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

NEUROLOGICAL EXAM

MUSCULOSKELETAL EXAM

FOOTWEAR INSPECTION

DERMATOLOGICAL EXAM

OEDEMA EXAM

IDENTIFYING INFECTION

1 MIN FOOT SCREENING

VASCULAR EXAM Ms Ng Jia Lin, Podiatrist

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?

NEUROLOGICAL EXAM Ms Polly Lim, Podiatrist

Ipswich Touch Test (IpTT)

10 sites x 2 feet = 20 sites

Previously… Monofilament 10g:

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)

(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 1st, 3rd, 5th 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

MUSCULOSKELETAL EXAM Mr Yeo Boon Kiak, Podiatrist

PRESSURE!

Intrinsic minus foot

• Bony prominence = increase risk of pressure/shear/frictional forces

• Digital deformities • Distal migration of fat pad • Prominent metatarsal heads • Intrinsic minus foot

• Motor neuropathy – Lack of muscle stimulation results in atrophic muscles within the foot

http://www.medemp.com/wp-content/uploads/2014/05/DiabeticShoes.jpg

Charcot neuroarthopathy

http://www.foothealthfacts.org/uploadedImages/FootHealthFactscom/News,_Videos_and_Podcasts/News/charcotfootprofile.jpg

• Inflammatory syndrome

• Varying degrees of bone and joint disorganisation

- Secondary to neuropathy, trauma and bone metabolism

• “Rocker-bottom” foot

- Midfoot collapse

Charcot neuroarthopathy

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!

DERMATOLOGICAL EXAM

Mr Muhd Afiq, Podiatrist

Callus and Corn

Before and after debridement of callus

Xerosis (Dry Skin)

Macerated interdigital / fungal infection

Nail conditions

Ingrown toenail Fungal nail Haematoma under nail

Thickened toenail Paronychia

Blisters

Blister

Blood Blister

FOOTWEAR EXAM

Ms Wong Wan Mun, Podiatrist

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

Firm heel counter

Flexible at forefoot

Low heel

Adjustable fastening around ankle

Firm at midfoot

Soft and breathable

uppers

Soft cushioning inner sole

Deep and wide toebox

Ideal features of a supportive footwear

OEDEMA EXAM

Mr Henry Lee, Podiatrist

• Oedema can affect wound healing, even if its a small blister or scratch

• May suggest possibility of fluid overload

Why check for oedema?

IDENTIFYING INFECTION

Ms Chelsea Law, Principal Podiatrist

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

Bunion Thick nails 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

US