1. Podiatrists How can we help? Sue McAusland Podiatrist Blackpool Teaching Hospital NS Foundation Trust

2. The NorthWest Clinical Effectiveness Guidelines for rheumatoid Arthritis Their objective: Improve foot and ankle assessment and management doing the right thing, to the right patient, in the right way, at the right time

3. Rheumatoid Arthritis (RA) The Statistics: Approx half a million sufferers of RA It affects ability to work and social life It costs money both for sufferer and NHS The foot is often the first area of the body to be systematically afflicted by RA 75% of people diagnosed suffer foot related problems within 4 years of diagnosis and within 10 years virtually 100% have foot complaints

4. How can RA affect the feet? hallux valgus, valgus heel deformity lesser toe deformities causing hard skin (callus) formation. In some this leads to foot ulceration particularly people with poor tissue viability. bacterial and fungal skin infections nail pathologies that increase risk of ulceration and systemic infection.

5. What are we trying to do? relieve pain, maintain function improve quality of life using safe/ cost-effective treatments, such as: palliative foot care, prescribed foot orthoses specialist footwear

6. How podiatrists help They range from simple foot care advice, palliative care for nails and skin and orthotic / specialist footwear provision through to management of ulceration and infection

7. Guidelines. What do they say? Prompt, aggressive intervention ARMA recommends to be seen by specialist within 12 weeks to confirm diagnosis and to give access to MDTs including foot health assessment Access to team of podiatrists who provide baseline vascular and sensory assessment eg dopplers and monofilament. Annual review Biomechanical assessment ARMA (ARrthritis and Musculoskeletal Alliance)

8. Essential requirements Clinical assessment including: Full medical history Full assessment of lower limb function, Pain assessment Vascular assessment Tissue assessment eg nails skin Pressure relief/footwear Onward referral to specialist surgery Annual review NICE (2009)- all people with RA should have access to a podiatrist SIGN (2000) -Early referral to podiatrist is important part of early management

9. Plantar callus Should we remove it? Argument for and against If callus removed – done frequently If infected can debride to expose ulcer Provide orthoses (pressure relieving and functional) Avoid use of plantar adhesive padding where tissue viability is problem Footwear advice

10. Fungal infections Increased risk with immuno-suppressed Increased risk of subungual ulceration if left untreated Treatment: Nail clippings

11. Ingrowing toenails Mild condition Conservative + antibiotics Severe condition Partial or total nail removal If on biologics should consult specialist rheumatologist

12. orthoses Early intervention Reduce pain and prevent deformity Advanced problems May prevent tissue breakdown and ulcers TYPES OF INSOLES Simple cushioning insoles with padding Contoured padding (custom or off-shelf)

13. Footwear Where do we start! ill fitting footwear

14. What makes a good shoe Stable heel Extended heel counter Padded topline No prominent internal seams Increase toe spring or rocker sole Low laced – for ease of access www.Britfoot.com

15. rockers

16. Can’t find a suitable shoe on high street? Refer to surgical appliances Stock or bespoke shoes Beware there are cosmetic downsides Refer for surgery as alternative

17. Now it’s time for some practical work Optional!!

18. Thank you for listening. I hope you found this useful.