Case studies

Paul Harradine: independent podiatrist

My PhD career journey as a podiatrist in independent practice

‘My PhD has given me much more than the title’

I qualified in 1994 from the Northampton School of Podiatry. Looking back, my lecturers’ positive attitude towards continuing education and professional development influenced me greatly. Steve Avil was completing a diploma in Sports Medicine (a very rare thing for a podiatrist at that time) and Tim Kilmartin was finishing his fellowship and PhD. Both shared their enthusiasm openly with students, and I saw no reason why my degree was the end. If lecturers carried on researching and learning, then why wouldn’t we all?

Between 1994 and 2000 I obtained an MSc and a CertEd and spent a short three years lecturing undergraduate podiatry combined with an NHS clinical post. I worked long clinical hours (sometimes over 60 hours a week) combining full-time NHS with building a private practice, before becoming a full-time independent practitioner in 2005. From 2001 family life slowly took over, and I was blessed with five amazing sons over the next nine years.

I continued with small research projects and with theoretical peer review publications, squeezed in between family and clinical responsibilities. I lectured frequently on gait analysis and started to form a larger and more complex question: Was it possible to develop a real-time clinical gait analysis best practice approach to aid in the assessment of MSK lower limb injury? Was it possible to scale or score gait dysfunction, such as the FPI-6 is used for static foot posture?

Even with a background of publications and research, I failed. My attempts were rejected for publication. Looking back now, thank goodness they were. As well as being incomplete, my work was full of bias and assumptions. It would have been a step backwards for podiatry and evidence-based practice, not forwards. 

With this frustration, I reached out to colleagues at the University of Southampton, and seven years ago I began my PhD. My initial experience with contacting my academic colleagues was completely positive, and I would advise any podiatrist interested in taking the research further to follow this approach. Ask those who know.

My PhD has changed me. Not just my professional life. The process is amazing, and my supervisors are some of the most patient, hardworking, and gifted professionals I have ever met. After completing my thesis, I was often asked “What would you do differently”. I’d answer “Nothing”. Although my work had many dead ends and difficulties, I needed to go through the development process of the PhD. It is hard, but if you trust the process and enjoy learning, it is incredibly fulfilling.

I’m not sure how much I will use the title “Dr” at work, as I’m aware it is confusing for patients. My family tries to ignore my “that’s what the Doctor ordered” one-liner every time Amazon deliver to our door. My PhD has given me much more than the title. I’ve added to the research in an area where there was hardly any. I’ve helped the podiatry profession move forward a little bit towards evidence-based practice and gait analysis. It has changed how I look at all research and every element of my practice. I believe I am a better clinician due to my PhD, and for that reason alone I would recommend anybody with an interest in research and a drive to improve to go for it!

Paul says:

‘I’ve added to the research in an area where there was hardly any, and I’ve helped the podiatry profession. 

‘I believe I am a better clinician due to my PhD, and for that reason alone I would recommend anybody with an interest in research and a drive to improve to go for it!’

FCP portfolio case study

The management of a paediatric patient with metatarsalgia demonstrating clinical excellence by a first contact podiatrist

A case of Freiberg’s disease in a nine-year-old girl, early detection, and management

Previous history

A nine-year-old girl was booked into the out-of-hours first contact podiatry telephone consultation. This was done following a review with the GP who noted in the patient's record there was generalised pain in the second and third toe for several weeks, normal range of motion, no tenderness when assessed and examined, no clinical signs of infection and unable to find cause of pain and wanted a second opinion.

Following a telephone consult a face-to-face was offered the following day. Although I was not concerned about any red flags from our conversation, a physical assessment was deemed necessary.

Clinical assessment and presentation

Presentation of unresolved pain in the front of the foot and the patient had been walking on the side to avoid the painful area. The pain was unremitting, described as a dull ache and located only to the right foot with an impact on toe push off. The duration was three months with no history of trauma or injury. There was no hand pain noted, no sudden weight loss and no early morning stiffness reported.

Mum thought it was growing pains but was now concerned as it was affecting gait. The patient was in good health, systemically well and was engaging throughout the consultation. She reported no pain at night.

On assessment, there was bilateral syndactyly of the second and third toes. Examining the joints for a range of motion there was definite reduced dorsiflexion and plantarflexion of the second digit at the second metatarso-phalangeal joint (MTPJ) compared to the left foot.

Gait showed no abnormalities apart from reduced propulsion through the second metatarsal head to the right foot. Normal muscle strength and power were evident and unremarkable. There were no neurological concerns with 100% detection of 10g monofilament and normal reflexes. Pulses were palpable. There was no oedema and no erythema noted on the digits. The impact on life was that she was managing school, but PE was becoming difficult and the pain not improving.

Investigations

Based on the clinical findings I referred the patient for ultrasound and x-ray due to the reduced range of motion in the second metatarso-phalangeal joint.

Differential diagnoses and clinical reasoning

Differential diagnosis based on this presentation included fracture, Morton's neuroma, or Freiberg's. For me recognising what was a normal range of motion and what was acceptable was the most important aspect of the assessment and the type of pain that was being described. With the duration being three months, absent of trauma it was unlikely to be a fracture unless it was a stress fracture. Equally, both Morton's neuroma and Freiberg's can cause pain around this area.

The pain associated was not considered to be pins and needles nor was it a burning sensation - more like a dull ache, and no mention of a stone-like feeling on the ball of the foot nor like walking on a pebble.

Freiberg's was my initial preferred diagnosis, but I felt she may be too young. Though Love and O'Mara in 2010 reported it is found in all age groups from children to the elderly, Freiberg's most commonly affects adolescent females, with a 5:1 predominance over males. This is the only osteochondrosis that favours females more than males (Cerrato 2011). On examination, the patient demonstrated a reduced range of motion and pain around the second metatarsal head area, with no indication of injury and trauma so did have the feature of Freiberg's.

In referring for an X-ray this would rule out any fracture or any bony abnormality. If suspecting early Freiberg's, then an X-ray can often miss the features and the patient is often then misdiagnosed or discharged. Ultrasound can be much more effective at picking up earlier, subtle changes.

An ultrasound scan of the area was undertaken and an X-ray. The patient was fitted with an off-loading device and appropriate follow up arranged with a safety net in case of any issues.

Image: Ultrasound of right forefoot showing increased vascularity to the dorsal second MTPJ, joint effusion and distension.

The ultrasound scan of the patient's foot shows joint effusion around the second MTPJ and a distended joint capsule. The report suggests some periosteal surface irregularity on the neck of the metatarsal – which could be deemed as age-related ossification, however, is relevant to the other pathology and the clinical symptoms.

Image: X-ray shows Freiberg's disease with flattening of the second metatarsal head

Early detection

Early detection and treatment of this pathology are needed. This allows for the appropriate conservative treatment to be delivered to prevent needing surgery, reduce pain levels for the patient, and improve  outcomes.

Presenting symptoms can be minimal with problems developing later in life if not managed appropriately. It can vary in severity and may develop over time. Complex cases can cause the bone to breakdown, causing early arthritis in the joint and leading to long-term problems, such as pain, unable to wear certain footwear, and participate in activities.

What is essential is early detection of this condition to allow for appropriate treatment options to prevent long-term effects on the foot.

Reference

Cerrato, R.A. (2011). Freiberg’s Disease. Foot and Ankle Clinics, 16(4), pp.647–658. doi:10.1016/j.fcl.2011.08.008.

Love, J.N. and O’Mara, S. (2010). Freiberg’s Disease in the Emergency Department. The Journal of Emergency Medicine, 38(4), pp.e23–e25. doi:10.1016/j.jemermed.2007.10.028.

FCP case study

The management of a patient presenting with heel pain demonstrating clinical excellence by first contact podiatrist

Previous history

The patient initially presented in my FCP Podiatry clinic reporting a new onset of heel pain after being triaged and signposted by the administrative team at his local GP practice.

The patient in this case study was a 35-year-old male with a medical history that includes psoriasis, hypertension and overweight with an eight-week duration of heel pain.

Clinical assessment and presentation

The pain was described to the right heel and indicated by the patient to involve the whole heel. The pain described as a dull ache most of the day and a sharp needle sensation in the heel for the first steps in the morning. Symptoms are relieved by cushioning under the heel and resting and are worse after rest, the first step in the morning and after a long day. Symptoms are also aggravated by walking barefoot. Verbal rating scales for pain were first steps of the morning 7/10 on VAS and during day 3/10.

Throughout the assessment lots of diagnoses were ruled out due to clinical features. Firstly, I was able to determine the likelihood of a red flag presentation was slim as the pain had a mechanical pattern to it as most red flag pains tend to hurt in a pattern different to this (NHS, 2021). There was no night pain or sudden weight loss reported on questioning for example.

The patient's symptoms are classical to plantar fasciopathy given the post-static dyskinesia symptoms. Post- static dyskinesia pain in the heel is largely associated with ligament and tendon complaints of a mechanical origin and these can then be differentiated based on location of pain.  (Alshami, Souvlis & Coppieters, 2008)

Diagnosis and clinical opinion

The following differential diagnoses were considered: heel fat pad atrophy, calcaneal stress fracture, and  insertional Achilles tendonitis. They were also ruled out as unlikely due to the location of the heel pain and its classical presentation with waxing and waning features.

The diagnosis was explained to the patient. I tend to explain plantar fasciopathy from a stress and strain standpoint (Korhonen & Saarakkala, 2011). It is my experience that patients tend to feel that non-medical treatments have a greater benefit when the rationale behind them is explained. By detailing to a patient the concept of stress vs strain we can now explain the difference between plantar fasciitis and plantar fasciopathy. This explanation I feel also drives home the importance of relative rest as a required treatment.

Over 95% of patients within my caseload presenting with this plantar fasciopathy symptoms will be sent away from the first consultation with the following treatments:

1. Stretching
2. Strengthening
3. Advice on footwear (and wearing footwear at home)
4. Advice on orthoses if they are assessed using physical assessment as suited to this
5. Taping.

When we consider patients might forget between 40%-80% of what is said in a consultation (Kessels, 2003) I also always follow up with:

• A text message containing a patient information leaflet on plantar fasciopathy
• Exercises sent via physiotherapy-centred video software
• A text telling the patient if they are not feeling better or seeing some improvement by 12 weeks then they should return to my care.

Follow-up and investigations

In this patient’s case, I revisited the idea of a possible systemic inflammatory cause. An ultrasound scan was agreed upon as it would help rule out other possible diagnoses such as heel bursitis and help toward confirming the diagnosis of plantar fasciopathy by demonstrating thickening of the fascia itself. If the ultrasound returned suggesting a florid swelling response (likely commented as hypoechogenicity on the US report), or lots of extra-articular features such as calcification at the Achilles tendon insertion, then the possibility of a systemic cause is once again reconsidered (Ieong, Afolayan, Carne & Solan, 2013).

In the meantime, the patient was asked to keep up with his conservative care of stretching, strengthening, footwear changes and taping. I also advised a bit further at this consultation on the value of insoles and signposted toward a particular device the patient might find helpful.

Follow-up appointment after imaging 7 weeks later

In this patient’s case, the ultrasound results suggested thickening of the medial fascia band with minimal other changes noted. I now discussed the options with the patient: his options, in this case, were either a steroid injection or a consideration of whether or if he would like to privately fund a course of shockwave therapy. We discussed the risks and benefits of each of these treatments and the pros and cons, considering one of the treatments had a financial attachment (Morrissey et al, 2021)

The patient opted at this juncture to have a steroid injection so appropriate literature was provided and an injection was booked for two weeks later.

Injection appointment

A landmark injection was provided into the right heel with a depomedrong and lidocaine mixture.

The follow-up phone call two weeks later

The patient reported a complete resolution in his heel pain at two weeks post injection. The patient reported no side effects from the injection.

Follow-up at 18 weeks

A follow-up call was completed at 18 weeks simply for the reason of completing this case study to assess if the patient's heel pain had remained resolved. The patient reported no return of symptoms.

Summary

This patient was consulted a total of five times during his management and two of these appointments were planned reviews. Assessment and management included considerations around requesting bloods, requesting appropriate diagnostic imaging and considering if onward referrals were required. Outside of the imaging the rest of the patient’s care was directed by one clinician: the FCP Podiatrist. The patient did not consult another member of the primary care during his period of care.

This case study demonstrates effective triage into the FCP Podiatrist clinic, effective safety netting and red flag screening, effective diagnostic and treatment skills and a good outcome for a patient without the need for onward referral or involvement of medical colleagues who were therefore freed up to treat other patients. The patient was under my care for 30 weeks.