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

2. 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.

3. 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.

4. 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.

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

6. Charcot Foot

7. 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

8. 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

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

10. 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.

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

12. Ankle Charcot

14. Ulcerated (Charcot) Rocker Bottom Foot

15. 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.

16. 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.

17. Bi-Planar plating

18. Mid Tarsal Joint Prolapse

19. Medial and lateral column beaming

20. Intermedullary Rod, Mid Tarsal Beam and Screws

21. 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

22. Tibialis Posterior Tendon Dysfunction

23. 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

24. Clinical Presentation of TPTD.

25. 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

26. 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)

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

28. 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

29. Ischaemic Ulcer

30. Gangrene

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

32. 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.

33. 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

34. Pes Planus (Flat Foot)

35. Midfoot Malfunction

36. 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?

37. 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.

38. Conclusion

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

40. Normal Foot

41. Footwear

42. Party girl
Miss Shelf

43. 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

44. 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