Feet First
Monday August 17, 2009
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“Approximately 75% of all Americans will develop foot pain during their lifetime,” says Ross E. Taubman, DPM, owner of Columbia Foot and Ankle Associates in Clarksville, Md. But he adds, “Foot pain in the geriatric patient is never normal.”
A typical examination of the painful foot generally includes orthopedic and neuromuscular considerations, as well as tests and screens with regard to neurological, vascular, and integumentary concerns. Taubman, president of the American Podiatric Medical Association, explains that the evaluation “begins with an appropriate and complete history of the patient. This should include the chief complaint with a history of the presenting problem, past medical history, including medications, surgeries, allergies, family and social history, and a review of systems.”
Inclusionary Criteria
Stephen Paulseth, PT, DPT, SCS, ATC, president and owner of Paulseth and Associates Physical Therapy in Century City and Santa Monica, Calif., states that he generally includes “standard orthopedic and neuromuscular evaluation techniques, such as range of motion, manual muscle testing, standing posture, gait, and balance.” He also closely evaluates the feet and their relation to more proximal lower extremity and trunk function.
Paulseth, president of the Foot and Ankle Special Interest Group of the APTA’s Orthopedic Section, emphasizes the need to consider causes of foot pain beyond its anatomical borders. “Many foot conditions can be traced proximally, especially in the geriatric population. One reason is that this population tends not to perform adequate stretching, which can create muscle imbalance and lead to foot pain,” he says. Additionally, Paulseth says he often includes lumbar screening to rule out stenosis as the cause of the foot pain.
Evaluating the orthopedic and neuromuscular aspects of the foot and ankle can be a time-consuming process. However, Roberta Nole, PT, MA, CPed, president of Stride Custom Orthotics in Middlebury, Conn., has developed a novel examination and orthotic treatment system. “The RX24 QuadraStep System is based on 24 unique, adult foot types,” she says. “With this method, I can identify a patient’s foot type in a few minutes and prescribe a treatment plan that may include orthotics, manual therapy, and therapeutic exercise.”
Nole looks at the foot progression angle, tibial-fibular rotation, and arch height, in addition to forefoot and heel alignment. “It is important not to treat all foot types the same way. We have found that correctly identifying a patient’s foot type significantly improves outcomes,” she says.
Socks Off
Evaluating foot pain in older patients presents PTs with an opportunity to identify possible systemic processes. “Because geriatric patients are at greater risk for vascular disease, systemic diseases such as diabetes mellitus, and foot deformities, they should be seeing [their healthcare provider] at the first sign of pain,” Taubman says.
In evaluating the neurological aspect of the foot, Taubman will assess deep tendon reflexes and proprioceptive responses, as well as perform cutaneous sensory tests, including vibration, light touch, pinprick, and a Semmes-Weinstein monofilament examination. He also includes nerve conduction studies as needed.
Taubman explains, “Abnormalities found during a neurologic exam, such as clonus, decreased sensation, or inappropriate reflex response, can indicate peripheral and central nervous system issues such as previous stroke, spinal cord injury, or neuropathy.”
Likewise, when evaluating the vascularity of the foot and ankle, certain systemic dysfunctions can be revealed. “The absence of pulses, swelling, redness, absence of hair growth, and poor skin turgor are the signs that make me concerned about vascular disease,” Taubman says.
Paulseth advocates examining the nail beds and distal pulses for clues about vascularity, including using the capillary refill test. He also checks for callous formation on the plantar aspect of the foot, which may indicate a potential ulceration. He explains, “Ulcerations themselves often signal vascular insufficiency or diabetes, and edema may be indicative of kidney disease, heart disease, or high blood pressure.”
Although PTs can treat a wide spectrum of orthopedic and neuromuscular pathologies in the foot, if a therapist is noticing signs of systemic disease during a geriatric foot evaluation, the patient should be referred to a physician for follow-up. Not only does this approach ensure that the patient receives proper care; it also helps PTs treat the whole patient and not just a single body part.
Jennifer W. Bresnick, PT, DPT, is a medical writer for the Gannett Healthcare Group. To comment, e-mail pteditor@gannetthg.com.
