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BRITISH BROADCASTING CORPORATION
RADIO SCIENCE UNIT
CASE NOTES
Programme 4. - Feet
RADIO 4
TUESDAY 25/09/07 2100-2130
PRESENTER:
MARK PORTER
REPORTER: TRICIA MACNAIR
CONTRIBUTORS:
EMMA SUPPLE
ERIC TONI
STEVEN KRISS
ANTHONY SAKELLARIOU
PRODUCER:
PAULA MCGRATH
NOT CHECKED AS BROADCAST
PORTER
Hello. They contain a quarter of all our bones. They produce up to half a pint of sweat a day. We stand on them and squeeze them into ill fitting shoes yet we rarely give our feet a second thought. Until that is something goes wrong with them, when it can be difficult to think of anything else.
CLIP
If I press there ...
Yeah that's ...
... that's quite sore but it's further up.
Ahh yeah.
PORTER
More about the cause, and treatment, of her painful heel later on. Along with a report from Tricia Macnair on an operation to treat her arthritic big toe. And a look at how Botox injections have become the latest treatment for sweaty feet.
And here to help me cover everything from ingrowing toenails and verrucas, to flat feet and bunions is podiatrist Emma Supple.
Emma, first a quick guide to who's who in the world of feet - what is a podiatrist?
SUPPLE
A podiatrist is someone who looks after your feet and formally used to be known as chiropodists.
PORTER
And a podiatric surgeon?
SUPPLE
Is somebody who's gone on, postgraduate training, to become a podiatric surgeon and specialises in foot surgery, bunions, flat foot correction, whatever it entails.
PORTER
Right so basically a podiatrist/chiropodist same thing?
SUPPLE
Exactly.
PORTER
Okay well let's start with some of the problems affecting the feet, let's start with the humble verruca. I mean basically it's a wart like any other wart but it just grows inwards because we're standing on it.
SUPPLE
Exactly, it gets squashed in just like a cauliflower but they are a pain and sometimes they sit there for a long time and are dormant and don't cause you any trouble other than cosmetically upsetting you and sometimes they can be quite sore and need treatment.
PORTER
And what happens if we don't do anything because a large proportion of these will disappear eventually on their own?
SUPPLE
That is the history of these - they have a natural resolution so you don't have to treat them if you don't want to. If however, you need treatment then start with a simple acid based preparations you can pick up from the chemist and then if you need some advice go and see your podiatrist.
PORTER
And these are the things that are literally dissolving away the surface layer of the verruca.
SUPPLE
That's right most of them have got salicylic acid in it and it's literally a keratin softener.
PORTER
Now I've got a bit of a bee in my bonnet about how people with verrucas are treated, what's your view, as a podiatrist, on whether children should be allowed to swim and carry on sports etc?
SUPPLE
Absolutely agree, the idea that a child is excluded from the swimming pool just because they've got a verruca, that's a normal wart, is really not very fair at all. So our advice is treat them, cover them up with nail varnish - blue for the girls and pink for the girls is always my particular thing - and just carry on swimming. It's a virus that you need a cut in the skin in order to get one and your normal immune system will pick them up. We also recommend selenium and zinc supplements and that helps just to shift them.
PORTER
Okay, moving on, on to the end of the foot - ingrowing toenails - another very common problem particularly in general practice, we see loads of them, particularly in teenage boys for some reason - is this a self induced problem?
SUPPLE
Well sometimes if you've broken the seal between the nail plate and the nail flesh and introduce an infection then yes it is and we tend to use that term as bathroom chiropody, in other words you've had a dig down the side. But also some people are just born with a very broad nail plate, so it's just literally too broad for the toe and then you couple that with a trainer that's got hot and sweaty, the sides get pressed on the nail and it's not very nice.
PORTER
What about this thing that people rather than cutting their toenails across tend to cut their toenails in a rounded fashion that means that they're more likely to have a leading edge that catches, is that a problem?
SUPPLE
Yes, I mean the professional advice is follow the contour of the nail, don't dig down the sides, don't break that all important seal which is a safety protection.
PORTER
So cut it straight across. The trouble is you end up with a sharp corner that catches in your sock all the time.
SUPPLE
That's where the follow the contour comes in, so just be a bit gentle, a bit savvy, but in essence cut it straight.
PORTER
And if I notice that I'm getting an early ingrowing toenail, that's a bit sore down one side or the other of the toe, is there something I can do at home to prevent it getting worse?
SUPPLE
Wear a wider shoe, so that you're not pressing that piece of nail and flesh together and then a little bit of olive oil or antiseptic lotion and literally just ease the flesh away from the side of the nail plate, that might do. But you may have this nail shape, this fanned shaped, too broad nail that may require surgery.
PORTER
Okay and let's assume that the problem doesn't get better, I end up referring them to somebody like you, what are you going to do?
SUPPLE
We're going to assess it, I mean we can give you instant relief because these things are very sore, it's like having a thorn sticking into the side of your toe. Instant relief, use a local anaesthetic, sort the problem out. If the problem's recurring or is going to recur because of the shape of the nail then a simple office based procedure will sort it out permanently.
PORTER
And that's done under local anaesthetic?
SUPPLE
Done under local anaesthetic, very simple, very common procedure.
PORTER
Okay. I want to move on to sweaty feet now, and a new treatment for people with seriously sweaty feet. It's a problem called hyperhidrosis which can mean having to change socks or tights - and sometimes shoes - numerous times a day.
Botox is best known for its muscle paralysing abilities. The toxin blocks the transmission of nerve impulses to muscles and is used to alleviate muscle spasm in conditions like cerebral palsy, and to melt away unwelcome frown lines and crow's feet. But it has a similar effect on the nerves supplying sweat glands - basically it switches them off for up to a year. Something cosmetic medical practitioner Dr Eric Toni uses to provide long term relief to patients with hyperhidrosis at his clinic in Enfield.
TONI
I'd say it lasts longer in sweat glands than in muscles, you'd probably think about it lasting seven months plus or minus in the sweat glands whereas in actual muscles it would last four months plus or minus.
PORTER
And how do you know which areas of the foot to inject, are you injecting the whole sole - are there sweat glands right across the base of the foot?
TONI
There are several techniques, I actually use some iodine and some starch to actually visualise the sweat glands but some people use a grid technique where you just divide the foot into grids and just inject. The actual substance diffuses out one centimetre from where I've injected it, so you can count on about sort of mainly 15-20 injection sites to cover the whole foot.
PORTER
So you're injecting the areas that have turned purple - that's where the sweat - the active sweat glands are, will you do the rest or will you just concentrate on that area?
TONI
I'll concentrate on that area and then I'll just make sure I get them all by just doing a few more.
PORTER
But these few in those areas could be what's causing the trouble?
TONI
Yeah they're the hyperactive ones.
PORTER
And what sort of patients are you seeing, I mean we all have sweaty feet to some degree but give us some idea of the sort of problems that your patients have had?
TONI
It is very embarrassing, especially for young women.
PORTER
And they can be very sweaty can't they.
TONI
Oh absolutely dripping. You've got to compare it with other treatments that have been available, such as Anhydrol Forte...
PORTER
Being a sort of professional grade antiperspirant, so it's like a roll on for the feet.
TONI
This is industrial strength stuff.
PORTER
Not always well tolerated.
TONI
The first few applications are fine and then you start to develop dermatitis where you get soreness and cracking.
PORTER
Presumably it's not that pleasant having multiple injections in your feet.
TONI
I think you have to have quite a high pain threshold for this. Although I put EMLA on, which is a local anaesthetic cream but that must be left on for a considerable length of time before doing this. Also use an ice block as well. There's other side effects - you could possibly get reflex hyperhydrosis, somewhere else, but this is really quite rare, that would mean that say you develop sweating on your thigh ...
PORTER
So you cure the feet but you start sweating excessively somewhere else on the leg perhaps.
TONI
Somewhere else but that really is temporary, it doesn't last very long at all, it would maybe last a couple of weeks. And you also have to remember that this treatment does not work immediately, it takes about 48 hours for it to kick in and 10-12 days for the maximum effect.
PORTER
You're offering the service here privately, so say someone was to come in, the average person, to have their feet treated how much is it costing?
TONI
It costs £500.
PORTER
And is there an equivalent service available on the NHS?
TONI
It's rare, I haven't heard of anybody actually offering it. You can in actual fact use it on the hands as well but that's a procedure that I don't undertake, it actually takes a medium nerve block because that really is very painful indeed. The NBA basketball players have it done but there are problems with muscle weakness of the interossii.
PORTER
They have it done presumably so they don't have sweaty hands, so they can grip the ball better?
TONI
Yeah but they get weak hands and they don't sweat, so it's a bit of a self defeating thing.
PORTER
Sue Nicholl has suffered from hot sweaty feet for many years - particularly during the winter months when she can't wear open shoes. She has to sleep with her feet over the edge of the bed, outside the duvet. Just after Dr Toni had performed her first Botox treatment, I asked her how it had gone.
NICHOLL
I think you would expect anybody putting a needle into your foot to be slightly unpleasant so I'd say it was slightly uncomfortable but not to the point that you wouldn't want to have it done again or ...
PORTER
Yeah when you were up there you were comparing it to - I heard you compare it to leg waxing, something I've never had done I hasten to add but something you wouldn't volunteer for but worth it for the end result.
NICHOLL
Definitely, definitely. And it's a short amount of time so you know that it's going to come to an end very shortly, you wouldn't want it done for hours.
PORTER
Sixty four thousand dollar question - when it wears off around hopefully Easter next year will you be back for another one do you think?
NICHOLL
Yeah if it cures the problem then yeah definitely.
PORTER
Sue Nicholl talking to me earlier at Dr Eric Toni's clinic in Enfield. You are listening to Case Notes, I am Dr Mark Porter and I am talking feet with my guest podiatrist Emma Supple.
Emma, let's move on to flat feet. What does the term actually mean - and can people tell whether or not they've got a healthy arch?
SUPPLE
Yes, flat feet is one of things that everyone knows the term but not many people actually understand what we're talking about.
PORTER
Including a lot of doctors, I hasten to add.
SUPPLE
What we're really looking for is does the foot do an excessive amount of movement when it takes weight on the ground. So if your foot tilts and rotates when it meets the ground and that does that excessively, starts to take other ligaments and tendons with it, then we're concerned. If it stays the same, whether it's up or down, i.e. as flat as a pancake, we're not too worried. If there's a movement from the up position to the ground then ...
PORTER
And that movement would be - you're looking at the inside edge of the foot would go towards the floor and generally that's a direction movement.
SUPPLE
You can actually watch the heel tilt as you make ground contact and then the rest of the foot - all those bones we were mentioning earlier - follow, that needs treatment.
PORTER
So it doesn't matter if you've got a - if you've already got a slightly collapsed arch and it stays the same but it's when it moves as you apply the weight to it. And that would lead to what sort of problems later on then?
SUPPLE
Well knees will follow wherever the foot goes, the hip will then follow wherever the knee goes in that old lovely nursery rhyme - hip bones connected etc. And essentially it's really important to give yourself a stable basis because obviously we use our feet for walking and therefore one foot is braced and holding the step, whilst the other one is swinging past you. So you have to have some stability and if you've added in an extra piece of movement there because that's the way your foot's made then that's what we call excessive pronation and we want to treat it.
PORTER
I get a lot of mums coming in, parents coming in, with young children who are starting to walk because they get quite - they often have quite flat looking feet to start with don't they.
SUPPLE
Yes, babies feet are obviously very cute but obviously before they wear shoes they have this slightly upturned toe position which can be mistaken for a flat foot. That does not mean to say that they won't maintain that because obviously there are lots of adults walking around with this flat foot, so the sooner we can get these children treated the better. But having said that it's always best to wait until the child has got into some shoes, walking a little bit, before you move into any territory and get a professional piece of advice there.
PORTER
And briefly if you saw someone you were worried about what sort of intervention can you offer them to help?
SUPPLE
For children, very soft orthotics that cut the heel and just don't allow that extra piece of movement downwards.
PORTER
And in adults as well?
SUPPLE
In adults they can become a little bit more rigid because obviously we're heavier and it's going back to this bracing idea. But essentially an insole or an orthotic, something that sits in your shoe and holds your foot in a more neutral position.
PORTER
Ok, I want to move on to another very common concern now - plantar fasciitis. It's sort of the foot equivalent of tennis elbow and the most common cause of heel pain. But what is the best way to tackle it. Podiatric surgeon Steven Kriss has a special interest in the condition - not surprising given that it accounts for around 10% of all the people he sees in his busy outpatients' clinic at West Berkshire Community Hospital.
KRISS
Hi Mia I'm Mr Kriss. Now I've got a letter from your GP saying that you've got pain, is it, in both of your heels or just the one?
MIA
Yes both of my heels.
KRISS
Are they both equally as painful?
MIA
No, no the left foot has lessened but the right foot has become quite bad.
KRISS
And how long has this been going on for?
MIA
Plus, minus two years.
KRISS
Two years. And do you remember doing anything at that time that might have started this off?
MIA
No I just thought being a nanny I'm on my feet all day, that's probably where it came from.
KRISS
What's it like when you get out of bed in the morning?
MIA
That hurts. I basically have to brace myself against the wall put my feet down and then stand up slowly, it's just like standing on glass really.
KRISS
The common story is that somebody wakes up and they put their heel to the ground and they experience excruciating pain. And they look at their heel to see if there's something there and they can't find anything and they take a few steps and then for some reason it seems to get better. And then when they sit down for a while and go to stand up it hurts once more. And they sort of soldier on with this for a while and then they decide that something probably should be done about it.
PORTER
And what do we think is going wrong because I mean people are up and about on their feet, they're using their feet, they're stressing this plantar fascia all of the time, why would they suddenly develop a problem there?
KRISS
Well probably little is known about this but what tends to happen is the fascia is pulled away from its origin to the heel bone and this can happen for a variety of reasons and often no obvious reason at all. But in some people it's because of say a sports injury or unaccustomed exercise, it can be associated with certain types of arthritis in a rare group of people. But for the vast majority there's no trauma and no particular story. In many people it's a self-limiting condition and after in some people three months, in some people a year, it just goes away.
PORTER
Presuming we catch it early in general practice what self-help measures are there?
KRISS
Well there are a number of things that people can do for themselves. Firstly it's to wear good comfortable supportive shoes and I often recommend trainers or a good soft lace up shoe, I think that's vital. The second ingredient is to carry out regular stretches, particularly of the calf muscle, because it seems that there's a connection between a tight Achilles tendon and the development of plantar fasciitis and you can google Achilles tendon stretches if you like and it will show you the stretches to do on the net. The other thing is some kind of support for the foot, some kind of an insole, as long as it's comfortable, soft, supportive of the arch and stops the foot from rolling in too much when people walk. It's the rolling in - what's called pronation - of the foot that seems to exacerbate the problem. And when you correct that problem for many people it solves the problem and that's what people should try initially.
PORTER
Assuming self-help measures don't help or the condition persists and the patient ends up being referred to somebody like you what are the next stages, I mean assuming that you've ruled out any underlying cause?
KRISS
A lot of people are prescribed non-steroidals - anti-inflammatory - drugs by their GPs and I've probably got a biased view of this because most of the people that come to see me have tried those and it hasn't worked for them. So I'm not sure how good they are actually. But those people that do come to see me who have persistent pain and who clearly have no other cause other than the standard, what I call, mechanical fasciitis - plantar fasciitis - I would probably start with a steroid injection into the heel. If I think they need to have an ultrasound scan because I'm suspicious of possibly some other cause like a trapped nerve around the ankle, what's called a tarsal tunnel syndrome - but if I feel that it's just a standard mechanical plantar fasciitis that hasn't responded and it's been going on for probably four or five months at that point I would give a steroid injection into the heel.
MIA
Well I've seen a - I think a chiropodist about 18 months ago, she gave me steroid injections in the left foot and some exercises to do which I still do daily but that's it, that's where it ended.
KRISS
And the steroids didn't help at all?
MIA
It lessened the left foot, as I say the left foot is now painful but manageable, yes.
PORTER
But what happens if the injection doesn't work, you and I both know that there are cases that persist despite injections, sometimes multiple injections?
KRISS
Yeah well I wouldn't inject more than two, maximum three times. Other techniques could include immobilisation of the limb for a while ...
PORTER
Put in plaster.
KRISS
Put in a plaster cast but in my experience again they're fine whilst you're in the cast, you come out of it and the pain comes back. And in the small minority of patients who have failed on all of these treatments then you're looking at surgery. And that would include, in my hands, what's called a fasciotomy, which basically means that you sever the fascia. The plantar fascia is in fact divided into three bands - the medial, the inside band which is commonly affected by plantar fasciitis is the strongest and that's the band that you sever. And I do tell patients that there is a small risk that there'll be some collapse in the arch of the foot as a result of this but you need to do your surgery carefully and in most patients I've operated on I've not seen that and once there's no connection of this band of fascia between the front and the back part of the foot then in general the pain goes.
PORTER
Podiatric surgeon Steven Kriss.
Emma, let's move from the back of the foot to the front - and common problems with the toes. Tell me about Morton's neuroma.
SUPPLE
Morton's neuroma is a painful condition. Essentially it's a trapping of the digital nerve as it passes up through the metatarsals. We all know about metatarsals now from our footballing prowess but essentially these little nerves give sensation and innovation to our toes and if they get bumped as they go past these metatarsals they swell. A swollen nerve, wherever it is, hurts and Morton's neuroma is the name that's given to these swollen digital nerves, so the words we use now is plantar digital neuritis, which essentially means that you're catching and trapping this nerve.
PORTER
And the key symptoms would be what?
SUPPLE
Pain and burning into this toe, so where these nerves are giving sensation in the cleft of your toe you get this horrible deep sharp shooting pain, really unpleasant, people classically talk about having to take their shoe off, massage their foot, sometimes they'll hear a click as this swollen nerve moves out of place and those are the pains that you get.
PORTER
And what can be done about them?
SUPPLE
Well first and foremost you want to move into a wider broader shoe because obviously any tightness or any very ...
PORTER
And allow the end of those bones to spread out a bit.
SUPPLE
Absolutely, that's the first thing you do. The calf muscle stretches are very important as well just to improve overall foot function and in the acute stages of this condition if you get some simple toe spacers and just spread your toes and just take the pressure of your nerve you might look a bit silly but it will work very well initially. Putting some anti-inflammatory gel onto that area will help and then go and seek some professional help if those measures don't stop it.
PORTER
Because some end up needing operations.
SUPPLE
Some do, yes, the research shows that the metatarsals - the third and the fourth toe - they need surgery. If you're getting pain in the second toe then increasingly we're realising that that's not a Morton's neuroma, that's more of a capsulitis and a catching of the nerve and the joint pain.
PORTER
I want to now go to the big toe which seems particularly susceptible to trouble, of course - well perhaps the most infamous of which would be the bunion, what is a bunion?
SUPPLE
A bunion is where the - again the big metatarsal, the first metatarsal, moves into the inward position of your body, so in other words it starts to lean inwards, whilst your big toe moves outwards, so you get this V shape happening. So the ...
PORTER
Basically the big toe ends up pointing outwards.
SUPPLE
Exactly, that's because of shoes. So what you see is this sort of turnip shape lump coming on the inside border of your foot and that is a bunion and of course it's taking up room in your shoes, it's starting to rub, the joint is becoming separated from itself so it's starting to get a bit arthritic and it hurts.
PORTER
Tell me about what causes these because they're much more common in women, certainly that's my understanding as a GP, is it the fact that women wear less sensible shoes than men or is there more at play here?
SUPPLE
There is more at play here, the actual aetiology is not completely understood but we know it's multi-factorial, in other words it's shoes, you have a huge genetic disposition to these ...
PORTER
They run in families.
SUPPLE
They run in families but men get them as well and people who've never worn shoes have got them. So even in unshod populations bunions do exist. So it's a foot fault.
PORTER
One thing for sure wearing high heels doesn't help.
SUPPLE
It doesn't help and will make it go faster.
PORTER
Well bunions are not the only painful problem that can afflict the big toe. As keen tennis player Tricia Macnair discovered to her cost.
MACNAIR
Well I've come down to my local tennis courts, as I do every week for a game, and as usual after 15-20 minutes I've just had to stop because the pain in my foot is quite unbearable. I've got a problem called Hallux rigidus. It's caused by arthritis in one of the main joints of the big toe and over the years I've had it injected and it just hasn't helped, so now I'm going to have to go for surgery and I've gone to see Mr Anthony Sakellariou, who's a consultant orthopaedic surgeon at Frimley Park Hospital and I'm going in to have my toe joint tidied up.
SAKELLARIOU
Hallux refers to the big toe, Hallux rigidus, again a rigid big toe. And it's rigid because you get arthritis degeneration in that joint. Often confused with Hallux valgus, which is the bunion.
MACNAIR
Everybody's looked at my foot and said well it looks perfectly normal, I think they were expecting to see a bunion shaped bump.
SAKELLARIOU
That's right because the difference is that Hallux valgus, the bump, is on the side of the foot and makes the foot wider, whereas in Hallux rigidus the bump is usually on the top of the joint.
Okay, let's take a look at your x-rays. If you look at the side on view you'll see these little spurs of bone at the top of what's called your metatarsal bone and also the top of what's called the proximal phalanx of your big toe joint.
MACNAIR
Yes they kind of stick out like little horns on the top of my bones.
SAKELLARIOU
That's right and those are called osteophytes and in this particular instance they're fairly typical of this disease and they irritate the soft tissues above the joint and that's one of the sources of your pain.
MACNAIR
Well it's two weeks since I had my operation and I'm back at Frimley Park Hospital for a check up with Mr Sakellarious. What did you find when you opened it up, how bad was it?
SAKELLARIOU
It was pretty typical in that the arthritis was at the top of the joint. The pain that you get from an arthritic big toe joint is two fold: One is from the little spurs, bony spurs, that you develop around the joint that irritate the soft tissues around the joint as you move but there's also sometimes pain which you will get from within the joint because it's degenerate, it's arthritic. And the operation you had was designed in some ways to address both - so by removing the little bony spurs you remove the irritation of the soft tissues around that joint, you make the joint look less bulky as well. Now in your particular case there was a little bit of extra arthritis in an area which isn't - wouldn't normally be removed from the [indistinct word], as it's called, removing those little spurs. And as it was bare bone I decided to do something called micro-fracture, which is where you break the bone, allow it to bleed, that bleeding clots and that clot forms a kind of false cartilage in that patch which is bare and it's better than having no cartilage at all.
MACNAIR
And I've actually managed to catch Sylvia, the physio, who gave me lots of advice when I first had the operation just afterwards. I've had two weeks of putting my feet up on the sofa, lots of wiggling the toes to keep the movement going, I've had ice packs, I've had non-steroidal anti-inflammatory drugs. So hopefully that's started to get the swelling down and it's been fairly pain free.
SYLVIA
So yes, I think you just still need to spend a bit of time working to elevate it and try and reduce the swelling because obviously it's still is looking a little bit swollen there.
MACNAIR
Straight after the operation you gave me some fairly specific advice about what to do with my foot and then the physio came along to see me, how important is all of that?
SAKELLARIOU
Well it's very important because the purpose of the operation is to maintain motion of this joint, so although in the first 48 hours after the operation I tell you to look after it and not walk on it much in the first couple of days, I do tell you that you must move the big toe straight away, even within the confines of the bandages. And we've talked about actively moving it, that's you moving it yourself and passively moving it - which is actually grabbing it with your finger and moving the joint through the range that is still comfortable.
MACNAIR
The big question here that I want to know is can I go back to wearing my heels? I hope you're going to say yes.
SAKELLARIOU
Well from what you've said so far it looks as if your operation has been successful. I would expect you to go on improving for at least two or three months and at the end of those three months yes I would expect you to be able to wear heels, you may not be able to wear four and six inch heels but ...
MACNAIR
Fortunately I think that's beyond me anyway.
PORTER
Orthopaedic surgeon Anthony Sakellariou and our reporter Tricia Macnair, who will no longer be able to blame the standard of her tennis on a painful big toe.
Emma, we haven't talked about skin complaints like athletes' foot and one of my bug bears - pitted keratolysis - two very different problems, with different causes and treatments, but often confused? Let's first of all start with athletes' foot, fungal infection, where do most people go wrong?
SUPPLE
Most people go wrong by missing it, they think that dry scaly skin on the sole of the foot is exactly that and treat it with an ordinary foot cream and actually it is a fungal infection and they just don't recognise it. So if you've got dry scaly skin and you're being fantastically diligent at moisturising your feet think fungal.
PORTER
And an antifungal cream and any better than any others?
SUPPLE
The antifungals have been revolutionised recently with the introduction of terbinafine which is the first fungicidal piece of...
PORTER
Which means it kills funguses rather than ...
SUPPLE
Everything else is fungus static and just literally made things go static.
PORTER
And that's available - you can ask your pharmacist about that.
Now talking about confusion of diagnosis, pitted keratolysis, I call this trainers' foot, it's not a very accurate term, but you get people coming in with this sort of white cheesy looking horrible ...
SUPPLE
Very unpleasant.
PORTER
... looking feet, very smelly, which they treat as athletes' foot and it doesn't get better because?
SUPPLE
Because it's actually a skin bacteria that sits on the skin and it creates little craters, little tiny craters, and that's where the pitted word comes from. And essentially the keratin is cratered by the bacteria. So straightforward - move your antibacterial soap from your kitchen sink and move it down to your feet and give your feet a good wash and antibacterial treatments will help enormously here.
PORTER
And we can use creams for that ...
SUPPLE
Not antifungals.
PORTER
No, not antifungals they don't work, antibacterial. Your basic tips for good foot care briefly?
SUPPLE
Never go to bed with dirty feet, years of experience have taught me and I really think this is true if you have dirty feet it contributes to hard skin and callous formation. Secondly, use a good foot cream and use it daily because good skin makes a big difference.
PORTER
And by foot cream you mean a moisturiser?
SUPPLE
I mean a moisturising cream. If you give the skin back its suppleness, excuse the pun, it helps enormously, it takes you out of danger. And third be sensible with your shoes, wear your high heels for high days and holidays, don't walk too far in too high and for too long.
PORTER
And buy the right size because daft though it may sound a lot of people don't have the right size.
SUPPLE
They don't, they had them last measured when they were 12 and they still think that that's their shoe size.
PORTER
Emma Supple, thank you very much.
As always you can listen back to any part of the programme by clicking on the Listen Again facility at bbc.co.uk/radio4 - where you will also find some useful foot related contacts and addresses. And if you don't have access to the internet then do try calling our Action Line on 0800 044 044.
Next week we'll be travelling to the other end of the body to find out about the latest developments in the management of headaches. Why don't most people with migraines seek their doctor's help? What treatments are they likely to be missing out on? And I'll be examining the widely held belief that eye strain is a common cause of headache, to determine whether it's fact or fiction.
ENDS
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