report. It is a reflection of the writer’s own views and experience and can comment on past research but displays the writer’s own ideas on the subject. Unlike a report, an essay does not contain graphs, diagrams, and charts although it is divided into cohesive paragraphs and ends in a conclusion that depends on the author’s own views. (Key Differences 2022). A very good example is the Chairman’s article on Minor Surgery in this edition of the Journal. (Harvey 2023).

In contrast to an essay, a dissertation is a long piece of work and is designed to research a single topic.

“Sometimes known as a thesis (in some countries, this term is used only for the final assignments of PhD degrees, while in other countries ‘thesis’ and ‘dissertation’ are interchangeable), a dissertation is a research project (often) completed as part of an undergraduate or postgraduate degree. Typically, a dissertation allows students to present their findings in response to a question or proposition that they choose themselves. The aim of the project is to test the independent research skills students have acquired during their time at university, with the assessment used to help determine their final grade. Although there is usually some guidance from your tutors, the dissertation project is largely independent.” (Collier S. 2022)

Dissertations are very interesting pieces of research and will add to the knowledge within the profession as well as being rewarding to the author. The fact that the choice of topic is that of the researcher and will therefore be relevant to the writer and to the profession as a whole makes time spent in the analysis of the subject worthwhile. Typically, a dissertation consists of roughly 10,000 to 15,000 words which may sound daunting but in practice, it is very often difficult to keep a paper down to this level since a very wide range of sources must be researched and analysed in the literature review and properly referenced for future researchers. A typical structure of a dissertation is an introduction of 1,000 words, a literature review of 2,000 words, evidential chapters in total of 6,000 words, and a conclusion of 1,000 words. (Mounsey C. 2013). A dissertation allows practitioners to identify an area of professional inquiry and an appropriate primary and secondary source

collection to engage in independent research and apply their professional knowledge to answer a relevant question of their choosing. (Department of History, Sheffield University 2016).

The Institute journal uses the Harvard system of referencing ie. Author name(s) with year of publication following in brackets. If the paper referenced has more than one author then the first three authors should be cited with more than three noted as ‘et al.’ All papers (with the occasional exception of essays) must be referenced. A non-referenced paper is of no scientific standing and is therefore a useless impediment to researchers. Likewise, copying the work of others (plagiarism) is simply cheating your colleagues but most of all yourself. As in this essay, quoting from others is part and parcel of a paper but it must be made clear by referencing which author is being cited. If a paragraph is cited, as in the quotation from Collier above, then the paragraph should be within quotation marks. Do not cite Wikipedia as a source. Wikipedia is an ‘open editing’ publication and is therefore unreliable. Many cases of ‘circular source’ have been noted. It is, however, reasonable to use it as a guide to reliable primary and secondary sources. As a general rule, if in doubt, follow the examples in ‘Podiatry Review’.

So, as the Chinese say, ‘a journey of 1000 miles begins with a single step’. Identify an interesting case and get writing. The Journal panel will always assist you!

REFERENCES:

Collier S. topuniversities.com/blog/what-dissertation”. Downloaded 03/11/2022

Department of History Sheffield University. MUSE (https://www.sheffield.ac.uk/nap/panel/login)

Harvey M. Minor Surgery. Podiatry Review 2023 Vol. 80 No 1. Keydifferences.com/difference-between-essay-and-report.html. Downloaded 01/11/22

Mounsey C. ‘How to write Successful Essays, Dissertations & Exams’ Oxford University Press 2013. 134

Royal Society.org/journals/authors/authorguidelines. Downloaded 30/10/22

Products & Procedures under the microscope

With Gaynor Wooldridge Chair of the Medicines and Procedures Panel (MaPP) of the Institute of Chiropodists and Podiatrists

Diabetes – IS IT THE NEXT GLOBAL PANDEMIC?

On March 11, 2020, the World Health Organisation (WHO) declared the novel coronavirus (COVID-19) outbreak a global pandemic after the numbers of cases outside of China increased 13-fold, and the number of countries with cases increased 3-fold (Cucinotta et al. 2020). To date (27 October 2022) 6,588, 474 people have been confirmed to have died so far from the coronavirus COVID -19 outbreak, in 228 countries and territories (worldometers, 2021).

The novel coronavirus pandemic is a perfect model for understanding what a pandemic is, and how it impacts life on a global scale. WHO declares a pandemic when a disease’s growth is exponential; its definition is based on the rate and spread of the disease, and not the severity (WHO, 2020). The Black Death was one of the most devastating pandemics in human history and killed as many as 20% of the world’s population in the 14th century (Benedictow, 2004). Diabetes was responsible for 6.7m deaths in 2021 alone (International Diabetes Federation, 2021).

Diabetes is an underrated, global health issue and the world can surely no longer ignore the ‘rise and rise’ (Zimmet, 2017) of diabetes mellitus type 2 (DMT2). A much clearer understanding of its drivers are urgently needed, with the discovery of vital, novel approaches to prevent a global pandemic.

DMT2 is a metabolic disorder that causes blood sugar levels to increase. There are two main types of diabetes mellitus. Type 1 (DMT1) usually develops in childhood or teenage years and is an autoimmune disorder where the resulting damage to the pancreas leaves it producing little or no insulin. In DMT2, which is the focus of this article, insulin is produced by the pancreas, but the body’s cells gradually lose the ability to absorb and use the insulin. DMT2 is much more common than DMT1, affecting approximately 90% of people diagnosed with diabetes (Murfet, 2017).

This article seeks to investigate exactly what DMT2 (once called late onset diabetes) is, some fascinating historical milestones to present day, and past and current treatments. We will also discuss some of the very exciting clinical trials underway targeting insulin resistance instead of focusing on hyperglycemia (Joubert, 2022).

What is diabetes?

DMT2 is fast becoming one of the biggest epidemics in the world (Murfet, 2017). During the recent COVID-19 pandemic, diabetes contributed to 1 in 3 deaths. The International Diabetes Federation (2019) described diabetes as a life-style disease affecting 9.3% (463m people globally) of the adult population, which is increasing at an ‘alarming rate’. They went on to state that it is one of the most common, non-communicable diseases of the current era.

Diabetes is a chronic health condition that affects how the body turns food into energy.

The pancreas is located in the upper abdomen behind the stomach and it has two important functions. It produces enzymes (lipases, proteases and amylases) to break down food in the intestines (exocrine=secreting externally); it also releases hormones (insulin and glucagon) to regulate blood sugar levels (endocrine=secreting internally).

Normally, the body breaks down most of the carbohydrate food we eat into sugar and releases it into our blood stream. When the sugar levels increase, it initiates a response from the pancreas to release insulin from the beta cells, found within clusters of cells known as the Islets of Langerhans in the pancreas. Primarily, the role of the beta cells is to produce and secrete insulin in a tightly regulated manner in order to maintain circulating glucose concentrations in a narrow, physiological range (Saisho, 2015). The alpha cells make the hormone glucagon, which raises the glucose levels in the blood. Insulin acts like a key to allow the blood sugar into the cells of the body for use as energy.

In DMT2, there is an impairment in the way the body regulates and uses sugar (glucose) as a fuel. Primarily, this is caused by two problems: the pancreas does not produce enough insulin and, also, the body’s cells respond poorly to insulin and take in less sugar. These are the main defects for DMT2: insulin resistance and beta cell dysfunction (Zyoud et al. 2022; Zinn and Crofts, 2022).

Diabetes through the Ages

internal secretion (endocrine), and they presented the first proof of the impact of the pancreas in diabetes (Ceranowicz, 2015). This paved the way for the pioneering work of Frederick Banting and Charles Best in 1921, with their discovery of insulin (Karamanou et al, 2016). They were able to isolate insulin from pancreatic islets and administer it to patients suffering from diabetes, thus inaugurating a new era in diabetes treatment.

“Diabetes

remarkable affliction… the course is the common one, namely, the kidneys and the bladder … one cannot stop drinking or making water… the disease appears to me to have the name diabetes as if from the Greek word (meaning siphon).

Aretaeus of Cappodocia (1st - 2nd century)

The first accurate description of the symptoms of diabetes was found in a collection of medical texts written around 1552 BCE called the Ebers Papyrus (Karamanou et a. 2016) ; it was noted that ants seemed to be attracted to the urine of people who had this disease (Zayac et al. 2009). The papyrus proposed a 4-day treatment of a concoction of bones, wheat, grain, grit, green lead and earth (Quionzon and Cheikh, 2012). This method of diagnostic practice of attracting ants continued in ancient India; they called this condition ‘madhumaha’, meaning honey urine (Guddoye et al. 2013; Kumar et al. 2018). The Indian physician, Sushruta, and the surgeon, Charaka (400-500 BCE) were able to distinguish between type 1 and 2 (Vecchio et al, 2018).

The first written recorded history of the term ‘diabetes’ can be attributed to Aretaeus the Cappodocian, one of the most celebrated Greek physicians (Tekiner, 2015). Cappodocia’s text displays great accuracy in the detail of symptoms and of the diagnostic character of the disease. Two of his manuscripts were discovered and published, in a Latin translation, in 1554. In these manuscripts, he gave diabetes its name; it was the earliest clearest account of diabetes.

Thomas Willis added the term ‘mellitus’ to the disease in 1674, in an attempt to differentiate the sweet urine of mellitus from the unrelated diabetes insipidus (Eknoyan et al. 2005). A century later, Matthew Dobson (1732-1784) experimentally demonstrated the presence of sugar in urine, but the disease continued to be attributed to the kidneys well into the middle of the 19th century.

It was the French physiologist Claude Bernard’s discoveries concerning the role of the pancreas in digestion, and the glycaemic action of the liver, that paved the way for further progress (Habert, 2022). Bernard’s concepts and discoveries were numerous and varied. He fiercely and passionately denied the accepted dominant medical philosophy, vitalism, that can be traced back to Aristotle. Vitalism continued to have advocates into the 19th century (Bechtel and Richardson, 1998; Normanden, 2007).

In 1889, Oskar Minkowski and Joseph von Mening performed their famous experiment of removing the pancreas from a dog. Sadly, this produced a fatal diabetes. Their work did, however, demonstrate that the pancreas was a gland of

As we know today, the Islets of Langerhans, with their alpha and beta cells, play a synergistic role in a paracrine manner. The release of insulin from the beta cells inhibit the alpha cell function and the alpha cells are stimulating for the beta cells in order to maintain blood glucose homeostasis (Baskin, 2015). However, nothing was known about the Islets of Langerhans until Edouard Laguesse suggested these ‘little heaps of cells’ (Paul Langerhans, 1869) might play a regulatory role in digestion in 1893, and named them the ‘Islets of Langerhans’ after their initial discoverer. Langerhans was also the first to describe dendritic cells in the supra basal region of the epidermis (Doebel et al. 2017; Jorgens, 2020).

Over the years following, insulin purification methods improved and new formulations were developed (White, 2014).

Current Understanding and Treatments

Metformin was introduced in 1959 as an antihyperglycaemic agent. Today, it is the only biguanide and is the most widely used antihyperglycaemic agent in the world. Its primary mechanism of action is to reduce hepatic glucose production, and also reduce glucose via a mild increase in insulinstimulated glucose uptake (White, 2008). There are now more than 11 different categories of medications directed at managing DMT2, some of which are frequently used by patients within our foot health practices (Table 1). These compounds have been developed during the past 90 years, with many subtypes also existing within these categories.

Advances in pharmacotherapy have made an incredible difference to the lives of people with diabetes, but it must be kept in mind that the treatment of DMT2 is multifactorial (Aschner, 2017).

Hammed et al.(2015) discussed the alarmingly increasing rate of T2DM and the chronic, low-grade inflammation it creates, leading to insulin resistance and beta cell dysfunction. The risk factors are many and include: being overweight, smoking, poor diet, ethnicity, gestational predisposition, some medications that affect sugar metabolism and genetic factors (NICE, 2022). Obesity and DMT2 are strongly intertwined however, and Surugue (2020) found that approximately 80% of obese subjects develop the disease. Metabolic syndrome is closely linked to insulin resistance.

Recent studies from the UK, US and Germany also point to a raised risk of developing DMT2 following the coronavirus

is a

Drug Type of drug How it works Possible Side Effects

Metformin Biguanide Usually first medication prescribed. Lowers glucose production in the liver and improves B12 deficiency, nausea, abdominal body’s sensitivity to insulin, so the body uses it more effectively. pain, diarrhoea

Glybunide Sulphonylureas Helps the body secrete more insulin

Low blood sugar, weight gain Glipizide

Repaglinide Glynides Stimulate pancreas to secrete more insulin. Faster acting than sulphonylureas, Low blood sugar, weight gain Nateglinide but duration of effect shorter Rosiglitazone Thiozolidinediones Makes the body’s tissues more sensitive to insulin

Risk of: congestive heart failure, Pioglitazone bladder cancer, bone fractures, high cholesterol, weight gain

Janumet (fixed Gliptins (DPP-4 Help blood sugar levels by blocking action of DPP-4 (enzyme that destroys the hormone, Gastrointestinal, hepatitis, rash, back combination inhibitors) incretin), but modest effect pain, infections dose metformin & sitagliptin) Vildagliptin

Liraglutide Incretin Mimetics Helps the pancreas produce more insulin, reduces the amount of sugar the Diarrhoea, nausea, headaches, loss of Sitagliptin (GLP-1 analogues) liver produces and slows digestion speed. Also reduces appetite appetite Alogliptin

Dapagliflozin SGLT2 inhibitors Reduces the amount of sugar the kidneys absorb and passed it out In urine so less in Genital yeast infections, flu like, Ertugliflozin (Sodium-glucose blood. Urine test will be glucose +ve because of how they work symptoms rare but can cause kidney Canaglifllozin transporter 2) injury and lead to amputations

Simvastatin Statins Diabetes can increase the risk of heart diseases. Statins reduce the ability for the Low platelets, headache, digestive Pravastatin body to manufacture LDL cholesterol. They reduce risk of cardiovascular event by 48% problems, nausea, unusually tired Ezetimibe

Injected evolocumab

infection (Riley, 2022); this is perhaps caused by inflammation in the body from the virus, creating insulin resistance. It is also possible that the virus directly infects and damages the insulinmaking beta cells (Cutolo et al, 2020).

For all of us working within the foot health profession, seeing and treating patients with diabetes is a regular part of our working lives. We are all aware that poor diabetic care increases the risk of ulceration, infection and limb loss. Our patients with diabetes mellitus have an increased risk for pedal ulceration due to microvascular, neuropathic and biomechanical changes to the foot. Neuropathic changes to the body result in decreased pedal sensation, making the diabetic foot prone to wounds from pressure injuries. Microvascular changes can also result in reduced blood flow to the lower extremities, delaying the healing of wounds. Hirpha et al (2020) studied diabetic foot practices among adult patients and their findings showed that they were not adequately self-inspecting and washing their feet daily, drying after washing or using moisturizing creams. They also highlighted that they were likely to walk bare foot, and wear shoes, sandals and slippers without socks for protection. As clinicians, we should make every DMT2 patient aware of the importance of foot inspection and hygiene, and advise on the risks of walking bare foot at each visit.

New breakthroughs – will there be a cure in the future?

There is currently no cure for diabetes. Scientists working on a ground breaking management study are hoping to be able to help people maintain remission (ReTune, 2018-2022), and maintain HbA1C levels below 6.5% without the need for medication.

There are some exciting new collaborative developments currently being undertaken by the University of Birmingham, Monash University, Australia and the Diabetes Division of the

US Food and Drugs Agency. They are looking at a completely new approach by targeting the underlying biologic mechanism responsible, rather than treatments attempting to mitigate the consequences of DMT2, which currently focuses primarily on glycaemic regulation. PATAS is an exciting, innovative peptide that works by specifically targeting the adipocytes (fat cells). Insulin resistance prevents fat cells from allowing glucose to enter the cells and, instead, creates an overspill of toxic fat which leads to higher blood sugar levels and the storage of fat in the wrong place; this causes a number of other serious issues. When the adipocytes become insulin resistant, glucose is blocked from entering. PATAS works like a passcode to restore the usual function and allow glucose to flow into the cells (Hiwot, 2022).

Fat cells control insulin resistance by absorbing 10% of the circulating glucose; this fuels a process called lipogenesis. PATAS is not an antihyperglycaemic-resistance treatment, but rather an insulin-resistance treatment (Schreyer et al. 2022). Adipose tissue is a key regulator of whole body metabolic fitness because of its role in controlling insulin sensitivity. Obesity is associated with hypertrophic adipocytes with impaired glucose absorption (Joubert, 2022). PATAS reduces insulin resistance and provides vital cardiovascular benefits. Phase 1 clinical trials will begin in 2023 to hopefully bring PATAS to the market as quickly as possible, and as the only drug to directly treat insulin resistance (AdipoPharma, 2022). It will hopefully restore the metabolic fitness of the adipose tissue, and also have significant beneficial effects on pancreatic beta cell plaque removal, liver steatosis and fibrosis.

There are also a new generation of drugs that have been developed as a weaponised gut hormone. These medications are known as incretins, and one of their physiological roles is to regulate the amount of insulin secreted after eating (Wook and Egan, 2008). They are accepted as routine treatments for diabetes and obesity. Tirzepatide, a once weekly drug that has been described as a ‘first if its kind’, has just been approved by the Medicines and Healthcare products Regulatory Agency (Jelley, 2022). It is a single novel molecule that activates the body’s receptors for GIP and GLP -1, which are the natural incretin hormones. Critical improvements were made in comparison to the first generation GLP-1 agonists, such as semaglutide, and its effects proved to be statistically significant and clinically meaningful (Vadher et al. 2022).

Final Thoughts

Diabetes is a complex disease and, subsequently, requires a multifaceted approach to treatment. Available evidence would indicate that lifestyle interventions are significant for its development and for the prevention of further complications. However, it is obvious that in order to prevent the high risk of

Glossary

GIP: gastric inhibitors polypeptide – stimulates insulin production.

GLP-1 receptor agonists: stimulate the release of insulin and suppress glucagon secretion when blood glucose concentrations are elevated.

Homeostasis: from the Greek word for ‘same’ or ‘steady’. Refers to any process that living things use to actively maintain stable conditions for survival.

Metabolic syndrome: the medical term for a combination of diabetes, hypertension and obesity.

Paracrine signalling: cellular communication.

Peptide: long or short chains of amino acids. Long chains are called proteins.

Vitalism: belief that living entities contain some fluid or a distinctive ‘spirit’.

REFERENCES

AdipoPharmacy (2020). Formerly ALMS therapeutics. ‘Adipeutics’

Baskin, DG (2015). A historical perspective on the identification of cells types in pancreatic Islets of Langerhans by staining and histochemical techniques. Journal of histochemistry and cytochemistry Voln63, Iss 8 Bechtel, W and Richardson, CR (1998). Vitalism. E. Craig (Ed). Routledge Encyclopoedia of Philosophy. London: Routledge Benedictow, OJ (2004). The Black Death, 1346-1353: the Complete History. Woodbridge: The Baydel Press Centres for Disease, Control and Prevention (1997). Trends in the Prevalence and Incidence of Self-Reported Diabetes Mellitus. Weekly 46(3): 1014-1018

Ceranowicz, P et al. (2015). The beginnings of pancreatology as a field of experimental and clinical. Biomed Res Int Cucinotta, D et al. (2020). WHO declares COVID-19 a pandemic. Acta Biomed 19: 91(1): 157-160

Cutolo, M, Smith, M, Paulino, V (2020). Understanding immune effects of oestrogens to explain the reduced morbidity and mortality in female versus male COVID-19 patients: comparison with autoimmunity and vaccination. Clin Exp Rheumatol 38: 383-386

Daebel, T et al. (2017). Langerhans cells – the macrophage in dendritic cell clothing. Trends Immunl 38(11): 817-828

Eknoyan, G et al. (2005). A history of diabetes mellitus or how a disease of the kidneys evolved into a kidney disease. Turk Neurosurg 25(3): 508-12

Guddoye, G, Vyas, M (2013). Role of diet and lifestyle in the management of madhumeha (diabetes mellitus). Ayu 34(2): 167-173

Habert, R (2022). Claude Bernard, the founder of modern medicine. Cells 11(10); 1702

Hirpha, N et al. (2020). Diabetic foot self -caree practices among adult diabetic patients: a descriptive cross sectional study. Diabetes, Metabolic Syndrome and Obesity: Targets and Therapy 13: 4779-4786

International Diabetes Federation (2021). Diabetes Atlas

these subsequent complications, permanent life-style change, alongside appropriate medication, is imperative.

Until very recently, the scope of the problem was not really fully understood. Insulin resistance was the accepted cause. However, research has proven that part of the problem lies with the beta cells in the pancreas, and the new and future developments can hopefully make living with DMT2 more manageable. Many specialists discuss diabetes in similar terms to cancer: remission and not cure.

Unfortunately, diabetes had reached epidemic proportions in 1994 (CDC, 1997), yet over the past 25 years we have failed to apply a dedicated and focused health approach, and DMT2 has tripled, with deaths and serious complications now at out-of-control proportions. Perhaps a universal screening to highlight those already pre-diabetic is needed, and an urgent assessment of social and community factors that might increase the risk?

It would seem that at this critical stage, only by combining clinical interventions with behavioural modifications, can this complex, multifactorial disease be possibly mitigated.

Figures and Tables

Fig 1: Coronavirus: www.shutteestock.com Image ID 1643947495

Fig. 2: Diabetes symptoms: www.shutterstock.com Image ID 1140753038

Fig. 3: Pancreas: www.shutterstock.com Image ID 635022062

Fig. 4: How insulin works: www.shutterstock.com Image ID 2000998226

Fig. 5: Insulin resistance: www.shutterstock.com Image ID 1342319067

Fig. 6: Islets of Langerhans: www.shutterstock.com Image ID 186698168

Fig. 7: Adipocyte cell: www.shutterstock.com Image ID 1906807798

Table 1: Compiled from information Diabetes UK. [Accessed 10 November @17:06]Gaynor Wooldridge

(10th edition). Novo Nordisk, Pfizer – MSD Alliance and Sonofi Corporate Sponsors Kelley, O (2022). Tirzepatide authorized by MHRA. Diabetes Times (Ed)

Jorgens, V (2020). Paul Langerhans: the man who discovered the islets. Historical Milestones in Diabetology Vol 29 pp 25-35

Joubert, H (2022). Targeting insulin resistance instead of hyperglycaemia in type 2 diabetes. Available from: http:// www.medscape.com/new article/978956. [Accessed 26 October @ 10:39]

NICE (2022). Diabetes Type 2 - what are the risk factors? Available: https://www.cks.nice.irf.uk/topics/diabetes -type-2/background -information/risk-factors/ [ Accessed: 9 November @ 13:18

Normanden, S (2007). Claude Bernard and an intrtto the story of experimental medicine: “physical vitalism”, dialectic and epistemology. J Hist Med Allied Sci 62(4): 495-528

Quionzon, CC and Cheikh, I (2021). History of insulin. J Community Hosp Int Med Perspect 2(2)

Riley, F (2022). Exploring Research: Can Coronavirus Cause Diabetes? Diabetes UK

Saisho, Y (2015). B-cell dysfunction: it’s critical role in prevention and management of type 2 diabetes. World J Diabetes 6(1): 109-124

Schreyer, ES et al. (2022). PATAS, a first-in-class therapeutic peptide biologic: improves while body insulin resistance and associated co-morbidities in vitro. Diabetes 71(9): 2034-2047

Surugue, L (2020). A new therapeutic target for type 2 diabetes discovered thanks to a rare disease. Available: https://www.presse.inserm.fr/en/a-new-therapeutictarget-for-type-2-diabetes-discovered-thanks-to-a-raredisease/41133 [Accessed: 10 November 15:39]

Tarekign, D and Huvet, G (2022). University of Birmingham Available: https://www.birmingham.ac.uk/news/2022/drugcould-unlock-natural-type-2-diabetes-defence [Accessed: 10 November @ 09:01]

Taylor, R (2022).ReTune 2018-2022. Project summary – to study whether weight loss in people with T2DM who aren’t

currently overweight can put their condition into remission. University of Newcastle Tekner, H (2015). Aretaeus of Cappodocia and his treatises on diseases. Turk Neurosurg 25(3): 508-12

Vecchio, I et al. (2018). The discovery of insulin: an important milestone in the history of medicine. Front Endocrinol 9: 613

Vadher, K et al. (2022). Efficacy of Tirzepatide 5, 10 and 15mg versus semaglutide 2mg in patients with type 2 diabetes: an adjusted, indirect treatment comparison. Diabetes, Obesity and Metabolism Vol 24, Iss 9 pp 1861-1868

White, JR and Campbell, RK (Eds) (2008). Overview of the medications used to treat type 2 diabetes. In Medications for the Treatment of Diabetes. Alexandria: American Diabetes Association pp 5-15

White, JR (2014). A brief history of the development of diabetes medications. Diabetes Spectr 27(2): 82-86

WHO (2020). Director General’s opening remarks at the media briefing on COVID-19. Available: https://www.who. int/director-general/speeches/detail/who-director-generalsooening-remarks-at-the-media-briefing-on-covid-19-11march-2020 [Accessed: 9 November @ 12:05]

Wook, K and Egan, JM (2008). The role of incretins in glucose homeostasis and diabetes treatment. Pharmacol Rev 60(4): 470-512

Worldometers (2021). Available: https://www.worldometers. info/coronavirus /coronavirus -dearh-toll/ [Accessed: 27 October @ 14:44]

Zajac, J et al. (2009). The main events in the history of diabetes. L. Paretsky (Ed). Principles of Diabetes Mellitus (2nd edition). New York: Springer pp 3-16

Zimmet, P (2017). Diabetes and its drivers: the largest epidemic in human history? Clinical Diabetes Endocrinology 3, 1

Zinn, C and Crofts, C (2022). Interpreting qualification: is this the achilles heel of insulin diagnostics? Journal of Insulin Resistance Vol 5, No 1

Zyoud, SH et al. (2022). Global research trends in the links between insulin resistance and obesity: a visualisation analysis. Translational Medicine Communications 7(18)

Footnotes

Foot Health Practitioners News - Issue 12

Dear readers

Hi everybody.

I hope that you all had a Merry Christmas and are looking forward to the New Year.

No doubt it is going to be expensive, if you are mobile the cost of petrol is shocking, if you are surgery based the cost of gas and electricity are going through the roof.

This got me thinking, is there any way that I could reduce my costs? I could increase my fee, but this may reduce the number of patients coming through the door. Not a thrilling prospect. It takes such a long time to build up a good patient base, so I have shelved that idea for the moment.

If like me, you have patients who you only see once i.e. “I have an ingrowing toenail”, or a corn etc. I have decided to charge a First consultation Fee, an extra £5.00.

I have it clearly displayed on the notice board, with a message reading “if another appointment is made within the next 12 months, the fee reverts to the standard fee charged”. I have been doing this for the last 4 weeks and not one patient has mentioned it. Some of my regular patients have even tried to give me the extra money, when I tell them it is not meant for them, they are very pleased. So far it has covered the cost of the extra electricity.

As my surgery door opens straight onto the outside world, I wait for the patient to approach the door and open it for them, they come in and I close it behind them very quickly.

As they are about to leave, I put my hand on the handle and after saying goodbye I open it for them. It sounds simple, but how many patients open the door, and then stand there with it wide open, telling you what their Grandson did in his last football match. Letting all your lovely warm air escape.

As I have electric heaters in the surgery. I also turn them off when the last patient comes in, I find that the room remains warm enough, and I can save on my heating bill.

I changed all the down lights to energy efficient bulbs, and I have invested in a dustpan and brush, so I don’t have to use the hoover so often. It would be fantastic to hear from anyone who has any money saving ideas.

If you have any you would like to share, drop me an email fenton303@ntlworld.com or let Julie at head office know julie@iocp.org.uk and we can pass them onto everybody.

Happy New Year! Regards Ian

To say that the last six months have been a whirlwind would be untrue, they have been a hurricane. As I mentioned in the last issue, I have gone from shadowing twice a week and sitting theory exams in my kitchen, to sitting my practical exams in Southport, to running my own clinic as an FHP; and now as 2022 draws to a close and 2023 begins, I am commuting twice a week from Hull to Huddersfield so I can attend my podiatry degree.

I haven’t stopped, but I am loving every moment!

University has been a thoroughly rewarding experience so far. In Southport, I was excited to meet a handful of like-minded people, who shared my passion for podiatry; you can imagine how enjoyable it is to be surrounded by dozens of friendly future podiatrists, new friends and expert lecturers. For developing your knowledge and pushing yourself further, there really is nothing like being in and amongst your peers.

It should almost go without saying, but the quality of the lecturers and the knowledge they are passing on is incredibly valuable. The standards we are set and the assignments we will be taking on are of an extremely high level; the work is taxing, but I know it will all be worth it when I can provide the very highest gold standard of care for my patients. What’s more, is that as I am learning, my work in the clinic is naturally becoming more advanced. I am growing more comfortable discussing advanced terminology with the podiatrists I work alongside. It works both ways as well, as I can take my practical experience of working as an FHP into the university clinic and help my peers who may not have as much experience as myself.

It’s fair to say that I am eager for future lectures so that I can learn even more. Although if I’m honest, I am nervous to learn about biomechanics and MSK, as these were not covered in too much detail by the FHP course. Still though, the physics involved intrigues me and it will be a great challenge to push me further.

It’s nice to see my fellow peers all in our uniform during the clinic hours at university. You can really see the next generation of podiatrists. I am proud to be a part of it.

Looking forward, I can’t see the hurricane slowing any time soon and I think the next four years as a student are going to fly by. It’s bittersweet in a way, to think that this experience will all too soon be a part of my past. But certainly, I am taking nothing for granted and enjoying every moment while I can.

Molly

Somuz & the Graduation Group

Louisa-Jayne Viccars Maria Lloyd

Dean Watterson

Emma Bretherton

The Graduation Group

Katherine Campbell

Lucie Francis

Mariya Ahktar

Marie Benoit

Philippa Mann

Why is a Patient’s Medical History Important?

Medical history is important because it indicates to information about a patient having a chiropody/ podiatry/ foot healthcare treatment. Foot health professionals can deliver the most appropriate and effective treatments that support the concerns that patients have about their presenting condition. It may also help with assessing or diagnosing foot problems.

A good medical history will include health information about the patient and close family. This can be particularly helpful to understand hereditary issues such as bunions and likely diseases in the patient’s family that may play a role in the patient’s health, such as diabetes. The risk for diabetes, or heart disease, and several types of cancers can be genetically inherited. While this doesn’t mean the patient will become ill, it does help the health practitioner, and the patient has more awareness of any hereditary conditions. It can often be a good guide for lifestyle changes, especially with the prevalence of many conditions that can influence the future health of the patient’s feet. This will also include the patient’s past and current medication, and vaccination records.

It is not unusual for patients who encounter medical or allied health professionals to have medical histories taken. The level of detail the history contains may depend on who is taking the medical history and, on the patient’s main complaint. The most detailed and complete history, when time is not a factor (not an emergency or where the patient is unconscious) may include primary, secondary, and tertiary histories, a review of the patient’s symptoms, and a past medical history.

The primary goal of obtaining a medical history from the patient is to understand the patient’s state of health and to further determine if the patient’s medical history is related to the patient’s presenting health complaint being evaluated, assessed, or diagnosed. The secondary goal is to gain information to prevent potential harm to the patient during treatment, for instance, avoiding any medicament being used i.e., skin preparations that could potentially cause an allergic reaction. For medical practitioners i.e., GPs this can be a complicated problem while trying to avoid administering or prescribing a medication the patient has previously taken and had an adverse reaction too.

For most allied health, chiropody, podiatry, and foot health professionals, taking medical histories usually entails taking down the patient’s name, address, date of birth, age, height, weight, (shoe size) and complaint/s. Thereafter, gathering the primary history, such as the symptoms and how long the patient has had the symptoms, which may reveal how much pain, on a scale of 0 to 10, the patient is experiencing. This would usually be recorded on the patient records or a separate medical history form, so there is an accurate account of what the patient tells the health practitioner.

The health practitioner should then expand on the patient information with a secondary history. This is where the patient is asked about any symptoms they are experiencing, related to their foot problem. Any associated symptoms can often be key to making a correct diagnosis and providing suitable treatments. Although it is not uncommon for the patient to understand or view associated symptoms having any relationship to their foot complaint.

A tertiary history is anything in the patient’s past medical history that may have something to do with the current foot or feet complaint. This further supports a clearer assessment of the problem and the care plan or treatment ideally suited for the patient. The health practitioner

could also include reviewing the symptoms and list anything that the patient feels might not be normal and wants the practitioner to look at.

Any past medical history or background information can help the health practitioner know more about the patient’s health, not just the current chief complaint or foot issue, as follows:

Allergies and drug reactions

Current medications, including over-the-counter

Current and past medical illnesses or conditions

drugs

Current and past hospitalisations and Immunisation status

Use of tobacco, alcohol, etc.

Family or marital status. Occupation

It is important to communicate with the patient about their medical history, which can have a significant impact on preventing possible medical or treatment errors. Whereby the health practitioner can provide the correct treatment/s. It is just as important to record the patient’s medical history with the patients record accurately, which may reduce medical/ health professional errors or improper assessments and/or diagnoses and treatments provided.

Any information gathered by any means will crucially guide and direct the care and treatments provided to the patient. Although, it should be during the initial encounter with patients that a patient’s medical history is taken and then any follow up or subsequent visits/ treatments should then only require a review of the medical history and possibly an update with any changes to diagnosed illnesses/ conditions, hospitalisations, or medications. It can also be important since Covid-19 to check immunisation status. An accurate medical history will support all aspects of the health professionals practice, and if necessary, any interprofessional team involved in the care of the patient.

Overall, a medical history is an inquiry of the patient’s medical history, past surgical history, family medical history, social history, allergies, and medications the patient is currently taking. This can direct treatments and avoid any potential harm to the patient regarding allergies or limited care during previous treatments; especially useful to support a patient’s current foot complaint.

All the best Beverley

Chair of Ethics and Vice-Chair of Education

REFERENCES

BMJ 2018;324:1533

Ingram S. Taking a comprehensive health history: learning through practice and reflection. Br J Nurs. 2017 Oct 12;26(18):1033-1037. doi: 10.12968/ bjon.2017.26.18.1033. PMID: 29034702.

Nichol JR, Sundjaja JH, Nelson G. Medical History. [Updated 2022 Sep 5]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan. Available from: https://www.ncbi.nlm.nih.gov/books/NBK534249/ van Diermen DE, Brand HS, Vissink A. Het belang van een goede medische anamnese [The importance of adequate medical history taking in dentistry]. Ned Tijdschr Tandheelkd. 2006 May;113(5):172-5. Dutch. PMID: 16729560.

Yorath MC. Why Complete H&Ps Should Be More Common In Podiatry. Podiatry Today. September 2005.

How shoe construction & styling can affect fit

Welcome to the first of a series of articles from ShoeMed Limited, your one stop footwear resource for you and your patients.

Through our Business Referral Scheme, we found there was a real need for educating and training podiatrists in footwear and including footwear as part of their patients’ treatment plan. About the author, Lisa Preston is a qualified Australian certified Pedorthist working with ShoeMed to help develop training resources for anybody with an interest in foot and ankle health, who wish to learn more about therapeutic footwear, fitting and modifications to shoes. Following our webinar in November 2022, this article further discusses shoe construction and how this can affect its fit. As Podiatrists, you are all aware of the many varying foot deformities and chronic health conditions which can affect the lower limbs; each condition posing a different challenge to finding the right footwear. How often are you asked for footwear advice? Could you confidently offer the right advice to support your treatment? Hopefully after you have read this short article you will have a little bit more knowledge and confidence to be able to guide your patients correctly. A starting point would always be an inspection of their current footwear.

Outsoles Leather, of course was the traditional choice of soling material, but is not often used now due to advances in man-made materials offering more comfort and durability. Some examples of soling materials used are:

Direct polyurethane (PU) injection moulded soles

o durable with correct care, cushioning, and waterproof.

Ethylene vinyl acetate (EVA)

Check the outsole wear – a useful inspection to help diagnosing biomechanical issues.

Check the inside wear – a top tip is to insert your hands inside your patients’ current shoes and have a good feel around which will give you information on the construction and the fit.

o What is the lining made of?

o Are there any wear patterns/holes at the end of the shoes?

• If the toes have been touching the ends of the shoes, the shoes are too short.

o Is there any excessive heel wear?

o Are there any removable insoles?

• What lies beneath these insoles?

Does your patient have diabetes?

o In this case you would be checking for sharp objects that could cause harm and damage to the foot.

Are there any seams?

o These could be sitting over hot spots which could result in corns.

Having checked the shoes, you now have a great deal of information, coupled with your biomechanical assessment you can now start the shoe conversation!

Materials & construction

Materials used in the construction of footwear do affect how a shoe fits. From the outside upper material to the lining used and the insoles fitted, all of this has an instant effect on how a shoe feels when tried on, but also a longer-term effect on how a shoe fits after some time of use.

As an example, an all leather, seam free upper on a shoe will be more inclined to form the shape of the foot, stretching in width as necessary. A synthetic lined upper with lots of decorative seams will not stretch as easily. However, a shoe upper made on a 3D knitting machine, a technique commonly used in running shoes is being used more and more by the comfort/lifestyle footwear sector, or with stretch uppers, either leather or manmade, will ease over the foot instantly giving comfort for bunions and hammer toes.

Many brands now use this upper technology, such as X sensible, Joya, Fidelio, DB Shoes and more. It is also important to note that this can therefore sometimes provide a vegan shoe choice.

o shock absorbing

o available in different densities and often used in sports shoes.

o used in therapeutic footwear also as it is easily adapted, lighter and available in sheet form.

o less durable and not as cushioning as PU.

o It can be used in cement (glued) construction and commonly used in insole and orthoses manufacturing.

Rubber soles

o very hard wearing, good grip but can be heavier.

Polyvinyl chloride (PVC)

o hard wearing, stronger, cheaper but do not offer as good a grip as other materials. Important to note that they are not biodegradable and more expensive to recycle.

Outsole heel shape

Let us start from the back of a shoe. Look at the width of the outsole at the heel. The wider the heel, the more stability. Many footwear manufacturers ‘roll’ the outsole of the heels and this will only be a problem if your patient requires rearfoot stability. When looking at a shoe, are the edges rounded or the heel flared?

The wider the heel, the more stability. You do not need to change brands – there is no doubt an option in the same brand but with a different outsole heel shape.

An example of this would be if you have a patient with excessive pronation. So, choosing a shoe with a heel such as the one shown above, can increase support for them and help to support your orthotic prescription.

Heel counters and heel fitting

At the heel area, a shoe to help people with foot problems should have a firm heel counter. This is a piece of thermoplastic material which is inserted between the lining and the upper and then lasted to form the shape of the heel.

A good heel counter should be nice and firm when new and should gradually mould to the shape of the wearers’ heel as they warm up. Your orthosis should fit neatly and securely between the heel counters and not bulge them out, as this will encourage heel slippage (every shoe fitter’s nightmare!). To keep the integrity of the heel counters the patient should always loosen the laces and use a shoehorn.

Finally, how wide does the heel look at the back, as if your patient has a wide forefoot but a narrow heel, then this heel fitting will need to be narrow. How deep are the shoes under the lateral malleoli? This is important if your patient has a history, for example, of an ulcer in this area, so the topline needs to sit well clear of the lateral malleoli. Not an impossible problem however, as a good shoe modifier can roll this topline down a little to help.

Most shoes will have a leather lining on the inside of the heel, often this is a suede finish for a better grip. Around the topline of the heel, there should be padding, and some have more than others, for example a sports style shoe will generally have a more padded topline and ‘peaks’.

Shoe linings

Even if the heels are leather lined, the whole shoe may not be leather lined. A good tip is to put your hand inside a shoe and have a good feel around if you are unsure. A full leather lined, all leather upper is perceived to stretch more readily to the shape of the foot. However, with advancing technology, many man-made materials are great for moisture wicking, insulation and conforming to the foot.

A handy tip to remember is that a GoreTex® lined shoe can fit a little snugger, as the lining wraps all around the inside of the shoe. If a shoe states ‘leather lined’ check which kind of leather – pigskin is a commonly used lining in a less expensive shoe.

Shoe fastenings – laces & straps

The way a shoe fastens has a huge impact on fit and function. A court shoe is always fitted too short so that it stays on the foot, as there is nothing holding the shoe onto the foot apart from this snugness. Smart/casual lace ups are thankfully now more acceptable for fashion, so starting with lace ups, always open the laces up fully, if the shoes are new and not been tried on before. Factory lacing is often very tight. If a patient has a wider and fuller in the foot, long lacing opening is essential.

Strap fastenings are useful to replace laces if a person is having difficult doing up laces, and strap fastenings can always be used in replacement of laces as an additional modification to a shoe. A tip also is that a strap fastening which just touches over, will not provide as much support as a strap which fastens through a metal loop then back on itself.

If the shoe is a full lace up style, then there will be a tongue which is either padded or not padded. Padding is useful to cushion the top of the foot and to assist in preventing the foot sliding forwards. Handy tip – an experienced shoe fitter will have self-adhesive tongue pads to use if necessary during the fitting.

Zips, whilst often included for fashion reasons in recent times alongside laces, are in fact very useful for removing shoes easily

The vamp

The vamp is the front portion of the shoe which covers the forefoot area, which as we know is the source of many problems with shoe fitting. Look closely at the depth of shoes. Shoes with a higher vamp are sometimes known as ‘extra depth’ so they give more room for bunions and retracted toes and also, of course, for a full-length orthosis.

Looking down onto the vamp will clearly show the shape of the forefoot area – if your patient has a square shaped forefoot then they will require a shoe with a similar forefoot shape, so if the toe shape is too narrow the shoe simply will not fit comfortably.

Shoes made with lots of pattern and therefore stitching on the vamps may look attractive, but where there is a seam sitting over a deformed joint there will be no stretch, which will potentially cause harm to the patient’s skin.

Removeable insoles/footbeds

Are there removeable insoles/ footbeds in the shoes? These can assist with fitting the shoe if a slight alteration is required.

For example, if there is a little too much room in the front of the shoe a forefoot liner can be added to make the fitting a little snugger. Or of course, you can design your orthosis to be slightly thicker at the front.

Some shoe brands in the comfort sector now offer two insoles as standard, so the depth fitting can be adjusted. Removeable insoles or footbeds are essential if you are fitting a foot orthosis.

The toes!

Ending at the toes – better constructed shoes have a ‘toe puff’ which again is heat mouldable, to hold the toe area of the vamp off and away from touching the toes and helping the shoe to keep its shape. When trying shoes on, it is not wise to push firmly with fingernails to feel where toes are, as this toe puff can get dented from this. Knowing the basics of footwear design and construction can help you to not only discuss this with your patients but can also give you more confidence for a conversation with footwear brands and representatives about the features, benefits, and points of difference they offer.

Essentials of Biomechanics

Principles of gait: The foot’s option’s at Acceleration

By Andy Horwood Visiting Lecturer & Fellow Staffordshire University Product Designer & Research at Healthy Step Ltd

INTRODUCTION

Acceleration from the foot usually involves changing its material properties from a structure that dissipates impact/collision energy to one that provides energy storage and force transfer. Thus, the foot is altering its material properties by responding to and creating variable gait impulses. This is only a reinterpretation of the classic description of the foot as a mobile adaptor becoming a rigid platform, a concept taught for over century. Research has now indicated how the foot changes its material properties in variable ways during each step (Kokubo et al, 2012; Bjelopetrovich and Barrios, 2016; Farris et al, 2019; Takabayashi et al, 2020). The foot is never fully compliant or totally rigid. However, it should become variably semi-stiffened to permit the transfer of Achilles tendon power across it and into the ground under the forefoot, as the heel raises (Holowka et al, 2017). This acceleration power provides forefoot stability on the ground while body weight is transferred forward onto the heel of the contralateral foot, an action which occurs during the brief last moments of ipsilateral single-limb support. It is important to appreciate how mechanisms are at work across the foot, that is acting as a beam to transfer acceleration power from the rearfoot to the forefoot, for this tells us much about what can go wrong.

Accessing the Power of the Triceps Surae

Energetics is the study of energy. On a biological basis, locomotive energy must be used effectively for it results from and drives evolutionary change (Pontzer et al, 2014). Muscle contraction requires energy. Some types, such as concentric and isometric contractions, are more expensive than others: i.e., eccentric contraction. Animal gaits utilise both elastic energy dissipation and storing properties of connective tissue combined with muscle generated forces, to creating safe power and stability during locomotion. The use of the triceps surae complex during late midstance in human walking is one of the best energetic examples of such mechanics among terrestrial animals. Its worth adding that this is not the same process as used in human running, which explains why humans are excellent endurance walkers but slow runners.

Triceps surae power is fundamental in restraining forward motion of the centre of mass (CoM) of the body and yet is does not generate the power that drives the body’s CoM forward (Honeine et al, 2013). During walking gait, triceps surae muscles of gastrocnemius and soleus start to activate after body weight is fully loaded onto the foot, once the braking events have ended. They continue their activity to the heel lift boundary (Crenna and Frigo, 1991; Anderson and Pandy, 2001; Franz and Kram, 2012; Murley et al, 2014). Triceps surae activity increases briefly before the CoM of the head, arms, and trunk segments (often called HAT) start to move anterior to the ankle joint. The swing limb should also be approaching the point where it passes anterior to the single-support phase limb, around

absolute midstance. Early midstance activity involves concentric contraction of triceps surae (high energetic cost) causing fibreshortening of the Achilles’ (Ishikawa et al, 2007), tightening the local connective tissues in the posterior calf and knee. This increases elasticity/stiffness within the lower limb while providing some ‘braking’ of anterior momentum.

Everything rapidly changes as the CoM of HAT and the swing limb passes anterior to the stance limb’s ankle joint. Eccentric contraction of triceps surae starts as part of the action of ‘braking’ the forward momentum of the HAT’s CoM as it falls anteriorly under the effects of gravity. This gravitational force is enhanced by gaining CoM height during early midstance. The Achilles’ fibres now start to lengthen, after having been pre-stress and stiffened at the end of early midstance (Ishikawa et al, 2007). Eccentric contraction has high force production at exceptional low energy costs. This low cost is due to the fact that elasticity within the connective tissues (particularly tendon) and within the muscle fibres (via a protein called titIn) can passively help resist the fibre lengthening, making eccentric contraction highly efficient (Hessel et al, 2017). The Achilles tendon can passively do most of the lengthening in late midstance, reducing the muscle fibre length changes (Ishikawa et al, 2007). The stretchenergy is stored for acceleration very efficiently due to the Achilles’ special energy storage structure (Thorpe et al, 2013a; Shearer et al, 2017). The body moves over the foot in a manner similar to a class three lever mechanism (Fig 1 overleaf).

Figure 1: Walking’s early midstance (left) involves reducing ankle plantar-flexion angles around its axis or fulcrum (F – black star) without dorsiflexor muscle activity. Instead, reduced ankle dorsiflexion is coupled to decreasing hip flexion angles via effort from gluteus maximus (GMaxE) activity and reducing knee flexion angles through quadriceps muscle effort (QE). Together with the hip abductors and adductors, these muscles help pull the CoM up to its high point over the ankle, reducing ankle plantarflexion angles towards a neutral 90º angle to the leg. Thus, it is the lever arms operating around the hip and knee fulcrums (hollow-centred stars) that control the ankle moments. However, at absolute midstance the CoM of HAT slips anterior to the ankle joint axis, thereby requiring the ankle plantarflexor muscles to restrain and control the CoM’s anterior progression during late midstance (right image). Triceps surae now eccentrically controls acceleration around and against increasing ankle joint dorsiflexion moments, brought about by the interplay of the GRF and body weight falling forward under gravity. This sets up a class three lever arm with the triceps surae proximal attachments becoming points of effort (GastrocE and SE) that slow the proximal resistance (R) of the HAT CoM. Power for heel lift is being stored within the elastic stretch of the Achilles by this action. Gastrocnemius’ attachment to the posterior aspects of the femoral condyles can also resist the knee extension moment generated by the fall of R.

Image from the upcoming text ‘Clinical Biomechanics in Human Locomotion: Gait and Pathomechanical Principles’. (Permission www.healthystep.co.uk).

Thus, as the anterior rotation of the tibia causes ankle dorsiflexion to allow the body to rotate forward, the Achilles is stretched and elastically loaded with potential energy. This energy reaches its peak as heel lift approaches. Once the ground reaction force (GRF) maintaining heel contact decreases to a force lower than the power within the Achilles, the heel springs off the ground. Thus, as the body’s CoM moves over the forefoot and beyond, the heel lifts under elastic recoil energy within the Achilles. The activity of gastrocnemius and soleus can now switch off, but the ankle will continue to plantarflex under the power still being released from the Achilles, while the knee will flex under residual gastrocnemius connective tissue recoil (Honeine et al, 2013). The ankle plantarflexion power is derived primarily from soleus, especially at slower walking speeds (Lenhart et al, 2014; Orselli et al, 2017). The midfoot should plantarflex under the power released by tibialis posterior and peroneus longus after heel lift (Kokubo et al, 2012; Murley et al, 2014; Maharaj et al, 2016; Holowka et al, 2017; ). An arguable class two lever system is now created (think wheelbarrow). See figure 2.

Figure 2: Heel lift power derives primarily from the triceps surae muscles, but it is released via energy stored within the Achilles from the midstance triceps surae eccentric muscle contraction. This provides the effort required to spring the heel off the ground. The heel lift effort raises all of the lower limb mass lying behind the metatarsophalangeal (MTP) joints acting as the fulcrum (F and vertical dashed line). This lower limb mass, consisting of the rearfoot and lower leg, provides the resistance that must be moved (R – grey circle).

However, plantarflexion-powered heel lift achieves so much more than just raising the heel. By forcing the foot to plantarflex at the ankle against the ground, the plantarflexion power generates a large GRF angled anteriorly that accelerates the body’s CoM forward and downward, assisting gravity to move body weight to the next step. This drops the swing limb around 1 cm to accelerate the rate of contact with the support surface, ending this swing phase.

Although this class two lever system does not primarily move the body’s CoM anteriorly (gravity and centrifugal forces from the swing limb do that), the effort it applies to gait during the terminal stance phase helps ‘power’ weight transfer onto the opposite limb, adding momentum to the HAT’s CoM that can persist into contralateral early stance phase.

Image from the upcoming text ‘Clinical Biomechanics in Human Locomotion: Gait and Pathomechanical Principles’. (Permission www.healthystep.co.uk)

How effective this power is transferred to acceleration of the body’s momentum in gait depends on what happens just before and at heel lift, for if the midfoot is too flexible acceleration power is lost.

The Acceleration Beam and the Concept of a ‘Goldilocks Zone’

The foot is semi-stiffened to act as a beam ready to become a crude class two lever for acceleration prior to heel lift (Horwood, 2022). For this to work, the midfoot must be relatively inflexible (stiffened) with the metatarsophalangeal (MTP) joints providing the primary location of any compliance and to thus act as a fulcrum point. Therefore, during late midstance the midfoot should only dorsiflex around 4º (Holowka et al, 2017). This midfoot compliance adaptability is necessary to prevent injury within the foot and ankle under the powerful ankle dorsiflexion moment that occurs during late midstance, prior to heel lift. Thus, during late midstance, some steps will absorb more power within the foot vault by using more midfoot motion, while the MTP joints should use their motion to provide energy dissipation during acceleration.

When on hard ground trying to walk softly, the foot might need to absorb more power, dissipating energy by providing greater compliance under reduced muscle activity. When walking very quickly, the foot might need to stay stiffer to use more power via released stored elastic energy by increasing foot stiffening-muscle activity. However, applying lots of power to a forefoot on very soft, unstable ground might cause the forefoot to sink too far into the ground for efficient walking. On very soft ground a more compliant foot and a slower gait speed is the best option. The somatosensory/sensorimotor system is the highly complex neuromusculoskeletal system that is used to get this process right. A subject for another time!

For power from the Achilles to be maximised, the fulcrum point needs to be kept at maximum distance from the Achilles effort point i.e., the attachment (enthesis) to the calcaneus. However, if that fulcrum point is too far away, then the forces within the Achilles required to achieve heel lift could result in the Achilles tendon or the triceps surae muscles being damage through excess power application (Takahashi et al, 2016). For every foot there will be a zone where power can be maximised safely, dependent on its length, foot strength, triceps surae strength, and the Achilles tendon quality/cross-sectional area. In this ‘Goldilocks zone’ should lie the freely moving (but tensioned) MTP joints that act as the fulcrums for heel lift. The resultant distance between the Achilles attachment and the fulcrum point used for heel lift is known as the ‘external moment arm of the Achilles’. Changing foot vault lengths and curvatures in gait help set this ‘Goldilocks zone’. Lowering the vault under sagging deflection caused by the ankle dorsiflexion moment of late midstance, increases the distance between the Achilles calcaneal attachment and the MTP joints. However, after heel lift the foot shortens and the vault rises to help stiffen it under reducing muscle activity (figure 3).

Figure 3: In midstance (A), the radius of curvature of the vault is increasing, meaning that stiffness via the mechanical laws of curvature is decreasing. The advantage of this is two-fold: energy can be dissipated through initial higher vault flexibility and that flexibility lengthens the connective tissues, stretch-stiffening them and storing elastic energy.

It also increases the distance between the Achilles and the MTP joints as the foot stiffens. After heel lift (B), ankle and midfoot plantarflexion couples to digital extension, actions that together raise the foot vault, increasing stiffness. A stiffer foot helps transfer stored plantarflexion muscle power into the forefoot creating a stabilising GRF.

However, it is the increased curvature across the smaller span distances within the transverse plane that stiffen the foot from medial to lateral, that are most likely necessary for permitting longitudinal changes in vault curvature and stiffness.

Image from the upcoming text ‘Clinical Biomechanics in Human Locomotion: Gait and Pathomechanical Principles. (Permission www.healthystep.co.uk).

Shortening and stiffening the foot after heel lift helps maintain ankle plantarflexion under decreasing power. However, if the foot is too lengthened and flexible at heel lift, the ‘Goldilocks zone’ is lost. This is also true if the foot is overly shortened and stiffened. This is why the continued stating that ‘foot supination occurs prior to heel lift to stiffen it’, is not only scientifically proven wrong, but is mechanically illogical. Those who repeat this falsehood are perpetuating an early misunderstanding of foot function. For every step, there are a number of factors that will dictate where best to position the MTP joints that are going to act as the acceleration fulcrum. This requires adaptability via variable foot pronation and gait angles prior to heel lift.

One common problem is insufficient stiffness generated across the midfoot during late midstance. If the foot fails to stiffen adequately, heel lift may occur around a fulcrum within the midfoot, with mobility derived particularly at the talonavicular and 4th and 5th tarsometatarsal joints (Lundgren et al, 2008; Wolf et al, 2008). Heel lift using midfoot joints as fulcrums of rotation cause midfoot dorsiflexion at heel lift and is known as midfoot break (DeSilva and MacLatchey, 2008; DeSilva et al, 2015).

Summary

Acceleration demands lots of energy during walking gait (Griffin et al, 2003), indicating that human muscles are busiest around the heel lift boundary. That means heel lift is a very vulnerable event in gait. Because there is no ‘active push-off’ during acceleration, the lower limb is required to facilitate an ‘easy’ mechanical heel lift from passive power. This requires the foot to be pre-stiffened (variable in levels of semi-stiffness) during late midstance to create a beam for a class two lever system that uses elastic recoil from the Achilles. This elastic recoil powers heel lift, adding momentum into the next step but does not provide the primary forward momentum (Ruina et al., 2005; Honeine et al, 2013).

REFERENCES:

Anderson FC, Pandy MG. (2001). Dynamic optimization of human walking. Journal of Biomechanical Engineering. 123(5): 381-390.

Bjelopetrovich A, Barrios JA. (2016). Effects of incremental ambulatory-range loading on arch height index parameters. Journal of Biomechanics. 49(14): 3555-3558.

Crenna P, Frigo C. (1991). A motor programme for the initiation of forwardoriented movements in humans. Journal of Physiology. 437(1): 635-653.

DeSilva JM, MacLatchy LM. (2008). Revisiting the midtarsal break. [In: Abstracts of AAPA poster and podium presentations.] American Journal of Physical Anthropology. 135(S46): 89.

DeSilva JM, Bonne-Annee R, Swanson Z, Gill CM, Sobel M, Uy J, et al. (2015). Midtarsal break variation in modern humans: Functional causes, skeletal correlates, and paleontological implications. American Journal of Physical Anthropology. 156(4): 543-552.

Farris DJ, Kelly LA, Cresswell AG, Lichtwark GA. (2019). The functional importance of human foot muscles for bipedal locomotion. Proceedings of the National Academy of Sciences of the United States of America. 116(5): 16451650.

Franz JR, Kram R. (2012). The effects of grade and speed on leg muscle activations during walking. Gait & Posture. 35(1): 143-147.

Hessel AL, Lindstedt SL, Nishikawa KC. (2017). Physiological mechanisms of eccentric contraction and its applications: A role for the giant titin protein. Frontiers in Physiology. 8: 70. doi: 10.3389/fphys.2017.00070.

Holowka NB, O’Neill MC, Thompson NE, Demes B. (2017). Chimpanzee and human midfoot motion during bipedal walking and the evolution of the longitudinal arch of the foot. Journal of Human Evolution. 104: 23-31.

Griffin TM, Roberts TJ, Kram R. (2003). Metabolic cost of generating muscular force in human walking: insight from load-carrying and speed experiments. Journal of Applied Physiology. 95(1): 172-183.

Honeine J-L, Schieppati M, Gagey O, Do M-C. (2013). The functional role of the triceps surae muscle during human locomotion. PLoS ONE. 8(1): e52943. doi: 10.1371/journal.pone.0052943.

Horwood A (2022). Essentials of biomechanics. Principles of gait: Using the acceleration lever system effectively. Podiatry Review. 79(4): 23-26.

Ishikawa M, Pakaslahti J, Komi PV. (2007). Medial gastrocnemius muscle behavior during human running and walking. Gait & Posture. 25(3): 380-384.

Kokubo T, Hashimoto T, Nagura T, Nakamura T, Suda Y, Matsumoto H, et al. (2012). Effect of the posterior tibial and peroneal longus on the mechanical

properties of the foot arch. Foot & Ankle International. 33(4): 320-325.

Lenhart RL, Francis CA, Lenz AL, Thelen DG. (2014). Empirical evaluation of gastrocnemius and soleus function during walking. Journal of Biomechanics. 47(12): 2969-2974.

Lundgren P, Nester C, Liu A, Arndt A, Jones R, Stacoff A, et al. (2008). Invasive in vivo measurement of rear-, mid- and forefoot motion during walking. Gait & Posture. 28(1): 93-100.

Maharaj JN, Cresswell AG, Lichtwark GA. (2016). The mechanical function of the tibialis posterior muscle and its tendon during locomotion. Journal of Biomechanics. 49(14): 3238-3243.

Murley GS, Menz HB, Landorf KB. (2014). Electromyographic patterns of tibialis posterior and related muscles when walking at different speeds. Gait & Posture. 39(4): 1080-1085.

Orselli MIV, Franz JR, Thelen DG. (2017). The effects of Achilles tendon compliance on triceps surae mechanics and energetics in walking. Journal of Biomechanics. 60: 227-231.

Pontzer H, Raichlen DA, Rodman PS. (2014). Bipedal and quadrupedal locomotion in chimpanzees. Journal of Human Evolution. 66: 64-82.

Ruina A, Bertram JEA, Srinivasan M. (2005). A collisional model of the energetic cost of support work qualitatively explains leg sequencing in walking and galloping, pseudo-elastic leg behavior in running and the walkto-run transition. Journal of Theoretical Biology. 237(2): 170-192.

Shearer T, Thorpe CT, Screen HRC. (2017). The relative compliance of energy-storing tendons may be due to the helical fibril arrangement of their fascicles. Journal of the Royal Society: Interface. 14(133): 20170261. doi: 10.1098/rsif.2017.0261.

Takabayashi T, Edama M, Inai T, Nakamura E, Kubo M. (2020). Effect of gender and load conditions on foot arch height index and flexibility in Japanese youths. Journal of Foot & Ankle Surgery. 59(6): 1144-1147.

Takahashi KZ, Gross MT, van Werkhoven H, Piazza SJ, Sawicki GS. (2016). Adding stiffness to the foot modulates soleus force-velocity behaviour during human walking. Scientific Reports. 6: 29870. doi: 10.1038/srep29870.

Thorpe CT, Klemt C, Riley GP, Birch HL, Clegg PD, Screen HRC. (2013a). Helical sub-structures in energy-storing tendons provide a possible mechanism for efficient energy storage and return. Acta Biomaterialia. 9(8): 7948-7956.

Wolf P, Stacoff A, Liu A, Nester C, Arndt A, Lundberg A, et al. (2008). Functional units of the human foot. Gait & Posture. 28(3): 434-441.

In the next issue we will look at the consequences of midfoot break on the power of acceleration.

PODARICK

NAILS IT!

Podarick can you help me?

I have a patient who is worried about her sports mad eight-year-old son. He has just been diagnosed with Osgood-Schlatter disease and the GP has told him that he must stop all sports when his knee hurts and take painkillers. My patient was wondering if there is any advice on alternative or natural remedies that are safe for children, and could help with the pain and maybe improve this condition?

Podarick says:

Osgood-Schlatter disease or osteochondrosis, is most common in young people around puberty, while joints are still forming, but very rare after the age of 16. In some children the bones of the leg are growing too fast for the tendons that attach muscle to bone to keep up and will likely affect the tibial tuberosity, which can become prominent. It may not be all that common in most young people, but it can happen to active ones. There is no cure, but the symptoms can be managed, which can last a year or more. Young people will find that the disease does go away on its own as they grow up. However, in some rare cases they may have to have surgery to help heal the issues of the disease before adulthood. The doctor may prescribe painkillers or support tights; in extreme cases, a leg cast, brace, knee support or splint may be used to take the pressure off the affected part of the leg. However, over-the-counter painkillers usually support this disease, which is an inflammatory condition. There are some natural remedies that will help to reduce inflammation and control the pain and swelling associated with the condition.

One of the most powerful anti-inflammatory remedies you can use is bromelain (Rathnavelu, Alitheen, Sohila, et al. 2016) an enzyme derived from pineapple stems. Bromelain tablets are safe to give children in correct doses, or by eating the pineapple fruit.

There are other natural painkillers available to help support this condition. These include collagen (Clark, Sebastianelli, Flechsenhar, et al. 2008), dry needling (Hsieh, Kao, Kuan, et al. 2007), eating bone broth, Epsom salts, peppermint oil (Kligler, Benjamin and Sapna Chaudhary. 2007); stretching before any exercise or strenuous activity, and spicy foods that contains the spice Capsaicin (Fattori, Hohmann, Rossaneis, et al 2016).

Send your Nail Clippings to Podarick: email: info@iocp.org.uk

PODARICK REFERENCES:

Clark KL, Sebastianelli W, Flechsenhar KR, Aukermann DF, Meza F, Millard RL, Deitch JR, Sherbondy PS, Albert A. 24-Week study on the use of collagen hydrolysate as a dietary supplement in athletes with activity-related joint pain. Curr Med Res Opin. 2008 May;24(5):1485-96. doi: 10.1185/030079908x291967. Epub 2008 Apr 15. PMID: 18416885.

Fattori, V, Hohmann, M.S.N, Rossaneis, A.C, Pinho-Ribeiro, F.A, Verri, W.A. Capsaicin: Current Understanding of Its Mechanisms and Therapy of Pain and Other Pre-Clinical and Clinical Uses. Molecules 2016, 21, 844. https://doi.org/10.3390/ molecules21070844

Hsieh YL, Kao MJ, Kuan TS, Chen SM, Chen JT, Hong CZ. Dry needling to a key myofascial trigger point may reduce the irritability of satellite MTrPs. Am J Phys Med Rehabil. 2007 May;86(5):397-403. doi: 10.1097/ PHM.0b013e31804a554d. PMID: 17449984.

Kligler, Benjamin and Sapna Chaudhary. “Peppermint oil.” Reactions 178 (2007): 9.

Rathnavelu V, Alitheen NB, Sohila S, Kanagesan S, Ramesh R. Potential role of bromelain in clinical and therapeutic applications. Biomed Rep. 2016 Sep;5(3):283-288. doi: 10.3892/br.2016.720. Epub 2016 Jul 18. PMID: 27602208; PMCID: PMC4998156.

Quality Keynote speakers

Dr J. A. Barbero-Brown

O. Frankowski N. O’Brian

D. James G. Hicks

Exploring the Unknown

How time flies! It has been a year since the question was asked by the Directorate of Global Health Partnerships (DGHP) to research the global state of Podiatry, with a view to exploring the possibility of building an ethical migratory pathway of overseas Podiatrists into the NHS. Here we reflect on the process, leading to where the project is now.

There were whispers and reassurances - almost a pre-emptive-cushion that ‘this is unlikely to be possible, but the process itself will be good for understanding the global picture, and it needs to be explored’. We felt some relief, knowing that the ‘ask’ was more of a scoping project than a concrete reality. With the Podiatry community and profession in general being quite small and ‘niche’, expectations of recruiting were low. However, we felt a sense of determination that surely, we could make this work! From the first exploration of this programme, (Choucri, 2022, p.35) success and opportunity were created with our Spanish counterparts. Due to time and financial constraints, once the partnership between Health Education England (HEE) and the University of Malaga had been established, we had to mobilise the operational aspects quickly.

SPAIN

The International Podiatry

The sequence of the scoping review was organic in that, like dangling a carrot to tease movement out of a donkey, the process itself became more tangible, evolving each step of the way, until I had a fuller and clearer picture of how the pathway should look. I use the word ‘organic’ because, although DGHP in HEE has a great wealth of international recruitment experience, and clear processes in place to guide, it had not been done before for the Podiatry profession. It was tip toeing into the unknown, but we had to try. We did this with transparency and honesty. We advised our stakeholders that this was new territory, and that we had to work together, be patient, and be open to whatever may present itself, be it positive or challenging.

The scoping review was guided by the following questions (not exhaustive):

• Does the Spanish Podiatry degree match that of the UK’s Universities?

• Is there a history of Health and Care Professional’s Council (HCPC) Registration?

• Are there enough candidates for a surplus to be recruited into the NHS?

• Do the candidates have an interest to work in the NHS?

• What is the NHS/UK pull for them to leave sunny Spain?

• Would the NHS Trust’s be interested in partnering with this pilot and be willing to do what it takes to make this a successful pilot programme?

• Will the candidates’ English language be good enough?

• Is the podiatry workforce in Spain in a healthy position that would allow ethical migration to take place?

Each question, each step of the way, we were met with ‘yes’, so we implemented the strategy and kept moving forward. We felt dubious - is this too good to be true? We proceeded with a ‘believe it when we see it approach’.

The Language: Spanner-in the-Works

Quite rightly the HCPC have strict English Language requirements for allied healthcare professionals. We screened the candidates to establish their current level of language. We were able to further gauge this and get a feel for the candidate’s language ability in our whistle stop, planes-trains-and automobiles style interview trip. This led us across the borders of Spain with little sleep but, with satisfied bellies full of Spanish culinary delights, to conduct face-to-face interviews.

We experienced fantastic, proud, hospitality and were pleased to experience some state-of-the-art Podiatry clinics within the universities. The interviews generated

The first cohort successfully achieved the required results and have completed their HCPC applications. Our first candidate should arrive in December, just in time for the Blackpool illuminations!

The middle and lowest scoring cohorts have shown significant improvement in their baseline tests, meaning that they will progress to the next English course to prepare them for their final OET exam. If successful, depending on the HCPC registration process- which can be up to 8 weeks and more in some cases, they should arrive early 2023.

Is it a win? Is it not?

Pilot Programme

doubts but fostered a great sense of confidence for others. We bit the bullet and offered band 5 Podiatry positions to the successful candidates. Collating the initial screening language scores along with successful interviews, we partnered with Occupational English Test (OET) to create custom language learning. In order to give candidates the best chance of success to meet the HCPC standard, candidates were filtered into groups according to baseline ability. This ensured those candidates with the highest scores could access programmes quickly and we hoped this would reduce attrition from the programme. The candidates were in for a long journey, summer arrivals turned into winter and beyond.

Thankfully the organic process, and the risk of what the unknown could bring, was familiar to all stakeholders, and although we lost a few candidates along the way, because they were unable to commit to the study hours required, everyone accepted the plan.

I fast forward to where we are now. With fondness and respect, I think of the candidates, they have put their lives on hold, declined jobs, sometimes felt frustrations at the pace of progress, but have persevered and dedicated themselves to their English courses.

The process, learning, research, relationships, and opportunities that have come from this project are unique, and quite special. From liaising with academics in America, Canada, South Africa, and being invited to attend the ENPODHE (European Network of Podiatry in Higher Education) conference in Belgium; and countless opportunities with so many individuals, have allowed for rich knowledge exchange. This learning and insight could not have been obtained without the appetite to find out who are the people behind the services and institutes, trying to sustain and build up the Podiatry profession.

We have witnessed great passion and learned about innovative ideas, but the international recruitment of Podiatrists is a long-term ambition. The scope for ‘long term’ ideas was not part of the initial brief, but there is absolutely space and enthusiasm for collaboration across the globe.

It struck me that one of the largest barriers for Podiatrists in Europe is scope of practice. Podiatry degrees in the UK, include the use of Local Anaesthetic, theoretically and practically. However LA is not part of some European degrees. The inclusion or development of modules for LA, for international students, could shape the future of podiatry for the benefit of the NHS, and the globe more widely. Consequently, that was why we were unable to collaborate within those countries despite the provision of Podiatry.

The journey has not been easy, but we have all learnt a great deal. The HEE research team has already begun to collect data via interviews and surveys from the Spanish candidates and our NHS partners. The timeline for the evaluation remains flexible according to the English language course and the HCPC registration process, but lessons learnt, and recommendations will be produced in due course.

The good news

We wait with excitement and anticipation for the arrival of our first few candidates who should be joining the NHS at the end of this year. They have successfully submitted their HCPC applications, and their pre-employment checks are under way.

Podiatry International Update, interview with Gabrielle Choucri

By David Holland, BSc, CSci, FFPM-RCPS(Glasg). Chartered Scientist and Podiatry Expert Witness

On page 178 of the first edition of Gray’s Anatomy (Henry Gray, 1858), human ankle articulations are described. The illustration - on the same page - shows a medial (inside) view of a right-sided foot and ankle dissection. The ligaments are notable for their robustness.

Ligaments are strong, flexible structures which connect bone to bone. They are composed of inorganic matter, fibroblasts, and an extracellular matrix (D Amiel, 1984). They allow minimal movement of bone whilst having the ability to resist applied forces so that joint congruency remains intact (Angela Lis et al - 2012).

Under muscular control the foot - shod or unshod - is able to conform to most types of supporting surface. The ligaments ensure that the articulating surfaces forming the joints stay in close proximity, enabling the foot to convert from a flexible structure on landing to a stiff structure for push-off during walking or running (James et al, 1978).

Erasmus Wilson (1842). It is impossible to do a direct comparison with Gray’s. The Quain’s illustration is drawn in a very different style, and the foot is slightly adducted on the long tibial axis, whereas in the Gray’s illustration the observer looks directly at the medial ankle in the sagittal plane.

Plate 29.

The bones and ligaments of the human body: in a series of plates, with references and physiological comments.

Jones Quain and Erasmus Wilson. London, Taylor and Walton. 1842

Gray and Carter only collaborated on the first (1858) edition of Gray’s (Ruth Richardson, 2008). The second edition was published in 1860 - Gray died suddenly in 1861. The meticulous editorial control exerted by the author - which included the illustrations by Carter, and which characterised the first edition, was thereby lost from the second edition onwards.

Page 178. - Gray’s Anatomy

A written account of Carters’ illustrations for the 1st edition of Gray’s confirms that in the main they were an accurate representation of the specimens in front of him.

“In the majority of cases, they (the illustrations) have been copied from, or corrected by, recent dissections, made jointly by the author (Gray) and Dr Carter” (H. Gray,1858).

Other anatomical texts of the time also show ankle ligaments. This next is from Quain’s, by Jones Quain and

Page 411. - Gray’s Anatomy

Descriptive and Applied. Henry Gray. 20th edition. London. Longmans, Green: 1918

(1st edition) Henry Gray, illustrated by DR H.V. Carter MD. London, Parker and Son. 1858.

The previous illustration is from the twentieth (1918) edition of Gray’s. The same illustration is found on page 455 of the twenty-fourth (1930) edition of Gray’s - both published by Longmans, Green of London.

A direct comparison between the first edition (1858) illustration in Gray’s, and this later (1918/1930) illustration is possible because they are both sagittal plane views of a right foot and ankle, drawn in a similar style. The ligaments in the later illustration are less robust. It is also interesting to note that although the illustrations were drawn by different artists, both show a clear medial longitudinal arch, formed by bony architecture and held in place by ligaments. The first edition makes no mention of foot arches at all.

A sagittal plane view of the medial ligaments of the left foot and ankle - in which the ligaments are even more attenuated compared with the 1918/1930 illustration - can be found in more recent editions of Gray’s (2008).

Background to the case-study subject

This case-study concerns the cadaver subject of the 1858 illustration by Dr H.V. Carter MD. Whilst it is impossible not to introduce some conjecture in a case study dependent on an accurate drawing of a specimen which is over a hundred and sixty years old, the author has been careful to explain his opinions and reasoning, and given references wherever possible.

It is important for the reader to note that it is highly likely that this (1858) illustration was drawn directly from a cadaver dissection, and not copied from a previous illustration.

In England in the 1850’s the only legal sources of cadavers for anatomical dissection were paupers and prisoners whose families could not pay for a burial, unclaimed bodies, and the deceased inmates of Workhouses (Anatomy Act of 1832). The cadaver may have been sourced illegally of course - from the euphemistically-named “resurrection men” (they resurrected the newly-buried dead). The dissection is suggestive of a fresh specimen - the cadaver was therefore relatively recently deceased at the time the illustration was made, there being no effective long-term cadaver storage facilities available to Gray or Carter.

The foot and ankle are those of an adult male or female, in good health at the time of death (i.e. with no obvious signs of systemic disease or decline). That points to the source of the cadaver as suicide or grave robbery, rather than the workhouse. The presence of physiological ageing, disease, and/or malnutrition are suggestive of poverty and perhaps the workhouse or prison. There are no signs which would indicate anything other than a healthy body on the specimen. Robust ligaments suggest well-developed musculature - to be expected in a manual worker used to heavy work. In mid-Victorian London manual-labour workers were usually male rather than female.

Robust ligamentous development then, in an ankle and foot in which there is no obvious disease, wasting of the tissues, physiological ageing of the ankle and foot, signs of

malnutrition, or putrefaction, strongly suggest that Carter’s illustration is of the foot and ankle of a male cadaver - either a recently-buried and recently “resurrected” accident victim in which the ankle and foot were undamaged (too many coincidences?), or a suicide, or an unclaimed body from prison or hospital. There is also an outside possibility that the foot and ankle could be from a limb amputation. It is such a good specimen that it is hard to imagine that Anatomists of the time would have allowed it to be destroyed.

The 1858 illustration

If the subject has been identified, as far as is possible to do so, what else can be gleaned from the 1858 illustration by Carter?

Archaic terminology - extant in 1858 - has been usedOs-Calcis for Calcaneum, Astragalus for Talus, and Scaphoid for Navicular, Internal-lateral rather than Medial (pertaining to the Deltoid ligament).

The bony and ligamentous architecture is clear, and anatomically correct. The specimen exhibits robustness of the ligaments in comparison to cadaver specimens today - one explanation for this may be our (largely) modern sedentary living habits compared to our Victorian forebears. Normal growth in bones, ligaments, and muscle is directly affected by use and disuse. Increased use will result in increased tissue mass, decreased use will result in decreased tissue mass.

The Medial Longitudinal (foot) Arch

There is a clear medial longitudinal arch in the 1858 illustration, yet Gray did not think to describe, or make any comment about it.

In general, foot arches gained medical attention only after the first edition of Gray’s had been published. Coincidentally, Darwin’s On the Origin of Species was published in 1859. The possibility raised - of evolutionary development over divine creation - caused a huge furore (M. R. Rose, 1998). The Church were particularly vehement in their support of orthodox Christian teaching. Man being created in God’s image was a main tenet of Christian teaching at the time. Did Gray try to ensure that his cadaver specimen reflected this by showing a developed foot arch which is only present in humans?

The question is almost redundant before it is asked. The 1st edition of Gray’s pre-dated Darwin, and even if Gray had been anti-Darwinian, he died in 1861. He had no involvement with any edition of his book past the second (1861) edition.

As Gray and Carter showed (unwittingly) back in 1858, the shape of the medial longitudinal arch depends - not on muscle - but upon the bony and ligamentous architecture of the foot and ankle (McMinn et al, 1996). Muscular activity affects arch-shape when the subject supports and ambulates. Arch-shape is also dependent upon the supporting surface - a mildly flat foot will appear normal, and function normally on an undulating and/or soft, supporting surface.

A scientific method of analysing the weight-bearing footprint during gait, by means of an inked mat, was initially formally described by Ernest Onimus (1876). The inked mat became an objective tool with which physicians could pronounce whether feet, and gait, was normal or abnormal. Arch-height - too much or too little - became an anomaly (mild cases) or a medical condition (severe cases). The inked mat depended on the subject standing or walking on the mat which was placed on a hard, flat surface in order to capture a satisfactory print. A medical convention - still in widespread use today - was thus established for examining foot arches, and gait - on hard, flat surfaces only.

The subject - a broad evaluation

This evaluation (and the biomechanical evaluation which follows it) is based upon the drawn evidence of a dissection of the right foot and ankle by Dr H.V. Carter (1958), together with what is already known about normal foot function.

The author of this article has assumed that the foot and ankle in question were drawn directly from a cadaver specimen. He has further assumed that the contralateral (left) limb was the same as the right (i.e. not deformed or malfunctioning in any way).

It is likely that the original owner of the 1858 first edition cadaver ankle and foot was male, and that he was a manual worker, in good health at the time of his demise. The sagittal plane view of the dissection exhibits a healthy right foot and ankle.

The robust Deltoid ligament so clearly seen on Carter’s illustration provides a strong tie between the distal end of the tibia and the calcaneus, the anterior and posterior portions of the talus, and the navicular. It ensured that the foot was able to move easily around the long axis of the tibia via the subtalar and mid-tarsal joints, without the arch collapsing. There was no excessive internal rotation of the tibia which is often found in conjunction with a flattened arch (B. Hinterman, 1994). The tibia was therefore able to remain vertical in the frontal plane (i.e. viewed from the front or back) when the subject supported and ambulated.

Vertical tibiae facilitate good posture. This geometry allows simultaneous tri-plane motion (inversion/eversion, adduction/abduction, dorsiflexion/plantarflexion) at the ankle-joint-complex, which comprises the subtalar and tala-crural joints. The tibiae are able to remain vertical in the frontal plane whilst the tai-plane motion occurs (Hagins and Pappas, 2012). The subject could therefore ambulate comfortably - which is to say efficiently and with no effort - on a mix of supporting surfaces. That is important - Victorian London (and surrounding areas) was not wellpaved, apart from a few areas, and certainly not paved and concreted like present-day London.

Biomechanical findings, and final analysis

The adult male subject had normal foot arches, good posture, and good balance. He was probably healthy at the time of death, physiologically well-built, and strong. Stridelength was normal for a man of his height. When standing, his feet were not overly abducted. The feet were capable of the normal sagittal plane components of gait - heel-strike, mid-stance, and toe-off - when walking on flat surfaces. On surfaces which were undulating and/or soft, the feet could conform to the supporting surface comfortably, whilst allowing the trunk to remain erect and balanced.

An observation by the author - Quain’s

The Quain’s of 1842 was not a lightweight text - it took two library staff to manoeuvre it onto the photocopier in order to obtain the image for this article! Gray’s Anatomy was miniature, and pocketable compared to Quain’s, which would explain, at least in part, the instant popularity of the early editions of Gray’s with medical students.

Acknowledgement

I’m very grateful to the Librarian and staff at the Royal College of Physicians and Surgeons of Glasgow for their time and help in sourcing original material for this article, suggesting alternative material when specific, early volumes were not immediately available, and for the use of their photocopying facilities.

REFERENCES:

Anatomy Act - An Act for regulating Schools of Anatomy. The National Archives. (1832).

Amiel D, Frank C, Harwood F, et al.Tendons and ligaments: A morphological and biochemical comparison. J Orthop Res, 1, 257.

Gray Henry. Gray’s Anatomy, Descriptive and Surgical. Pub: John W Parker and Son. 1858.

Gray H, Gray’s Anatomy - preface to first ed (1858).

Ibid. Pub: Longmans, Green, London (1918). Ibid (1930).

Ibid Pub: Churchill Livingstone Elsevier (2008).

Hagins M, Pappas E. Biomechanics of the Foot and Ankle, in Basic Biomechanics of the Musculoskeletal System, 4th (international) ed. Pub: Wolters Kluwer, Lippincott, Williams and Wilkins, pp 228. (2012).

James SL, Bates BT, Osterning L R. Injuries to runners. Am J of Sp Med. 6, 2, 40-49 (1978).

Lis A, Castro C D, Nordin M. Biomechanics of Tendons and Ligaments, in Basic Biomechanics of the Musculoskeletal System, 4th (international) ed. Pub: Wolters Kluwer, Lippincott, Williams and Wilkins 2012 - pp 109/110.

McMinn, RMH, Hutchings RT, Logan BM. Colour Atlas of Foot and Ankle Anatomy, 2nd ed, Pub: Mosby-Wolfe, pp 84 (1996).

Onimus E. “Des deformations de la plante des pieds, spécialement chez les enfants, dans les affections atrophiées et paralytiques de la jambe: Memoire lu a L’Association française pour l’avancement des sciences, dans la seance du 19 aout 1876.” Gazette hebdomadaire de médecine et de chirurgie 34, pp 531-33 (1876).

Quain Jones, Wilson Erasmus. The bones and ligaments of the human body: in a series of plates, with references and physiological comments. Pub: London, Taylor and Walton (1842).

Richardson, R. The Making of Mr Gray’s Anatomy. Pub: Oxford University Press (2008) pp 229.

Rose M J. Darwins Spectre. Evolutionary Biology in the Modern World. Pub: Princeton University Press, pp 31 (1998).

3Mid Wales Diary

David Holland BSc(Hons) Pod-Med, CBiol, CSci, FFPM-RCPS(Glasg).

We grow garlic each year (we eat a lot of garlic), and have found that instead of buying garlic sold specifically to be planted, it is much cheaper to buy jumbo garlic from a market. The garlic is also better quality, being fresh, and as long as your soil is well-fed it is easy to grow. Of course, you can also plant supermarket garlic, but that tends to grow small bulbs. Hay-on-Wye Thursday market is recommended for good, fresh garlic, as is Ludlow market.

I was discussing - with a colleague - the early days (almost 50 years ago) of Chiropodists injecting local anaesthetic (LA) and carrying out minor skin surgery. Not many Podiatrists realise that in the 1970’s we almost lost the right to inject LA solution stronger than 1%. That would have put a firm hold on any thoughts of Chiropodists/ Podiatrists carrying out deep tissue surgery or bone surgery - which was the intention I believe.

In those days we had to be seen to be absolutely aboveboard when it came to hygiene, and aseptic technique. Before each nail surgery session, we (my practice partner and I) washed the walls, floor, and units down with a weak antiseptic solution. For the surgical session - as well as gloves and masks we gowned up with sterile gowns and caps. Drapes were autoclaved as well as instruments. Over the top? Perhaps.

On autoclaves, it was recommended that a pressure-cooker would do at a pinch, and that is what we used in 1975 and 1976, along with autoclave bags and indicator-tape (brown lines appear when the contents are “done”). An autoclave is really just an expensive pressure cooker of course. Please note - I strongly recommend you do not use a kitchen pressure cooker for sterilisation today.

Degree updates for Chiropodists were introduced in the 1980’s. They allowed Chiropodists who were HCPC-registered onto a degree programme which - if the necessary grade was achieved - could be used as a stepping stone onto a Medical or Law degree, or in my case a PhD in Bioengineering which I started but failed to complete. I converted to a research MSc when the ups and downs of life got in the way (it often does with mature students) of doing a part-time PhD whilst holding down a full-time job.

Speaking of research - do you know what our main weakness in Podiatry as a profession is? We have no robust research base. We must therefore hang on to our medical colleague’s (metaphorical) coat-tails for anything other than simple footcare. That was appropriate in the 1970’s - less so now.

We are, I believe, close to unravelling the biomechanics puzzle which has its’ origins in the Root et al paper from 1966. The use of established biological tenets helped, but both authors are or were also Podiatrists, and it is fitting that the peer-reviewed results - when they are published - become part of a Podiatric - not medical - research-base.

Prescription Only Medicines

Continuing Professional Development by Suzanna Vacha MInstChP

Introduction

Podiatrists are specialised practitioners often leading in managing many pathologies of the foot and associated structures. Pathologies may include treatment of infections which may be associated with:

• Wounds

• Blisters

• Diabetic and ischaemic foot ulcers

• Ingrowing toenails

• Mycosis

Podiatrist’s exemptions from the Medicines Act 1968

Prescription-only medicines (POMs) usually are only accessed by medical and independent prescribers as per the Medicines Act 1968. Podiatrists have exemptions from the Medicines Act 1968, giving them access to certain POMs if they have relevant training (1). Podiatrists also have access to a handful of medicinal pharmacy (P) products and General Sales List (GSL) products for sale and supply (1). It is responsible that all Podiatrists keep regularly updated on the medications they sell, supply and administer, as well as those that the patients may be prescribed by a medical professional for specific pathologies such as cardiovascular disease, diabetes mellitus, renal disease etc. This is because medicines evolve and update frequently and can cause serious consequences if incorrectly supplied and administered (2; 3). Therefore, all Podiatrists must stay current through continuing professional education (CPD) to maintain safe and effective practice (4)

A very short history to date of Podiatry

Podiatrists (formally Chiropodists) had access to some medicaments and local anaesthetics in an unregulated capacity

The drive of the Podiatry profession led to the approval of the Chiropodists Board to the teaching of the administration of local anaesthetics (LA), which became an important part of Podiatry training

access to medicines

Two legislations came into operation giving Podiatrists legal access to a handful of P and GSL products for sale and supply. Podiatrists certified in analgesics were given legal access to a small list of LA for administration

Figure 1: A brief history (5; 6; 7; 8; 9; 10; 11; 12; 1; 13)

The Medicines act 1968 came into effect. The legislation excluded Podiatrists from POMs

Recognised Training

Current podiatry training includes POMs certification. Podiatrists who do not have this training can still learn this skill through standalone approved HCPC programmes. To search post registration POM courses, please visit www.hcpc-uk.org/education/approved-programmes.

Podiatrists could access POMs via patient specific directions which were issued by a Doctor

Table 1: POM Annotation (3)

Annotation: Meaning

POM-A Administration of certain POM medications such as local anaesthetic used for minor surgery of ingrowing toenails.

Podiatrists can train as supplementary prescribers

Other ways to access certain POM for supply may be through a written instruction known as a patient group direction from a medical or independent prescriber (14). Trained and HCPC registered Podiatrists who can sell /supply, and or administer certain medicines will have one or more of the HCPC annotations (Table 1). Further training is also recognised in supplementary and independent prescribing.

POM-S The sale/supply of certain POM medications such as antibiotics for the treatment of infection

SP Supplementary prescribing

IP Independent prescribing

This article will examine access to certain medicines by HCPC registered podiatrists and how antibiotics fit into current practice.

Specialist Podiatrists could access a wider rage of medicines via Patient Group Directions

GSL and P medicinal products Podiatrists have access to

All HCPC registered Chiropodists and Podiatrists have exemptions from restrictions on the sale and supply of GSL medicinal products if they are for external use and not veterinary products (1). Table 2 lists certain external use only P medicines. It is worth noting that P products should not exceed the strength stated and must only contain the active ingredient unless otherwise stated (1). It is therefore important for podiatrists to be aware of P products available to them.

Table 2: P medicines and their properties

P Medicine Summary/Category Indications

Potassium permanganate Antiseptic, disinfectant, insecticide, miticide, and algaecide. Antimicrobial action is due to oxygen Infected eczema. crystals or solution being released when it meets the compounds within the skin. It also acts as an astringent (15; 16) Open and blistering wounds. Athlete’s foot. Impetigo (15; 16) Ointment of heparinoid Heparinoid is used to provide soothing relief of superficial bruising through anti-coagulant activity. Bruises, Haematoma, and hyaluronidase Hyaluronidase is an enzyme used to improve absorption (17; 18)

Superficial thrombophlebitis (17; 18)

9% Borotannic complex Antifungal (19) Mycosis (19)

10% Buclosamide Antifungal (20)

Dermatomycoses (20)

3% Chlorquinaldol Antiseptic (discontinued) (21) Iodine alternative (21)

1% Clotrimazole Antifungal (22) Dermatomycoses (21)

10% Crotamiton Antipruritic thought a cooling effect and antiparasitic through an unknown mechanism but Pruritus caused by scabies or toxic to scabies mites (23) sunburn and eradication of scabies (22)

5% Diamthazole Antifungal (Discontinued) (24) Dermatomycoses (23) hydrochloride

1% Econazole nitrate Antifungal (25)

Dermatomycoses (24)

1% Fenticlor Antibacterial and antifungal (Discontinued) (26) Dermatomycoses (25)

10% Glutaraldehyde Fungicides, Antimicrobials, Bactericides. It can be used as a disinfectant (27)

1% Griseofulvin Antifungal (29)

Warts, particularly plantar warts (28)

Dermatomycoses (29)

0.4% Hydrargaphen Anti-Infective Agents (30) As a biocide (29)

2% Mepyramine maleate Antihistamine (31)

2% Miconazole nitrate Antifungal (32)

Symptomatic relief of skin irritation caused by insect stings, insect bites and nettle stings (30)

Dermatomycoses (31)

2% Phenoxypropan-2-ol Antibacterial agent (33) In soaps and cosmetics (32)

20% Podophyllum resin Crude alcohol derived from the roots of the mayapple plant: antifungal (34) Viral warts (33)

10% Polynoxylin Antibacterial (35) As an antiseptic (34)

70% Pyrogallol Acid (Discontinued) (36) Warts and verrucae (35)

70% Salicylic acid Acid (35) Warts and verrucae (35)

1% Terbinafine Antifungal (37) Dermatomycoses (36) 0.1% Thiomersal Mercury-based preservative with antiseptic and antifungal properties (38) Unclear

A new legislation which consolidated and the previous legislations came into force which extended the rights of the Podiatrist known as the Human Medicines Regulations

2006 2012 2013

Law was amended to include a list of POMs for sale and supply including three antibiotics and an expanded list of POMs for administration including Methylprednisolone

Table 3: Injectables (POM-A) (1)

This legislation was amended to enable training and recognition of independent prescribing for Podiatrists

Injectable POM medicine Summary

Adrenaline

Access to POM products for administration

HCPC registered Chiropodists or Podiatrists with POM-S annotation indicate that minimum pharmacology training and training for administering POMs have been completed. It is important to remember that:

• Access and administration shall only be during their professional practice.

• The chiropodist or podiatrist should never combine them unless they have done additional training in independent prescribing. Table 3 highlights the POM products available.

Used for the emergency treatment of anaphylaxis

• Bupivacaine hydrochloride • Lidocaine hydrochloride Local anaesthetics for minor surgery/pain relief / diagnostic injection

• Levobupivacaine hydrochloride • Prilocaine hydrochloride

• Mepivacaine hydrochloride • Ropivacaine hydrochloride

• Bupivacaine hydrochloride with adrenaline where the maximum

Local anaesthetics for minor surgery/pain relief / diagnostic injection strength of adrenaline does not exceed 1 mg in 200 ml of bupivacaine hydrochloride

• Lidocaine hydrochloride with adrenaline where the maximum strength of adrenaline does not exceed 1 mg in 200 ml of lignocaine hydrochloride

Methylprednisolone

Anti-inflammatory steroidal medicine

POM products for sale and supply that are available to Podiatrists

Registered HCPC Chiropodists or Podiatrists with POM-S annotation indicate a minimum training in pharmacology and sale/ supply of POMs has been obtained. POM-S Podiatrists can sell or supply certain POMs via a signed order by the Podiatrist. Sale and supply must only be within the course of their professional practice. POMs must have been prepared for sale or supply in a container elsewhere than where it is sold or supplied. A list of Podiatry exemptions for topical POMs are seen in table 4 and oral POMs in table 5.

Table 4: Topical POMs for Sale and supply (POM-S) (1)

POM-A name Summary/Category Indications

• Amorolfine hydrochloride cream where the Antifungal (39) Onychomycosis (39) maximum strength of the Amorolfine in the cream does not exceed 0.25 per cent by weight in weight,

• Amorolfine hydrochloride lacquer where the maximum strength of Amorolfine in lacquer does not exceed 5 per cent by weight in volume

• Silver Sulfadiazine

Antimicrobials (40)

• Burn wounds • Apical injuries

• Skin graft donor sites • Extensive abrasions

• Short-term treatment of infected pressure sores and leg ulcers (40)

• Tioconazole 28%

Antifungals (41) Onychomycosis (41)

• Hydrocortisone, where the maximum strength of Anti-inflammatory (42) Mild inflammatory skin disorders such as eczemas (42) hydrocortisone in the medicinal product does not exceed 1 per cent by weight in weight.

Table 5: Oral POMs for Sale and supply (POM-S) (1)

POM-A name Summary/Category

• Amoxicillin Antibiotics

Indications

Oral POMs

Firstline management of mild to moderate cellulitis and diabetic foot infections.

• Erythromycin, May include infected: - Wounds / Blisters - Ingrowing toenails - Foot ulcers

• Flucloxacillin - Secondary bacterial infections from injury or skin conditions

• Co-Codamol Pain Short-term patient management, including - Acute MSK injuries

• Co-dydramol 10/500 - Post-operative care tablets,

• Codeine Phosphate

Continuing professional development (CPD)

Using medicine in practice presents high-risk consequences if misused. Therefore, podiatrists must undertake the relevant CPD regarding these products to stay current, continue to practise safely and remain registered (3; 4). The British National Formulary (BNF) is a rigorous publication which updates frequently and allows Podiatrists to keep their knowledge of medications up to date to maintain best practices. National Institutes of Clinical Excellence (NICE) are also important, as they produce a variety of evidencebased, cost-effective recommendations to support and manage specific conditions, including infections. Other updates to be aware of are from local guidelines, professional body updates, conferences etc. The onus is still on the individual podiatrist to be aware of the current literature and changes in the context of use. It is also important to note that Podiatry exemptions are tightly controlled by legislation and can only change if the law changes; changes happen over time as the profession evolves (3).

The use of POM-S products and infection management

Mild or local bacterial infections can arise from a break in the skin; however, this can spread and lead to the life-threatening systemic infection known as sepsis (43; 44). Registered Podiatrists with POM-S annotation on the HCPC will have access to three antibiotics: flucloxacillin, amoxicillin and erythromycin, as per current law. Access to antibiotics can aid rapid first-line management of foot infections such as cellulitis from cuts, wounds and ingrowing toenails to infections arising from diabetic foot problems (45; 46)

Specific Guidelines to be aware of

National guidelines for antibiotics prescription or supply

There are two important national guidelines to help determine the prescription or supply of antibiotics: the NICE NG19 guidelines for diabetic foot problems and the NICE NG141 guidelines for cellulitis which is useful for non-diabetic patients. Both advise first-line oral antibiotics for treating bacterial infections (as long as the severity of the infection does not require intravenous antibiotics) (45; 46). The NICE NG15 for Antimicrobial stewardship recommends that local authorities and local clinical commissioning groups (CCG) provide an antimicrobial stewardship trust-wide approach. This includes local resistance monitoring and the development of local guidelines

for the prescription or supply of antibiotics (47). This is important as local antimicrobial prescribing recommendations by the local CCG may differ from national recommendations.

Local Guidance

The best way to find your local antimicrobial guidelines is through your local CCG website. To help find your local CCG you can search here: www.nhs.uk/Service-Search/other-services/ Clinical%20Commissioning%20Group/LocationSearch/1

Guidelines are updated frequently therefore, try to access guidelines via a webpage for the more recent update and not a browser like Google; this will prevent accidental access to archived material. Once you have found your local CCG guidelines you can find the guidance for “cellulitis and erysipelas” and for “diabetic foot infections” which can help determine which antibiotics are best for first-line management.

For example

The NHS Somerset CCG webpage for Infection Management maintains the most up-to-date information on managing common infections locally to Somerset: https://nhssomerset. nhs.uk/prescribing-and-medicines-management/ antimicrobial/. The Somerset CCG guidelines (true as of March 2022) signpost to professionals the use of Flucloxacillin 500mg1g QDS for 7 days for “cellulitis and erysipelas” and for “diabetic foot infections”, and has the same alternatives (Clarithromycin, Erythromycin and Doxycycline) as seen in national guidelines. However, this may not be the case in every CCG area, so local guidelines are worth checking.

Guidelines on Microbiology testing

NICE recommends microbiology testing as this plays an integral part in antimicrobial management. The UK Standards of Microbiological Investigations (UK SMI) have a set of algorithms and procedures for clinical microbiology. These include the indications and collection guidelines for taking various samples for culturing including superficial wound swabs for soft tissue infections and other tissue samples for suspected bone infection. Recommended guidelines of Podiatric interest are:

• UK SMI B 11: swabs from skin and superficial soft tissue infections

• UK SMI B 14: investigation of pus and exudates

• UK SMI B 42: investigation of bone and soft tissue associated with osteomyelitis

• UK SMI B 39: investigation of dermatological specimens for superficial mycoses

Testing should ideally be done before the supply of antimicrobials where possible unless immediate empirical antibiotics are required (47; 48). This allows the results to determine the most appropriate treatment and streamline therapy to the most affective antimicrobial for that infection (45; 49). The UK Standards of Microbiological Investigations (UK SMI) can be found here: www.gov.uk/government/collections/standards-formicrobiology-investigations-smi.

Guidelines on Prophylaxis

According to the Surgical site infections NICE guideline [NG125] and Prophylaxis against infective endocarditis NICE guidelines [CG64], states routinely prophylaxis use of antibiotics is not required for clean non-prosthetic uncomplicated surgery. People with certain

heart conditions may be more vulnerable to infective endocarditis however, prophylactic antibiotics for patients at risk from endocarditis are not recommended unless tissue infection is evident. Infective endocarditis is an infection of the heart lining mainly caused by bacteria entering the blood and travelling to the heart.

Guidelines Summary

Podiatrists should consider becoming familiar with relevant national and local CCG and NHS Trust guidelines when working within the NHS and independent practice. Local CCG guidelines should be available publicly so if you have problems assessing this information please get in touch with your local NICE trust for assistance. Cultures should ideally be available per NICE, UK SMI and local CGG antimicrobial guidelines. Developing a local Podiatry pathway for your department or practice are recommended for best practice well as supporting CPD. Local NHS trusts are likely to also have policies pathways and medicine management department to support your team if working in the NHS.

Antibiotics of Podiatric Interest

Table 6 looks at NICE NG19 and NG141 guidelines and Podiatry POM-S and the benefits and drawbacks to be aware of. Flucloxacillin is the first line antibiotics for managing bacterial infections of the foot; it is available to Podiatrists with a POM-S annotation and is relatively safe to use in most cases. Alternatives to flucloxacillin are limited for a POM-S annotated Podiatrist. Amoxicillin is not indicated for bacterial infections of the foot unless there is specialist input. Erythromycin is an alternative option but mainly for pregnant patients and is contraindicated in patients with cardiac disease. The alternatives should be available through a PGD, supplementary or independent prescribers.

Conclusion

As a profession, Podiatrists have come a long way and continue to evolve. With access to any medicines, including GSL, P and POMs, Podiatrists must continue to update themselves to provide safe and effective treatment.

In the case of bacterial infection, Podiatrists should be able to:

• Identify levels of infection and determine the urgency of therapy

• Identify the need for oral antibiotics (as long as the severity of the infection does not require admission for intravenous antibiotics).

• Supply antibiotics appropriately depending on medical history and as per current national and local guidelines and pathways, using microbiology testing where appropriate.

• Do not supply antibiotics prophylactically in clean uncomplicated surgery

• Be aware of associated risks, contraindications and the scope and limitations of POM-S access.

• Liaise with a medical or independent prescriber for a prescription that POM-S cannot cover.

Don’t hesitate to contact your local branch or professional body if you want to know more.

Name Podiatric Indication

Flucloxacillin

Amoxicillin

Clarithromycin

Erythromycin

Benefit

Drawbacks

Doxycycline

A first-choice oral antibiotic for cellulitis,

• Available to Podiatrists (POM-S)

• Avoid in patients with hypersensitivity erysipelas and mild-moderate diabetic

• Narrow spectrum (low risk of C-Diff) to ß-lactam antibiotics (e.g., penicillin, foot infection

• OK in pregnancy & breastfeeding cephalosporins) or excipients.

• OK (with caution) in hepatic disease

• Limited bioavailability, generally good in bone but low in joints

No Podiatric induction unless specialist

• Available to Podiatrists (POM-S)

• OK in pregnancy and breastfeeding

• Avoid in patients with hypersensitivity

• Moderate to broad-spectrum (risk of C-Diff) requests / Microbiology

• OK (with caution) in hepatic disease to ß-lactam antibiotics (e.g., penicillin,

• Good oral bioavailability with cephalosporins) or excipients penetration into bone tissues & joint

• Not indicated for first-line diabetic foot infection or cellulitis

• Excellent bone penetration and oral • Avoid in patients with hypersensitivity penicillin allergy or if flucloxacillin is bioavailability to macrolides unsuitable. Indicated for cellulitis,

Alternative first-choice antibiotics for

• Not available to Podiatrists erysipelas&mild diabetic foot infections

• OK in cardiac disease

• Avoid in pregnancy and breastfeeding

• Avoid in severe renal/hepatic impairment

• Broad-spectrum (risk of C-Diff)

An alternative oral antibiotic for penicillin

• Available to Podiatrists (POM-S)

• Avoid in patients with hypersensitivity allergy in pregnancy. Indicated for cellulitis, • OK in pregnancy and breastfeeding to macrolides erysipelas and mild diabetic foot infections

• Broad-spectrum (risk of C-Diff)

• Low bone penetration

• Increased risk of cardiac events in those with cardiac disease

Alternative first-choice antibiotics for • Good oral bioavailability with

• Avoid in patients with hypersensitivity penicillin allergy or if flucloxacillin is penetration into bone tissues& joint to tetracyclines unsuitable. Indicated for cellulitis, • OK in cardiac disease

• Not available to Podiatrists erysipelas & mild diabetic foot infections. • OK (with caution) in renal disease

• Avoid in pregnancy and breastfeeding

REFERENCES

1. UK Statutory Instruments. The Human Medicines Regulations 2012. Legislation.gov. uk. [Online] 2012. [Cited: 5 February 2022.] https://www.legislation.gov.uk/uksi/2012/1916/ contents.

2. BNF. About. BNF.org [online]. [Online] 2022. [Cited: 5 February 2022.] https://www.bnf.org/ about/.

3. HCPC. Our professions’ medicines and prescribing rights [online]. HCPC. [Online] 2021. [Cited: 5 February 2022.] https://www.hcpc-uk.org/standards/meeting-our-standards/scopeof-practice/medicines-and-prescribing-rights/our-professions-medicines-and-prescribingrights/.

4. —. Our standards for CPD [online]. HCPC. [Online] 2018b. [Cited: 5 February 2022.] https:// www.hcpc-uk.org/cpd/your-cpd/our-standards-for-cpd/.

5. Tollafield, D. When did podiatrists first use local anaesthetic? [online]. Consulting Foot Pain. [Online] 2021. [Cited: 7 February 2022.] https://consultingfootpain.co.uk/when-didpodiatrists-first-use-local-anaesthetic/.

6. Rising from the ranks. Potter, M. January/February, 2021, The Podiatrist, pp. 36-39.

7. UK Statutory Instruments. Medicines Act 1968. Legislation.gov.uk. [Online] 1968. [Cited: 7 February 2022.] https://www.legislation.gov.uk/ukpga/1968/67/enacted.

8. Podiatry. Klenerman, L. 1, 1991, Journal of Bone and Joint Surgery, Vols. 73-B, pp. 1-2.

9. Department of Health. Engagement exercise | Podiatrists. GOV.UK. [Online] 2010. [Cited: 7 February 2022.] https://assets.publishing.service.gov.uk/government/uploads/system/ uploads/attachment_data/file/216033/dh_119374.pdf.

10. UK Statutory Instruments. The Medicines (Pharmacy and General Sale— Exemption) Order 1980. Legislation.gov.uk. [Online] 1980a. [Cited: 5 February 2022.] https://www. legislation.gov.uk/uksi/1980/1924/made.

11. —. The Medicines (Prescription Only) Order 1980. Legislation.gov.uk. [Online] 1980b. [Cited: 7 February 2022.] https://www.legislation.gov.uk/uksi/1980/1921/contents/made.

12. —. The Medicines for Human Use (Administration and Sale or Supply) (Miscellaneous Amendments) Order 2006. Legislation.gov.uk. [Online] 2006. [Cited: 5 February 2022.] https:// www.legislation.gov.uk/uksi/2006/2807/contents/made.

13. —. The Human Medicines (Amendment) Regulations 2013. Legislation.gov.uk. [Online] 2013. [Cited: 6 February 2022.] https://www.legislation.gov.uk/uksi/2013/1855/made.

14. NICE. Recommendations | Patient group directions | Guidance [online]. MPG2. [Online] 2017a. [Cited: 6 February 2022.] https://www.nice.org.uk/guidance/mpg2/chapter/ Recommendations.

15. Healthline. How Do I Use Potassium Permanganate? Healthline. [Online] 2018. [Cited: 10 September 2022.] https://www.healthline.com/health/potassium-permanganate-uses#uses.

16. National Center for Biotechnology Information. PubChem Compound Summary for CID 516875, Potassium permanganate. National Center for Biotechnology Information. [Online] 2022. [Cited: 10 September 2022.] https://pubchem.ncbi.nlm.nih.gov/compound/Potassiumpermanganate.

17. EMC. Hirudoid Cream. Medicines.org.uk. [Online] 2019. [Cited: 9 September 2022.] https:// www.medicines.org.uk/emc/product/1341/smpc#gref.

18. Drugbank. Hyaluronidase. go.drugbank. [Online] 2021. [Cited: 10 September 2022.] https://go.drugbank.com/drugs/DB14740.

19. Thorp, C M. Pharmacology for the Health Care Professions. Oxford : Wiley-Blackwell, 2008.

20. National Center for Biotechnology Information. Compound Summary for CID 68466,

Buclosamide. PubChem. [Online] 2022. [Cited: 11 September 2022.] https://pubchem.ncbi. nlm.nih.gov/compound/Buclosamide.

21. —. Compound Summary for CID 6301, Chlorquinaldol. PubChem. [Online] 2022. [Cited: 11 September 2022.] https://pubchem.ncbi.nlm.nih.gov/compound/Chlorquinaldol. 22. BNF. Clotrimazole. BNF. [Online] 2022. [Cited: 11 September 2022.] https://bnf.nice.org. uk/drugs/clotrimazole/#other-drugs-in-class.

23. Drugbank. Crotamiton. Drugbank. [Online] 2022. [Cited: 11 September 2022.] https:// go.drugbank.com/drugs/DB00265.

24. Inxight drugs. DIAMTHAZOLE DIHYDROCHLORIDE. Drugs [Online] 2011. [Cited: 11 September 2022.] https://drugs.ncats.io/drug/3LF09TBB5W#:~:text=Description, associated%20with%20neuropsychiatric%20adverse%20reactions..

25. WebMD. Econazole NITRATE Cream - Uses, Side Effects, and More. WebMD. [Online] 2022. [Cited: 11 September 2022.] https://www.webmd.com/drugs/2/drug-11726-592/econazoletopical/econazole-cream-topical/details.

26. Inxight Drugs. FENTICLOR. Drugs. [Online] 2022. [Cited: 11 September 2022.] https:// drugs.ncats.io/drug/D61659OVD0.

27. National Center for Biotechnology Information. Compound Summary for CID 3485, Glutaraldehyde. PubChem. [Online] 2022. [Cited: 11 September 2022.] https://pubchem.ncbi. nlm.nih.gov/compound/Glutaraldehyde.

28. BNF. Glutaraldehyde. BNF. [Online] 2022b. [Cited: 12 September 2022.] https://bnf.nice. org.uk/drugs/glutaraldehyde/.

29. —. Griseofulvin. BNF. [Online] 2022c. [Cited: 11 September 2022.] https://bnf.nice.org.uk/ drugs/griseofulvin/#indications-and-dose.

30. National Center for Biotechnology Information. Compound Summary for CID 16683105, Hydrargaphen. PubChem. [Online] 2022b. [Cited: 12 September 2022.] https:// pubchem.ncbi.nlm.nih.gov/compound/Hydrargaphen.

31. EMC. Anthisan Bite and Sting 2% w/w Cream. EMC. [Online] 2022. [Cited: 12 September 2022.] https://www.medicines.org.uk/emc/product/1633/smpc.

32. WebMD. Miconazole Nitrate 2 % Topical Cream - Uses, Side Effects, and More. WebMD. [Online] 2022b. [Cited: 12 September 2022.] https://www.webmd.com/drugs/2/drug-3841787/miconazole-nitrate-topical/miconazole-topical/details.

33. National Center for Biotechnology Information. Compound Summary for CID 92839, 1-Phenoxy-2-propanol. PubChem. [Online] 2022b. [Cited: 12 September 2022.] https:// pubchem.ncbi.nlm.nih.gov/compound/1-Phenoxy-2-propanol.

34. Dermnet. Podophyllotoxin. Dermnet. [Online] [Cited: 12 September 2022.] https:// dermnetnz.org/topics/podophyllotoxin.

35. WikiDoc. Polynoxylin. WikiDoc. [Online] 2022. [Cited: 12 September 2022.] https://www. wikidoc.org/index.php/Polynoxylin.

36. Lindsey Ebbs Podiatry - Podiatry Insights. Verrucae and Warts. Foot Check. [Online] 2022. [Cited: 12 September 2022.] https://footcheck.co.uk/podiatry-insights/verrucae-andwarts/.

37. NHS. Terbinafine. NHS. [Online] 2022. [Cited: 12 September 2022.] https://www.nhs.uk/ medicines/terbinafine/.

38. Wikipedia. Thiomersal. Wikipedia. [Online] 2022. [Cited: 12 September 2022.] https:// en.wikipedia.org/wiki/Thiomersal#Uses.

39. BNF. Amorolfine. BNF. [Online] 2022. [Cited: 12 September 2022.] https://bnf.nice.org.uk/ drugs/amorolfine/.

REFERENCES

We are proud to announce our partnership with Community trade union, we believe a good modern trade union is not only essential to a positive and safe workplace but more importantly gives self-employed workers like us a strong and collective voice.

Community is a proud champion of the over four million strong self-employed and freelance community across the UK, including chiropodists and podiatrists.

For many people, self-employment is the answer to finding a good work-life balance and can be extremely rewarding. It can also mean longer hours, less pay, more worry about your finances and employment. By partnering with Community we want to give you that help, as well as campaign on the issues that matter to us as a sector.

have:

Advice and support

Community union provides advice and support through their service centre of expert legal advisors, dedicated to supporting members with any questions or help members may need.

Whether its advice on client relations, self-assessment tax returns, debt recovery and late payments, welfare benefits, discrimination and health and safety issues – Community can help.

Campaign and organise

By building and strengthening our collective voice as part of Community, we can ensure our voices are heard. Community is a proud campaigning union and the strength of their membership paired with their political affiliations means they can take the issues you care about and make sure they are heard across the UK at every level.

Pay and conditions

Community can support you at work with individual representation to get the best deal, and secure fair treatment and fair pay, including chasing your unpaid invoices.

Education and training

By becoming a member of Community, you can access bespoke education and training opportunities that works well for freelancers and the self-employed. This includes access to hundreds of free online courses to develop key business skills, regular online webinars to help with negotiating, securing better pay, completing your tax returns to confidence courses.

Discounts and savings

money on a range of leisure, insurance and retail products through Community’s discounts on a range of professional and personal products and services.

Recession-proofing your business

Being in business has certainly been tough over the last few years. Every generation has its challenges, but since covid struck at the beginning of 2020, we certainly seem to have had more than our fair share. There is nothing but doom, gloom and scaremongering on every news report, and with a government that can’t seem to agree on the best way to resolve the country’s financial problems (at the time of writing at least!) there doesn’t seem much to look forward to.

Kate Harrison MInstChP, DChM

However, I think that we are in a very fortunate position - there is a nationwide shortage of podiatrists, and to a lesser extent, FHPs, AND there is increasing demand for our services, given the pressures on the NHS.

It is also important to remember that not everyone is affected by the cost of living crisis in the same way. Martin Lewis has quoted that a whopping £190 billion pounds of savings were built up during the worst of the pandemic so whilst this is undoubtedly a worrying time for a large proportion of the population, there are still people with money to spend.

But, whilst that may be true, I am sure that many of us will be seeing a drop-off in phone calls, diaries that were booked solid for several weeks now looking holey which can be a great cause of anxiety.

So what can we do to offset these problems? To ensure that our businesses survive and come out the other side stronger than ever? Although it might seem as though the situation has no end in sight, history shows us time and again that all economic downturns are followed by an uplift. So building strong foundations now will stand you in good stead when the good times return.

look after our existing clients

A few ideas to look after the clients you already have:

Offer a payment plan

Instead of paying at the time of the appointment, why not offer your patients a monthly payment plan to help spread the cost. A company like GoCardless makes it very straightforward to set up direct debits for different treatment options. We work out what they would pay us over the average 12 month period and then divide that figure by 12. We then round down the monthly sum to make it better value for them and offer 10% off products as an added incentive. So while we take less than if they pay as they go, we benefit from the regular payments appearing in our account, minimal administration and less time taken at the reception desk.

Keep in touch

If you use practice management software, this is very easy to do, if not, it will be a case of going through your record cards. We pull off our ‘Missed Appointment’ list, and ‘Clients without upcoming appointments’ list and give people a call. Whilst automated email generation websites, such as CliniqApps, can be time-saving, you will probably get a much better response by talking in person. We use a script along the lines of “Hello, Mrs XX, this is Kate calling from XXX. It’s just a courtesy call to see how you’re doing and if there is anything we can do for you.”

This is a great way to fill some gaps in your diary, and can really brighten the day of someone stuck at home.

If you have a large database, an easier option could be to send a bulk SMS message. Using a website like Text Magic, this can be a cost effective way to reach a lot of people and

has a better response rate than email. Something along the lines of “Hi XX, this is Kate from XXX. Is there anything I can do for you right now?”. Short and to the point with no hard sell.

Send email newsletters

This is another great way to stay in touch with your patients. We send them on a monthly basis, keeping them short and chatty with a mix of foot care tips, clinic news and promotion of a service. This can be daunting to set up yourself, but paying a local social media expert to set you up with a template and give you some basic training is money well spent.

Attracting new clients

You may need to cast your net a little wider to find new clients during a recession, particularly if you service a less affluent area.

You also need to stand out from the crowd. So many printed ads just have a list of all the usual things we treat: corns, callus, toe nail trimming, etc, plus a phone number. Here are a few ideas to help you stand out:

• Include a photo and your name, don’t just use your trading name. People want to know who they’re contacting before they pick up the phone.

• Can you offer online bookings? Most PMS systems will have this facility and makes it super easy for potential patients to get themselves booked in at 11pm when they’re scrolling on their phone.

• Is there something that you love treating? Promote this above the other stuff. You will still get bookings for the full range of foot problems, but this will help set you apart and appeal to people with that particular problem.

• Can you offer something extra? For example, nail bracing, wax treatments, massage with organic foot care products?

Investing in your business

This might seem like a counter intuitive thing to do during a recession, but this can really put you in a stronger position to ride out the storm. There are a number of ways you can invest for a brighter future:

Social media support

If social media fills you with dread, why not book a session with an expert who can show you how to plan, create and schedule your posts as painlessly as possible. Get your face seen and your name known.

Accounting/bookkeeping support

Similarly, if trying to balance your books is your least favourite job of the week / month / year, take on an expert. A good bookkeeper or accountant will save you time and money. If it’s not your area of expertise, pass it over to someone else. Free your time up to do what you are good at, and what brings in the money.

Free (or nearly free) support

Not all support needs to be paid for. Investigate all your local options:

Invest in technology

Swift machines, gait analysis equipment, shockwave, laserdepending on your scope of practice, there is some great kit available that will enable you to offer advanced podiatry to your patients.

If spending thousands of pounds seems scary, investigate what the cost would be over 5 years. How many clients would you have to see each month to cover that cost? Probably only one or two if you set your prices accordingly.

One person spending £300 will mean that you don’t need to worry if 2 or 3 patients cancel their routine appointments.

Preparation is key. Plan ahead. Make sure EVERY client that comes into your clinic knows about this amazing new treatment that you will soon be offering. Put it in your newsletters, social media, and hand out leaflets. Tell the local paper - they are always on the lookout for good news stories!

Cherry pick a few clients to treat first, at a reduced rate if necessary, to build your confidence. Ask them for testimonials. Offer payment packages to make it more affordable.

Invest in support

Business Coaching

It might seem an extravagance, but I for one have found it invaluable. A fresh, unbiased, non-judgemental pair of eyes cast over your business will spot things that you can’t see because you are right in the middle of it. A good coach will help you prioritise, keep you accountable and cheer you on.

You trained as a clinical professional - running a business is a whole different ball-game.

Why try and figure it all out yourself? And whilst you will probably learn from any business coach, you will get more bang for your buck if you use someone within the Podiatry field. There are a few out there, do some research and find someone you can click with.

• Contact your Local Enterprise Partnership who can put you in touch with free training in a whole host of areas.

• Your Local Chamber of Trade or Commerce (there may be a small annual fee, but it’s a great way to network and get known in your local area)

• Other local networking groups. Most allow you to attend as a visitor before you enroll.

• Podiatry / FHP FaceBook groups. Some are more supportive than others, but can be a great way to pick the brains of a larger group.

• Join your town’s local FaceBook group. Comment when it is appropriate to do so and help support other local businesses. They are then more likely to return the favour.

• There are a host of free podcasts available which are a great way to expand your horizons.

Look for clinical AND business related ones. It can be really interesting to hear about businesses outside of the healthcare world. We can learn a lot from a different perspective.

• And of course, your local IoCP Branch who are always there for moral support and will probably have a fair few years experience under their collective belt.

My Role as a Paramedic in Primary Care

Gary: Si, how did you first get the idea to work in primary care? What got you started?

Si: I’ve always looked for challenges throughout my career, whether it’s working as a Royal Marines commando paramedic managing trauma in Afghanistan or working as a paramedic practitioner within the emergency department. It was in 2015 during a home assessment for a frail elderly couple with many medical and social needs. I was working as an Emergency Care Practitioner (Specialist Paramedic) for SWAST. I ended meeting an innovative GP who liked the autonomous practice and holistic care being provided. He offered me a job to do the same role but with greater opportunities to develop further with support and mentorship. Beacon Medical Group would allow me to use greater levels of autonomy and increase my scope of practice and push the boundaries of my profession. I would have greater input in patient care through diagnosis, treatment, and recovery.

Gary: What were the biggest challenges you faced in your first few months in this new environment?

Si: We did not know how to indemnify my practice. We spoke with numerous insurance companies and professional bodies and the regulator, HCPC. We asked the College of Paramedics, the General Medical Council and even had a ‘Pulse’ journalist research paramedics in primary care but we could not find any other primary care providers who employed a paramedic within the UK at that time. With regards to training and development there was little in the way of useful structure or frameworks available, so we developed our own (still used today).

Additional challenges included other health care providers and staff not understanding the versatility of the paramedic and, still the need to address the misconceived idea that paramedics were just ambulance drivers. We kept hearing phrases like ’you can’t do that, you’re just a paramedic’. We also had issues with secondary care refusing referrals. We launched a campaign with a nurse practitioner and pharmacist about the advantages of right care, right place, right time and I have spoken multiple times at the national best practice conferences about my role which was seen as a catalyst for paramedics within primary care.

Gary: I believe the practice fairly rapidly identified you as its resuscitation lead, which seems a good use of a paramedic to me. How did that work out?

Si: This was good for me as a former lecturer practitioner at Plymouth University where you and I first met. It meant that I could keep my teaching up-to-date and it saved the practice money by arranging training ‘in house’. It was especially useful to create realistic primary care scenarios to make the learning authentic. I’ve since handed the role over to one of our ACPs (also a paramedic) but I’m still keen, when time allows, to get involved.

Gary: Tell us about your educational role in the practice and how that developed.

Si: Initially, I thought this role was to keep me quiet(!), however this was before Health Education England (HEE) had really addressed the issue of paramedics working at an advanced level in primary care. We created our own developmental framework for the urgent care team.

Gary Strong MCPara, National CPD Lead, chats to Simon Robinson MCPara, Advanced Clinical Practitioner, Paramedic, Partner at Beacon Medical Group in Devon.

This unifies our team of paramedics, physiotherapists, nurses and a paediatric nurse working at the advanced level. My aim was for the practitioner to follow the same development framework allowing for differences in training and backgrounds but to keep their professional identity. This was linked to HEE recommendations but designed specifically for primary care and recognising all healthcare professionals working at the advanced level in a simple format.

Currently, we are also supporting 18 undergraduate paramedic students with placements, showing them the diversity of presentations encountered and skillsets needed for primary care. I have also designed and implemented training courses including paediatric fever courses supporting efficient, safe patient management.

Gary: What do you find most rewarding about your role?

Si: The variety of the role and patient presentations of all ages. There is always something new to learn. Primary care undertakes 90% of all NHS work but receives 10% of the budget. It has been a really tough last couple of years. There has been 85% changeover of my team with some of our staff returning to the ambulance service and secondary care due to the stresses and workload. At times, I’ve found it the most stressful job, beating all previous roles. Primary care is not for everyone.

However, putting a new multi-disciplinary team together and supporting their development is really rewarding. It’s great to see them grow as individuals and the team grow in confidence. You wouldn’t pick a rugby team full of scrum halves and expect the team to play well… this diversity of background really does work. I have a highly-motivated team with a multitude of experiences gained from their various backgrounds and professions.

Gary: You have recently become a practice partner. How did that come about, and what difference has it made to your working life?

Si: I was asked, then voted in by the other partners. As mentioned, Beacon has a very contemporary outlook and the partnership wanted other professions as partners as well as GPs. I have always been keen to push the boundaries to influence positive change to improve service delivery. I try to use my enthusiasm to help support others within the group and externally supporting with ACP and team development as an example.

My team manages around 30% of the practice’s daily contacts. I am passionate about how, as a team we manage patients and support with patient flow. This is reflected in our low emergency

department admission rates due to our improved access to triage and treatment abilities via the phone, text or e-consults. Being a partner is a huge commitment as along with the other partners I share responsibility for 200 staff and the provision of health care for approximately 43,000 patients. It will allow me to have a greater input in shaping our work force to meet the needs of the local population.

Gary: This seems like an exciting time for paramedics in primary care. What do you think the future might hold, and what kind of leadership skills do we need to develop as a profession in primary care?

Si: The profession is so universal now. As generalists, with the right support and development, we can turn our hands to most health care needs. Within primary care we have paramedics learning to run joint injection clinics, minor surgery clinics, women’s health clinics, paediatric clinics and much more. These are exciting times to be a paramedic in primary care.

The opportunities are endless. I was once told: ‘A paramedic in a GP surgery? This won’t work, you will never be able to prescribe for a start’. We need to keep pushing forward and challenge legislation that holds us back. Don’t be afraid to say ‘Why? I can do that’. Push for courses such as prescribing. Volunteer to project manage and take ownership.

Gary: What would be your advice to any recently registered paramedics who are keen to work in the area?

Si: Use the four advanced practice pillars as a framework towards development. Learn about the potential next stages of patient care after your assessment. Manage risk and treat the patient. Do not attempt to ‘shoehorn’ patients to guidelines. Get placements in primary care, this role is not for everyone. Make sure any job opportunities come with training and development and check the versatility of the role and support being offered.

Gary: Thank you Si.

The Institute of Chiropodists and Podiatrists are proud to offer our members comprehensive, market leading support and unrivalled insurance packages, tailored to suit your needs! Including insurance to colleagues in the Republic of Ireland, we’ll never leave you stranded!

• Continuing Professional Development Support – Guidance and assistance with the members continuing professional development portfolio for HCPC audits.

• Business Support and special discounts from our trade and advice partners

• Access to the members area of the Institute website including a private discussion forum

• Member rates on all our CPD courses and access to our free CPD webinars!

• Join the IOCP ‘Find a practitioner’ service to promote your business to members of the public finding the IOCP website through search engines.

• Network through local member branches, situated throughout the United Kingdom and the Republic of Ireland for peer support and CPD events

• Access our confidential advice service, including advice from the IOCP medicines and procedures panel (MaPP) on the use of drugs and therapeutics as well as appropriate podiatric procedures.

Head to our website: www.iocp.org.uk or contact our team: info@iocp.org.uk

Sussex News

I

It was great to see Valerie and everyone else face to face once again. It’s been a long time. Zoom meetings aren’t everybody’s “cup of tea” as many groups have found out! I for one look forward to getting back to some sort of normality in the near future.

So, thanks for all you have done Valerie and all the best for the future!

Goble

would like to thank former members of the Sussex Branch who recently gathered to wish Valerie Probert-Broster a happy retirement after 20 years running a practice in Plumpton and holding the role as Branch Chairman.

Clive

Former Branch Chairman Sussex Branch

SVTS Chiropody Drill repair and sales

We offer an excellent competitive and efficient repair service for all makes of Podiatry/chiropody Nail drills. Berchtold, Hadewe, Suda, Footman, Podiacare, Podo Tronic and Podo Pro EVO-30,40&50 drills. We sell Berchtold S35/ S30, Hadewe, EVO 30,40.50 Dust Bags from £1.25 – £2 each. WE ALSO BUY UNWANTED DRILLS.

Unit 255 Stratford Workshops, Burford Road, London E15 2SP Contact us on 0208 5190044 or www.chiropodydrillrepair.co.uk

Chiropodist/ Podiatrist required in Heswall, Wirral

We are situated in Heswall, Wirral. We are a busy multi-discipline clinic in the heart of a thriving village. Our clinic is exceptionally busy with five chiropodists and full-time reception staff. The position is offered with hours to suit applicant.

The successful candidate must be personable, not afraid of being busy and have great attention to detail. In return they can earn £200-300 per day. This is a self-employed position and payment is on a fee sharing basis.

Tel: 01513 429665 for further information

Please note: all products advertised in the Podiatry Review and on the Website are accepted by the Institute of Chiropodists and Podiatrists on the basis of a commercial advertising service and purchasers should carry out their own assessment as to the suitability of such products for their own specific needs. Acceptance of the advertisement by the Institute does not imply our endorsement or approval of the product. To place an advert here or for more information please email julie@iocp.org.uk

JANUARY 2023

8 Wolverhampton Branch Meeting & AGM

At 10am at the Reading Rooms, Market Street, Penkridge, Staffs. ST19 5DH.

Contact: David on 01785 716607 or email djcollett@hotmail.co.uk

8 Cheshire, North Wales Branch Meeting and AGM

At 10.00am at Harvest Court, 8 Harvest Lane, Moreton. Wirral. CH46 7UU

Speaker Mr Phil Ellis, Councillor “How to deal with our patients when they received bad news”

Contact: Michele on 07766 700027 email missminou@hotmail.co.uk

25 London AGM Meeting

At 7.30pm via Zoom. Contact Sarah on 07790 717833 or email footwoman@gmail.com

MARCH 2023

24 Prescrption Orthoses course – Staffordshire University

DIARY OF EVENTS

SOUTH WALES AND MONMOUTH BRANCH

Meetings are taking place via Zoom, members who would like details of the next meeting and wish to attend please contact Esther on 01656 740772 or email estherdanahar@ yahoo.co.uk

Please email julie@iocp.org.uk with information about Branch Meetings whether face-to-face or via Zoom etc. Keep your Branch members up to date so they can attend.

REFERENCES CONTINUED FROM PAGE 38

40. —. Silver sulfadiazine. BNF. [Online] 2022. [Cited: 13 September 2022.] https://bnf.nice. org.uk/drugs/silver-sulfadiazine/.

41. —. Tioconazole. BNF. [Online] 2022. [Cited: 13 September 2022.] https://bnf.nice.org.uk/ drugs/tioconazole/.

42. —. Hydrocortisone. BNF. [Online] 2022. [Cited: 12 September 2022.] https://bnf.nice.org. uk/drugs/hydrocortisone/.

43. Duda, K. Bacterial Infections: Symptoms, Causes, Diagnosis, and Treatment [online]. Verywell Health. [Online] 2021. [Cited: 5 February 2022.] https://www.verywellhealth.com/ what-is-a-bacterial-infection-770565.

44. NICE. Recommendations | Sepsis: recognition, diagnosis and early management | Guidance [online]. NG51. [Online] 2017b. [Cited: 5 February 2022.] https://www.nice.org.uk/ guidance/ng51/chapter/Recommendations.

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