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Information Sheet

Information Sheet

Although the specific effects of Parkinson’s disease on feet can differ significantly from person to person, people with Parkinson’s may be particularly prone to problems because of the difficulties they can experience with walking (their gait), posture and cramps. They may also have difficulty bending over to take care of their toenails, or in controlling the fine movements of the hands needed to cut nails safely.

For these and other problems (such as corns, callus, and ingrowing toenails), regular general care and treatment is available from a podiatrist or chiropodist. Abnormal foot function, if not addressed, often causes great discomfort and can have a detrimental effect on a person’s mobility, putting them at greater risk of falling.

Are podiatry and chiropody different?

There is no difference in meaning between the terms podiatry and chiropody. ‘Podiatry’ is the internationally recognised term for specialised foot care and for the purposes of this information sheet this will be the term used. The terms ‘podiatrist’ and ‘chiropodist’ are protected titles. To use these titles

the practitioner must be registered with the Health Professions Council (see the ‘Further information’ section at the end of this information sheet for contact details) – to achieve this standard of recognition, a practitioner must have completed a BSc degree, or equivalent, in podiatric medicine. Podiatrists are concerned with all aspects of foot care, including the analysis of how the foot should function during normal walking, and how to address the problems that can occur when walking does not fall into a ‘normal’ pattern. This is called ‘biomechanics’. A

podiatrist can often work with a physiotherapist

in addressing foot-related mobility problems and prevention of falls.

A podiatrist can also develop and produce tailor-made devices (called orthoses) to alleviate foot and leg pain and improve gait – these can involve shoe inserts or arch supports and can be placed in the patient’s own suitable footwear or, in cases of severe deformity, in specially made shoes.

Where can I find a podiatrist?

Podiatrists work in a variety of places, both for the NHS and privately; these include community health centres, nursing homes, doctors’ surgeries, hospitals, private practices and industry. For people with serious mobility problems, a home visit can be arranged. Depending on regulations in your local health authority, you may need a referral from the primary care team (for example a GP, practice nurse, district nurse or physiotherapist) for NHS care. You do not need to be referred to a private practitioner. See your local telephone directory for the relevant telephone numbers. Alternatively, the Society of Chiropodists & Podiatrists can advise on how to find a practitioner in your local area (see the

‘Further information’ section at the end of this informaton sheet for contact details).

What can I expect from my podiatrist? Making the first appointment

Try to make an appointment for a time when you can be accompanied by someone, so that you can discuss future shared care and, if necessary, the podiatrist can demonstrate simple techniques that could bring relief from some problems. Also, make the appointment at a time when you are least likely to experience tremor or other involuntary

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Information Sheet

movements, as the podiatrist may need to use very sharp instruments and may not be able to complete a treatment if there is a risk of injury.

Initial examination

The podiatrist will first need to take a full medical history regarding not only your Parkinson’s symptoms, but also any other health problems, as these can have side effects on the feet. If you take a number of medications, it helps if you have a clearly written list of the names of all the medications and what they are for.

The podiatrist will then assess your feet by doing some simple tests to check the circulation and the nerves in your feet. They will do a gait analysis by watching the way you walk and by turning your feet into different positions. They will also assess the condition of your skin and nails.

Treatment

Treatment of any immediate problems can then be carried out and a future care plan can be agreed – with you, your carer and the podiatrist all playing their part. This may include follow-up appointments and advice on self-care such as filing your nails, the use of creams and exercise.

What foot problems can people with Parkinson’s experience?

There are a number of general foot problems (such as corns, bunions and verrucae to name a few). People with Parkinson’s are faced with further difficulties arising mainly from rigidity, muscular contractions and altered gait pattern. Rigidity and/or contraction, particularly in the area of the calf muscles, can reduce a person’s ability to flex their ankles, affecting the body’s

ability to absorb the shock of ground contact. This in turn can lead to pressure problems such as excess callus on the soles of the feet. Loss of balance and poor posture as well as gait problems are among the most commonly recognised features of Parkinson’s. In general, the stride length shortens and the amount of time both feet remain in contact with the ground increases. A ‘normal’ walking action is to strike the ground firstly with the heel and then finally push off with the toes – commonly described as a ‘heel-to-toe’ gait. Because of the rigidity within the ankle, the person with Parkinson’s can often begin to lose this normal heel-to-toe type of gait and a more shuffling action can begin to predominate.

This more flat-footed type of gait can produce foot, leg and even knee pain as well as significantly reduce the foot’s ability to adequately absorb the shock of ground contact. In the long term, this type of flat-footed stance (see figure 1) can seriously impact on an individual’s mobility.

Figure 1

In contrast, some people with Parkinson’s will complain of ‘walking on their toes’. This is a common problem and it is usually associated with the accompanying rigidity of Parkinson’s.

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Information Sheet

The rigidity can affect the ankle joint and, in particular, its ability to bend the foot up. Due to this rigidity, the foot can then assume a downward-pointing position resulting in the feeling that the person is ‘toe-walking’.

Your podiatrist (along with a physiotherapist) can advise you about particular exercises to stretch the muscles in order to lessen the effects of rigidity on the foot (see the section on ‘Exercise’ later in this sheet). Alternatively, a custom-made orthotic device will spread the force of ground contact over the sole of the foot. It is estimated that three times the body’s weight passes through the foot when the heel strikes the ground!

Dystonia and toe-curling

The muscle cramps and dystonia experienced by people with Parkinson’s are frequently felt in the feet. The contraction of muscles can cause the toes to curl in, in a claw-like way. Occasionally, the ankle may also turn inwards (this is known as inversion: see figure 2) and put pressure on the outside of the foot. There may also be ‘hyperextension’ of the big toe, which causes it to stick up and rub on the top of the shoe. These all lead to pressure problems on areas of the foot not designed to withstand these pressures.

Figure 2

In some cases, dystonia can be connected to your anti-Parkinson’s medication. It is best to discuss this with your doctor or Parkinson’s Disease Nurse Specialist, as they are best placed to advise you whether adjustment of your medication is likely to help your dystonia. Your podiatrist can also advise you on suitable treatments for toe-curling (see the section on ‘Toe splints’ later in this sheet).

Dystonia can also affect the Achilles tendon at the back of the heel, causing it to tighten up and pull the foot in a downward position. This is another possible cause of the problem of ‘toe-walking’ that some individuals experience. For more information, see the PDS information sheet Muscle Cramps and Dystonia.

Oedema

Swelling of the feet can also occur, usually in people with significant problems with slowness of movement (bradykinesia). Circulation of the blood relies on movement of the legs and contractions of the leg muscles that propel the blood in the veins upwards to the heart. If a person is not moving very much, the veins become congested, resulting in some fluid leaking out and accumulating in the tissues of the feet and ankles.

This effect, known as ‘oedema’, usually builds up during the day and diminishes overnight. It is commonly referred to as ‘postural oedema’ because it is the effect of gravity as the person stands that causes the accumulation of fluid around the ankles. While the swelling is usually mild, some people can describe their legs as feeling heavy and can have difficulty putting on tight shoes. Footwear that can be loosened during the day is often necessary.

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Information Sheet

This type of oedema usually diminishes when the Parkinson’s can be effectively treated and when the person becomes more mobile. If the individual is less mobile, taking time out during the day to lie flat with the legs slightly raised for an hour or so can help dissipate some of this excess fluid. Sometimes, a drug known as a diuretic can be used to help remove excess fluid from the body by increasing the amount lost as urine. Your GP, Parkinson’s Disease Nurse Specialist and/or podiatrist should be able to advise you further.

What can be done to help? Footwear

Well-chosen footwear can go a long way towards helping. Most people don’t need a podiatrist to explain the harmthat wrong-fitting shoes can cause. The following diagrams illustrate the harmful effect of wearing shoes that are too narrow at the toes (figure 3) and the areas of pressure placed on the foot if the heel is too high (figure 4).

Figure 3

Supportive shoes with cushioned inserts can absorb some of the shock. It is advisable to wear slippers as little as possible. Although slippers may feel comfortable they provide the foot with little or no support.

Ideally, shoes should have a low, broad heel, and fasten over the top of the foot close to the ankle. Laces are the best, but Velcro or a strap and buckle are a good alternative. A slip-on shoe, even if it is a good fit, requires additional clawing of the toes to keep it on the foot. You need a deep toe box that gives enough room for you to wiggle your toes. The weight of the shoes can be very significant if you experience problems in initiating movement. The lighter the shoe the better. Trainers made from natural or breathable fibres are often an ideal choice.

Figure 4

Some people who experience ‘freezing’ (a symptom of Parkinson’s that causes the person to stop suddenly while walking) may find that leather-soled shoes permit slippages that facilitate movement, although this may slightly increase the risk of falling through slipping. Others say that a sole with ‘grip’ makes the person think about lifting up the foot to walk and therefore maintain a more ‘normal’ gait for longer. This does not

necessarily reduce the risk of falls, because the prevention of sliding may cause the patient to fall forwards. As stated earlier, every person

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Information Sheet

with Parkinson’s is different. Each person should be assessed and advised according to their particular problems and needs.

If you have been prescribed an orthosis or insert, make sure you take it with you when buying shoes. Try to shop for shoes when your feet are at their worst. What fits when you are on top form will not be quite so good when you are experiencing an ‘off’ period. Remember, if a shoe needs ‘breaking in’ it does not fit.

Exercise

Your podiatrist can train you to stretch and exercise the muscles concerned in order to lessen the effects of stiffness or rigidity on the foot. They can also instruct carers in simple massage techniques to improve movement and circulation. Figure 5 gives some examples of exercises that may be helpful. A custom-made orthotic device will also spread the forces of ground contact over the whole of the sole of the foot and by improving gait will allow the foot and calf muscles to work more effectively.

Toe splints

For toe-curling, a removable silicone ‘splint’ can be provided to prevent worsening of the condition and to give the toes something to grip. Alternatively, if there is still some flexibility in the toes, they can be supported in a straightened position with a simple and effective device made from quick-setting silicone rubber. This is moulded around the toes and allowed to set in situ, ensuring a proper fit. A podiatrist can advise you on suitable treatments for toe-curling, including surgery in more severe cases.

Figure 5

(The diagram is taken from the leaflet Fitter Feet produced by Help the Aged and is

reproduced with kind permission Tel: 020 7239 1845 for more details.)

Some general foot care advice

• Wash your feet daily in warm (not hot) water with gentle soap that does not irritate the skin. Do not soak them for any longer than a normal bath time as this may destroy some of the skin’s natural oils. Strong antiseptics such as iodine, carbolic acid, Lysol and bleach will also destroy these oils. Dry skin carefully, especially between the toes, but

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Information Sheet

do not try to get a towel between the toes if they are curled or rigid. A baby wipe is ideal for this job.

• If your skin is dry, use moisturising cream all over the foot except between the toes. You may also use lanolin or olive oil.

• Remove hard skin by rubbing gently with pumice stone or foot dresser. Apply emollient little and often (twice daily). If hard skin is painful, consult a podiatrist.

• Do not cut corns, calluses or ingrown nails yourself or treat them with ‘corn cures’ or ‘corn plasters’, as these contain strong acids that can lead to burns or ulcers if they are not used with caution.

• File your toe nails regularly using a ‘diamond deb’ file with a rounded end or, alternatively, you can use an emery board. Little and often is the golden rule, weekly if possible. File following the shape of the toe end, not too short and not down at the corners, as this can lead to in-growing nails. Do not use sharp instruments such as nail clippers or scissors, especially if you experienced tremor or involuntary movements, as even a small cut can lead to potentially serious problems if not treated properly. If you find it hard to manage your toe nails yourself, or your carer is unable to help, your podiatrist will be able to help.

• Seek prompt treatment for burns, cuts and breaks in the skin and for any unusual changes in colour, smell or temperature. • Avoid exposure to extreme temperatures and

dampness. Keep feet warm and exercise to improve circulation.

• Extend the life and fit of your shoes by using a shoe horn (a long-handled one is easiest to use) and shoe trees. Don’t wear the same shoes all the time. Alternate daily if possible, as this will lengthen the life of your shoes and redistribute pressures on your feet.

Further information

Health Professions Council Park House

184 Kennington Park Road London SE11 4BU

Tel: 020 7582 0866 Website: www.hpc-uk.org

The Society of Chiropodists & Podiatrists 1 Fellmonger’s Path

Tower Bridge Road London SE1 3LY Tel: 0845 450 3720

Website: www.feetforlife.org

Acknowledgements

The PDS would like to thank Liz Hurst BSc (Hons) Podiatry with Health Education, MChS (Chief IV Podiatrist) for her help in producing this sheet.

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Information Sheet

Parkinson’s Disease Society

215 Vauxhall Bridge Road, London SW1V 1EJ, UK

Tel: 020 7931 8080 Fax: 020 7233 9908

Helpline: 0808 800 0303 Textphone: 0800 111 4204 (The Helpline is a confidential service.

Calls are free from UK landlines and some mobile networks)

Email: enquiries@parkinsons.org.uk Website: www.parkinsons.org.uk

© Parkinson’s Disease Society of the United Kingdom (2008)

Charity registered in England and Wales No. 258197 and in Scotland No. SC037554. A company limited by guarantee. Registered No. 948776 (London)

Registered office: 215 Vauxhall Bridge Road, London SW1V 1EJ Revised December 2008

To obtain any PDS resource, please go online to www.parkinsons.org.uk or contact Sharward Services Ltd, the appointed PDS Distribution House, at Westerfield Business Centre, Main Road, Westerfield,

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