Feet FirstFoot Health & Podiatry for

Homeless People

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

Westminster PCT

Westminster Primary Care Trust

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

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

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

• “When your feet hurt you hurt all over.” (Socrates)

• “The foot is a masterpiece of engineering & a

work of art.” (Leonardo da Vinci)

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.

What do Podiatrists treat? Foot Conditions

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

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

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

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

Neglected Nails

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

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.

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

Biomechanical ProblemsHeel, forefoot, knee, hip, back pain

• Cause. Acquired, congenital• Treatment. Biomechanical assessment , Orthotics, exercises, shoe advice, NSAIDS

Trench Foot

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

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

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.

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.

AMPUTATION & INFECTION risks reduced by

• Good diabetic control

• Foot care education

• Annual screening for neurovascular foot complications

• Podiatric treatment of any foot problems

Why are homeless and vulnerable people

more prone to foot problems?

• 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

• 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

• Alcohol. Peripheral neuropathy, increasedrisk 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

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

CASE STUDIES

Westminster Homeless Podiatry Service

• 57 year old

• Rough sleeping white male

• Alcoholism

• ‘Trench foot’

• Issued with socks and shoes, foot care advice.

• 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.

• 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

• 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

• 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

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

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.

• 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?

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.

Thank you!

Podiatry Head OfficeHealth at The Stowe260 Harrow Road,London W2 Tel: 0207 316 6808

Alison.gardiner@westminster-pct.nhs.uk07752 832539