Time to discuss a clinical topic Section

Medicine and feet. Nothing is too much trouble!

A consultant podiatric surgeon shares his case load diary this week, focusing on medicine.

Case 1: John came into clinic to have a simple cyst managed on one of his toes. Podiatrists not only specialise in feet but have to understand medicine broadly. John had a routine screening and we found his haemoglobin levels lower than they should be. This meant he had iron deficiency anaemia and not ideal for his heart and lungs which easily fatigued. Six weeks after surgery his cyst has healed and he also feels better with treatment for his anaemia.

Case 2: Irene was told by her insurer they would not pay for her urine test, only a blood test. This is incredulous as urine tests are cheap and highly valuable picking up early kidney disease, urine infection, diabetes and renal function. We would avoid any need for taking bloods unless necessary. Patients must not be bullied by insurers so that consultants cannot make essential decisions using cheaper methods. No-one likes needles unnecessarily. Better to have a pee test… Urine tests are now sensitive to many chemicals found in urine and can help define disease. 4% of patients with diabetes can be picked up by routine tests. Blood tests should be used as second phase testing in normal patients or those with less suspicion. Patients should always be aware that no single test alone should mark confidence that disease is present so self diagnosis can be misleading. Insurers often try to cut down costs by limiting testing which in Irene’s case was frustrating. Always be careful when selecting private providers and ask what might be restricted when you purchase that expensive package.

Case 3: A chiropodist panicked a patient after carrying out a vibration test. The lady was over sixty and vibration tests are not that reliable and in fact diminish in the lower limb as we get older. Perhaps she would not be wise to have surgery so the chiropodist thought? Vibration sense is important but varies in patients. With the absence of medical disease in older patients this is harmless. Had the chiropodist used more tests and general knowledge other than a single test, this would have been less alarming for the patient. The patient’s GP was bemused and wanted me to discuss this. All was well and our full medical evaluation before surgery reassured her.

Case 4: A 14 year old student with type 1 diabetes had blisters and thick skin on her heels. As we contrast case 3 we know that early signs of vibration loss and other neurological signs can be relevant. The young girl tipped her ankles out because her inverter muscles were overworking. Her reflexes were normal but proprioception ability in the ankle was sub normal. Small nerve fibres ensure that we know where our joints are in space (off the ground) and under pressure (in contact with the ground). Diabetes affects the small fibres through diminished blood flow at microvascular level. These are vessels smaller than usual. Even though diabetes can be well controlled even small signs must be noted. The inverted heel squashed the fat pad which weakened. The overlying skin layer (epidermis) responded to this physiological change, causing blistering and thickened skin. Fat and skin share a close relationship. The objective of podiatry treatment is to balance the foot mechanics and to do this we work with physiotherapy at Spire Hospital and local GPs to maintain good diabetic care.



Leave a Reply

Your email address will not be published. Required fields are marked *