Feet First

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Feet First
Westminster


Primary Care Trust

• Foot Health Podiatry for Homeless People

Alison A Gardiner BSc MChS HPC Reg Specialist
Podiatrist for Homeless and Vulnerable
People Westminster PCT
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Content

• Westminster PCT health care provision for
  homeless people overview
• Westminster Homeless Podiatry service.
• Foot facts
• Common foot conditions
• Diabetes and Feet. Health inequalities
• Why are homeless people more prone to foot
  problems?
• Case studies
• Important considerations
• Conclusion

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Westminster PCT Homeless Health Care

• The Homeless Health Team - GPs, nurses, CPN and
  podiatrist.
• PCT leases premises in 3 charity run day centres.
  Also linked to 2 GP practices for homeless people
  with dentist, psychiatrist, benefits advice,
  legal advice, drug and alcohol worker, optician
  etc. Podiatry at 3 day centres one GP surgery.
  Four podiatry sessions a week in total.
• Day centre volunteers help with running of
  clinics
• Computer records kept. Vision. All sites
  linked.
• Telephone interpreters. Language Line

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Podiatry Service

• 60 of my post
• Funding by podiatry service and Homeless Health
  Team.
• Clinical provision in day centres. Occasional
  street visits. Hostel visits for housebound.
• Health promotion for service users in day
  centres/hostels. Training for hostel/day centre
  staff
• Promote access of vulnerable people to mainstream
  service. Training for colleagues mental health,
  drugs and alcohol, working with interpreters etc.
  Rotations for colleagues. Undergraduate
  placements and teaching. University of East
  London

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• When your feet hurt you hurt all over.
  (Socrates)
• The foot is a masterpiece of engineering a
  work of art. (Leonardo da Vinci)

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• Foot Facts
• The foot contains 26 bones, 100 ligaments, 33
  joints 20 muscles.
• The skin of the feet have 250,000 sweat glands
  releasing nearly a cup of moisture a day.
• The average person walks 4 miles every day.

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What do Podiatrists treat? Foot Conditions
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• Corns. (Hard and Soft). (Heloma durum, heloma
  molle)
• Cause. Pressure, (eg shoes, biomechanics,
  deformity)
• Treatment. Scalpel debridement, shoe and self
  care advice, not to use corn plasters, insoles,
  biomechanical assessment

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• Bunion
• (Hallux abducto valgus)
• Description Medially deviated 1st toe with OA
  enlargement of 1st metatarsophalangeal joint,
  restricted ranger of motion, may push up 2nd toe
  which may become dislocated. Difficulty with shoe
  fitting.
• Cause. Biomechanics, footwear, RA, OA
• Treatment. Shoe advice, orthopaedic shoes,
  biomechanical assessment, orthoses, surgery.

• Hammer Toes Clawed deformity of lesser toes.
  Dorsal lesions can occur difficulty with shoe
  fitting.
• Cause and treatment. Similar to bunion

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• Verruca Cauliflower appearance with overlying
  callus. May be painful if occurs on weight
  bearing area of foot.
• Cause. Viral skin infection.
• Treatment . Acid, cryotherapy, laser, occlusion

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• Heel Fissures crack in heel. May be shallow or
  deep. May become infected if open to deeper
  layers of skin
• Cause. Dry callused skin round perimeter of heel.
  Dermatitis, psoriasis.
• Treatment. Callus debridement, advice to use a
  foot file, emollient, shoe advice,
  dressings/antibiotics if open/infected.
• Ingrown toenail - May be inflamed /infected.
• Cause. Footwear, involuted nail, trauma, nail
  spicule left by poor nail cutting which has
  pierced skin.
• Treatment. Conservative. Antibiotics. Shoe
  advice. Surgery

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Neglected Nails
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• Mycotic Infections infected nails appear
  thickened discoloured. Infected skin may appear
  inflamed, blistered wet if between the toes.
  May have a dry, peeling, blistered appearance on
  other parts of the foot. Usually very itchy.
• Cause. Poor hygiene, sleeping in shoes
• Treatment. Nail cutting, foot care advice,
  topical preparations. Oral medication or lacquer
  for nail infections

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High arched, cavoid feet- A very rigid foot
type. High pressure loading to balls of feet
heels with may result in painful corns callus.
Lesser toes often clawed causing dorsal lesions.
May be related to neurological conditions such as
Charcot Marie Tooth disease. May need reduction
of pressure lesions insoles. Shoe advice
Pes Planus Flat feet- A very mobile foot type.
Thought to be related to development of bunions
other biomechanical foot problems. Orthotics may
be helpful if symptomatic.
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• Biomechanical Problems
• Heel, forefoot, knee, hip, back pain
• Cause. Acquired, congenital
• Treatment. Biomechanical assessment , Orthotics,
  exercises, shoe advice, NSAIDS

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• Trench Foot
• Causes. Not removing shoes,
• sweaty feet, poor footwear often plastic
• Treatment. Advice to air feet, hygiene, provision
  shoes/socks

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Diabetes

• 1.3 million diagnosed cases in the UK but can go
  undiagnosed for years
• 1 in 20 over age of 65
• Most common cause of amputation of the lower limb
  in the UK

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• Health Inequalities Diabetes
• Men more likely to develop diabetes but women
  have higher rates of complications and mortality.
• Black and ethnic minority groups
• Social exclusion/ deprivation/ mental health
  problems/learning difficulties
• See National Service Framework for Diabetes,
  section on Health Inequalities.

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Diabetes Feet

• Poor diabetic control can lead to
• Peripheral neuropathy
• Peripheral vascular disease
• Ulceration, infection, gangrene and amputation.
• NB Ulcers may be painless if neuropathy is
  present.

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• AMPUTATION INFECTION risks reduced by
• Good diabetic control
• Foot care education
• Annual screening for neurovascular foot
  complications
• Podiatric treatment of any foot problems

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Why are homeless and vulnerable people more
prone to foot problems?
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• Increased risk of diabetes diabetic
  complications
• Walking long distances. Stress relief. No choice!
  Blisters, biomechanical problems.
• Mental health. Self neglect. Can border on self
  harm.
• Poor hygiene. Scabies, infections (fungal and
  bacterial).
• Exposure to elements. Cold/wet/heat
• Poor nutrition. Poor healing and infection. May
  not get to food hand outs etc due to foot pain

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• Finance. Lack of money for good well fitting
  shoes, (ideal leather lace ups/trainers), socks
  nail clippers. Pulling off nails, sharing
  clippers.
• Not removing shoes/socks. Fear of theft, self
  neglect, need move quickly. Trench foot. Fungal
  infections
• Self treating with blades, knives. Ulceration.
  Infection and scarring.
• Smoking
• Sharing showers. Verrucae

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• Alcohol. Peripheral neuropathy, increased
• risk of diabetes, osteoporosis, poor immunity,
  assault, accidents. Self medication of foot pain
• Sleeping with legs dependant on buses/benches
  oedematous feet and legs.
• Drugs. Infection of injection sites, thrombosis,
  HIV. Self medication for foot pain.
• Asylum seekers. Conditions rarely seen in UK
  which can affect feet polio, TB, leprosy,
  rickets, polydactyly, industrial/agricultural
  accidents, torture

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• Difficulty accessing health care
• Not registered with a GP
• Forgetting appointments, frustration with making
  appointments, no mail address, waiting times.
• Stressful waiting rooms, difficulty
  communicating with medical staff/receptionists
  due to mental health problems etc.,
  perceived/actual insensitive treatment by medical
  staff. Embarrassment.
• Language barriers, illiteracy, no glasses
• Lack of awareness of podiatry
• No internet access

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CASE STUDIES Westminster Homeless Podiatry
Service
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• 57 year old
• Rough sleeping white male
• Alcoholism
• Trench foot
• Issued with socks and shoes, foot care advice.

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• Age 45 black African male hostel resident
• Good health
• Bow legs - (childhood rickets?)
• Heavy heel callus
• Callus removed, advice on self care with foot
  file, emollient prescription, orthotics, shoe
  advice.

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• Afro Caribbean 39 year old male rough sleeper
• Alcohol, cannabis, cocaine, heroin, smoker
• Fracture of left leg age 24 led to clawed toes
  large painful corn under left foot
• Patient self treated
• Infection hospitalisation.
• Corn removed, self care advice,
  physio/orthopaedic/podiatric surgery referral,
  orthopaedic shoes, insoles

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• 44 years old rough sleeper
• Born Bombay. UK resident many years
• Crack heroin
• Previous fracture right leg
• Painful corn fungal nail infection
• Corn removed, self care advice, wider shoes

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• White male rough sleeper, 63
• Frequent hostel evictions. Revolving door
  prison/street/hostel
• Alcoholic, Wernicke-Korsakoff Syndrome, epilepsy.
  Poor circulation, heavy smoker
• Fracture right ankle age 15 not set. Walks on
  side of foot.
• Infected ulcer right foot. Trench foot

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• Seen many times in day centre clinic but not able
  to self refer or follow advice due to
  Korsakoffs. Never takes off shoes/socks. Not
  suitable for surgery. Ulcer dressing and padding.
  Antibiotics. Orthopaedic shoe referral
  eventually!

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• Important considerations
• Aim to provide a service which is equal to
  mainstream i.e. access to specialities, (diabetes
  specialist podiatrist, musculo skeletal
  specialist), equipment, infection control etc.
  Good links to mainstream helpful.
• Common podiatry problems may need a different
  approach e.g.. Verrucae, ingrown toenails.
• Less common problems trench foot, torture
• Annual diabetic foot check. How to achieve?
• Supplies of shoes and socks . Encourage day
  centre to provide. Supporting letter to benefit
  office.

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• If in stable accommodation, can refer to the
  mainstream podiatry service if appropriate.
• Assertive promotion of service. Flyers, posters
  etc.
• Challenges and opportunities of working alongside
  non NHS organisations and staff.
• Safety! Room set up, alarms, client info,
  training, agreed policies, (seeing intoxicated
  patients etc.)
• Consent issues
• Inter-professional working /holistic approach.
  Signposting to counselling, other medical
  services etc.,
• Other vulnerable groups prisoners, travellers
• Drop in versus appointments?

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• Mainstream medical services can benefit hugely
  from drawing on the expertise and experience of
  homeless services in providing health care to
  groups that are vulnerable and difficult to
  reach, thus helping to reduce health inequalities
  in the UK.

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Thank you!

• Podiatry Head Office
• Health at The Stowe
• 260 Harrow Road,
• London W2
• Tel [phone]
• Alison.gardiner_at_westminster-pct.nhs.uk
• 07752 832539