Vascular assessment in podiatry

Many podiatric conditions have multifactorial etiologies and require a comprehensive treatment approach. This often calls for inclusion of other specialists, particularly with systemic diseases like arthritis (rheumatology), diabetes (diabetology) and cardiovascular conditions (angiology, cardiology). Comprehensive assessment at the podiatry office is therefore a must and should also include a vascular check-up. This is especially important in wound treatment; insufficient lower extremity arterial perfusion can be a symptom of Peripheral Arterial Disease (PAD), a principal cause behind poor wound healing. Podiatrists screening for PAD are therefore in a unique position to identify at-risk patients and refer them to other specialists if necessary. This article discusses the impact of major risk factors on podiatry patients, and a simple way to screen patients at the podiatry office if they belong to a group at risk of PAD. 

In this blog you will learn: 

• What are the major non-modifiable risk factors for podiatric conditions?
• What are the major modifiable risk factors for podiatric conditions?
• How to easily perform vascular assessments at the podiatry office?

What are the major non-modifiable risk factors for podiatric conditions?

Genetics (family history)

Recognising and understanding the genetic component of diseases has been a major medical breakthrough. Many common podiatric conditions are hereditary, and a podiatrist should inquire about the family health history of every patient – not just in connection with podiatric conditions, but in general. Research shows that genetics plays an important role in more than a hundred different podiatric conditions, ranging from very common ones like hammer toe to ectrodactyly [1] [2] [3]​. Genetics is also a factor in many (usually systemic) conditions that can cause podiatric issues, worsen symptoms and/or hinder treatment. An example is arthritis, a disease with growing prevalence ​[4]​. 

Arthritis

According to research, more than 90% of patients with rheumatoid arthritis (RA) report podiatric issues, along with significantly reduced quality of life [5]​; for example, some of the issues can lead to reduced walking distance and increased fall risk. This is particularly worrisome in elderly patients as the impact can be worse ​[6] [7] [8] [9]​. Advanced age is also a risk factor for RA itself; other risk factors include smoking, obesity and diabetes [10]​.  

Despite RA being one of the two most common rheumatic diseases (the other one is osteoarthritis), its etiology is still unknown ​[11] [12]. Research shows a strong genetic component [13]​; for example, individuals with a family history of RA are three to five times more likely to develop this condition ​[14]​. Genetics also plays a role in diabetes – a growing health issue worldwide.  

What are the major modifiable risk factors for podiatric conditions?

Diabetes

In 2021, the global prevalence in people aged 20–79 was estimated to be 536.6 million ​[15] [16]​. Diabetes has a strong genetic component and is both a modifiable and non-modifiable risk factor for a number of podiatric conditions. [15] [16] 

Diabetes is non-modifiable when we talk about type 1 diabetes. It represents 5-10% of all cases and cannot be prevented or delayed through lifestyle modifications although they play an important role in the management of the disease ​[17] [18]​.  

On the other hand, type 2 diabetes (up to 95% of all cases) can be managed or in some cases even prevented through lifestyle modifications if diagnosed in a timely manner because many patients show symptoms of prediabetes ​[19]. Nevertheless, type 2 diabetes is on the rise, mainly due to lifestyle-related risk factors; some of them (obesity, lack of physical activity, smoking) can also contribute to podiatric issues [20] [21] [22]​. 

The aforementioned factors namely increase the risk for Peripheral Arterial Disease (PAD), which is also growing in prevalence; it is estimated that there were at least 230 million adults with PAD in 2021) ​[23]​. A check-up for PAD is helpful to a podiatrist during differential diagnosis when a patient presents with pain in the lower extremities (due to intermittent claudication or something else). A podiatrist may also make the first step in making the diagnosis of PAD – especially if treating a patient with leg ulcers, which are frequent in patients with late-stage PAD, diabetes or often both.  

The most common types of leg ulcers are venous ulcers, representing 72% of all cases. Arterial insufficiency (ischemic) ulcers come in second, with a prevalence of between 10-30% ​[25]​. The rest are neuropathic ulcers, lymphatic ulcers, infectious ulcers, and ulcers of mixed etiology. Mixed ulcers  tend to be particularly difficult to treat due to comorbidity with other, often systemic diseases [25].  

The treatment of the two most common types of leg ulcers (venous and arterial) differs considerably, with the latter more complex and costly ​[24]​. In any case, however, the effects of inadequate, late or no treatment of leg ulcers are serious and can progress into gangrene and amputation of the affected limb. This results in increased mortality (5-year mortality rate post amputation is around 50%) as well as impaired mobility [26]​. In many cases, these complications result from poorly managed or undiagnosed diabetes; such patients are often physically inactive or have a rather sedentary lifestyle prior to the diagnosis of diabetes (and the onset of the related complications). They are also likely overweight or obese (more than 90% of patients with type 2 diabetes have a BMI ≥25.0 kg/m²) ​[27]​. 

Obesity

Obesity, lack of physical exercise, diabetes and cardiovascular issues (diagnosis of PAD is indicative of systemic atherosclerosis) can go hand in hand, resulting in decreased quality of life and higher mortality rates [28]​. From a podiatric perspective, a significant weight increase is a risk factor for non-specific foot pain, chronic plantar heel pain (CPHP) and foot joint pain (FJP) ​[29]​ [30]​ [31]​​. The impact on the cardiovascular system should also not be underestimated since obesity is increasing in prevalence ​[28]​ [32]​​. Fortunately, the prevalence of smoking (another major risk factor for cardiovascular diseases) has decreased significantly, although to a lesser degree in low- and middle-income countries ​[33]​​.  

Smoking

Research has identified smoking as the single biggest risk factor for the development of PAD in both genders. In comparison with those who have never smoked, the prevalence of symptomatic PAD is 2.4 times higher in current smokers and 2.6 times higher in former smokers ​​[34]​. Female smokers are 20 times more at risk than females who have never smoked ​​[35].  

The association between smoking and PAD is estimated to be 2 to 3 times stronger than that of smoking and the incidence of coronary artery disease (CAD) ​​​[36]. Smoking doubles the rate of major fatal and non-fatal CVD events in smokers in comparison with non-smokers, and triples the rates of cerebrovascular disease, acute myocardial infarction (AMI) and heart failure ​​​[37]. Podiatrists can help lower this statistic by performing a short arterial assessment at their office on all patients who belong to PAD risk groups. 

How to easily perform vascular assessments at the podiatry office?

Ankle-Brachial index (ABI) measurement

The Ankle-Brachial Index (ABI) is a comparison of blood pressure in the legs and the arms. It is non-invasive and painless. Using automated MESI mTABLET ABI, the procedure is quick and simple – it only takes 1 minute. The results of the ABI measurement are automatically saved into the patient’s electronic record and can also be immediately shared for a specialist opinion in PDF format.  

The clinical significance of ABI should not be underestimated. In addition to being a reliable predictor of PAD, low ABI is associated with: 

• coronary artery disease (CAD) and cerebrovascular disease (CVD) (32% of patients with PAD) ​[38]​, 

• renal insufficiency (RI) (39.7% of patients with PAD) ​[39]​, 

• diabetes (49.7% of patients with PAD) ​[40]​, 

• metabolic syndrome (58–63% of patients with PAD) [41] [42]​, 

• hypertension (35–55% of patients with PAD) ​[43]​, 

• hypercholesterolemia (60% of patients with PAD) ​[44]​. 

Toe-Brachial Index (TBI) measurement

When an ABI result is quite high (more than 1.30 or 1.40) or inconclusive, it can be suspected that the patient suffers from incompressible arteries (medial arterial calcification – also known as Mönckeberg’s sclerosis). This calls for an additional Toe-Brachial Index measurement (i.e. a comparison of the blood pressure in the toes and the arms). 

Medial arterial calcification often occurs in patients with diabetic complications, advanced renal disease or rheumatoid arthritis, so it is advisable to measure TBI rather than ABI in such cases ​[45]​. The TBI result is more reliable because calcification rarely affects the arteries in the toes ​[46]​. Again, the measurement of the Toe-Brachial Index with the MESI mTABLET TBI only takes 1 minute. 

Like the ABI, the TBI also has prognostic value. Research shows association between: low TBI and an increased risk of recurrent CVD; progression of diabetic nephropathy in patients with type 2 diabetes; and an increased risk of all-cause mortality in dialysis patients ​[47]​ [48]​ [49]​​.  

ABI and TBI measurements can be easily expanded with an inclusion of another important predictor of cardiovascular health – pulse wave velocity (PWV). 

Pulse wave velocity (PWV) measurement

Studies have found that each 1 m/s increase in pulse wave velocity (PWV) increases the overall cardiovascular mortality by 12-14%; a carotid-femoral PWV of above 10 m/s is classified as asymptomatic organ damage in the 2018 ESC/ESC Guidelines for the Management of Arterial Hypertension ​[50]​​ [51]​​​. Using the MESI mTABLET diagnostic system, pulse wave velocity can be assessed together with the Ankle-Brachial Index measurement on the MESI mTABLET ABI. The user only needs the PWV app, and a comprehensive arterial assessment can be performed right there at your podiatry office.