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Feet: Facts, Fallacies & Fetishes The role of podiatry
Ms Bec Daebeler Manager, Podiatry Services Flinders Medical Centre August 2008
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Facts, fallacies and fetishes
The High Risk Foot Charcot Foot What podiatrists can do… Footcare IQ
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Podiatry Need to be registered to practice
The scope of Podiatry as defined by the Australasian Podiatry Council - “podiatry deals with the prevention, diagnosis, treatment and rehabilitation of medical and surgical conditions of the feet and lower limbs. The conditions podiatrists treat include those resulting from bone and joint disorders such as arthritis and soft-tissue and muscular pathologies, as well as neurological and circulatory disease.” Need to be registered to practice
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What is the High Risk Foot?
Any foot with an increased risk of ulceration, infection and subsequent amputation. So…who is at risk?
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The High Risk Foot peripheral vascular disease peripheral neuropathy
Individuals who are at high risk of developing Foot problems are those with either: peripheral vascular disease peripheral neuropathy severe foot deformity history of or a current foot wound. National Association of Diabetes Centres in partnership with the Australian Podiatry Association, 2000
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What are the Statistics?
3 year survival rate for anyone who has undergone a lower limb amputation is 50% Over half of diabetic related amputations occur as a result of barefoot injuries The attributable cost of for a 40 – 65 y.o male with a new foot ulcer was $27,987 (US) for 2 years after diagnosis Diabetes Care, Vol.22, no. 3, March 1999
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What are the Statistics?
15% of patients with Diabetes will develop a foot or leg ulcer 50% of those with a foot or leg ulcer will have an amputation at some stage in their lifetime People with Diabetes (3-4% of pop.) account for 50% of non-traumatic Lower Extremity Amputation. Frykberg RG, The Team Approach to Diabetic Foot Management, Advances in Wound Care, 11(2); 71-7: 1998
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Patient Assessment Vascular status Occupation/Activities
Neurological status Footwear Bio-mechanics Occupation/Activities Systemic disorders Medications Patient needs
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Peripheral Vascular Disease
Slows healing ability Infections more likely to develop Increases the chance of gangrene Increases the risk of foot/amputation
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Peripheral Vascular Disease
Increased risk of ulceration Tissue ischaemia Atrophic skin changes Following Ulceration Retards wound healing Increases risk of infection Increases risk of amputation Lavery et al (2000)
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Peripheral Vascular Disease
Obtain patient history Pain or cramping in calves/thighs may indicate intermittent claudication May experience night pain in more advanced cases Lipids Smoking history BSL’s BP exercise levels
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Peripheral Vascular Disease
Symptoms of: “Burning” Claudication Rest pain
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Risk Factors Family Hx Diabetes Obesity Diet Exercise Smoking
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Macrovascular Disease
Occlusive and often repairable Atherosclerosis of arteries Calcification of arteries Input by Vascular Surgeon important Always check pulses in the lower leg Femoral Popliteal Posterior Tibial - Dorsalis Pedis 9
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Microvascular Disease
Not occlusive, basement membrane thickening, not repairable Caused by changes in the structure of the arteries and blood cells Plays a component in the development of peripheral neuropathy Leads to poor O2 perfusion in tissues and delays healing of wounds Worsened by smoking 10
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Vascular Assessment Pulse palpation SVPFT Colour, Warmth, Hair Growth
Posterior Tibial Dorsalis Pedis SVPFT Colour, Warmth, Hair Growth Doppler (ABI), Toe pressures, Duplex, Angiogram Consider Referral to Vascular Surgeon
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Clinical signs Dystrophic nail and skin changes
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Management Quit smoking Good BGL control Encourage walking/activity
Refer to Vascular Surgeon Education 11
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Smoking and Peripheral Vascular Disease (PVD)
Smoking is the number one risk factor for PVD and symptoms develop earlier in life Over 80% of people with PVD affecting the lower limbs are smokers or ex-smokers Smoking causes 40% of PVD in men and 34% of PVD in women in Australia
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Smoking and PVD For people who develop symptoms of PVD, quitting slows down the progress of the disease. Compared to smokers, people who quit have less severe pain when walking and are less likely to develop pain at rest. They live longer, respond better to treatment, and are less likely to require amputation.
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Peripheral Neuropathy
Numerous causes (eg diabetes, alcoholism, Syphilis, Leprosy, renal failure, HIV, CMT, spina bifida, spinal cord injury, stroke and RA) Diabetes is most common Exclude Malignancies Toxic (alcohol) Infections (HIV) Referral to Neurologist Jude & Boulton (1999)
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Peripheral Neuropathy
Sensory Neuropathy Autonomic Neuropathy Motor Neuropathy
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Diabetic Peripheral Neuropathy
Paradox: Patients with insensate feet who are asymptomatic may first present with foot ulcers Patients with severe neuropathic pain who on examination may have only a minimal deficit
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Diabetic Peripheral Neuropathy
Two main types: 1. Acute sensory neuropathy 2. Chronic sensorimotor neuropathy
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Acute sensory neuropathy
Characterised by severe sensory symptoms Few if any clinical signs Usually precipitated by episode glycaemic instability (ketoacidosis or institution of insulin) Gradual improvement symptoms with establishment of stable glycaemic control (appropriate symptomatic treatment)
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Chronic Sensorimotor neuropathy
Insidious onset Up to 50% may be asymptomatic 10-20% may experience painful symptoms Often accompanied by autonomic dysfunction Late sequelae: foot ulceration, Charcot neuroarthropathy Prevalence increases age and duration of diabetes
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Typical Neuropathic Symptoms
Painful Non painful Burning pain Asleep Knife like “Dead” Electrical sensations Numbness Squeezing sensations Tingling Constricting Prickling Hurting Freezing Throbbing Allodynia
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Sensory Neuropathy Loss of temperature, pain and pressure sensation
Increases chance of unnoticed foot injury Burns (physical, chemical) Cuts (accidental, self inflicted) Pressure lesions (corn, callus, blisters) Wounds may develop and progress to a lower extremity amputation
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Loss of protective sensation (LOPS)
LOPS greatest risk factor for development of plantar ulcers Peripheral sensory neuropathy primary factor in 60-90% of all diabetic foot ulcers Daily foot inspections/examinations
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Sensory neuropathy ‘healthy’ but hazardous
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Autonomic Neuropathy Loss of flare response
Loss of function of skin structures Sweat glands Skin tears Atrophic skin changes Arterio-venous shunting May lead to neuropathic osteoarthropathy (Charcot’s Foot) Loss of flare response Infection may not present clinically reduces visible erythema
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Motor Neuropathy Loss of intrinsic muscle function
Decreases foot stability Muscle atrophy Altered foot structure Development bony prominences Increased focal pressure areas Increased risk of pressure wounds Lavery et al, (2000) Loss of anterior muscle group function Promotes development of foot deformity
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Motor Neuropathy Toes curled up (claw like changes)
Metatarsal heads on the plantar surface prominent Fat pads pushed upwards proximally (fullness noted at base of toes) Absence of ankle and knee reflexes
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Neurological Assessment
10g Monofilament Fine Touch Vibration Proprioception Reflex AJ KJ Hot/Cold Subjective Hx.
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Structural Changes - the forgotten factor!
Alter foot structure increased load sites foot type flat/pronated feet callus bunions, hammer toes diabetes related motor neuropathy Glycosylation (reduced or lost joint mobility) increased loads + neuropathy = ulcers simple, low tech measures can prevent
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Plantar Pressure An excessively pronating foot will cause an increase in shear stresses
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Severe foot deformity Blisters Callus Corns
Increases the chance of pressure lesions Blisters Callus Corns Usually associated with poor fitting footwear May result in ulcers / amputation
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Footwear Assessment Length Width Stable heel counter
Sole flexes at ball of foot only Appropriate for activity Socks/hosiery Wear them!
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History of or a Current Foot Ulcer/Amputation
Increased chance of reoccurrence Foot wound may progress to lower extremity amputation
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Common problems following amputation
Callus Contracted digits Limited joint mobility Foot deformity Foot ulcers
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Biomechanical impact Peak plantar pressures are higher in patients with diabetes following partial foot amputation Areas of high pressures implicated as one of the most important cofactors in ulceration of patients with diabetes
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Biomechanical Impact Causes of peak plantar pressures includes:
Foot deformity Clawing of toes Callus formation Limited joint mobility Lack of soft tissue cushioning Charcot foot
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Types of Amputation Digital amputation Ray Resections
Transmetatarsal amputation Midfoot amputation Lisfranc’s amputation – tarsometatarsal jt. line Chopart’s amputation – midtarsal jt. line Syme’s amputation – disarticulation of the ankle Rearfoot amputation
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Amputation Management
Foot care programs / education Appropriate wound care Padding Orthoses AFO Shoes Restoration of joint and muscle function Liasing with orthopaedic / vascular specialties/Orthotists/Prosthetists
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Charcot Foot Neuropathic Osteoarthropathy (NOA) otherwise known as Charcot Foot Characterized by: Pathologic fractures Joint dislocation Deformity occurring in individuals with a neuropathic foot.
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Risk factors Neuropathy
Osteoporosis reduced bone density leads to reduced bone strength increasing chance of traumatic fracture Elevated plantar pressures Retinopathy reduced visual acuity may increase trauma to foot Nephropathy Recent history of trauma
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Risk factors Duration of diabetes for >10 years
Poorly controlled diabetes Progressive sensory, motor and autonomic neuropathy Obesity elevated plantar pressures Renal transplantation: immunosuppressive agents Limited joint mobility: promotes increased plantar pressures and altered biomechanics Rupture of the plantar fascia: loss of windlass mechanism to support longitudinal arch may reduce foot stability Multiple amputations of the foot
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Aetiology Contemporary thought about the aetiology lies somewhere between the neuro-traumatic and neuro-vascular theories Autonomic neuropathy may cause osteopenia by an increase in blood flow to the extremity Sensory neuropathy makes the patients unaware of the abnormal stress on the joint caused by motor neuropathy Abnormal stress can cause bone damage through osteoclastic activity and which can lead to fractures.
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Pathomechanics - Charcot
1.A/V shunting => increase blood flow in arterioles 2.Increase in blood flow => de-mineralisation of bones 3.Demineralised bones more fragile 4.Un-noticed trauma with neuropathy leads to micro-fractures
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Pathomechanics - Charcot
5.Massive inflammation occurs with repetitive fractures 6.Foot becomes swollen, hot and red with inflammation 7.Foot deformity develops with multiple fractures 8.Foot ulceration may follow due to deformity and neuropathy
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Differential Diagnosis
Osteomyelitis Cellulitis/abscess Polyarthroses DVT Trauma/Fracture Lymphoedema Gout Malignancy Tertiary Syphilis Alcoholism
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Critical assessment for patients who present with a warm, red, and swollen foot
Checking the medical history thoroughly for conditions such as diabetes, cellulitis, DVT or inflammatory arthritis Checking visually for any signs of foot deformity (especially around the midfoot) Palpating for bounding pedal pulses Assessing for sensory neuropathy with monofilament/tuning fork Taking temperature measurements for comparison to the contralateral foot
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Critical assessment for patients who present with a warm, red, and swollen foot
Asking if the patient can recall any history of trauma Checking for any portals for infection such as wounds or tinea Asking if the patient has been unsuccessfully prescribed antibiotics X-rays (weight bearing AP & lateral, Non-weight bearing medial oblique) should be taken and reviewed ASAP Blood specimens or other investigations
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Radiograph views Lateral views:
Normally the talar neck should be parallel to the 1st metatarsal shaft on lateral views. The angle of calcaneal inclination should be between degrees A Charcot foot may display deviation between the talar neck and 1st metatarsal and a decreased angle of calcaneal inclination. A rocker bottom deformity develops as the Tibia acts like a piston collapsing the arch.
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Radiograph view (lateral)
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Radiograph view (lateral)
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Radiograph views Dorsal/Plantar (DP) views:
Normally a line drawn between the 1st and 2nd cuneiform will be parallel with the medial shaft of the 2nd metatarsal. A Charcot foot may display deviation of the 2nd metatarsal laterally as the midfoot collapses
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Charcot Treatment The management of acute Charcot foot is to maintain the existing architecture of the foot Prevent further bony destruction. The focus is on immobilization and reduction of stress (Armstrong and Lavery 1997) Total Contact Cast (TCC) Charcot Restraint Orthotic Walker (CROW) Air Cast Back slab
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Offloading Choices The stage of the condition
The degree of foot deformity The amount of oedema The degree of patient compliance and self care capacity The clinics ability to dispense and cost a device The presence, depth, and likelihood of wound infection
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Treatment of Foot Wounds
Patient education Determine aetiology Provide optimum wound healing environment Maintain systemic health Manage contralateral foot Prevent recurrence
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Wound Management Control Systemic Factors
Diabetes - glycaemic control reduces complications Diet - certain nutrients essential for wound healing Alcohol intake Smoking - eliminate or reduce Skin disorders - psoriasis
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Treatment of Foot Wounds
Control Aetiology Off-load pressure areas Restore vascular supply Remove foreign bodies Multi-disciplinary approach
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Debridement Important to remove devitalised tissue
Removal of devitalised tissue increases the healing or neuropathic ulcerations Regular aggressive sharp debridement (weekly-monthly) Performed if adequate blood supply for healing
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Wound Assessment Site Size Time present Depth Wound base Exudate
Surrounding skin Previous treatments Pain levels Possible prognosis
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Wound Management Maintain Optimum Wound Environment
Moisture Balance Promotes granulation and epithelialisation Optimum temperature 37ºC Reduce / Prevent infection Contamination, colonisation or infection
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Infection Diabetes = compromised immunity
Leads to reduced resistance to infection Exacerbated blood sugars poor control (impaired neutrophil chemotaxis) Diabetes may suppress classical inflammatory signs of infection
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Blood flow, neuropathy & infection
“The germ is nothing; it is the terrain in which it grows that is every thing” Louis Pasteur blood supply BSL’s organisms antibiotics pressure Mx wound care
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Wound Management Prevent Recurrence
Healed wounds have increased risk of recurrence due to reduced tensile strength. Remodeling continues for up to two years. Continue patient education. Monitor the site continuously.
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Manage the Contralateral Foot
The factors responsible for the original wound may be present in the contralateral foot. So… Observe both feet at regular intervals Reduce excessive pressure loading
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Self-care & Support elderly poor vision poor mobility living alone
socio-economic awareness ‘wilful self-neglect’
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“Who cares” - a guide to nail management
Self care Can see Can reach Normal nails No PVD Family/friends Can’t see Can’t reach Normal nails No PVD Podiatrist Can/can’t see Can/can’t Abnormal nails PVD reach Evans,Phillips,Popplewell 1994
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Summary - The big 4 + an ulcer
Vascular look, listen, palpate, vascular studies, educate Neurological look, listen, test, educate Structural * weight bearing callus * look, sensate?, shoes, Podiatry, educate Self-care & Support can they? will they? help? educate
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What can Podiatry do? Removable walking casts Total contact casts
Foot assessment, education and management planning Regular wound bed preparation including debridement 3. Manufacture of pressure relieving devices including: Removable walking casts Total contact casts Accommodative insoles Padded insoles Felt padding Footwear prescription and modification
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Offloading – pressure relieving devices
Total contact cast Removable walking cast Accommodative insoles Padded insoles Felt padding Footwear prescription & modification
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What can Podiatry do? Appropriate dressing selections
Ongoing maintenance and monitoring following wound resolution 6. Work with Multi-D Teams of Vascular Specialists, Orthopaedic Foot & Ankle Specialists, Endocrinologists, Wound Care Consultants, Orthotists, Diabetes Educators and Allied Health professionals to ensure the best possible outcome for clients with foot wounds
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Education Check and Clean feet Daily
Always wear something on your feet Never self treat corns or callus Don’t use wart or corn cures Careful of heaters and other sources of heat First aid Dry between toes Cut nails straight across Appropriate footwear
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What to check for….. Callus Corns Blisters Rub marks/pressure
Non healing sores Inflammation Dermatitis IGTN Subungual haematoma Other – anything that wasn’t there yesterday
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Where to check ….. Inter-digital spaces (in-between toes)
Plantar foot (sole)/Dorsum (top) Bony prominences Toes Heel MPJ Ankle Shin
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Remember! One Pair Must Last A Lifetime
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WHAT IS YOUR FOOTCARE IQ?
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About one-quarter of all bones of the body are in our feet.
TRUE or FALSE True Human feet contain about 52 bones (25% of the bones in the human body) as well as numerous joints, ligaments, muscles and tendons
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The average person will walk around 128,000 km’s in a lifetime
TRUE or FALSE True The average person will walk around 128,800 km’s in a life time - that’s more than thee times around the earth.
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People with diabetes should visit a podiatrist at least every 12 months for a foot assessment
TRUE or FALSE True Diabetes can effect the blood and nerve supply to the feet. People with diabetes should have yearly podiatry appointments to assess the health of their feet.
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People with diabetes are more likely to be hospitalised due to foot problems than for any other reason. TRUE or FALSE True Foot problems are one of the most common reasons for admission to hospital for people with diabetes
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People with diabetes should never walk barefooted
TRUE or FALSE True Over half of the amputations performed on people with diabetes have started from developing injuries while barefoot
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Shop for shoes in the morning to get the best fit
TRUE or FALSE False It is best to shop for shoes late in the afternoon when the feet start to swell and are at their largest. Incorrectly fitting footwear may result in shoes that rub and cause sores or blisters.
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People with diabetes should cut corns or callus with scissors or a sharp blade to reduce the build up of hard skin TRUE or FALSE False Build-up of hard skin like as callus and corns should be removed by a podiatrist. Home surgery with scissors or blades commonly result in serious injuries and infection due to poor feeling and blood supply to the feet.
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Toenails grow more rapidly in the summer than in winter
TRUE or FALSE True Nails grow more rapidly in the summer than in the winter. If you are right-handed, the nails on your right hand grow faster than on your left, but toenails grow at the same rate on each foot.
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Altocalciphilia describes sexual arousal due to . . .
A - High heels B - Flat feet C - Hairy feet D - Long or Ingrown toenails High heels This attraction has its origins from our primal instinct to seek out the lame and weakened. The weakened gait widens the division of power between the genders. Men may be attracted because they feel superior or a driving need to protect the vulnerable.
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What would turn on an apotemnophile?
A - Meeting a person born with too many fingers or toes (Polydactylism) B - Having a limb amputated, C - Cutting toenails extremely short, D - Dirty/smelly feet E - extremely small feet Having a limb amputated Apotemnophilia is the medical term for an individual with the sexual fetish or paraphilia of being an amputee. An individual with true apotemnophilia may be chronically unsatisfied with their sexual relationships or even completely sexually dysfunctional until their desire for amputation is realised.
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What would turn someone with a foot fetish on?
A - size of the foot B - curve of the arch and instep C - length and straightness of the toes D - texture and complexion of the skin E - softness of the sole F - foot odour G - all or any of the above G – all or any of the above Fetishists view the foot as others seek aesthetic pleasure from some other erogenous form. The fetish is usually meticulous about cleanliness although there have been reports in the scientific literature about dirty feet being of particular attraction, especially in homosexual foot fetishists. Foot odour is a powerful sexual arousal factor for podophiliacs. There are reports that the smell of feet was to the fetishist the same as the smell of the genitals to others. Foot lovers like to be stimulated visually and will gaze at pictures of feet. By in large foot lovers enjoy relatively gentle aesthetically pleasing scenes that concentrate on soft caresses, kissing or licking
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Intellectual property:
This presentation remains the intellectual property of the author. No part of this presentation shall be reproduced, saved or altered without the author’s express permission. Disclaimer: This presentation reflects the individual author’s views and may not represent the views of SAWMA. This information is intended as a general guide only. Application of this information should consider each person’s individual circumstances. No responsibility is taken by SAWMA for any harm to person or property arising from the information contained in this presentation. No responsibility is accepted by SAWMA for the consequence of inaccuracy or omission of information contained in this presentation. Provision of this information by SAWMA does not constitute endorsement of any product or organisation.
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