Involuted Nails

Here at the Footcare Clinic, we often  hear people complain of ingrown toenails. Sometimes they are ingrown, but more often they are 'involuted'.

Involuted nails can be very painful as the two sides of the nail curl towards each other pressing into the skin at the edges of the nail. Looking at the nail from the end of the toe, the nail has a profile similar to a staple, as in the picture below. Sometimes the curvature of the nail is so great that the tip of the nail curls in a circle causing the skin to be pinched. They usually they don't break the skin or become infected but they can become painful due to pressure.

It doesn't take a wild imagination to understand the problems that nails like this can cause. The nipping action of the nail makes them feel very tight and any added pressure on the top of the nail from footwear for example, can cause friction in the nail sulcus and lead to a build up of hard skin. As hard skin develops at the nail edges, the amount of pressure increases and this makes the toes more painful.  

Very often, the shape of the nail increases the total depth of the toe, necessitating a much deeper toebox in footwear. With insufficient room in the toebox, pressure on the nail causes the nail plate to thicken up, leading to increased pressure, more hard skin in the sulcus and even corns. So the circle of events continues.

Some  people with involuted nails never have any problems with them, but the liklihood of the nail pressing on the skin and becoming sore is much greater than in people with flatter nails.

The problems really occur when the pain causes people to cut their nails back in an attempt to gain relief. Sometimes this works, but only for a short period of time. Occasionally this 'self care' can leave small spikes of nail which can then penetrate the skin and  become embedded, causing an infection and an ingrown nail, ( onychocryptosis)

With involuted nails, it is important to cut them straight across the natural line of the nail. Cutting away at the sides often leads to other problems. It is also important to ensure there is sufficient depth in the toebox of a shoe, to prevent excessive downward force on the nail. Professional help is always advised.

If this becomes a long standing problem, then a simple procedure known as a Partial Nail Avulsion can help. This involves removing the side or sides of the offending nail permanently so that the nail that is left behind is flatter, easier to manage and has no curved bits to dig into the sides. 

Restless Legs

"I'm not sleeping well"

"Once my legs start to jump, I know I won't get any peace"

Have you ever felt this way?

Strangely, people tend to mention this whilst in the podiatrist's chair as a topic of conversation, rather than visit their GP. They feel it is something they should tolerate and not "worth bothering" their doctor with. Some even feel they will be laughed at.

It is called 'Restless Leg Syndrome'  and was first described by Ekbom in 1944 as occurring mainly at rest and included 'sensory symptoms'. Legs jump and twitch and are sometimes painful. Sensations similar to electric shocks have been reported, as have crawly and fizzing sensations. All symptoms are worse at night and are improved with exercise. Some people find that staying still for any length of time is difficult and they avoid trips to the theatre, cinema or even travelling by car or plane.

It commonly disrupts sleep causing tiredness through the day and may even lead to depression. Many adults report that their symptoms began in childhood and studies have proved that nearly 2% of children have significant symptoms which are often dismissed as 'growing pains'.  

A strong genetic link has been identified by Daniel Picchietti, a professor of paediatrics in the University of Illinois College of Medicine; who reported that more than 70% of children with the condition have at least one parent with symptoms.

Sometimes it can be secondary to another condition, such as iron deficient anaemia, magnesium deficiency or pregnancy.

Some people have found the condition improves by walking and stretching; taking warm baths; yoga and relaxation; reducing alcohol and caffeine intake. Eating foods rich in magnesium has helped in many instances.  

Ignoring the symptoms may cause stress and an inability to cope. Lack of sleep can cause irritability  and lead to inevitable problems at work.

But there is no need to suffer in silence as your G.P. can help.

For more advice about podiatric issues, click here.

Gout

Gout has a very long history. Hippocrates (c. 460 – c. 370 BC) identified gout (Greek: podogra) as different from other forms of arthritis. It is a member of the family of arthritides, it is inflammation of joints, but it differs because it is caused by the build up of monosodium urate crystals. These are often referred to as uric acid.

Two very brave gentlemen, Faires and MacCarty, investigated the role of these crystals in gout during the 1960's by injecting their left knee joints with them. Within four hours they were experiencing violent attacks of gout and the pain was excruciating.

Surveys have found that gout is an agonising and incapacitating form of  arthritis which "negatively affects daily activities, lifestyle and work "  (N. Lawrence Edwards, MD, Professor of Medicine, Rheumatology and Clinical Immunology, University of Florida College of Medicine) Flare ups are sudden, intense and last an average of 8 days.

Gout sufferers usually produce too much uric acid or are unable to get rid of the excess produced by their bodies. The uric acid forms needle-like crystals which are deposited in the joints. It typically affects one joint, often the big toe (62% of cases) and it can also cause feverish symptoms.

The presence of the crystals trigger an immune response, leading to  inflammation;  joint swelling, pain, heat, redness and stiffness. In some patients the condition can become chronic causing repeated flare ups, joint damage, kidney stones and kidney disease.

Gout tends to run in families, affects about 1% of the population and, it is more common in men than women.

For a long time, alcohol has been considered a trigger for gout attacks.  Little research has been carried out in this area, although one recent study on 197 subjects found that alcohol can  trigger recurrent gout attacks, usually occurring within 24 hours of consumption.

Dehydration is another factor often associated with gout. During periods of increased perspiration, less uric acid is excreted and so at times of high humidity and high temperatures, those prone to gout should drink lots of water. 

A very interesting paper in 2007 (Arthritis Rheum. 2007;56:2048-2054,) connects a reduced incidence of recurrent gout attacks in men over the age of 40 with coffee drinking,

"A study of a nationally representative sample of US adults showed that coffee consumption was associated with a lower serum level of uric acid and a lower frequency of hyperuricemia."

Many gout patients are managed with Allopurinol, the urate lowering drug, with varied success. Allopurinol will not work during an attack as it is not a painkiller and, it may take up to 3 months to be effective against another episode.

If you are unfortunate enough to suffer with gout, one of the most painful conditions known, please reduce your alcohol intake and  increase your fluid levels, especially in hot and humid weather.  Your GP can prescribe painkillers for use during an attack; it's worth paying a visit.

For more information on Podiatry, click here: The Footcare Clinic

Shin Splints

"The pain starts when I begin running, but eases off after a while. My friend had some therapy for shin splints, maybe that's what I need?"

"I'm training for a marathon but haven't kept to the schedule. On  Sunday I ran for 20 miles through the city, to 'catch up'. I now have terrible pains in my shins - I'm worried I may have shin splints "

There really is no such syndrome as 'shin splints', although it is a commonly used terminology. As a diagnosis, it is almost as exact as using the term, 'foot pain'.  When people refer to 'shin splints' they are generally referring to pain in their 'shins', towards the inside of the leg. The pain spreads across quite a wide area of the lower leg and usually affects those people who are involved in intense exercise. It is in fact, self inflicted.

There are a number of specific disorders covered by this title, including  fractures, muscle strains or tears, nerve entrapment and artery entrapment.  Most commonly however, it refers to a condition entitled, Medial Tibial Stress Syndrome. (MTSS) . 

The pain experienced with MTSS is worse at the beginning of training and subsides during the session. As the condition progresses in time, the pain is present with less activity and it may even occur when resting. Running on hard surfaces makes it worse as does suddenly increasing the intensity or duration of training. It can develop into a stress fracture due to repeated trauma on the leg structures

It is more common in women, in whom it is 3x more likely to advance into a stress fracture. The cause is often associated with biomechanical abnormalities. 

To recap; pain in the lower leg is not a 'shin splint' but one of many different disorders.

So if you are suffering with this,

·         stop training,

·         rest the area,

·         use ice on the leg immediately after exercise and,

·         seek the advice of a podiatrist or biomechanist who will guide you through the recovery process.