OsteoGait Podiatry

Podiatrist in Kensington, London

Our highly professional team based in Kensington offer prompt diagnosis and treatment of foot and ankle problems using the very latest advancements in foot and ankle healthcare.

Gait Analysis, Biomechanics & Sports Injuries

Specialists in Heel & Foot Pain

Custom Orthotics/Insoles

Ingrowing Nails

Minor Surgery

Verrucas

Corns

Plantar versus Dorsal Incision: Morton's Neuroma Pearls

This blog post was written by special guest and expert witness: 

Mr Ian Reilly, Consultant Podiatric Surgeon

www.podsurgeon.co.uk

Mr Reilly is a Consultant Podiatric Surgeon specialising in both the non-surgical and surgical management of foot and ankle problems. His private practice is based in the Midlands, primarily within the green county of Northamptonshire where he has performed nearly 10,000 surgical procedure.

His special interests include hallux valgus deformity (bunion), neuroma and other soft tissue pathologies of the foot & ankle. 


The Background

A Morton’s neuroma is a common condition seen in both primary and secondary care and has gone under many names including Morton’s neuroma – the classic 3/4 interspace lesion, plantar digital neuritis, Morton’s toe, et al.  Though attributed to Morton, at least two other authors could be credited with its discovery, the most famous being Durlacher who was surgeon/chiropodist to Queen Victoria. 

the Clinical Picture

We are all familiar with the typical neuroma patient: often a woman and often wearing somewhat closed-in or high heels.  This typically presents as a neuralgic infliction on one foot but it can be bilateral and can affect multiple interspaces.  Patients present with sharp shooting and burning neuritis, aggravated by activity and relieved by rest and massage. 

The Pathomechanics

There is still quite a debate over the exact cause of the neuroma which could include stretching, compression or ischaemia of the nerve.  My own view is that this is a compression neuropathy, typically with a nerve caught between adjacent proximal phalanges, occasionally metatarsal heads and occasionally the deep transverse metatarsal ligament.  The common digital nerve is affected as it splits into the proper digital branches and in the 3rd interspace there is a communicating branch between the medial and lateral plantar nerve. 

  What does a Neuroma look like? 

What does a Neuroma look like? 

the Conservative Treatment

Caught early, I think there is a good argument for orthotic management and shaft padding and although it is not Rootian in thinking, I have come to recognise that the medial and lateral being between the first three medial and the two lateral metatarsals can be an issue.  I am increasingly noticing that patients with Morton’s neuroma have relative hypermobility of the forefoot and in doing Mulder’s click particularly, I often see some entrapment between the adjacent medial and lateral beams of the foot. 

  Type of insole or orthotic for a Neuroma

Type of insole or orthotic for a Neuroma

The Prognosis

More established cases seem to do well with cortisone shots but there is certainly a feeling in the literature that lesions below 6mm in size (if we take 2mm as a normal) tend to do better and that would certainly make sense.  A smaller, less thickened, less inflamed neuroma is likely to do well with a fairly modest shot of steroid than a more established chronic and thickened neuroma.

Surgical Pearls – The Plantar Approach

Recalcitrant cases and I think this is an increasing majority of patients, go forward for surgery and there is a hot debate on whether this is a plantar or dorsal approach.  I very much favour the plantar approach as this allows better visualisation of the nerve, allows the nerve to be traced back further and doesn’t do the trauma to the top of the foot in struggling to get at the nerve through an increasingly narrow interspace.  I written elsewhere on this subject and presented at various conferences and this has certainly been my own experience.

Evidence based medicine which is the goal of all health professionals is not merely what seems to be the best technique as described in the literature.  It is a combination of the best evidence, patient roles and practitioner experience and it is therefore a semi-scientific what works best in my hands approach.  For me that is very much the plantar approach.  While I have seen some painful plantar scarring the number of these has been very small and is outweighed by the number of stump neuroma I have seen – two in the last eight years. 

I continue to read and reflect on my treatment of Morton’s neuroma and in fact just today came across a very good e-book written by my old friend and colleague, David Tollafield.  He is a (now retired) Podiatric Surgeon of considerable experience who very recently had a Morton’s neuroma excised himself.   He has done a very readable e-book aimed at the motivated patient and covers the journey in great detail and I would recommend this book to patients and practitioners alike. 

 


WRITTEN BY GUEST BLOGGER:

MR IAN REILLY, FCPODS

CONSULTANT PODIATRIC SURGEON

www.podsurgeon.co.uk

ireilly.jpg

Mr Reilly is a Consultant Podiatric Surgeon specialising in both the non-surgical and surgical management of foot and ankle problems. His private practice is based in the Midlands, primarily within the green county of Northamptonshire where he has performed nearly 10,000 surgical procedure.

Besides offering invasive and non-invasive services in the care of foot & problems, Mr Reilly is an experienced expert witness within the medical negligence field and has provided many a Podiatrist with training in Corticosteroid therapy, AO fixation and more recently Verruca needling. He is committed to providing the best care for his patients and contributing to the Podiatric Surgery and Podiatry profession., 

 


Insoles & Orthotics (Orthoses)
Insoles, also known as orthotics or orthoses, can be very effective at improving your foot alignment within your chosen shoes. This then adjusts the leg position and can help reduce the chance of injury when weightbearing by redistributing stress on affected structures and improving the efficacy of your walking or running pattern.

At OsteoGait Podiatry we provide fully customised specialist orthotics for the average walker, part-time runner to the elite Premier League footballer (more information). Additionally, we commonly utilise Corticosteroid therapy should this approach fail to improve symptoms. 

IF YOU REQUIRE ADVICE ON ANY OF THESE TOPICS OR A PAIR OF CUSTOM MADE INSOLES OR ORTHOTICS FOR A PAINFUL neuroma, WE ARE ABLE TO PROVIDE THESE THROUGH FULL RUNNING AND MOTION ANALYSIS VIA OUR GAIT LAB, PLEASE CONTACT US FOR MORE DETAILS OR CLICK (MORE INFORMATION).

 

 

 

Posted by London Podiatrist

Top Tips For Achilles Tendinopathy

This blog post was written by special guest and top foot & ankle surgeon: 

Mr Jonathan Larholt, Consultant Podiatric Surgeon

www.jonathanlarholt.co.uk

Mr Larholt is a Consultant Podiatric Surgeon specialising in both the non-surgical and surgical management of foot and ankle problems. His private practice is based in Central, North and South London

His special interests include hallux valgus deformity (bunion), hallux limitus (arthritic big toe joints) and tendon pathology particularly the Achilles tendon.

Achilles Tendon

What is the Achilles Tendon?

The Achilles tendon is the largest tendon of the body and acts by lifting the heel of the ground and transferring the weight / force to the ball of the foot contributing to forward propulsion.

The Achilles tendon is situated at the back of the ankle and foot and the tendon is formed from two muscles, which are collectively termed the calf muscle. The tendon begins in the lower third of the leg and inserts into the back of the heel bone where it progresses to the underside of the heel to merge with the plantar fascia (a thick fibrous band on the sole of the foot which supports the arch and contributes to the function of the foot. Injury of the origin of the plantar fascia on the underside of the heel bone is the most common cause of heel pain, plantar fasciitis).

Unlike other tendons of the body the Achilles tendons fibres are orientated in a spiral manner; this allows the tendon to store energy for when the heel comes off of the ground, the “spring in your step!”

The Achilles tendon is a very powerful tendon and is prone to injury. Injury can occur in one of two areas; within the main body of the tendon, termed non-insertional Achilles tendinopathy or where it inserts onto the heel bone: insertional Achilles tendinopathy. This blog focuses on non-insertional Achilles tendinopathy.

What might be the pain I get related to the Achilles Tendon?

Non-insertional Achilles tendinopathy develops when the force placed upon the tendon is greater than the tendons strength (tensile). This force is often repetitive, however, an isolated incident can occur to cause injury and often produce rupture of the tendon.

What may surprise people is that Achilles tendinopathy is not an inflammatory condition but a degenerative condition (The term tendinopathy: degenerative / tendinitis inflammatory. When the tendon becomes injured the damaged collagen begins to breakdown and releases chemicals which sensitise the nerves to produce the pain.

Non-insertional Achilles tendinopathy is experienced as pain and swelling approximately 2 to 6 centimetres above the heel bone. The pain can be associated with swelling, morning stiffness or stiffness that can return after periods of rest, stiffness associated with activity, reduction in motion and pain on motion. A common factor of the condition is thickening of the tendon itself. As well as the tendon being affected the sheath around the tendon can become inflamed and if this is the case a creaking sensation and sound may be heard activity, pain associated with the tendon sheath is inflammatory in nature.

Why might I have Achilles Tendinopathy and what causes it?

There are many factors which can lead to non-insertional Achilles tendinopathy and these are often divided into extrinsic (things outside of the body) and intrinsic (associated with the body). Some of these factors are modifiable and can be addressed to reduce the risk of developing Achilles tendinopathy and assist in its management.

Extrinsic factors include:

  • Running surface (modifiable): running on a hill or cambered surface can increase stress on the tendons
  • Overuse / over training (modifiable):  increases in the duration and or frequency of training. This leads to an imbalance with an increase in wear and insufficient time for repair
  • Inflexibility / improper stretching (modifiable): the tendons are tighter and more susceptible to tensile loading and injury
  • Footwear: worn out trainers or improper footwear (modifiable): if the heel of the shoe is worn out this would lead to altered foot mechanics

Intrinsic factors include:

  • Increased age: as we age our tendons become more inflexible and susceptible to injury
  • Obesity (modifiable): increased weight produces increased load onto the tendon
  • Genetic predisposition: recently there has been much research into genetic markers and the development of Achilles tendinopathy
  • Poor foot function (modifiable through orthoses/insoles): a pronated foot produces compensation within the foot and ankle and leads to a whipping action of the Achilles which can lead to damage
  • Malnutrition (modifiable): a poor diet does not provide the body with the building blocks to allow for the reparative process to take place
  • Previous tendinopathy: previous tendinopathy is a large risk factor for developing future tendinopathy
  • Antibiotics (modifiable): The class of antibiotics Fluoroquinolones to include Cirpofloxacillin can reduce the strength of tendons and increase their susceptibility to injury
  • Tendinopathy secondary to the plantaris tendon: the plantaris tendon is a long tendon on the inside aspect of the leg which is in close proximity to the Achilles tendon. It is absent in a third of the population and is somewhat redundant in humans but is important in jumping mammals such as Kangaroos. This tendon can produce pressure onto the Achilles tendon and lead to an Achilles tendinopathy

What scans are useful for Achilles Tendinopathy?

To further assess the pathology investigations such as ultrasound and MRI are often requested. Investigations also allow other pathologies such as tears to be ruled out. The management of a tear is very different from a tendinopathy.

The scans often show a variety of changes:

  • Thickening of the tendon
  • Blood vessel infiltration: accompanying the blood vessel can be nerves which can produce the pain associated with the condition.
  • Degeneration
  • Tears

What treatment is there for Achilles Tendinopathy?  

  • Orthoses: An Insole or Orthosis may be extremely beneficial in helping to reduce the pathological motions involved in placing the Achilles tendon under great load during various stages in the gait cycle and aims to correct the biomechanics involved in the condition, which is the root of the issue.
  • Loading of the tendon: Isometric loading (no change in the length of the muscle): stretching & Isotonic loading (change in length but tension remains the same) to include eccentric stretching. This is where the heel is dropped beneath the level of a step, which puts tension on the muscle and tendon and helps to stimulate the repair process.
  • Shockwave therapy: This is a machine that passes shockwaves to the affected area to stimulate repair and reduce pain.
  • High Volume Injection Therapy: This involves using ultrasound to guide a needle between the tendon and tendon sheath followed by the administration of a large volume of saline. This separates the tendon sheath (paratenon) from the tendon itself and can reduce the amount of new blood vessels into the tendon, part of the pathology. With this treatment the pain also reduces and patients are able to perform their stretching exercises more appropriately.
  • Sclerosing therapy: This is where a sclerosing agent is injected around areas of microtears. This can reduce pain and improve function, this treatment is also performed under ultrasound guidance.
  • Plasma Rich Platelet (PRP): PRP is used to promote healing of the tendon and is obtained by drawing blood form the patient and spinning the blood to obtain certain products which are then injected around the tendon. The evidence for PRP is not as strong as the aforementioned treatments.

When is surgery indicated for Achilles Tendinopathy?

Prior to any surgical management, conservative and medical care (outlined above) is continued for six months.

There are a number of different surgical approaches and these are dependent on the amount of tendon degeneration and associated pathologies e.g. inflammation of the tendon sheath enlarged plantaris tendon.

What type of surgery is involved for Achilles Tendinopathy?

  • Removal of degenerative areas and longitudinal incisions within the tendon to stimulate repair.
  • Surgical stripping of the paratenon to reduce the infiltration of new blood vessels and allow for tendon healing.
  • Resection of the plantaris tendon
  • Tendon transfer: If the degeneration of the tendon is greater than 50% a tendon transfer is often required to reinforce the Achilles.

The outcome of surgical management can be variable and should only be entertained once all conservative care has failed. With all treatments a cure is not guaranteed, but patients are in less pain and more functional and thereby able to enhance their activities or daily living and quality of life.


WHAT IF I WANTED TO SEE OSTEOGAIT PODIATRY ABOUT MY Achilles tendinopathy?

This five step plan for pain free feet is apart of our Achilles protocol:

  • Accurate diagnosis of Achilles tendinopathy via biomechanical and video gait analysis.
  • Custom orthotic therapy to address the imbalance within the foot or lower limb and minimise the mechanical tension on the Achilles tendon
  • Footwear advice and a course of Physiotherapy
  • Specialist guided injections using corticosteroid to reduce joint inflammation and pain.
  • Referral for surgical consult should the above fail. Visit www.jonathanlarholt.co.uk for details 

If you require advice on any of these topics or a pair of custom made insoles or orthotics for a painful arthritic feet, a flatfoot or high arched foot, click (more information).


Written by guest blogger:

Mr Jonathan Larholt, FcPods

Consultant Podiatric Surgeon

Jonathan Larholt

www.jonathanlarholt.co.uk

Mr Jonathan Larholt is a Consultant Podiatric Surgeon (HCPC registered CH13765) specialising in both the non-surgical and surgical management of foot and ankle problems.

He believes in involving the patient in each step of the consultation and decision making process so that treatment is not only effective in managing your complaint but it is tailored to your needs i.e. physical activity, work and social circumstances.


His private practice is based in Central, North and South London and he forms part of a team made up of Consultant Musculoskeletal Radiologists, Physiotherapists with a special interest in foot and ankle rehabilitation, Podiatric Biomechanists (gait analysis and insoles) as well as Podiatrists.

His special interests include hallux valgus deformity (bunion), hallux limitus (arthritic big toe joints) and tendon pathology particularly the Achilles tendon.

 

 

 

 

Posted by London Podiatrist

TOP TIPS FOR BEGINNER MARATHON RUNNERS

Prepare For The London Marathon With OsteoGait Podiatry 

 Prepare for the London Marathon with OsteoGait Podiatry

Prepare for the London Marathon with OsteoGait Podiatry

 

Race Swag

Consider the fabric used as part of your running gear. Cotton and heavy materials can be difficult to run a race in and more modern materials offer a lightweight breathable experience such as the CoolMax variety. Practice in you gear to ensure it does not irritate your skin or cause blistering (socks). You will gain a huge amount of confidence if you like your gear and take pride in your marathon appearance.

Custom Made Orthotics / Insoles

Modern day athletic shoes are developed to ensure peak performance and give you plenty of comfort when running, however every individual runner will have unique biomechanics and anatomical function. Therefore if you are suffering from discomfort when training, a Video Gait Analysis and pair of custom Orthoses/Insoles may go a long way to helping you prepare for your marathon and stay pain-free.

Simulate the Race

In the lead up to the final race you must train on the same topographic landscape as the marathon. If you live in a flat area and are preparing for a hilly marathon, run with incline on a treadmill. If you are running a reasonably flat marathon then you are likely to lack variation in terrain during the race and will use the same muscles in the same fashion for the duration of the race, so it is important to condition to this.

Visit a Podiatrist

If you have any niggling injuries such as arch pain, heel pain, ball of the foot pain, ankle pain etc or suffer with ingrowing toenails, corns etc then training for a big race may make your foot pain worse. In light of this, a HCPC registered Podiatrist at OsteoGait Podiatry can give you a complete analysis of your lower limb mechanics and treat/address any concerns prior to undertaking your race preparations.

Thirst-quenching

It is imperative to stay hydrated during the race. You may want to switch from water to an isotonic sports drink which helps rebalance electrolytes and replenishes depleted glycogen stores during the course of the race.

Relax

Minimise life stress in the lead up to the event. Ensure work projects are under wraps, politely decline invitations to late nights out, and save long days where you will be on your feet for after the race. The few days before the marathon get plenty of rest, sleep and relaxation before you pump up for the event.

Carbo-Load

Several hours before racing consume a carbohydrate rich breakfast to ensure you have plenty of reserves for the marathon. Typical foods have a relative gycaemic index and you will need both long and short acting foods. Long acting foods at breakfast and short acting during the race is ideal. Examples include pasta, rice, potato, bagels, bananas, sports drinks, high calorie protein shakes etc.

Footwear Advice from a Professional

The number one golden rule. Most running stores will provide advice on appropriate footwear but this will be from someone who fits the shoes in-store rather than a health professional who has extensive experience in managing foot & ankle injury/pain. A Video Gait Analysis session with our HCPC registered Podiatrists can advise further on this if you are unsure which style of running shoe is best for you.

Never wear a new pair of shoes to run a marathon the very first time. New shoes should have been previously trialed in training and this is key to ensure you can run the race to the best of your ability and do not get yourself injured. New shoes require an adjustment period and should be tailored to your foot profile.

If you have any further questions about your preparation, would like to discuss running analysis or are thinking about getting a pair of custom insoles / orthoses manufactured then please contact us at info@osteogait.com or visit www.osteogait.com

 

Happy Running,

The London Podiatrist

 

 

 

 

Posted by London Podiatrist

The best running trainers for painful feet: The London Podiatrist Advises on how to avoid getting foot pain

What is a good running shoe? This is a question we are asked here at OsteoGait Podiatry on a very frequent basis. This useful guide should enable you to make a sensible decision regarding the shoes you run or excercise in. Should you be encountering any further pain or discomfort we are able to analyse your gait and running style to design and advise a training and rehabilitation regime as well as prescribe custom orthotics after conducting a full video gait analysis in our lab. View the running shoe guide.

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Posted by London Podiatrist

What is arthritis? The London Podiatrist Explains Why You May Get Foot Pain As A Result

Pain in the foot can often be linked to arthritic changes, this article gives a broad overview of foot related arthritis and how a podiatrist is able to help manage the pain accordingly. At OsteoGait Podiatry we use the latest technology and collaborate with a wide range of medical specialties across London in order to provide holistic care for our patients. View full post

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Posted by London Podiatrist

Our services cover the following locations (if your location is not listed please don't hesistate to get in touch and ask us if we can help you)

Kensington - W8 - W14 - SW7 - Notting Hill - W11 - W2 - W10 - Chelsea - SW10 - Knightsbridge SW1 - SW3 - Fulham - SW6 - Hammersmith - W6 - W12 - Hyde Park and Holland Park