Are Patients With Foot Pain At A Higher Risk Of Recurrent Falls?
Severe foot pain and planus posture leave patients at a higher risk of falling, according to a recent study in Gerontology.
The study, focusing on 1,375 patients with a mean age of 69, found that 263 patients related one fall in the past year and 152 patients had two or more falls. Researchers note that foot pain was linked with a 62 percent greater risk of recurrent falls and patients experiencing moderate or severe foot pain had higher odds of two or more falls. In addition, the study notes that patients with planus foot posture have a 78 percent higher risk of falls while foot function had no association with falls.
In his practice, Doug Richie, DPM, FACFAS, has found patients with foot pain have significant impairment of balance.
“This is obvious when we watch (patients) walk but more dramatic when asking them to perform specific balance tests such as the modified Romberg test where they stand on one foot with arms folded and close their eyes,” says Dr. Richie, an Adjunct Associate Professor within the Department of Applied Biomechanics at the California School of Podiatric Medicine at Samuel Merritt University in Oakland, Calif.
David G. Armstrong, DPM, MD, PhD, acknowledges the long-held idea that instability is a driver of fear of further movement and can increase the risk for falls. The study lends “strong evidence to the fact that what we do in podiatric medicine and surgery can have a profound impact in stabilizing that thing that’s closest to the ground,” according to Dr. Armstrong, an incoming Professor of Surgery at the Keck School of Medicine at the University of Southern California and the Director of the Southwestern Academic Limb Salvage Alliance (SALSA).
As for planus foot posture, Dr. Richie notes the older patient with adult-acquired flatfoot clearly demonstrates balance impairments with clinical testing. Anecdotally, he has found this patient population will report more falls than the average older patient in his practice. As for all patients with planus foot types, Dr. Richie has not seen a trend toward increased fall risk in his own patient population unless those patients also have pain. He notes research has shown that patients with various foot postures and a planus foot type have compromised dynamic balance.
Patients with foot pain and planus foot posture demonstrate weakness of the ankle, which Dr. Richie says compromises their “ankle strategy” to maintain upright posture.
“Strengthening all the lower extremity muscles from the hip down can definitely improve balance over time. Balance training with a wobble board or other devices will also improve postural control in all patient populations,” notes Dr. Richie.
When most clinicians think about instability, Dr. Armstrong feels they focus on the brain or the head and neck, and do not think very much about the foot and ankle. He says the recent study highlights the need for focusing on the lower extremity in preventing falls.
As for older patients with foot pain, Dr. Richie notes studies have shown that specific strengthening of the toe flexors combined with the use of customized foot orthoses can reduce fall risk. To reduce falls in his own clinical practice, he commonly refers elderly patients to a qualified physical therapist for balance training and makes specific footwear recommendations, including requiring patients to wear shoes at home. Finally, Dr. Richie implements custom foot orthotic therapy to improve balance in elderly patients with foot pain and abnormal foot posture.
How Effective Is The Direct Plantar Approach To Plantar Plate Repair?
By Brian McCurdy, Managing Editor
A recent study in the Journal of Foot and Ankle Surgery relates good postoperative pain relief, better foot function, and fewer limitations to activity when patients have plantar plate repair with a direct plantar approach.
Researchers performed a retrospective analysis of patients who had direct plantar plate repair with or without a Weil osteotomy, focusing on 144 toes in 131 patients. Authors noted a well-aligned toe resulted in 87.1 percent of patients with a 7.6 percent recurrence rate and a 2.8 percent revision rate. The authors note further studies should compare the plantar and dorsal approaches to the plantar plate.
Craig Camasta, DPM, FACFAS, FASPS, cites several advantages to the plantar approach, including gaining direct access to pathology on the plantar surface and not needing to perform an unnecessary metatarsal osteotomy (Weil or other configuration). He also notes the plantar approach can address both a ruptured or attenuated plantar plate and debride frayed tissue with direct access. Furthermore, he says the plantar approach can correct for some transverse plane deformity by wedging the plantar plate repair, and can allow surgeons to combine flexor tendon transfer with the plantar plate repair.
There is also a shorter operating time and lower cost with the plantar approach as well as higher patient satisfaction, according to Dr. Camasta, a faculty member of the Podiatry Institute, who is in private practice at Village Podiatry Centers in Atlanta.
Although a plantar scar is a commonly cited reason to not use the plantar approach, Dr. Camasta has found the plantar scar is not a problem in most cases with only 5 percent of patients reporting ongoing problems related to the plantar scar.
In contrast, avoidance of plantar scar is the only advantage to the dorsal approach for Dr. Camasta. He cites several disadvantages to the dorsal approach, including needing to unnecessarily detach soft tissue from the base of the proximal phalanx to access the use of suture devices and needing to perform an unnecessary metatarsal osteotomy in most cases (he performs a metatarsal osteotomy in less than 25 percent of cases for the plantar approach). Dr. Camasta says the dorsal approach also has a longer operating time, a lack of studies with long-term results and requires expensive sutures and anchoring implants.
For further reading, see “Emerging Concepts In Plantar Plate Repair” in the February 2015 issue of Podiatry Today or “Point-Counterpoint: Is The Dorsal Approach Better Than The Plantar Approach For Plantar Plate Repair?” In the October 2015 issue.
Study: Metatarsal Head Resection Is Superior To Medical Therapy For Neuropathic DFUs
By Brian McCurdy, Managing Editor
A recent study in the Journal of Foot and Ankle Surgery compares metatarsal head resection with a medical approach to neuropathic diabetic foot ulcers (DFUs) at the plantar surface of metatarsal heads.
The retrospective study compared the use of metatarsal head resection in 24 neuropathic diabetic foot ulcers to the use of medical therapy in a control group of 25 ulcers. Authors found the resection group had faster wound healing and a lower infection rate while the medial therapy group had higher rates of DFU recurrence and hospitalization.
As Monica Schweinberger, DPM, FACFAS, notes, a single metatarsal head resection can take pressure off the plantar skin and help with ulcer healing. However, she does note considerable potential for a transfer lesion, which could lead to recurrent ulceration.
“I would not consider metatarsal head resection in isolation unless the patient has osteomyelitis,” says Dr. Schweinberger, who is affiliated with the Veterans Affairs Medical Center in Cheyenne, WY. “If more than one metatarsal head was involved, I would recommend transmetatarsal amputation with appropriate tendon balancing.”
With good wound care and offloading, Dr. Schweinberger notes many neuropathic foot ulcers will heal without any surgical intervention. Patients having medical therapy need adequate circulation for healing as well but she says this would also be necessary for successful surgical intervention. If deformities are causing the pressure that resulted in ulceration, Dr. Schweinberger says one may need to correct those deformities although she recommends waiting until the ulcer heals if possible. She notes appropriate offloading with shoe gear/orthotics/bracing will be necessary after ulcer healing to help prevent recurrence.
Patients without severe deformity fare the best with conservative treatment, according to Dr. Schweinberger. If patients are able to stay off their affected foot, she says they will also do better. Patients with good blood sugar control as well as good or restorable blood flow will tend to do better with any treatment, notes Dr. Schweinberger.
