Addressing Ingrown Toe Nails: Wives Tales and Wise Tales


Addressing Ingrown Toe Nails: Wives Tales and Wise Tales

It doesn’t take much. One small nail spike or pressure from callus building within the sulci of the toe and BOOM, there is a good chance you will be off your feet…or at least in thongs. The ingrown toe nail has been a pressing issue for centuries – falling those in the wars, benching those in sports, homing the socialites and keeping kids from school.
A number of wife’s tales have developed over this time to try and combat the pesky issue however, many have offer little more than temporary relief to the sufferer.

In todays article we look at some of the causes of ingrown toe nails, the fallacies associated with them and what can really be done to address the complaint.

An ingrown toe nail is commonly recognized as a slither of nail which has forced itself into the healthy skin of the toe, promoting irritation and pain. Not all ingrown nails have an associated infection and not all are directly correlated to a misshapen nail, as pathological skin or pressure may be a contributing factor.
Ingrown toe nails associated directly with a misshapen or poorly trimmed nail will typically have a sliver of missed nail within the sulci which grows in a forward direction, at a slow rate into healthy skin. The nail pierces the skin causing pain and irritation. In some causes due to a now open wound one the toe, a local infection may arise.
In other cases increased external pressures may be the cause of an ingrown toe nail. Tshutterstock_149255009.jpghe type of footwear which is worn, although it may not seem like it is causing pressure, will often place a tiny amount of compression upon the larger toes, directing the skin of the sulci into the nail and causing pain. With the increased compression, especially over time, pathological tissue can build within the sulci narrowing the space in which the nail would usually grow through.

A number of old wives’ tales have surfaced for the management of ingrown toe nails; some can be successful others are full of garbage. Here are just a few which you may come across in your travels.

  1. Cut a wedge in the middle of the nail – the theory here is the nail will curve to have the wedge narrow pulling the ingrown nail away from the affected area. In truth the nail will continue to grow straight and no relief will be felt.
  2. Soak in salt water/EPSOM salts – this has so merit for pain relief but not so much for relief of infection or the embedded irritant which is causing the pain. The heat will allow the tissues to expand taking a small amount of pressure from where the nail is embedding itself.
  3. Pedicure – most pedicures places these day will use metal tools, which are often not appropriately sterilized. As a result, many infections can actually begin as a result of attending one of these practices.
  4. Retraining the Nail – The theory runs that if you are able to guide the nail past the skin it will be retrained to continue to do so for evermore. More often than not the nail will grow past the skin for that small amount of time, after that or after the next nail trim you will be back to square-one.

There are a number of ways a podiatrist can help in these situations. The first is removal of the nail spike (if possible) with sterilized instruments and education on appropriate footwear while you are currently suffering from this condition.
The second and more invasive procedure is a partial nail matrix resection which involves the use of a local anaesthetic to numb the toe and removing the nail spike if it is too painful or too deep to remove appropriately. The next step is to cauterize the nail matrix to stop nail regrowth.
The end result is a slightly narrower nail but less a lot less pain.

Until Next Time,

 

Jackson McCosker
Director/ Chief Editor

Plantar Fascial Injury


 

Plantar Fascial Injury

Plantar fascial injury is one of the, if not the most seen musculoskeletal injury by podiatrists. It is commonly described by patients as chronic condition which has built up gradually and has now hit a breaking point of which needs to be addressed.
Frequently named Plantar Fasciitis, which indicates an inflammation of the plantar fascia. The chronic nature of the condition and the subsequent studies of the tissue histology suggest that this is not the case and as such Plantar Fasciosis is the more appropriate terminology, given the degenerative findings within the tissue. However, purely for the case of easy reading for our readers who are not medically inclined. Throughout this article plantar fascial injury will be called plantar fasciitis – ENJOY!sesamoids

The plantar fascia is a flat sheet of thickened, poorly vascularised and poorly innovated, deep fibrous connective tissue of the foot which can measure between 2.2 and 5.4milimetres (Cardina, Chhem, Beauregard, Aubin, & Pelletier, 1996). The broad white longitudinal fibres originated at the medial tuberosity of the calcaneus and insert at the proximal head of the phalanges. Anteriorly, at the metatarsal-phalangeal joints latitudinal connective tissue fibres reinforce the supportive nature of the plantar aponeurosis creating the Transverse Arch of the foot. Similarly, a medial and lateral longitudinal band of connective tissue further support the respective arches while protecting deeper structures of the foot (Brukner, 2013).
The plantar fascia is able to support up to twenty-five percent of the load experienced by the medial longitudinal arch. During dynamic gait the plantar aponeurosis may only elongate up to two percent of its relaxed size however, the stretch tension and isometric contraction which occurs in association with the windlass mechanism acts like a spring moment during propulsion. The windlass mechanism occurs when the first phalangeal dorsiflexes and the metatarsal plantarflexes – stretching the plantar aponeurosis and lifting the medial longitudinal arch height through shortening the distance between the bones of the foot (Michaud, 2011).

Although clinical diagnosis of plantar fasciitis can be made with reasonable certainty through routine assessment, sometimes medical imaging may be deemed appropriate to rule out other potential diagnosis. The common signs and symptoms of plantar fasciitis result in a gradual onset of pain which causes a dull ache or throbbing after long periods of standing or actively moving on cement flooring. A tell-tale sign of the condition is the unmistakable “first step pain” in the morning or after short periods of rest (Dubin & Joshua, 2007)

Biomechanical influences and training error are two of the most common reasons for the development of such a condition. Ankle equinus (restricted ankle joint ROM) as a result of hard or soft tissue can influence the onset of plantar fascial pain by increasing tension within the plantar fascia and achillies tendon causing repetitive trauma. Additionally, the restricted joint ROM can lead to an increase in pronatory forces, lengthening the plantar fascia and leading to micro-trauma.
A sudden increase in training load can lead to not only an increase in frequency of these movements but additional fatigue of the tissues in question, furthering the development of pain (Dubin & Joshua, 2007)

It is stated by (Buchbinder, 2004) that the causes of plantar fasciitis are multifactorial in nature and therefore treatment/management modalities are required to be multifactorial as well. The following treatment modalities are commonly used in the management of plantar fasciitis.

Tissue Specific Stretching

It was found in a prospective randomized study conducted by (DiGiovanni, Nawoczenski, lintal, Murray, Wilding, & Baumhauer, 2003)that tissue specific plantar fascia stretching showed significantly better results when compared to a generalized calves and achillies tendon based stretching regime. Most notable were the decreases in worst pain measured via VAS score with a p-value = 0.02 and first step function and pain with a p-value =0.006. From these results it can be inferred that the use of non-weight bearing stretching exercises specific to the plantar aspect of the foot creates greater pain reduction than a standard weight-bearing achillies tendon stretching program. These findings were further supported in a Ramdomized Study (DiGiovanni B. , et al., 2003)and Clinical Trial with two year follow up by (DiGiovanni B. , et al., 2003) who found that a program of non-weight bearing stretches specific to the foot produced superior results to weight bearing achillies tendon stretching for symptoms of plantar fasciitis.

Strength Training Program
Developing both extrinsic and intrinsic muscle activation, control and strength is important for the aiding of pain reduction and future prevention of such injuries. As mentioned above, common causes of plantar fasciitis are fatigue and tissue stress due to an increased workload. It then makes sense that re-establishing the mind-muscle connection and adequate preparation of these tissues be addressed during the management process.
Extracorporeal Shock Wave Therapy
Chew, Leong, Lin, Lim and Tan established in a 2013 randomized trial that both plasma injection and extracorporeal shockwave therapy combined with conventional treatment created more improved outcomes for patient pain and function when compared with conventional treatment as a standalone. However, no significant difference was found between ESWT and plasma injection (Chew, Leong, Lin, Lim, & Tan, 2013).
In a 2014 randomized control study by (Suleymanoglu, Esmaeilzadeh, Sen, Diracoglu, Yaliman, & Eskiyurt, 2014)comparing radial shock wave therapy and low level laser therapy for chronic plantar fasciitis it was concluded that both RSWT and LLLT were significantly effective in the decrease of thickened plantar fascia immediately after the 3-month assessment p<0.001. The specific modalities mentioned here are not included in the above table due to practitioner cost, invasive nature and the point that this measure was used after a 6 months non response period to conservative interventions.

Offloading Devices and Taping
There is a wide range of prefabricated and custom made offloading devices available to patients who are seeing allied health professionals.  When comparing full-length silicone insoles versus ultrasound-guided corticosteroid injection for the management of plantar fasciitis through means of randomized clinical trials, it was found that after one month of treatment both groups had significant improvement of both pain and function related to their foot pain, however those involved in the injection group were found to have statistically significant differences (p<0.005) in VAS, ultra-sonographic thickness of plantar fascia, foot and ankle outcome score for daily living activities and sport and recreation function. However, conclusively it was advised that silicone insoles were used as a first line treatment given the minimally non-invasive nature (Yucel, et al., 2013).
A randomized controlled trial of calcaneal taping, sham taping and plantar fascia stretching in 2006 found a significant difference between calcaneal taping and stretching of the plantar fascia/ sham taping/control in the category of VAS pain (p<0.006) , (p<0.001) and (p<0.001) respectively. Stretching was found to have statistical significance over the control group (p=0.026). It was concluded that calcaneal taping was shown to be more effective as an intervention for plantar heel pain (Hyland, Webber- Gaffney, Cohen, & Lichtman, 2006).
In the event of kinesiology taping for the short term treatment of plantar fasciitis it was found that no significant difference was seen in the either group using kinesiology taping with traditional physical therapy or just traditional physical therapy (Tsai, Chang, & Lee, 2010).

Surgery
When exploring more invasive treatments plantar fasciotomy with the use of endoscopic or radiofrequency lesioning techniques have been found to be around 70-90% effective, however with any surgical intervention comes risk, in this case both flattening of the medial longitudinal arch and heel hypoesthesia (Davies, Weiss, & Saxby, 1999).

So concludes our article on plantar fascial injury, I hope it has been informative. If you have any question or suggestion, please feel free to comment and I will get back to you as soon as possible.

Until next time,

Jackson McCosker
Director/Chief Editor

 

References

Brukner, P. (2013). Bruker and Khan’s Clinical Sports Medicine. North Ryde: McGraw-Hill Education Pty Ltd.

Buchbinder, R. (2004, May 20). The New England Journal of Medicine. Plantar Fasciitis. Massachusetts, United States of America.

Cardina, l. E., Chhem, R., Beauregard, C., Aubin, B., & Pelletier, M. (1996). Plantar fasciitis: sonographic evaluation. Radiology, 257- 259.

Chew, K., Leong, D., Lin, C., Lim, K., & Tan, B. (2013). Comparison of Autologous Conditioned Plasma Injection, Extracorporeal Shockwave Therapy and Conventional Treatment for Plantar Fasciitis: A Randomized Trial. PM and R, 1035 – 1043.

Davies, M., Weiss, G., & Saxby, T. (1999). Plantar Fasciitis: How Successful is Surgical Intervention? Foot and Ankle International, 803 – 807.

Department of Physical Therapy, U. o. (2006). Plantar Fascia-Specific Stretching Exercise Improves Outcomes in Patients with Chronic Plantar Fasciitis. The Journal of Bone and Joint Surgery.

DiGiovanni, B., Nawoczenski, D., Lintal, M., Moore, E., Murray, J., Wilding, G., & Baumhauer, J. (2003). Tissue – Specific Plantar Fascia Stretching Exercise Enhances Outcomes In Patients with Chronic Heel Pain. The Journal of Bone and Joint Surgery.

DiGiovanni, B., Nawoczenski, D., lintal, M., Murray, J., Wilding, G., & Baumhauer, J. (2003). Tissue-Specific Plantar Fascia-Stretching Exercise Enhances Outcomes in Patients with Chronic Heel Pain. Journal of Bone and Joint Surgery, 1270-1277.

Dubin, & Joshua. (2007). Evidence Based Treatment for Plantar Fasciitis. Sports Therapy.

Hyland, M., Webber- Gaffney, A., Cohen, L., & Lichtman, P. (2006). Randomized Controlled Trial of Calcaneal Taping, Sham Taping and Plantar Fascia Stretching for the Short-Term Management of Plantar Heel Pain. Journal of Orthopaedic and Sports Physical Therapy, 364 – 371.

Michaud, T. (2011). Human Locomotion: the Conservative Management of Gait-Related Disorders. Newton: Newton Biomechanics.

Suleymanoglu, T., Esmaeilzadeh, S., Sen, E., Diracoglu, D., Yaliman, A., & Eskiyurt, N. (2014). The Effects of Radial Shockwave Therapy and Low Level Laser Therapy in the Treatment of Chronic Plantar Fasciitis: A Random Controlled Study. Annals of the Rheumatic Disease.

Tsai, C., Chang, W., & Lee, J. (2010). Effects of Short Term Treatment with Kinesiotaping for Plantar Fasciitis. Journal of Musculoskeletal Pain, 71 – 80.

Wang, C.-J., Wang, F.-S., Yang, K., Weng, L.-H., & Ko, J.-Y. (2006). Long-Term Results of Extracorporeal Shockwave Treatment for Plantar Fasciitis. The American Journal of Sports Medicine, 592 – 596.

Yucel, U., Kucuksen, S., Cingoz, H., Anliacik, E., Ozbek, O., Salli, A., & Ugurlu, H. (2013). Full-Length Silicone Insoles Versus Ultrasound-Guided Cortisone Injection in the Management of Plantar Fasciitis: A Randomized Clinical Trial. Prosthetics and Orthotics International, 471 – 476.

Understanding The Enhance Primary Care (EPC) Plan


The Enhanced Primary Care Plan: Does Your Patient Really Understand It?

The Enhanced Primary Care Plan (EPC) was introduced by the Australian government as a Medicare initiative in 1999. The program is designed to be a Medicare rebate, covering part of the consult cost for up to a maximum of five visits per calendar year. Presently the EPC rebate for podiatric services is $52.95 per appointment, this has quickly become an issue for both patient and podiatrist as costs of business have grown beyond the point where this is a sustainable rate per appointment (especially for those in metropolitan areas) and a GAP payment is now a required for those attending.
The plans are designed for those who require on-going multi-disciplinary care provided in a structured manner and allows the General Practitioner to oversee and coordinate the management of patients with complex conditions.

The rest of tshutterstock_195284591.jpghis article looks to keep this in plain English and as straight forward as possible so all parties can understand the role they play in the under-taking of an EPC program and what the initiative has really been developed for.

Eligibility
Community-based patients (attending private practice or community centres) may be eligible for a EPC plan if they currently have chronic or terminal condition which relates directly to the service which they have been referred too. It is important to highlight at this point that an EPC is received because you as a patient have a chronic condition and your eligibility is NOT based on your age or economic status such as being on a pension.
A chronic condition is best defined as an ailment which has been present for or is likely to be present for more than six months. There is no official list of conditions, however, those which are commonly referred to include;

  • High Blood Pressure
  • Diabetes
  • Stroke
  • Heart Attack
  • Osteoarthritis
  • Musculoskeletal Conditions
  • Auto-immune Disease

As stated above, the condition identified as being the reason for referral needs to be directly related to the scope of practice of that professional and must be identified in the care plan completed by the GP.
A referral is valid for the full number of stated appointments on the care plan, if not all appointments are used within a calendar year then left over appointments can be used the following year. However, there are restrictions of 5 rebated appointments per calendar year and any further visits will most likely require full consult payment.

Practitioners Role
It is necessary for the practitioner to meet specific requirements proposed by Medicare Australia and the Department of Human Services.
Full assessment and management details obtained within the first visit of the EPC plan should be communicated back to the referring GP at the soonest possible convenience. Additional, communication may be considered necessary dependant on the circumstances of the individual.
At the end of the final allocated visit further information should be once again communicated to the GP about the patient’s current condition status and what management plan has been suggested for further intervention.


Claiming with Medicare
With the added benefit of most private practitioners and clinics having HICAPS facilities these days the ability to claim your Medicare rebate has become much easier. It is possible to claim for anyone who is listed upon your Medicare card.
It is suggested by Medicare Australia that you register the following details with the organisation to decrease the chances of any delay in receiving your rebate benefit.
Make sure to; Register your bank account details, register your family for Medicare Safety Net, destroy old Medicare Cards, take your Medicare card with you when attending all health appointments and inform Medicare when you change address.

The first article to be released this financial year for FootNotes may seem a boring read but it is important to understand how the system works to reduce misunderstandings with both practitioners and patients.
Our next article focuses on plantar fasciitis and how heel pain can affect your quality of life.

Until Next Time

 

Jackson McCosker
Director/Chief Editor

 

References

Chronic Disease Management. (2014, February). Individual Allied Health Services Under Medicare. Australia: Australian Government Department of Health.

Medicare Services. (2016, May). Medicare Services. Australia: Australian Government Department of Health Services.