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Foot ulceration in diabetes mellitus is common. Foot problems remain the commonest cause of hospital admission amongst patients with diabetes in Western countries. The lifetime risk of a patient with diabetes developing an ulcer is 25%, and up to 85% of all lower limb amputations in diabetes are preceded by foot ulcers. As many as 50% of older patients with type 2 diabetes have risk factors for foot problems and regular screening by careful clinical examination is essential; those found to be at risk should attend more regular follow-up together with education in foot self-care. The key to management of diabetic neuropathic foot ulceration is aggressive debridement with removal of callus and dead tissue, followed by application of some form of cast to offload the ulcer area. Most ulcers will heal if pressure is removed from the ulcer site, if the arterial circulation is sufficient and if infection is managed and treated aggressively. Any patient with a warm swollen foot without ulceration should be presumed to have acute Charcot neuroarthropathy (CN) until proven otherwise. The optimal approach to reducing ulceration requires regular screening, patient education and a team approach to management, both in the community and in hospital.

This article describes the development of a nurse-led voluntary organisation that provides basic foot care to the homeless at street level in three Welsh cities. There is a large percentage of street sleepers who choose not to access professional health and care services for various reasons, and many of these individuals have foot health problems, such as sore, painful, swollen feet from continuous walking, calluses, dried skin, blisters that are often de-roofed and trench foot. Through support and education, however, several of these people have been able to take ownership of their identified problems, by building trusting relationships with Homeless Hope nurses. Through collaborative communication with professional services, Homeless Hope nurses provide an informal link between non-engaging rough sleepers and the services in place to help support them.

Charcot arthropathy is a progressive condition primarily affecting the lower limbs in patients with diabetes mellitus. It is a rare complication of diabetic neuropathy and if left untreated can lead to severe limb destruction necessitating major amputation. Here, we report the case of a 41-year-old female who presented with rapidly progressive Charcot foot over a 10-day period, necessitating open reduction and internal fixation of Lisfranc-type fracture dislocations. Her presentation with a rapidly progressing red, swollen foot with a blister on the plantar aspect prompted initial treatment on the basis of a diabetic foot infection. The report will therefore serve as a useful reminder to maintain a high index of suspicion for Charcot foot, which may present in an atypical manner.

Aim The aim of this study was to assess the relationship between ultrasonographic features of tibialis posterior (TP) tendon in rheumatoid arthritis (RA) patients and associated pes planovalgus (PPV) foot deformity. Patients and methods This study included 20 (40 feet) RA patients with PPV and ultrasound-proven TP tenosynovitis. The following variables were recorded for patients: the number of tender and swollen foot joints count, foot posture index (FPI), Health Assessment Questionnaire, and Disease Activity Score 28 (DAS28). FPI is a clinical tool used to quantify the degree to which a foot is pronated, neutral, or supinated using the set criteria. Patients underwent high-resolution ultrasound of the TP tendon. Measurement of tendon diameter was recorded in the retromalleolar region. The presence of fluid around the TP tendon and levels of power Doppler signal (PDS) were assessed. Results High disease activity was detected in patients (mean DAS28 of 5.89). Eighteen (45%) feet had thickened transverse diameter and 15 (37.5%) feet had thickened longitudinal diameter. Twenty-three feet showed PDS. Nineteen feet had fluid around the tendon, detected only in the retromalleolar region. Regarding FPI, 14 feet were mild to moderate pronated feet and 26 feet were highly pronated feet. There were direct correlation between FPI and both DAS28 (p=0.05) and transverse diameter thickness (p=0.01). Highly pronated feet had higher DAS28 (p=0.03), increased transverse diameter thickness (p=0.04), more detection of fluid around the TP tendon (p=0.005) as well as higher incidence of PDS around the TP tendon (p=0.002). Conclusion Higher degree of pronation in RA feet with PPV is associated with ultrasonographic increased tendon thickness, PDS, and fluid around TP tendon. Early diagnosis and intervention for TP tenosynovitis may prevent progressive PPV foot deformity.

Diabetes is an increasing problem in the modern world. Along with the rise in prevalence of the disease the number of diabetic complications presenting is increasing and amongst these is diabetic foot issues. Foot infection and Charcot arthropathy are the two key pathologies that present acutely with a hot swollen foot. Both require timely diagnosis and management to prevent disastrous long-term sequelae. Acutely presenting foot infections are both limb and life threatening and require urgent intervention to improve the chance of limb salvage. The ability to recognize and acutely deal with a diabetic foot requiring urgent surgical drainage is relevant to all orthopaedic surgeons with an on-call commitment and not solely to the foot and ankle specialist. Charcot arthropathy results in foot deformity that increases the likelihood of future ulceration and infection. The differentiation and acute management of the two conditions will be discussed.

At least half of all amputations occur in people with diabetes, most commonly because of an infected diabetic foot ulcer. A thorough understanding of the causes and management of diabetic foot ulceration is essential to reducing lower-extremity amputation risk. This compendium elucidates the pathways leading to foot ulcers and enumerates multiple contributory risk factors. The authors emphasize the importance of appropriate screening and wound classification and explain when patients should be referred for specialist care, targeted education, or therapeutic shoes or insoles. They provide a comprehensive review of treatment approaches, including devices for foot lesion off-loading and aggressive wound debridement through mechanical, enzymatic, autolytic, biologic, and surgical means. Because infection and peripheral artery disease are key contributors to amputation risk, the authors discuss the diagnosis and management of these conditions in detail. They also review the expanding armamentarium of evidence-based adjunctive treatments for foot ulcers, including growth factors, skin substitutes, stem cells, and other biologics. Because Charcot neuroarthropathy is a serious but frequently missed condition in people with diabetic neuropathy, the authors explain the differential diagnosis of the hot, swollen foot that is a hallmark of this condition. The article ends with an overview of four strategies for maintaining a foot in remission, followed by a brief look at the future of diabetic foot care.

Patients with diabetes and a painful, hot, swollen foot can sometimes present a diagnostic challenge. Gout can often present in a similar fashion to diabetic foot infections or acute Charcot neuro-osteoarthropathy, and cases have been described where patients with Charcot neuro-osteoarthropathy were misdiagnosed as having gout, leading to treatment delay. We describe a patient who presented with a painful, swollen, warm foot who did not respond to initial treatment with antibiotics. Improvement in his symptoms occurred following treatment for gout, however he then went on to develop Charcot neuro-osteoarthropathy. As far as we are aware, this is the first case described in the literature where acute gout may have triggered acute Charcot neuro-osteoarthropathy. It is important to bear in mind that more than one pathology may be present in a patient at the same time or may closely follow one another.

The usual presentation of Charcot neuropathic osteoarthropathy (CN) is of a hot red swollen foot but later presentations are characterised by deformity and ulceration, which may be complicated by infection. Having reached the stage of significant foot deformity and sometimes ulceration, patients with CN may also have peripheral arterial disease. It is unlikely that significant ischaemia was present at the onset of the CN but in the time interval from onset of the Charcot foot to acquiring deformity, it may have developed. Such patients can occasionally present with rest pain. Also, an association between Charcot foot, diabetic neuropathy, and medial arterial calcification has also been noted. The disease is usually infrapopoliteal but may be also femoro-popliteal. Arterial disease may compromise ulcer healing and surgical and orthopaedic interventions for the Charcot foot and thus all patients with this advanced presentation of CN should be investigated for vascular disease. A limited number of studies show the effectiveness of endovascular treatment in cases with Charcot foot and peripheral arterial disease. In a series of patients with ischaemic foot and also CN, the limb salvage rate was 90% and mean time to healing was 197 days after endovascular treatment. In conclusion, all Charcot foot patients with ulceration and those being considered for surgery should have vascular investigations. If surgery is planned for the Charcot foot, revascularisation, within a multidisciplinary approach, should be considered before surgery for limb preservation.

Acute Charcot neuroarthropathy of the foot and ankle presents with the insidious onset of a unilateral acutely edematous, erythematous, and warm lower extremity. The acute stages are typically defined as Eichenholtz Stage 1, or Stage 0, which was first described by Shibata et al. in 1990. The ultimate goal of treatment is maintenance of a stable, plantigrade foot which can be easily shod, minimizing the risk of callus, ulceration, infection, and amputation. The gold standard of treatment is non-weight-bearing immobilization in a total contact cast. Surgical intervention remains controversial. A review of the literature was performed to provide an evidenced-based approach to the conservative and surgical management of acute Charcot neuroarthropathy of the foot and ankle.Keywords: foot collapse; neuroarthropathy; peripheral neuropathy; swollen foot; total contact cast(Published: 19 March 2015)Citation: Diabetic Foot & Ankle 2015, 6: 26627 - http://dx.doi.org/10.3402/dfa.v6.26627

Charcot neuropathic osteoarthropathy (CN) is one of the most debilitating complications of diabetic neuropathy. It classically presents as a red hot swollen foot, precipitated by trauma. The latter le

Category: Diabetes Introduction/Purpose: Charcot osteooarthropathy (CN) is a debilitating condition afflicting the bone, soft tissue and joints of foot and ankle and is related to pain insensitivity. Its pathogenesis and natural progression is poorly understood. In patients with high clinical suspicion, treatment with immediate off-loading and immobilisation may halt and (help to) reverse or prevent deformity. We aim to establish the role of SPECT CT in the diagnosis of acute charcot osteoarthropathy of the red swollen foot prior to radiographic changes and assess its reliability in diagnostic accuracy and guiding treatment. Methods: A prospective, observational review of all patients presenting to the multidisciplinary diabetic foot clinic from 1st Jan 2009 to 1st Jan 2013 with clinically suspected acute active charcot arthropathy was performed. All patients with a high clinical suspicion of acute CN and normal radiographs, underwent SPECT-CT within 10 days of the assessment after emergency off-loading in a TCC. A positive SPECT CT scan for new onset acute CN was diagnosed if radioisotope uptake was seen in all 3 phases of scanning. Further CT fusion images provided localization of ongoing activity. All patients were followed up for 1-year or until treatment ceased and treated in concordance with clinical symptoms and SPECT CT imaging. Results: In total 137 patients were referred or self referred with a high suspicion of new onset acute CN. The majority being diabetic (98%), including 116 unilaterally symptomatic feet with normal radiographs; 86 were consequently positively confirmed on SPECT-CT CN; 15 new ‘diabetic’ fractures were diagnosed on the CT component. At 1 year – only 5 patients went on to develop radiological changes consistent with charcot arthropathy even with accepted off loading in TCC. Thirty negative scans were recorded where no triple phase trace response & localisation was uni-focal or not associated with skeletal structures. Differential diagnosis included cellulitis, degenerative changes, old fractures, and planter fasciitis were made. At 1-year none of the patients were found to have developed CN in neither in the form of foot deformity nor radiological evidence of fragmentation or loss of normal bone anatomy. Conclusion: A combination of symptoms including swelling, pain and/or heat, positive three phase tracer uptake and localisation on SPECT CT can identify and aid the management of acute active CN in radiographically normal feet. Positive scans seem to identify an intermediate grade of charcot arthropathy where cortical fractures have occurred with significant subchondral bone turnover. A negative scan excludes high-risk feet for CN confidently and thus can direct treatment. We find SPECT CT a valuable addition to the armamentarium of the treating physician in instituting off loading to prevent the possible progression and onset of deformity and avoiding unnecessary treatment.

In patients with long-standing, poorly controlled diabetes and peripheral neuropathy, a red, hot, swollen foot without open ulceration should raise the suspicion of Charcot neuroarthropathy, an often-overlooked diabetic foot complication. The authors discuss key diagnostic features and how to differentiate this condition from cellulitis, osteomyelitis, and other conditions. They review key elements of the workup and emphasize the importance of early diagnosis and prompt treatment to preserve a functioning foot.

A cross-sectional survey of 68 integrated Irish pig farms was conducted to determine the prevalence and risk factors for foot and limb lesions in 2948 piglets from 272 litters. One litter was selected per age category; 3–7 days, 8–14 days, 15–21 days and 22–28 days per farm. All piglets were examined for sole bruising, sole erosion, coronary band injuries, limb abrasions, alopecia, swollen limbs and swollen feet and scored from 0 to 3 based on relative size. Environmental parameters were recorded for each litter examined. A questionnaire was completed on management, health and performance factors for each farm. The overall prevalence of each lesion was calculated and multilevel mixed effect logistic regression models were used to elucidate risk factors. The prevalence (farm range) of lesions were: sole bruising = 61.5% (7–100%), sole erosion = 34.1% (0–100%), coronary band injuries = 11.3% (0–46%), limb abrasions = 55.7% (11–98%), alopecia = 24.8% (0–83%), swollen limbs = 2.4% (0–11%) and swollen feet = 4.4% (0–14%). Age was negatively associated with sole bruising (OR 0.42; CI 0.37, 0.50) and coronary band injury (OR 0.69; CI 0.60, 0.81) and positively associated with limb abrasions (OR 1.54; CI 1.12, 2.14). There was a reduced risk of sole bruising in piglets in pens with plastic slats with oval voids in the piglet area of the pen with a plastic solid area for piglets and metal slats under the crate (OR 0.32; CI 0.15, 0.70) compared with plastic stats throughout and a plastic solid area for piglets. There was an increased risk of sole erosion (OR 1.81; CI 1.07, 3.09) and foot and limb swellings (OR 1.90; CI 1.01, 3.57) in pigs in pens with metal slats only and a solid plastic area for piglets compared with plastic stats throughout and a solid plastic area for piglets. There was an increased risk of coronary band injury in pens with metal slats throughout and a metal solid area for piglets (OR 4.25; CI 1.96, 3.57) compared with plastic stats throughout and a plastic solid area for piglets. We conclude no single floor type was ideal for piglet foot and limb health with all floors influencing different lesions in different ways, however, the positive association between sole erosions, coronary band injury and foot and limb swellings and metal slats suggest that this floor type was most detrimental and most likely to be associated with joint infections that lead to severe health and welfare concerns.

This review describes a decision pathway for the conservative management of foot problems in persons with diabetes mellitus. The decision pathway was developed by the Louisiana State University Health Sciences Center Diabetes Foot Program as part of the Statewide Diabetes Disease Management Initiative to standardize foot care in a medically underserved population. The pathway describes the prevention and/or management of foot problems through 5 clinical subpathways: injury prevention, warm swollen foot, ulcer, osteomyelitis, and remodeling. The pathway provides physiatrists and other rehabilitation practitioners with a framework to evaluate and manage neuropathic foot problems in a multidisciplinary setting.

We studied the clinical course of 5 patients (2 males and 3 females) with rheumatoid arthritis (RA) whose first symptoms were foot or ankle pain. To assess the changes in swollen feet and ankles, we examined them by fat-suppressed, gadolinium-enhanced magnetic resonance imaging (MRI). In each patient, the synovium or Achilles tendon sheath showed high signal intensity.It is difficult to diagnose early stage RA in patients complaining of pain and swelling of the foot or ankle.Fat-suppressed, gadolinium-enhanced MRI however proved useful for detecting tenosynovitis in the foot or ankle and for early diagnosis of RA.

Foot ulceration and Charcot neuroarthropathy (CN) are well recognized and documented late sequelae of diabetic peripheral, somatic, and sympathetic autonomic neuropathy. The neuropathic foot, however, does not ulcerate spontaneously: it is a combination of loss of sensation due to neuropathy together with other factors such as foot deformity and external trauma that results in ulceration and indeed CN. The commonest trauma leading to foot ulcers in the neuropathic foot in Western countries is from inappropriate footwear. Much of the management of the insensate foot in diabetes has been learned from leprosy which similarly gives rise to insensitive foot ulceration. No expensive equipment is required to identify the high risk foot and recently developed tests such as the Ipswich Touch Test and the Vibratip have been shown to be useful in identifying the high risk foot. A comprehensive screening program, together with education of high risk patients, should help to reduce the all too high incidence of ulceration in diabetes. More recently another very high risk group has been identified, namely patients on dialysis, who are at extremely high risk of developing foot ulceration; this should be preventable. The most important feature in management of neuropathic foot ulceration is offloading as patients can easily walk on active foot ulcers due to the loss of pain sensation. Infection should be treated aggressively and if there is any evidence of peripheral vascular disease, arteriography and appropriate surgical management is also indicated. CN often presents with a unilateral hot, swollen foot and any patient presenting with these features known to have neuropathy should be treated as a Charcot until this is proven otherwise. Most important in the management of acute CN is offloading, often in a total contact cast.

Skin temperature assessment is a promising modality for early detection of diabetic foot problems, but its diagnostic value has not been studied. Our aims were to investigate the diagnostic value of different cutoff skin temperature values for detecting diabetes-related foot complications such as ulceration, infection, and Charcot foot and to determine urgency of treatment in case of diagnosed infection or a red-hot swollen foot. Materials and Methods: The plantar foot surfaces of 54 patients with diabetes visiting the outpatient foot clinic were imaged with an infrared camera. Nine patients had complications requiring immediate treatment, 25 patients had complications requiring non-immediate treatment, and 20 patients had no complications requiring treatment. Average pixel temperature was calculated for six predefined spots and for the whole foot. We calculated the area under the receiver operating characteristic curve for different cutoff skin temperature values using clinical assessment as reference and defined the sensitivity and specificity for the most optimal cutoff temperature value. Mean temperature difference between feet was analyzed using the Kruskal-Wallis tests. Results: The most optimal cutoff skin temperature value for detection of diabetes-related foot complications was a 2.2 degrees C difference between contralateral spots (sensitivity, 76%; specificity, 40%). The most optimal cutoff skin temperature value for determining urgency of treatment was a 1.35 degrees C difference between the mean temperature of the left and right foot (sensitivity, 89%; specificity, 78%). Conclusions: Detection of diabetes-related foot complications based on local skin temperature assessment is hindered by low diagnostic values. Mean temperature difference between two feet may be an adequate marker for determining urgency of treatment.

Foot pain in patients diagnosed with early rheumatoid arthritis is common.To investigate effects of off-the-shelf foot orthoses on outcomes of swollen and tender joints, and pain, in patients with early rheumatoid arthritis.Thirty-five patients with painful and swollen foot joints were recruited. None had previously used foot orthoses or had contraindications to their use. Any patients with concomitant musculoskeletal disease, endocrine disorders, and neurological disease, were excluded. At baseline, participants were prescribed a customised off-the-shelf foot orthosis with chair-side modifications. Data was collected at baseline, three and six months. Foot pain (using Visual Analogue Scale) and the number of tender and swollen foot joints was measured.There was a trend towards a reduction in the number of swollen and tender joints by 3 months with a further improvement by 6 months. Statistically (p0.05) and clinically significant reductions in pain levels were also noted.Patients diagnosed with early RA may benefit from using off-the-shelf foot orthoses with the majority of their pain reduction occurring within the first 3 months of use, but with some small further symptomatic improvement up to 6 months. There was a tendency to a reduction in swollen and tender joints although more studies are required to substantiate these findings.

Methods 14 JIA patients with a history of foot disease and 10 healthy controls were recruited. Participants underwent 3D gait analysis, plantar foot pressure and spatio-temporal gait evaluation. Each participant completed the Juvenile Arthritis Foot Disability Index (JAFI) and CHAQ. US scores for effusions and synovial hypertrophy, tender/swollen foot joint counts, and deformity scores were recorded to assess localised disease activity and impairments. Mean differences and 95% confidence intervals (CI) were calculated using the t distribution.

A 43-year-old man with a 28-year history of type 1 diabetes presented to our foot clinic in February 2008 with a fractured left second proximal phalanx due to trauma. His diabetes control was poor, with an HbA1c of 79 mmol/mol (9.4%) [reference range

Background Conservative management of foot problems in patients with rheumatoid arthritis (RA) may consist of the prescription of customised foot orthoses. Indications for foot orthoses are not clear and the effectiveness of the intervention is highly variable among patients. Knowledge on which patients benefit the most from foot orthoses can help to select patients eligible for this type of intervention. The objective of the present study was to determine clinical and demographic factors that predict the outcome of customised foot orthoses on pain and disability in patients with RA. Methods A total of 135 RA patients who were supplied with customised foot orthoses were included in this prospective cohort study. Pain and disability were measured before and after the intervention period using a Numeric Rating Scale (NRS) for foot pain, the Foot Function Index (FFI), the Western Ontario and McMasters Universities Osteoarthritis Index (WOMAC) and a 10-meter walking test. The intervention period consisted of one or more appointments with the podiatrist during which the foot orthoses were customised. Swollen foot joint count, foot deformity scores, forefoot peak pressure, disease duration, age, gender, body mass index and baseline values of the outcome measures were selected as potential factors predicting outcome. Multivariate linear regression analyses were performed to determine factors associated with change in pain and disability (at P < 0.05). Results Disease duration was negatively associated with the change scores in NRS foot pain (P = 0.018), WOMAC pain (P = 0.001), FFI disability (P = 0.003) and WOMAC physical function (P = 0.002). Age was negatively associated with the change score in 10 meter walking time (P = 0.008). For all outcome measures baseline values were positively associated with the change scores (P < 0.001). Conclusions Shorter disease duration predicted greater improvements in self-reported foot pain and disability, and younger age predicted greater improvements in walking time after intervention with foot orthoses. Also, higher baseline values of pain and disability predicted greater improvements. Referral for conservative management with foot orthoses in the early stage of RA seems important when aiming to achieve reduction in pain and improvement in daily activities.

Rheumatoid arthritis is a chronic inflammatory joint disease which affects the joints and soft-tissues of the foot and ankle. The aim of this study was to evaluate biomechanical foot function and determine factors associated with localised disease burden in patients with this disease.Seventy-four rheumatoid arthritis patients (mean (standard deviation) age, 56 years (12); median (interquartile range) disease duration, 13 (5,19)) and 54 able-bodied adults (mean (standard deviation) age, 55 years (12)) completed the Leeds foot impact scale. Biomechanical foot function was measured using three-dimensional instrumented gait analysis. Disease activity score, the number of swollen and tender foot joints, and rearfoot and forefoot deformity were recorded. Sequential multiple linear regression was undertaken to identify independent predictors of foot disease burden.The median (interquartile range) Leeds foot impact scale scores in the impairment and activity/participation subscales were 13 (10,14) and 17 (12,22) for the rheumatoid arthritis and 1 (0,3) and 0 (0,1) for the able-bodied adults, P0.0001 both subscales. The patients had significantly higher numbers of swollen (P0.0001) and tender foot joints (P0.0001) and greater rearfoot (P0.0001) and forefoot (P0.0001) deformity. Rheumatoid arthritis patients walked slower (P0.0001) and had altered biomechanical foot function. Sequential regression analysis revealed that when the effects of global disease activity and disease duration were statistically controlled for, foot pain, the number of swollen foot joints and walking speed, and foot pain and walking speed were able to predict disease burden on the Leeds foot impact scale impairment (P0.0005) and Leeds foot impact scale activity/participation (P0.0005) subscales, respectively.In this cohort of rheumatoid arthritis patients, foot pain, swollen foot joint count and walking speed were identified as independent predictors of impairment and activity limitation and participation restriction. The foot disease burden model comprises important elements of pain, inflammatory and functional (biomechanical) factors.

Although patients with acute Charcot osteoarthropathy exhibit a marked local inflammatory response to trauma by the classical presentation of a red, hot swollen foot, the systemic acute phase response has not been fully investigated. The aim of this study was to measure the systemic serologic markers of inflammation in acute Charcot osteoarthropathy. We studied 36 consecutive patients who presented to the Diabetic Foot Clinic over the last 5 years with a red, hot swollen foot and a skin temperature >2°C compared with the same site on the contralateral foot and who had no previous treatment. There was no evidence of any skin breakdown or ulceration. Foot skin temperatures were measured by Dermatemp 1001 (Exergen, Watertown, MA). The diagnosis of Charcot osteoarthropathy was confirmed in 25 cases by evidence of subluxation, dislocation, or fragmentation of bone on standard foot radiographs and in 11 cases by the presence of an increased focal uptake on the bony (third) phase of the triphasic Technetium-Diphosphonate bone scan (Tyco Healthcare) even though the radiographs at presentation were normal. In the patients with radiological abnormalities, the patterns of involvement were described using Sanders and Frykberg's classification (1). Four patients presented with pattern I …

Bone stress injuries are rarely being diagnosed in patients with sensory neuropathy, most likely because they may be silent in terms of pain. Load-related pain is considered a key feature of any bone stress injury, a symptom, which may be partially or completely absent in subjects with sensory neuropathy (loss of protective sensation). We evaluated the clinical course of bone stress injuries in insensitive feet in diabetic patients with polyneuropathy. We investigated 12 consecutive diabetic patients with bone stress injuries of the foot (bone marrow edema, bone bruise and microtrabecular fractures, on magnetic resonance imaging MRI), which were undetectable on plain X-ray. All patients suffered from diabetic polyneuropathy, none of them had an active foot ulcer. The patients presented with a swollen foot, which was only mildly painful and did not prevent them from walking. Complaints were related to the swelling, which increased during load-bearing. In seven cases, a traumatic event preceding the onset of symptoms could be ascertained. MRI disclosed stress injuries in 2.5 (1–8) [median (range)] bones per foot. In 11 patients, treatment was started immediately by off-loading with total contact cast for 17 (8–52) weeks, followed by gradual increase in weight bearing. One patient unfortunately received off-loading treatment only after deforming fractures had developed. All bone injuries healed uneventuelly in eight patients, and with residual mild osteoarthrosis in three patients without gross deformities. However, the untreated patient developed severe Charcot foot deformity. In diabetic patients with polyneuropathy, symptoms of bone stress injuries of the foot are atypical, in that there is load-related swelling rather than load-related pain. Immediate diagnosis, and treatment with off-loading, leads to a restitutio ad integrum like in non-neuropathic patients. Delayed cessation of overuse, however, may cause irreversible joint and bone damage (Charcot foot).

Previous foot studies have consistently reported high prevalence estimates in self-reported foot disorders. Few population studies, however, have attempted to assess the impact of foot problems in terms of pain and disability so that the burden associated with foot pain is unknown. A cross-sectional postal survey was conducted on a random community sample of 4780 individuals with 3417 (84%) responding. Subjects reporting foot pain in the past month, current pain and marking one item on the Manchester Foot Pain and Disability Index were classified as having disabling foot pain. Those with disabling foot pain and a random sample with no symptoms (matched for age and gender) received a follow-up interview and standardised foot examination. Self-reported nail problems, corns and callosities, swollen feet, foot deformities and recent foot injuries were found to be associated with disabling foot pain. Foot disability was also associated with pain in the shoulder, axial skeleton, hip/upper leg and knee along with other indicators of poor general health. Clinician diagnosed foot problems associated with disabling foot pain were swollen feet, knee and foot joint tenderness. Only 36% of persons with disabling foot pain received professional foot treatment in the 6 months preceding the survey. The results showed that 323/3417 (9.5%) reported symptoms of disabling foot pain and that this condition is likely to be multi-factorial in origin. Further work is necessary to understand more about the extent and type of unmet need and on how patients presenting with symptoms of disabling foot pain should best be managed.

29 patients with diabetic neuropathy presented with 40 fractures of the foot and ankle to the Diabetic Foot Clinic between 1980 and 1989. All the patients presented with a swollen foot, but only 3 gave a history of trauma. There was a particularly high incidence of metatarsal fractures. 26 fractures were treated by bandage support and non-weightbearing with crutches. The other 14 fractures were treated by a plaster of Paris splint. The mean follow-up was 24 months (range 14–36 months). 34 fractures went on to clinical and radiological union, 2 went on to delayed union, and 4 had non-union. Delayed union or non-union only occurred in patients treated by unprotected non-weightbearing. Charcot changes of the foot occurred in 6 patients. Only 1 patient treated with a plaster of Paris splint developed Charcot joint changes, whereas the other 5 patients were treated by unprotected non-weightbearing. We recommend a high index of suspicion in diabetic patients with neuropathy presenting with a swollen foot. Fractures should be managed with a protective splint to promote union and reduce the risk of progression to Charcot joint changes.

C. T., aged 14, from Tower Hill, Ill., came into my service with a painful and swollen foot due to a horse falling on it. Examination showed marked deformity of the right foot, and suspected fracture with dislocation. A roentgenogram by Dr. Fred O'Hara disclosed a dorsal dislocation of the proximal phalanx of the great toe, with a plantar displacement of the metatarsal, and a fracture of the distal end of the second metatarsal bone. Though Malgaigne calls attention to the fact that four out of ten cases of this type are irreducible, reduction under general anesthesia was readily accomplished and the end-results are perfect. Skillern 1 refers to the rarity of the condition in his report of a case, and I am desirous of adding my case to those already reported, which now total twenty.

Aims:\ud The aim of this study was to identify the biomechanical, neurological and clinical parameters along with other demographics and life style risk factors that could explain the presence of foot ulcer in patients with diabetes in Africa. \ud Methods:\ud A total of 1270 (M/F:696/574) patients; 77(M/F:53/24) with ulcerated vs 1193 (M/F: 643/550) with non-ulcerated feet; participated in this study. A set of 28 parameters were collected and compared between the participants with and without active foot ulcers. Multivariate logistic regression was utilised to develop an explanatory model for foot ulceration. \ud Results:\ud Foot swelling (χ2(1,n=1270)=265.9,P=0.000,Phi=0.464) and impaired sensation to monofilament (χ2(2,n=1270)=114.2,P=0.000,Cramer’sV=0.300) showed strong association with presence of ulceration. A lower Temperature sensitivity to cold stimuli and limited ankle joint mobility were observed to be significant (P

FRACTURES at the base of the fifth metatarsal bone occur most often as a result of twisting injuries to the foot, and are frequently mistaken for sprains unless adequate x-ray studies are made. These injuries are seen with sufficient frequency by general practitioners to warrant a brief consideration of practical management. They occur in all ages from 10 to 70. The patient hobbles into the office or clinic with a painful swollen foot on which he cannot bear weight without increasing pain. The author has seen a large number of these injuries and has used a simple, practical program of treatment. Mechanism of Injury A sudden twisting of the forefoot applies a supinator force resulting in a rupture of the lateral interosseus ligament between the cuboid and fifth metatarsal base. The attachment of the peroneus brevis tendon is torn loose carrying with it a portion of the bone. Usually there