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'''Original Editors ''' - [[User:Scott Buxton|Scott Buxton]]
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== Introduction  ==
<h2> Introduction  </h2>
 
<p>Foot problems are commonplace in people over the age of 75 moreso than a younger population<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="Clarke">Clarke M. Trouble with feet. In: Clark M ed.fckLROccasional papers on Social Administration NofckLR29. London: Bell, 1969.</span>. Foot impairment contributes to falls, immobility, the progression of frailty and can lead to a quicker progression towards <b>dependence and not independence<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="Ebrahim">Ebrahim SBJ, Sainsbury R, Watson S. FootfckLRproblems of the elderly: a hospital survey. BMJfckLR1981; 283: 949–50.</span></b>.&nbsp;It is understandable that even without co-morbidity to spped up progression of the effects of aging feet are often affected. Consider how many miles an average person walks in their lifetime.&nbsp;  
Foot problems are commonplace in people over the age of 75 moreso than a younger population<ref name="Clarke">Clarke M. Trouble with feet. In: Clark M ed.fckLROccasional papers on Social Administration NofckLR29. London: Bell, 1969.</ref>. Foot impairment contributes to falls, immobility, the progression of frailty and can lead to a quicker progression towards '''dependence and not independence<ref name="Ebrahim">Ebrahim SBJ, Sainsbury R, Watson S. FootfckLRproblems of the elderly: a hospital survey. BMJfckLR1981; 283: 949–50.</ref>'''.&nbsp;It is understandable that even without co-morbidity to spped up progression of the effects of aging feet are often affected. Consider how many miles an average person walks in their lifetime.&nbsp;  
</p>
<blockquote>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<ref name="Snow.">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]</ref>. </blockquote>  
<blockquote>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<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="Snow.">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]</span>. </blockquote>  
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.  
<p>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.  
 
</p>
=== A Word of Caution...  ===
<h3> A Word of Caution...  </h3>
 
<p>Just before diving into the information below please make sure you consider the impact different management strategies will have on the older person as a whole. The person is more than a foot ulcer, more than someone with foot pain, they are often vulnerable and frail. Slight alteration to their routine or body may cause unintended concequences to their coping strategies and they may not be able to tolerate the treatment anyway. Quite often their ability to cope is in fine balance and something you or I appear to be minor can have vast concequences for them.&nbsp;<b>Sometimes less is more in the context of elderly care.</b>
Just before diving into the information below please make sure you consider the impact different management strategies will have on the older person as a whole. The person is more than a foot ulcer, more than someone with foot pain, they are often vulnerable and frail. Slight alteration to their routine or body may cause unintended concequences to their coping strategies and they may not be able to tolerate the treatment anyway. Quite often their ability to cope is in fine balance and something you or I appear to be minor can have vast concequences for them.&nbsp;'''Sometimes less is more in the context of elderly care.'''
</p>
 
<h2> Prevalence  </h2>
== Prevalence  ==
<p>It is estimated that around 80% of older people have foot problems however many of these people do not seek medical attention<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="Harvey">Harvey I et al (1997) Foot morbidity and exposure to chiropody: population based study. The BMJ; 315: 7115, 1054-1055.</span><span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="Evans">Evans G. The Aged Foot. Reviews in Clinical Gerontology. 2002:12;175-180.</span>. 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<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="Munro">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.</span>.  
 
</p><p>The most common foot problems tend to be nail problems, calluses, bunions, corns, hallux valgus, generalised pain, swollen feet and circulatory problems<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="NSW">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</span>. Most of these issues derive from poorly fitting shoes, obesity and chonic conditions such as diabetes, cardiovascular disease or osteoporosis<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="H&A">Health in Aging. Foot Problems. [ONLINE] Accessed from http://www.healthinaging.org/aging-and-health-a-to-z/topic:foot-problems/ [23/03/2017]</span>.<br />  
It is estimated that around 80% of older people have foot problems however many of these people do not seek medical attention<ref name="Harvey">Harvey I et al (1997) Foot morbidity and exposure to chiropody: population based study. The BMJ; 315: 7115, 1054-1055.</ref><ref name="Evans">Evans G. The Aged Foot. Reviews in Clinical Gerontology. 2002:12;175-180.</ref>. 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<ref name="Munro">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.</ref>.  
</p>
 
<h2> Common Problems  </h2>
The most common foot problems tend to be nail problems, calluses, bunions, corns, hallux valgus, generalised pain, swollen feet and circulatory problems<ref name="NSW">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</ref>. Most of these issues derive from poorly fitting shoes, obesity and chonic conditions such as diabetes, cardiovascular disease or osteoporosis<ref name="H&A">Health in Aging. Foot Problems. [ONLINE] Accessed from http://www.healthinaging.org/aging-and-health-a-to-z/topic:foot-problems/ [23/03/2017]</ref>.<br>  
<p>The problems listed below are not all physiotherapy ameanable however it is important that physiotherapists are aware of them and how they can affect an older person. In particular all of these issues can contribute to a multifactorial picture of falls.  
 
</p>
== Common Problems  ==
<h3> Toenail Issues  </h3>
 
<p>Toenail issues arise because of many issues but the largest contributor is likely the fact that cutting is difficult.  
The problems listed below are not all physiotherapy ameanable however it is important that physiotherapists are aware of them and how they can affect an older person. In particular all of these issues can contribute to a multifactorial picture of falls.
</p><p>31% of older people are unable to cut their own toenails because<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="Soliman">Soliman A, Brogan M (2014) Foot assessment and care for older people. Nursing Times; 110: 50, 12-15.</span>:  
 
</p>
=== Toenail Issues  ===
<ul><li>Unable to reach their feet  
 
</li><li>Lack finger deterity to the point they are unable to use the clippers  
Toenail issues arise because of many issues but the largest contributor is likely the fact that cutting is difficult.  
</li><li>Get dizzy when bending  
 
</li><li>Of visual &nbsp;impairment  
31% of older people are unable to cut their own toenails because<ref name="Soliman">Soliman A, Brogan M (2014) Foot assessment and care for older people. Nursing Times; 110: 50, 12-15.</ref>:  
</li><li>Thick toenails
 
</li></ul>
*Unable to reach their feet  
<p>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<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="H&A" />.  
*Lack finger deterity to the point they are unable to use the clippers  
</p><p>With advancing age growth rate and morphology of the nail plate occurs with a reduction in growth rate as well as changes in colour and contour<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="Cohen">Cohen PR, Scher RK. Geriatric nail disorders: diagnosis and treatment. J Am Acad Dermatol. 1992;26(4):521–31.</span>. They tend to become a yellow-gray colour and can become opaque and a peculiar discolouration called "<i>Neapolitan nail</i>" occurs in ~20% of older people<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="Abdullah">Abdullah L, Abbas O. Common nail changes and disorders in older people: Diagnosis and management. Canadian Family Physician. 2011;57(2):173-181.</span>. The nail can also become fissured, split or striated which can cause some alarm for some people. It is important to note that all become more common in those with osteoporosis<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="Abdullah" />.  
*Get dizzy when bending  
</p><p><b>Brittle nails </b>(fragilitas unguium) affects around 20% of the population and in most places in the world this is a conservative estimate in the elderly population. It clinically manifestd with varying degrees of&nbsp;<b>onychoschizia </b>(localized hypertrophy of the nail plate)<b>&nbsp;</b>or&nbsp;<b>onychorrhexis </b>(subungual corn).  
*Of visual &nbsp;impairment  
</p><p>Onychoschizia is usually caused by impairment of intercellular adhesion between the corneocytes that make up the nail plate. This results in transverse splitting due to breakage of the lateral edges of the nail plate and in lamellar splitting of the free edge and distal portion of the nail plate. Exogenous factors (eg, repetitive cycles of wetting and drying, trauma, and fungal proteolytic products) and chemicals or cosmetics (eg, cuticle removers, nail enamel solvents, and nail hardeners) are among the underlying causes.&nbsp;Onychorrhexis, on the other hand, frequently manifests as nail plate splitting or ridging, longitudinal thickening, or multiple splits leading to triangular fragments at the free edge. It is usually the result of nail matrix involvement leading to abnormalities in epithelial growth and keratinization. Among the various factors causing onychorrhexis are abnormalities of vascularization and oxygenation (such as anemia or arteriosclerosis), as well as systemic (metabolic, endocrine, etc) and dermatologic diseases (disorders of cornification and inflammatory diseases).  
*Thick toenails
</p><p><b>Onychomycosis</b> is the most common nail infection (representing around 50% of all infections) and is common in the elderly<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="Gupta">Gupta AK, Ricci MJ. Diagnosing onychomycosis. Dermatol Clin. 2006;24(3):365–9.</span>.&nbsp;Increased risk of onychomycosis is associated with multiple factors, including male sex, old age, smoking, underlying medical diseases (eg, peripheral arterial disease, diabetes, and immunodeficiency), and predisposing genetic factors<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="Gupta" />.  
 
</p>
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<ref name="H&A" />.  
<h3> Bunion / Hallux Valgus  </h3>
 
<p>Foot width and length often increases with age in addition to peripheral swelling which often occurs throughout the day<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="Woodrow">Woodrow P et al (2005) Foot care for non-diabetic older people. Nursing Older People; 17: 8, 31-32.</span>. This change in shape can lead to misshapen joints resulting in pressure changes in the skin leading to bunions.  
With advancing age growth rate and morphology of the nail plate occurs with a reduction in growth rate as well as changes in colour and contour<ref name="Cohen">Cohen PR, Scher RK. Geriatric nail disorders: diagnosis and treatment. J Am Acad Dermatol. 1992;26(4):521–31.</ref>. They tend to become a yellow-gray colour and can become opaque and a peculiar discolouration called "''Neapolitan nail''" occurs in ~20% of older people<ref name="Abdullah">Abdullah L, Abbas O. Common nail changes and disorders in older people: Diagnosis and management. Canadian Family Physician. 2011;57(2):173-181.</ref>. The nail can also become fissured, split or striated which can cause some alarm for some people. It is important to note that all become more common in those with osteoporosis<ref name="Abdullah" />.  
</p><p>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<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="NHSD">NHS Direct. Bunions. [ONLINE] Accessed from: http://www.nhs.uk/conditions/Bunion/Pages/Introduction.aspx [23/03/2017].</span>.<br />  
 
</p><p>Symptoms include:  
'''Brittle nails '''(fragilitas unguium) affects around 20% of the population and in most places in the world this is a conservative estimate in the elderly population. It clinically manifestd with varying degrees of&nbsp;'''onychoschizia '''(localized hypertrophy of the nail plate)'''&nbsp;'''or&nbsp;'''onychorrhexis '''(subungual corn).  
</p>
 
<ul><li>a swollen, bony bump on the outside edge of your foot  
Onychoschizia is usually caused by impairment of intercellular adhesion between the corneocytes that make up the nail plate. This results in transverse splitting due to breakage of the lateral edges of the nail plate and in lamellar splitting of the free edge and distal portion of the nail plate. Exogenous factors (eg, repetitive cycles of wetting and drying, trauma, and fungal proteolytic products) and chemicals or cosmetics (eg, cuticle removers, nail enamel solvents, and nail hardeners) are among the underlying causes.&nbsp;Onychorrhexis, on the other hand, frequently manifests as nail plate splitting or ridging, longitudinal thickening, or multiple splits leading to triangular fragments at the free edge. It is usually the result of nail matrix involvement leading to abnormalities in epithelial growth and keratinization. Among the various factors causing onychorrhexis are abnormalities of vascularization and oxygenation (such as anemia or arteriosclerosis), as well as systemic (metabolic, endocrine, etc) and dermatologic diseases (disorders of cornification and inflammatory diseases).  
</li><li>pain and swelling over your big toe joint that's made worse by pressure from wearing shoes  
 
</li><li>hard, callused and red skin caused by your big toe and second toe overlapping  
'''Onychomycosis''' is the most common nail infection (representing around 50% of all infections) and is common in the elderly<ref name="Gupta">Gupta AK, Ricci MJ. Diagnosing onychomycosis. Dermatol Clin. 2006;24(3):365–9.</ref>.&nbsp;Increased risk of onychomycosis is associated with multiple factors, including male sex, old age, smoking, underlying medical diseases (eg, peripheral arterial disease, diabetes, and immunodeficiency), and predisposing genetic factors<ref name="Gupta" />.  
</li><li>sore skin over the top of the bunion
 
</li></ul>
=== Bunion / Hallux Valgus  ===
<h3> Corn / Callus  </h3>
 
<p>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.  
Foot width and length often increases with age in addition to peripheral swelling which often occurs throughout the day<ref name="Woodrow">Woodrow P et al (2005) Foot care for non-diabetic older people. Nursing Older People; 17: 8, 31-32.</ref>. This change in shape can lead to misshapen joints resulting in pressure changes in the skin leading to bunions.  
</p>
 
<h3> Ankle Osteoarthritis  </h3>
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<ref name="NHSD">NHS Direct. Bunions. [ONLINE] Accessed from: http://www.nhs.uk/conditions/Bunion/Pages/Introduction.aspx [23/03/2017].</ref>.<br>  
<p>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<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="Crielaard">Crielaard J.M., Dequeker J., Famaey J.P., et al. (1985). Osteoartrose. Brussel: Pfizer. p. 148-167.fckLRLevel of evidence: D</span>.&nbsp;<br />  
 
</p><p>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.  
Symptoms include:  
</p><p>In terms of which type of OA tends to occur in the ankle it tends to be primary OA.  
 
</p>
*a swollen, bony bump on the outside edge of your foot  
<blockquote>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<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref">http://www.physio-pedia.com/Osteoarthritis</span>. </blockquote>  
*pain and swelling over your big toe joint that's made worse by pressure from wearing shoes  
<p>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<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="Meachim">Meachim and Emery, 1974; However, 1975; Koepp et al., 1999</span> . 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<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="Kimikuza">Kimikuza et al. 1980 Arch Orthop Trauma Surg 96: 45-49</span>. 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<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="Wynarsky">Wynarsky and Greenwald, 1983</span>. 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).<br />  
*hard, callused and red skin caused by your big toe and second toe overlapping  
</p>
*sore skin over the top of the bunion
<h3> Gout  </h3>
 
<p>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 &gt;6.8 mg/dL <span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="Martillo">Martillo, Miguel A., Lama Nazzal, Daria B, Crittenden. The crystallization of monosodium urate. Current rheumatology reports 2014;16(2):1-8.</span>.  
=== Corn / Callus  ===
</p>
 
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<ref name="Crielaard">Crielaard J.M., Dequeker J., Famaey J.P., et al. (1985). Osteoartrose. Brussel: Pfizer. p. 148-167.fckLRLevel of evidence: D</ref>.&nbsp;<br>  
 
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.  
<blockquote>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<ref>http://www.physio-pedia.com/Osteoarthritis</ref>. </blockquote>  
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<ref name="Meachim">Meachim and Emery, 1974; However, 1975; Koepp et al., 1999</ref> . 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<ref name="Kimikuza">Kimikuza et al. 1980 Arch Orthop Trauma Surg 96: 45-49</ref>. 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<ref name="Wynarsky">Wynarsky and Greenwald, 1983</ref>. 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).<br>  
 
=== 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 &gt;6.8 mg/dL <ref name="Martillo">Martillo, Miguel A., Lama Nazzal, Daria B, Crittenden. The crystallization of monosodium urate. Current rheumatology reports 2014;16(2):1-8.</ref>.  
<blockquote>Gout is often described as a burning pain and can be extremely severe in nature with an attack lasting upwards of a week. During this period of immobility an elderly person can lose a significant amount of independence and may require help to function. </blockquote>  
<blockquote>Gout is often described as a burning pain and can be extremely severe in nature with an attack lasting upwards of a week. During this period of immobility an elderly person can lose a significant amount of independence and may require help to function. </blockquote>  
While gout is commonly considered to be a disease affecting men, this gender difference diminishes after the age of 65, likely due to hormonal influences<ref>Kim KY, Ralph Schumacher H, Hunsche E, Wertheimer AI, Kong SX. A literature review of the epidemiology and treatment of acute gout. Clin Ther 2003 Jun;25(6):1593-1617.</ref>. Several factors contribute to the high prevalence of gout in the elderly. The risk of gout is related to the duration of hyperuricemia, and hence related to longevity. Increase in cardiovascular, renal, and metabolic morbidity in the elderly, resulting in decreased GFR and reduced uric acid excretion, along with polypharmacy, may precipitate hyperuricemia<ref name="Roddy">Roddy, Edward, and Michael Doherty. “Gout. Epidemiology of Gout.” Arthritis Research &amp;amp;amp;amp;amp; Therapy 12.6 (2010): 223. PMC. Web. 29 Mar. 2017.</ref><ref>Smith E, Díaz-Torné C, Perez-Ruiz F, March L. Epidemiology of gout: an update. Best Pract Res Clin Rheumatol 2010 Dec;24(6):811-27.</ref><span style="font-size: 13.28px;">.</span>  
<p>While gout is commonly considered to be a disease affecting men, this gender difference diminishes after the age of 65, likely due to hormonal influences<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref">Kim KY, Ralph Schumacher H, Hunsche E, Wertheimer AI, Kong SX. A literature review of the epidemiology and treatment of acute gout. Clin Ther 2003 Jun;25(6):1593-1617.</span>. Several factors contribute to the high prevalence of gout in the elderly. The risk of gout is related to the duration of hyperuricemia, and hence related to longevity. Increase in cardiovascular, renal, and metabolic morbidity in the elderly, resulting in decreased GFR and reduced uric acid excretion, along with polypharmacy, may precipitate hyperuricemia<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="Roddy">Roddy, Edward, and Michael Doherty. “Gout. Epidemiology of Gout.” Arthritis Research; Therapy 12.6 (2010): 223. PMC. Web. 29 Mar. 2017.</span><span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref">Smith E, Díaz-Torné C, Perez-Ruiz F, March L. Epidemiology of gout: an update. Best Pract Res Clin Rheumatol 2010 Dec;24(6):811-27.</span><span style="font-size: 13.28px;">.</span>  
 
</p><p>In many frail elderly people gout can often be interpreted as something more severe such as a fracture or infective arthritis. This is because a flare of a disorder can knock those who have 'just about been coping' with all of their other morbidity over the edge. With their body now unable to cope with a new complaint they often become immobile and unable to function as before.&nbsp;  
In many frail elderly people gout can often be interpreted as something more severe such as a fracture or infective arthritis. This is because a flare of a disorder can knock those who have 'just about been coping' with all of their other morbidity over the edge. With their body now unable to cope with a new complaint they often become immobile and unable to function as before.&nbsp;  
</p><p><br />  
 
</p><p><img src="/images/b/ba/Gout_foot.jpg" _fck_mw_filename="Gout foot.jpg" alt="" />
<br>  
</p><p><br />  
 
</p>
[[Image:Gout foot.jpg]]
<h3> Hallux Rigidus  </h3>
 
<p>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.  
<br>  
</p><p><img src="/images/thumb/9/96/Hallux_rigidus_XR.jpg/100px-Hallux_rigidus_XR.jpg" _fck_mw_filename="Hallux rigidus XR.jpg" _fck_mw_location="right" _fck_mw_width="100" alt="" class="fck_mw_right" />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.&nbsp;The normal dorsiflexion range of motion of the first MTP joint is at least 65 degrees<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="Root et al">Root ML, Orien WP, Weed JH. Normal and abnormal function of the foot. In Clinical Biomechanics, vol II, Clinical Biomechanics Corp., Los Angeles, 1977.nbsp; Nawoczenski, et al ref name=&quot;Nawoczenski et al&quot;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.</span> 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.&nbsp;<br />  
 
</p>
=== Hallux Rigidus  ===
<h3> Rheumatoid Arthritis  </h3>
 
<p>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.&nbsp;Thus, RA causes dramatic interference with quality of life if early diagnosis and appropriate treatment are not obtained.&nbsp;<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="KNGF">KNGF-richtlijn. Reumatoïde artritis. 2008</span><span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="Maura et al">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 )</span>  
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.  
</p><p>In rheumatoid arthritis joint complaints are on the foreground. Typically in a first stage &nbsp;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.&nbsp;Rheumatoid arthritis causes deformity, pain, weakness and restricted mobility and will result in loss of function.<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="SARAH et al">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)</span>  
 
</p>
[[Image:Hallux rigidus XR.jpg|right|100px]]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.&nbsp;The normal dorsiflexion range of motion of the first MTP joint is at least 65 degrees<ref name="Root et al">Root ML, Orien WP, Weed JH. Normal and abnormal function of the foot. In Clinical Biomechanics, vol II, Clinical Biomechanics Corp., Los Angeles, 1977.&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;nbsp; Nawoczenski, et al&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt;ref name="Nawoczenski et al"&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;gt;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.</ref> 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.&nbsp;<br>  
<h3> Diabetic Foot Ulcers  </h3>
 
<p>15-20% of diabetics will develop a foot ulcer in their lifetime and effective monitoring is essential to prevent further issues developing alongside<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="Frykberg">Frykberg RG et al (1998) Role of neuropathy and high foot pressures in diabetic foot ulceration. Diabetes Care; 21: 10, 1054-1055.</span>.&nbsp;The NICE in England recommends an annual check for all with diabetes with all assessments including:  
=== Rheumatoid Arthritis  ===
</p>
 
<ul><li>Loss of sensation and callus formation  
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.&nbsp;Thus, RA causes dramatic interference with quality of life if early diagnosis and appropriate treatment are not obtained.&nbsp;<ref name="KNGF">KNGF-richtlijn. Reumatoïde artritis. 2008</ref><ref name="Maura et al">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 )</ref>  
</li><li>Reduction blood supply from diseases such as PVD, renal failure, poor diabetes control and CVD&nbsp;  
 
</li><li>Bony deformities or changes  
In rheumatoid arthritis joint complaints are on the foreground. Typically in a first stage &nbsp;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.&nbsp;Rheumatoid arthritis causes deformity, pain, weakness and restricted mobility and will result in loss of function.<ref name="SARAH et al">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)</ref>  
</li><li>Impaired ability to care for yourself through cognitive or physical impairment
 
</li></ul>
=== Diabetic Foot Ulcers  ===
<p>One of the largest reason for ulcers occurring is that diabetic neuropathies (appearing in almost 50% of older people with T2DM<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="Boulton" />) prevent the person from feeling areas of increased pressure. Things are worse in those which suffer from distal sensory polyneuropathy as symptoms are so variable, with some neuropathies being pain free. In this case the end of the toes can become completely numb and therefore a sore is easily created, leading to an ulcer in no time.&nbsp;  
 
</p>
15-20% of diabetics will develop a foot ulcer in their lifetime and effective monitoring is essential to prevent further issues developing alongside<ref name="Frykberg">Frykberg RG et al (1998) Role of neuropathy and high foot pressures in diabetic foot ulceration. Diabetes Care; 21: 10, 1054-1055.</ref>.&nbsp;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&nbsp;  
*Bony deformities or changes  
*Impaired ability to care for yourself through cognitive or physical impairment
 
One of the largest reason for ulcers occurring is that diabetic neuropathies (appearing in almost 50% of older people with T2DM<ref name="Boulton" />) prevent the person from feeling areas of increased pressure. Things are worse in those which suffer from distal sensory polyneuropathy as symptoms are so variable, with some neuropathies being pain free. In this case the end of the toes can become completely numb and therefore a sore is easily created, leading to an ulcer in no time.&nbsp;  
<blockquote>Up to 50% of patients with neuropathy never experience symptoms, so absence of neuropathic symptomatology must never be associated with absence of risk of foot ulceration. </blockquote>  
<blockquote>Up to 50% of patients with neuropathy never experience symptoms, so absence of neuropathic symptomatology must never be associated with absence of risk of foot ulceration. </blockquote>  
This is where hot/cold, pin prick sensation and vibration testing all come into their own. This is how you assess the loaction and severity of neuropathy and act upon it swiftly, if not the person is at 6x the risk of develping an ulcer<ref name="Abbott">Abbott CA, Carrington AL, Ashe H, et al. The North-West Diabetes Foot Care Study: incidence of, and risk factors for, new diabetic foot ulceration in a community-based patient cohort. Diabet Med 2002;19:377–384.</ref>.  
<p>This is where hot/cold, pin prick sensation and vibration testing all come into their own. This is how you assess the loaction and severity of neuropathy and act upon it swiftly, if not the person is at 6x the risk of develping an ulcer<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="Abbott">Abbott CA, Carrington AL, Ashe H, et al. The North-West Diabetes Foot Care Study: incidence of, and risk factors for, new diabetic foot ulceration in a community-based patient cohort. Diabet Med 2002;19:377–384.</span>.  
 
</p><p>Peripheral autonomic dysfunction also contributes to ulcers through increased peripheral blood flow in the absence of large vessel obstructive vascular disease, together with dry skin because of a lack of sweating. This along with neuropathy creates a warm dry and insensitive foot.  
Peripheral autonomic dysfunction also contributes to ulcers through increased peripheral blood flow in the absence of large vessel obstructive vascular disease, together with dry skin because of a lack of sweating. This along with neuropathy creates a warm dry and insensitive foot.  
</p><p>The above mechanism usually leads to an ulcer developing overtime however the insensitive foot is also at high risk of trauma, particularly in those elderly who are still doing their own higher acitvites of daily living such as gardening.&nbsp;  
 
</p><p><img src="/images/c/c3/Footulceration_Flowchart.png" _fck_mw_filename="Footulceration Flowchart.png" _fck_mw_location="center" _fck_mw_width="700" _fck_mw_height="500" _fck_mw_type="frame" alt="Taken from Boulton, A. Pressure and the diabetic fot: clinical science and offloading techniques. The A J Surg. 2004:187;17s-24s." class="fck_mw_frame fck_mw_center" />
The above mechanism usually leads to an ulcer developing overtime however the insensitive foot is also at high risk of trauma, particularly in those elderly who are still doing their own higher acitvites of daily living such as gardening.&nbsp;  
</p><p>Biomechanics also plays a part in the development of ulcers, particularly in those with high plantar pressures<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="Veves">Veves A, Murray HJ, Young MJ, Boulton AJ. The risk of foot ulceration in diabetic patients with high foot pressure: a prospective study. Diabetologia 1992;35:660–663</span>. This high pressure leads to a mechanical recurrent stress which the patient is unable to feel. Eventually the skin becaomes sore, breaks down and becomes ulcerated. This is particularly an issue for those mobile elderly who have an altered gait pattern due to something such as osteoarthritis, and this is where awareness of their frailty comes into play. It is particularly important to consider such issues as the damage caused by repetitive application of high pressures over a bony prominence beging deep and is not visible.&nbsp;  
 
</p>
[[Image:Footulceration Flowchart.png|frame|center|700x500px|Taken from Boulton, A. Pressure and the diabetic fot: clinical science and offloading techniques. The A J Surg. 2004:187;17s-24s.]]
<h3> Skin  </h3>
 
<p>As you age skin becomes thinner, loses fat, takes longer to heal and is more prone to damage.&nbsp;<br />  
Biomechanics also plays a part in the development of ulcers, particularly in those with high plantar pressures<ref name="Veves">Veves A, Murray HJ, Young MJ, Boulton AJ. The risk of foot ulceration in diabetic patients with high foot pressure: a prospective study. Diabetologia 1992;35:660–663</ref>. This high pressure leads to a mechanical recurrent stress which the patient is unable to feel. Eventually the skin becaomes sore, breaks down and becomes ulcerated. This is particularly an issue for those mobile elderly who have an altered gait pattern due to something such as osteoarthritis, and this is where awareness of their frailty comes into play. It is particularly important to consider such issues as the damage caused by repetitive application of high pressures over a bony prominence beging deep and is not visible.&nbsp;  
</p>
 
<h3> Obesity  </h3>
=== Skin  ===
<p>15% of men and 28% of women over 60 are obese and this has a significant effect on the biomechanics of the feet. Obese elderly tend to have a higher incidence of foot pain because of structural changes and this also has implications for day to day life, mobility and general well-being. They tend to have larger foot dimensions, thicher plantar fat pads under the heels, a lower hallux and overall foot strength. These contribute to generating a higher overall force, a greater plantar contact time with a greater contact area therefore greater pressure-time. Therefore providing interventions to combat their obesity ensures a reduction in foot pain, an increase in independence and better overall quality of life<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="Steele">Steele, J. Mickle, K. Munro, B. 2009. Fat flat frail feet: how does obesity affect the older foot. XXII Congress of the International Society of Biomechanics.</span>.  
 
</p>
As you age skin becomes thinner, loses fat, takes longer to heal and is more prone to damage.&nbsp;<br>  
<h2> Management  </h2>
 
<p>It is important that with older people you remember to think about the person as a whole and in terms of their <a href="Frailty: Theoretical Frameworks">frailty</a> and <a href="Falls">falls risk</a>.  
=== Obesity  ===
</p>
 
<h3> Prevention  </h3>
15% of men and 28% of women over 60 are obese and this has a significant effect on the biomechanics of the feet. Obese elderly tend to have a higher incidence of foot pain because of structural changes and this also has implications for day to day life, mobility and general well-being. They tend to have larger foot dimensions, thicher plantar fat pads under the heels, a lower hallux and overall foot strength. These contribute to generating a higher overall force, a greater plantar contact time with a greater contact area therefore greater pressure-time. Therefore providing interventions to combat their obesity ensures a reduction in foot pain, an increase in independence and better overall quality of life<ref name="Steele">Steele, J. Mickle, K. Munro, B. 2009. Fat flat frail feet: how does obesity affect the older foot. XXII Congress of the International Society of Biomechanics.</ref>.
<ol><li><b>Regular Checks.</b>&nbsp;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.&nbsp;<b>Prevention is the best protection</b>, you do this with your eyes, why is it different for your feet?<br />  
 
</li><li><b>Nails. </b>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.&nbsp;<b>You look after your fingernails, why not your toenails?&nbsp;&nbsp;</b>
== Management  ==
</li><li><b>Skin Quality. </b>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. <b>You care about the skin on your face, why not your feet?</b>
 
</li><li><b>Correct Footwear. </b>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.&nbsp;<b>Why do you think runners spend so much on good quality running shoes?</b>
It is important that with older people you remember to think about the person as a whole and in terms of their [[Frailty:_Theoretical_Frameworks|frailty]] and [[Falls|falls risk]].  
</li></ol>
 
<h3> Essential Care  </h3>
=== Prevention  ===
<p>Some basic essential care points can make all the different for elderly people<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="Soliman" />.  
 
</p>
#'''Regular Checks.'''&nbsp;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.&nbsp;'''Prevention is the best protection''', you do this with your eyes, why is it different for your feet?<br>  
<ul><li>Ideally daily washing  
#'''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.&nbsp;'''You look after your fingernails, why not your toenails?&nbsp;&nbsp;'''
</li><li>A good and thorough drying routine  
#'''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?'''
</li><li>Avoiding talcum powder  
#'''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.&nbsp;'''Why do you think runners spend so much on good quality running shoes?'''
</li><li>Fresh socks  
 
</li><li>Moisturising the feet <b>avoiding</b> over apllication between the toes  
=== Essential Care  ===
</li><li>Routinely buying new footwear and minimal use of slipper
 
</li></ul>
Some basic essential care points can make all the different for elderly people<ref name="Soliman" />.  
<h3> Ulcers&nbsp;  </h3>
 
<p><b>When considering the prevention or management of ulcers in older people it is essential that you consider the implications of their other issues.</b>
*Ideally daily washing  
</p><p>As with all aspects of managing the foot prevention is the patients best friend. During assessment it is essential that the therapist is aware of areas of high pressure as to then offload it through different approaches<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="Boulton">Boulton, A. Pressure and the diabetic foot: clinical science and offloading techniques. The Americal Journal of Surgery. 2004;17s-24s.</span><span style="font-size: 13.28px;">. One of the oldest techniques (and most effective) is offloading footwear and those wearing appropriate footwear have significantly fewer ulcers<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="Uccioli">Uccioli L, Faglia E, Monticone G, et al. Manufactured shoes in the prevention of diabetic foot ulcers. Diabetes Care 1995;18:1376–1378</span>. Don't forget that if the ulcer is severe enough then bed rest, the use of wheel chair or crutches can also be appropriate. A word of caution though, bed rest can lead to rapid deconditioning and immobility in elderly so perhaps casting or therapeutic shoes is more appropriate.</span><br />  
*A good and thorough drying routine  
</p>
*Avoiding talcum powder  
<h3> Gout  </h3>
*Fresh socks  
<p>Aside from the management of hyperuricemia and the pharmocology-side of the treatment physiotherapy is important. Patient education, optimising mobility and lifestyle modification are essential parts of the holistic gout management plan.  
*Moisturising the feet '''avoiding''' over apllication between the toes  
</p><p>It is important that the elderly person with gout remains as active as possible during the attack of symptoms as the rest of their muscular system will atrophy and it may be difficult to get the muscle bulk and function back afterwards. Seated or weightbearing exercise plans are a suitable options alongside provision of mobility aids. For those elderly able to attend outpatient clinics ultrasound therapy may also be an option. As gout is an inflammatory disorder don't forget the efficacy of ice.  
*Routinely buying new footwear and minimal use of slipper
</p><p>It is also that the person avoids alcohol, highly calorific food, sea food in the long term and if applicable to them, optimisie their BMI. This will reduce the risk of ongoing flares<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref">Chowalloor PV, Keen HI, Inderjeeth CA. Gout in the elderly. OA Elderly Medicine 2013 Aug 01;1(1):2.</span>.  
 
</p>
=== Ulcers&nbsp;  ===
<h3> Toenails  </h3>
 
<p>Owning individual nail clippers and files prevents corss contamination of infections along with regular washing and maintenance<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="Woodrow" />.&nbsp;Toenail cutting services may be an alternative option to those unable to cut their own nails.  
'''When considering the prevention or management of ulcers in older people it is essential that you consider the implications of their other issues.'''
</p><p>Top tips include:  
 
</p>
As with all aspects of managing the foot prevention is the patients best friend. During assessment it is essential that the therapist is aware of areas of high pressure as to then offload it through different approaches<ref name="Boulton">Boulton, A. Pressure and the diabetic foot: clinical science and offloading techniques. The Americal Journal of Surgery. 2004;17s-24s.</ref><span style="font-size: 13.28px;">. One of the oldest techniques (and most effective) is offloading footwear and those wearing appropriate footwear have significantly fewer ulcers<ref name="Uccioli">Uccioli L, Faglia E, Monticone G, et al. Manufactured shoes in the prevention of diabetic foot ulcers. Diabetes Care 1995;18:1376–1378</ref>. Don't forget that if the ulcer is severe enough then bed rest, the use of wheel chair or crutches can also be appropriate. A word of caution though, bed rest can lead to rapid deconditioning and immobility in elderly so perhaps casting or therapeutic shoes is more appropriate.</span><br>  
<ol><li><b>Easier to cut after having a warm bath</b>
 
</li><li><b>Straight cuts to the nails</b>
=== Gout  ===
</li><li><b>Filed sharp or rough edges</b>
 
</li></ol>
Aside from the management of hyperuricemia and the pharmocology-side of the treatment physiotherapy is important. Patient education, optimising mobility and lifestyle modification are essential parts of the holistic gout management plan.  
<p>In the context of brittle nails it is important to consider the predominance of either&nbsp;onychoschizia or onychorrhexis and then correct these underlying issues. General therapeutic management may include nail hydration with daily 15-minute soaks using emollients rich in phospholipids<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="Van de Kerkhof">Van de Kerkhof PC, Pasch MC, Scher RK, Kerscher M, Gieler U, Haneke E, et al. Brittle nail syndrome: a pathogenesis-based approach with a proposed grading system. J Am Acad Dermatol. 2005;53(4):644–51.</span>.&nbsp;pplication of nail hardeners containing formaldehyde can be used to strengthen the nail plate<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref" name="Van de Kerkhof" />; nevertheless, caution should be entertained when using these products, as they might cause brittleness, subungual hyperkeratosis, or onycholysis (ie, separation of the nail plate from the underlying nail bed). Mechanical nail plate protection and fracture filling can be accomplished using enamel; however, considerable dehydration might occur when it is removed afterward.<br />  
 
</p><p>Overall it is not always the physiotherapists job to manage the nail conditions however, basic advice is always worth sharing with the patient. The main thing to be aware of is that elderly patients might complain of common nail changes and dystrophies that cause pain, affect daily activities, are of cosmetic concern. Awareness of these conditions is essential for onward referral to optimally manage the issues.  
It is important that the elderly person with gout remains as active as possible during the attack of symptoms as the rest of their muscular system will atrophy and it may be difficult to get the muscle bulk and function back afterwards. Seated or weightbearing exercise plans are a suitable options alongside provision of mobility aids. For those elderly able to attend outpatient clinics ultrasound therapy may also be an option. As gout is an inflammatory disorder don't forget the efficacy of ice.  
</p>
 
<h3> Skin  </h3>
It is also that the person avoids alcohol, highly calorific food, sea food in the long term and if applicable to them, optimisie their BMI. This will reduce the risk of ongoing flares<ref>Chowalloor PV, Keen HI, Inderjeeth CA. Gout in the elderly. OA Elderly Medicine 2013 Aug 01;1(1):2.</ref>.  
<p>Keeping feet moisturised is an essential part of caring for aged skin which is prone to drying out.  
 
</p>
=== Toenails  ===
<h3> Bunions  </h3>
 
<p>A bunion may only need treatment if it is severe and causing significant pain and alteration to daily life. Non-surgical options incluse pain killers, bunion pads and orthotics all alongside appropriate footwear. It is important to be aware that surgery is the only way to correct a bunion and is not for cosmetic reasons alone<span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref">Bunion. NHS Choices. [ONLINE] http://www.nhs.uk/Conditions/Bunion/Pages/Treatment.aspx Accessed 29/03/2017.</span>. The surgical options include an osteotomy, which is removal of the problematic part of the bone alongside correction of any soft tissue deformity which has occurred. Arthrodesis is also an option. This is when the metatarsophalangeal joint is fused and is only recommended in severe joint degeneration.&nbsp;<br />  
Owning individual nail clippers and files prevents corss contamination of infections along with regular washing and maintenance<ref name="Woodrow" />.&nbsp;Toenail cutting services may be an alternative option to those unable to cut their own nails.  
</p>
 
<table width="100%" cellspacing="1" cellpadding="1">
Top tips include:  
 
#'''Easier to cut after having a warm bath'''
#'''Straight cuts to the nails'''
#'''Filed sharp or rough edges'''
 
In the context of brittle nails it is important to consider the predominance of either&nbsp;onychoschizia or onychorrhexis and then correct these underlying issues. General therapeutic management may include nail hydration with daily 15-minute soaks using emollients rich in phospholipids<ref name="Van de Kerkhof">Van de Kerkhof PC, Pasch MC, Scher RK, Kerscher M, Gieler U, Haneke E, et al. Brittle nail syndrome: a pathogenesis-based approach with a proposed grading system. J Am Acad Dermatol. 2005;53(4):644–51.</ref>.&nbsp;pplication of nail hardeners containing formaldehyde can be used to strengthen the nail plate<ref name="Van de Kerkhof" />; nevertheless, caution should be entertained when using these products, as they might cause brittleness, subungual hyperkeratosis, or onycholysis (ie, separation of the nail plate from the underlying nail bed). Mechanical nail plate protection and fracture filling can be accomplished using enamel; however, considerable dehydration might occur when it is removed afterward.<br>  
 
Overall it is not always the physiotherapists job to manage the nail conditions however, basic advice is always worth sharing with the patient. The main thing to be aware of is that elderly patients might complain of common nail changes and dystrophies that cause pain, affect daily activities, are of cosmetic concern. Awareness of these conditions is essential for onward referral to optimally manage the issues.  
 
=== Skin  ===
 
Keeping feet moisturised is an essential part of caring for aged skin which is prone to drying out.  
 
=== Bunions  ===
 
A bunion may only need treatment if it is severe and causing significant pain and alteration to daily life. Non-surgical options incluse pain killers, bunion pads and orthotics all alongside appropriate footwear. It is important to be aware that surgery is the only way to correct a bunion and is not for cosmetic reasons alone<ref>Bunion. NHS Choices. [ONLINE] http://www.nhs.uk/Conditions/Bunion/Pages/Treatment.aspx Accessed 29/03/2017.</ref>. The surgical options include an osteotomy, which is removal of the problematic part of the bone alongside correction of any soft tissue deformity which has occurred. Arthrodesis is also an option. This is when the metatarsophalangeal joint is fused and is only recommended in severe joint degeneration.&nbsp;<br>  
 
{| width="100%" cellspacing="1" cellpadding="1"
|-
| {{#ev:youtube|_s6aCcrMYS0|300}}<ref>Bunion Surgery. Dr Richard Moy.</ref>  
| {{#ev:youtube|HKudJlhwwMU|300}}<ref>Minimally Invasive Key Hole Bunion Surgery David Gordon.</ref>
|}
 
== References  ==


<references />
<tr>
<td> <span class="fck_mw_template">{{#ev:youtube|_s6aCcrMYS0|300}}</span><span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref">Bunion Surgery. Dr Richard Moy.</span>
</td><td> <span class="fck_mw_template">{{#ev:youtube|HKudJlhwwMU|300}}</span><span class="fck_mw_ref" _fck_mw_customtag="true" _fck_mw_tagname="ref">Minimally Invasive Key Hole Bunion Surgery David Gordon.</span>
</td></tr></table>
<h2> References  </h2>
<p><span class="fck_mw_references" _fck_mw_customtag="true" _fck_mw_tagname="references" />
</p>

Revision as of 20:37, 29 March 2017

Original Editors - <a href="User:Scott Buxton">Scott Buxton</a>

Top Contributors - Scott Buxton, Lucinda hampton, Kim Jackson, 127.0.0.1, Lauren Lopez and Khloud Shreif

Introduction

Foot problems are commonplace in people over the age of 75 moreso than a younger populationClarke M. Trouble with feet. In: Clark M ed.fckLROccasional papers on Social Administration NofckLR29. London: Bell, 1969.. Foot impairment contributes to falls, immobility, the progression of frailty and can lead to a quicker progression towards dependence and not independenceEbrahim SBJ, Sainsbury R, Watson S. FootfckLRproblems of the elderly: a hospital survey. BMJfckLR1981; 283: 949–50.. It is understandable that even without co-morbidity to spped up progression of the effects of aging feet are often affected. 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 milesSnowBrains. 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].

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.

A Word of Caution...

Just before diving into the information below please make sure you consider the impact different management strategies will have on the older person as a whole. The person is more than a foot ulcer, more than someone with foot pain, they are often vulnerable and frail. Slight alteration to their routine or body may cause unintended concequences to their coping strategies and they may not be able to tolerate the treatment anyway. Quite often their ability to cope is in fine balance and something you or I appear to be minor can have vast concequences for them. Sometimes less is more in the context of elderly care.

Prevalence

It is estimated that around 80% of older people have foot problems however many of these people do not seek medical attentionHarvey I et al (1997) Foot morbidity and exposure to chiropody: population based study. The BMJ; 315: 7115, 1054-1055.Evans G. The Aged Foot. Reviews in Clinical Gerontology. 2002:12;175-180.. 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 itBJ 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..

The most common foot problems tend to be nail problems, calluses, bunions, corns, hallux valgus, generalised pain, swollen feet and circulatory problemsNEW 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. Most of these issues derive from poorly fitting shoes, obesity and chonic conditions such as diabetes, cardiovascular disease or osteoporosisHealth in Aging. Foot Problems. [ONLINE] Accessed from http://www.healthinaging.org/aging-and-health-a-to-z/topic:foot-problems/ [23/03/2017].

Common Problems

The problems listed below are not all physiotherapy ameanable however it is important that physiotherapists are aware of them and how they can affect an older person. In particular all of these issues can contribute to a multifactorial picture of falls.

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 becauseSoliman A, Brogan M (2014) Foot assessment and care for older people. Nursing Times; 110: 50, 12-15.:

  • 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.

With advancing age growth rate and morphology of the nail plate occurs with a reduction in growth rate as well as changes in colour and contourCohen PR, Scher RK. Geriatric nail disorders: diagnosis and treatment. J Am Acad Dermatol. 1992;26(4):521–31.. They tend to become a yellow-gray colour and can become opaque and a peculiar discolouration called "Neapolitan nail" occurs in ~20% of older peopleAbdullah L, Abbas O. Common nail changes and disorders in older people: Diagnosis and management. Canadian Family Physician. 2011;57(2):173-181.. The nail can also become fissured, split or striated which can cause some alarm for some people. It is important to note that all become more common in those with osteoporosis.

Brittle nails (fragilitas unguium) affects around 20% of the population and in most places in the world this is a conservative estimate in the elderly population. It clinically manifestd with varying degrees of onychoschizia (localized hypertrophy of the nail plate) or onychorrhexis (subungual corn).

Onychoschizia is usually caused by impairment of intercellular adhesion between the corneocytes that make up the nail plate. This results in transverse splitting due to breakage of the lateral edges of the nail plate and in lamellar splitting of the free edge and distal portion of the nail plate. Exogenous factors (eg, repetitive cycles of wetting and drying, trauma, and fungal proteolytic products) and chemicals or cosmetics (eg, cuticle removers, nail enamel solvents, and nail hardeners) are among the underlying causes. Onychorrhexis, on the other hand, frequently manifests as nail plate splitting or ridging, longitudinal thickening, or multiple splits leading to triangular fragments at the free edge. It is usually the result of nail matrix involvement leading to abnormalities in epithelial growth and keratinization. Among the various factors causing onychorrhexis are abnormalities of vascularization and oxygenation (such as anemia or arteriosclerosis), as well as systemic (metabolic, endocrine, etc) and dermatologic diseases (disorders of cornification and inflammatory diseases).

Onychomycosis is the most common nail infection (representing around 50% of all infections) and is common in the elderlyGupta AK, Ricci MJ. Diagnosing onychomycosis. Dermatol Clin. 2006;24(3):365–9.. Increased risk of onychomycosis is associated with multiple factors, including male sex, old age, smoking, underlying medical diseases (eg, peripheral arterial disease, diabetes, and immunodeficiency), and predisposing genetic factors.

Bunion / Hallux Valgus

Foot width and length often increases with age in addition to peripheral swelling which often occurs throughout the dayWoodrow P et al (2005) Foot care for non-diabetic older people. Nursing Older People; 17: 8, 31-32.. 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 soreNHS Direct. Bunions. [ONLINE] Accessed from: http://www.nhs.uk/conditions/Bunion/Pages/Introduction.aspx [23/03/2017]..

Symptoms include:

  • a swollen, bony bump on the outside edge of your foot
  • pain and swelling over your big toe joint that's made worse by pressure from wearing shoes
  • hard, callused and red skin caused by your big toe and second toe overlapping
  • sore skin over the top of the bunion

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 compartmentCrielaard J.M., Dequeker J., Famaey J.P., et al. (1985). Osteoartrose. Brussel: Pfizer. p. 148-167.fckLRLevel of evidence: D

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 examinationhttp://www.physio-pedia.com/Osteoarthritis.

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 observedMeachim and Emery, 1974; However, 1975; Koepp et al., 1999 . 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 jointsKimikuza et al. 1980 Arch Orthop Trauma Surg 96: 45-49. 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 pressuresWynarsky and Greenwald, 1983. 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 Martillo, Miguel A., Lama Nazzal, Daria B, Crittenden. The crystallization of monosodium urate. Current rheumatology reports 2014;16(2):1-8..

Gout is often described as a burning pain and can be extremely severe in nature with an attack lasting upwards of a week. During this period of immobility an elderly person can lose a significant amount of independence and may require help to function.

While gout is commonly considered to be a disease affecting men, this gender difference diminishes after the age of 65, likely due to hormonal influencesKim KY, Ralph Schumacher H, Hunsche E, Wertheimer AI, Kong SX. A literature review of the epidemiology and treatment of acute gout. Clin Ther 2003 Jun;25(6):1593-1617.. Several factors contribute to the high prevalence of gout in the elderly. The risk of gout is related to the duration of hyperuricemia, and hence related to longevity. Increase in cardiovascular, renal, and metabolic morbidity in the elderly, resulting in decreased GFR and reduced uric acid excretion, along with polypharmacy, may precipitate hyperuricemiaRoddy, Edward, and Michael Doherty. “Gout. Epidemiology of Gout.” Arthritis Research; Therapy 12.6 (2010): 223. PMC. Web. 29 Mar. 2017.Smith E, Díaz-Torné C, Perez-Ruiz F, March L. Epidemiology of gout: an update. Best Pract Res Clin Rheumatol 2010 Dec;24(6):811-27..

In many frail elderly people gout can often be interpreted as something more severe such as a fracture or infective arthritis. This is because a flare of a disorder can knock those who have 'just about been coping' with all of their other morbidity over the edge. With their body now unable to cope with a new complaint they often become immobile and unable to function as before. 


<img src="/images/b/ba/Gout_foot.jpg" _fck_mw_filename="Gout foot.jpg" alt="" />


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.

<img src="/images/thumb/9/96/Hallux_rigidus_XR.jpg/100px-Hallux_rigidus_XR.jpg" _fck_mw_filename="Hallux rigidus XR.jpg" _fck_mw_location="right" _fck_mw_width="100" alt="" class="fck_mw_right" />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 degreesRoot ML, Orien WP, Weed JH. Normal and abnormal function of the foot. In Clinical Biomechanics, vol II, Clinical Biomechanics Corp., Los Angeles, 1977.nbsp; 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. 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. 

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. KNGF-richtlijn. Reumatoïde artritis. 2008Maura 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 )

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.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)

Diabetic Foot Ulcers

15-20% of diabetics will develop a foot ulcer in their lifetime and effective monitoring is essential to prevent further issues developing alongsideFrykberg RG et al (1998) Role of neuropathy and high foot pressures in diabetic foot ulceration. Diabetes Care; 21: 10, 1054-1055.. 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

One of the largest reason for ulcers occurring is that diabetic neuropathies (appearing in almost 50% of older people with T2DM) prevent the person from feeling areas of increased pressure. Things are worse in those which suffer from distal sensory polyneuropathy as symptoms are so variable, with some neuropathies being pain free. In this case the end of the toes can become completely numb and therefore a sore is easily created, leading to an ulcer in no time. 

Up to 50% of patients with neuropathy never experience symptoms, so absence of neuropathic symptomatology must never be associated with absence of risk of foot ulceration.

This is where hot/cold, pin prick sensation and vibration testing all come into their own. This is how you assess the loaction and severity of neuropathy and act upon it swiftly, if not the person is at 6x the risk of develping an ulcerAbbott CA, Carrington AL, Ashe H, et al. The North-West Diabetes Foot Care Study: incidence of, and risk factors for, new diabetic foot ulceration in a community-based patient cohort. Diabet Med 2002;19:377–384..

Peripheral autonomic dysfunction also contributes to ulcers through increased peripheral blood flow in the absence of large vessel obstructive vascular disease, together with dry skin because of a lack of sweating. This along with neuropathy creates a warm dry and insensitive foot.

The above mechanism usually leads to an ulcer developing overtime however the insensitive foot is also at high risk of trauma, particularly in those elderly who are still doing their own higher acitvites of daily living such as gardening. 

<img src="/images/c/c3/Footulceration_Flowchart.png" _fck_mw_filename="Footulceration Flowchart.png" _fck_mw_location="center" _fck_mw_width="700" _fck_mw_height="500" _fck_mw_type="frame" alt="Taken from Boulton, A. Pressure and the diabetic fot: clinical science and offloading techniques. The A J Surg. 2004:187;17s-24s." class="fck_mw_frame fck_mw_center" />

Biomechanics also plays a part in the development of ulcers, particularly in those with high plantar pressuresVeves A, Murray HJ, Young MJ, Boulton AJ. The risk of foot ulceration in diabetic patients with high foot pressure: a prospective study. Diabetologia 1992;35:660–663. This high pressure leads to a mechanical recurrent stress which the patient is unable to feel. Eventually the skin becaomes sore, breaks down and becomes ulcerated. This is particularly an issue for those mobile elderly who have an altered gait pattern due to something such as osteoarthritis, and this is where awareness of their frailty comes into play. It is particularly important to consider such issues as the damage caused by repetitive application of high pressures over a bony prominence beging deep and is not visible. 

Skin

As you age skin becomes thinner, loses fat, takes longer to heal and is more prone to damage. 

Obesity

15% of men and 28% of women over 60 are obese and this has a significant effect on the biomechanics of the feet. Obese elderly tend to have a higher incidence of foot pain because of structural changes and this also has implications for day to day life, mobility and general well-being. They tend to have larger foot dimensions, thicher plantar fat pads under the heels, a lower hallux and overall foot strength. These contribute to generating a higher overall force, a greater plantar contact time with a greater contact area therefore greater pressure-time. Therefore providing interventions to combat their obesity ensures a reduction in foot pain, an increase in independence and better overall quality of lifeSteele, J. Mickle, K. Munro, B. 2009. Fat flat frail feet: how does obesity affect the older foot. XXII Congress of the International Society of Biomechanics..

Management

It is important that with older people you remember to think about the person as a whole and in terms of their <a href="Frailty: Theoretical Frameworks">frailty</a> and <a href="Falls">falls risk</a>.

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.

  • 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 

When considering the prevention or management of ulcers in older people it is essential that you consider the implications of their other issues.

As with all aspects of managing the foot prevention is the patients best friend. During assessment it is essential that the therapist is aware of areas of high pressure as to then offload it through different approachesBoulton, A. Pressure and the diabetic foot: clinical science and offloading techniques. The Americal Journal of Surgery. 2004;17s-24s.. One of the oldest techniques (and most effective) is offloading footwear and those wearing appropriate footwear have significantly fewer ulcersUccioli L, Faglia E, Monticone G, et al. Manufactured shoes in the prevention of diabetic foot ulcers. Diabetes Care 1995;18:1376–1378. Don't forget that if the ulcer is severe enough then bed rest, the use of wheel chair or crutches can also be appropriate. A word of caution though, bed rest can lead to rapid deconditioning and immobility in elderly so perhaps casting or therapeutic shoes is more appropriate.

Gout

Aside from the management of hyperuricemia and the pharmocology-side of the treatment physiotherapy is important. Patient education, optimising mobility and lifestyle modification are essential parts of the holistic gout management plan.

It is important that the elderly person with gout remains as active as possible during the attack of symptoms as the rest of their muscular system will atrophy and it may be difficult to get the muscle bulk and function back afterwards. Seated or weightbearing exercise plans are a suitable options alongside provision of mobility aids. For those elderly able to attend outpatient clinics ultrasound therapy may also be an option. As gout is an inflammatory disorder don't forget the efficacy of ice.

It is also that the person avoids alcohol, highly calorific food, sea food in the long term and if applicable to them, optimisie their BMI. This will reduce the risk of ongoing flaresChowalloor PV, Keen HI, Inderjeeth CA. Gout in the elderly. OA Elderly Medicine 2013 Aug 01;1(1):2..

Toenails

Owning individual nail clippers and files prevents corss contamination of infections along with regular washing and maintenance. 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

In the context of brittle nails it is important to consider the predominance of either onychoschizia or onychorrhexis and then correct these underlying issues. General therapeutic management may include nail hydration with daily 15-minute soaks using emollients rich in phospholipidsVan de Kerkhof PC, Pasch MC, Scher RK, Kerscher M, Gieler U, Haneke E, et al. Brittle nail syndrome: a pathogenesis-based approach with a proposed grading system. J Am Acad Dermatol. 2005;53(4):644–51.. pplication of nail hardeners containing formaldehyde can be used to strengthen the nail plate; nevertheless, caution should be entertained when using these products, as they might cause brittleness, subungual hyperkeratosis, or onycholysis (ie, separation of the nail plate from the underlying nail bed). Mechanical nail plate protection and fracture filling can be accomplished using enamel; however, considerable dehydration might occur when it is removed afterward.

Overall it is not always the physiotherapists job to manage the nail conditions however, basic advice is always worth sharing with the patient. The main thing to be aware of is that elderly patients might complain of common nail changes and dystrophies that cause pain, affect daily activities, are of cosmetic concern. Awareness of these conditions is essential for onward referral to optimally manage the issues.

Skin

Keeping feet moisturised is an essential part of caring for aged skin which is prone to drying out.

Bunions

A bunion may only need treatment if it is severe and causing significant pain and alteration to daily life. Non-surgical options incluse pain killers, bunion pads and orthotics all alongside appropriate footwear. It is important to be aware that surgery is the only way to correct a bunion and is not for cosmetic reasons aloneBunion. NHS Choices. [ONLINE] http://www.nhs.uk/Conditions/Bunion/Pages/Treatment.aspx Accessed 29/03/2017.. The surgical options include an osteotomy, which is removal of the problematic part of the bone alongside correction of any soft tissue deformity which has occurred. Arthrodesis is also an option. This is when the metatarsophalangeal joint is fused and is only recommended in severe joint degeneration. 

Bunion Surgery. Dr Richard Moy.
Minimally Invasive Key Hole Bunion Surgery David Gordon.

References