Podiatric Perspective on Lower Limb Conditions Tim Pettit-Specialist Podiatrist November 2018

My Background Essex county fire and rescue service Qualified from BSO in 2000 Worked for various practices as an assistant in the southeast and midlands Qualified from Brighton University in 2006 (School of health professions). NHS since 2008 mainly as a musculoskeletal specialist.

Aims of Presentation Look at lower limb conditions that are seen in both Podiatry and Osteopathy but are often overlooked. Examine pathology behind the conditions. Help with Early diagnosis-of conditions.

Differences between Private Practice and NHS All patients on the Trust caseload are classified as high risk, low risk patients not seen. Majority are DM-T2, Rheumatoid, other Inflammatory arthropathies, current ulceration for any reason. Patients not seen by same practioner from assessment to treatment.

Conditions/Pathologies Charcot Foot. Tibialis Posterior Tendon Dysfunction. Peripheral Arterial Disease. Pes-Planus.

Charcot Foot

Charcot foot Often discussed at BSO but rarely seen. Has become increasingly common in last 10 years. Diabetes is the most common cause Early recognition is important. By the time it presents as a typical Charcot foot the damage is done. Can lead to ulcerations, BKAs, death

Pathogenesis Patient normally diabetic (Long term), but can be due to other peripheral neuropathies) Patient normally neuropathic and Insensate. Minor insult to foot which Pt may or may not notice Stubbed toe, something dropped on foot etc. or may be due to Ulceration. Injury/ Ulcer causes an inflammatory reaction bones become plastic and foot becomes warm and swollen. Is now considered to be an inflammatory type condition

Pathogenesis Related to renal function as very common in Dialysis patients. PVD-Revascularisation of PVD patients can cause Charcot.

Clinical Presentation. Normally diabetic (Other neuropathies) Patient may present with a warm, erythemic mildly swollen foot. May have had a minor injury to foot or ankle. Not normally painful as patient neuropathic, but may have some sensation/pain Temperature differential between feet (3 degrees) Can be difficult to identify in its early stages and also if patients have conditions that mask it, e.g Cellulitis, Oedema, associated with it.

Types of Charcot Foot MTPJs-(Least common) Tarso-Metatarsal joint-(Most common) Mid Tarsal joint. Sub-Talar joint and ankle Mr Shooter

Ankle Charcot

Ulcerated (Charcot) Rocker Bottom Foot

Charcot can be divided into 3 stages 1-Active Phase-0-3 months-Needs to be immobilised as soon as possible. Weight must be kept off of the foot to prevent damage. 2-Healing Phase, bones start to fuse /heal, weight bearing can be increased, foot remains casted or walker used. 3-Rehab Phase-Bones continue to strengthen, foot protected using orthoses or orthopaedic footwear. Possible reconstructive surgery.

Calcaneo cuboid joint fusion. Mid-foot Fusion Bolt Pan Talar fusion(Intermedullary rod from calcaneus through Talus into tibia) Medial column beaming. Calcaneo cuboid joint fusion.

Bi-Planar plating

Mid Tarsal Joint Prolapse

Medial and lateral column beaming

Intermedullary Rod, Mid Tarsal Beam and Screws

Suspect Charcot If patient is Diabetic and Neuropathic Recent minor injury If foot is swollen or erythemic If foot is hot to palpation (3 degrees difference) Revascularised. Immobilise,Refer,Advise Mrs Ben

Tibialis Posterior Tendon Dysfunction

Tibialis Posterior Tendon Dysfunction (TPTD) Generally 4 stages 1-tendon becomes inflamed but no symptoms/mild symptoms. 2-pain along the medial side of the ankle and foot, some swelling. 3-(Chronic) Loss of arch height, midfoot pronation and forefoot abduction, medial ankle bulge. 4-Loss of foot function, pain, rigid pronation, ankle and foot pain. Generally seen in older women. Aetiology uncertain but includes obesity, excessive pronation, Arthritis, trauma, Iatrogenic 23

Clinical Presentation of TPTD.

Treatment. Treatment depends on stage of presentation Normally in Biomech at least stage 2 or 3 Use of an orthotic to support the arch of the foot. If rigid only simple inner soles can be used. If still mobile then hard shell orthotics can be helpful. Referral to Podiatric surgery for assessment. Mrs Miggins Patients often older and so often refuse surgery. Cane be severe and disabling 25

Peripheral Arterial Disease (PAD) Very common in Podiatry clinics. Related to Diabetes Often leads to ulceration and amputation Often dismissed as musculoskeletal problem in its early stages.(Also night cramps, Arthritis, Diabetic neuropathy)

Risk Factors Diabetes Elevated Cholesterol Smoking Hypertension Obesity and inactivity Risk factors are accumulative. Renal Disease

Signs and Symptoms Intermittent claudication ( most common in the Calf, but can be in Thighs or buttocks) Night pain Rest pain. Reduced healing rate Small punched out non healing ulcers

Ischaemic Ulcer

Gangrene

Signs and Symptoms Loss of hair on lower extremity Shiny skin Tissue Loss Muscle wasting.

Diagnosis Case history Palpation of lower limb pulses (Popliteal, Dorsalis Pedis, Posterior Tibial. Colour and temperature. Doppler scan. Ankle Brachial Pressure index. Atrophic skin and nails. Muscle and tissue loss.

Treatment Control of risk factors. Drugs for claudication (Iloprost) Exercise therapy (2 hours/wk-NICE guideline). Treatment of related ulcers. Referral to Vascular. (Often not indicated unless current ulceration) Surgery may include angioplasty, stents, bypass

Pes Planus (Flat Foot)

Midfoot Malfunction

Pes Planus Otherwise known as flat foot. Not necessarily pathological. Dependant on ethnicity Rigid or flexible? (Jacks test and tip toe test) Unilateral/Bilateral Pain associated with condition? In adolescents consider a Tarsal bar To treat or not treat?

Treatment If Pes-Planus is flexible a hard shell orthotic can be used to support arch and control calcaneal position. If rigid then corrective Orthoses not advisable. If metatarsal bar present then surgical opinion should be sought. Reassure concerned parents.

Conclusion

Perils of Footwear Prevention is better than cure: Our vision to help you live well for longer Department of Health and Social Care 2018.

Normal Foot

Footwear

Party girl Miss Shelf

Bibliography Clinical skill in treating the foot-Turner W A, Merriman L M and Merriman, 2nd edition, 2005, Churchill Livingstone Neale’s disorders of the foot-Lorimer D, French G, O’Donnel M, Burrow G, Wall B, Seventh edition, 2006, Churchill Livingstone Clinical Biomechanics of the lower extremity, Valmassy D L, 1995 Mosby, 1st Edition

Bibliography Nice Guideline (CG147),Peripheral Arterial Disease: Diagnosis and Management. 2012, updated 2018. Nice Guideline (NG) 19,Diabetic Foot Problems: Prevention and Management, 2015, updated 2016