If you google the term ‘tendinitis treatment’ one of the commonest pieces of advice is to ‘stretch’ the affected tendon and surrounding muscles. This might sound good in theory but can actually be detrimental in getting your tendon better. Tendinitis is now better termed ‘tendinopathy’ given that research has now shown there is virtually a nil inflammatory process taking place in most cases.
Tendons are made of collagenous tissue within an extra-cellular matrix.They essentially join muscles to our bones but also play an important part is transferring load. Research has shown that tendons can be subjected to two main types of loads – tensile and compressive.
Tendons are subjected to tensile loads every day and they can withstand 6-8 times our body weight of load. For example, a runner’s Achilles tendon would be subjected to more tensile load if they increased their mileage.
Compressive loads have been shown to also aggravate tendons. A compressive load on the Achilles tendon example would be whereby the foot and ankle is in a dorsiflexed or upwards position and the tendon is in a lengthened position e.g. during a squat position. An achilles tendon would be placed under a compressive load if one was to do a calf stretch against a wall. This stretch is commonly advised for Achilles tendinitis and may actually provoke an already aggravated tendon.
Other commonly prescribed treatments may not always be the best for reactive tendons; eccentric exercises are also commonly prescribed for this condition whereby the heel is dropped down over a stair, again applying a compressive load to the tendon.
Massage to a reactive tendon may also aggravate it further. Better treatments particularly in the reactive phase of tendinopathy would be massage to the muscle belly or surrounding muscles and/or isometric loading exercises. There are other treatment adjuncts to these that may also be helpful for tendinopathy.
An intoed gait (where the toes point inwards) when walking and running is quite common in children. In some cases this is part of normal development and other times not. A common side effect of intoed gait is increased tripping and falling (sometimes worse when running or playing sport). It is not usually painful.
How common is it?
Studies have shown that at 1 in 10 (or more) children have intoed gait. Intoed gait is quite common up to the age of 6 years, and then tends to reduct with increasing aga, so the good news is that many people grow out of it during childhood.
What causes it?
Intoed gait can arise from a single cause or multiple causes, and the primary causes of intoed gait are usually caused by different things at different age groups, as follows:
Infants (1-2 years): metatarsus adductus (when the front part of the foot bends towads the midline between the two feet
Toddlers (2-3 years): internal tibial torsion (when the shin bone twists towards the mid
Childnren (over 3 years): femoral torsion (a twisting of the thigh bone)
Sometimes, there is no deformity and the cause can be related to tight muscles. In all cases a thorough assessment is warranted in order to exclude other conditions.
In order to come up with a diagnosis, your podiatrist may ask questions about the child’s birth, growth and development, as well as conducting a physical examination and assessment of gait. At the Perth Foot & Ankle Clinic we also have a Bodytech treadmill and gait analysis machine, which is not only helpful in diagnosis, but is also a valuable tool to help monitor a child’s development over time.
Often the cause of intoed gait is developmental (i.e. part of growing up) and it will resolve over time.
Intoed gait can run in families, so it can be more likely if siblings or parents have had the same problem.
Some neurological problems can cause intoed gait
Some other orthopaedic problems can cause changes in the hips, legs or feet which can lead to intoed gait.
Treatment depends upon the diagnosis, and may include the following:
Monitoring and observation (in other words, no treatment)
Changes in sitting/sleeping postures
Stretches and exercises (usually in the form of games in younger children)
Different shoe choices
Special orthotics called gait plates, that encourage the foot to work in a more straight position and minimise tripping/falling
Just like adults, children suffer from aches and pains in the legs too. Growing pains in children are quite common, and treatment options are available. This article describes growing pains, how this condition is diagnosed, and what can be done about it.
Growing pains refers to non-specific muscle pain (i.e. not related to a known injury or other cause) of both legs, which occurs at night time.
Pain in the joints of the legs and feet are not growing pains, and need to be assessed to see if there is another problem.
Over the years, there has been some discussion as to what “growing pains” actually is and what causes it. Even if we are not exactly sure what does cause it, growing pains occur commonly enough in children to be regularly seen by Podiatrists and other health professionals. About one third of children will experience growing pains at some point.
What causes growing pains?
The exact cause of growing pains is still uncertain. There are 3 main theories at present:
The anatomical theory, where orthopaedic or biomehanical factors such as flat feet or knock knees create increased muscle use in the legs.
The fatigue theory, which proposes that the pain is from overuse of leg muscles in active children.
The psychological theory, which views growing pains as part of a larger syndrome of pain and susceptability to pain, including abdominal pain and headaches, particularly migraine headaches.
Whatever the cause, there is also a family pattern to growing pains, so that children whose parents or siblings have had growing pains are much more likely to develop them. There is also concern that children whose pain is not adequately addressed are less likely to be able to cope with pain as adults, which makes it important to properly treat growing pains.
Because growing pains are non-specific, a diagnosis is usually made by excluding all the other things it might be, and if nothing else if left, then that’s what it must be. The following table summarises things that could be growing pains and things that are definitely not growing pains.
Sometimes, further investigations or referral to a specialist may be required if it is possible that there are other reasons for the pain.
Typical features of the child with growing pains
Usually the child will complain of aching, sore legs at bed time or they may wake up during the night with the same problem. The amount of distress the child experiences may result in complaining, crying or even screaming in some cases.
The typical pattern of growing pains is that they may occur for a few nights, and then none for one to three months. Sometimes it is more common to get growing pains after a day of intense physical activity.
Many treatment options have been suggested for growing pains, but most do not have any scientific evidence to support them.
A good first step is to get the parents to start keeping a pain diary, which charts how often child gets growing pains and how severe the pain is.
Mild cases may be alleviated with reassurance, rubbing the legs, or perhaps a hot water bottle.
More severe cases may be helped with medication, such as paracetamol.
The best scientific evidence supports muscle stretching (thigh and calf stretches). Your podiatrist can provide a suitable stretching programme
If there is an underlying biomechanical problem (for example, flat feet) that might be contributing to the problem, then this can be assessed and treated (for example with orthotics) as well.
See our podiatrists at the Perth Foot & Ankle Clinic for information about and treatment of fungal nail infections.
Fungal infections of the nails (technically known as onychomycosis or tinea unguim) are quite common, affecting up to 10% of adults in Western countries, and increasing to about 20% of older people. It is much more common to get fungal infections of the toenails than the fingernails (perhaps because feet often live in the dark, humid environment of shoes).
Fungal nail infections are most commonly caused by a class of fungi called dermatophytes, which can infect the skin as well as the nails. Some yeasts can also cause infections of the nails, and there may be infection by a combination of fungi, yeasts, and bacteria. Sometimes the skin around the nail is involved. If you have a fungal nail infection then you almost certainly have the same fungus on your skin (even if you cannot see a problem with the skin).
Appearance and classification
The most common type of fungal nail infection starts at the ends or sides of the nail and spreads slowly towards the cuticle. The infected area may be white or yellow, and there may be a gap between the nail and the underlying toe (called onycholysis).
More rarely, the infection may start at the base of the nail. This is more commonly associated with underlying medical problems.
Sometimes only the surface of the nail is involved, especially in those who wear nail polish frequently.
Over time, the infected nail may become thickened, misshapen and flakey.
Causes and risk factors
In normal, healthy people, fungal infections of the nails are most commonly caused by a fungus that is caught from moist, wet areas. Communal showers, such as those at a gym or swimming pools, are common sources. Going to nail salons that inadequately sanitise instruments (such as clippers, filers, and foot tubs) in addition to living with family members who have fungal nails are also risk factors. Using nail polish, especially for extended periods of time, make the nails more susceptible to fungal infections. Athletes have been proven to be more susceptible to nail fungus. This is presumed to be due to the wearing of tight-fitting, sweaty shoes and associated with repetitive trauma to the toenails. Having athlete’s foot makes it more likely that the fungus will infect your toenails. Repetitive trauma also weakens the nail, which makes the nail more susceptible to fungal infection.
Elderly people and people with certain underlying disease states are also at higher risk. These include anything that impairs your immune system, making you prone to getting infected with the fungus. For example, conditions such as diabetes, cancer, AIDS, psoriasis, or taking immunosuppressive medications such as steroids.
Are fungal nail infections contagious?
Fungal infections of the skin and nails are only slightly contagious, and so transmission from one person to another is unlikely, unless there is intimate contact or sharing of socks or footwear. Some people are more susceptible than others. For example, two people can share the same bed, but only one may develop a fungal infection, even though the other person is exposed to the fungi as well.
Fungal nail infections are either diagnosed clinically (which means by a health practitioner examining them and concluding that the appearance is most likely caused by a fungal infection), or by collecting samples of the nail and sending them to a pathology laboratory for confirmation. While this can give a definitive diagnosis, there are often false negatives (which means that there is a fungal infection, but the laboratory sample could not confirm it). Also, fungal nail infections are more likely to occur in nails which already have other problems, so there might be a fungal nail infection and another problem with the nails. Nails may look abnormal for several other reasons. For information on other causes of funny looking nails, see here.
Who should get treated?
Many people do not actively treat their fungal nail infections, even though they are unsightly. Reasons to treat them include:
Concerns with the appearance of the nails.
Pain or discomfort (sometimes worse when wearing shoes, or with certain activities, such as sports).
Those who are at increased risk of getting other infections, or who have had infections or ulcers on their feet or legs in the past.
Those with certain medical problems, including diabetes.
Successful treatment is not always guaranteed and sometimes a recurrence can occur. It can also take 12 months or longer for the nails to appear normal again even after successful treatment because the nails grow slowly. The new healthy nail takes time to replace the old fungal-looking nail. Whatever treatment option you choose, you will need to be patient!
Regularly keeping the nails properly trimmed and thinned (if necessary) makes them look and feel better and minimises the amount of fungus in the nails. It is highly recommended to do this whatever treatment is chosen.
Treatment options include:
The most commonly used oral medication in Australia is Terbinafine (e.g. Lamisil). Tablets are taken daily for up to 6 months. It is generally quite effective, but not always. You may need to have blood tests whilst taking this medication.
Other oral medications less commonly used include Itraconazole (e.g. Sporanox), Fluconazole (e.g. Diflucan) and Griseofulvin (e.g. Grisovin)
Amorolfine lacquer (e.g. Loceryl) is applied regularly to the nail, which needs to be filed down first. It is quite effective, but relies on regular application. It is less effective if the nail infection goes all the way to the base of the nail.
Ciclopirox (Rejuvenail). Another drugs which is applied to the nail.
Terbinafine (e.g. Lamisil, Solveasy). Available in several formulations, including spray, cream etc. Great for treating fungal skin infections, but not very effective on nails as the only treatment method.
Others. There are a number of antifungal products available from chemists. Most of these are not particularly effective for treating fungal nail infections.
A laser of a specific wavelength is used to penetrate the nail and kill the fungus. Laser fungal nail treatment is painless and convenient, and usually requires 2 to 4 treatments over several months.
Surgical removal of the nail. This can be done when the nail has a fungal infection, or when it has been damaged by trauma or other infections. Further treatment with anti-fungal medications (either oral or topical) may be warranted in order to prevent recurrence.
Products such as Emtrix claim to help the nail look better as well as making the nail a difficult environment for the fungal infection to survive.
Home Remedies. There are quite a few of these. Most have minimal scientific evidence to support their use.
Vinegar is probably not helpful for most fungal infections, but may be helpful with yeast infections, especially of the skin.
Oils, such as tea tree oil, essential oils, coconut oil and oil of cedar leaf.
Bleach, Hydrogen Peroxide. These can cause skin irritation.
Urea cream softens the nail, and makes it easy to trim and thin.
Undecylenic acid, propylene glycol: these ingredients may be listed in some off-the-shelf treatments. They have anti-fungal properties, but may have difficulty in penetrating the nail, and can irritate the skin in some cases.
Prognosis (will it get better?)
Curing fungal nails can be difficult and treatment can take more than 12 months. Relapse and reinfection are common (40%-70% reinfection rate). Trying to remove or modify your risk factors, if possible, is essential to preventing reinfection. People who have medical illnesses that predispose them to fungal nails can have an even more difficult time eradicating the fungus.
Recurrence (will it come back?)
If you are predisposed to getting fungal nail infections or tinea, then it can come back. A recurrence after a previous treatment does not mean that the treatment failed; you can get another infection later on.
There are also ways to minimise the chance of reinfections. These include:
Clean and dry your feet regularly.
Keep your toenails properly trimmed. If you can’t do this yourself, get your podiatrist to do it on a regular basis.
Good hygiene with socks and footwear. Wear clean, dry socks and properly fitting shoes. If your washing machine has a hot wash option, then washing in water at least 60 degrees centigrade will kill most fungus. Using anti-fungal laundry additives such as Canesten laundry rinse may also help.
Rotating shoes, so you don’t wear the same pair every day. This allows them to air and dry out. You can also use portable UV light sanitisers and other methods to disinfect shoes.
Don’t wear shoes all the time. If you live in a warm climate then open shoes and bare feet from time to time helps. Get some air and light onto your feet!
Athlete’s foot (tinea) is caused by the same bug that causes fungal nail infections, and so can spread to the nails. If you have athlete’s foot, then treat this with an appropriate anti-fungal cream containing Terbinafine (e.g. Lamisil, Solveasy).
Don’t wear nail polish continuously. Have a break from time to time.
Dancers are a special type of athlete whose art form is physically rigorous. They possess extraordinary physical attributes and abilities; the feet and ankles comprise just one region of the body where this is true. Foot and ankle injuries make up approximately 50-70% of all injuries that dancers sustain.
Overuse injuries are more common than traumatic injuries, given the repetitive load requirements of dance coupled with the inability of the body’s tissues to withstand the demands that are imposed on them. The foot/ankle/lower leg area is vulnerable to a wide range of injuries, including stress fractures, tendon injuries, sprains, and strains.
Tendinopathy is commonly an overuse injury whereby the tendon becomes painful, stiff and swollen. The Achilles tendon and the Flexor Hallucis Longus tendon are two tendons that are commonly affected in dancers. Factors that contribute to the development of this condition include extrinsic factors such as flooring, changes in training schedule or poor technique. Intrinsic factors include tendon vascularity, gastrocnemius-soleus function and age/weight. Treatment includes rest, use of electro-physical agents such as low level laser therapy, activity modification, orthotic therapy and strengthening exercises.
Posterior Ankle Impingement
Posterior ankle impingement is a condition characterised by tissue damage at the back of the ankle joint due to compression of these tissues during maximal ankle plantarflexion. This condition is commonly associated with ballet dancers who require extreme range of motion in their ankle joint to achieve the en pointe position. The impingement may be associated with poor ankle joint mobility causing the tissues to become damaged when forcing the foot to an en pointe position. Soft tissue impingement can be caused by thickening or irritation of the FHL tendon, posterior joint capsule thickening or synovitis. In other cases a separate extra bone (os trigonum) may develop or extra bony growth on the talus may prevent the dancer from obtaining full ankle plantarflexion.
Initially conservative management should be the first line approach. This includes a period of rest and occasionally an immobilising boot be may be required. Physical therapy such as myofascial release, low level laser therapy, joint mobilisation and taping can help settle symptoms. Rehabilitation should address any biomechanical anomalies, muscular weaknesses or poor athletic technique that may be contributing to the development of the syndrome. In extreme cases or cases that do not respond to conservative care, a surgical opinion may be required.
Stress fractures are incomplete breaks of the bone. A stress fracture of the metatarsal typically occurs over time with excessive weight bearing activity such as running, sprinting, jumping or dancing. It is commonly associated with changes in the intensity of activity (i.e. sudden increase of activity) or changes in the training conditions (such as footwear, surfaces, etc.). It may also be caused traumatically such as a poor landing from a jump in dancers or landing from a height. Poor calf muscle strength can cause excessive forefoot loading and fatigue of these muscles in dancers may contribute to the development of this condition. It commonly affects the 2nd and 5th metatarsals.
The management of stress fractures requires a rest period from weight bearing aggravating activities for 6-8 weeks. In the initial phase of treatment an offloading walker is used for two to four weeks. Low level laser therapy may be useful in reducing pain, swelling and increase bony remodelling. Orthotic therapy may be required to help reduce abnormal load from poor foot mechanics. Exercises to improve the function of the intrinsic and extrinsic foot muscles may help to prevent recurrence.
How Your Podiatrist Can Help
Podiatrists are equipped to diagnose, treat, manage and prevent these injuries. We have the ability to refer for imaging if necessary, such as x-ray, ultrasound and other modalities if required. We also have a broad range of manual skills including, joint mobilisation, dry needling, myofascial release, strapping/taping along with rehabilitation and strengthening exercise prescription. We also offer the common podiatry modalities such as skin and nail debridement. The Perth Foot and Ankle Clinic offers Low Level Laser Therapy as an adjunctive therapy. This is a painless, effective and drug free treatment option that can be beneficial to the dancing population whereby other treatment options such as orthotics cannot be used.