Foot and Nail Care: A&P of Foot, Common Pathologic Conditions Affecting Feet and Nails
Skin and Wound Care. Produced by the Emory Nursing Wound Ostomy Continence Nursing Education Center.
Transcript
In the last few classes, we've been talking about a number of pathologic conditions that place the lower extremity at risk and also create problems with foot and nail care.
Speaker A:And that's what we're going to focus on in this class.
Speaker A:So, you know, when you take care of patients with diabetes, when you take care of patients with lower extremity arterial disease, one of the things you constantly emphasize to them is the importance of preventive foot and nail care.
Speaker A:We tell them not to do any kind of bathroom surgery.
Speaker A:We tell them to have their feet professionally cared for and their nails professionally cared for.
Speaker A:Now, many wound care nurses actually incorporate foot and nail care as part of their practice.
Speaker A:Some of them do this on the side, kind of as an independent practice.
Speaker A:That's what we're going to be addressing in this section.
Speaker A:So our objectives are to describe the anatomy and physiology of the nail bed and implications for management of nail pathology.
Speaker A:We'll describe common pathologic conditions that affect the foot and nail to include clinical presentation and guidelines for management.
Speaker A:We'll identify guidelines for appropriate foot and nail care for the individual with a compromised limb due either to vascular insufficiency or neuropathy.
Speaker A:And we'll describe or demonstrate correct technique for each of the identification of the free nail border and clipping of the nails, thinning of thickened nails with an electric grinder, paring of corns and calluses, and lifting and packing of ingrown nails.
Speaker A:So in this class we'll discuss the theory, but when you come to bridge week, we'll actually practice pairing.
Speaker A:And if you go to foot and nail clinic, you'll also practice identification of the free nail border, nail clipping and nail thinning.
Speaker A:There will be four videos associated with this class because it's a very long class, so we're breaking it up for you.
Speaker A:There are learning exercises, and again, there's an excellent and very thorough chapter in the core curriculum.
Speaker A:Curriculum.
Speaker A:If you decide to pursue foot and nail certification, you will definitely want to study chapter 25 in the core curriculum.
Speaker A:So these are the things we're going to cover in the first section.
Speaker A:In part one, we're going to review amp of the foot.
Speaker A:We're going to start on common pathologic conditions that affect the feet and the nails.
Speaker A:So first of all, a lot of us fail to really appreciate how important our feet are.
Speaker A:Some people hate feet.
Speaker A:They do not want to do foot care, which is fine.
Speaker A:As we age, our feet frequently become gnarly, so they're not very pretty.
Speaker A:But even if they're ugly, they're still pretty impressive because you think what they do for you every day, every step you take, is dependent on your feet.
Speaker A:Your ambulatory stability is dependent on your feet.
Speaker A:If you're a runner, it depends on your feet.
Speaker A:So those 2ft can sustain enormous pressure.
Speaker A:I can't remember what the exact force is when you're running, but it's very, very significant.
Speaker A:And the way your feet manage that amount of mechanical force is the 26 bones.
Speaker A:So there's all these little bones in the foot, because there's 26 small bones that gives your foot a lot of flexibility.
Speaker A:Those bones are locked in place with connective tissue that provides support as well as flexibility.
Speaker A:And so the end result is, no matter whether you think your feet are pretty or not, they provide you with support, balance and mobility.
Speaker A:Now, let's look at the key structures and the implications for us in providing foot and nail care.
Speaker A:First of all, as you've heard me say several times, you have 26 bones in each foot.
Speaker A:So no matter where you have a wound, it's not very far from a bone.
Speaker A:And osteomyelitis is a very common complication of foot wounds.
Speaker A:That's the last bullet point on this slide.
Speaker A:Now, it's helpful to know how bones are named in the foot, especially if you do take the certification exam.
Speaker A:You will definitely need to know this terminology.
Speaker A:So, the forefoot, you have phalanges and metatarsals.
Speaker A:The phalanges are your toe bones and the metatarsals are your foot bones.
Speaker A:Many times you'll have a patient who has necrosis or gangrene of the toes, and they'll do toe amputations.
Speaker A:Sometimes they'll do a ray amputation, which, as you see, involves the phalange and it's associated metatarsal.
Speaker A:So they take the toe and they come down and take the foot bone to which it connects.
Speaker A:Sometimes you'll have a patient who has a TMA transmetatarsal amputation.
Speaker A:That means they've taken the toes and the bones of the distal foot.
Speaker A:So you should know the term phalanges, you should know the term metatarsals, you should know what a transmetatarsal amputation involves, and you should know what array amputation involves.
Speaker A:Of course, you have joints between all of these bones.
Speaker A:So you have Pip and dip joints.
Speaker A:The Pip joints are your proximal interphalangeal joints, and the dip joints are the distal interphalangeal joints in the midfoot.
Speaker A:They don't always ask you about these bones, but they can be very important, especially in patients who have charcoal deformity.
Speaker A:The bones in the midfoot are the cuneiforms, the navicular, and the cuboid.
Speaker A:I'm sorry, those are the three major bones in the midfoot.
Speaker A:In the hind foot, you have the talus and the calcaneus.
Speaker A:And, you know, the calcaneus is that heel bone which you've seen in previous slides, and you see on this slide as well.
Speaker A:The calcaneus is a large bone with very little sub q covering.
Speaker A:And so that's the bone that's frequently involved or that helps to cause heel pressure injuries.
Speaker A:You've got all these little bones, you've got all these joints between bones, and then you've got multiple tendons and ligaments.
Speaker A:So ligaments attach bone to bone, tendons attach muscles, a bone.
Speaker A:So lots of bones, lots of tendons, lots of ligaments.
Speaker A:Now, one thing that happens with aging is that your feet tend to become stiff.
Speaker A:People complain that they don't have the same flexibility, they don't have the same range of motion, that their feet feel stiff and are painful when they're walking.
Speaker A:Some people say they don't feel like they have the same degree of balance.
Speaker A:And so you see more and more people using canes or using walkers, using beer, ambulatory aids to add stability.
Speaker A:The other thing you might notice in yourself, in your friends and family members, and in your patients is that many times the feet become wider and longer because there's relaxation of the ligaments.
Speaker A:So the foot kind of stretches out.
Speaker A:So you might not wear the same shoe size that you did when you were younger.
Speaker A:Now, let's talk about muscles and nerves.
Speaker A:Obviously, both muscles and nerves, critically important to normal foot function, to your balance, to your stability, to normal gait.
Speaker A:You have four layers of muscles over the bottom of the foot.
Speaker A:And as we've said, absolutely critical to normal function also tells you that no matter where you are with a wound, you're not very far from a muscle.
Speaker A:You're not far from a muscle, you're not far from bone.
Speaker A:You have to be extremely careful if you're doing any debridement on a foot wound.
Speaker A:And what about nerves?
Speaker A:Well, we know that muscles don't work without nerves.
Speaker A:We've talked a lot about the negative impact of neuropathy.
Speaker A:We've talked about the difference between sensory neuropathy and motor neuropathy and the impact of combined sensory and motor neuropathy.
Speaker A:So the end result is, is loss of protective sensation and increased risk of painless, and therefore unrecognized trauma and altered gait foot deformities that increase their risk of foot ulceration, either on the toes or on the plantar surface of the foot blood vessels.
Speaker A:We've also discussed these, so all of this should be a quick review for you of the things that we talked about when we talked about lower extremity arterial disease, lower extremity venous disease, and lower extremity neuropathic disease.
Speaker A:So you remember that the major artery is the tibial artery, and that's what supplies the foot.
Speaker A:And you have two branches of that.
Speaker A:You have the dorsalis pedis, which runs along the dorsal surface of the foot, which you palpate, typically right over the forefoot, all over the arch, and then you have the posterior tibialis that runs just behind the medial malleolus.
Speaker A:You know the indicators of arterial insufficiency, and we'll come back to this when we talk about assessing the patient before you provide foot and nail care.
Speaker A:So you're going to look for thin skin, hair loss.
Speaker A:You're going to look for dependent rubr, you're going to palpate for pulses.
Speaker A:You're going to be very alert to diminished pulses.
Speaker A:You're going to look for prolonged capillary refill.
Speaker A:If you're in a setting where you can do an ABI and assess for venous filling time, you will.
Speaker A:Sometimes in foot clinics, your client is sitting and you cannot do an ABi, and you cannot assess for venous filling time.
Speaker A:But even if you cannot do an ABi and even if you can't assess for venous filling time, you can still look at the skin, you can observe patterns of hair growth, you can check pulses, you can check capillary refill, and you can observe for dependent.
Speaker A:Rupert, you know the impact of arterial insufficiency.
Speaker A:You know that they're high risk for spontaneous ulceration, that if they develop a wound, that they're going to have delayed healing and they have increased risk of amputation.
Speaker A:If you cannot get that wound to heal, the, that means that when you do the vascular assessment on a patient for whom you're going to provide nail care, if you find evidence of arterial insufficiency, you're going to be very conservative in pairing the callus and in trimming nails, because you do not want to risk injury that could turn into a non healing wound.
Speaker A:What about veins?
Speaker A:Again, a quick review.
Speaker A:You know, you've got your superficial, deep and perforated veins.
Speaker A:The superficial veins are the same saphenous veins in light blue.
Speaker A:The deep veins are the perineal and tibial veins, and then the perforator veins connect the two systems, superficial and deep.
Speaker A:So superficial veins pick up blood from the tissues, shunt it through the perforator veins into the deep veins.
Speaker A:Calf muscle pump milks the deep veins and propels blood back to the heart.
Speaker A:We talked a lot in the class on venous insufficiency, about the importance of normal valvular function.
Speaker A:We talked about what happens if the valves get disrupted, damaged, or pulled apart.
Speaker A:Once the valves fail to function normally, you get reflux of blood from the deep system into the superficial system, the saphenous veins, and you get transfer of the high pressures in the deep system into the superficial system.
Speaker A:So you get venous hypertension and venous insufficiency.
Speaker A:We also talked about the importance of normal muscle function because it's that calf muscle pump that routinely melts the deep veins and propels the blood back to the heart that assures effective emptying of the venous system and that maintains low venous pressures when you're walking.
Speaker A:But if you have a patient who is sedentary, if you have a patient who's paralyzed, if there's some reason that the calf muscle is not working, if you have altered gait so that you're shuffling along instead of engaging that heel strike toe off, that causes calf muscle contraction, all of those things are negatively going to impact on venous return.
Speaker A:When you're doing your screening assessment for a patient, when you're preparing to do foot nail care, you want to be alert to indicators of venous insufficiency, just as you're alert to indicators of arterial insufficiency.
Speaker A:As you know, primary indicator is venous insufficiency.
Speaker A:Edema, usually pitting edema, that hemosiderosis, that gray brown black staining in the sock area of the leg that occurs when red blood cells leak out of the capillary bed into the tissues, break down and leave their pigment.
Speaker A:You might see varicosities.
Speaker A:Occasionally, you might see that venous dermatitis.
Speaker A:What's the impact of venous insufficiency again?
Speaker A:Because of changes in the tissue, inflammatory changes in the tissue?
Speaker A:If you have venous insufficiency, you're high risk for ulceration with very minor trauma.
Speaker A:Maybe you scratch and you get a wound, you get an insect bite, you get a wound, you bump your leg, you get a wound and delayed healing.
Speaker A:We also talked about the lymphatic system and about lymphedema.
Speaker A:So we know that the lymphatic system that third member of the circulatory system is responsible for transporting protein rich fluid back into the venous system.
Speaker A:You know that lymphedema occurs when lymphatic function is compromised.
Speaker A:In our country, compromise of the lymphatic system most commonly occurs in patients with malignancies when we do radical resections that involve lymph node dissection, removal of whole sections of the lymphatic system.
Speaker A:But we can also see lymphedema in patients who have longstanding venous insufficiency because long standing venous insufficiency causes fibrotic changes in the soft tissue that essentially shut down the lymphatic channels.
Speaker A:So you might start out with venous insufficiency.
Speaker A:If it's poorly managed, you might end up with a patient who has both venous insufficiency and lymphedema.
Speaker A:Lymphedema a very serious problem.
Speaker A:If you're doing foot and nail care for a patient with lymphedema, you want to try to get them into a lymphedema treatment center because severe lymphedema results not only in non pitting edema, it also results in multiple skin and soft tissue changes.
Speaker A:So you get breakdown of the elastic components of the skin.
Speaker A:You get that cobblestoning effect.
Speaker A:You start to trap moisture and bacteria and the skin and the little folds in the skin, very high risk for infections.
Speaker A:So you want to be very careful when you're providing foot and nail care to a patient with lymphedema, and you want to try to get them into a lymphedema treatment center.
Speaker A:Your major focus will be on managing the nails, on counseling the patient about hygienic care of the skin and keeping the skin supple by using moisturizers on a routine basis, educating them about the significance of lymphedema, and again, referring them.
Speaker A:Okay, so let's talk about the skin itself and the appendages.
Speaker A:Again, this will be a quick review of things we've already covered.
Speaker A:So you think about the plantar surface of the foot.
Speaker A:The bones are protected in part by fat pads.
Speaker A:So if you take off your shoes and socks and palpate the bottom of your feet, pay particular attention to the metatarsal heads, and you'll find that you have fat pads over the metatarsal heads.
Speaker A:The biggest fat pad is over the first metatarsal head, next biggest, third smallest, over the fifth.
Speaker A:Now, what does that pad do?
Speaker A:Those fat pads are really important because when you're walking or running.
Speaker A:Remember, you do heel strike, you roll up over the metatarsal head and you toe off.
Speaker A:So you get a lot of shear and friction over the metatarsal heads.
Speaker A:As long as those fat pads are intact, they help to distribute the weight, distribute the friction, distribute the shear, and protect you from ulceration.
Speaker A:But with aging, those fat pads start to thin, and then you get increased risk for trauma, especially over the heels and the metatarsal heads of so many.
Speaker A:Many of your elderly patients will need customized insoles.
Speaker A:Some of them can use pharmacy level insoles.
Speaker A:If they don't have any significant pathology, they don't have abnormal gait.
Speaker A:They just have thinned out fat pads.
Speaker A:Yes, they can buy their insoles over the counter, but if you have a diabetic patient who has neuropathy and has altered gait and thinned out fat pads and callus formation, they need to be referred to an orthotist or a podorthus so that they can get customized insoles that work optimally for their feet.
Speaker A:And, you know, whenever you see Callus, what does it tell you?
Speaker A:It tells you there's abnormal repetitive trauma being exerted in that area.
Speaker A:So critical to counsel that patient about their footwear to provide appropriate referrals.
Speaker A:We've talked a lot about keeping the skin healthy.
Speaker A:This is one of the things you'll talk to your clients about when you're providing foot and nail care.
Speaker A:It's amazing to me how little care people sometimes provide their feet.
Speaker A:They come into the hospital and you're like, what has happened here?
Speaker A:This looks like an alligator crawled into the bed.
Speaker A:And I don't think that we allow alligators in the front door of this hospital.
Speaker A:So when's the last time you washed your feet?
Speaker A:When's the last time you moisturized?
Speaker A:That's what I'm thinking.
Speaker A:Hopefully I don't say it just like that.
Speaker A:What are the things we want to teach our patients?
Speaker A:Teach our clients they should be washing their feet routinely.
Speaker A:They should be drying well between the toes to prevent fissure formation and to prevent fungal infections between the toes.
Speaker A:They should be routinely using emollients and humectants to keep the skin soft.
Speaker A:If they're diabetic and they have autonomic neuropathy, they're going to have very dry skin.
Speaker A:So it's not going to be enough to use an over the counter lotion unless it's specifically designed for diabetic foot care.
Speaker A:There are some products on the market that are specifically designed for that.
Speaker A:Otherwise, you're going to counsel them to use things like petrolatum, they might get a prescription for lack hydrin.
Speaker A:You might suggest attractane, which is an over the counter humectant.
Speaker A:But you want to have them focus on keeping their skin clean and soft.
Speaker A:You should teach them to use a pumice or an emery board to manage callus so you can tell them every time.
Speaker A:When you get out of the shower, dry your feet.
Speaker A:Take your emery board or your pumice, rub it over that area.
Speaker A:Don't go back and forth.
Speaker A:Buff only in one direction, five to ten times to keep that calluse reduced.
Speaker A:We've talked before about managing very dry, scaly feet cirrhosis.
Speaker A:We talked about using a vinegar water soak, one part white vinegar, three parts water soak for ten to 15 minutes.
Speaker A:Make sure the temperature is appropriate.
Speaker A:Make sure you dry well between the toes, and then follow with your emollients or humectants.
Speaker A:Okay, now let's focus specifically on the nails, the structure of the nails, because you need to understand this if you're going to provide nail care.
Speaker A:So you've got the nail plate itself.
Speaker A:That's what we call the toenail.
Speaker A:Okay.
Speaker A:The official term is the nail plate.
Speaker A:The nail bed is the layer of skin to which the nail plate adheres.
Speaker A:And you normally have very tight adherence between the nail plate and the nail bed.
Speaker A:The nail matrix is the reproductive area of the nail, and it's actually the area where you have that little white crescent moon shape right at the base of the nail.
Speaker A:We'll come back to that.
Speaker A:The hyponychium is what we commonly call the quick.
Speaker A:It's the junction between the attached nail and the free nail border.
Speaker A:The nail folds and the nail grooves are the flaps of skin, or folds of skin right adjacent to the nail.
Speaker A:So the folds of skin are called nail folds.
Speaker A:And then obviously the base is the groove, and the free border is the portion of the nail that can be trimmed.
Speaker A:It's the nail that extends past the skin and is literally free.
Speaker A:So let's talk about each of those structures just a little bit more.
Speaker A:So the nail plate, the toenail itself, there's actually three layers to the nail plate, and they overlap.
Speaker A:The outer layer is relatively thin.
Speaker A:That's the dorsal layer.
Speaker A:You have a thick middle layer.
Speaker A:And then the inner layer is continuous with and derived from the nail bed.
Speaker A:Remember, the nail bed is the layer of skin to which the nail attaches.
Speaker A:So that base layer is actually comes from the nail bed and is continuous.
Speaker A:It literally feeds into the nail bed.
Speaker A:The nail plate is composed of amino acids.
Speaker A:So protein.
Speaker A:If you've ever taken gelatin to try to grow stronger nails, you understand the importance of protein in normal nail production.
Speaker A:So amino acids, inorganic elements and water.
Speaker A:And normally the nail is about ten to 30% water.
Speaker A:If the nail is over hydrated, it becomes very, very soft.
Speaker A:If it's under hydrated, it becomes very brittle.
Speaker A:So you want that normal concentration of water in the healthy nail.
Speaker A:What do nails do?
Speaker A:What do toenails do?
Speaker A:Okay.
Speaker A:Other than serve as a decorative point, if you get pedicures, what else do they do?
Speaker A:They provide protection for the underlying nail bed and for the toe.
Speaker A:So we've said that the nail bed is the support surface.
Speaker A:So that's the layer of skin to which the nail itself attaches.
Speaker A:It's a very tight interlocking configuration.
Speaker A:You know how tightly adherent the nail normally is to the nail bed.
Speaker A:You know how painful it is if the nail gets ripped off the nail bed traumatically, there's a reason that that's one of the things they do when they torture people.
Speaker A:They pull off nails because it's very painful.
Speaker A:That nail is tightly attached and that gives stability.
Speaker A:Now, the nail matrix is the reproductive area of the nail.
Speaker A:And I tried to show you here on this slide the area that's involved in reproduction of the nail and production of new nail cells.
Speaker A:So it extends from about 8 mm proximal to the cuticle.
Speaker A:Okay, so you've got your cuticle here, and then you think proximal is back toward the hand.
Speaker A:So about 8 mm proximal to the cuticle.
Speaker A:And then it covers the area, the lunula, that little crescent shaped area that you can see at the base of the nail, that's the reproductive area.
Speaker A:Now, that's important because, number one, it controls normal nail production.
Speaker A:But also if you have something like a fungal nail infection and you're trying to eradicate the fungal infection, primarily you focus on the nail matrix, which is right around the cuticle.
Speaker A:That's where the reproducing cells are.
Speaker A:So usually you're trying to kill the fungus in the reproducing area of the nail, hoping that the new nail will grow out fungus free, very hard to kill fungus in the existing nail.
Speaker A:So you focus on the developing nail.
Speaker A:The nail folds and nail grooves, we've already explained, are the folds of skin and soft tissue that are adjacent to the nail plate.
Speaker A:Now, the proximal fold is the most important one.
Speaker A:So it's right here at the base of the nail.
Speaker A:It's actually continuous with the cuticle.
Speaker A:The cuticle literally wraps around and seals, it's continuous with the nail bed.
Speaker A:So remember, the nail bed is that base layer of skin.
Speaker A:The nail bed is continuous with the cuticle, which is continuous with the proximal nail fold.
Speaker A:The cuticle is really an important protective element because it keeps bacteria out of the nail bede.
Speaker A:So, you know, you've seen people who bite their nails and they have ragged cuticles, and they frequently get little infections in the soft tissue around the nail, or they have areas where you can see there's been bleeding.
Speaker A:So protecting the cuticle is important because the cuticle seals the nail bed and keeps bacteria, fungal organisms out the free border.
Speaker A:One of the things we'll teach you to do is to take either an orange wood stick or a metal spatula and to identify the free border of the nail.
Speaker A:So you literally just come under the nail plate and the portion of the nail that extends beyond the skin, the unattached portion of the nail, that's the free border.
Speaker A:Okay, so it's the point at which the nail separates from the skin.
Speaker A:The hyponychium is the border between the attached nail and the unattached nail.
Speaker A:And you never want to cut past the hyponychium when you're trimming nails because if you do, you expose skin and it's very painful.
Speaker A:How fast do nails grow?
Speaker A:How quickly are they replaced?
Speaker A:Well, it's normally about 2 month, so not very fast.
Speaker A:It takes about six months to replace a fingernail.
Speaker A:It takes twelve to 18 months to completely replace a toenail.
Speaker A:That's not very fast.
Speaker A:And there's a number of factors that impact on the rate of nail growth.
Speaker A:So psoriasis actually increases the rate of growth.
Speaker A:Vascular compromise reduces the rate of nail growth.
Speaker A:And interestingly, climate has an impact.
Speaker A:So nails grow faster in warm climates, more slowly in cold climates.
Speaker A:So I guess if you're in the south, you have to have pedicures more often than if you're in the north.
Speaker A:I don't know.
Speaker A:We should do a study.
Speaker A:Okay, we're going to talk briefly about pathologic conditions that affect the feet and nails, because if you are providing foot and nail care, you're always screening your patient or your client for evidence of any systemic process that requires intervention that might require referral.
Speaker A:A lot of these things we've already talked about, so we'll go through them quickly.
Speaker A:It'll be a quick review.
Speaker A:So let's talk about vascular disorders.
Speaker A:You already know about lower extremity arterial disease, very common in your diabetic patients.
Speaker A:Very common in smokers, and you know that the end result is you get diminished blood flow to the tissues.
Speaker A:The tissues become chronically ischemic.
Speaker A:They're high risk for ulceration, very high risk for delayed healing or for total failure to heal.
Speaker A:Burgers is a very different phenomenon.
Speaker A:That's also known as thromboangitis obliterates.
Speaker A:It's much more common in men who are heavy smokers.
Speaker A:They can actually lose digits because of burgers.
Speaker A:They have symptoms of claudication.
Speaker A:So pain with activity.
Speaker A:The big intervention is smoking cessation.
Speaker A:So if you can get them to stop smoking, then you essentially solve the problem.
Speaker A:What about raynauds?
Speaker A:Many people with essentially normal perfusion have raynauds, and you know what that is?
Speaker A:It's vasospasm that occurs in response to cold or stressed.
Speaker A:And so you'll sometimes see white fingers or white blue fingers, and the person will tell you, oh, yes, that happens to these two fingers.
Speaker A:That happens to these three fingers whenever I get, when I'm exposed to cold or when I'm really stressed out.
Speaker A:Typically, raynauds is not significant in terms of pathology, usually causes no tissue damage, but that intermittent vasospasm can contribute to brittleness of the nail.
Speaker A:So you might notice that when you're giving nail care, you don't really have to modify anything you do with the patient with raynauds.
Speaker A:With a patient with burgers, you want to be very careful because they have diminished blood flow to their digits, to their toes, to their fingers.
Speaker A:And certainly in the patient with lower extremity arterial disease, you want to be very careful.
Speaker A:Any injury in the patient with lower extremity arterial disease or burgers could result in a non healing wound.
Speaker A:There's one phenomenon.
Speaker A:You may never see it, but you definitely want to be aware of it.
Speaker A:They usually ask about this on certification exam, and that is Blueto syndrome.
Speaker A:And it's a patient who has sudden onset of cyanosis or pallor, usually cyanosis and sudden onset of pain affecting a digit because they have just thrown an embolus and shut down perfusion to that.
Speaker A:Digit pulses are usually palpable because it's usually involving the arterioles distal to the major arteries.
Speaker A:And obviously, when you see any evidence of acute ischemia, you want to do an urgent referral because many times they can do an embolectomy and save that toe.
Speaker A:Now, bottom line, you will always assess perfusion before you provide nail care.
Speaker A:If you see any evidence of lower extremity arterial disease, any evidence of burgers, you're going to be extremely cautious.
Speaker A:You're going to leave the bottom layer of callus.
Speaker A:You won't pare all the way down.
Speaker A:You follow the free nail border meticulously to avoid nicking the skin.
Speaker A:And you make sure that that patient is being followed by the appropriate provider for their lower extremity.
Speaker A:Arterial.
Speaker A:So we've talked about arterial insufficiency.
Speaker A:What about venous insufficiency?
Speaker A:So we've already talked about what happens here.
Speaker A:You get failure of valve function, so you get venous insufficiency, reflux of blood from the deep system to the superficial system, back pressure on the capillaries, leakage of fluids and cells out into the tissues, and edema.
Speaker A:So we will see edema.
Speaker A:You might very well see patients who have ulcerations or who have healed ulcers.
Speaker A:You want to make sure that if you see evidence of venous insufficiency, that that patient is being followed.
Speaker A:If you see significant edema, you want to know, are they wearing compression stockings?
Speaker A:Who sized them?
Speaker A:Do they have trouble getting them on?
Speaker A:Do they wear them consistently?
Speaker A:When did they last buy new stockings?
Speaker A:Anytime you have concerns about venous insufficiency and there's evidence that the patient's not being managed comprehensively or appropriately, you want to refer them.
Speaker A:Let's talk about autoimmune conditions that can affect the skin over the foot and the lower extremity, and that might impact, when you're providing foot and nail care, any autoimmune condition you think of.
Speaker A:Scleroderma.
Speaker A:That's one thing that we see a good bit of.
Speaker A:And you know that scleroderma does just what the name says.
Speaker A:It causes hardening of the soft tissue.
Speaker A:So that means that the skin in the soft tissue is not supple at all.
Speaker A:It means that you're going to get delayed healing.
Speaker A:And so, again, what's the take home message for us?
Speaker A:If I look on this patient's record, if I ask them about their medical history and they tell me they have scleroderma, they have lupus and scleroderma, I'm going to be very, very cautious, impairing a callus and trimming their nails, I want to make sure I do not cause any trauma.
Speaker A:We will see a lot of patients with arthritis.
Speaker A:So you know that rheumatoid arthritis affects the small joints, causes a lot of deformities and a lot of pain.
Speaker A:You might have a patient who has psoriatic arthritis that typically involves the toe joints.
Speaker A:You might have a patient with gout and that typically affects the great toe.
Speaker A:It's called pedagra.
Speaker A:When it affects the great toe, you know that the problem is overproduction of uric acid.
Speaker A:Sometimes you'll have an open ulcer, sometimes you'll have that white, creamy white exudate.
Speaker A:And that just represents urate crystals oozing out of the wound.
Speaker A:So you want to make sure that the patient's being followed for management of the underlying condition and for wound care.
Speaker A:Many of your patients will have osteoarthritis, also known as wear and tear arthritis.
Speaker A:They'll tell you that they're stiff, especially in the morning, but things get better throughout the day.
Speaker A:The main thing is you assess their gait.
Speaker A:You look to see is it causing any problems with abnormalities in terms of deformities or altered gait with callus formation.
Speaker A:So they tell me they're stiff, they tell me they have problems in the morning, I want to watch them walk, I want to look at the planter surface, I want to look at wear patterns on their shoes and see what intervention might be required.
Speaker A:Obviously, we always do a sensory assessment before we provide foot and nail care.
Speaker A:Any patient with altered sensation is high risk for foot trauma and for unrecognized foot trauma.
Speaker A:So there's a lot of education to be done.
Speaker A:So we're very alert to our diabetic population, we're very alert to our elderly population, any patient with a neurologic process like spinal cord injury, spina bifida, anything like that.
Speaker A:So we know that those patients are high risk.
Speaker A:We're going to assess their feet very carefully.
Speaker A:If I see any evidence of trauma, I'm going to say, how long have you had this?
Speaker A:How did this happen?
Speaker A:If they tell me, they don't know, it's a teaching moment, right?
Speaker A:I can reinforce the impact of sensory neuropathy.
Speaker A:I can reinforce the critical importance of daily foot inspection, and I can reinforce the critical importance of always, always wearing protective footwear and shaking their shoes out before they put them on.
Speaker A:So we're going to screen for sensory neuropathy.
Speaker A:We're going to reinforce or provide appropriate education.
Speaker A:We're going to ask them, how do you buy your shoes?
Speaker A:Where do you buy your shoes?
Speaker A:Who helps you buy your shoes?
Speaker A:And if they say, well, I just, you know, I just go wherever there's a sale, or I order them online because it's so hard for me to go to the store.
Speaker A:Then again, a teaching moment about the importance of properly and professionally fitted footwear.
Speaker A:And you want to give them specific places to go.
Speaker A:A lot of people who have foot and nail clinics or who provide these services on a routine basis, create a printout of centers in their area that provide professionally fitted footwear and customized insults so that they can provide that to their clients and to their clients caregivers or family members.
Speaker A:Also, we're very alert.
Speaker A:We talked about assessing hygienic care.
Speaker A:So you want to ask the patient, you know, do you shower?
Speaker A:Do you tub bathe?
Speaker A:Do you sponge bathe?
Speaker A:Does anyone help you wash your feet?
Speaker A:Because your feet are hard to get to.
Speaker A:So is anyone helping you wash your feet?
Speaker A:How do you dry between your toes?
Speaker A:Do you use any kind of lotion or special cream on your feet?
Speaker A:Would you if you had it?
Speaker A:So you want to find out about their hygienic care.
Speaker A:You're going to pay attention to their nutritional status and to their overall self care, specifically self care of the feet of.
Speaker A:If you have patients with dementia, you know they're not providing appropriate self care.
Speaker A:So you've got to make sure they have appropriate caregivers who have been taught.
Speaker A:Same thing with patients who have significant neurologic lesions that inhibit self care.
Speaker A:And finally, you're very alert to anything that would make it hard for this patient to clot normally.
Speaker A:Anything that, like chemotherapy, that would knock their platelet counts down, or if they're on anticoagulants for venous thrombolic disease, any of those things, you have to be, again, very cautious.
Speaker A:Okay, so we have talked about the anatomy and physiology of the foot.
Speaker A:We've said all, every foot has 26 bones, a lot of muscles, a lot of nerves.
Speaker A:Foot wounds are associated with very high risk of infection that could tunnel all the way to the bone.
Speaker A:So we're very, very careful in providing foot and nail care.
Speaker A:We've also talked about the structures of the nail itself.
Speaker A:We've talked about how long it takes to replace a nail.
Speaker A:And that explains why typically, treatment for fungal nail infections is very long term.
Speaker A:Twelve to 18 months to grow a new nail, you've got to keep treating until the nails replaced.
Speaker A:So that tells you why fungal treatment takes forever.
Speaker A:Okay, so that's it for part one, we're going to move on to part two.
Speaker A:And in part two, we're going to continue our discussion of pathologic conditions that affect the feet and the nails.
Speaker A:We're going to talk specifically about gait disorders, skin and soft tissue disorders, cold related lesions, bony deformities and painful conditions.
Speaker A:So, gait disorders, one of the things we said you want to do when you're providing foot and nail care is have the patient walk and observe their gait.
Speaker A:And when you're observing them walk, one of the things you're looking for is excessive pronation.
Speaker A:So if you have any reason to suspect excessive pronation, you take off their shoes and have them stand so that you can observe and see what happens.
Speaker A:And you can see right here what you would see in a patient with excessive pronation.
Speaker A:They have no visible arch during weight varying.
Speaker A:So this can be a patient that when they're just sitting there with their feet off the floor?
Speaker A:Yes, you see the arch, because this is not an anatomic issue.
Speaker A:This is a functional issue.
Speaker A:So I have an arch at rest, but when I stand, I lose the arch and I become essentially flat footed.
Speaker A:That's excessive pronation.
Speaker A:Does it matter?
Speaker A:Yes, it does matter.
Speaker A:It causes marked increase in the pressure exerted against the plantar surface muscles, tendons, ligaments, and that is a common contributing factor to plantar fasciitis and other painful foot conditions.
Speaker A:So look at my contour setting.
Speaker A:If you have any concerns, stand me and watch for excessive pronation.
Speaker A:If you see this in a patient, really important to refer them for customized inserts because they need support.
Speaker A:They need to maintain that arch when they're walking so that they don't get that excessive pressure on all the plantar surface structures.
Speaker A:When you create all that excess pressure, you're pulling on the fascia, pulling on the muscles, you're causing trauma and inflammation.
Speaker A:What about disorders of the sweat glands?
Speaker A:So you do have sweat glands in the feet.
Speaker A:Normally, they help to keep the skin hydrated.
Speaker A:You are going to have problems if you have excessive sweating.
Speaker A:You're going to have problems if you don't sweat enough.
Speaker A:And if you have excessive sweating, you might also have problems with foot odor.
Speaker A:And that's the basis for that little cartoon slide.
Speaker A:So what is hyperhidrosis?
Speaker A:Hyper means too much.
Speaker A:Hydrosis means sweating.
Speaker A:So excessive sweating.
Speaker A:If you have a patient who has excessive sweating, the problem is that their feet are always wet.
Speaker A:And that's a wonderful medium for bacterial growth.
Speaker A:Plus it increases the risk for fungal infections and fissure formation.
Speaker A:So you want to keep the skin relatively dry.
Speaker A:So what we tell them to do, dry your skin well, think about using antiperspirants to your feet.
Speaker A:It works in your underarms, it'll work on your feet.
Speaker A:A lot of them use absorbent powders, and they should be using cotton socks.
Speaker A:So something that's absorbed anhydrosis is much more common.
Speaker A:That's that really dry skin that you get when you don't sweat enough.
Speaker A:And we've talked a lot about that in relation to our diabetic patients.
Speaker A:We've said, if that's what we're seeing, critically important to teach them about routine use of emollients and humectants to keep their skin soft.
Speaker A:Bromhydrosis is probably what bothers patients and their family members the most.
Speaker A:And this is essentially smelly feet.
Speaker A:These are feet that stink.
Speaker A:So it's a combination of hyperhidrosis, excessive sweating, plus bacterial overgrowth.
Speaker A:So we want to do two things.
Speaker A:We want to reduce sweat formation, and we certainly want to reduce bacterial overgrowth.
Speaker A:So we counsel these patients to routinely bathe using an antibacterial soap.
Speaker A:We include all of the measures that we talked about under hyperhidrosis.
Speaker A:So think about antiperspirants to the feet.
Speaker A:Think about absorbent powders.
Speaker A:Think about absorbent powders that have an antifungal antibacterial component that will help to reduce odor.
Speaker A:Your cotton socks.
Speaker A:There are products that are designed specifically, specifically for people who have a combination of excessive sweating and bacterial overgrowth, and they are the bromi products.
Speaker A:So you'll find bromi lotions, bromi powders.
Speaker A:So if you're looking for this type of product online or in the pharmacy, look for anything that starts out B r o m I.
Speaker A:There's also some prescription agents.
Speaker A:So if it's a very serious problem for a patient, if you're advanced practice, you can prescribe this.
Speaker A:But if you're not advanced practice, you would refer them typically to a podiatrist for this.
Speaker A:So the formidon fissures, we have talked about fissures before.
Speaker A:We talked about fissures when we talked about the effects of autonomic neuropathy.
Speaker A:So you know what fissures are?
Speaker A:They're cracks in the skin that extend into or through the dermis, is like throwing the door open and inviting bacteria and fungal organisms in, and they will come.
Speaker A:So we want to prevent fissure formation by teaching patients appropriate routine care.
Speaker A:So filing down calloused areas using humectants on a routine basis.
Speaker A:But what if they already have a fissure?
Speaker A:Then what are you going to do?
Speaker A:Well, you're going to pair all the way around the fissure.
Speaker A:You're either going to file or pear to try to reduce the height of the fissure.
Speaker A:So you're kind of taking down the sidewalls of the fissure to create the flattest wound possible so that you can dress the wound if indicated.
Speaker A:Many times we do dress the wound either with a hydrocolloid dressing or with a soft adhesive silicone foam dressing.
Speaker A:So if you're very worried about bacterial penetration, fungal penetration, or if the fissures are painful to the patient, think about using a protective dressing.
Speaker A:Always, you're using a combination of paring or filing and humectants and demolish blisters.
Speaker A:You've all had blisters.
Speaker A:You will frequently see blisters on the plantar surface of the foot.
Speaker A:You know, blisters always represent friction injury when they're on the surface of the foot.
Speaker A:So it's what happens when the patient's walking and the soft tissues are moving over the bone.
Speaker A:So you get this recurrent shear and friction, and you can get a blister when the epidermis separates from the dermis.
Speaker A:That's typically what we see.
Speaker A:Occasionally, you'll see a very deep, blood filled blister when the dermis separates from the subcu, but that's much less common.
Speaker A:Typically, you're seeing just what you see here, separation between the epidermis and the dermis and a clear, fluid filled blister.
Speaker A:So your first question is, well, what caused this?
Speaker A:Do you want to go talk to the patient?
Speaker A:How long have you had this?
Speaker A:Did anything precede it?
Speaker A:Well, I had a new pair of shoes, and I went to the mall, and I walked around in those new shoes all day long.
Speaker A:Okay, well, now you know what caused it.
Speaker A:So you want to talk to the patient about breaking in footwear gradually, and they may very well need a referral for an appropriate insult.
Speaker A:How do you manage the blister?
Speaker A:So if it's a small, fluid filled blister, typically we leave it alone and just allow the fluid to reabsorb.
Speaker A:You may cover it with a soft foam dressing until it does reabsorb just to provide added protection.
Speaker A:If you have a large blister, you want to un roof the blister, you might create a window that allows all the fluid to drain out, and then you can dress the wound.
Speaker A:Definitely.
Speaker A:If it's a fluid filled blister, you want to evacuate the fluid.
Speaker A:But that's not typically what we see.
Speaker A:So we've said you could use a hydrocolloid.
Speaker A:We've said you could use a soft foam.
Speaker A:You could use a transparent adhesive.
Speaker A:You could use a solid gel, as long as it's glycerin based.
Speaker A:So, most important thing, correct the cause.
Speaker A:Look at their footwear.
Speaker A:Look at whether or not they had the appropriate insults.
Speaker A:But short term, you also want to manage the blister itself.
Speaker A:So drain large blisters.
Speaker A:Leave small ones alone.
Speaker A:Protect until healed, either with transparent adhesive dressing, hydrocolloid, soft silicone foam, glycerin based gel, that kind of thing.
Speaker A:You will see a lot of callus.
Speaker A:Now, the official term for callus is a tyloma.
Speaker A:It's thickening of the skin in an area exposed to repetitive friction.
Speaker A:So you can have callus that's hard.
Speaker A:You can have calluses that are soft.
Speaker A:Typically hard callus is on the plantar surface of the foot.
Speaker A:But if you have a callus right over the metatarsal head, and if you also have hyperhidrosis, abnormal sweating, then that callus can be solved.
Speaker A:How are you going to manage?
Speaker A:You always want to take down the callus.
Speaker A:Now, if you have extensive callus formation, typically you're going to buff that area.
Speaker A:So you might do a vinegar water soak to soften the calluse.
Speaker A:Buff with a dry cloth to see what comes off spontaneously after the soak.
Speaker A:Then you might take either a pumice or a large, coarse emery board and buff in one direction.
Speaker A:Some centers use an electric grinder with a standing bit to buff off excess callus.
Speaker A:If you have localized callus, which is what you see on the bottom, that's known as an intractable plantar keratoma.
Speaker A:Sounds terrible, IPK, but it just means a localized callus right over a bony prominence.
Speaker A:So again, you've got very well demarcated edges.
Speaker A:It's a pretty deep crater right in the center.
Speaker A:So you're going to take a scalpel, usually, and you're going to pare that keratoma, pare that callus.
Speaker A:Sometimes you can use the tip of the scalpel to lift out the center.
Speaker A:And then again, you're going to look at what is causing this.
Speaker A:So what's wrong with their footwear?
Speaker A:Do they need customized insults, that kind of thing?
Speaker A:Corns are exactly the same thing as callus over growth of skin, except they occur on the tops of the toes or between the toes.
Speaker A:So calluses on the bottom of the foot or overgrowth of skin on the bottom of the foot is known as calluses.
Speaker A:Overgrowth of skin on the tops of the toes or between the toes is known as a corn or a haloma.
Speaker A:We say corns and calluses, but you can say hilomas and tylomas if you want to sound really official.
Speaker A:So it's the same pathology, basically the same management.
Speaker A:So, you know it occurs because of abnormal friction and shears.
Speaker A:So you go back and you look at their footwear.
Speaker A:You're like, okay, so you've got corns on your 2nd, third and fourth toes, affecting the proximal interphalangeal joints, and you have hammer toes.
Speaker A:So I know what the problem is.
Speaker A:Your toes are rubbing against the tops of your shoes.
Speaker A:Let me look at your shoes.
Speaker A:That person is going to need modifications in their footwear to accommodate their toes, or they're going to keep forming these over and over.
Speaker A:So you look at, you need shoes with an extra deep toe box.
Speaker A:So I might need to refer you to a center where they can fit you appropriately.
Speaker A:Sometimes we'll use little toe sleeves over a toe to provide additional protection against shear and friction.
Speaker A:If you have callus between the toes, we definitely use little toe sleeves to stop that rubbing effect.
Speaker A:So we're going to look at your footwear, we're going to pair the corn or the callus, and we're going to try to keep it from coming back.
Speaker A:Now, plantar warts look a lot like a callus, but when you look at them very carefully, see all those little dark specks throughout the surface?
Speaker A:Those are capillaries.
Speaker A:Because plantar warts are actually viral lesions.
Speaker A:There are papilloviruses, and they can be treated with antiviral solutions, but that would be done typically by a dermatologist or a podiatrist.
Speaker A:In terms of just symptomatic management, you're going to ask the patient, is this bothering you?
Speaker A:Is this painful?
Speaker A:Most of the time, we pare it down just like we would pare down a calluse we refer them if they want further treatment.
Speaker A:People do all kinds of things to try to eliminate plantar warts, so sometimes they cover them with occlusive tapes to try to cut off oxygen.
Speaker A:You'll hear about all of these things.
Speaker A:If you really want definitive treatment, you go to a podiatrist or you go to a dermatologist and they will prescribe an appropriate solution to kill the virus.
Speaker A:Or they might do an in office treatment to kill the virus.
Speaker A:But if all the patient or client wants is for someone to take down the thickness, you can do that.
Speaker A:You can pair a plantar wart just like you pair a callus.
Speaker A:Fungal infections are probably the most common infection affecting feet and nails, because it's a perfect environment, right?
Speaker A:Especially if the person tends to trap sweat or if they use community showers.
Speaker A:So if you use community showers, you walk barefoot on carpets where other people are walking barefoot.
Speaker A:You're going to pick up fungal organisms.
Speaker A:They're everywhere.
Speaker A:So you can have fungal infection affecting the skin, or you can have fungal infection affecting the nail if it's affecting the skin.
Speaker A:It's known as tinea pedis.
Speaker A:So risk factors include age, because, as we discussed earlier, the immune system becomes less attentive with age and less functional with age.
Speaker A:So maybe when you were 30 and you were using community showers, you didn't have any problems with athlete's foot, but now you're 60 and you're using community showers and all of a sudden you're developing athletes foot.
Speaker A:It's because your immune system isn't giving you the same level of protection at 60 that it did at 50.
Speaker A:So age is a risk factor.
Speaker A:Diabetes is a risk factor, probably in part because of elevated glucose levels, in part because hyperglycemia impairs white blood cell function.
Speaker A:Anybody with wet feet is higher risk.
Speaker A:So if someone works in an area where their feet are constantly exposed to moisture, they're higher risk.
Speaker A:If they have hyperhidrosis, they're higher risk.
Speaker A:And anyone who's immunosuppressed now, there's both chronic and acute forms of tinea pedis.
Speaker A:The most common is chronic, and that's where you see this dry, scaly rash across the entire plantar surface of the foot.
Speaker A:A lot of times, if you ask the person who has tinea pedesthe chronic version, is this bothering you?
Speaker A:They'll be like, well, you know, my feet are always dry and scaling, but it doesn't hurt and it doesn't itch.
Speaker A:So treatment is pretty much up to the patient.
Speaker A:They can treat with an over the counter antifungal spray.
Speaker A:Excuse me.
Speaker A:Or they can elect to leave it alone because it's not going to hurt anything.
Speaker A:But if they have acute tinea pedestrians, it causes a lot of symptoms and that's what you see on the middle slide and the bottom slide.
Speaker A:So when it's acute, it's typically between the toes and you get a lot of fissure formation.
Speaker A:And, you know, fissures between the toes can be very painful, you might get blister formation, you might have a lot of itching, you might have a lot of tenderness, you might have a lot of burning.
Speaker A:So you're definitely going to treat acute tinea pedis.
Speaker A:So here's how you treat.
Speaker A:You do everything you can to keep the feet dry.
Speaker A:So you tell the person, let's be sure you're drying well between your toes.
Speaker A:After your shower, after your bath, make sure you're wearing cotton socks.
Speaker A:Change your socks when they get wet.
Speaker A:Use an over the counter antifungal spray.
Speaker A:It takes three to four weeks to eradicate the organism.
Speaker A:So any of your azole sprays, the myconazole type sprays.
Speaker A:So your ten actin is very commonly used, but they can use store brand.
Speaker A:It doesn't have to be a name brand.
Speaker A:Now, here's the thing you've got.
Speaker A:If you have tinea pedis, you've got fungal organisms in your shoes.
Speaker A:And if you keep wearing the same shoes and you don't treat those shoes, you will get recurrent fungal infection.
Speaker A:So you either want to replace your shoes two to three weeks into treatment or treat your shoes.
Speaker A:And there's a specific antifungal spray for shoes that's called micamist.
Speaker A:So make sure you talk to patients about that.
Speaker A:Psoriasis.
Speaker A:Psoriasis can affect skin anywhere on the body.
Speaker A:If your patient has a diagnosis of psoriasis, you want to be very aware of that because it can also affect the feet, it can cause plaque formation, it can cause a pustular rash on the dorsal surface, not the dorsal, the plantar surface of the foot.
Speaker A:You can get yellow gray callus like you see on the bottom slide, and you can get deep, painful fissures.
Speaker A:So you're always alert when you see abnormal skin lesions.
Speaker A:You want to go back to what's their dermatologic history?
Speaker A:Many times it relates to something that they've had before.
Speaker A:How are you going to treat?
Speaker A:The same way as they treat psoriasis everywhere else on the body, and that's up to their dermatologist.
Speaker A:So we're not going to prescribe treatment.
Speaker A:Usually we're going to refer them back to their dermatologist.
Speaker A:You're going to see a lot of little warts or not warts, moles on the foot, pigmented nevi.
Speaker A:But you could also see a melanoma, and you never want to miss a melanoma.
Speaker A:So you want to be able to differentiate between benign growths and malignant growths.
Speaker A:So your benign growths are moles, also known as pigmented nevi.
Speaker A:Think about benign lesions.
Speaker A:They can be flat, they can be raised, they have well defined margins and they are not enlarging, so they stay the same.
Speaker A:The color can be variable, but it doesn't change.
Speaker A:So they can be flat, they can be raised, they can be pink, they can be brown.
Speaker A:The big determining factor.
Speaker A:Do you see any change between January and February?
Speaker A:Between January and March?
Speaker A:Look at the difference between the wounds, the lesions on top, the moles, and the malignant melanoma slides on bottom.
Speaker A:So you can use that a, b, c, d, so with melanoma, you get asymmetrical lesions.
Speaker A:So they're not well defined and round or symmetric.
Speaker A:They're asymmetric.
Speaker A:They typically have irregular borders.
Speaker A:That's the b.
Speaker A:Color is variable, so it can be variable within the lesion.
Speaker A:And most importantly, the dimensions are changing.
Speaker A:So you're getting constant enlargement.
Speaker A:If you have any reason to suspect melanoma or if you're just not sure, it's never, ever wrong to refer.
Speaker A:So you can say to the client, to the patient, you know, I think this is probably benign, but we don't want to take a chance.
Speaker A:I'm going to refer you to the dermatologist now.
Speaker A:Just a few more things we need to go over.
Speaker A:Depending on where you live, you may have clients with cold injuries.
Speaker A:There's two levels of cold injuries.
Speaker A:One is mild to moderate, and it's almost always self.
Speaker A:You know, repairing it very rarely would result in anything serious.
Speaker A:But frostbite is a very significant, very serious injury that frequently results in major tissue loss.
Speaker A:So let's talk about the difference.
Speaker A:So, with mild to moderate cold injury, also known as chilblain or pernio, you're going to see reddish purple discoloration.
Speaker A:It can be blotchy or it can be evenly distributed.
Speaker A:You'll see that involving, typically, the toes.
Speaker A:And the person will complain that my toes, they sting, they burn, they itch, they're really, really uncomfortable.
Speaker A:But typically, all we have to do is just say, that's because your feet have been exposed to abnormal cold.
Speaker A:It's going to fix itself, but you have to keep your feet warm, so don't go back out in the cold.
Speaker A:Wear warm socks, warm shoes, allow your feet to recover.
Speaker A:Frostbite, totally different.
Speaker A:When it says frostbite, it means that the soft tissues actually became frozen with prolonged exposure to severe cold.
Speaker A:Now, you don't have this reddish purple.
Speaker A:No, you've got purple black.
Speaker A:You can have purple black blisters or purple black discoloration of the tissue itself.
Speaker A:Typically, it progresses to eschar formation and very frequently to tissue loss.
Speaker A:In any areas where they see patients with frostbite, they'll have very defined protocols for gradual rewarming of the tissues.
Speaker A:Once you do gradual rewarming, all you can do is wait.
Speaker A:You have to wait it out.
Speaker A:And what's going to happen is that the tissues that cannot be salvaged, that are literally dead, will self demarcate, and then you will have an open wound almost always.
Speaker A:And then you provide moist wound healing.
Speaker A:But all you can do is identify it, work with the team on rewarming and then watchful waiting.
Speaker A:Back to talking about contours of the foot, musculoskeletal issues.
Speaker A:So you've heard of people being flat footed, and you might have heard the term claw foot.
Speaker A:Past planus is flatfoot.
Speaker A:Past clavis is claw foot.
Speaker A:Now, the difference in flat foot and excessive pronation, which we discussed earlier, is that the person with past plavis has no arch.
Speaker A:Their feet are flat all the time.
Speaker A:So if you look at me at rest, there's no arch.
Speaker A:You look at me standing, no archite, that's pest plants.
Speaker A:So arch, absent at rest and with weight bearing, if they have no symptoms, they're like, no, my feet don't hurt.
Speaker A:It's because that's the normal contour for their foot.
Speaker A:And if they're not getting excessive pronation, this is just the way their foot is made.
Speaker A:They're not getting excessive traction on plantar surface structures, so no intervention is needed unless they have symptoms of symptoms, in which case you would refer them back to the orthotist to have appropriately designed footwear insoles or inserts.
Speaker A:Now, a claw foot pest, cavus, is an abnormally high arch, and they will need customized inserts to provide arch support.
Speaker A:Otherwise they're going to have a lot of pain.
Speaker A:So again, you look at the contours of the foot.
Speaker A:You observe them sitting and non weight bearing.
Speaker A:You observe them weight bearing.
Speaker A:Many of you have hammer toes.
Speaker A:Many of your clients will have hammertoes.
Speaker A:Many of your patients will have hammertoes.
Speaker A:So hammertoes represent flexion contractors of the proximal interphalangeal joints, the pip joints.
Speaker A:They start out being flexible, meaning you can stretch them out, but then they become rigid, which means you can no longer stretch them out.
Speaker A:The big problem with hammertoes, in addition to the way they look, is that they create increased risk for corns and calluses and ulcers.
Speaker A:So they tend to get corns over the pip joints, and then they can get ulcerations if they are wearing inappropriate footwear and they're constantly rubbing against the top of the shoe.
Speaker A:But we can teach them.
Speaker A:When you buy shoes, make sure you're getting shoes with a deep toe box to accommodate your hammertoes.
Speaker A:What are their management options?
Speaker A:Well, because they'll ask you, well, what can you do about this?
Speaker A:I don't like the way they look.
Speaker A:I don't like having to be careful with the shoes I buy.
Speaker A:What can be done if they're still flexible?
Speaker A:If you can still stretch them out, you can use exercises, and there's little splints that are available.
Speaker A:You can get them online, you can get them from a podiatrist.
Speaker A:That will help maintain normal structure of the toes.
Speaker A:Once they're rigid, the only intervention is surgical correction.
Speaker A:Some people will go for that.
Speaker A:Most people are like, never mind, I'll wear those deep shoes.
Speaker A:What about a claw foot or claw toe?
Speaker A:We're talking claw toe now, not claw foot.
Speaker A:So ignore that.
Speaker A:A claw toe is where you have flexion contracture of both the proximal interphalangeal joint and the distal interphalangeal joint.
Speaker A:And so it literally turns the toe into a claw.
Speaker A:And the problem is that the tip of the toe is now digging into the shoe and the top of the toe is rubbing against the top of the shoe.
Speaker A:So it can cause a corn here, a callus here, and eventually it can cause ulcers.
Speaker A:It can be corrected surgically.
Speaker A:Otherwise, it's all about modifying footwear to protect the toes and prevent ulceration.
Speaker A:There's also mallet toe, and that's where you have flexion contracture.
Speaker A:It's hard for me to show you this.
Speaker A:I tried to show you on the slide malletto.
Speaker A:The proximal joint's normal distal joint is flexed, and so the main issue is that it digs against the bottom of the shoe and you get a lot of calluses on the tips of the toes.
Speaker A:Eventually it could cause an ulcer, but usually it's just callus.
Speaker A:And so again, you have two choices.
Speaker A:You can protect the tip of the toe, there's little foam sleeves that help protect the tip of the toe, or they can have surgical correction bunions.
Speaker A:You'll see lots of patients who have hallux falgus, meaning that the great toe deviates from the midline toward the fifth toe, and the bunion joint becomes abnormally prominent.
Speaker A:So the great toe deviates, the metatarsal head enlarges, and that's the classic bunion.
Speaker A:It's commonly caused by excessive pronation.
Speaker A:People typically blame their footwear for bunion formation, but according to the textbooks, it's usually excessive pronation that causes this.
Speaker A:And you have two options.
Speaker A:You can modify footwear, so you need a wide toe box, or you can do surgery.
Speaker A:Also, we sometimes take large foam sleeves and cut it to fit over the great toe and over the bunion, just for a little bit of added protection.
Speaker A:What about overlapping toes?
Speaker A:Sorry?
Speaker A:What about overlapping toes?
Speaker A:You'll see those in your diabetic patients with motor neuropathy.
Speaker A:And this is one of the deformities that occurs.
Speaker A:Obviously, if you have one toe overlapping another toe, you have increased risk of friction injury against your shoe, also of corns from rubbing against the shoe.
Speaker A:And it's all about protective sleeves, modified footwear, or surgical correction.
Speaker A:Painful conditions that affect the foot include Morton's neuroma and plantar fasciitis.
Speaker A:Those are the two most common.
Speaker A:Morton's neuroma is also known as a neurofibroma.
Speaker A:And what happens is that you get scar tissue forming around the plantar transmetatarsal nerve, usually due to minor injury caused by excessive pronation.
Speaker A:So you get excessive pronation, you get traction on the tissues, causes injury to the connective tissue, tendons and ligaments, and all the other connective tissue, the fascia.
Speaker A:Now the injury triggers the repair process.
Speaker A:Now you get scar formation.
Speaker A:And that scar formation can affect the nerve.
Speaker A:So this is what people tell you.
Speaker A:They'll say, I'm fine as long as I'm sitting, but when I walk, the longer I walk, the more it hurts.
Speaker A:And typically it hurts along the fourth and fifth toes.
Speaker A:So I tried to show you that on the slide as well.
Speaker A:And some people are saying, oh, it's not too bad.
Speaker A:It kind of tingles and burns, and it stops when I stop walking.
Speaker A:But other people are like, no, it hurts a lot.
Speaker A:It cramps, it burns, and I have to do a lot of walking for my job.
Speaker A:I need something done about this.
Speaker A:And basically it comes down to cortisone injections or surgery to manage that.
Speaker A:So our role would be to recognize it if we say, are you having any pain affecting your foot?
Speaker A:Yes, it's right here.
Speaker A:When does it hurt?
Speaker A:When I walk.
Speaker A:What does it feel like?
Speaker A:I can't fix that.
Speaker A:You can't fix that, but a surgeon can fix that, either with a cortisone injection or with surgical correction.
Speaker A:What about plantar fasciitis?
Speaker A:Again, excessive pronation puts abnormal stretch on the fascia, the connective tissue, tendons and ligaments, the plantar surface of the foot.
Speaker A:So you're doing this all day.
Speaker A:You're causing injury, causing inflammation, because you're up, you're walking, and you're pronating.
Speaker A:Then you go to bed, and that inflammation causes a lot of edema to form.
Speaker A:And so when you wake up in the morning, your nerves and muscles surrounded by edema fluid, and when you put your foot on the floor, it causes compression of the nerve, and it hurts like heck.
Speaker A:Now, if you can keep walking, if you're tough and you walk through it, you keep walking, you force the edema fluid out, and the pain subsides to some extent.
Speaker A:So you get swelling during inactivity, acute pain with walking that gradually subsides somewhat.
Speaker A:You want to treat this because it's just going to get worse.
Speaker A:And the primary treatment is orthotics, to normalize gait.
Speaker A:So that's why it's so important for us to watch our patients, our clients walk, to assess their gait, to ask them about painful conditions, and then to make appropriate referrals.
Speaker A:So in part one and part two, we've talked about normal anatomy and function of the foot and the nail, and we've talked about common conditions, systemic conditions that can affect the feet and the nails.
Speaker A:We've talked about musculoskeletal and some of the skin conditions.
Speaker A:And then in the next section, we'll talk about nail conditions.
Speaker A:Okay, so this is it for part two.
