GP Symposium 2015 Workshop Rapid Foot Screening Ms Chelsea Law, Principal Podiatrist Mr Henry Lee, Podiatrist Ms Ng Jia Lin, Podiatrist Ms Polly Lim, Podiatrist Ms Wong Wan Mun, Podiatrist Mr Yeo Boon Kiak, Podiatrist Mr Muhd Afiq, Podiatrist
Why foot screening? Prevent catastrophic outcomes with good foot care practices and knowledge MANY FOOT PROBLEMS STEMS FROM POOR FOOTWEAR OR POOR FOOT CARE
VASCULAR EXAM FOOTWEAR INSPECTION DERMATOLOGICAL EXAM NEUROLOGICAL EXAM 1 MIN FOOT SCREENING OEDEMA EXAM MUSCULOSKELETAL EXAM IDENTIFYING INFECTION
Ms Ng Jia Lin, Podiatrist VASCULAR EXAM
Dorsalis Pedis Artery Just lateral to extensor hallucis Palpate with 2 fingers
Posterior Tibial Artery Just behind medial malleolus Medial Malleolus
Popliteal Artery Behind the knee at middle to medial aspect Best palpated with knee bent slightly and patient completely relaxed
Capillary Refill To test for indications of poor peripheral perfusion or dehydration < 3seconds
Colour Dark Red / Dusky / Purple
Colour Black or Necrotic
Visual Assessments Reduced hair growth Thin, shiny skin appearance Temperature gradient from knees down, comparing bilateral legs (eg. warm, cool, cold)
Claudication Intermittent claudication 1. Do you get dull ache in your leg when walking? 2. How far can you walk? 3. What happens when you get dull ache? 4. Does it happen after the same distance again? Rest pain 1. Do you have pain in your legs that affects your sleep? 2. What relieves the pain?
Ms Polly Lim, Podiatrist NEUROLOGICAL EXAM
Previously Monofilament 10g: Ipswich Touch Test (IpTT) Faster Cheaper Convenient Reliable Validated Excellent agreement between both tests (ĸ = 0.88, P < 0.0001) Inter-rater agreement for IpTT moderate (ĸ = 0.68) 10 sites x 2 feet = 20 sites (Rayman et al., 2011; Sharma et al., 2014) 3 sites x 2 feet = 6 sites
Ipswich Touch Test DO s The touch must be as light as a feather; on apex of 1 st, 3 rd, 5 th toes Brief (1 to 2 seconds) DON Ts Do not attempt to press harder if the patient does not respond Do not touch each toe more than once Neuropathy: 2 6 sites insensate
Proprioception test With your eyes close, can you tell me if your big toe is up or down (towards you or away from you)? Hold the distal phalanx of the great toe on either side so that you can flex the interphalangeal joint. Show the patient that when you hold the joint extended, that represents Up whereas when you hold it flexed that represents Down. Ask the patient to close their eyes and, having moved the joint a few times hold it in one position up or down. Ask the patient which position the joint is in.
Neurological symptoms Pain Burning Tingling Ants crawling Numbness Pulling sensation Frequent pins and needles
Mr Yeo Boon Kiak, Podiatrist MUSCULOSKELETAL EXAM
PRESSURE!
Intrinsic minus foot Motor neuropathy Lack of muscle stimulation results in atrophic muscles within the foot Digital deformities Distal migration of fat pad Prominent metatarsal heads Intrinsic minus foot Bony prominence = increase risk of pressure/shear/frictional forces
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Charcot neuroarthopathy http://www.foothealthfacts.org/uploadedimages/foothealthfactscom/news,_videos_and_podcasts/news/charcotfootprofile.jpg
Charcot neuroarthopathy Inflammatory syndrome Varying degrees of bone and joint disorganisation - Secondary to neuropathy, trauma and bone metabolism Rocker-bottom foot - Midfoot collapse
Charcot neuroarthopathy Early stage Red, hot, swollen foot May have history of trauma, symptoms of neuropathy No fever Late stage Signs of inflammation absent Rocker bottom deformity
http://www.thetampapodiatrist.com/wp-content/uploads/2014/02/charcot_foot.jpg http://bestpractice.bmj.com/best-practice/images/bp/en-gb/531-6_default.jpg
REFER! OFFLOAD!
Mr Muhd Afiq, Podiatrist DERMATOLOGICAL EXAM
Callus and Corn Before and after debridement of callus
Xerosis (Dry Skin)
Macerated interdigital / fungal infection
Nail conditions Thickened toenail Paronychia Ingrown toenail Haematoma under nail Fungal nail
Blisters Blister Blood Blister
Ms Wong Wan Mun, Podiatrist FOOTWEAR EXAM
Fixation around the ankle Allow shoe to hold onto foot Reduces the development of toe deformities Reduces risk of falling
Short heel Reduces forefoot pressure and pain Reduces strain on lower back and knees
Cushioning insole
Wide toebox Reduces development of bunions Reduces likelihood of blisters and unwanted wounds
Deeper toebox Reduces development of toe deformities Reduces likelihood of blisters and unwanted wounds
Firm midsole and flexible forefoot Bends at forefoot and not midfoot to provide arch support Allows distribution of pressure at forefoot, reducing callus formation
Firm heel counter
Soft and breathable upper Allows skin to breathe Reduces risk of blister and fungal infection
Ideal features of a supportive footwear Adjustable fastening around ankle Soft cushioning inner sole Soft and breathable uppers Firm heel counter Deep and wide toebox Flexible at forefoot Firm at midfoot Low heel
Mr Henry Lee, Podiatrist OEDEMA EXAM
Why check for oedema? Oedema can affect wound healing, even if its a small blister or scratch May suggest possibility of fluid overload
Ms Chelsea Law, Principal Podiatrist IDENTIFYING INFECTION
Sign & symptoms Red Hot Swollen Pain Fever (not always) Pus / haemoserous discharge But in DM foot, may not have pain Redness may not be significant due to lack of inflammatory response
Sign & symptoms Palpation of surrounding tissue reveals bogginess Check for discharge when palpating tissue (pus / serous discharge) Surrounding skin appears very anhidrotic due to excessive warmth (i.e. dry flaky skin) May or may not be associated with open ulcer May have blood clot or blackish appearance due to skin necrosis Blister-like appearance or excessive maceration
Cellulitis
Bruising
Sausage Toes
Osteomyelitis / Abscess?
Probe to bone
Muffin-top
PUTTING IT ALL TOGETHER
Prevent catastrophic outcomes with good foot care practices and knowledge
Callus Callus Thick nails Bunion Thick nails
Putting it all together Low risk Inspect feet every visit Repeat foot screening annually At risk Any identifiable risk factors Refer to a friendly podiatrist for co-management High risk Any signs of infection & presence of wounds Early access to specialist
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