Practical advice when treating feet

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1 Practical advice when treating feet Helen Mandic Clinical Lead Podiatrist in Health Promotion and Student Mentor Department of Podiatry and Foot Health Dawlish Hospital

2 Falls Prevention The Role of the Podiatrist Falls Awareness Week Webinar 25/06/13 Helen Mandic Clinical Lead Podiatrist in Health Promotion Torbay and Southern Devon Health and Care NHS Trust 2

3 Introduction Falls are a major cause of disability and mortality in the over 75 age group Falling has a major impact on health and healthcare Falling is not an inevitable result of ageing (NICE, 2004) Up to 80% of older people have a foot or leg problem Foot problems affect mobility and balance Increases the risk of falling Podiatry has a role in falls prevention and this may be as part of a multidisciplinary team (Tompkins, Farndon 2012) 3

4 Age related changes affecting feet Peripheral Arterial Disease-skin less resistant to pressure and more likely to form calluses, corns or to ulcerate Neuropathy, diminished sensation and reduced proprioception can affect balance and gait Less able to see or reach feet Foot, skin and nail care neglected Mobility affected and risk of falling increases 4

5 Common foot problems in older age Toenail deformities-involuted, onychogryphotic Bunions and lesser toe deformities Atrophy of plantar metatarsal pad-loss of protection Corns and calluses-dorsum of toes/metatarsal heads Changing foot shape E.g. pes planus or pes cavus Reduced muscle strength and reflex responses Diminished or loss of proprioception Slip on shoes may no longer fit foot shape More likely to wear loose-fitting shoes or slippers When at home, may only wear socks/hosiery or be barefoot 5

6 What can a podiatrist do to help prevent falls? Diagnose and treat foot problems such as lesions that cause pain and affect gait and balance Undertake a comprehensive assessment of neurological and vascular status, of muscle function and structural function of the leg, ankle and foot Treat functional problems that could cause falls Advise about appropriate footwear styles that help to prevent falls Refer for further investigation if appropriate 6

7 Circulation testing Dopplar Ultrasound Dorsalis pedis pulse Posterior tibial pulse Triphasic/biphasic/normal Monophasic/disease Podiatrist would refer:- For ankle-brachial index To vascular team 7

8 Sensory testing 10g monofilament Failure to detect sensation would indicate neuropathy May be age related May require investigation Common causes:- Diabetes Thyroid deficiency Vitamin deficiency Neurological disorder 8

9 Incorrectly fitting shoes can: Affect posture, balance and stability Compromise biomechanical stability of the foot Restrict joint flexibility and weaken musculature Increase the risk of having a fall 9

10 Unsuitable Shoes No restraint means no support or stability and increases risk of ankle sprain or fall or both High heels increase forefoot loading and shifts the body s centre of gravity forward Greater risk of toppling forward 10

11 Painful toes Slip on shoes with a narrow toe box cause pressure on the dorsum of toes, resulting in the formation of painful calluses and corns Painful toes affect gait and balance and increase risk of a fall 11

12 A SHOE-SHAPED FOOT 12

13 An ideal shoe Wide, square shaped toe box To reduce pressure on the toes Closed-in padded heel counter for comfort and support Adequate length, width and depth Soft, flexible, breathable upper and lining Smooth internal seams and cushioning insole Shock absorbing sole to cushion the foot Lightweight, flexible and slip resistant sole Low broad heel for stability when walking Adjustable fastening for support 13

14 Heel counter Good restraint Soft breathable upper Foot shaped toe box Lightweight flexible sole 14

15 Worn soles can adversely affect balance and gait and thus increase risk of falling 15

16 Neuro-Musculoskeletal changes Changes in foot shape and toe positions Altered joint flexibility in hip, knee & ankle Decreasing muscle strength Balance affected Less likely to detect and respond to changes in the body s centre of gravity Fallers tend to walk more slowly, crouch forward and sway more Less likely to lift foot clear of ground More likely to trip and slip when walking 16

17 What can a podiatrist do to help prevent falls? Provide insoles to:- Reduce pain Aid stability through supporting the foot Positively affect posture Diagnose risk factors Educate client and carer on risk factors Refer to other health professionals for specialist intervention including the orthotist for footwear modifications 17

18 Wedged sole and heel can be added on the medial or lateral side of the base of the shoe This will re-align the rear foot and forefoot Will also rotate the leg medially or laterally when in contact with the ground 18

19 Insoles and orthotics: Modify the functionality of the foot and ankle Control a deformity Support and stabilize Improve mobility Reduce pain The type of insole used depends on the type of foot problem Picture above shows a pronated foot correction with insole 19

20 Feet support the entire body weight Leg length discrepancy and resulting postural disorder corrected with a heel raise 20

21 Rocker Sole This helps prevents flexion and extension of forepart of foot Also enable a more flowing gait 21

22 Ligament injuries can be helped with an ankle brace 22

23 When to refer to podiatry Follow national and local guidelines about referral pathway E.g. Map of Medicine on Falls Prevention. Be clear and realistic on what your expectations are about how podiatry intervention can help. How to refer to podiatry Follow local referral guidelines 23

24 In conclusion The risk of falling can be minimised The risk of falling related to footwear is potentially reversible A single fall may have multiple causes 24

25 References Jakins, Ian (2013) Orthotics to help prevent falls. NICE Clinical practice guideline for the assessment and prevention of falls in older people (2004) RCN Pages 14, 71, 128 Appendix E, page 4 25

26 References Podiatry Now Journal. MAY 2009 Tompkins, Hazel. A review of the role of the podiatrist in falls prevention. Pages Vernon, Wesley. Healthy Footwear Guide. Page 35 Podiatry Now Journal. MAY 2012 Farndon, Lisa. Et al. The effectiveness of core podiatry. Pages The authors concluded that: Foot health education can improve the knowledge and foot care practices of individuals. Removing core podiatry services can lead to a decline in foot health 26

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