Feet

• Feet should be routinely checked and managed
• Referrals are important, however just referring problem feet to a podiatrist or high risk foot team is not good practice. The podiatrist may not come often, the high risk foot team may not see the person for weeks unless they are evacuated

High risk foot

Medical Consult for High risk foot — two or more issues, may be one or both feet

• Peripheral neuropathy
• Peripheral vascular disease
• Foot deformity
• End stage renal failure
• History of foot amputations or foot wounds

Note: A high risk foot is one that requires urgent referral due to red flags OR charcot joint (see below) — refer to a high-risk foot team

Charcot foot

• Charcot foot or joint can occur when neuropathy (nerve damage) is present
• In acute phase bones suddenly become brittle allowing joints to be permanently deformed — Figure 10.89
• If managed early, deformity can be prevented. Once deformity occurs, limb prognosis poor

 Signs of acute Charcot foot or joint

• Unilateral heat and swelling
• Neuropathy and no other cause for unilateral heat and swelling identified

Foot examination

What you need

• 10g monofilament — if not available, tissue/cotton wool for rough assessment
• Soap and water
• Scalpel blade and handle
• Nail clippers, single use best
• Single use nail file
• If active lesion — sterile blunt end probe

What you do

Ask

• Sensation of numbness, tingling, burning, weakness in feet
• Foot pain at night
• Cramping foot pain when walking
• Any foot wounds that take a long time to heal
• Medicines — antibiotics, dosing regime
• Access to footwear and how it is worn
• Ability to care for feet
• Consider level of understanding, vision, can they reach feet

Look for

• Amputations
• Colour
• Shape both feet — compare
• Deformities — crooked toes, bunions, bony prominences
• Calluses, corns, hard skin, thick nails, cracks or fissures
• Wounds or blood in calluses
• Toe nail abnormalities, infections
• Footwear — fit and comfort

Feel for

• Temperature and/or swelling on both feet and near wounds
• Joint stiffness both feet

Foot pulses in both feet — should be 2 pulses in each foot

• One on top of foot — Figure 10.90
• One behind medial malleolus (inner ankle) — posterior tibial — Figure 10.91

Sensation using 10g monofilament — loss of protective sensation (ie neuropathy) if monofilament at more than one site cannot be detected

• Sit person with legs out straight, feet level, eyes closed
• Hold filament at 90° to skin, press hard enough to bend filament — Figure 10.92, then remove. Takes about 2 seconds
• Test 3 sites on each foot with filament (Figure 10.93) avoiding hard skin (callous) and wounds
• Ask if they can feel touch, and which foot you are touching

Foot management

• All anomalies — medical consult
• If person can't feel monofilament —
• Record area of nerve damage (peripheral neuropathy)
• Remind person they need to check and feel their feet every day
• Use nail clippers and file to reduce long, thick toenails
• Debride (remove thick hard skin) with scalpel or nail file to relieve pressure, prevent ulcers forming
• Calluses occurring over/under a joint or bony prominence need offloading — podiatry consult

Wounds

Painless wounds are sign of peripheral neuropathy. Painful or traumatic wounds may be infected or ischaemic (have reduced blood flow)

• Probe wounds with sterile blunt end probe to check whether bone involved
• Wound care — regular inspection, debridement and dressings — see Wound dressings
• Give antibiotics as indicated — see Injuries — soft tissue
• Offload pressure as indicated — podiatry consult
• Medical consult — ensure good chronic disease management
• Podiatry consult
• X-ray referral if suspected bony involvement and/or chronic wounds

Follow-up

• People with high risk foot need
• Management plan
• To be taught daily foot care
• 3 monthly foot checks
• People with feet at low risk (especially if new diagnosis of diabetes) need
• To be taught daily foot care
• Yearly foot checks

Daily foot care

Attention

• Talk about and show people as part of routine health checks
• Monitor foot care practices at every opportunity
• Daily foot care needs to be done daily
• Take care not to injure skin
• Do not use sharp instruments (eg scissors, razor blades, graters)
• Advise to come to clinic if any wounds on feet
• Encourage wearing comfortable, soft-soled shoes to cushion and protect feet

What you need

• Soap
• Clean cloth
• Bucket
• Non-abrasive kitchen scourer
• Clean towel
• Simple moisturiser
• Nail clippers, single use best
• Single use nail file
• Simple dressings
• Clean socks and comfortable, soft-soled shoes

What you do

Show person how to

• Wash feet well with soap and cloth — Figure 10.94
• Safer to do this seated with feet in bucket, not in shower
• Use scourer with soap and water to reduce thick skin
• Do not use sharp instruments
• Gently dry all skin surfaces with towel — Figure 10.95
• Look at and feel both feet all over including between toes. Check for blisters, cracks, injuries, changes in skin colour, temperature, texture — Figure 10.96
• Rub moisturiser into dry skin
• Trim toenails straight across or follow natural curve — Figure 10.97
• Do not cut down sides
• Use file to smooth edges, lessen thickness of nail
• Clean and cover small skin sores (blisters, scratches, cracks) with simple dressing to keep dirt out. If sores get smelly or sticky (infected) — go to clinic straight away

Tell person

• To care for their feet they need to
• Do foot care every day
• Have feet checked regularly by health team
• Control diabetes — keep as active as possible, eat healthy food, take their medicines
• Protect feet by wearing socks and shoes. Thongs better than bare feet
• Shake rubbish (eg sand, seeds, stones) out of shoes before putting on

Supporting resources

• Multidisciplinary high risk foot team — Alice Springs and Darwin Hospitals
• International Working Group for Diabetic Foot guidelines