Dr Helen Crawley: Raynaud’s phenomenon occurs when the blood vessels in your fingers or toes constrict causing them to go white, then blue as oxygen is used up, then red as blood flow returns. The symptoms can be set off by stress or – as in your case – by cold weather or a change in temperature.
Raynaud’s is sometimes associated with other conditions, such as auto-immune diseases or caused by vibrating hand tools. Smoking, caffeine and some medications can make Raynaud’s worse, so ask your pharmacist or GP if you are taking tablets.
Keep your hands warm with gloves, wrap up before you go out, and consider buying heated socks and gloves. Regular exercise and relaxation therapies may also help your symptoms. In severe cases, medication such as nifedipine is sometimes prescribed.
If this does not help, your GP might consider referring you for hospital care, where possible treatments include surgery to block nerve signals and prevent the blood vessels from constricting.
Dr Helen Crawley: This sounds very much like ‘golfer’s vasculitis’. Your rash has not responded to antihistamines as it isn’t caused by an allergy.
In one published study, a rash similar to the one you describe was found in golfers and hikers, especially when they were active in warm conditions. Most people did not develop the rash until they were over 50 years old, and many of the sufferers had undergone extensive allergy testing to no avail.
Biopsies demonstrated that the rash was caused by vasculitis, an inflammation of the blood vessels. It usually goes in a few days. Try keeping your legs cool with looser clothing and use wet towels or a cooling bath to sooth your legs after walking.
Dr Helen Crawley: I’m delighted you’ve been able to take up walking with such success. Foot drop can have various causes, from nerve issues to injuries. Your individually-made SAFO envelopes the foot in silicone and prevents it from dropping down when you raise it up to step forward.
You also mention that you’ve had an arthroscopy on your left foot, which is a simple procedure that uses a small camera to look inside a joint. I wonder if you actually mean arthrodesis, in which the joint (perhaps the ankle in your case) is fused in a fixed position so that the foot does not flop down. If that is the case, walking will no doubt be putting a strain on your left ankle.
Your GP might refer you to an orthopaedic surgeon specializing in foot problems who can check that your fusion is at the correct angle. Alternatively, you may benefit from seeing a physiotherapist to examine your gait and or an orthotist, who can supply specialized footwear. Any of these professionals could also advise you on whether your particular foot problems would be helped or hindered by rocker shoes, which will offer more support to the arch and foot overall.
Dr Helen Crawley: Your plantar fascia is a band of strong tissue supporting the arch of your foot. Plantar fasciitis is when it becomes painful where it attaches to the heel bone under your foot. You are quite correct to rest it, and this is often enough to sort the problem. Ice, painkillers and heel supports from a chemist, physiotherapist or orthotist can also help treat and prevent the pain from recurring, as well as specific exercises to stretch your Achilles tendon and plantar fascia. In most cases, and whatever you do, the symptoms go within around a year. If not, possible next steps include a steroid injection or high energy sound waves (extracorporeal shockwave therapy or EST). The benefits of EST are controversial but it doesn’t seem to cause harm. Studies have also looked at treating plantar fasciitis with radiotherapy, botulinum toxin or a walking brace. As a final resort, your GP could refer you to an orthopaedic surgeon to consider cutting the plantar fascia to release it from your heel. Whenever your symptoms have gone, make sure you ease yourself gently back into your hiking.
Dr Helen Crawley: I’m not sure exactly what is causing your burning sensation. It could be a skin disease or infection, such as athlete’s foot, in which case wearing breathable socks should help. Locally painful conditions, such as osteoarthritis or Morton’s neuroma, can feel like a painful burning and be tender to the touch. However, a burning sensation is more likely to be coming from within your foot. A problem with the nerve supply, due to inflammation or pressure on the nerve, is one possibility. Another is that the blood supply to your foot is reduced due to narrowing of the arteries. See your GP and they can check to see if you need treatment or a referral.
Dr Helen Crawley: See your GP to make sure there isn’t something important worsening your breathlessness. Possibilities include lung disease or angina. If one or more of the coronary arteries are narrowed, this restricts blood supply to the heart muscles. The blood supply may provide sufficient oxygen to the heart at rest but when you go uphill, your heart pumps faster and needs more oxygen. Insufficient oxygen supply to the heart muscles causes angina. The most usual symptom is chest pains, but sometimes angina is felt as breathlessness or tightness in the chest. Lung problems or anaemia can also cause breathlessness. So do get checked out.
Dr Helen Crawley: I suggest you have a detailed discussion with your orthopaedic surgeon and make sure that you’re happy with the risks and potential advantages to you of having your knee replaced. There’s a fine balance between having a knee replacement too early, then needing a second replacement later on; and leaving the operation so late that knee deformities develop, affecting the chances of a successful operation. As you’re still able to walk 10–15 miles, it seems your knee function is still very good, so it may be worth discussing alternatives to replacement surgery – such as better pain control. If you do have the operation, it’s important that afterwards you do all the exercises your physiotherapist suggests, and that you start to increase your walking distance gradually. You should be able to resume normal leisure activities three-to-six weeks after surgery, but it may take up to three months for the pain and swelling to settle down. Your new knee should then continue to recover for up to two years after your operation.
Dr Helen Crawley: A variety of conditions can cause knee pain. Your discomfort could originate in your knees, in the structures around them, or could be referred from other areas, such as your hips. Different causes are more common at certain ages, but tight hamstrings (as you suggest in your letter) are probably not to blame. Exercises that help to strengthen the muscles around your knees will probably help with your pain, but I suggest you get a better idea of the cause first. See your GP or a physiotherapist to discuss the most likely diagnoses and what to do next. They might suggest a simple exercise regime, or conduct a scan or X-ray. Or they may refer you to an orthopaedic specialist for further investigations or an operation, such as an arthroscopy (keyhole surgery to diagnose and treat joint problems).
Dr Helen Crawley: You most likely have golfer’s vasculitis, also known as hiker’s or exercise-induced vasculitis or Disney rash. The proper name is leukocytoclastic vasculitis, and it’s an inflammatory reaction in the blood vessels. Blood leaks from the vessels to form small bruises or a rash. It’s common in people over 50 after prolonged walking in the heat. Although it can be uncomfortable or itchy, it’s harmless and usually fades in a few days. Unfortunately, there’s no prevention or treatment. Other causes may include an allergy to something in your socks, pressure from your walking boots, heat rash or eczema.
Dr Helen Crawley: An x-ray will only show bone damage and not more common injuries, such as ligamentous sprains, muscle strains or problems with the cartilage. If the x-ray showed ‘no deterioration’, this may have meant that you already had problems with wear-and-tear arthritis (osteoarthritis) on a previous x-ray.
Applying ice wrapped in a damp towel for 15-20 minutes every 2-3 hours, and avoiding alcohol, non-steroidal anti-inflamatory drugs, massages and heat, will reduce the risk of swelling and bleeding in the first two or three days.
Cycling is generally good exercise for a painful knee as it’s non-weight-bearing, so start your recovery after a few days by getting out on your bike. If your knee gets worse, or doesn’t steadily improve, consult a physiotherapist or your GP. They may suggest specific knee strengthening exercises or a referral to an orthopaedic specialist for scans or an arthroscopy.
Dr Helen Crawley: It sounds as if you are bruising your toes under your toenails when you walk. You might also be damaging the nail bed at the base of your nails, where the nail grows from, causing your toenails to drop off (they should grow back slowly). Your toes are more likely to get a bashing if you’re walking downhill as they can slip forward and hit the inside of your boots.
Next time you buy your boots, make sure there is plenty of room for your toes, with uppers that are softer and more flexible. Before you go out, cut your nails so they don’t extend beyond the end of your toes. And when you’re about to go down a hill, stop and give your laces an extra pull to make sure your foot is held tightly in place at the back of the boot. If none of these measures works, you could try using walking poles to lessen the impact on your feet.
Dr Helen Crawley: The fine particles present in dust, soot and exhaust fumes can affect your health, especially if you already have heart or lung problems. Carbon monoxide prevents the uptake of oxygen by the blood and can worsen some heart diseases. Whereas gaseous nitrogen dioxide, sulphur dioxide and ozone may irritate the lungs, exacerbating breathing problems such as asthma.
While a simple surgical face mask reduces the spread of infection, they are in fact useless against air pollution. More expensive, high-performance masks have been shown to reduce the risks of pollution in Beijing. But in Britain, levels of pollution are generally much lower and there is little evidence that masks have any real benefit.
On balance, walking or cycling in British cities without a mask should improve your overall health and fitness. But if you are affected by air pollution, try to avoid strenuous outdoor activities and take a more rural route if levels are high, (check www.airquality.co.uk for pollution forecasts). In which case, asthmatic patients may need to use more of their inhalers.
Dr Helen Crawley: It’s quite common for painful tensions to occur in the muscles around the shoulders, head and neck, with these muscles pulling on the tendons that attach them to the bones.
The most likely cause of your discomfort is your posture when walking with a rucksack. Try stopping to stretch your neck and shoulders every mile or so, and use a rucksack with a good hip-strap to take the weight off your shoulders. A chest-strap is worth trying: it could improve the stresses on your neck but may also make them worse.
If you are still getting problems, consider seeing a physiotherapist for advice. You could see an Alexander Technique teacher – they are experts in identifying harmful postural habits and helping you to correct them. I’m quite certain you’ll find a way to continue your walking without the strains and pains.
Dr Helen Crawley: As you don’t have any pain or stiffness, I don’t think you need to see your GP. Your out-turned foot could be caused by long-standing minor deformities or asymmetries in your foot, ankle, knee, leg or hip.
Another possibility is that you have developed early wear and tear in your joints, causing a change in your posture. Unless you have other symptoms, surgery is not generally recommended.
If your out-turned toe does start to cause you pain or problems walking, you could see a physiotherapist who can identify the problem and advise you on exercises to improve your gait. Or an orthotist may be able to suggest special shoes or inserts to correct your posture.
Dr Helen Crawley: I can understand how worried you are about your leg symptoms and the hardest time can be waiting for a diagnosis. I am not sure why you think you have muscular dystrophy, but I believe this is unlikely. Your GP would have referred you to a neurologist if they thought you had a form of muscular dystrophy, which is a condition causing progressive, painless muscle weakness and most commonly affects children (most commonly boys). Musculoskeletal specialists are trained in the diagnosis and treatment
of problems affecting the muscles, bones, ligaments and tendons, especially when there is a mechanical problem causing pain. Your pain affects one leg and gets a bit better after taking a few paces, so I suggest you carry on walking for now – but keep your rambles short enough to avoid severe pain. The specialist can advise you further.
Dr Helen Crawley: It sounds as if you are suffering from Achilles tendonitis, which usually takes weeks or months to recover from. Boots that cover the Achilles tendon can exacerbate the swelling, so use low-backed walking shoes until you are completely recovered. You could make an appointment to see a physiotherapist privately. They can suggest exercises, treatment options, and help improve your gait, perhaps with shoe inserts. For the pain, try paracetamol or non-steroidal anti-inflammatory drugs - gels are often effective. If symptoms persist, see your GP. They can refer you for physiotherpay and may suggest you see a specialist. Treatment includes steroid injections, extracorporeal shock-wave therapy, complete rest, using a plaster cast and surgery.