Feet: Facts, Fallacies & FetishesThe role of podiatry

Ms Bec DaebelerManager, Podiatry Services

Flinders Medical Centre

August 2008

Facts, fallacies and fetishes

The High Risk Foot Charcot Foot What podiatrists can do… Footcare IQ

Podiatry

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

What is the High Risk Foot?

Any foot with an increased risk of ulceration,

infection and subsequent amputation.

So…who is at risk?

The High Risk Foot

Individuals who are at high risk of developing

Foot problems are those with either:

1. peripheral vascular disease2. peripheral neuropathy3. severe foot deformity 4. history of or a current foot wound.

National Association of Diabetes Centres in partnership with the Australian Podiatry Association, 2000

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

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

Patient Assessment

Vascular status

Neurological status

Footwear

Bio-mechanics

Occupation/Activities

Systemic disorders

Medications

Patient needs

Peripheral Vascular Disease

Slows healing ability Infections more likely to develop Increases the chance of gangrene Increases the risk of foot/amputation

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)

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

Peripheral Vascular Disease

Symptoms of: “Burning” Claudication Rest pain

Risk Factors

Family Hx Diabetes Obesity Diet Exercise Smoking

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

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

Vascular Assessment

Pulse palpation– Posterior Tibial– Dorsalis Pedis

SVPFT Colour, Warmth, Hair Growth Doppler (ABI), Toe pressures, Duplex,

Angiogram Consider Referral to Vascular Surgeon

Clinical signs

Dystrophic nail and skin changes

Management

Quit smoking

Good BGL control

Encourage walking/activity

Refer to Vascular Surgeon

Education

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

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.

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)

Peripheral Neuropathy

Sensory Neuropathy

Autonomic Neuropathy

Motor Neuropathy

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

Diabetic Peripheral Neuropathy

Two main types:

1. Acute sensory neuropathy

2. Chronic sensorimotor neuropathy

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)

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

Typical Neuropathic Symptoms

Painful Non painfulBurning pain AsleepKnife like “Dead”Electrical sensations NumbnessSqueezing sensations TinglingConstricting PricklingHurtingFreezingThrobbingAllodynia

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

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

Sensory neuropathy

‘healthy’ but hazardous

Autonomic Neuropathy

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 responseInfection may not present clinicallyreduces visible erythema

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

Muscle atrophy

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

Neurological Assessment

10g Monofilament Fine Touch Vibration Proprioception Reflex

– AJ– KJ

Hot/Cold Subjective Hx.

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

Plantar Pressure

Severe foot deformity

Increases the chance of pressure lesions– Blisters– Callus – Corns

Usually associated with poor fitting footwear

May result in ulcers / amputation

Footwear Assessment

Length Width Stable heel counter Sole flexes at ball of foot only Appropriate for activity Socks/hosiery Wear them!

History of or a Current Foot Ulcer/Amputation

Increased chance of reoccurrence

Foot wound may progress to lower extremity amputation

Common problems following amputation

Callus

Contracted digits

Limited joint mobility

Foot deformity

Foot ulcers

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

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

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

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

Charcot Foot

Neuropathic Osteoarthropathy (NOA) otherwise known as Charcot Foot

Characterized by:

Pathologic fractures

Joint dislocation Deformity occurring in individuals with a

neuropathic foot.

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

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

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.

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

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

Differential Diagnosis

Osteomyelitis Cellulitis/abscess Polyarthroses DVT Trauma/Fracture Lymphoedema Gout Malignancy Tertiary Syphilis Alcoholism

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

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

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 30-45 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.

Radiograph view (lateral)

Radiograph view (lateral)

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

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

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

Treatment of Foot Wounds

Patient education

Determine aetiology

Provide optimum wound healing environment

Maintain systemic health

Manage contralateral foot

Prevent recurrence

Wound ManagementControl Systemic Factors

Diabetes - glycaemic control reduces complications

Diet - certain nutrients essential for wound healing

Alcohol intake

Smoking - eliminate or reduce

Skin disorders - psoriasis

Treatment of Foot Wounds

Control Aetiology

Off-load pressure areas

Restore vascular supply

Remove foreign bodies

Multi-disciplinary approach

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

Wound Assessment

Site

Size

Time present

Depth

Wound base

Exudate

Surrounding skin

Previous treatments

Pain levels

Possible prognosis

Wound ManagementMaintain Optimum Wound Environment

Moisture BalancePromotes granulation and epithelialisation

Optimum temperature37ºC

Reduce / Prevent infectionContamination, colonisation or infection

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

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

Wound ManagementPrevent 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.

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

Self-care & Support

elderly poor vision poor mobility living alone socio-economic awareness ‘wilful self-neglect’

“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

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

What can Podiatry do?

1. Foot assessment, education and management planning

2. 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

Offloading – pressure relieving devices

Pressure relieving devices: Total contact cast Removable walking cast Accommodative insoles Padded insoles Felt padding Footwear prescription & modification

What can Podiatry do?

4. Appropriate dressing selections

5. 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

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

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

Where to check …..

Inter-digital spaces (in-between toes) Plantar foot (sole)/Dorsum (top) Bony prominences

– Toes– Heel– MPJ– Ankle– Shin

Remember!

One Pair

Must Last A Lifetime

WHAT IS YOUR FOOTCARE IQ?

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

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.

People with diabetes should visit a podiatrist at least every 12 months for a foot assessment

TRUE or FALSE

TrueDiabetes 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.

People with diabetes are more likely to be hospitalised due to foot problems than for any other reason.

TRUE or FALSE

TrueTrueFoot problems are one of the most common reasons for admission Foot problems are one of the most common reasons for admission

to hospital for people with diabetesto hospital for people with diabetes

People with diabetes should never walk barefooted

TRUE or FALSE

TrueOver half of the amputations performed on people with diabetes

have started from developing injuries while barefoot

Shop for shoes in the morning to get the best fit

TRUE or FALSE

FalseIt 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.

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

FalseBuild-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.

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.

Altocalciphilia describes sexual arousal due to . . .

A - High heels

B - Flat feet

C - Hairy feet

D - Long or Ingrown toenails

High 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.

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 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.

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 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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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.