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Challenges in podiatry


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Disorders of the foot, ankle and lower limb can be successfully treated at primary care level or by medical profiles like podiatrists, but some conditions require a multidisciplinary approach. Easy sharing of diagnostic measurement results and other data between different specialists is therefore a must. That is often easier said than done, especially if paper records are used and there is more time spent on keeping track of who has which documentation and where. Electronic health records (EHRs) are far more versatile when it comes to data sharing; some can be easily integrated with digital diagnostic measurement devices, which can greatly improve the workflow at any podiatric office.

In this blog you will learn: 

What are some foot, leg and limb conditions that may require a multidisciplinary approach?

Diabetes-related conditions

Diabetes is a multi-systemic disorder whose treatment requires a multidisciplinary approach with a diabetologist at the helm (effective management of glucose levels). Diabetes affects all parts of the human body, including the lower extremities, which it can impact in various visible and hidden ways. An example of the former is diabetic foot, primarily caused by Peripheral Arterial Disease (PAD), sensory neuropathy or often both (to various degrees) ​[1]​. It is estimated that, in 2016, the global prevalence of diabetes-related lower-extremity problems was around 131 million individuals [2].  Around 4.3 million of them had amputations and were without a prosthesis, while 2.5 million had amputations and were provided with a prosthesis ​[2]​. However, many amputations could be prevented with an effective and timely diabetes management. Amputations are often (in up to 85% of cases) preceded by ulcers, which must be properly differentiated for treatment with the help of  vascular assessment ​[3]

Vascular conditions

Most lower extremity ulcers are venous, comprising around 72% of all cases, followed by arterial insufficiency (ischemic) ulcers with a prevalence from 10% to 30%, and neuropathic ulcers with a prevalence between 15% and 25% ​[4]​. The latter are most frequently found in those with diabetes, who can have ulcers of mixed aetiology (up to 20% of diabetics have both neuropathy and PAD) ​[4]​. The treatment always depends on the ulcer type. For example, venous and ischemic ulcers have vastly different treatments, from a cost perspective (arterial are usually more costly to treat) to the seriousness of other associated health conditions.  

The relationship between ischemic ulcers, PAD, and increased cardiovascular mortality is well established, but research has also found that individuals who are at a high risk of venous thrombosis, but have not been diagnosed with it, are also more likely to have venous ulcers [5] [6]. Deep vein thrombosis (DVT) may be difficult to diagnose since it can exhibit a wide variety of symptoms and signs that could be attributed to other (podiatric) conditions. Explicit signs such as phlegmasia cerulea dolens are uncommon and may even be misdiagnosed as cellulitis, necessitating (in the absence of diagnostic tools such as contrast venography) a consultation with a dermatologist ​[7]​. For the role of the Ankle-Brachial Index and Pulse Wave Velocity in arterial assessment, click here.

Dermatological conditions

Like other parts of the body, lower extremities can be affected by a number of skin conditions, which may require the expertise of a dermatologist or even oncological treatment. Malignant melanoma of the foot is a good example of a serious condition that requires urgent medical attention. It is estimated that approximately 3% to 5% of all cutaneous melanomas arise in the foot and can be difficult to recognise in early stages (especially within the nail unit and on the plantar surface) ​[8][9]​. Consequently, malignant melanomas of the foot carry a worse prognosis in comparison with melanoma arising at other body sites, especially if they metastasise and require an aggressive and comprehensive treatment ​​[9]​. 

Tumours of the foot and ankle

Inclusion of an oncologist in podiatric treatment is also necessary when it is suspected that the patient may have bone tumours (of foot and ankle). Foot and ankle bone cancer is generally rare; only about 6% of bone tumours occur in the foot and only about 25% of those are cancerous ​​[10]. Still, timely diagnosis may be difficult due to a variety of reasons; for example, visible red and swollen tumour lumps could be mistaken for gout (and vice versa) ​​[11][12]​. 

Rheumatic conditions

Gout was historically known as “the rich man’s disease”; traditionally, only the affluent were able to access the kinds and amounts of food and beverages conducive to the development of gout. Nowadays,  it is known that dietary causes account for only about 12% of cases, but gout has become far more prevalent in all social strata[13]​. The prevalence varies across regions and countries, ranging from more than 10% (certain indigenous groups) to between 1% and 4% in North America and Western Europe [14]​. However, both prevalence and incidence are increasing in many developed countries due to the rising prevalence of metabolic syndrome, cardiovascular disease, and renal diseases, which are well-recognised risk factors for gout​ [15] [16] [17]​. Patients with gout therefore often require a holistic treatment approach that involves not just podiatrists and rheumatologists, but also cardiologists, nephrologists, and diabetologists. The latter should be included if the patient has Charcot foot – caused by conditions that decrease peripheral sensation, proprioception and fine motor control; most frequently, the condition appears in diabetics [18]​. 

Neurological conditions

In primary care, diabetic peripheral neuropathy (DPN) has a prevalence ranging between 2.4% and 24.1%; in secondary care, the number is even higher, up to 31.1%. DPN also requires the attention of the neurologist, particularly in patients with painful diabetic peripheral neuropathy (pDPN), who need medications for pain management ​[19] [20]​. The same goes for patients with Morton’s neuroma, tarsal tunnel syndrome (TTS) or Raynaud syndrome (also known as Raynaud’s phenomenon) albeit to different extents.  

Both Morton’s neuroma (five times more common in females than males) and TTS (unknown prevalence, often underdiagnosed) present with painful symptoms and physical sensations that are difficult to distinguish from other foot and leg conditions and require the inclusion of a neurologist to diagnose and treat ​​[21]​ ​[22]​. 

On the feet, Raynaud syndrome often presents with visually explicit symptoms and sensations of having cold toes a painful “pins and needles” sensation when the toes change temperature from cold to warm (or the emotional stressors subside) ​[23]​​. At least in those with primary Raynaud syndrome (most common form, up to 90% of cases), the condition is largely harmless but unpleasant; in very rare cases, it may result in the development of gangrene. However, those with secondary Raynaud syndrome (associated with number of other conditions) may have a serious underlying condition, e.g. Lyme disease ​[23][24]​​.

Infections

Around 70% of Lyme infections start with a typical rash (often in the form of a ‘bullseye’) that should be easy for a podiatrist to identify, although a dermatologist should be consulted on the nature of the rash ​[25]​. An infectiologist should also be contacted when suspecting osteomyelitis (after visible trauma or if the patient is a diabetic or an intravenous drug user) because some of its symptoms (pain, skin redness) are similar to many other podiatric and dermatological conditions ​[26]​. Cooperation with an infectiologist and a dermatologist is also a must if there are indications of a staphylococcal infection; they are often found in diabetic patients with foot ulcers and associated with increased mortality compared to patients without such infection ​[27]​. Effective sharing of the diagnostic measurement results and other patient data between all the specialists treating the patient can importantly contribute to the speed and success of the treatment.  

How to easily share photographic documentation and other diagnostic data for a second or specialist opinion?

Leg and feet examinations can yield a wealth of diagnostic data that can be difficult to store, organise and share with other medical professionals, especially photographic capture of pathological changes and improvements. Enter the MESI mTABLET, a diagnostic system with a certified medical tablet with a built-in camera for convenient documentation of skin changes, wounds and treatment progress. The photos and diagnostic measurements (the Ankle-Brachial Index, the Toe-Brachial Index, Pulse Wave Velocity, etc.) can be automatically saved into the user’s EHR system. If necessary, the photos and diagnostic measurements results can immediately be shared for a second or specialist opinion. The recipient does not need a MESI mTABLET, but receives the result in PDF with the patient data anonymised in accordance with the legislation. All this contributes to faster diagnostic work and better patient outcomes.