Doc, My Feet Hurt

Dear Dr. B: I have been walking a lot this summer. My feet hurt and that restricts my activities. What I can do about it?

Like back pain there is no perfect cure for all ailments of the feet. Most of us are on our feet longer than any other part of our body. So our feet receive the biggest brunt of all the damage we inflict on ourselves.

Feet problems present in different ways with pain, deformity and swelling.

About 10 per cent of the general population suffer from feet pain, and in the elderly it is much higher – ranges from 53 to 95 per cent. Proximal plantar fasciitis (inflammation of the fascia – a thick tissue which runs from the heel to the ball of each foot) is the most common cause of painful feet in clinical practice, and is twice as common among women as among men.

Metatarsalgia (pain in the forefoot in the region of the base of the toes) is probably the most common cause of foot pain among middle-aged women. Most women in this age-group have been exposed to high-heeled shoes over many years.

There are many other conditions which cause painful feet. Some of these are: plantar warts, corns, calluses, ingrown toe nails, hammer toes, flat feet, bunions, arthritis, gout, stress fractures and some others.

Treatment for most of these conditions remain the same: elevate and rest your feet as much as you can – but with the busy schedule we keep, not many of us have time to do that. Other management points are: lose weight, use pain killers, hot or cold compresses, arch support, good quality fitting shoes, foam cushions to relieve pressure on painful areas, and keep feet clean and dry.

Gout and other types of arthritis may require anti-inflammatory medications. Ingrown toe nail can be surgically fixed in a doctor’s office. Some conditions require injection of cortisone to relieve inflammation and pain. Physiotherapy can relieve many ailments of the feet.

One may have to try different combinations of therapy to find relief.

Foot is a complex structure and needs to be treated with respect. There are 26 bones in our foot and they are held together by ligaments. In addition to that, there are variable numbers of accessory bones called sesamoids.

Foot is divided into forefoot, midfoot and hindfoot. When one stands normally, the body weight is equally distributed between the heel and the ball of the foot. The weight distribution depends on muscle contraction.

“Studies have shown that relatively small changes in muscle balance and tone can result in significant changes in the load distribution of the foot,” says Dr. William Hamilton in the Surgical Anatomy of the Foot and Ankle. The normal function of the foot depends on the bones, ligaments, and muscles acting in concert.

A lot depends on how you stand, how you walk, how you run, what you wear, how much you weigh, and how much care you take of your feet. Foot pain and deformities are widespread. So, treat your feet with respect. Without them you cannot go too far comfortably!

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Arthritis – The Painful Crippling Problem

Dear Dr. B: Can you please write about arthritis? Are there different types of arthritis? Is there any treatment?

Answer: Recently, a friend was diagnosed with arthritis. My immediate query was, “What kind of arthritis?”

Like cancer, arthritis is not one disease. There are more than 100 conditions in which symptoms of arthritis are present. In fact, it is estimated that 46 million adults and 300,000 children suffer from arthritis in U.S. alone. It can be a painful and crippling disease although milder forms of arthritis are not uncommon in majority of the people.

Osteoarthritis (OA) is the most common form of arthritis. It is prevalent in people over the age of 60. But arthritis, in one form or the other, may affect people of any age group starting from infancy to old age. It affects more women than man (60 per cent to 40 per cent).

American Heritage Dictionary defines arthritis as inflammation of a joint, usually accompanied by pain, swelling and stiffness, resulting from infection, trauma, degenerative changes, metabolic disturbances or other causes. It occurs in various forms, such as bacterial arthritis (due to infection), osteoarthritis (wear and tear of cartilage), rheumatoid arthritis (overactive immune system) and gout (abnormal metabolism). These are just a few examples.

The joints are swollen and deformed from inflammation and destruction of the cartilage. Arthritis is a major cause of disability in the U.S. and Canada and it costs billions of dollars in medical costs, lost wages and production of goods.

Diagnosis of arthritis depends on your history, symptoms and physical findings. Your doctor will order blood tests and plain x-rays. If necessary, CAT scan and MRI will help in the diagnosis.

Is there a good treatment for arthritis?

Usually, there is no cure for arthritis. Treatment is aimed at relieving symptoms of pain and stiffness by reducing inflammation in the joints with the hope that it will slow down damage to the joints.

Most people with arthritis try over the counter medications like aspirin, acetaminophen, ibuprofen and variety of other NSAIDs (non-steroidal anti-inflammatory) available in the market. As the pain and stiffness deteriorates the patients require stronger medications like steroids. Some patients require combination of NSAIDs and steroids. Steroids can be injected into the joints as well. Certain types of arthritis require specific medical treatment.

Eventually surgery becomes an option to relieve pain or correct the deformity. Most commonly performed surgeries are total joint replacement (arthroplasty), tendon repair and removal of the joint lining (synovectomy). Surgery carries a risk of bleeding, infection and pain. You should carefully discuss and understand the benefits and risks of the procedure with your doctor.

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Vioxx Withdrawal

Vioxx is off the shelves and off the medicine cabinets. In five years, Vioxx took a dive from being a super drug for arthritis and acute pain to the dust bin.

It was a made in Canada drug. Last year, 3.4 million prescriptions were filled by Canadians, and 84 million people swallowed the pill around the world. Worldwide sales of Vioxx in 2003 were $2.5 billion.

Soon after the withdrawal of Vioxx, the stock price of Merck and Co., a U.S.-based pharmaceutical giant, the world’s second-largest drug maker, fell $12.07, or 26.8 per cent, to close at an eight-year low of $33 in New York.

The company’s legal problems continue to grow as it was hit with class-action lawsuits in Canada and USA.

So, why all the fuss about Vioxx?

It is simple. It is a good drug for arthritis and acute pain but it is not good for the heart. And here is how they found out.

A study was designed to evaluate the efficacy of Vioxx 25 mg. in preventing recurrence of colon and rectal polyps in patients with a history of colon and rectal adenomas (pre-malignant polyps).

The study, involving 2,600 patients between the ages of 40 and 96, was to have lasted three years. But last week, just 18 months into the research, the company learned the risk of heart attack and stroke was double in patients taking Vioxx and halted the trial.

This information was not new to the company. Previous studies had created a suspicion that Vioxx might be bad for the heart. The question is: Why did it take so long for the company to come to grips with the situation? Is there something wrong with the regulations, the way new drugs are brought into market?

Two weeks ago, we discussed in this column, the side-effects and dangers of using non-steroidal anti-inflammatory medications (NSAIDS). The column can be read again on my website: These drugs are used to treat arthritis but do increase the risk of ulcers or bleeding in the stomach in the long term. Vioxx comparatively had fewer gastrointestinal complications.

The drug had become very popular. Some doctors have even prescribed Vioxx to young girls to treat menstrual cramps although it is not approved for use in children.

Why does Vioxx increase the risk of heart problems?

The answer is not clear. It probably raises the blood pressure. Now the tables have turned. At this time, I presume, the blood pressure of the CEO of Merck and Co. must be fairly high.

What happens now?

Arthritis affects millions of Canadians and they are all looking for pain relief. Nobody likes pain. Especially, if it is painful to move and walk. There are many drugs in the market for arthritis. Your physician will have to carefully evaluate your situation and advise you accordingly. Do not make any drastic or sudden changes in your medications until you have discussed the situation with your doctor.

Thought for the week:
“I joined a health club last year, spent about 400 bucks. Haven’t lost a pound yet. Apparently, you have to go there.”

E-mail from a friend.

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Treatment of Arthritis

Arthritis means pain, inflammation, and stiffness in one or more joints. There are many different types of arthritis. Osteoarthritis is the most common type. Arthritis can affect any joint – most commonly knees, hips, and hands.

Osteoarthritis is rare before the age of 45. But it becomes increasingly common over the age of 60. It is twice as common in females. It can run in families.

What are the risk factors? Any joints subjected to repetitive and strenuous activity are prone to get arthritis. People who are overweight are at higher risk. Injury to a joint can cause arthritis. Often there is no obvious cause.

Many patients with osteoarthritis require regular pain killers to provide comfort and mobility. There are numerous pain killers in the market for arthritis. Some can be bought over the counter, some require prescription. All pain killers have some sort of side effects which affects some people more than others.

Many of the pain killers for arthritis are known as non-steroidal anti-inflammatory drugs (NSAID). NSAIDs commonly cause upset stomach which may result in ulcers and bleeding. Sometimes this can be life threatening – especially in people over the age of 60. Some of these pills can also damage your kidneys and adversely affect your cardiovascular system.

It is estimated that NSAID induced gastric complications in the United States’ arthritic population alone is more than US$4 billion annually.

NSAIDs are the most commonly prescribed drugs in North America. In Canada alone, more than 10 million prescriptions are written for NSAIDs – this does not include the purchase of NSAIDs over the counter.

Is there a safer and effective alternative to taking pills by mouth?

There has been some research going on the local application of NSAIDs. Topical or local application of the NSAIDs, such as diclofenac solution, has been reported to have fewer side effects.

Diclofenac solution contains a substance called dimethyl sulfoxide (DMSO) which enhances the absorption of NSAID through the skin to provide relief of symptoms when applied to a joint with arthritis – most commonly the knees.

A recent study, using diclofenac solution (commercially available as Pennsaid), showed that four weeks of treatment with this topical solution relieved the symptoms of primary knee osteoarthritis significantly better than a placebo.

Systemic side effects were minimal and local reaction was insignificant except for some dryness of the skin. The study, published in the Canadian Medical Association Journal, concludes that given the current practice guidelines, this topical NSAID treatment is a reasonable new option for the management of osteoarthritis of the knee.

The next reasonable question is, should you be using this if you have osteoarthritis? And a reasonable answer is – speak to your family physician first. Your physician should be able to provide you with a reasonable advice.


Thought for the week:

This is from my friend George: “Don’t let worry kill you, let the church help!” Now this will keep you thinking (or worried) for a long time if you saw this on your church notice board!

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