Clinical examination is probably the most fundamental skill a clinician can offer their patients, however if poorly applied, can lead to poor (or even disastrous) outcomes.

One of the first things that we are taught at podiatry school is anatomy. We start off learning the anatomy as this then allows us to be able to accurately diagnose the problems our patients come in with.

The only part of the examination that is more useful is the 'patient history'. I can confidently say that 8 times out of 10, I know exactly what is going on with you before I have touched your foot. This being said, it relies on me allowing you the time and respect to discuss your concerns and share your story in detail.

Once I have heard about all of your concerns, I will then assess your foot, lower limb, and sometimes even some functional movements around your hips and spine. From here, a treatment plan will then be developed and you will then be able to decide on how you would like to proceed.

I will never use any pressure selling techniques and I will always cover all of the most appropriate treatment modalities, whether I offer them or not.

Dermoscopy is a method of looking at the skin through a specialised tool called a 'dermatascope'. A dermatascope allows your podiatrist to look at lesions at a higher magnification and make diagnoses with far greater confidence.

The healthcare world is putting a real emphasis on identifying healh-changing lesions and diseases earlier, and I try to make sure that I keep up!

Dermoscopy has been around for a very long time however is infrequently used by podiatrists and doctors alike. It is highly effective for assessing skin lesions that may be cancerous and can also be used to reassure you of lesions which are not.

Clearly the best placed clinicians for assessing these lesions are dermatologists and GPs who specialise in dermatology, however getting in to see one can be expensive and mean long waiting times. As a result, I purchased a dermatascope and will often assess lesions with it for greater reassurance or for justifying onward referral.

It is not yet a 'specialist' service which I offer, however I have developed the skills to use it safely for identifying 'concerning' and 'not-concerning' lesions. Whilst this is not the strongest sales pitch - I owe it to you as a potential patient to be up-front about my skillsets, and so I will advise you that I offer dermoscopy for differentiating malignant from benign lesions, but my use of it for complex diagnosis is limited and I will always be honest with you on this.

The use of a dermascope is significantly more accurate and useful than using a magnifying glass or 'loupe' as is used in a lot of clinics. This is because the lesion is not obscured by external light sources and the dermascope is engineered so as to ensure that all aspects of the structure can be visualised.

Any images I take which are for cataloguing purposes can be made available to you upon request.

Any lesions which cause me concern will have a referral letter written.

Diabetes is a condition where your body fails to absorb sugar from your blood into the cells, and as a result, large amounts of sugar remain in your blood stream. This allows the sugar to collect in the soft tissues, as well as damaging blood vessels and nerves.

Although managing your diabetes is something that you have to take responsibility for, managing your feet can be harder to do.

Podiatrists will ensure that they check the sensation in your feet regularly and assess the circulation in your feet too. This is because it is hard to tell that your ability to identify pain has reduced due to nerve damage in the early stages, and if this is happening, there could also be damage occurring to your circulatory system too.

By having your feet checked by a podiatrist regularly, you will be able to know that any changes are spotted and an action plan can be put in place. Quite often, you will find that you might even mention something in passing and we will latch onto it.

You probably go to your dentist or optician for a regular check up, seeing a podiatrist is another member of the team that is very worthwhile. The reason being that as the feet are furthest away from the body and probably work the hardest: they can also be incredibly hard to heal and will show signs of disease sooner than other parts of the body.

Force plate and in-shoe podobarography (foot-force measurement) is useful for looking at how different parts of the foot interact with the ground and also in what order you start to use different parts of the foot.

With gait analysis, I will sometimes be able to extract huge amounts of information from just videos of a patient moving on a treadmill or even just walking along the road.

In more complex circumstances, I may wish to see how the foot pressures load and at what points in the gait cycle different parts of the feet load. Some examples of this would be for a person who walks a lot and always gets forefoot pain on their right foot. If they are on their right foot for 1000ms and their left foot for 800ms, that means they spend 200ms more time on their right foot, which means there is 200ms more time with the foot impacting the ground... This being said, it may also be that they actually spend 600 ms on their forefoot on the right meaning that 75% of their time on the right foot is spent on the forefoot. This means that the treatment - rather than more cushioning under the forefoot or telling them to walk quicker, may need to be a heel raise so that they spend less time with just their forefoot on the ground and so that the force gets evened up.

Using a foreceplate before and after running gait analysis can also be helpful for objectively identifying changes to foot functioning and musculature.

Gait analysis is most useful for patients who do long distance walking or running and do not develop pain until later in their walk / run.
It can also be useful for people who develop recurring issues such as heel pain, ankle pain or knee pain despite doing plenty of physiotherapy or rehabillitation.

Gait analysis is often thought to be the panacea of care and diagnosis. I have seen it described on patient forums as being the 'Gold Standard', however I have to mostly disagree with this.

Gait analysis can be extremely useful in identifying 'poor movement patterns' that result in pain, however, if doing detailed gait analysis on someone who is currently in pain, then all I am doing is seeing what their movement pattern is for whilst they're in pain.

Given that the treatment may end up in a suggestion that you have insoles - and these can be costly - it does not make sense for me to start you down this route of costly treatment when your gait may change once you are out of pain.

I only really use gait analysis in the early phases of injury when my patients will definitely see a benefit. Mostly, I recommend my patients have a standard musculoskeletal consultation and gait analysis if recommended.

NB: Gait analysis can range from putting you on a treadmill for 2 hours if you are marathon training to watching you walk across the room a couple of times. I will be writing a guide on how to take videos for remote gait analysis. If you are wanting this before the blog is written, please get in touch below.

All of these modalities can be used for short and long term treatment plans. Their role may be either to support the function of a structure that is injured or to prevent the functioning of a structure that is irritable.

The devices mentioned are all supportive in one way or another. Their roles are to stop, reduce, improve or replacing a lack of movement with 'fake movement' there aren't any. This can be achieved either through preventing the movement occurring - such as with an ankle brace; reducing the amount of movement that occurs, such as with an orthotic arch support that prevents some aspects of pronation; by improving the function of the big toe joint through improvement of the arch's profile or even creating fake movement through the use of a rounded shoe base if the foot struggles with flexing.

They can all be used as either a long term therapy or as a short term aide, and this will depend on the condition, the amount of disability it causes you and what your expectations are for what you should achieve in day-to-day life.

I very rarely recommend prescribing an insole 'for life' and consider that any practitioner who does prescribe like this to have a somewhat more questionnable practice style; but this is very case dependent and can never be one-size-fits all. I would say, however, that I probably prescribe one custom insole for every 30 off-the-shelf or modified off-the-shelf set of insoles that get prescribed.

MRI Scans can be extremely useful sometimes, but can even be 'too' useful.
I have arrangements with local hospital facilities organise MRI Scans.

Magnets have 'poles' - so like a north and south pole. Likewise, MRI scans do too; they work by flipping the polarity of the magnets rapidly and that 'flipping' means that the water molecules inside of you react to the magnetic field flipping and so an image is produced.

MRI gives a huge amount of information and can sometimes be unhelpful as it may show problems that are unrelated to why you have come in and, as a result, you may end up with new symptoms!

Nail surgery is primarily performed for ingrowing toenails. It can also be used for severely and permanently damaged nails, fungally infected nails and where trauma has occurred.

Ingrowing toenails can be extremely painful, and whilst they are sometimes the result of poor cutting technique, they can also occur due to injury to the toe, misshaping of the nail, or damage to the bone under the nail.

Nail surgery is a highly effective way to prevent and resolve ingrowing toenails so that you do not have to keep managing them yourself.

By opting to have nail surgery, instead of conservative treatment, you are reducing your long-term risks of recurrent infections and pain. More importantly, you are able to select when you have the procedure and ensure that you are not held hostage by your ingrowing nails.

Prehabilitation is more important than rehabilitation. Almost. The idea of prehabilitation is that you are preventing the need for rehabilitation.

Prehabilitation focuses on identifying your potential strengths and weaknesses and looking at ways to prevent these turning into problems.
As a clinician, it is imperative that I do not medicalise a non-issue.. So I will not just say "you should have insoles for those flat feet" or that you need to buy an expensive pair of trainers because your big toe joint might have a bit of limited movement.
I will work with you to identify your short, medium and long-term goals; discuss factors that may lead to you struggling with your lower limb, and suggest a program of exercises that you can follow to prevent you developing issues.
The most important point is education though. If you understand the way that injuries develop, you are more than half way to having a long and active athletic career, whether you are 18 or 80... I will still treat you so that you are optimised to the level you want to be, rather than a cookie cutter approach that you can download from anywhere online.

We will begin in this chapter by dealing with some general quantum mechanical ideas. Some of the statements will be quite precise, others only partially precise. It will be hard to tell you as we go along which is which, but by the time you have finished the rest of the book, you will understand in looking back which parts hold up and which parts were only explained roughly.

Rehabilitation is often sold as being something that physiotherapy offers, rather than podiatry… and that's really stupid.

The purpose of rehabilitation is to take you back to the level you were at before your injury. There are several ways to do this: protecting the foot with a cast, using insoles, doing exercises, taping and strapping the foot and ankle.

The most effective treatment is education though, and this is something that I focus on for you. When you understand what causes your symptoms and how these relate to your daily function: you are then able to start to become more independent of me for treatment. I rarely find that patients who have been educated about their condition and taken on board what has been explained require more than three treatment sessions to get them comfortably on the road to recovery.

If you needed more, I'm always there for you, but I should be the most expensive part of the treatment, not the custom orthotics you you buy, and if you understand what is going on, and why you have developed your injury, I'm confident that you will be able to keep yourself from darkening my door!

Also, you will find that I am releasing lots of free resources for patients I see, and that there are other resources that are affordable and, if you understand them, will really help to get you better and you can use me for the times when your symptoms are not changing.

Perfect for the busy professional or the stay at home mum who cannot find someone to look after her kids for the day. These consultations also mean that you will be listened and heard - after all, I can't physically assess you.

I can offer remote consultations at any time of day to suit you, whether you're in Berkshire, Bradford or Bahraine, you can get some time in front of me to go through your concerns.

Specialising in the management of complex conditions, I have heard so many different ways to describe symptoms and, as a result, can get the diagnosis just from what you have told me.

Available on Zoom, Google Meets, FaceTime, WhatsApp, Skype as well as specialist GDPR and HIPAA compliant systems... as well as the traditional telephone, I can help with your concerns at your convenience.

If the timings offered do not suit you, please get in touch and I will create some other timings to suit you.

Using specialist exercise prescription software, and with the internet making the world a smaller place, I can provide almost exactly the same level of care online as I would remotely.

Please note that if you struggle with technology or have poor flexibility, then it is preferable that you try to book a time that will mean you have the assistance of a friend or member of your family.

Shockwave therapy uses a system of soundwaves to create localised soft tissue inflammation. Although inflammation may sound like the last thing that you would want to be applied to your irritable foot, it can very effective for reducing pain levels in the short term as well as encouraging damaged structures to heal.

When a tendon problem fails to resolve within a period of approximately three months, the condition is then described as chronic. This has various implications, but one of which is that the injured area is then described as 'degenerative'.

Although this sounds particularly worrying, the 'degeneration' does not mean poorer long term outcomes - it is just a bit of medical terminology.

By using shockwave, we are able to break down the damaged and unhealthy structures, and (combined with excellent rehabillitation, can then optimise the healing process for you.

It is uncomfortable and can be painful in the early stages of treatment, however do not let this put you off. It is remarkably effective and has actually meant that surgeons have been able to stop doing as much surgery.

Primarily used for their powerful anti-inflammatory properties, steroid injections are an effective strategy when dealing with injuries in the first 1-3 months. They can be used beyond this point, however this decision should be discussed.

A lot of people are unable to use non-steroidal anti-inflammatory drugs due to asthma or issues with their stomach. When this is the case, a steroid injection that is specifically targeted into the site of pain can be a highly effective method of returning you to the activities you love.

I am frequently asked if there are risks associated with steroid injections like there are with taking steroids by mouth. The likelihood of weight gain is minimal, as the steroid is injected into a specific structure, as opposed to being absorbed by your body.

Steroid injections are not without risks, and can actually increase your pain for (up to) a few days after. If your pain is severe, however, then the improvement you experience can be spectacular. The other side effects of steroids are often short lived.

Elite athletes, weekend warriors, those taking up a new activity that they want to continue, those that do not want to stop what they are doing.

Ultrasound, in the hands of a skilled clinician, can provide a lot of very useful information. It is proven to be useful for assessing soft tissue as well as fractures, and is highly accurate for the assessment of joint inflammation.

Ultrasound uses sound waves that are shot out of a handpiece (transducer) and then will travel through the tissue. As the soundwaves collide with structures of different thicknesses: some soundwaves bounce off of the part that is a different thickness, whilst others will continue through.

It can be hard to understand and 'see' what the images represent if you do not spend a lot of time looking at the images, however ultrasound has been proven to be more accurate than X-ray and MRI as well as being safer for assessing some things. The only issue can be that the ultrasound operator may not know their technical limitations, which is why it is always worth finding out the experience of the operator assessing you... but politely and discretely - after all, they can see which bits are likely to hurt if they press on them!

Health professionals who perform ultrasound do not need to be regulated, however often are. These health professionals are typically either Radiologists (medical doctors specialising in imaging) or Sonographers. Sonographers are typically regulated by their original profession, and so could be a podiatrist (like me), a physiotherapist, radiographer, nurse or any other profession. It is not a requirement to be a health professional to be a sonographer, but what is important is to make sure they are certified. The certification to look for is whether they are "CASE accredited".

Essential for those with diabetes, current or ex-smokers, those with kidney failure or cardiovascular disease.

Vascular assessment involves looking at the arterial, venous and microvascular supply of the foot, leg and lower limb.

Beecause the vascular system is effectively a highway that feeds from very large vessels down to much smaller vessels, we are able to tell the health of your lower limb through assessment of the blood supply further down; a good blood supply at the feet will mean that your vascular health further up your leg is fine. If the blood supply at the feet is poor, then I will try to identify how far up the problem is so that you can be referred appropriately.

The most basic vascular assessments for feet include a visual check to assess skin quality and health as well as looking at (toe) hair and nail growth. I will also assess the temperature of the feet, checking for differences in temperature, how long it takes for the skin to 'pink up' after I press on the skin, and also check your pulses.

If your pulses are poor, I will listen to them with a Doppler machine, this allows me to hear the quality of movement of blood. It also allows me to check for certain cardiac irregularities such as atrial fibrillation - a leading cause of strokes (however I can also do this with my fingers, but by listening to your pulses, I have an extra layer of certainty to write to your GP with.

I may also assess your Ankle-Brachial Pressure Index. This is a method of assessing the ratio of your blood pressure in your arms and the blood pressure in your ankles. We then try to work out how evenly distributed the blood pressure is, and if there are differences, then further assessment from a vascular specialist may be required.

Depending on the severity of your symptoms, I can assess your blood supply as far up as your femoral artery. If you are coming in for vascular assessment and have been a heavy smoker, had extended periods of poor control of your diabetes, or get a numb / cramping / tingling pain in your buttocks, thighs, or calves whilst walking which goes within a minute or two of stopping, please ensure you wear loose fitting clothes to your appointment so that I can assess higher up your leg. Your dignity will be maintained at all times if this is necessary and you will be informed of all actions that may need to be undertaken.

Verruca Needling, also known as Falknor's needling, and incorrectly known as 'Dry Needling' - is a method whereby a verruca is punctured multiple times under a local anaesthetic block to stimulate the necessary immune response for it's resolution.

Verrucae are a benign virus that do not cause any harm. One could even argue that they do not actually need treating. They can be painful and unsightly, and these would be good reasons to treat a verruca.

There are many treatments available for verrucae, including doing nothing, however for painful lesions, or those lesions that have been hanging around a while: verruca needling can be an excellent treatment option.

Using local anaesthetic, either the area where the lesion is or the whole of the foot will be numbed. Lesions in the forefoot are numbed from the top of the foot and lesions under the heel or arch will be numbed at the ankle, meaning that the whole foot is made numb. Alternative options are available if the whole foot cannot be made numb for safety reasons (stability or needing to drive etc).

The lesion is then punctured multiple times and wrapped in a large dressing to keep the region clean and infection free. The procedure is quick - taking only 5-10 minutes and the time allocated is often as little as 30 minutes and rarely more than an hour (the number and size of lesions are a factor for this).

My patients have often found Swift (microwave therapy) to be very painful as well as expensive, and as a result have opted for needling if they have not had partial / total resolution within a set number of sessions - usually no more than five.

I can however offer: Debridement, curettage, cryosurgery, caustics, Swift and needling.

X-rays use very low dose radiation to assess structures within your body. For the foot, x-rays are primarily used to look at structure and check for fractures. It can calso be used as part of an assessment of infection and soft tissue health - especially arterial health.

X-rays form part of the electromagnetic spectrum. Their use has been associated with developing cancer in the past, however, these days the accuracy of an X-ray beam and the doses that get used are highly regulated and well controlled.

X-rays are generally considered to be the first line investigation following a foot injury, and although this is the generally accepted scenario; there are other imaging modalities that are more accurate and can give better information that what is seen via x-ray.