Peripheral Neuropathy

It is characterized by a gradual loss of protective sensation in the feet, legs and, sometimes, arms and hands. Perception of touch, pressure, temperature, and pain are affected. It’s important because it is the most significant predictor of foot ulceration and other complications in the diabetic population. The lack of painful feedback makes it easy for unnoticed repetitive trauma to occur to the feet. Now, let’s look at the three main types of neuropathy: sensory, motor, and autonomic.

Sensory neuropathy is the loss of sensation, specifically, inability to feel pressure and pain caused by outside forces, as well as altered proprioception: inability to know the position of the feet. Since sensory nerves send messages from the muscles to the spinal cord and the brain, when these nerves cease to function, the message or impulse about sensation does not get sent. The result is extreme sensitivity to touch, numbness, tingling, and pain. Loss of protective sensation can lead to repeated injuries, including burns and abrasions, as well as mechanical stress.

Motor neuropathy often leads to foot deformities which further predispose a diabetic foot to ulceration. Some common deformities include: contracted toes, hammer and claw toes, limited joint mobility, prominent metatarsal heads, as well as weakness and deformity of the small muscles of the foot. It’s the function of the motor nerves to send impulses from the brain and spinal cord to all the muscles in the body. When these nerves are damaged the result is muscles spasms, cramps and weakness, as well as difficulty moving and walking.

Autonomic neuropathy leads to no oil or sweat being produced by the skin due to autonomic system dysfunction. Autonomic system is involuntary. It presides over such bodily functions as blood pressure, heart rate, sweating, and digestion. When the skin can no longer produce sweat or oil it becomes dry, non-elastic, and hot to touch, which can lead to cracking, wound formation, and, possibly, infection.

All clients with diabetes but without neuropathy are considered to be at high risk of developing neuropathy. It is essential for them to examine their feet every day looking for abnormalities, sores, and abrasions, check footwear for foreign objects, avoid going barefoot, check water temperature before getting into shower or bath, wear wide shoes with good insoles and big toe box, and tell their doctor if they have any issues with their feet.

Crossover Toe Deformity

Dislocation of the second toe usually happens slowly, where the toe drifts and, eventually, overlaps the big toe. It often occurs concurrently to a bunion. The cause is a tear in the Plantar Plate, the tough fibrocartilagenous thickening which attaches the toes to the pad that covers the joint at the base of the toes. Its main function is to resist the force of toe off.

This deformity can happen due to chronic inflammation or acute trauma to the second metatarsophalangeal joint (the area of attachment of the bones of the toes to the base of the toes called metatarsal heads). Progressive inflammation in the MTP joint leads to rupture of the plantar plate and collateral ligaments. In fact, any structural of functional deformity that results in inflammation of the plantar plate can result in joint instability.

Localized inflammation and pain of the 2nd MTP joint are early signs of strain of the plantar plate. When weight-bearing the toe may not shift sideways and may not touch the ground, which will cause more pressure on the bottom part of the metatarsal heads leading to bone bruise, callusing, and pain. Eventually, the pressure on the misaligned joint may cause arthritis. The biomechanics and functionality will also be altered.

Swelling around the base of the toe is a common symptom, as well as the distinct change in the position of the toe during the previous weeks or months. An X-ray as well as a physical examination will confirm the diagnosis. Common treatments include pain relief with NSAID medications, orthotics, and accommodative padding, as well as avoidance of high-heeled shoes. Taping is effective if the toe is deviated but not if it is dislocated. However, prolonged taping may cause swelling and/or an ulcer to form.

Corticosteroid injection in the joint is usually not recommended because it may weaken an already compromised plantar plate. Surgical removal of the toe will cause the 3rd toe to drift to the place of the missing toe so it’s not often recommended.

Varicose Veins: Causes and Remedies.

Varicose Veins are veins usually in your lower legs that are blue or purple, twisted, and bulging out. Veins bring blood back to the heart. In order to bring the blood back to the heart the muscles in the vein walls must push against gravity. As the blood is pushed up, valves that close prevent it from coming down again. People with varicose veins have valves that no longer close so the blood does not get pumped back to the heart effectively. It pools and causes distension in the veins of the lower legs, which are most effected by gravity. Pressure around the abdomen, such as during constipation or pregnancy, will also make it difficult for the blood to be pumped to the heart.

For some people who have no other symptoms the concern is that they look awful. But others can experience pain that gets worse after sitting or standing, swelling in the lower legs, muscle cramps, burning or throbbing, heavy feeling in the legs, itchiness, dry skin, and skin discoloration.

Varicose veins can be caused by heredity, female gender, age 50 or older, being overweight (high body-mass index), pregnancy, and standing for long periods of time. Weight lifting can make varicose veins worse.

Whether varicose veins are a cosmetic concern or a serious discomfort, there are some things you can do about them. The same things that prevent varicose veins also help treat them. They are: weight reduction, a diet high in fiber and low in salt, exercise, compression stockings, reducing constipation, elevation of the legs, avoidance of crossing the legs, avoidance of high heels and tight hosiery, and changing the standing and sitting position often. Also, there are procedures where a doctor can remove and close veins.

Flat Feet

Flat feet or Pes Planus is when the arches of your feet become flat as soon as you stand up from a sitting position. Having flat feet is very common. In fact, up to 22% of Canadians have flat feet. One in ten of these people will have foot pain or soreness. This condition is usually hereditary but can also be caused by pregnancy, aging, arthritis, obesity, injury, or another disease, such as muscular dystrophy, cerebral palsy, or spina bifida.

     Since all of your weight-bearing joints are connected, that means your back, hips, knees, ankles, and feet, a deformity of the feet affects all the rest of these joints. Pain and imbalance in your feet will lead to pain in other joints as well as gait and postural changes. Working to correct flat feet will bring your body into alignment and help correct other problems caused by having flat feet.

     It is normal for infants to have flat feet. Children 2-3 years old usually develop non-flattening arches as the tendons and ligaments in the feet tighten. Common categories of flat feet are: posterior tibial tendon dysfunction, tight Achilles tendon, and flexible flat foot.

     Flexible Flat Foot is the least problematic and most common of the three. It begins in childhood and is characterized by an arch present only when feet are lifted above the ground, when on the ground the arch falls flat. A tendon connects muscle to a bone. Achilles tendon connects gastrocnemeus (your calf muscle) to calcaneus (your heel bone) directly behind your heel. Having flat feet leads to tightness in this tendon, which in turn leads to soreness and pain when walking and running. To compensate and prevent further pain, the heel can lift prematurely when weight bearing.

     Posterior tibial tendon connects tibialis posterior muscle in the back of your leg and navicular (a bone in the arch of the foot). It supports the arch of the foot and helps to turn the foot in. Posterior Tibial Tendon Dysfunction can occur once there is an injury, tear, or swelling in the posterior tibial tendon. It is characterized by pain on the inside of the foot and ankle and on the outside of the ankle. This can happen in one or both feet. Diagnosis is made through obtaining family history, foot examination, and MRI.

     Common symptoms associated with flat feet are aching when walking or standing for a long time, pain in the ankles and lower legs, callouses, numbness, and stiffness. If you don’t experience any discomfort but you have flat feet, treatment may not be necessary. If you’re experiencing any of the above symptoms, see a pedorthist, chiropodist, or podiatrist. You will need orthoses, proper footwear, and footwear modifications. Non-steroidal anti-inflammatory medications for pain and inflammation and/or physiotherapy may be prescribed by a foot care professional. In extreme cases surgery may be indicated.

Hallux Valgus (Bunion)

Hallux Valgus also called a Bunion, is a deformity of the first metatarsophalangeal joint (the joint at the base of the big toe). “Hallux” is the big toe and “valgus” means the deformity of the big toe. It is more common in women. Family history of hallux valgus is the main cause of this deformity, more so than ill-fitting shoes. In feet with bunions, there is an imbalance between the following muscles of the feet: flexor halluces brevis, and adductor and abductor halluces muscles. The severity of the bunion is determined by the degree of the following angles: the hallux valgus angle (HVA) and intermetatarsal angle (IMA). As the metatarsophalangeal joint is compressed and widened during repeated impact when walking, additional bone is added to the first metatarsal head at the site of the bunion. This joint also becomes dorsiflexed and inverted, hence it’s shape.

     Many people with bunions will only experience pain at the site of the bunion when wearing tight narrow shoes with a small toe box. Some will complain of redness, tenderness, swelling, and pain with plantar flexion. If the bunion is severe, the second toe may become “hammered”: the two joints of the second toe become permanently flexed. The second toe may overlap the big toe.

     Proper fitting foot orthotics with a rocker sole, no seams over the bunion, and a deep vamp are the best treatment option. A pedorthist, podiatrist, or chiropodist may place a metatarsal pad under the top cover of the orthotic just underneath metatarsal heads (the joints at the base of the toes) will help unload the pressure off the forefoot. Surgery may be considered if pain in the bunion is extreme or for aesthetic reasons. It is not covered by OHIP and tends to be expensive. Complications of a surgical procedure include long-term pain in metatarsal heads, recurrence of bunions, and necrosis of the first metatarsal.

Who Is a Foot Care Nurse and What Does a Foot Care Nurse Do?

A foot care nurse can be a Registered Nurse or a Registered Practical Nurse. She will assess the skin condition, hair distribution, and structure of your feet as well as your pulses and feeling with a monofilament to test the dermatomes. This confirms presence of adequate or inadequate circulation. The monofilament is used to check for neuropathy, a lack of feeling in the feet that could be an advanced sign of Diabetes. The nurse will also check what medications you are on and for what health conditions. History of surgery or injury to the feet, ankles, hips, and back is especially important because foot care must be tailored to support the feet as they are with all their health history. Of course, nails are cut, callouses are reduced, and corns are removed. However, a foot care nurse is not just there for the one-time visit, but someone who oversees the state of your feet and provides ongoing care, health teaching, and recommendations about self-care. If nail fungus or Athlete’s foot is present, the foot care nurse will let you know and explain which over-the-counter or home remedies can be used as long as it does not interact with what is prescribed by your healthcare practitioner. In summary, a foot care nurse knows what your feet have been through and how to optimize their health.

Haglund’s Deformity (also called Bauer bump or pump bump)

This type of deformity looks like an enlargement of the bone (the bone is called calcaneus) just above and behind the heel. There is no swelling at the site, only pain and/or soreness. If a person wears shoes with a tight heel counter (the part of the shoe around the heel), then they aggravate it so wearing sandals is more comfortable.

Haglund’s deformity is caused by an inflexible heel counter that is often present in ice skates and high-heeled shoes. This is when the bony prominence (exostosis) begins to develop; soreness develops only later.

This type of deformity can lead to retrocalcaneal bursitis (inflammation of the bursa behind the calcaneus). Furthermore, the prominence itself leads to more bursitis by irritating it. In fact, Haglund’s deformity is often misdiagnosed as retrocalcaneal bursitis. While both conditions have the symptoms of irritation, redness, and enlargement at or near the base of Achilles tendon, Haglund’s deformity is painful only when pressed and has redness and swelling that does not spread further than the prominence itself.

X-ray images help to diagnose Haglund’s deformity and MRI can show its outline.

To help with the pain upon pressure and reduce the strain on Achilles tendon, one can wear shoes without heels or with stretched, cushioned or softer heel counters. Also, the heels of the shoes can be modified with a 6 mm heel-raise, which can be done by a certified pedorthist.

The common treatment is PRICEMM: Protection, relative Rest, Ice, Compression, Elevation, Medication, and rehabilitation exercise Modalities. It’s also useful to complete an eccentric strengthening program and perform soleus and gastrocnemius stretching. If this treatment has not helped, after 6 months surgery may be recommended.

Ankle Ligament Sprains

Ankle ligaments hold the joint and bones together in a joint called a talocrural joint. The bones that are held together here are lower tibia and fibula of the lower legs, as well as talus, a small bone that fits between them. This joint is like a hinge: it moves allowing the toes to lift off the ground (dorsiflexion) and swings down to plant the foot firmly on the ground (plantarflexion). The list of ligaments of the foot that are commonly injured can be found in the previous blog entry. If the foot is rotated outward during a sprain, it’s called an eversion sprain. It comprises 5-10% of all ankle sprains and takes much longer to heal than an inversion sprain. An inversion sprain is much more common.

 Ankle sprains are classified into Grades 1, 2, & 3, depending on their severity. Grade 1 is a mild sprain. There is some pain and very little swelling because the ligament has been stretched but there is no deformity; return to normal function can be expected in 2 weeks. Grade 2 is when the ligament is partially torn. Some bleeding and bruising can occur and is often lower than the injury site due to gravity. Here rehabilitation is necessary and the person can return to normal activities within 2-6 weeks. Grade 3 sprain is a complete tear of a ligament. Pain is severe at first but then subsides quicker than a Grade 2 sprain. Surgery could be necessary and return to activity can take as long as 6 weeks or more.

Common testing includes Ottawa ankles rules: if pain is present near the malleoli (the two bones protruding on the inside and outside of the ankle) and the person cannot walk for 4 steps after injury, an X-ray should be ordered. Treatment includes avoiding HARM (heat, alcoholic beverages, running, and massage). Ultrasound can be indicated to reduce swelling only if the person is 18 years old or older. Casting a sprained ankle is not recommended. Use the acronym PRICE (protection, rest, ice, compression, and elevation).

There are many different types of ankle braces that can provide protection. An ankle can be taped to provide support short-term. If there is a severe sprain, a short-leg cast or a walking boot can be used to partially immobilize the leg but not completely. Elevate the ankle and apply ice-packs wrapped in a wet towel for 15-20 minutes every 2 hours for the first 2-3 days. Compressive wrap should be applied correctly to ensure adequate blood flow to the toes. Once the swelling begins to subside, your MD will refer you to a physiotherapist whose advice the client should follow as precisely as possible. Gradually begin to move the ankle 48 hours after the sprain as part of rehabilitation. Make sure footwear is roomy enough to accommodate swelling and it gives enough ankle support through a wide stable base. The soles of the shoes should not be worn down especially at the heel causing ankle instability.

Chronic Ankle Instability (CAI)

Clients describe CAI as a feeling of “giving way” and instability resulting in swelling, prolonged pain, increased or (if ankle sprain has previously occurred) limited range of motion. CAI often leads to ankle injuries and, most commonly, ankle sprains. The three most common ankle sprains are: inversion sprains (the sole of the foot is rotated inward to face the other foot), eversion sprains (the rotation is outward and usually affects deltoid ligaments), and high ankle sprains (harm to the syndesmotic ligaments). 75% of all ankle injuries are sprains and 85% of all ankle sprains are inversion sprains, which tend to recur. People most affected by CAI are usually physically active. Those that tend to have lax ankle ligaments (mechanical issue) and have an active lifestyle (functional issue) tend to suffer from CAI the most. Those with a cavus foot (high arch of the sole of the foot) are also more likely to have CAI, particularly, lateral ankle instability. If the joint is stable, intact and ligaments are strong, injury is less likely to occur.

Anterior talofibular ligament is the most commonly injured and also the weakest ankle ligament. ATFL inversion sprain can occur when a foot is inverted and plantarflexed (the position of the foot when toes are pointed out) while the leg is externally rotated (leg is turned to point to the side). The next most common sprain is a tear in the calcaneofibular ligament (CFL) often followed by a tear of the AFTL. A sprain of the posterior talofibular ligament (PTFL) of the outer side of the ankle is least common of the three because it’s the third weakest ligament. The medial (inner or facing the midline) ligaments are: tibiocalaneal, tibionavicular, superficial tibiotalar, and posterior tibiotalar ligaments and are least likely to be sprained.

As part of the assessment, the physician would often order stress radiographs and X-rays. To estimate loss or return of functional ankle control and predict future ankle injury postural control is used. Postural control is one’s ability to keep centre of mass centred over one single foot. Most commonly, to improve postural control taping, bracing, and orthotics are used. In extreme cases, the physician may recommend reconstructive surgery of the ankle.

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