Patient Management: What I’ve Learnt but Struggled to Enforce as a New Graduate


Patient Management:
What I’ve Learnt but Struggled to Enforce as a New Graduate 

Recently Podiatry Today published a piece written by Lynn Homisak discussing the “Twenty-Four Things You Should Know About Managing Your Practice…” Many of the points were very much directed at those who own a business or are at least looking too. For those of us who have recently graduated much of what is divulged almost seems straight forward, less of an ah ha moment and more of a duh moment, but truth be told as practical as these dot points may seem they are regularly over looked by those who have been in the business world a long time as well as those who have just entered because putting them in place is much harder to accomplish in real life than producing the statement.                                                                                                                      

The remarks which caught my attention as a New Graduate were specifically those associated with patient management. While at University there is no doubt we learnt a lot, but there is so much which can only be learnt when you’re thrown in the deep end with the ability to see a patient on any given day of the week as opposed to two or three designated days a week at a student clinic which almost guarantees no less than a week review time – a habit which becomes quite hard to break. Let’s take a look at four of twenty-four dot points Lynn discussed in more of an in-depth view of what I have learnt since entering the work force.

1. “Do not be your patient’s financial adviser. Offer care based on what is best for your patients, not based on the jeans they wear, the phone they carry, the car they drive or the insurance they have. Let them decide what they can and cannot afford”

This statement made me ask the question; at times does our caring compassionate nature distract us from providing the best possible treatment to a patient? How often have you adjusted your management to try and fit a client’s current financial situation? If you’re anything like me you’ve tried to be as accommodating as possible to try and get your patient back to better health, many times over looking the Gold Standard to provide sub-par options which may or may not achieve your intended goal.
The idea of intervention expenses is a relatively new concept for many of us who are fresh out of the lecture theatres and public hospital placements. The comparison of prices offered at the university clinic as opposed to many of the private work places we now occupy is significant. If a patient walks into the treating room and within their first few sentences once asked “how have things been?” have anything to do with money woes the difficulty in even being able to bring  up the need for a $600+ pair of custom orthotics is exacerbated.
I grew up in the country and moved to Melbourne for university, my monthly budget was $1300 which had to go towards rent, food, bills, petrol and whatever was left either was saved or went towards some kind of entertainment –  there was very rarely much left over. It’s difficult not to think of these struggles I had when patients talk about their own issues associated with cash flow.
Quite often by supplying the Gold Standard intervention the patient gets back to pre-injury health faster, minimising the amount of re-scheduling needed to evaluate interventions and patient conditions, therefore reducing the risk of patients being unable to afford scheduled appointments and opting for the “play it by ear” comment which often leads to a visit to another practitioner.
It is our responsibility to offer the best possible to care to a patient, if they are adamant that the primary option offered is too expensive then document what has been vocalised and approach with the next viable option. If after a predetermined amount of time the patient is not progressing as efficiently as you had hoped it’s time to re-visit your original management plan and have the “investment in your health talk”.
Leading us into our next dot point.

2. “Overall, doctors do not make the best managers and ‘playing it by ear’ is mostly ineffective”

Let’s face it, we are busy people, and when a patient calls you and you are nowhere near their case notes, starting a conversation with “Hi, its John Doe, I’m the one with the flat feet”, you’re in a bit of strife. As I stated earlier, playing it by ear is not effective unless you have discharged your patient because they have reached the pre-injury stage of rehabilitation. Re-scheduling a patient who is 95% better is a necessity, assuming they are going to reach that 100% mark in the next week with your implemented intervention breaches your duty of care. You are better to re-schedule and have the patient ring to cancel if they are better and then proceed with a follow up phone call to answer any further questions or re-assure them you are only a phone call away if they begin to relapse.
From a New Graduate perspective I found this hard to grasp, not so much the breaching duty of care but the patient spending money just to be told they are in good health. This really comes down to you having the confidence to back yourself as a professional and no longer a student. The education you give your patients about their condition, how to treat it and how to prevent further injury can all be found with a simple Google search and a bulk billed/Medicare rebated trip to the doctors. Put simply, anyone can post anything on the internet and your patient has approached you for your professional opinion and giving a clean bill of health can be seen as an investment as opposed to an expense. I mean, why get a prostate exam or mammogram if you have no signs or symptoms of illness? Because that little money spent on a clean bill of health as a preventative measure has the potential to save a lot more money, stress and loss of wages down the track – comparing non-life threatening conditions to biomechanical issues of the foot and ankle may seem like an extreme example but the potential to be unable to stand/walk/run or decrease hip and lower back pain in a chronic setting has impending consequence of being unable to work, unable to exercise and increase possibility of depression or other physiological conditions .

  1. “Patients will not leave you for another doctor if you properly reschedule them to evaluate, diagnose and treat the three other conditions they bring to your attention during their reserved 10-15 minute encounter”.

Continuing on the topic of re-scheduling, the restricted times we have to fully evaluate a patient and delivering a prognosis which will be the basis for your proposed management plan. For every patient the same two questions need to be asked; “when should I schedule the next appointment and why am I scheduling within that timeframe?”
While attending university our time frame for treating patients could be anywhere from an hour to an hour and a half, in that time we may see a patient with elongated nails and some HK through to a stress fracture or tendon rupture. In the real world, most private practices offer appointment times of forty minutes for an initial and half that for a review. Additionally, you’re potential to re-schedule a patient as soon as the next day in private practice places you in a much better position clinically than the often seven day waiting period at a student associated clinic.
Let me give an example; If you have a patient who has been taped for calcaneus inversion bilaterally due to excessive pronation causing plantar foot pain and additionally has been provided Theraband strengthening exercises for rehabilitation which is expected to show results in two weeks, when should rescheduling take place?
The taping is only going to last approximately two days, if it has had the desired affect the patient will be feeling great and want to make it a permanent thing. If they have to wait a further twelve days before they see you again, are they going to remember that feeling or are they only going to associate how they feel now with the last couple days of pain?
If the tape is only going to last two days then try to get the patient rescheduled in three for evaluation of pain and re-assessment of exercises prescribed are being completed correctly.

Providing a definite diagnosis of a primary complaint may be a little difficult with only a forty minute appointment however, delivering a prognosis is at least viable. Patients want to leave your treatment room with a sense of direction; they want a name of the conditions so they can tell their friends or co-workers and they want an estimated time of rehabilitation provided that all goes according to plan.

As for the three other concerns they have regarding the lower limb, it is important to not provide a sub-par biomechanical/diabetes assessment in the interest of getting as many issues seen too as possible during the patient’s short initial consultation. Find out the patient’s primary concern and do everything you can to address it in an initial circumstance to provide the best outcome. Educate the patient about time restraints and if time permits, other issues will be attended too. If those other complaints happen to be the cause or caused by the primary complaint then killing two birds with one stone during initial management will elevate your status in the patients mind. If however, your patient happens to have relatively unrelated conditions; uncontrolled diabetes, osteoarthritis in the knee and a Morton’s neuroma then it is imperative that you see to the patients concern and not necessarily your own concerns about the patient, although acknowledging them.
By achieving this management practice during your first encounter with a patient you are able to change their expectations of management to be more suited to the interventions you wish to implement. Therefore, preventing the final dot point from becoming an issue for you and other staff.

4. “When you spend extra time accommodating a patient for unscheduled conditions, you are being unfair to your patients who came on time and are waiting unnecessarily”

In conclusion, I hope this will help with your patient management or has shown you the barriers new graduates may face when left to trust their own judgement when managing patients. If you have experience similar and have a different take on the ideas discussed or would like to further talk about that published today please feel free to leave a comment.

Lynn Homisak’s original published article can be found at the following address:
http://www.podiatrytoday.com/blogged/twenty-four-things-you-should-know-about-your-staff-i-die

Jackson McCosker
Director /Chief Editor

References:

Homisak, L. (2014). Twenty-Four Things You Should Know About Managing Your Practice Before I Die. Retrieved June 9, 2014, from http://www.podiatrytoday.com/blogged/twenty-four-things-you-should-know-about-your-staff-i-die

Ankle Sprains: Lateral Ligaments, Instability and Rehabilitation


Ankle Sprains:
Lateral Ligaments, Instability and RehabilitationSocceroo's Mascot

With the FIFA World Cup about to kick off in just a couple of hours and Australia once again managing to be drawn in to a group of beautiful game powerhouses, we can only hope that our
underdog status will once again work to our advantage in progressing to the second round. Ange Postecoglou has just made his final cuts to the team and we have seen the disposal of Tom Rogic; once compared to a young Harry Kewell and Josh Kennedy who in Postecoglou’s defence has had on-going form drop in recent months.
But let’s separate ourselves for a second from the patriotic bandwagon of the Socceroos and take a narrowed look past group rounds, Qatar’s alleged bribery controversy and who the Oscar will go to for best dive; to the actual injuries which are sustained in such a high quality competition, more precisely lateral ankle sprains and the rehabilitation necessary for the swiftest return to sport.

The expression lateral ankle sprain is used loosely and in lemans terms commonly refers to a lateral ligament injury; where during play the foot is found in a inverted and plantarflexed position placing pressures on ATFL and CFL beyond that which they can tolerate resulting in tear or rupture of the structures( Brukner, P.,2013).
Please note a new grading system is soon to be published in 2014 for tendon/ligament damage we will review this at a later date.

Lateral ankle sprains have been identified as the most common structural injury amongst athletes outside of non-specific bruising ( Beynnon, B. D., Murphy, D. F., & Alosa, D. M. 2002). There have been a number of predictive factors flagged throughout the research identifying both intrinsic and extrinsic influences which have potential to cause lateral ankle sprains. One of the most positively linked intrinsic factor associated with lateral ankle sprains, is in fact previous history of a sprain. The initial injury is believed to cause a partial differentiation of the ankle, rendering it unstable biomechanically as a result of ligament compromise. Additionally, muscle reaction time, more specifically closed-loop efferent reflex response, was shown to be slower in previously injured athletes reducing the stabilizing effect of the gastrocnemius and tibialis anterior, suggesting a neuromuscular deficit (Beynnon, B. D., et al.2002)
Postural sway has also been shown to influence an athlete’s risk of ankle sprain. Taking into consideration that an athlete changes their centre of gravity multiple times within seconds of play, this is a key finding when it comes to rehabilitation as it is influenced by both the central and peripheral nervous system. Other intrinsic predictive influences which have been flagged but to date have not been individually proven include; gender, height, weight, limb dominance, anatomical foot type, foot size, hypermobility and muscle strength although clinically these finding may help in developing an overall reasoning for the injury.
Extrinsic risk factors influencing ankle sprains have primarily been observed through prospective studies inclusive of bracing, taping, shoe type and the duration and intensity of competition.
There have been a number of studies looking at the use of ankle braces and rigid taping in the prevention of ankle sprains, many of which have shown nil association in the prevention of an initial ligamentous injury; however consensus amongst researchers appears to be that the use of n ankle brace or taping has a positive influence in reducing a re-occurrence of injury. Given these findings contradict each other from a biomechanical standing, it is reasonable to deduct that the presence of a compressive force such as that previously mentioned provides proprioceptive feedback to the athlete.
Shoe Type has been found to have nil association with the incidence of ankle sprain injury. In two well-controlled studies comparing high top basketball shoes to light weight infantry boots and high top basketball shoes vs low top basketball shoes during military training exercises it was shown there was no difference in the incidence of ankle sprains. Additionally, when addressing duration of time played on field, field position and intensity of competition, no difference was found over one thousands hours of basketball game play. However, it should be noted that injury was more likely to take place during officiated game play rather than practice.

FIFA World Cup 2014 - BRAZIL

Prevention:
So how do we prevent such an injury which can leave an athlete out of game play anywhere from seven days to twelve weeks? The answer unfortunately is not a straight forward one, in fact, in terms of developing a prevention program for ankle sprains it is suggested clubs establish more specific technical training based on landing, take off and lateral cutting movements (Stasinopoulos, D. 2002). As mentioned previously, tape has only been found to have a positive preventative effect on athletes who have already sustained an injury, the same can be said for the use of custom orthoses which are recommended for at least twelve months following a serious ankle sprain due to duration it takes for ligaments to reach full repair and regain proprioceptive ability.
In short, research shows the preventative strategies were most effective in participants who had previously suffered an ankle sprain and not necessarily in limiting the possibility of initial instance.

Treatment:
So what are our treatment options once the injury has taken place?
It is suggested by that in the period 0-48 hours that basic soft tissue injury protocol takes place with the addition of protected mobilization as follows;

  • Protected Mobilization (open chain, controlled movements with nil resistance)
  • Rest
  • Ice
  • Compression
  • Elevation

Ideally, for best healing in times such as sleep where an athlete has little to no control over foot position it is suggested that a night splint sock be used to hold the foot in a dorsiflexed position where the talus remains in a stable position and the Achilles is under tension which enhances the concept of joint compression. Many people relax their bodies during sleep, plantarflexing the foot and elongating the peroneals, which opposes the strengthening management program which we will talk about soon.
In the case of recurrent lateral ankle sprains or chronic instability of the ankle as a result of a previous moderate to severe ankle sprain there is an indicated need for the development of strength and proprioception rehabilitation. It is hypothesized by (Willems, T., Witvrouw, E., Verstuyft, J., Vaes, P., & Clercq, D. D. 2002), that when the inverted foot makes contact with a surface due to the structures diminished proprioception, it may result in a varus thrust from an inversion lever through the subtalar axis. In many cases everter muscles are not strong enough to reduce the velocity of this motion and the strength of the lateral ligaments are tested beyond its limits resulting in injury.
Developing a functional exercises program for the rehabilitation of an athlete with a lateral ankle sprain should be primarily sport specific or aimed towards reaching a players SMART Goals, however given we do not have a specific client at our grasp, I will provide an example of a progressive program, staying in the blogs opening theme of soccer.

WEEK Strengthening Proprioception Movement Patterns
1 -Double Support heel raise from flat surface – controlled motion, hold for 2sec at top.
2×6-8 twice daily- Theraband (yellow) looped around both feet, straight legs, abducting the feet. 2×8-10 twice daily
Barefoot standing on pillow, moving feet up and down.(progress to closing eyes) Walking/slow pace forward, backwards, lateral stepping.
figure 8’s10-15min
2 Single Support heel raise from flat surface – controlled motion, hold for 2sec at top.
2×6-8 twice daily
– Theraband (yellow) looped around both feet, straight legs, abducting the feet. 3×8-10 twice daily
Barefoot change through multiple different surface, grass, concrete, pillow, rubber matting ect(progress to stepping over objects ie boxes, hurdles) Walking/slow pace forward, backwards, lateral steps and vine.
figure 8 patterns
10-15min
3 – Double stance heel raise with single stance eccentric phase on step, below level ground..- Theraband (Green) looped around both feet, straight legs, abducting the feet. 3×8-10 twice daily Wobble board stabilization
5x 45-60sec twice daily
Ladder step exercises
small ball skills
object avoidance movement
10-15mn
4 – Single stance heel raise on step, both eccentric and concentric phase below level ground..- Theraband (Green) looped around both feet, straight legs, abducting the feet. 3×8-10 twice daily Wobble board circles
8-10 clockwise + 8-10 counter clockwise
3 sets each way twice daily
Advance ladder step exercises
ball movement skills
ie: drag backs, light dribbling, light passingCutting movements slowly
5 – Single stance heel raise on step, weighted back pack, below level ground..- Theraband (blue) looped around both feet, straight legs, abducting the feet. 3×8-10 twice daily Single stance balance
20sec each leg
10sets
twice daily
Cutting movements faster
Sudden stops
Lateral hopping
jump and land
increase kicking intensity
6 RETURN TO SPORT/regular training RETURN TO SPORT/regular training RETURN TO SPORT/regular training

* Weekly progression is only viable if the patient feels little to no pain and is able to complete current exercises to the satisfaction of clinician.
** The example has not been tested and aims to show a combination of different rehabilitation modalities which can be progressed.

In conclusion, rehabilitation of an athlete whether; weekend warrior or Olympic representative requires the inclusion of more than just a “stretch and strengthen” approach which was once looked upon favourably by many allied health clinicians. Taking in to consideration the structures involved, their mechanism of action and the supporting influences associated is imperative, as well as the need for neuromuscular retraining for proprioceptive sense enhancement.

I hope you enjoyed the second blog published by FootNotes and please stay tuned for our up coming sports events and podiatric interventions including; Tour De France and the US OPEN.

“JOGA BONITO”

Jackson McCosker
Director /Chief Editor

References

Beynnon, B. D., Murphy, D. F., & Alosa, D. M. (2002). Predictive Factors for Lateral Ankle Sprains: A Literature Review. Journal of Athletic Training, 4, 376 -380.

Brukner, P. (2013). Brukner and Khan’s Clinical Sports Medicine (4thth ed.). Australia: McGraw-Hill Education. (Original work published 2007).

Douglas H. Richie Jr. D.P.M. (n.d.). Chronic Ankle Instability. Retrieved June 2, 2014, from http://www.aolabs.com/wp-content/uploads/2011/11/lecture-Richie-Lat-Ankle-Instab-2011.pdf

Stasinopoulos, D. (2002). Comparison of three preventive methods in order to reduce the incidence of ankle inversion sprains among female volleyball players. Br J Sports Med, 182 -185.

Willems, T., Witvrouw, E., Verstuyft, J., Vaes, P., & Clercq, D. D. (2002). Proprioception and Muscle Strength in Subjects With a History of Ankle Sprains and Chronic Instability. Journal of Athletic Training, 4, 487 – 493.

Heat, Wynd and Badwater: What it takes to represent Australia in an Ultra Marathon


Heat, Wynd and Badwater:
What it takes to represent Australia in an Ultra Marathon

Today I sit down with Nikki Wynd, 2011 Ultramarathon Runner of the Year. Nikki is the only runner to be representing Australia this year at Badwater, California; a 217 kilometre slog through the desert where temperatures can reach over fifty degrees.

FootNotes: First of all Nikki Congratulations! How did you feel when you were first informed about this and how long had you been working to try and achieve this goal?

2011 Ultramarathon Runner Nikki Wynd

2011 Ultramarathon Runner Nikki Wynd

Nikki Wynd: Umm, the day I got the text I was really really excited! I was literally sitting at my desk all morning, checking my phone over and over to get the e-mail because I knew it was coming in that day. So when I did actually receive it, it was a massive relief because I’d probably been training for this for about three years, and thought…where to from here if I don’t get in?

So it was a huge relief!

FootNotes: What has your training schedule been like since you found out you did get in, in regards to kilometres covered, hill training and pace?

Nikki Wynd: Umm, to be honest I don’t really on pace, well I sort of do but really it’s more about, learning how to run long and slow, I have probably been trying to cover 180-200 kilometres a week. I have done a couple of races in there as well, which was manly to try and trial things like nutrition, time on feet and because I live out in the Dandenong’s near Lysterfield a lot of my training is done in the hills. So, I follow a structured program which includes; roads, hills, a couple of track sessions as well as religiously trying to cover that 180-200km a week.

FootNotes: Have you included any cross training at all?

Nikki Wynd: No, it’s mostly just been running and walking. I know I probably should be doing some cross training. My aim when I return from Badwater is to begin Pilates and maybe start doing some strength training…that’s the plan anyway.

FootNotes: So what have you done to prepare yourself for the heat, humidity and possible dehydration of Badwater?

Nikki Wynd: Umm, I haven’t done anything as yet but we leave in two week, to head to California, so I’m hoping heading there five weeks before the race I can acclimatize, I’ll do some training there and walking around spending time in the heat. I’ll be using my sponsor Tailwind Nutrition to hydrate me, so my crew will keep me hydrated with ice water and Tailwind for the entirety of the race.

FootNotes: Have you got a strategy worked out for how much fluid you plan to intake over so many kilometres?

Nikki Wynd: I can’t say I’ve worked out anything scientific, but during the race I’ll have my crew spraying me down and handing me bottles of fluid, I don’t think you can have too much water and electrolytes in that kind of race.

FootNotes: Have you developed any strategies for the race itself?

Nikki Wynd: I think my strategy is to just walk the hills, if anyone has seen the race profile; there are three pretty significant hills in there. The first one is forty kilometres long! So I plan to not go out too hard, walk the hills strong and pace myself, I do do a lot of hill walking as part of my training and I rate that as one of my strengths. So I’ll probably walk the hills hard and hopefully come home strong. (Graphic below is in miles)

Badwater Ultramarathon Profile

FootNotes: What kind of eating habits have you adopted for being so successful and running such big kilometres? I must take a pretty big toll on your body.

Nikki Wynd: I’m not a big eater, I never have been a really big eater, in fact most people are quite surprised at how little I eat for what I do, but I have consulted Konsita (Rowville Sports Medicine Centres Dietician) and she has advised me that if I’m eating what I’m eating and still able to do the workload that I am completing then it must be working for me. I tend just to snack all day, I don’t eat big meals as I don’t like the feeling of being full; even when I race I just have small amounts of food every half an hour because I just can’t handle large meals.
I do try and carb load, so heading into a race I will try and eat more pasta, rice and bread to get the carbs in before a race and then just the small amounts during.

FootNotes: What’s been your drive or your inspiration to do what you do as an athlete?

Nikki Wynd: I think for me it’s the fun I get from running with my friends, I love nothing more than just going out and doing a fifty kilometre run. Some people go out and sit down to have a coffee or head to a night club and I think this is my thing, running with some many different people I’ve made a lot of different friendships and I suppose it’s always trying to push my body. I started off doing a marathon and just wanted to keep improving.

FootNotes: What convinced you to start running big kilometres?

Nikki Wynd: I’ve been a bit of a gym junkie all my life, I joined the gym when I was twelve, my dad was really into health and fitness, he’s a strict vegetarian and we were just a very health conscious family. As I got older I’d do one marathon a year, then when I was in my thirties, some friends and I decided we would complete Oxfam 100km walk, it was a huge challenge for me as I’d never done longer than a marathon, so we trained and set out to run the race. I think we completed it in about 15hours and then two years later I went back with a different group, we were the first mixed team to cross the line and did it in 12hours. Then another two years later I went back with another mixed team and completed it in 10hrs 40min which was is the fastest female time ever in Oxfam. Then, this year I went back in a female team, we came second overall and beat the previous record by over an hour. I think just by doing those races, it leaves you asking what’s next.
First it’s a 50K, then an 80K, then 100…my furtherest race to date is 246 kilometres, Coast to Kosci, so from Eden to the top of Kosciusko.

FootNotes: Working long days and fitting in training must have you leaving the house at all hours of the morning and returning at all hours of the night. What does a typical day look like for you and what does your family think of these habits?

Nikki Wynd: It’s funny, I was actually saying to one of the reception staff at work the other day, my life is insane! That’s the only way to describe it. It’s getting up at 5am every morning and getting in a run before work, get myself ready for work and my 10yr old son (Daniel) up and ready for school, I head to work and three nights a week I do a double session, so I run for 2hrs after work, I’ll take Daniel to his sport and go off to do my training which may see me arrive back home between 8-8:30 at night. Then it’s literally having something small to eat and off to bed.
Luckily for me, my partner is also my running coach, so we basically train together, live and breathe running our whole life. For some people it’s pretty boring but for us it’s what we love! It’s good for us to be able to train together and we have a lot of running clients so we are able to bounce ideas off each other during training and talk about their programs. Really it’s just great to have someone who supports what you do.

FootNotes: Have you had many injuries over your career?

Nikki Wynd: Touch wood I’ve had none! Which I think is due to listening to my body, I may want to go out and run 180-200km in a week but if I feel niggles or unwell I won’t push myself to stupid limits. I’m lucky enough to work at Rowville Physiotherapy, so I do see the physio once a week, I have massage, I see Caleb McInnes the Podiatrist at Rowville Sports Medicine Centre who looks after my feet, tells me when to replace my shoes and makes sure I’m wearing the right shoes. I do wear orthotics, so Caleb will inspect them, make sure they are still doing the job they are suppose to be doing. He’ll cut my toe nails and remove any skin build up and all that kind of stuff.

FootNotes: What kind of runners are you typically in and is it a part of a sponsorship deal?

Nikki Wynd: I am sponsored by Hoka, so I usually wear Hoka Stinsons and Mizuno. Hoka I like to wear for the longer stuff as they are more comfortable cushioned shoes, so I do find they are better for the big kilometres. I will usually begin a race with a Mizuno, as I really like the feel of them, they are a good firm shoe and I’ve always felt comfortable in them, I have a great really good relationship with the guys at Mizuno.
I’ll probably take 3-4 pairs of runners to Badwater, I don’t know how often I’ll change them, I try to stay in the one pair for as long as I can. Your shoes tend to melt due to the temperature of the road at Badwater so I have to run on the painted white lines to prevent that from happening. The race this year doesn’t actually go through the notorious Death Valley as it has previous years, so I don’t know if it will actually reach the 50 degree temperatures but the elevation has increased.

hoka stinson

FootNotes: Do you have any plans for blister management at this stage?

Nikki Wynd: I don’t really get blisters, I don’t want to speak too soon but I’ve been pretty lucky, I can usually wear any socks from the discount bin at Rebel and tend to be OK. I do like to wear a thinner sock and I always BodyGlide my feet, so just lather it all over my feet and make sure my nails are short and file away any unwanted skin at night.

FootNotes: Well Nikki thank you for your time and all the best with your endeavours as the only Australian to representing us at Badwater this year. Just getting to this spot you have already done us proud.

FootNotes will endeavour to catch up with Nikki Wynd when she returns and find out all about the experience.

Jackson McCosker
Director /Chief Editor