Presentation on theme: "Feet: Facts, Fallacies & Fetishes The role of podiatry"— Presentation transcript:
1 Feet: Facts, Fallacies & Fetishes The role of podiatry Ms Bec DaebelerManager, Podiatry ServicesFlinders Medical CentreAugust 2008
2 Facts, fallacies and fetishes The High Risk FootCharcot FootWhat podiatrists can do…Footcare IQ
3 Podiatry Need to be registered to practice The scope of Podiatry as defined by theAustralasian 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
4 What is the High Risk Foot? Any foot with an increased risk of ulceration, infection and subsequent amputation.So…who is at risk?
5 The High Risk Foot peripheral vascular disease peripheral neuropathy Individuals who are at high risk of developingFoot problems are those with either:peripheral vascular diseaseperipheral neuropathysevere foot deformityhistory of or a current foot wound.National Association of Diabetes Centres in partnership with the Australian Podiatry Association, 2000
6 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 injuriesThe attributable cost of for a 40 – 65 y.o male with a new foot ulcer was $27,987 (US) for 2 years after diagnosisDiabetes Care, Vol.22, no. 3, March 1999
7 What are the Statistics? 15% of patients with Diabetes will develop a foot or leg ulcer50% of those with a foot or leg ulcer will have an amputation at some stage in their lifetimePeople 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
8 Patient Assessment Vascular status Occupation/Activities Neurological statusFootwearBio-mechanicsOccupation/ActivitiesSystemic disordersMedicationsPatient needs
9 Peripheral Vascular Disease Slows healing abilityInfections more likely to developIncreases the chance of gangreneIncreases the risk of foot/amputation
10 Peripheral Vascular Disease Increased risk of ulcerationTissue ischaemiaAtrophic skin changesFollowing UlcerationRetards wound healingIncreases risk of infectionIncreases risk of amputationLavery et al (2000)
11 Peripheral Vascular Disease Obtain patient historyPain or cramping in calves/thighs may indicate intermittent claudicationMay experience night pain in more advanced casesLipidsSmoking historyBSL’sBPexercise levels
14 Macrovascular Disease Occlusive and often repairableAtherosclerosis of arteriesCalcification of arteriesInput by Vascular Surgeon importantAlways check pulses in the lower legFemoralPoplitealPosterior Tibial- Dorsalis Pedis9
15 Microvascular Disease Not occlusive, basement membrane thickening, not repairableCaused by changes in the structure of the arteries and blood cellsPlays a component in the development of peripheral neuropathyLeads to poor O2 perfusion in tissues and delays healing of woundsWorsened by smoking10
19 Management Quit smoking Good BGL control Encourage walking/activity Refer to Vascular SurgeonEducation11
20 Smoking and Peripheral Vascular Disease (PVD) Smoking is the number one risk factor for PVD and symptoms develop earlier in lifeOver 80% of people with PVD affecting the lower limbs are smokers or ex-smokersSmoking causes 40% of PVD in men and 34% of PVD in women in Australia
21 Smoking and PVDFor 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.
22 Peripheral Neuropathy Numerous causes (eg diabetes, alcoholism, Syphilis, Leprosy, renal failure, HIV, CMT, spina bifida, spinal cord injury, stroke and RA)Diabetes is most commonExcludeMalignanciesToxic (alcohol)Infections (HIV)Referral to NeurologistJude & Boulton (1999)
24 Diabetic Peripheral Neuropathy Paradox:Patients with insensate feet who are asymptomatic may first present with foot ulcersPatients with severe neuropathic pain who on examination may have only a minimal deficit
25 Diabetic Peripheral Neuropathy Two main types:1. Acute sensory neuropathy2. Chronic sensorimotor neuropathy
26 Acute sensory neuropathy Characterised by severe sensory symptomsFew if any clinical signsUsually precipitated by episode glycaemic instability (ketoacidosis or institution of insulin)Gradual improvement symptoms with establishment of stable glycaemic control (appropriate symptomatic treatment)
27 Chronic Sensorimotor neuropathy Insidious onsetUp to 50% may be asymptomatic10-20% may experience painful symptomsOften accompanied by autonomic dysfunctionLate sequelae: foot ulceration, Charcot neuroarthropathyPrevalence increases age and duration of diabetes
28 Typical Neuropathic Symptoms Painful Non painfulBurning pain AsleepKnife like “Dead”Electrical sensations NumbnessSqueezing sensations TinglingConstricting PricklingHurtingFreezingThrobbingAllodynia
29 Sensory Neuropathy Loss of temperature, pain and pressure sensation Increases chance of unnoticed foot injuryBurns (physical, chemical)Cuts (accidental, self inflicted)Pressure lesions (corn, callus, blisters)Wounds may develop and progress to a lower extremity amputation
30 Loss of protective sensation (LOPS) LOPS greatest risk factor for development of plantar ulcersPeripheral sensory neuropathy primary factor in 60-90% of all diabetic foot ulcersDaily foot inspections/examinations
32 Autonomic Neuropathy Loss of flare response Loss of function of skin structuresSweat glandsSkin tearsAtrophic skin changesArterio-venous shuntingMay lead to neuropathic osteoarthropathy(Charcot’s Foot)Loss of flare responseInfection may not present clinicallyreduces visible erythema
33 Motor Neuropathy Loss of intrinsic muscle function Decreases foot stabilityMuscle atrophyAltered foot structureDevelopment bony prominencesIncreased focal pressure areasIncreased risk of pressure wounds Lavery et al, (2000)Loss of anterior muscle group functionPromotes development of foot deformity
34 Motor Neuropathy Toes curled up (claw like changes) Metatarsal heads on the plantar surface prominentFat pads pushed upwards proximally (fullness noted at base of toes)Absence of ankle and knee reflexes
36 Structural Changes - the forgotten factor! Alter foot structure increased load sitesfoot typeflat/pronated feet callusbunions, hammer toesdiabetes relatedmotor neuropathyGlycosylation (reduced or lost joint mobility)increased loads + neuropathy = ulcerssimple, low tech measures can prevent
37 Plantar PressureAn excessively pronating foot will cause an increase in shear stresses
38 Severe foot deformity Blisters Callus Corns Increases the chance of pressure lesionsBlistersCallusCornsUsually associated with poor fitting footwearMay result in ulcers / amputation
39 Footwear Assessment Length Width Stable heel counter Sole flexes at ball of foot onlyAppropriate for activitySocks/hosieryWear them!
40 History of or a Current Foot Ulcer/Amputation Increased chance of reoccurrenceFoot wound may progress to lower extremity amputation
41 Common problems following amputation CallusContracted digitsLimited joint mobilityFoot deformityFoot ulcers
42 Biomechanical impactPeak plantar pressures are higher in patients with diabetes following partial foot amputationAreas of high pressures implicated as one of the most important cofactors in ulceration of patients with diabetes
43 Biomechanical Impact Causes of peak plantar pressures includes: Foot deformityClawing of toesCallus formationLimited joint mobilityLack of soft tissue cushioningCharcot foot
44 Types of Amputation Digital amputation Ray Resections Transmetatarsal amputationMidfoot amputationLisfranc’s amputation – tarsometatarsal jt. lineChopart’s amputation – midtarsal jt. lineSyme’s amputation – disarticulation of the ankleRearfoot amputation
45 Amputation Management Foot care programs / educationAppropriate wound carePaddingOrthosesAFOShoesRestoration of joint and muscle functionLiasing with orthopaedic / vascularspecialties/Orthotists/Prosthetists
46 Charcot FootNeuropathic Osteoarthropathy (NOA) otherwise known as Charcot FootCharacterized by:Pathologic fracturesJoint dislocationDeformity occurring in individuals with a neuropathic foot.
47 Risk factors Neuropathy Osteoporosis reduced bone density leads to reduced bone strength increasing chance of traumatic fractureElevated plantar pressuresRetinopathy reduced visual acuity may increase trauma to footNephropathyRecent history of trauma
48 Risk factors Duration of diabetes for >10 years Poorly controlled diabetes Progressive sensory, motor and autonomic neuropathyObesity elevated plantar pressuresRenal transplantation: immunosuppressive agentsLimited joint mobility: promotes increased plantar pressures and altered biomechanicsRupture of the plantar fascia: loss of windlass mechanism to support longitudinal arch may reduce foot stabilityMultiple amputations of the foot
49 AetiologyContemporary thought about the aetiology lies somewhere between the neuro-traumatic and neuro-vascular theoriesAutonomic neuropathy may cause osteopenia by an increase in blood flow to the extremitySensory neuropathy makes the patients unaware of the abnormal stress on the joint caused by motor neuropathyAbnormal stress can cause bone damage through osteoclastic activity and which can lead to fractures.
50 Pathomechanics - Charcot 1.A/V shunting => increase blood flow in arterioles2.Increase in blood flow => de-mineralisation of bones3.Demineralised bones more fragile4.Un-noticed trauma with neuropathy leads to micro-fractures
51 Pathomechanics - Charcot 5.Massive inflammation occurs with repetitive fractures6.Foot becomes swollen, hot and red with inflammation7.Foot deformity develops with multiple fractures8.Foot ulceration may follow due to deformity and neuropathy
53 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 arthritisChecking visually for any signs of foot deformity (especially around the midfoot)Palpating for bounding pedal pulsesAssessing for sensory neuropathy with monofilament/tuning forkTaking temperature measurements for comparison to the contralateral foot
54 Critical assessment for patients who present with a warm, red, and swollen foot Asking if the patient can recall any history of traumaChecking for any portals for infection such as wounds or tineaAsking if the patient has been unsuccessfully prescribed antibioticsX-rays (weight bearing AP & lateral, Non-weight bearing medial oblique) should be taken and reviewed ASAPBlood specimens or other investigations
55 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 degreesA 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.
58 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
59 Charcot TreatmentThe management of acute Charcot foot is to maintain the existing architecture of the footPrevent 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 CastBack slab
60 Offloading Choices The stage of the condition The degree of foot deformityThe amount of oedemaThe degree of patient compliance and self care capacityThe clinics ability to dispense and cost a deviceThe presence, depth, and likelihood of wound infection
62 Wound Management Control Systemic Factors Diabetes - glycaemic control reduces complicationsDiet - certain nutrients essential for wound healingAlcohol intakeSmoking - eliminate or reduceSkin disorders - psoriasis
63 Treatment of Foot Wounds Control AetiologyOff-load pressure areasRestore vascular supplyRemove foreign bodiesMulti-disciplinary approach
64 Debridement Important to remove devitalised tissue Removal of devitalised tissue increases the healing or neuropathic ulcerationsRegular aggressive sharp debridement (weekly-monthly)Performed if adequate blood supply for healing
65 Wound Assessment Site Size Time present Depth Wound base Exudate Surrounding skinPrevious treatmentsPain levelsPossible prognosis
66 Wound Management Maintain Optimum Wound Environment Moisture BalancePromotes granulation and epithelialisationOptimum temperature37ºCReduce / Prevent infectionContamination, colonisation or infection
67 Infection Diabetes = compromised immunity Leads to reduced resistance to infectionExacerbated blood sugars poor control(impaired neutrophil chemotaxis)Diabetes may suppress classical inflammatory signs of infection
68 Blood flow, neuropathy & infection “The germ is nothing; it is the terrain in which it grows that is every thing” Louis Pasteurblood supplyBSL’sorganismsantibioticspressure Mxwound care
69 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.
70 Manage the Contralateral Foot The factors responsible for the original wound may be present in the contralateral foot.So…Observe both feet at regular intervalsReduce excessive pressure loading
71 Self-care & Support elderly poor vision poor mobility living alone socio-economicawareness‘wilful self-neglect’
72 “Who cares” - a guide to nail management Self careCan see Can reach Normal nails No PVDFamily/friendsCan’t see Can’t reach Normal nails No PVDPodiatristCan/can’t see Can/can’t Abnormal nails PVDreachEvans,Phillips,Popplewell 1994
73 Summary - The big 4 + an ulcer Vascularlook, listen, palpate, vascular studies, educateNeurologicallook, listen, test, educateStructural * weight bearing callus *look, sensate?, shoes, Podiatry, educateSelf-care & Supportcan they? will they? help? educate
74 What can Podiatry do? Removable walking casts Total contact casts Foot assessment, education and management planningRegular wound bed preparation including debridement3. Manufacture of pressure relieving devices including:Removable walking castsTotal contact castsAccommodative insolesPadded insolesFelt paddingFootwear prescription and modification
76 What can Podiatry do? Appropriate dressing selections Ongoing maintenance and monitoring following wound resolution6. 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
77 Education Check and Clean feet Daily Always wear something on your feetNever self treat corns or callusDon’t use wart or corn curesCareful of heaters and other sources of heatFirst aidDry between toesCut nails straight acrossAppropriate footwear
78 What to check for….. Callus Corns Blisters Rub marks/pressure Non healing soresInflammationDermatitisIGTNSubungual haematomaOther – anything that wasn’t there yesterday
79 Where to check ….. Inter-digital spaces (in-between toes) Plantar foot (sole)/Dorsum (top)Bony prominencesToesHeelMPJAnkleShin
82 About one-quarter of all bones of the body are in our feet. TRUE or FALSETrueHuman feet contain about 52 bones (25% of the bones in the human body) as well as numerous joints, ligaments, muscles and tendons
83 The average person will walk around 128,000 km’s in a lifetime TRUE or FALSETrueThe average person will walk around128,800 km’s in a life time - that’s morethan thee times around the earth.
84 People with diabetes should visit a podiatrist at least every 12 months for a foot assessment TRUE or FALSETrueDiabetes 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.
85 People with diabetes are more likely to be hospitalised due to foot problems than for any other reason.TRUE or FALSETrueFoot problems are one of the most common reasons for admission to hospital for people with diabetes
86 People with diabetes should never walk barefooted TRUE or FALSETrueOver half of the amputations performed on people with diabetes have started from developing injuries while barefoot
87 Shop for shoes in the morning to get the best fit TRUE or FALSEFalseIt 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.
88 People with diabetes should cut corns or callus with scissors or a sharp blade to reduce the build up of hard skinTRUE or FALSEFalseBuild-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.
89 Toenails grow more rapidly in the summer than in winter TRUE or FALSETrueNails 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.
90 Altocalciphilia describes sexual arousal due to . . . A - High heelsB - Flat feetC - Hairy feetD - Long or Ingrown toenailsHigh heelsThis 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.
91 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 feetE - extremely small feetHaving a limb amputatedApotemnophilia 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.
92 What would turn someone with a foot fetish on? A - size of the footB - curve of the arch and instepC - length and straightness of the toesD - texture and complexion of the skinE - softness of the soleF - foot odourG - all or any of the aboveG – all or any of the aboveFetishists 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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