• Introducing the team at Waikato Podiatry

• 2007 Musculoskeletal Physicians Conference

• Shoe v Shoe

• Opening hours over Christmas period

• Locate our Clinics

Welcome to the first of the new format, Waikato PodiEtry newsletter.

We are very conscious at Waikato Podiatry of the support we receive from a wide group of health professionals and that we are not always able to reciprocate their support with patient referrals. Another way we can express our gratitude for their continuing and ongoing support is to keep them up to date with some current findings and literature that are valid to their practices and their patients. We also like to keep you up to date with the changes at Waikato Podiatry on a more personal note.

Please feel free to provide feedback on the articles included in this edition.

More information on these topics is available from Andrew.

Andrew Jones - Principal Podiatrist
Musculoskeletal specialist podiatrist - special interest area chronic heel pain
Megan Taylor
Megan has recently joined us and will be covering all aspects of Podiatry in our clinics. Megan will also be based at Rototuna Medical Centre where we have started a Northern Waikato Podiatry Clinic, one day a week.

Leigh Henry
Leigh is our part-time Podiatrist who focuses mainly on diabetic foot management.

Denise Johanson
Denise is our Practice Manager and clinic administrator. Denise has a good understanding of how things run in the medical field and has worked in several clinics in the Hamilton area previously.

"Muscle in on the tendon"
Palmerston North - Keynote speakers Karim Khan, Jill Cook

The importance of exercise in promoting healthy tendons.
How do the heavy load eccentric exercises actually help heal tendons?
By Karim Khan

The importance of exercise in healing tendon injuries is that it stimulates the tendons through a number of mechanisms collectively known as "mechanotransduction". (What a mouth-full!)

This term refers to a combination of the following:

• mechanical load - converted to biochemical signals;
• cell to cell communication - increased by physical stimulation;
• gene and protein synthesis - upregulation

- Reference BJSM 2007

Practice Point

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You may have seen an article in the Waikato Times recently. This article was initiated from a paper published in the British Journal of Sports Medicine - "Do you get value for money when you buy an expensive pair of running shoes?" - BJSM October 2007.

The researchers concluded from this study that there was no difference in the cushioning performance between the shoes tested regardless of price.

A limitation that I could see with this study, is that it is not comparing the right types of shoes, e.g. it was not comparing a poorly constructed running shoe that you would by for $15-$20 at a non-specialist sports shoe shop with a better constructed higher end shoe. What it did was compare two shoes that are fairly similar in construction and makeup.

The so called low cost shoe they used converts to NZ $135 and the high price shoe at NZ$225. This assessment was based on 15 steps in total and we all know the difference beween how a running shoe feels in the shop and how it performs when you start running in it.

What would have been very interesting and valid would be to review the person's opinion and cushioning properties on the shoes after running in them for 2-3 months.

I feel this study struggles to have validity in many respects, as we know the appropriate running shoe is not only about cushioning, it is also about durability and fitting the right shoe to the right foot type and gait style.

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Waikato Podiatry will be closed on 25^th and 26^th December and open again on 27^th and 28^th December.

We will then be closed again on 1^st and 2^nd January and will be open again on 3^rd and 4^th January 2008. Usual hours will resume from 7^th January.

The answer phone messages will be cleared regularly over this Christmas/New Year period.

In the City:
Waikato Podiatry Clinic, 10 Pembroke Street, Hamilton

In the Suburbs:
Northern Waikato Podiatry Clinic, Rototuna Medical Centre, Rototuna

Thanks to Asics and Smiths Sports Shoes Hamilton for supporting this newsletter.

Have a safe and relaxing break over summer. We look forward to working with you in 2008.

Kind regards,

Andrew Jones
Waikato Podiatry

email: andrew@waikatopodiatry.co.nz
phone: 07 838 0003
web: www.waikatopodiatry.co.nz

• Biomechanical Boot Camp 2008 "Forces in Motion"

• May the force be with you!

• Horses for Courses!

• Force plate information should be interpreted with care

• Laterally wedged insoles and knee osteoarthritis

• Rugby Season is here

Welcome to the first Waikato PodiEtry news for 2008.

We trust you have had a great break over the summer and were able to enjoy some of the sunshine. Hopefully there will be some rain soon to green up the farms, gardens and sports fields.

The first event scheduled for ongoing education at Waikato Podiatry Clinic this year was Biomechanical Boot Camp 2008 "Forces in Motion" presented by Podiatrist Craig Payne from La Trobe University, Melbourne.

Craig is a New Zealand trained podiatrist who has taken up a teaching and research position at La Trobe University, for the last six years. He is one of the foremost researchers in Podiatric biomechanics, and a true international speaker.

I apologise for any jargon or terms that may sound technical to the non-medical people receiving this newsletter but several of the concepts involved in discussion of the Boot Camp do use a little technical terminology.

Craig's focus is mainly around research into how orthotics 'work' and how they are able to provide the best clinical outcomes (fix people). Recent results suggest orthotic effect can occur without obvious large positional changes occurring in the foot and leg.

If the foot was a plastic structure we would be able to see obvious positional changes a lot more easily, however unfortunately the foot is not as simple as this, and sometimes positional changes are not as easily detected.

The heel and the foot is made up of lots of fat pad, bursa, osseous, ligamentous, and soft tissue structures making it a complex dynamic structure.

Answers to the question about how orthotics work, seems to be firmly headed down the Kinetic force pathway. Let me explain.

Kinematics - Describes positional change and change in motion.

Kinetics - Refers to the forces used to drive this change in motion.

Craig's research has been able to show that with orthotic use you are able to change the forces acting on a joint more effectively than changing the actual physical position.

The idea orthotics always produce large positional changes is often overdone in enthusiastic marketing such as this.

The foot has numerous small joints and their ranges of motion are relatively small, however the forces going through them are huge, for example when running these can be 2-3 times bodyweight.

This is why it makes sense that orthotics can alter forces without huge positional changes. By reducing specific forces this unloads the burden of the fatigued muscle, tendon or joint and allows pain free function.

Guiding of theses forces within the foot have specific implications for both shoe selection, orthotic prescription and patient selection.

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Another reoccurring theme that is coming through in orthotic research is that clinical outcomes are often highly subject specific and variable (we have known this clinically for a while).

What does this mean?

Basically it means that orthotics work like magic for some people but they are not going to work for everyone or in all problems. This places increased emphasis on patient selection to optimise clinical outcomes. If we select appropriate candidates for orthotic use we are a lot more likely to have consistently better outcomes, and to us at Waikato Podiatry Clinic this is what we are all about.

How do we know who will respond well?

To help with patient selection and to improve patient outcomes there have been a number of new tests developed that focus on the forces and loading of the lower limb rather than objective appearance of the foot, eg high or low arch.

These include:

Supination Resistance, Rearfoot Axis, Subtalar Joint Axis of the foot, High gear / Low gear Analysis, Functional Foot Drop, Subtalar Joint Equilibrium, Preferred Motion Pathway, Plantar Pressure Mapping, Pathology Specific Prescribing and Tissue Stress Model, Functional Foot Typing.

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Plantar Pressure Mapping:

While on the topic of forces, plantar pressure mapping is one way of determining where force is travelling through the foot in a dynamic situation.

How reliable is this information and how should it be used?

There are a number of systems used to take impressions of the different forces underneath the foot.

This can be very helpful in a clinical situation, however it is important to realise that there is a huge amount of variability produced in a normal gait cycle and it is suggested that the most accurate way of capturing relevant information is through the "in-shoe f-scan systems" (a small innersole with sensors that fits inside the shoe).

Unfortunately these systems can cost between $35,000 to $90,000. If the force platform systems are to be used that are not in-shoe then there needs to be a program that is able to integrate up to 6-8 different gait samples per foot to be able to come up with the typical average gait pattern. A single one-off pressure map is not an accurate representation of how the foot will function and can sometimes be misleading.

Osteoarthritis (OA) affects 30% of people over the age of 65 years. High external knee adduction alignment is one of the major risk factors for medial compartment OA and is significant predictor of the rate of OA progression. On normal walking, ground reaction forces pass inside the joint line centre and tend to compress this medial section.

Initially this may start as a valgus knee positioning then as the medial cartilage advances further the knee adopts a more and more varus knee positioning (see picture), hence the narrowing of the medial compartment secondary to the OA wear. You will have all seen people with knees of this particular shape.

There is currently a lot of research directed at lateral wedging and the positive effects it can produce in these cases. Several case study reports show a decrease in pain reduction by 53-82%. A paper Craig was involved in showed the pain and function scale reduced by 69% - 72% at three months post intervention. Unfortunately the four randomised control trials on this posting are conflicting in their outcomes probably because the length of the lateral wedges is not uniform with all studies.

Again in keeping with the theme of this newsletter there were more kinetic changes than kinematic changes and the fact that patient selection is vital to good outcomes! i.e. Several Rheumatology associations have included lateral posting in their standard guidelines for OA treatment.

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With the onset of Rugby and with the grounds being as firm as they are this provides a great opportunity for players to use the current ASICS Lethal Rugby Boot.

(Gadde et al). "Cinical Journal of Sports Medicine" Vol 14, No.2 March 2004 identified that only lack of ankle dorsiflexion measured in the lunge test weightbearing position was significantly associated with lower limb injury for their group of 148 Australian Football players. It is this and similar running shoe research that makes the small raise (positive pitch) in the back of the ASICS lethal such an important innovation.

Despite what we now know about the importance of retaining a positive pitch in sports shoes, it is still concerning the number of rugby boots that are on the market that don't do this.

Fortunately some do - such as the ASICS Lethal.

Thanks to Asics and Smiths Sports Shoes Hamilton for their continued suport of PodiEtry News.

Kind regards,

Andrew Jones
Waikato Podiatry

email: andrew@waikatopodiatry.co.nz
phone: 07 838 0003
web: www.waikatopodiatry.co.nz

• A Balanced Approach to Injury Prevention

• Poor prep equals more injuries**

• Training Errors

• A New Level of Foot Strength

Welcome to the third edition of Waikato PodiEtry news.

Isn't is great to be able to sit back and watch the Olympic athletes in what would be the pinnacle of most of these athletes' careers. It seems to be all too easy to forget the hours, years of hard work and discipline that they have gone through to achieve these times and results. Athletes must balance everyday financial and life pressures on top of the ever elusive balance between supreme fitness and injury and illness.

"A balanced approach to injury prevention"

One thing that all of these athletes will have learned is how to subtly balance the demands of training with demands of your body for rest and recuperation. There are numerous examples referring to the importance of maintaining this balance.

Examples:
Lance Armstrong is known to be a phenomenally hard trainer however he openly admits that he cannot and does not maintain this degree of training for anywhere near the full year. He admits that it is vital to have a deconditioning period and a rest phase. In his book "Lance, how does he do it?" he acknowledges the fact that to be at his supreme best he can only be in top shape for a limited amount of time. In fact he only raced for 50 days a year over a four month period when other cyclists' were racing 150+ days a year over an 8-9 month season. We are also seeing this in the "All Blacks" with differing degrees of success in the elusive search for the balance between rest and peak physical condition.

This article discusses the fact that there is an increasing pressure on school children to perform all year round, which is not necessarily healthy physically or mentally. It discusses the demands on young bodies and the fact that the body will always "sacrifice quality of motion for quantity of motion, when the body steals motion from one rested part of the body to compensate for a tired part, this is often when injuries occur".

Not only are young bodies going through puberty, they need to adapt to new centres of gravity as they grow and "make sure that their muscular structure is keeping up with the osseous structure" it is cited in this article that one coach had noticed that towards the end of the season that more than half of his team were seeking treatment for injuries.

Some proposed solutions were restricting the number of competitive tournaments played. There is a German model that limits halves to 20 minutes and restricted competitive minutes to no more than 100 minutes in a 24 hour period.

The representative level creates an added load on young people to increase their volume of training and they will often have two representative practices plus games as well as their normal school practices plus games.

One of the individuals we saw recently had tallied it up and he is practicing and playing hockey for eight hours a week at the age of 13. A 16 year old was doing, at the peak of the season, 12-14hrs netball (not including fitness testing).

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While not underestimating the role of lower limb biomechanics in a lot of sporting injuries, the training errors also play an equally important role and if these can be identified early and the principles of quality versus quantity are applied these will help athletes both young and old to play at their best, enjoy their sport and remain uninjured.

In a Nutshell:

• Check your equipment - Shoes, or Orthotics if required prior to commencing a season's training to make sure they are functioning well.
• Remember a prior history of injury is the most accurate prediction of future injury, revisit any previously prescribed exercises or stretches prior to starting training.
• Start the training slowly and steadily increase. Plan your sporting year to incorporate some rest periods. Get help with this if you need to. WINTEC sport and exercise science students are often willing to help structure training plans at little cost.
• Perhaps sporting codes need to look at providing healthy training guides to junior participants.
• Set realistic goals and enjoy your sport.

New product:

The "ArchCOACH^TM" is a new clinical tool that has recently been developed by an Australian Podiatrist, Ash Mahoney.

Ash has an interesting background, as a Podiatrist he is involved fairly exclusively with the athletes in based in Brisbane, Australia. He is from a sprinting/hurdle background and his first introduction to podiatry occurred after suffering a navicular stress fracture - a notorious hurdling injury.

Ash uses foot strengthening exercises as a key part of his treatment regime in his athletic clients. To help do this he has devised a tool which is known as "the ArchCOACH^TM". It is a fabric and Velcro structure that enables the person to apply certain degrees of resistance to the foot through the physical strength of the arms and work against this restraining mechanism. Ash has also written two books that describe structured strengthening approaches to the rehabilitation of certain foot conditions, both with and without the ArchCOACH^TM.

For more information visit www.footstrength.com.

* "How Lance Does It?" Brad Kearns., McGraw Hill 2007
** America Soccer Journal September 2007

Thanks to Asics and Smiths Sports Shoes Hamilton for their continued suport of PodiEtry News.

Kind regards,

Andrew Jones
Waikato Podiatry

email: andrew@waikatopodiatry.co.nz
phone: 07 838 0003
web: www.waikatopodiatry.co.nz

• Diabetes Related Foot Facts

• Diabetic Shoe Review - Asics Gel "4 to 8 "

Welcome to the fourth edition of Waikato PodiEtry news.

Isn't is great to be able to sit back and watch the Olympic athletes in what would be the pinnacle of most of these athletes' careers. It seems to be all too easy to forget the hours, years of hard work and discipline that they have gone through to achieve these times and results. Athletes must balance everyday financial and life pressures on top of the ever elusive balance between supreme fitness and injury and illness.

Diabetes Related Foot Facts

• Lower limb disease is twice as common in people with diabetes than non-diabetes.
• The risk of developing a lower limb amputation is 15 times higher with diabetes than without.
• Prevalence rates for diabetes is set to rise between 40% - 90% in the next 20 years.
• Diabetes can often be avoided and controlled by diet and exercise.
• Tight blood sugar monitoring and regulation drastically reduces all diabetic related complications.
• Podiatry intervention can lower the chance of ulceration, amputation, and improve quality of life.
• Specialist shoes and socks are available.
• There is a team of specialists that work with a Podiatrist to help you.

Toes burnt too close to heater in Diabetic Neuropathy

Causes:

• Uncontrolled/Poorly controlled diabetes mellitus.
• Vascular insufficiency (Poor blood flow to or from the feet).
• Lack of sensation (neuropathy - a complication of diabetes).
• Ill-fitting shoes.
• Trauma.

Rubbing over a tailors bunion (shoe too narrow)

• Consult a Podiatrist immediately.
• Alert the Podiatrist that you are a diabetic with a sore foot.
• Self-treatment is not recommended for this serious condition.

1. Regular inspection and examination (by a Health Professional)
2. Identify "at Risk feet" (Podiatrist specialty)
3. Education of patient and family
4. Appropriate footwear
5. Treatment of non-ulcerative pathology (corns, callous, heel cracks etc)

Rubbing and pressure on toes caused by shoe box not deep enough

What Might A Podiatrist Do?:

• Initiate total medical team approach, which may include your family practice doctor, endocrinologist, internist, vascular surgeon, and infectious disease specialist.
• Perform a physical examination.
• Perform x-ray evaluation.
• Perform debridement and wound care.
• Conduct laboratory tests.
• Advise on appropriate shoes and sizing/fitting.
• Treatment of non-ulcerative pathology.

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Diabetic Shoe Review - Asics Gel "4 to 8"

Problem: 31% of hospital admissions for diabetic foot complications are directly related to footwear.

Solution: a shoe designed with diabetic foot safety and comfort in mind. As the name suggests the Asics "4 to 8" is this shoe and its name a reference to "ideal" blood sugar levels in diabetes.

Not only does this shoe have the great feature of the Duromax cradle extended through to the midfoot both medially and laterally for support it has combined this feature with a super soft shock absorbing heel to try to reduce the effect of shock at heel strike which can be aggravating in people with osteoarthritis. This also has the effect of being an entry point to the rocker bar effect for heel contact and toe spring "feels like swimming with the current rather than against it". These features alone would make it an ideal shoe for a large number of people, however as is typically Asics there are a number of additional features that make it even more appropriate, for the hard to fit foot. This may be due to either oedematous limbs, or where added protection is required such as peripheral neuropathy in diabetes or rheumatoid arthritis.

Additional features that add to the shoe's overall package include:

• extended nice round toebox allowing for minimal toe friction and rubbing
• the stitching has been carefully placed to allow for minimal forefoot impingement around both the 1^st & 5^th metatarsal heads (A point where we would tend to see increased width and rubbing issues with both HAV and Taylors bunions)
• the super soft comfortable liner which is encompassed throughout most of the shoe and has minimal stitch joinings, this gives you an impressive instant comfort feel when first put on
• the heightened toe box which is part of the new last in this shoe adds a further insurance that there will be no impingement around the toe area for those problematic retracted toes and associated rubbing.
• as you would expect to find in a shoe like this it is also available in an extra wide sizing.

Thanks to Asics and Smiths Sports Shoes Hamilton for their continued suport of PodiEtry News.

Kind regards,

Andrew Jones
Waikato Podiatry

email: andrew@waikatopodiatry.co.nz
phone: 07 838 0003
web: www.waikatopodiatry.co.nz

• "One in Five"

• Stress Fracture

Welcome to the fifth edition of Waikato PodiEtry news.

A lot has happened since our last newsletter... Andrew broke his right wrist in three places on 30 August which has meant some enforced time away from work. Apologies to those of you who found appointments hard to get over this time. Megan has helped keep things going, which has been great!

Welcome Amy:

Amy Booth is a very experienced (8 years) sports podiatrist who has joined our team and is located at our Rotoruna Clinic. Amy is working part time and bookings can be made on 838 0003.

Foot Health Week 2009 brought to light some fundamental issues regarding foot health in New Zealand.

"One in Five"

A recent study found one in five New Zealanders suffer from foot pain and a disproportionate number of men aged 20-34 years leave it untreated.

It can be a serious matter. Foot pain can reflect medical problems that may have serious health consequences.

A perception that podiatry is only for older people could be why many younger people are unaware of podiatry services. This study suggested that a lack of publicly funded podiatry services for people without chronic diseases could also be a factor.

The President of the Australasian Podiatry Council has called for a national campaign to raise awareness about podiatry services within communities and among general practitioners.

As many as 15% of athletic injuries are stress fractures, the highest amount occurring in track athletes.

Stress fractures often are the result of increasing the amount or intensity of an activity too rapidly. They also can be caused by the impact of an unfamiliar surface (a tennis player who has switched surfaces from a soft clay court to a hard court); improper equipment (a runner using worn or less flexible shoes); and increased physical stress (a basketball player who has had a substantial increase in playing time).

Stress fractures affect people of all ages who participate in repetitive sporting activities, like running.

Medical studies have shown that female athletes seem to experience more stress fractures than their male counterparts. This is partly due to a condition referred to as "the female athlete triad". This triad is made up of eating disorders (bulimia or anorexia), amenorrhea (infrequent menstrual cycle), and osteoporosis (weak bones), this reduces bone density. As a female's bone mass decreases, her chances of getting a stress fracture increase.

The most important treatment is early, accurate diagnosis followed by rest. Individuals need to rest from the activity that caused the stress fracture, and engage in a pain-free low intensity activity during the six to eight weeks it takes most stress fractures to heal. Aqua jogging can be a good way to maintain cardiovascular fitness during this time.

If the activity that caused the stress fracture is resumed too quickly, larger, harder-to-heal stress fractures can develop. Re-injury also could lead to chronic problems where the stress fracture might never heal properly.

Some stress fractures are prone to slow healing and "non-union", these are Navicular and Anterior tibial fractures. Thankfully these are not that common.

In addition to rest, shoe inserts or braces may be used to help these injuries heal and speed return to activity time.

Thanks to Asics and Smiths Sports Shoes Hamilton for their continued suport of PodiEtry News.

Kind regards,

Andrew Jones
Waikato Podiatry

email: andrew@waikatopodiatry.co.nz
phone: 07 838 0003
web: www.waikatopodiatry.co.nz

• Orthotic Care and Maintenance

• The Big Picture

I hope that you all enjoyed the long sunny summer that we have had and have been taking the opportunity to get outside, as we have.

Welcome Amy:

I would like to take this opportunity to welcome "Whitney King" to our Team at Waikato Podiatry Clinic. Whitney is an enthusiastic new Podiatry graduate who has several years experience in competitive gymnastics and gymnastics coaching. This experience has given her an excellent platform to further her sports medicine interests. She also enjoys the experience of meeting a range of interesting people in her general Podiatry treatments. We welcome Whitney to our team and hope to introduce her to you shortly.

Orthotic Care and Maintenance

Orthotics are usually issued with a specific purpose in mind. This usually involves resolving pain or dysfunction that is being experienced. Because we live in a dynamic environment and our lifestyles and activities are ever changing, this means that the requirement of the orthotics are also rapidly changing.

Orthotic manufacture is very diverse and there are a number of different materials used. The lifespan of the foam depends on its density. Most orthotic companies grade the density of foam with a different colour. There is a close relationship between density and durability, the higher density of the orthotic material the more durable it is, however the higher the density is, the lower the cushioning effect.

We urge you to please contact us for an orthotic review if you have not had one in the last 18 months or if you are not happy with the comfort or function of any of your orthotics. We do not have to have seen you previously to be able to do this.

The Big Picture

As we are all very busy in our day to day lives we sometimes lose sight of the bigger picture, by this I mean what is happening in other areas outside our specialist area.

I have found an excellent way to be able to keep up to speed with some of the current issues around sports medicine, diabetes, rehabilitation, general practice and Maori health has been in registering for the research summaries that are an excellent monthly review of the some of the relevant research from these different areas. You are able to log onto this at www.researchreview.co.nz.

Congratulations to Dr Chris Milne for his first research review in the Sports Medicine category.

Thanks to Asics and Smiths Sports Shoes Hamilton for their continued suport of PodiEtry News.

Kind regards,

Andrew Jones
Waikato Podiatry

email: andrew@waikatopodiatry.co.nz
phone: 07 838 0003
web: www.waikatopodiatry.co.nz