PodiatristsHow can we help?

Sue McAuslandPodiatrist

Blackpool Teaching Hospital NS Foundation Trust

The NorthWest Clinical Effectiveness Guidelines for rheumatoid Arthritis

Their objective: Improve foot and ankle assessment and management

• doing the right thing,• to the right patient, • in the right way, • at the right time

Rheumatoid Arthritis (RA)The Statistics:

• Approx half a million sufferers of RA• It affects ability to work and social life• It costs money both for sufferer and NHS• The foot is often the first area of the body to be

systematically afflicted by RA • 75% of people diagnosed suffer foot related

problems within 4 years of diagnosis and within 10 years virtually 100% have foot complaints

How can RA affect the feet?

• hallux valgus,• valgus heel deformity• lesser toe deformities causing hard skin (callus)

formation. In some this leads to foot ulceration particularly people with poor tissue viability.

• bacterial and fungal skin infections • nail pathologies that increase risk of ulceration and

systemic infection.

What are we trying to do?

• relieve pain, • maintain function• improve quality of life

using safe/ cost-effective treatments, such as:• palliative foot care, • prescribed foot orthoses• specialist footwear

How podiatrists help

• They range from simple foot care advice, palliative care for nails and skin and orthotic / specialist footwear provision through to management of ulceration and infection

Guidelines. What do they say?• Prompt, aggressive intervention• ARMA recommends to be seen by specialist within 12 weeks

to confirm diagnosis and to give access to MDTs including foot health assessment

• Access to team of podiatrists who provide baseline vascular and sensory assessment eg dopplers and monofilament.

• Annual review• Biomechanical assessment

• ARMA (ARrthritis and Musculoskeletal Alliance)

Essential requirements• Clinical assessment including:• Full medical history• Full assessment of lower limb function, • Pain assessment• Vascular assessment• Tissue assessment eg nails skin• Pressure relief/footwear• Onward referral to specialist surgery• Annual review• NICE (2009)- all people with RA should have access to a podiatrist• SIGN (2000) -Early referral to podiatrist is important part of early

management

Plantar callus

• Should we remove it?Argument for and againstIf callus removed – done frequentlyIf infected can debride to expose ulcerProvide orthoses (pressure relieving and functional)Avoid use of plantar adhesive padding where tissue viability is problemFootwear advice

Fungal infections

• Increased risk with immuno-suppressed• Increased risk of subungual ulceration if left

untreated• Treatment:• Nail clippings

Ingrowing toenails

• Mild condition• Conservative + antibiotics

• Severe condition• Partial or total nail removal

• If on biologics should consult specialist rheumatologist

orthoses

• Early interventionReduce pain and prevent deformity

• Advanced problemsMay prevent tissue breakdown and ulcers

TYPES OF INSOLES• Simple cushioning• insoles with padding• Contoured padding (custom or off-shelf)

Footwear

Where do we start!ill fitting footwear

What makes a good shoe

• Stable heel• Extended heel counter• Padded topline• No prominent internal seams• Increase toe spring or rocker sole • Low laced – for ease of access

• www.Britfoot.com

rockers

Can’t find a suitable shoe on high street?

• Refer to surgical appliances• Stock or bespoke shoes• Beware there are cosmetic downsides

• Refer for surgery as alternative

Now it’s time for some practical work

Optional!!

• Thank you for listening.

• I hope you found this useful.