Thursday, 09 August 2012

YOUR HEALTH Dr James Le Fanu: 10 August

Mysterious foot pain, odd twitchings in the night… and whether or not to induce an overdue pregnancy

Written by Dr James Le Fanu
The human foot is a most sophisticated, durable piece of mechanical engineering – which is certainly a good thing as it is much the most traumatised part of the body. Its most impressive feature is the independence of all its structures so that bones, tendons, muscles and sheaths of tissue fit together distributing the downward load of the human frame.

The regrettable corollary of this is that when things go wrong, the pain can seem to involve the entire foot and be quite crippling.

Dr Graham Hunter, a family doctor in East Sussex, writing in the journal Medical Monitor recounts the case of a 70-year-old woman – whom he describes as 'formerly a tough and formidable nursing sister in the Army' – with a pain in the right foot becoming increasingly severe over several weeks. 'At first a stick, then crutches until it was all she could do to open the door,' he writes.

She became ever more despondent and when an X-ray showed only mild arthritis, he advised a referral to an orthopaedic surgeon. This was duly arranged and Dr Hunter even volunteered to take her in a wheelchair to the clinic himself – which was how he was in a position to witness the following illuminating consultation.

First the surgeon perused her notes, then asked her to try standing with her instep over the toe of his shoe. This simple manoeuvre, surprisingly, provided some relief. He then produced a piece of plastic which, when inserted into her shoe, allowed her to hobble to the door. 'The culprit turned out to be an acute sprain of her longitudinal arch,' he writes. 'She was put into a belowknee plaster and by the next morning the pain had gone and she was able to move about the house.' This is a most instructive episode.

Though there are numerous potential causes of a pain in the foot, it can be difficult to know what precisely is amiss so the family doctor may be tempted to prescribe an anti-inflammatory drug to see what happens. As this case illustrates only too well, however, the priority should be to see someone who knows what they are talking about to advise accurately what form of treatment is most appropriate.

This week's medical problem comes courtesy of a lady from Essex writing on behalf of her 80-year-old husband, and indeed herself. He has for many years 'twitched' while asleep. These movements occur at regular 10-second intervals involving his shoulders and legs and the only way to stop them is for her to shake him so that he wakes. Meanwhile, the regularity of the movements keep her awake and she wonders whether there is anything to be done that would obviate the need of going to the expense of getting single beds.

This certainly sounds like Periodic Limb Movement Disorder, otherwise known as nocturnal myoclonus. Its cause is not known but presumably involves sleep-induced activation of the relevant parts of the motor cortex of the brain. The standard treatment is the drug clonazepam, though finding the right dose can be difficult as insufficient is ineffective while excessive may exacerbate daytime tiredness and drowsiness. If this does not do the trick, the drug ropinirole in a low dose is probably the preferred choice.




Bring it on

There is a longstanding conundrum whether a pregnant woman who has passed her Expected Date of Delivery should carry on in anticipation her baby will emerge in its own good time – or to get things moving by inducing the onset of labour. Dr Sarah Stock of Edinburgh University has surveyed the outcome of over a million births in Scotland over 25 years – with very interesting results. She found that induction of labour to be marginally safer in preventing the death of one child for every 1,000 births. Put another way it is necessary, in order to save the life of one baby, for approximately 999 women to have their labour induced unnecessarily.

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