The Aged Foot

Original Editors - Scott Buxton

Top Contributors -

Scott Buxton

Contents

Introduction

Foot problems are commonplace in people over the age of 75 moreso than a younger population[1]. Foot impairment contributes to falls, immobility, the progression of frailty and can lead to a quicker progression towards dependence and not independence[2]. It is understandable when you consider how many miles an average person walks in their lifetime. 

The average moderately active person take around 7,500 step/day. If you maintain that daily average and live until 80 years of age, you'll have walked about 216,262,500 steps in your lifetime. Doing the math, the average person with the average stride living until 80 will walk a distance of around 110,000 miles[3].

The management of the aged foot is typically aimed at achieving comfort through the reduction of pain as well as increasing mobility. Both ultimately preventing dependence and reduce the need and demand for other services. Thankfully most common issues can be treated successfully by Podiatrists as well as Physiotherapists. The aim of this article is highlight the common issues as well as basic methods of management.

Prevalence

It is estimated that around 80% of older people have foot problems however many of these people do not seek medical attention[4][5]. Multiple studies in many countries have found the same, older people do not seek help for foot problems even when something can be done about it[6].

The most common foot problems tend to be nail problems, calluses, bunions, corns, hallux valgus, generalised pain, swollen feet and circulatory problems[7]. Most of these issues derive from poorly fitting shoes, obesity and chonic conditions such as diabetes, cardiovascular disease or osteoporosis[8].

Common Problems

Toenail Issues

Toenail issues arise because of many issues but the largest contributor is likely the fact that cutting is difficult.

31% of older people are unable to cut their own toenails because[9]:

  • Unable to reach their feet
  • Lack finger deterity to the point they are unable to use the clippers
  • Get dizzy when bending
  • Of visual  impairment
  • Thick toenails

It is also estimated that around a third of older people have fungal infections of the toenail, even higher in those with diabetes, CVD or obesity[8].

Bunion / Hallux Valgus

Foot width and length often increases with age in addition to peripheral swelling which often occurs throughtout the day[10]. This change in shape can lead to misshapen joints resulting in pressure changes in the skin leading to bunions.

A bunion is a bony deformity of the joint at the base of the big toe. The main sign is the big toe pointing towards the other toes on the same foot causing a swollen bumpy lump on the medial aspect of the foot. This causes a painful callus to form which could potentially develop into a sore[11].

Corn / Callus

As well as being caused by bunions ill-fitting shoes and the deterioration of fat pads can lead to pressure areas. This is called a corn or callus. They are circular masses of tissue which form on the outside of the toes, usually the outer ones, which is painful on direct pressure. They are usually caused by ill-fitting shoes and deterioration of fats pads.

Ankle Osteoarthritis

Ankle osteoarthritis is the occurrence of osteoarthritis (OA) in the ankle joint. The ankle joint consists of two synovial joints, namely the talocrural joint and the subtalar joint. In both joints osteoarthritis can be diagnosed in the medial and the lateral compartment[12]

The ankle joint is far less commonly affected by arthritis than other major joints. The reasons for this include differences in articular cartilage, joint motion, and the susceptibility of cartilage to inflammatory mediators. There is relatively good containment and conformity of the ankle joint, the talus is firmly bound on three sides by the fibula, tibial plafond and medial malleolus and their strong ligamentous attachments. This design potentially gives the ankle a better cartilaginous loading profile. The most common cause of end-stage arthritis of the ankle is trauma. Additional causative factors include arthropathies, chronic ankle instability, malalignment, and certain medical conditions, such as hemophilia.

In terms of which type of OA tends to occur in the ankle it tends to be primary OA.

This is the form of osteoarthritis in which you don't know what could trigger the disease. You can't infer anything from history, nor clinical or radiographic examination[13].

Compared with results reported for knee and hip, there is a substantially lower rate of primary ankle OA. Although early cartilage degeneration occurs, progression to severe grades of degeneration is not frequently observed[14] . This phenomenon is thought to be caused by the unique anatomic, biomechanical and cartilage characteristics of the ankle. Specifically the ankle has a smaller contact area than the hip or knee in a load-bearing pattern and subsequently pressure distribution is different which explains the differences between joints[15]. There is also a relative higher cartilage resistance in the ankle, which might protect it from degenerative changes leading to primary OA. This higher cartilage resistance in the ankle is due to the fact that the ankle is primarily a rolling joint with congruent surfaces at high load, which allows it to withstand large pressures[16]. Although the ankle cartilage is thinner compared with knee or hip cartilage, it shows higher compressive stiffness and proteoglycan density, lower matrix degradation and less response to catabolic stimulations. So the ankle is not generally a site of primary OA (This occurs only in approximately 7% of all ankle OA cases).

Gout

Gout is a crystal-induced arthritis, in which monosodium urate (MSU) crystals precipitate within joints and soft tissues and elicit a highly inflammatory but localized response. The susceptibility to form MSU crystals is a consequence of excessive blood levels of soluble urate, one of the final products of the metabolic breakdown of purine nucleotides. Hyperuricemia is typically defined as occurring above the saturation point of MSU, at which point the risk of crystallization increases. Using this definition, hyperuricemia occurs at serum urate levels >6.8 mg/dL [17].


Hallux Rigidus

Hallux Rigidus is a progressive disorder. The toe’s motion is decreased over time. Some causes are faulty function or biomechanics and structural abnormalities which can lead to OA.

Pain, stiffness and loss of motion are the some signs of hallux rigidus. Burning pain and paraesthesia can be present. Walking, standing and wearing heels aggravate the pain. Symptoms are relieved by rest. The normal dorsiflexion range of motion of the first MTP joint is at least 65 degrees[18] showed a new standard of “normal” range of dorsiflexion range of motion of the great toe joint should now be set at approximately 45 degrees. However, this dorsiflexion range has only been verified for walking gait, not running.

Rheumatoid Arthritis

Rheumatoid arthritis (RA) is a systematic autoimmune inflammatory disease and results in persistent inflammation of synovial tissue especially of the wrists, hands and feet. Individuals with RA are 8 times more likely to have functional disability compared with adults in the general population from the same community. The structures around the joint can also be affected, like the tendon sheath, the bursa and tendons. This pathology causes pain, stiffness in the morning and after periods of inactivity, joint swelling, weakness, fatigue and restricted joint mobility leading to reduced function. Without treatment RA can lead to irreversible damage, namely deformity and finally provoke considerable physical functional loss or even permanent disability. Thus, RA causes dramatic interference with quality of life if early diagnosis and appropriate treatment are not obtained. [19][20]

In rheumatoid arthritis joint complaints are on the foreground. Typically in a first stage  there is a chronic, symmetrical inflammation of the joints of the hands and the feet, especially the metatarsophalangeal joints (MTP), the wrists, the metacarpophalangeal joints (MCP) and the proximal interphalangeal joints (PIP). Softening of the ligaments can lead to deformation of the fingers, like luxations of the metacarpophalangeal joints. Rheumatoid arthritis causes deformity, pain, weakness and restricted mobility and will result in loss of function.[21]

Diabetic Feet

15-20% of diabetics will develop a foot ulcer in their lifetime and effective monitoring is essential to prevent further issues developing alongside[22]. The NICE in England recommends an annual check for all with diabetes with all assessments including:

  • Loss of sensation and callus formation
  • Reduction blood supply from diseases such as PVD, renal failure, poor diabetes control and CVD 
  • Bony deformities or changes
  • Impaired ability to care for yourself through cognitive or physical impairment

Osteomyelitis

Hammertoe

Morton's Neuroma

Management

Prevention

  1. Regular Checks. Long-term conditions increase the likelihood of developing issues particularly those disorders which affect circulation. The signs of deterioration are subtle and therefore long-term vascular issues need to be monitored. It is essential that alongside regular check-ups those most vulnerable seek primary care advice as soon as any new issues arise such as blisters, cracks or obvious changes. Prevention is the best protection, you do this with your eyes, why is it different for your feet?
  2. Nails. As we age it is increasingly difficult to reach our toe nails but cutting them should not go to the wayside. Poorly looked after nails can become ingrown and infected resulting in pain and immobility. The nails get long, press against shoes, the pressure causes sores, the sores become infected and then ulcerated. You look after your fingernails, why not your toenails?  
  3. Skin Quality. As we age our skin becomes dry, cracked, have a reduced circulation and a reduction in fat pad absorption. Once the dryness and cracked skin with sores sets in they are a rife place for infection. Cellulitis is common in elderly people and frequently reoccurs. You care about the skin on your face, why not your feet?
  4. Correct Footwear. Optimum alignment and weight distribution is essential to keep joints and soft tissues working effectively. A good pair of closed heel flat shoes with good shock absorption promotes good walking posture and balance whislt reducing any risk of chaffing or rubbing. Additionally they should be roomy enough to allow for minor swelling which occurs during the day. Why do you think runners spend so much on good quality running shoes?

Essential Care

Some basic essential care points can make all the different for elderly people[9].

  • Ideally daily washing
  • A good and thorough drying routine
  • Avoiding talcum powder
  • Fresh socks
  • Moisturising the feet avoiding over apllication between the toes
  • Routinely buying new footwear and minimal use of slipper

Ulcers 

Toenails

Owning individual nail clippers and files prevents corss contamination of infections along with regular washing and maintenance[10]. Toenail cutting services may be an alternative option to those unable to cut their own nails.

Top tips include:

  1. Easier to cut after having a warm bath
  2. Straight cuts to the nails
  3. Filed sharp or rough edges

Skin

Foot Pain

References

  1. Clarke M. Trouble with feet. In: Clark M ed.fckLROccasional papers on Social Administration NofckLR29. London: Bell, 1969.
  2. Ebrahim SBJ, Sainsbury R, Watson S. FootfckLRproblems of the elderly: a hospital survey. BMJfckLR1981; 283: 949–50.
  3. SnowBrains. How Far Does the Average Human Walk in a Lifetime? [ONLINE] http://snowbrains.com/brain-post-how-far-does-the-average-human-walk-in-a-lifetime/ [Accessed 21/03/17 @19:20]
  4. Harvey I et al (1997) Foot morbidity and exposure to chiropody: population based study. The BMJ; 315: 7115, 1054-1055.
  5. Evans G. The Aged Foot. Reviews in Clinical Gerontology. 2002:12;175-180.
  6. BJ Munro and JR Steele (1998) Foot-care awareness. A survey of persons aged 65 years and older. Journal of the American Podiatric Medical Association: May 1998, Vol. 88, No. 5, pp. 242-248.
  7. NEW SOUTH WALES DEPARTMENT OF HEALTH PODIATRYfckLRSURVEY STEERING COMMITTEE: Podiatry Survey: SurveyfckLRof Foot Problems in Households and Health InstitutionsfckLRin NSW, State Health Publication No. (CDB) 91-fckLR31, Department of Health, Sydney, 1991
  8. 8.0 8.1 Health in Aging. Foot Problems. [ONLINE] Accessed from http://www.healthinaging.org/aging-and-health-a-to-z/topic:foot-problems/ [23/03/2017]
  9. 9.0 9.1 Soliman A, Brogan M (2014) Foot assessment and care for older people. Nursing Times; 110: 50, 12-15.
  10. 10.0 10.1 Woodrow P et al (2005) Foot care for non-diabetic older people. Nursing Older People; 17: 8, 31-32.
  11. NHS Direct. Bunions. [ONLINE] Accessed from: http://www.nhs.uk/conditions/Bunion/Pages/Introduction.aspx [23/03/2017].
  12. Crielaard J.M., Dequeker J., Famaey J.P., et al. (1985). Osteoartrose. Brussel: Pfizer. p. 148-167.fckLRLevel of evidence: D
  13. http://www.physio-pedia.com/Osteoarthritis
  14. Meachim and Emery, 1974; However, 1975; Koepp et al., 1999
  15. Kimikuza et al. 1980 Arch Orthop Trauma Surg 96: 45-49
  16. Wynarsky and Greenwald, 1983
  17. Martillo, Miguel A., Lama Nazzal, Daria B, Crittenden. The crystallization of monosodium urate. Current rheumatology reports 2014;16(2):1-8.
  18. Root ML, Orien WP, Weed JH. Normal and abnormal function of the foot. In Clinical Biomechanics, vol II, Clinical Biomechanics Corp., Los Angeles, 1977.  Nawoczenski, et al<ref name="Nawoczenski et al">Nawoczenski DA, Baumhauer JF, Umberger BR. Relationship between clinical measurements and motion of the first metatarsophangeal joint during gait. J Bone Joint Surg 81(3): 370-6, 1999.
  19. KNGF-richtlijn. Reumatoïde artritis. 2008
  20. Maura D. Iversen et. Al, Predictors of the use of physical therapy services among patients with rheumatoid arthritis © 2011 American Physical Therapy Association, Issue 91, pages 65-67 (Level 2B )
  21. SARAH Trial Team et al., Strengthening and stretching for rheumatoid arthritis of the hand (SARAH): design of a randomised controlled trial of a hand and upper limb exercise intervention - ISRCTN89936343, Trial Team et al. BMC Musculoskeletal Disorders 2012, 13:230 (Level 1A)
  22. Frykberg RG et al (1998) Role of neuropathy and high foot pressures in diabetic foot ulceration. Diabetes Care; 21: 10, 1054-1055.