Managing different palpitation cases
How to manage a patient with 'terrible feet'
Mrs Smith says she has 'terrible feet' and you can't help but agree. Although only in her mid-40s she is developing bilateral bunions, has corns on two hammer toes and is complaining of pain underneath her right foot. Dr Melanie Wynne-Jones discusses.
Why didn't Mrs Smith go to a chiropodist instead?
NHS chiropody is only available to restricted groups such as diabetics, the elderly and people with certain medical conditions like rheumatoid arthritis; check out your local referral criteria. Much routine work is carried out by footcare assistants.
Everyone else has to care for their own feet, or pay for private chiropody which is beyond some patients' means. Pharmacies also sell footcare products such as corn plasters, verrucca treatments, cushioning pads and insoles.
What can chiropodists do?
Podiatrists, as many prefer to be called, have a wide range of skills including:
·General foot care, trimming nails, dealing with corns, calluses; using electrotherapy units to treat a wide range of soft tissue problems.
·Biomechanics diagnosis and treatment of malfunction in the foot and lower limb in order to develop, preserve or restore function; this includes gait problems, sports injuries and the use of orthotics (specially-made shoe inserts/moulds).
·Assessment and care of patients with rheumatological problems to maximise their stability and mobility.
·Neurovascular assessment and care of patients with diabetes, rheumatoid arthritis, cerebral palsy, peripheral arterial disease and peripheral nerve damage. Podiatry intervention in the care of these patients can reduce amputation rates by 40 per cent and patients should be encouraged to attend.
·State registered practitioners are qualified to administer local anaesthetics and perform surgical procedures such as nail and minor soft tissue surgery. Some podiatrists train as a podiatric surgeons who surgically manage bone and joint disorders within the foot.
What are corns?
Corns and calluses are the foot's response to pressure, usually over a bony prominence. They
may be the consequence of bad footwear, foot deformities, including pes cavus (high arched feet), or unsuspected neuropathy. A corn is a small area of hard skin, often with a 'seed' in the centre while calluses are larger and thicker. Either may become painful under pressure. Soft corns develop between moist toe surfaces and may become infected.
The patient should be advised about footwear and referred to the pharmacy for corn pads which act as cushions to relieve pressure, or corn plasters which contain salicylic acid to remove keratin.
Calluses can be smoothed down with a pumice or hard-skin cream. If the pressure is caused by deformity such as hammer toe, the patient may need to be referred for corrective surgery.
Should verruccas be treated?
As they are self-limiting, treatment should only be recommended for those that are painful. Parents are often unhappy with this advice, although the PILS leaflet may reassure them.
Verruccas can be distinguished from plantar corns by gentle paring; they contain a black dot which is a thrombosed capillary (beware plantar melanomas!).
If treatment is required, patients need to understand that the actual infection is deeply buried and that overlying hard skin needs to be removed by rubbing with a pumice stone or emery board before applying a keratolytic such as salicylic acid. This may be a gel such as Bazooka Verrucca; covering the verrucca with a plaster also encourages more skin shedding.
Cryotherapy is quicker but more painful, and thus unsuitable for children with multiple verruccas,
What is the pain under Mrs Smith's foot?
There are several possibilities. Poor foot position can result in what is known as 'walking on the bones of the feet' metatarsalgia arising from repeated trauma to the metatarsal heads. A change of shoes, a metatarsal pad (available OTC or on prescription) or a formal orthotic will help.
In Morton's neuroma, localised pain and tenderness occurs over the plantar nerve, usually in the third interspace, between the third and fourth toes; surgery may be required.
Plantar fasciitis is a common cause of pain under the heel (which may locate to one tender spot) and is classically worst when putting the foot to the floor in the morning, after a long walk or when standing on tip-toe. It usually settles with time, but rest, supportive footwear, a 1cm-thick heel pad, painkillers and gentle exercises that stretch the Achilles tendon and plantar fascia can help. Steroid injections may be used for persistent or severe pain.
Do her bunions need surgery?
Hallux valgus (lateral deviation of the great toe) is often followed by bunion formation deformity of the metatarsophalangeal joint. This can lead to a bursa which may become inflamed or infected. Tight-fitting, pointed, or high-heeled shoes chafe and put extra pressure on the bunion, whereas wider flatter shoes will reduce pain and slow down its development.
Corrective surgery may improve both pain and deformity; the exact operation depends on bunion severity, underlying foot shape, and the presence of arthritis or other factors. However, success is not guaranteed and Mrs Smith would be best advised to switch to appropriate footwear and postpone an operation as she may be be able to manage without.
·Footcare assistants provide much routine NHS care
·Fully-trained podiatrists can advise on gait, biomechanics and preventive footcare for patients with serious medical problems
·The limited availability of NHS chiropody means that GPs are often asked about simple foot problems such as corns, verruccas.and bunions
·Pharmacies also provide a range of simple foot health products
Bookmark these for information on foot problems and solutions from:
·PILS leaflets on a range of foot conditions access via PRODIGY website http://www.prodigy.nhs.uk/PILs/index.asp
·Feet for Life The Society of Chiropodists and Podiatrists http://www.feetforlife.org
·Podiatry Channel (US site) http://www.podiatrychannel.com
Melanie Wynne-Jones is a GP in Marple, Cheshire