Attention to foot education and care is especially important as people age. The National Institute on Aging reports high prevalence of lower extremity joint pain among older women. For those relating "severe" pain 17 percent was foot related.
The foot is a complex area consisting of twenty-six bones, thirty-three joints, and several ligaments, muscles, veins, arteries, and nerves. As a primary weight-bearing structure the foot is subject to more deforming forces than any other part of the body. It is estimated that the average person takes eight thousand to ten thousand steps a day and covers about 115,000 miles in an average lifetime. The aging process affects all areas of the foot. With the added insult of normal and abnormal stresses (i.e., shoes, weight bearing, walking, etc.) several foot problems commonly present or are worse in the older population. An outline of common foot deformities found in the aging foot follows.
Nail ailments are common in the geriatric population. Systemic diseases (i.e., psoriasis, poor circulation, diabetes mellitus, syphilis, reiters syndrome, gout, rheumatoid arthritis, lupus), poor nutrition, and poor circulation can cause changes in nail texture color and presentation. Treatment of underlying disease can help resolution of nail conditions.
Any nail deformity, tight shoes, or improper cutting can lead to painful ingrown nails. In time skin penetration can lead to bacterial infections and chronic inflammation causing a condition referred to as a paronychia. Treatment may consist of nail removal and antibiotics. All nails should be cut straight across to avoid curved edges. If pain is present in nail edges professional help should be sought.
Fungal nail infections, or onychomycosis, are prevalent in older adults. Fungus tends to grow under the nail and cause a discoloration, thickening, and deformed appearance causing pain and nail loss. This condition usually presents at the tip or sides of the nail and progresses to the base. Treatment for onychomycosis can be difficult. In the past topical preparations and removal of the nail produced limited or no results. More recently, oral medications have shown a higher cure rate. Topical preparations have a low risk of side effects but a longer treatment time (about one year). Oral medications have a shorter treatment period (about three months) but present more side effects due to the nature of the treatment. In severe cases, where medications are not appropriate, permanent removal of the nail may be warranted.
Evaluations of nail conditions should include screening for systemic diseases, such as psoriasis, diabetes, gout, and poor circulation, as well as attention to diet and nail cultures to rule out fungus. Although malignancies are rare in the foot, a biopsy of nail or skin changes should be considered.
Older adults show a high prevalence of dry skin or xerosis due to normal metabolic and nutritional skin changes that causes dehydration and decreased elasticity in skin layers. Severe dry skin can lead to fissures or cuts and predispose the patient to serious bacterial and fungal infections.
To avoid misdiagnosis all initial skin presentations should be evaluated professionally with microbiological tests if necessary. Xerosis and fungal infections can be treated with topical preparations. For severe xerosis, creams used under occlusion (i.e., plastic wrap) have proved helpful. The use of pumice stones are helpful in safely removing skin cells but rarely relieve the condition alone.
Corns and calluses are common in elderly persons. Caused by constant pressure, friction, or trauma to one area, this skin thickness or hyperkeratosis can be very painful.
Ulcerations or abscesses can occur under these lesions, requiring immediate medical treatment. Footwear should be evaluated for proper fit as tight shoes can contribute to and exacerbate this condition. Periodic scalpel debridement by a podiatrist has been shown to cause immediate relief. Over the counter "corn removers" should be used with caution. They often contain acid and can be dangerous in patients with diabetes or poor circulation.
Joint and bone conditions
In older adults, joint pain, weakness, stiffness, and swelling is often attributed to arthritis. A multitude of factors can contribute to this condition. Cellular metabolism and repair decrease with age contributing to unrepaired lower extremity microtrauma in everyday activities. Progressive weakness and instability and longstanding medical conditions can contribute to further joint destruction. Longstanding arthritis can lead to a breakdown in joint surfaces or cartilage causing painful ambulation. Bone deformity becomes rigid with age, affecting mobility as well as increased areas of skin pressure and contributing to painful hyperkeratotic lesions. In diabetics or individuals with circulatory and neurological problems, skin breakdown or ulcerations can occur.
Treatment for arthritis is dependent on the primary cause. Pain and swelling is often managed with prescription medications. In older persons the dose and amount of medication must be adjusted to accommodate normal decrease in drug metabolism and interactions with current medications. Use of steroid injections can help to alleviate acute pain and swelling but should be limited to avoid destruction of surrounding areas. Elderly persons are often good candidates for more conservative treatment consisting of special molded shoes to decrease skin pressure areas or special padding and/or inserts for existing shoes. Early physical therapy intervention can be helpful in increasing mobility, decreasing long-term rigidity, and helping with stability in the older person.
In addition to arthritis, older persons have a high rate of foot abnormalities such as bunions and hammer toes. A bunion is a deformity or misalignment of the first toe joint or first metatarsal phalangeal joint. This condition causes the toe to deviate toward the second toe and the head of the first bone or metatarsal can be seen as a "bump". With time the joint can become misaligned and stiff. Hammer toes, mallet toes, and claw toes are caused by contractions at joints in the lesser four toes. Pain is often due to the decreased motion in the joint, arthritic changes, and pressure in footwear. Special shoe inserts such as orthotics or shoe modifications may be helpful. If the condition is still painful and debilitating surgical management may be recommended. This could include removing or repositioning bone to decrease the length of the toe and reduce the deformity.
The circulatory system of the lower extremity can be described in two parts, venous (brings deoxygenated blood from the extremity to the heart) and arterial (brings oxygenated blood from the heart to the extremity). Aging affects both components.
Circulatory complications and treatments are system related. In the case of arterial circulation, healing rate, gangrene, ulcerations, and limb loss can occur. The level and degree of arterial insufficiency is important. With venous insufficiency severe swelling and skin ulceration can occur. Long-standing ulceration is an area for potential infection.
The foot is supplied by two major arteries, the dorsal pedius located on the top of the foot and the posterior tibials located on the inner ankle. These arteries should be palpitated at each general medical exam. When these arteries are difficult to feel, special devices know as dopplers can be used to determine the strength rhythm and pressure of these vessels. In the case of arterisclosrosis, special diagnostic exams can visualize and evaluate the interior of the artery for possible occlusions.
Arterial problems are usually caused by an occlusion or blockage of an artery. Atherosclerosis obliterans is the name given to an age-related condition that causes plaque to form inside the vessel walls of arteries. Although any artery can be affected, it is more common in the lower extremities. Common symptoms in arterial disease are ambulatory muscle cramps or pain relieved by rest, coldness, numbness, pain felt while at rest, and skin color changes. Muscle cramps induced by activity and relieved by rest are referred to as intermittent claudication. Common in the calf muscle, this is believed to be caused by decreased oxygen to the muscle.
Rest pain alone is a most likely arterial in nature. When the foot is deprived of blood and oxygen for too long a period, cells start to die. Some elderly persons also suffer from nerve damage or neuropathy and cannot feel the initial symptom of pain. In these individuals, gangrene may be the first sign of trouble. All symptoms should be evaluated for diagnosis and cause.
Veins contain valves to assist in the movement of blood against gravity. Venous problems are often due the incompetence of these valves, a natural process of aging. This incompetence can cause mild to severe swelling in the legs and feet due to the pooling of blood, making ambulation and the wearing of shoes difficult. Longstanding and severe swelling can lead to skin discolorations and ulcerations. Elevating legs, such as in bed, helps in eliminating the fluid and can decrease the swelling.
Special compression stockings can be helpful in "squeezing" the fluid out of the leg and acting as a pump to compensate for the loss of valve function. Older persons sometimes find this stocking difficult to use due to the tightness of the device, arthritis in the fingers, and difficulty in bending. Most companies make compression stockings in a variety of styles and designs and the individual should be fitted and evaluated for the most appropriate one.
Standing, sitting, and walking can increase the amount of swelling. Swelling can occur gradually over the course of a day. Tight shoes, stockings, socks, or garters can cause a painful band and strangulation of the tissue or limb. All socks, shoes, stockings, and garters should be checked periodically for appropriate fit. Elastic bands should be avoided in these individuals.
Individuals with diabetes are more prone to circulatory and neurological problems than the general population. Increased disease duration and severity will affect the presentation of the foot complications. Neurological sensation is a common loss in the diabetic. A simple test determining the ability of one to feel certain pressure thresholds can crudely determine the extent or presence of a neuropathy. Depending on the results of this test, circulatory status, previous foot conditions, and deformities, appropriate follow-up visits can be scheduled. Diabetic people should have their feet thoroughly examined every one to twelve months, depending on their risk categories.
Proper shoe gear and selection
Shoes can both protect and deform. When selecting shoe gear it is important for the shoe to be comfortable at the time of purchase. Certain shoe materials will stretch with time but deformity forces placed on your foot can cause serious conditions. Shoes should be inspected for any areas of rubbing or tightness. It is best to use shoe size as a guide, shop in the middle of the day to account for possible swelling, and bring socks that are normally worn with the shoe. If a special insert or orthotic is worn it should be brought.
People with diabetes need to pay particular attention to the shoes they purchase. Due to their predisposition for neuropathy all shoes should be inspected for foreign objects or areas of irritation before wearing. Going barefoot should be avoided. In some cases special molded shoes are the best option for the diabetic foot. In the case of a short leg, special shoes with lifts may be required.
Feet play an important part in daily activities. As the older population ages, proper foot health will help to maintain quality of life. Keeping active is important and paying attention to and addressing foot ailments is a part of this. With a little prevention and modification and consistent attention, the elderly population should be able to maintain good foot health.
Donna M. Alfieri
See also Arthritis; Diabetes Mellitus.
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foot / foŏt/ • n. (pl. feet / fēt/ ) 1. the lower extremity of the leg below the ankle, on which a person stands or walks. ∎ a corresponding part of the leg in vertebrate animals. ∎ Zool. a locomotory or adhesive organ of an invertebrate. ∎ the part of a sock or stocking that covers the foot. ∎ poetic/lit. a person's manner or speed of walking or running: fleet of foot.2. the lower or lowest part of something standing or perceived as standing vertically; the base or bottom: the foot of the stairs. ∎ the end of a table that is furthest from where the host sits. ∎ the end of a bed, couch, or grave where the occupant's feet normally rest. ∎ a device on a sewing machine for holding the material steady as it is sewn. ∎ Bot. the part by which a petal is attached. ∎ the lower edge of a sail.3. a unit of linear measure equal to 12 inches (30.48 cm): shallow water no more than a foot deep. (Symbol: ′) ∎ [usu. as adj.] Mus. a unit used in describing sets of organ pipes or harpsichord strings, in terms of the average or approximate length of the vibrating column of air or the string which produces the sound: a sixteen-foot stop.4. Prosody a group of syllables constituting a metrical unit. In English poetry it consists of stressed and unstressed syllables, while in ancient classical poetry it consists of long and short syllables.• v. [tr.] 1. inf. pay (the bill) for something, esp. when the bill is considered large or unreasonable.2. (foot it) cover a distance, esp. a long one, on foot: the rider was left to foot it ten or twelve miles back to camp. ∎ archaic dance: the dance of fairies, footing it to the cricket's song.PHRASES: at someone's feet as someone's disciple or subject: you would like to sit at my feet and thus acquire my wisdom.feet of clay a fundamental flaw or weakness in a person otherwise revered.get one's feet wet begin to participate in an activity.get (or start) off on the right (or wrong) foot make a good (or bad) start at something, esp. a task or relationship.have something at one's feet have something in one's power or command: a perfect couple with the world at their feet.have (or keep) one's (or both) feet on the ground be (or remain) practical and sensible.have a foot in both camps have an interest or stake concurrently in two parties or sides: I can have a foot in both the creative and business camps.have (or get) a foot in the door gain or have a first introduction to a profession or organization.have one foot in the grave inf., often humorous be near death through old age or illness.my foot! inf. said to express strong contradiction: Efficient, my foot!off one's feet so as to be no longer standing: she was blown off her feet by the shock wave from the explosion.on one's feet standing: she's in the shop on her feet all day. ∎ well enough after an illness or injury to walk around: we'll have you back on your feet in no time.on (or by) foot walking rather than traveling by car or using other transport.put one's best foot forward embark on an undertaking with as much effort and determination as possible.put one's feet up inf. take a rest, esp. when reclining with one's feet raised and supported.put one's foot down inf. adopt a firm policy when faced with opposition or disobedience. put one's foot in it (or put one's foot in one's mouth) inf. say or do something tactless or embarrassing; commit a blunder or indiscretion.set foot on (or in) enter; go into: he hasn't set foot in the place since the war.set something on foot archaic set an action or process in motion: a plan had lately been set on foot for their relief.Compare with afootsweep someone off their feet charm someone quickly and overpoweringly.think on one's feet react to events decisively, effectively, and without prior thought or planning.to one's feet to a standing position: he leaped to his feet.DERIVATIVES: foot·ed / ˈfoŏtəd/ adj. [in comb.] the black-footed ferret.foot·less adj.ORIGIN: Old English fōt, of Germanic origin; related to Dutch voet and German Fuss, from an Indo-European root shared by Sanskrit pad, pāda, Greek pous, pod-, and Latin pes, ped- ‘foot.’
Hence foot vb. dance XIV; †add up XV; walk; strike, etc. with the foot XVI. footing (dial.) foothold XIV; (fig.) XVI; settled condition XVII. football XV, footfall XVII, foothold XVII. footman foot-soldier XIII; (dial.) pedestrian XIV; attendant on foot XV. footnote XIX. footpace walking-pace; raised floor (for an altar). XVI. footpad highwayman who robs on foot. XVII; pad, canting use of var. of PATH. footpath XVI. footstep XIV (once XIII as pl. fet steppes). footstool XVI.
get off on the right (or wrong) foot make a good (or bad) start at something.
have a foot in both camps have an interest or stake in two parties or sides without commitment to either (with allusion to the military sense of forces in encampment).
have (or get) a foot in the door have (or gain) a first introduction to a profession or organization.
have one foot in the grave (informal, and often humorous) be near death through old age or illness.
put one's best foot forward embark on an undertaking with as much effort and determination as possible.
put one's foot down adopt a firm policy when faced with opposition or disobedience.
put one's foot in one's mouth say or do something tactless or embarrassing.
see also feet, shoot yourself in the foot.