what-when-how
In Depth Tutorials and Information
Author
Note
Patients with RA presenting with deformity, vasculitis, neuropathy and
inappropriate footwear are at high risk of ulceration. Accommodative
foot orthoses should be considered in addition to protective footwear.
In contrast to the evidence supporting reduction of callus as an effective
way of reducing damaging foot pressure in the diabetic foot (
Young
et al 1992
), there is evidence (
Davys et al 2005
) that the pain associated
with callus in the RA foot is more likely to be caused by inflammation
of the plantar bursae and/or boney erosions occurring around the meta-
tarsal heads and proximal phalanges'. This study found that the meta-
tarso-phalangeal joints with overlying callus were more eroded than those
without, suggesting a relationship between local stresses, joint damage,
callus formation and painful symptoms. The authors of the study indicate
that callus debridement should continue as there is no clear evidence over
a longer time period that leaving the callus may not result in increased
symptoms and the risk of ulceration. They strongly recommend provision
of other modalities of treatment. This would include foot orthoses and
footwear therapy as well as considering referral for forefoot surgery.
Author
Note
Callus reduction should be carried out with caution and foot orthoses
should always be supplied to manage the excessive foot pressures
leading to the callus formation.
summary
Alterations in foot structure and gait have significant and often devastating
consequences for people with diabetes and rheumatoid arthritis and
these problems are compounded with increasing age. An understanding
of these foot problems is necessary in order to be able to provide the
correct orthoses and footwear. These interventions are covered in the
following chapters.
Review questions
Reflection
1.
Can I identify the structural changes that occur in feet affected by:
• the complications of diabetes?
• rheumatoid arthritis?
