Variation in diagnosis and management of common foot problems by GPs

The epidemiology of symptomatic midfoot osteoarthritis in community-dwelling older adults: cross-sectional findings from the Clinical Assessment Study of the Foot

Introduction

The foot is largely overlooked in calls for better characterisation of clinical phenotypes in osteoarthritis (OA). Yet the midfoot complex in particular has the potential to provide important insights into OA pathogenesis given its central role in lower limb load transmission and alignment. Its recent inclusion in radiographic atlases has paved the way for international studies. In this UK study, we provide the first comprehensive account of the descriptive epidemiology of symptomatic midfoot OA.

Methods

Participants aged ≥50 years registered with four general practices were recruited via a mailed health survey (n = 5109 responders) and research clinic (n = 560 responders). Symptomatic midfoot OA was defined as midfoot pain in the last 4 weeks, combined with radiographic OA in one or more joints (1st and 2nd cuneometatarsal, navicular first cuneiform and talonavicular joints) graded from weight-bearing dorso-plantar and lateral radiographs using a validated atlas. Prevalence estimates, overall and stratified by age, gender, and socio-economic class, were derived using multiple imputation and weighted logistic regression. Associations between symptomatic midfoot OA and current body mass index, previous injury, history of high-heeled footwear, nodal interphalangeal joint OA and patterns of comorbidity were estimated using binary logistic regression. Healthcare use was summarised.

Results

Symptomatic midfoot OA was present in 12.0 % (95 % CI: 10.9, 13.2) of the population aged over 50 years. Higher occurrence was observed in females, adults aged over 75 years, and those in intermediate/routine occupational classes. Obesity, previous foot/ankle injury, and pain in other weight-loaded joints, but not high-heeled footwear or nodal interphalangeal joint OA, were associated with increased risk of symptomatic midfoot OA. Persons with symptomatic midfoot OA were also more likely to report multiple non-musculoskeletal comorbidities, including diabetes. In the previous 12 months, the proportions consulting a general practitioner, physiotherapist or podiatrist/chiropodist about foot pain were 46.2 %, 18.5 % and 47.9 % respectively. A total of 64.7 % had used oral analgesia in the past month for foot pain (36.1 % paracetamol, 31.9 % mild/moderate opioids, 27.7 % NSAIDs).

Conclusions

Our study confirms that symptomatic OA frequently affects the midfoot. The patterns of associations are interpreted as being largely consistent with the role of mechanical factors in its pathogenesis.

Electronic supplementary material

The online version of this article (doi:10.1186/s13075-015-0693-3) contains supplementary material, which is available to authorized users.

Treatment of forefoot problems in older people: a randomized clinical trial comparing podiatric treatment with standardized shoe advice

PURPOSE

Consultations for forefoot pain are frequent in primary care, but scientific support of treatment options is scarce. The purpose of this study is to investigate the effect of podiatric treatment vs standardized advice on proper shoe characteristics and fit of shoes by means of an information leaflet for people aged 50 years and older with forefoot pain in primary care.

METHODS

In this randomized controlled trial, 205 participants aged 50 years and older with hindering nontraumatic forefoot pain have been recruited at their general practitioner's office. Exclusion criteria were treatment of forefoot problem of less than 6 months' duration before inclusion, rheumatoid arthritis, and diabetic neuropathy or having pain considered not to be musculoskeletal (eg, warts). Participants received shoe advice by means of an information leaflet or podiatric care. Foot pain, foot-related dysfunction, general health, and social participation were assessed by means of questionnaires every 3 months for 1 year. Using multilevel analysis, we analyzed results at the level of (1) outcome measures, (2) the individual, and (3) the general practitioner.

RESULTS

No differences were found between the 2 treatment groups. Both intervention groups showed an improvement over time in foot pain and foot-related dysfunction.

CONCLUSION

This study found that shoe advice provided to patients consulting their general practitioner for forefoot pain and symptom relief resulted in outcomes similar to treatment outcomes in patients consulting a podiatrist. Based on these results, primary care physicians should be cautious when referring a patient to a podiatrist; instead, they should start by providing advice on proper characteristics and fit of shoes.

Development and evaluation of a leaflet containing shoe advice: a randomized controlled trial

BACKGROUND

Providing advice to wear good quality shoes with appropriate fit is one of the possibilities GPs have when treating patients with foot problems.

OBJECTIVES

The aims of this study are to (i) determine which shoe characteristics are important when providing shoe advice; (ii) develop a shoe advice leaflet and (iii) evaluate if women choose better shoes with the aid of the leaflet.

METHODS

We performed a literature search on the effect of separate shoe characteristics on foot pathologies and kinematics and developed an information leaflet with the aid of multidisciplinary experts. The leaflet was tested in a group of women aged 50 years or over who did not receive podiatric treatment or shoe advice in the year prior to the study. The women were asked to select shoes; half of them were provided with the leaflet. Shoe characteristics were scored blinded for the condition by two podiatrists. Data were analysed using a t-test for independent measures.

RESULTS

The developed leaflet contains nine shoe characteristics. A total of 57 women ranging from 54 to 86 years old (average 69) consented to participate in testing the efficacy of the leaflet. Women using the leaflet (n = 29) selected better shoes than without (P = 0.049).

CONCLUSIONS

Based on a literature search and expert opinion, we have developed an information leaflet for GPs to provide as a supplement to oral shoe advice. Women using this leaflet were able to select shoes of better quality and better fit than women selecting shoes without using the leaflet.

Decision rules for GHB (γ-hydroxybutyric acid) detoxification: a vignette study

BACKGROUND

GHB dependent patients can suffer from a severe and sometimes life-threatening withdrawal syndrome. Therefore, most of the patients are treated within inpatient settings. However, some prefers an outpatient approach to treatment. The aim of this study was to develop decision rules for addiction physicians to determine whether an outpatient or inpatient setting should be chosen for a safe GHB detoxification.

METHODS

A prospective vignette study was performed. Forty addiction medicine specialists from various treatment settings and residents of the Addiction Medicine postgraduate Master training were asked to contribute vignettes of GHB dependent patients. A focus group of 15 psychiatrists and addiction medicine specialists was asked to recommend an outpatient or inpatient setting for GHB detoxification treatment per vignette. Finally, five addiction medicine specialists, experts in GHB dependence treatment in the Netherlands, assessed the bio-psychosocial reasons for the choices of the focus group and formulated the recommended criteria.

RESULTS

Based on the bio-psychosocial state of twenty vignette patients, addiction physicians and psychiatrists established the criteria and conditions recommended for the indication of an outpatient GHB detoxification. Intensity of addiction (GHB dose ≤32 g/d and frequency of abuse ≤2 h) was stated as the primary criterion in determining the setting as well as the complexity of the psychiatric comorbid disorders. The importance of a stable support system was emphasised.

CONCLUSION

The vignette study resulted in a set of criteria with which addiction medicine specialists can make a weighted decision as to an outpatient or inpatient setting for GHB detoxification.

"Somebody to say 'come on we can sort this'": a qualitative study of primary care consultation among older adults with symptomatic foot osteoarthritis

Objective

To examine the experiences of primary care consultation among older adults with symptomatic foot osteoarthritis (OA).

Methods

Eleven participants (6 women and 5 men) ages 56–80 years who had radiographically confirmed symptomatic foot OA and consulted a general practitioner in the last 12 months for foot pain were purposively sampled. Semistructured interviews explored the nature of the foot problem, help-seeking behaviors, and consultation experiences. Verbatim transcripts were analyzed using interpretative phenomenological analysis.

Results

The decision to consult a physician was often the outcome of a complex process influenced by quantitative and qualitative changes in symptoms, difficulty maintaining day-to-day roles and responsibilities and the effect this had on family and work colleagues, and a reluctance to present a fragile or aging self to the outside world. Self-management was commonly negotiated alongside multimorbidities. Upon seeking help, participants often believed they received limited information, they were given a brief or even cursory assessment, and that treatment was focused on the prescription of analgesic drugs.

Conclusion

This is the first qualitative study of primary care experiences among patients with symptomatic foot OA. The experience of primary care seldom appeared to move beyond a label of arthritis and an unwelcome emphasis on pharmacologic treatment.

Inter and intra-rater repeatability of the scoring of foot pain drawings

Background

Foot pain drawings (manikins) are commonly used to describe foot pain location in self-report health surveys. Respondents shade the manikin where they experience pain. The manikin is then scored via a transparent overlay that divides the drawings into areas. In large population based studies they are often scored by multiple raters. A difference in how different raters score manikins (inter-rater repeatability), or in how an individual rater scores manikins over time (intra-rater repeatability) can therefore affect data quality. This study aimed to assess inter- and intra-rater repeatability of scoring of the foot manikin.

Methods

A random sample was generated of 50 respondents to a large population based survey of adults aged 50 years and older who experienced foot pain and completed a foot manikin. Manikins were initially scored by any one of six administrative staff (Rating 1). These manikins were re-scored by a second rater (Rating 2). The second rater then re-scored the manikins one week later (Rating 3). The following scores were compared: Rating 1 versus Rating 2 (inter-rater repeatability), and Rating 2 versus Rating 3 (intra-rater repeatability). A novel set of clinically relevant foot pain regions made up of one or more individual areas on the foot manikin were developed, and assessed for inter- and intra-rater repeatability.

Results

Scoring agreement of 100% (all 50 manikins) was seen in 69% (40 out of 58) of individual areas for inter-rater scoring (range 94 to 100%), and 81% (47 out of 58) of areas for intra-rater scoring (range 96 to 100%). All areas had a kappa value of ≥0.70 for inter- and intra-rater scoring. Scoring agreement of 100% was seen in 50% (10 out of 20) of pain regions for inter-rater scoring (range 96 to 100%), and 95% (19 out of 20) of regions for intra-rater scoring (range 98 to 100%). All regions had a kappa value of >0.70 for inter- and intra-rater scoring.

Conclusions

Individual and multiple raters can reliably score the foot pain manikin. In addition, our proposed regions may be used to reliably classify different patterns of foot pain using the foot manikin.

Process evaluation of podiatric treatment of patients with forefoot pain

BACKGROUND

Foot pain is a common problem for people aged 50 and over and occurs more often in women than in men. About 60% of the foot problems are forefoot problems and slightly more than half of these patients seek medical help, mainly in the form of podiatric care. Podiatric treatment of forefoot problems is known to be heterogeneous. The aims of the present study are to describe the podiatric treatment of patients with forefoot pain and to evaluate the podiatric examination and treatment using an expert panel.

METHOD

We invited twenty-five randomly selected subjects with forefoot problems who had received podiatric treatment in a pragmatic randomised clinical trial to participate in an analysis of their treatment by an expert panel. The panel retrospectively established the cause of the foot problem as well as the therapeutic goals and evaluated the treatment. These findings were compared to those reported by the treating podiatrist.

RESULTS

Two fundamentally different approaches were found in approach of podiatric examination; a functional approach (n =13) and a non-functional approach (n =12). In nine cases the expert panel agreed with the cause recorded by the podiatrist. In five other cases the expert panel concluded that the treatment of the podiatrist was not consistent with the cause of the problem recorded by the podiatrist. Of the 10 patients for whom the podiatrist had recorded to have given shoe advice, only two were able to recollect the proper advice. Three patients did not remember receiving advice at all.

CONCLUSION

In this study almost half of the podiatrists worked according to a non-functional approach where the other half (like the expert panel) chose a functional strategy that analyses the underlying problem. Fundamental differences in treatment plans and thus heterogeneous treatments could be a consequence.

Treatment of forefoot problems in older people: study protocol for a randomised clinical trial comparing podiatric treatment to standardised shoe advice

Background

Foot problems in general and forefoot problems in particular can lead to a decrease in mobility and a higher risk of falling. Forefoot problems increase with age and are more common in women than in men. Around 20% of people over 65 suffer from non-traumatic foot problems and 60% of these problems are localised in the forefoot. Little is known about the best way to treat forefoot problems in older people. The aim of this study is to compare the effects of two common modes of treatment in the Netherlands: shoe advice and podiatric treatment. This paper describes the design of this study.

Methods

The study is designed as a pragmatic randomised clinical trial (RCT) with 2 parallel intervention groups. People aged 50 years and over who have visited their general practitioner (GP) with non traumatic pain in the forefoot in the preceding year and those who will visit their GP during the recruitment period with a similar complaint will be recruited for this study. Participants must be able to walk unaided for 7 metres and be able to fill in questionnaires. Exclusion criteria are: rheumatoid arthritis, neuropathy of the foot or pain caused by skin problems (e.g. warts, eczema). Inclusion and exclusion criteria will be assessed by a screening questionnaire and baseline assessment. Those consenting to participation will be randomly assigned to either a group receiving a standardised shoe advice leaflet (n = 100) or a group receiving podiatric treatment (n = 100). Primary outcomes will be the severity of forefoot pain (0-10 on a numerical rating scale) and foot function (Foot Function 5-pts Index and Manchester Foot Pain and Disability Index). Treatment adherence, social participation and quality of life will be the secondary outcomes. All outcomes will be obtained through self-administered questionnaires at the start of the study and after 3, 6, 9 and 12 months. Data will be analysed according to the "intention-to-treat" principle using multilevel level analysis.

Discussion

Strength of this study is the comparison between two common primary care treatments for forefoot problems, ensuring a high external validity of this trial.

Trial registration

Netherlands Trial Register (NTR): NTR2212

Musculoskeletal foot problems in primary care: what influences older people to consult?

Objective. To estimate the incidence of, and factors associated with, consultation for musculoskeletal foot problems in primary care.

Methods. Survey data from 13 986 people aged ≥50 years who took part in the North Staffordshire Osteoarthritis Project were linked to a database of primary care consultations. Foot problems were defined as responding affirmatively to the questions: ‘Have you had any problems with your feet over the last year?’ or ‘Have you had pain in the last year in and around the foot?’. The main outcome measure was a record of a musculoskeletal foot-related consultation within 18 months following the survey.

Results. Of the 3858 participants with foot problems who had not consulted before the survey, 350 (9.1%) consulted in the 18 months following the survey. Age, sex, education, general health and pain in other regions were not associated with future consultation. However, those who consulted were more likely to have reported foot pain [adjusted odds ratio (OR) 2.04; 95% CI 1.22, 3.42) and to consider treatments to be effective in controlling disease (OR 1.54; 95% CI 1.07, 2.21) in the baseline survey, and to have been a frequent consulter in the 18 months before the survey (OR 1.65; 95% CI 1.30, 2.09).

Conclusions. Only a minority of older people with musculoskeletal foot problems consult their general practitioner about them. Foot pain, frequent consultation for other problems and positive perceptions of treatment efficacy appear to be the strongest factors influencing future consultation.

Characteristics of primary care consultations for musculoskeletal foot and ankle problems in the UK

Objective. Foot and ankle problems are highly prevalent in the general population; however, little is known about the characteristics of those seeking medical assessment for these problems. The objective of this study was to explore the extent and types of musculoskeletal foot and ankle problems in primary care.

Methods. Consultation data related to musculoskeletal foot and ankle problems in 2006 were extracted from the Consultations in Primary Care Archive (CiPCA), which covers consultations in 12 general practices in North Staffordshire. Data were cross-tabulated by age and gender, and annual consultation prevalence per 10 000 registered persons was calculated.

Results. Of the 55 033 musculoskeletal consultations documented in CiPCA in 2006, 4500 (8%) related to foot and ankle problems. The most commonly documented Read term was ‘foot pain’ (1281 consultations; 28%), followed by ‘ankle pain’ [451 (10%)]. Most consultations [3538 (79%)] involved non-traumatic conditions. Females accounted for slightly more consultations than males (55 vs 45%), and the highest proportion of consultations involved people aged 45–64 years (36%). The number of consultations per patient ranged from 1 to 11. Annual consultation prevalence was 290 per 10 000 registered persons and increased with age, reaching a peak in the 65- to 74-year age group (411 per 10 000 registered persons).

Conclusion. Foot and ankle problems account for a substantial number of consultations in primary care, and most frequently involve non-traumatic conditions. Further research is required to evaluate the factors that influence consultation for foot problems and strategies that general practitioners use to manage these conditions.

An electrophysiological severity scale in tarsal tunnel syndrome

OBJECTIVE

To propose a neurophysiological classification of tarsal tunnel syndrome.

MATERIAL AND METHODS

We retrospectively reviewed the medical records of two electromyography laboratories. Case inclusion criteria were based on clinical parameters. Motor conduction velocity, distal motor latency (DML), sensory conduction velocity (SCV) and sensory action potential (SAP) from big toe (T1) and from fifth toe (T5) to medial malleolus were measured in the medial and plantar nerves. When SCVs of T1 and T5 were normal, we considered the difference in T1 SCV between affected and unaffected side and in T1 SCV of the affected side with sural nerve distal SCV. Feet with TTS were classified in six electrophysiological classes: 0, normal SCV and DML; 1, normal absolute SCV with abnormal comparative tests; 2, slowing of T1 and T5 SCV and normal DML; 3, slowing of SCV and DML; 4, absence of T1 and T5 SAPs and abnormal DML; 5, absence of sensory and motor response.

RESULTS

A total of 111 feet belonging to 96 patients (27 men, 69 women; mean age 49.6 years) were diagnosed with TTS. T1 and T5 SCV were abnormal in 82 and 73% of cases, respectively, and comparative tests were abnormal in a further 7% of cases. DML was abnormal in 82 feet (73.9%). Eight feet (7%) were without neurographic abnormalities. The distribution of feet in neurophysiological classes was: stage 0, 7%; stage 1, 9%; stage 2, 10%; stage 3, 39%; stage 4, 32%; stage 5, 3%. Higher clinical scores coincided with higher neurographic classes.

CONCLUSION

The progression of neurographic abnormalities in TTS reflects the relation between SCV and DML, and between neurographic values and clinical severity. The scale assigns severity classes in a reliable and non-arbitrary way. This classification can easily be used by electrophysiological laboratories with their own electrophysiological techniques and normal values.