The Podiatrist July/August 2021

A N T I M I C R O B I A L R E S I S TA N C E

BUSINESS

C A S E S T U DY

THE NEW RISKS OF OVERPRESCRIBING

TREATING DANCERS AND ATHLETES

HELP FOR AQUAGENIC KERATODERMA

JULY/AUG 2021 VOLUME 24 NUMBER 4

JULY/AUGUST 2021

T H E P R O F E S S I O N A L M A G A Z I N E O F T H E C O L L E G E O F P O D I AT R Y

ANTIMICROBIAL RESISTANCE TREATMENTS FOR DANCERS EMPLOYMENT LAW FIRST CONTACT PRACTITIONERS

The changing picture and implications for foot care

AQUAGENIC KERATODERMA

+ CLTI and Covid: a podiatric approach

CPD PAPER

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JULY/AUGUST 2021 CONTENTS 3

Contents THE S&O 5

WELCOME Chief executive Steve Jamieson talks AGM success and the return of conference season

7

THE LATEST Podiatry news, including the return of face-to-face conferences, and a new pay deal

9

NEWS ANALYSIS The risk of overprescribing antibiotics remains – how can podiatrists help?

12 DID YOU KNOW? Our mighty quiz returns, with more surprising foot facts

15

34 APPRENTICESHIPS Could a programme of paid apprenticeships be key to growing the workforce?

32

CPD

16 ONE TO ONE Denzil Trebilcock gives a fascinating insight into his role as principal podiatrist at the Royal Ballet

22 COVER STORY Making a difference to the lives of HIV-positive patients

38 CAREER DEVELOPMENT How one podiatric surgeon successfully rebranded himself during a time of career uncertainty 40 CHARTERED SCIENTISTS Gafin Morgan talks about his journey to CSci status

15 THE BIG QUESTION Is there really any more need for paper records?

18 EMPLOYMENT LAW Before taking on or working as a self-employed associate, it’s important to know your rights, says Martin Furlong

32 HOW TO...

Advice on treating a very particular patient group: professional athletes and dancers

20 OBITUARY The life and achievements of Michael Whiting, a true pioneer and innovator in podiatry education

THE PRACTICE 27 HEE ROADMAP A look at the development pathway for podiatrists looking to move into primary care, as encouraged by the NHS Long Term Plan 30 FCP ROLE Meet Louis Mamode, a first contact practitioner who talks about the progression of his role and career

CLTI AND COVID: A PODIATRIC APPROACH Chronic limb-threatening ischaemia in a pandemic

THE EVIDENCE 43 RESEARCH ROUND-UP Behaviour-change approaches to improve self-management of the diabetic foot 44 CASE STUDY Two unusual instances of aquagenic keratoderma and how they were treated

THE END 48 60 SECONDS WITH...

Podiatrist, author, lecturer and podcaster Simon Bartold J U LY/AU G U ST 2 0 2 1 T H E P O D I AT R I ST

3 CONTENTS_THE PODIATRIST JULY AUG_Podiatry Now.indd 3

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WELCOME EDITORIAL 5

THE COLLEGE OF PODIATRY Quartz House 207 Providence Square Mill Street London SE1 2EW 020 7234 8620 cop.org.uk

One step at a time

PROFESSIONAL EDITOR Chris Morriss-Roberts PhD, MA, MCPod, FCPM, CSci DEPUTY PROFESSIONAL EDITORS Fran Campbell MSc, BSc Beverley Durrant PhD Michael Stephenson BSc EDITORIAL Editor Emma Godfrey emma@the-podiatrist.co.uk 020 7324 2751 Deputy editor Katie Smith katie@the-podiatrist.co.uk Assistant editor Kathryn Manning Content sub-editor James Hundleby

Planning for our future as we continue to adapt in the face of adversity.

DESIGN Art editor Sarah Auld Picture editor Jessica Marsh

S

PUBLISHING Publishing director Joanna Marsh EDITORIAL CONTRIBUTIONS editorial@the-podiatrist.co.uk ADVERTISING the-podiatrist@redactive.co.uk the-podiatristjobs@redactive.co.uk 020 7880 6230 SUBSCRIPTIONS contact@cop.org.uk or 020 7234 8620 PRODUCTION rachel.young@redactive.co.uk PRINTER Warners Midlands plc © The College of Podiatry. 2021

The editor and council of the College of Podiatry do not accept responsibility for opinions expressed by contributors to the magazine, including advertising.

While every effort is made to ensure accuracy, they cannot accept responsibility for any inaccuracies in the information provided. The editor reserves the right to edit any material submitted for publication.

ISSN 2634-2901

Cover: Jesper Klausen / Science Photo Library / iStock – Khaneeros

The Podiatrist, incorporating The British Journal of Podiatry, The Journal of British Podiatric Medicine (The Chiropodist incorporating the British Journal of Chiropody and The British Chiropody Journal) and the British Journal of Podiatric Medicine and Surgery, Society News section of The Journal of British Podiatric Medicine, SeaRCh News and Instep

ummer is always a busy time at the College as we plan for events in autumn and winter.

Thankfully, this year we have been afforded more certainty to prepare than we had in 2020.

The government’s delay to the end of restrictions until 19 July is a necessary measure to combat the rise in cases.

Many of you will understand the legitimate reasons for this but feel a sense of frustration. The College and our members remain committed to reducing transmission of Covid-19 in their everyday lives and workplaces and to ensure patients can still access services safely.

It has been a particularly challenging time for final-year students. These accomplished people, the future of our profession, are about to venture out into the world. It is a rite of passage that is difficult to adjust to even in normal circumstances. My thoughts are with all those studying podiatry who have had to suffer interruptions and unfortunate conditions in the final years of their education. The quality of this year’s graduates is as high as ever, and the College stands ready to support them at every stage in their career.

For the second time in its history, the College hosted its AGM online.

This has allowed more of you to attend and has boosted engagement between the College and our members. Now, more than ever, there are increasing opportunities for you to ask questions about our performance. I was pleased to see members of all stripes attend the event and have their say, and many more of you vote on our resolutions by proxy. We have published the results, which were followed by many of you live on social media, on our news channels.

The day of the AGM held extra significance, of course, as later that afternoon our Summer Festival of Learning concluded. More than 1000 of you attended this two-day event.

Many thanks to all who attended and took part, including our speakers, sponsors and online exhibitors.

We have much to look forward to in the coming months. College staff are now planning the annual conference and exhibition at the ACC Liverpool from 18 to 20 November – three days of expert speeches, plenary and concurrent sessions and the largest podiatry exhibition in Europe. Those exhibitors who have signed up to attend so far are industry-leading, diverse and exciting.

Despite the forecasted end to restrictions this month, the College stands ready to adapt to any eventuality. We will keep members informed on these pages and across our usual channels.

For now, I hope you enjoy this issue of The Podiatrist, continue to stay safe, and have a lovely summer.

STEVE JAMIESON Chief executive

J U LY/AU G U ST 2 0 2 1 T H E P O D I AT R I ST

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Microwave energy is the safe, clean and effective approach to treating warts and verrucae.

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23/06/2021 12:25

THE BIG 5 THE S&O 7 M U C O R M YC O S I S

4

India warns of ‘black fungus’ in Covid patients THE SUBJECTIVE AND OBJECTIVE

PAY D E A L

Scotland pay rise agreed as unions accept offer The Scottish government has confirmed the pay increase for NHS Scotland staff will be implemented ‘as soon as possible’ after the offer was unanimously accepted by unions.

In an online survey, College of Podiatry members in Scotland voted:

87.5% to accept 12.5% to reject the offer

E L E C T I V E S U R G E RY

2

College solution ut n for surgery waits

Podiatric surgery is an ‘essential service’, the College has asserted in a document outlining its solution for reducing elective foot surgery waits in England.

The statement proposes that: Podiatric surgery keeps the ageing population mobile and active, addressing physical and mental health priorities.

Non-medical independent prescribing improves continuity of care, facilitates quicker consultations and access to services and medicines.

Podiatric surgeons are integrated with multidisciplinary diabetic foot services and apply their knowledge and surgical skills to reduce amputations.

To read the position statement in full, go to bit.ly/statement-elective-surgery

1

In a letter responding to the C College’s ollege leg acceptance of the deal, thee Scottish S tish ish government said: ‘Ministerss are clear that staff should feel the benefit off this h pay uplift as soon as possible.’

Just two of the nine unions represented among Agenda for Change staff did not vote to accept ‘the biggest pay deal since devolution’, the government letter noted.

To read the letter in full, go to bit.ly/Scot-gov-pay-letter

Doctors in India treating Covid-19 patients have been urged to look for signs of mucormycosis, as cases rise.

The Indian Council of Medical Research (ICMR) said those vulnerable to the potentially fatal infection, known as ‘black fungus’, included people with diabetes and compromised immune systems. Early symptoms include sinus pain and one-sided headaches, and it can lead to blackening of the nose and coughing up blood.

Ivan Bristow, a podiatrist who has published research into Covid toes, said: ‘This has been identified in a number of countries, including a case in the UK. ‘The condition most often occurs in patients given systemic steroids.

These are administered to patients with Covid-related breathing difficulties.

The side effect of this is the potential for mucormycosis.’

He added: ‘Around half the patients who develop this have diabetes.’

Find the ICMR’s advice on screening, diagnosing and managing this condition at bit.ly/ICMR-mucormycosis

C O L L E G E O F P O D I AT RY

In-person conference returns Attendees of this year’s annual College conference and exhibition will be able to meet face to face in Liverpool.

When and where? It will be held at the ACC Liverpool on 18 to 20 November.

Who? Speaker highlights include 7/7 survivor and Paralympian Martine Wright, former deputy leader of the Labour Party Tom Watson, and Paul Nowak, TUC deputy general secretary.

How? The College assured members the event would adhere to Covid-19 safety guidance that’s in place at the time in a series of FAQs.

3

Find out more: to see the latest programme, book tickets and read the FAQs, go to cop.org.uk/copc21

COMMITTEE ELECTIONS

We need you!

5

Elections are to take place for the College’s employment support committee (ESC) and health, safety and wellbeing panel (HS&WP).

What they do: The ESC deals with employment matters, while the HS&WP looks after all matters relating to the health and safety issues that affect members in their workplaces.

Who they need: Both groups comprise a mix of trade union representatives and members from private practices.

When? The elections will take place in September and October; for private practices, they’ll be in early 2022.

How to stand: If you’re interested in putting yourself forward for either committee, as a trade union or private practice rep, contact your employment support officer, or email employmentsupport@cop.org.uk J U LY/AU G U ST 2 0 2 1 T H E P O D I AT R I ST

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23/06/2021 12:26

NEWS ANALYSIS THE S&O 9

T

he NHS is worried about the emergence of strains of bacteria such as MRSA and C. diff that have developed resistance to many antibiotics. The biggest fear is that new strains may emerge that cannot be treated by any existing antibiotics. Health organisations across the world are therefore trying to reduce the use of antibiotics, especially for conditions that are not serious (NHS, 2019).

It might not seem immediately apparent why this is a concern for podiatrists – most don’t prescribe antibiotics (see What proportion of the profession can prescribe antibiotics? on page 11) and the ones that do are very cautious about it. However, Covid-19 restrictions have reduced the amount of face-toface interactions between clinicians and patients with foot problems and a problem that already existed is getting worse.

The root of the problem It starts with the patients, says Katrina Waller, who has more than 34 years of experience in podiatry. Before setting up

ANTIBIOTICS

Resistance isn’t futile Covid restrictions have increased the risk of overprescribing and the incorrect prescription of antibiotics to patients, but what can podiatrists do?

Words Steve Smethurst

Compleet Feet in Hampshire in 2007, she worked for 12 years full-time at the Ministry of Defence’s Royal Hospital Haslar until its closure. ‘As a podiatrist, it’s frustrating that the public doesn’t seem to be aware that they should see the appropriate health professional,’ says Katrina.

‘If patients have a problem with their feet, they tend to make a GP appointment. If they have an ingrown toenail, for example, the GP would take a look and probably prescribe antibiotics.’

Jacob Penkethman agrees.

The principal diabetes podiatrist and independent prescriber at Cambridgeshire and Peterborough NHS Foundation Trust says it’s unusual to find anybody who presents with an obvious ingrowing toenail who hasn’t been prescribed antibiotics from their primary care physician, or other non-podiatrist prescriber. ‘As many symptoms of an ingrowing toenail can mimic infection, it usually leads to antibiotics being prescribed inappropriately,’ says Jacob. ‘For clinicians who aren’t used to seeing them, their first step will be to prescribe antibiotics.’

The problem even extends to post-nail surgery. ‘If we perform surgery and apply phenol to stop the nail from growing back again, this can also mimic signs of infection, which leads to GPs initiating antibiotics for a healthy healing wound,’ he says. ‘From an ingrowing toenail standpoint, there is a massive overuse of antibiotics in my opinion.’

Covid impact Lockdowns have exacerbated the situation, says Katrina: ‘It’s been difficult to get a face-to-face appointment with a GP. When set up and orchestrated well, a virtual appointment can suffice for many medical problems, but there are many flaws: no physical examination, no observation of patient mood, and not being able to do simple diagnostic tests.

J U LY/AU G U ST 2 0 2 1 T H E P O D I AT R I ST

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10 THE S&O NEWS ANALYSIS

‘Patients are left at risk and issues can be missed. Overprescribing of antibiotics is just one of the issues.

Covid may have brought this to the fore, but it was apparent before March last year. It’s not only ingrown toenails, it might be a broken chilblain or bursitic corn. It’s a concern because as podiatrists we have so many dressings to mitigate the need for antibiotics.’

Jacob, who has worked across two trusts since the pandemic began, has also seen an increase in ‘unnecessary’ antibiotic prescriptions. ‘This was much less common pre-Covid,’ he says.

‘This is because clinicians sleep easier at night having been overcautious, as opposed to missing a possible infection which could lead to amputation. This is particularly true for patients with a history of diabetic foot problems.

Therefore, in my opinion, virtual consultations are not the best way to assess patients, as they can lead to elements being missed – for example, ischaemia – which can have detrimental consequences.’

Covid also had an impact through the cancellation of non-urgent hospital appointments and the reluctance of many high-risk patients, who would have routinely been seen for long-standing ulcers or preventative management and observation, to attend face-to-face appointments.

‘As a consequence,’ says Jacob, ‘many patients presented at crisis point when their infections were much more severe.

This often meant that longer courses or multiple combinations of antibiotics were required, which may not have been necessary if the infection had been reviewed sooner.

‘Granted, their infection would still have needed antibiotics; however, some of these mild infections could have been managed with lower doses and shorter courses.’

Other complications While there is no real safe substitute for a face-to-face consultation, patients today can send photographs or show their foot problems on screen.

However, firewalls sometimes block attachments and a screen image may not show the full extent of a problem.

Antimicrobial stewardship at London’s Homerton Hospital Debbie Coleman, diabetic foot coordinator at Homerton University Hospital in East London, was approached recently by one of the hospital’s vascular access nurses who wanted to arrange antimicrobial stewardship training for the podiatry team, as it requires an interprofessional effort across the continuum of care.

The aim of the training is to improve patient outcomes and reduce the spread of multiresistant organisms by modifying prescribing practices and reducing the use of antimicrobials, particularly antibiotics. Debbie says: ‘If antimicrobial resistance (AMR) isn’t addressed, it is estimated that 10 million people globally per year will die due to it by 2050. This is 1.8 million more than cancer. Currently, 33,000 people die each year from antimicrobial infections across Europe alone’ (Cassini et al, 2018; O’Neill, 2014).

She adds that the training was designed more for healthcare professionals from a nursing or medical background working in an acute setting, but it still provided an excellent overview of the problems of AMR. She adds: ‘It was also a good reminder to the team about the importance of thorough assessment of the patient with suspected infection and the need to take appropriate samples early in treatment.’

T H E P O D I AT R I ST J U LY/AU G U ST 2 0 2 1

9-11 sando analysis_THE PODIATRIST JULY AUG_Podiatry Now.indd 10

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NEWS ANALYSIS THE S&O 11

The race against time There are

42 antibiotics in clinical development

11 have the potential to treat WHO’s critical threat pathogens

33 thousand people die each year from antimicrobial infections across Europe alone

10 million people a year could die around the world due to antimicrobial resistance by 2050

What proportion of the profession can prescribe antibiotics?

3.5% can prescribe as independent prescribers

4% can prescribe as supplementary prescribers

Images: iStock

50% of HCPC-registered podiatrists are POM-A and POM-S annotated

Another issue facing remote medicine is that antibiotics are often prescribed without appropriate microbiology. Jacob says: ‘Not all antibiotics cover every infecting organism. Flucloxacillin is often prescribed but it won’t cover complex anaerobic and gram-negative infections and patients won’t have up-to-date swabs and tissue samples to aid prescribing decisions.’

Some patients can be treated for weeks with antibiotics that may be ineffective or resistant to the infection organism. Jacob also explains that if a patient requires courses of antibiotics for six weeks or longer, it is sometimes not until week four or five that somebody conducts a swab or tissue sample that finds the infection is resistant to the antibiotics that they’re taking. ‘We often find that our patients with chronic long-term infections are resistant to multiple antibiotics,’ Jacob says. ‘It’s usually because they’ve had an array of antibiotics that have not been targeted appropriately, or they’ve been taking them for so long that it has led to competitive overgrowth of other species and polymicrobial infection.’

With a lack of face-to-face contact, Jacob says that his team relies to some extent on what patients tell them. ‘There are certain red-flag words. These include “red”, “hot”, “swollen” and “infection”. If picked up by an administrative member of the team, they would highlight it to the diabetes team or one of the advanced podiatrists, who would then make a decision. If there were any concerns, the patient would be offered a face-to-face appointment within 24 to 48 hours.’

What can the profession do?

With regard to ingrowing toenails, Jacob says he’s had many conversations with GPs. ‘Much of the problem comes from a lack of understanding about referral processes,’ Jacob says.

‘Some GPs don’t think that podiatry is commissioned to provide ingrowing toenail surgery. Delayed referrals are extremely common. I’ve seen patients that have had as many as eight courses of antibiotics in one year before being referred to podiatry.’

RESOURCES NICE guidance on antimicrobial stewardship: bit.ly/NICE-antimicrobial-stewardship NICE systems and processes for effective antimicrobial medicine use: nice.org.uk/guidance/NG15 Government antimicrobial resistance resources: bit.ly/Gov-AMR-resources Free e-learning and resources from e-Learning for Healthcare: bit.ly/eLfH-AMR Review of clinical effectiveness of antibiotics: bit.ly/reviewantibiotic-effectiveness

Katrina says that it’s difficult to speak to GPs. ‘I would love our profession to work more closely with GPs to let them know that patients should really try to come to us.’ During Covid, she visited all the GP practices in her area, offering to help them with any issues they had with foot care. ‘I even offered reduced rates. They never took me up on it. Perhaps they would be more receptive if we were NHS, but they don’t tend to work very well with private practitioners.’

Jacob acknowledges that his own antibiotic knowledge was limited when he first qualified and he didn’t really appreciate concepts of antimicrobial stewardship until his master’s degree.

‘When I mentor staff,’ he says, ‘the understanding of antibiotics and resistance is low. I would certainly support more training on antibiotics and resistance, particularly for undergraduate students.’

Katrina says that the increase in antimicrobial stewardship programmes to reduce antibiotic prescriptions in recent years can only be a good thing (see Antimicrobial stewardship at London’s Homerton Hospital, left): ‘Bacteria is becoming resistant to many of the older antibiotics, making it harder to treat bacterial infections,’ Katrina says. ‘In addition, Covid-19 is a viral infection that weakens the body to cause secondary bacterial infections.

Strong antibiotics are required to fight these life-threatening infections. If they don’t work on a patient because they have developed antibiotic resistance, then we have a real problem.’

J U LY/AU G U ST 2 0 2 1 T H E P O D I AT R I ST

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12 THE S&O QUESTION TIME

1

DID YOU KNOW?

Let’s get quizzical

How long does it take for a toenail to completely regrow?

It’s been a while since we’ve run a quiz, so we wanted to bring it back in style. How many do you know? Are you surprised by any? Let us know on Twitter @ThePodiatrist using #DidYouKnow

2

TRUE OR FALSE?

The Achilles tendon is the strongest tendon in the body.

4 How many nerve endings are in each foot?

6

3 Capable of producing half a pint of sweat in a single day, how many sweat glands are in the feet?

5

Almost a quarter of our bones can be found in our feet, so how many bones are in each foot?

At what age have the bones in the feet fully ossified?

T H E P O D I AT R I ST J U LY/AU G U ST 2 0 2 1

12-13 sando infographic_THE PODIATRIST JULY AUG_Podiatry Now.indd 12

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QUESTION TIME THE S&O 13

7

8

Based on the size of a barleycorn – an old English unit that equates to inch/8.47mm,

Who called the feet ‘a masterpiece of engineering and a work of art’?

how old is the British shoe-sizing system?

10 11

When was the term ‘podiatry’ first used?

9 A rudimentary leather shoe found in an Armenian cave showed that humans have been wearing shoes for how long?

When was the earliest recorded use of podiatry?

12

More so even than blisters, calluses, foot fatigue or athlete’s foot, what is the most common foot ailment?

13

Images: iStock / Vecteezy

How many miles does the average person walk in their lifetime?

15

What is the most significant cause of peripheral vascular disease?

14

What percentage of women over the age of 60 suffer from osteoarthritis in their feet?

16

How much does the NHS spend each year on injuries caused by flip flops?

Answers: 1. 12 to 18 months 2. True 3. 250,000 4. More than 7000 5. 26 6. Around the age of 18 7. Leonardo da Vinci 8. Almost 700 years old. The system was created by Edward II in 1324 9. At least 5500 years. The shoe dated back to 3500BCE 10. In 1917 by Dr Maurice J Lewi 11. c.1500BCE, in Ancient Egypt 12. Ankle sprain 13. 115,000 – more than four times around the globe 14. 70% 15. Smoking 16. Almost £40m

J U LY/AU G U ST 2 0 2 1 T H E P O D I AT R I ST

12-13 sando infographic_THE PODIATRIST JULY AUG_Podiatry Now.indd 13

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23/06/2021 12:27

HOT TOPIC THE S&O 15

THE BIG QUESTION

Patient records: electronic or paper?

In an increasingly digital age, is there any need for paper files? Are electronic records better for managing patient information?

THOMAS CALDERBANK Managing director of Care Home Podiatry in Lichfield

DAVID HOLLAND Chartered Scientist and podiatrist expert witness in Wales I keep written and duplicate electronic records according to legal requirements.

Legal records and evidence documents are often produced on paper but sent out electronically. The clinical records I see, particularly hospital records, are usually handwritten. I had clinics at Nuffield and Spire, and both were keen on handwritten records.

There is an advantage in having hard copies. According to an article by ARE Taylor, Future-proof: bunkered data centres and the selling of ultrasecure cloud storage, while the cloud is well-protected against cyber crime, some cloud storage is not well protected against theft of servers. Storage in obsolete nuclear bunkers is secure against cyber and all other forms of criminal damage or theft. There is an argument for having a hard copy backup, but it comes with the responsibility of safe disposal. A good cross-shredder is an absolute must.

Image: Shutterstock

TAKE THE COURSE To access the College’s record-keeping course and webinar on its teaching and learning update system (TALUS), go to bit.ly/college-academy.

If you have queries on record-keeping, contact professionalsupport@cop.org.uk

Working exclusively in the care home sector, electronic records are essential to the way we work. They allow us to have up-to-date information on our patients –whether we’re out on visits or receiving queries at the office, while eliminating the data security dangers of carrying paper records around.

We love the ability to complete a patient’s notes at the bedside on a smartphone – it makes our notes more accurate, and we think there are fewer infection control risks than if we were carrying paper records around.

We’ve also been able to automate some of our administrative functions, such as sending outcome letters to be added to care plans. We can auto-populate letters straight from our clinical notes, without duplicating the work. It’s a real time saver.

KATIE COLLINS Professional support officer at the College Healthcare professionals must keep patient records for anyone they treat. Whether they’re electronic or paper is down to personal preference, but they must comply with legislation, which the College Clinical Standards of record-keeping and consent explain. See bit.ly/standards-of-practice (log in first).

One of the main issues we find with paper notes is illegibility, and this is where electronic notes can help immensely. Electronic patient notes have to be compliant with the Information Commissioner’s Office (ICO), and you need to be registered with the ICO. Now many electronic systems also have the added advantage of recording digital signatures, making consent even more streamlined without the need for reams of paper. Whichever way you record patient notes, ensure they are in-depth and comply with our standards. Some 80% of litigation and HCPC cases we see have poor consent and record-keeping at the heart of them.

WOULD YOU LIKE TO TAKE PART IN A FUTURE BIG QUESTION? If so, please contact The Podiatrist editorial team at editorial@the-podiatrist.co.uk J U LY/AU G U ST 2 0 2 1 T H E P O D I AT R I ST

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22/06/2021 12:44

16 THE S&O ONE TO ONE

Lord of the dance The Royal Ballet’s principal podiatrist, Denzil Trebilcock, explains how the art of dance interacts with the hard science of biomechanics.

Interview Matt Lamy

W

hen an audience sits rapt, watching the dancers of the Royal Ballet perform, the idea that these supreme athletes with perfect poise, form and balance could suffer from corns and ingrowing toenails is probably the furthest thing from the onlookers’ minds. But for the Royal Ballet and Royal Ballet School’s principal podiatrist, Denzil Trebilcock, the issues the dancers face – and the major effect that seemingly minor problems can have – are very familiar.

‘The range of complaints I see is fairly varied,’ Denzil says. ‘A lot of what I do is a combination of biomechanics and completely classical routine care: all the delights and horrors of soft corns, ingrowing toenails and the excruciating wounds that dancers get. But equally, the important thing to remember is that if a dancer gets something as innocuous as a soft corn, that will alter how they go into a position to try to avoid loading. Unless we deal with these small things, it can have a knock-on effect that causes impingements or restrictions, or overwork.’

Denzil’s reference to biomechanics is a clue to how he came to work with the Royal Ballet. He took a degree in physics at King’s College London, but after graduating and being underwhelmed by career options, someone suggested human mechanics might be of interest.

‘I ended up sitting in with a podiatrist and was introduced to this wonderful world of classical mechanics associated with how humans move – all the relevant forces, mass times acceleration, Young’s modulus in terms of how tendons work,

and how much strain you can put them under. It all fitted really perfectly with the areas that I had enjoyed while studying physics,’ he says.

Dancing return After studying podiatric medicine at University College London and the London Foot Hospital, Denzil worked for the NHS at Lambeth Primary Care Trust (PCT) for five years, becoming Lambeth PCT department lead for the musculoskeletal foot and ankle centre.

At the same time, he also enjoyed working in private practice; it was through this that his connection – or more accurately a reconnection – with the Royal Ballet occurred.

‘I was working for a physiotherapy clinic and the lead physiotherapist was contacted in an emergency to see if she knew a podiatrist who could look after a ballerina’s feet. She called me, so I went in on my day off and I spent a really productive hour or two with Leanne Benjamin, who at the time was principal dancer at the Royal Ballet,’ Denzil says.

‘Afterwards, I thought it was fun but nothing more. However, Leanne went back to the Royal Opera House and must have said she’d been treated by me. The next day I was contacted by the Royal Ballet’s head of healthcare, who said they were in desperate need of a podiatrist, and could I go in for a chat. I graduated in 2005 and this was in 2009, so it was still all very new to me and I hadn’t specifically dealt with dancers at that time, so it was a bit nerve-racking.

‘Funnily enough, my grandmother used to be in charge of all the ballet shoes at the Royal Ballet from the 1960s to the 1980s.

Weekends during my childhood were spent walking round this very old, strange place where all these dancers were leaping and jumping. So I suppose from a very early age I was primed and aware of what ballet was.’

A new focus Although the world of ballet that Denzil re-entered was familiar, it was about to undergo an overhaul of its approach to dancers’ health and wellbeing.

Digital goals During the pandemic, Denzil has been using his technological background to think about other ways he can help patients.

‘One of the things that I’ve always had at the back of my mind is the concept that, as a profession, we need to be face-to-face with people in order to do what we do,’ he says.

‘So I’ve been looking at ways to provide a distanced form of analysis that we can use to establish whether or not there is a need for further treatment. I’m learning the programming needed in order to design various apps for that.’

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ONE TO ONE THE S&O 17

‘Ballet is an art form, but one where the dancers strain themselves physically to make it look beautiful. But it wasn’t seen in the same light as an elite sport in its treatment processes at that time – it was very much a case of patch them up, send them on their way, see what happens and then we’ll go onto the next phase – which invariably would be surgery and the like,’ Denzil says.

‘But in around 2013 or 2014, there was a complete change. The Royal Ballet brought in a top British Olympic medical director and he set up a full sports science-based modality programme.

The doctors were all sports medicine doctors, the physios were all in tune with screening and monitoring, and that’s where I started to fit in.

‘As the only podiatrist on the team, it can be challenging to say, “I can do that.” The physios look at me and wonder what I’m doing with my podiatry hocus-pocus, while I explain why my approach might have a better outcome. It’s a case of not treading on any toes but offering my help and making suggestions where I see opportunities. It’s really about providing another weapon in their arsenal, whereas before they were very much about icing, strapping and immobilising injuries.’

‘As a result of those clinics, I’ll tell the physios what I’ll be doing.

Most of the treatments involve biomechanical control – orthotics, taping, strapping, padding – it’s all of the things needed in order to offload and redistribute.

‘From a podiatry point of view, I can provide very temporary solutions while they’re dancing. But we’re still dealing with an art form, so the dancers don’t like to have anything that shows around the leg or the foot, and they don’t want it to change the shape of the foot. So I’m actually quite limited in terms of how I can make an immediate difference.’

Where Denzil does have a role, though, is in longerterm options.

‘It’s all very well treating and asking them to manage and stabilise themselves when they’re dancing, but that damage can still be done, or the healing pathways can still be disrupted if they have a biomechanical abnormality when they’re just standing or walking normally.

I can help them when they just want to go for a walk or a run without irritating the area. That is very much h a case of orthotics and bringing in processes to stabilise the feet themselves lves over the long term,’ he says.

‘I’ve been very privileged to have worked with h some amazing people through the Royal Ballet, but treating dancers is actually ctually much like treating anybody else. e. I know it’s a cliché, but just helping people is why we do this job. Podiatrists ists are really honoured in that we can do things where people immediatelyy stand up and say, “Oh, that feels so much ch better.” It makes me very happy to hear ar someone saying they feel great as theyy walk out.’

Or, in this case, perhaps – dance away.

‘It’s a case of not treading on any toes but offering my help and making suggestions where I see opportunities’’

Images: iStock / Shutterstock

Long-term approach While Denzil’s ballet caseload can involve almost any condition, the biomechanical and overwork issues have the potential to be the most serious.

‘I have a designated clinic once a month where the Royal Ballet sends me people who need looking at but who aren’t emergencies. They come to Harley Street and I treat them there rather than at the opera house because a lot of the biomechanical work that I do is easier in clinic, where we have treadmills and video capture technology,’ Denzil says.

Flat feet ‘The very nature of what a ballet dancer does is completely artificial for what the foot is designed to do,’ Denzil says.

‘The classic plié is a really forced situation – the idea of turning your feet out and then being able to bend the knees – you’re forcing that midtarsal joint into a completely compromised position, so it’s no wonder that the majority of ballet dancers are flat footed.’

New shoes?

One of Denzil’s own long-term goals isn’t just for dancers.

‘I’m fascinated by ballet footwear but also everyday footwear for non-dancers,’ he says.

‘There are very good shoes out there, but equally there are people who will need stabilising and support but who don’t want ugly or orthopaedic shoes. We haven’t really found a happy medium, so I’m very interested to see how we can do that.’

For top tips on how to treat a patient with a dancing or sports injury, go o to page 32.

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18 THE S&O EMPLOYMENT LAW

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e are regularly contacted by self-employed associates in respect of the HMRC IR35 arrangements, which can treat some self-employed workers as being ‘employed’ for the purposes of tax and National Insurance (NI). IR35 is intended to ensure that those who are working in what might be described as ‘pseudo self-employment’ pay the same tax and NI as if they were an employee.

IR35 has a small-company exemption, so not everyone who is self-employed will be affected.

We are also contacted by business owners who are concerned that those they have contracted with on an associate basis may, irrespective of any IR35 issues, claim at a later date that they were an employee or a ‘worker’ and thus claim the associated benefits and employment protection of being employed: holiday pay, pension,

MARTIN FURLONG is head of employment relations at the College

annual leave and contractual notice periods.

For the associate and the client, the issue to be clear on is, what is the position in employment law terms? Is the associate ‘self-employed’, or are they, in reality, working as an employee?

This is not just about how the contract purports to describe the relationship, but is equally about what happens on a day-to-day basis – does this show that the reality of the relationship is one of ‘employment’ or ‘self-employment’?

The developing law on whether workers are self-employed or not (see Pimlico Plumbers and the Uber cases) has meant that, as much as we would like to, the College is no longer able to provide a draft ‘associate/fee-sharing’ contract to members. At the moment, we do not believe that the previous ‘draft’ fee-sharing contract provides the necessary certainty for either the associate or their client.

Self-employed associate If someone is ‘self-employed’ they are effectively working on their own account, and in doing so, they bear the whole cost and risk of running their business.

The contract they will have with a client(s) will be a ‘contract for services’– that is, it will state what work they have agreed to do within the contract and no more. This work will be done without the associate being directly controlled by their client. It will usually be for the associate to decide how the work is done and when.

It may also be clear that it is for the associate to decide who undertakes the work – that is, it may not be themselves, but they can substitute an appropriate person (for example, another qualified podiatrist) to deliver the contract. This is often referred to as a ‘substitution clause’. In the case of the associate, it is they who are providing the substitute, and in

Know your rights When it comes to hiring or working as a self-employed associate, clarifying the terms of contract are key – and can prevent legal pitfalls later down the line.

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EMPLOYMENT LAW THE S&O 19

IR35: where can you get help?

such cases you would expect the associate, rather than the client, to bear that cost, and invoice the client afterwards.

A self-employed person will normally provide their own equipment, professional insurance and clothing. They will be paid gross (that is, without a deduction for tax and NI) for their services and it will be their responsibility to ensure that they pay the required tax and NI to HMRC. A self-employed person will have to provide and fund their own pension, sick pay, maternity and annual leave costs. There will be no entitlement to any redundancy or statutory notice pay.

Someone who is self-employed cannot access the benefits of being an employed person, and cannot claim unfair dismissal, redundancy or sick pay from their client.

As a self-employed person there may be costs associated with running their business that they can claim tax relief on, such as the costs of running an office or clinic, travel costs, the purchasing of necessary equipment, laundry, insurance and training costs.

If someone is ‘self-employed’, it is likely they will have a number of clients they provide services to.

The least direction and control a client/company may have over a self-employed associate may indicate a ‘contract for services’. Conversely, the more direction and control a client has over a self-employed person may indicate there is a ‘contract of service’ (employment).

An employee, on the other hand, will be working under a ‘contract of service’ and the employer will deduct tax and NI at source.

If someone is an employee, they will have a contract with

Image: iStock

Employment

As this article shows, there are several strands to consider when reviewing your working arrangements, or looking to take on new people to help your practice.

If you are a self-employed associate, you may also want to review your arrangements.

If you need more help: Our employment support team are always happy to help with your contractual queries – email employmentsupport@ cop.org.uk Our professional officers can also help with general queries – contact professionalsupport@ cop.org.uk You can get general accountancy help from our approved advisers twdaccounts.co.uk/cop (please note additional charges may apply).

If you wish to employ a podiatrist, or to be employed, we have a library of employment policies you can access as a member at membersarea.cop.org. uk/podiatric-practice/ professional-resourcesarea/guidelines and can also supply a standard employment contract.

ACAS also has a wealth of material on its website, acas.org.uk Our advice is in general terms for podiatrists and is free to members. If you need more specialist advice, we can provide details of how to get specialist legal suppport at competitive rates.

an employer. That contract will be clear in its terms. The employee will be expected to perform work themselves. There will be a duty of mutual obligation. For example, the employer will expect the employee to be available for work and to work as directed, and the employee will be entitled to receive pay for the work done.

If there is no work to do, the employee must be paid anyway as per their contract. It may also state that the employee is not allowed to work for anyone else without their express agreement. In such cases, the employer will provide what is required for the work to be undertaken, for example, the tools and equipment for the work and clothing (if necessary).

At all times during the contract, the employee will be under the direct control of the employer in respect of their work. The employer will also have to provide annual leave, maternity leave, a workplace pension, notice pay and redundancy benefits to the employee.

I am the client If you are the person with whom the associate has contracted to provide services, you will want to ensure that there is clarity in the working arrangements made.

You have chosen to enter this contract for particular reasons.

For example, your business does not have a sufficient caseload to require someone on fixed terms, you do not wish to be an employer of staff (with its associated costs and responsibilities), you may wish to be able to ‘flex’ your service to changing events and patient demand, and would wish to bring in people for particular work as and when required. It follows that you will want to ensure the contract you have with the associate is such that they cannot claim later they are, in effect, your employee. If this were to be the case, you may be liable for costs to your business, such as holiday pay, workplace pensions, maternity pay and redundancy.

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23/06/2021 15:54

20 THE S&O OBITUARY

A driver of change Friends and family pay tribute to Michael hael W Whiting, hiting, ducation, a ‘pioneer and innovator’ in podiatry education, who died earlier this year.

O

ur friend and colleague Michael Whiting passed away in January. During his career in higher education he was considered a pioneer of evidence-based podiatry, an innovator in learning and teaching, an early proponent of degree programmes in podiatry and an advocate of clinical research.

Early seeds As a chiropody student at the London Foot Hospital (LFH), Michael developed a keen interest in pharmacology, thanks to a part-time job in a local chemist.

His teaching potential was clear to see from the outset, as he and fellow student

Paul Shenton n nton were single singled ed out in their i second year and ir nd asked to consider c a futuree in education. i ion.

Michael Sussex e founded the Suss el sex School off Chiropody at Brigh Brighton hton Polytechnic Paul n in 1982, with Pa nic aul following g him a few monthss later. It was w a time of major change in i both the NHS and d higher education. e

Proud d mome moments As head of school at Brighton (later l t tto become the University of Brighton), Michael and a small group of staff took the first cohort of students onto what was

then th hen the the he chiropody chi hiro ropo ro pody dy diploma dip iplo loma ma course coursee in 1982, 1982 19 82, temporarily tem te mporar a ily based b sed at Saint Mary’s ba Hospital in Eastbourne.

The small, smal , first-year intake moved to a permanent base at Leaf Hospital ospital it l in 1983.

1983 The repurposed hospital building was refurbished exclusively for the course,

Michael’s career

1967

1968

1972

1978

1981

1988

Qualified in chiropody at London Foot Hospital and began a student teaching post

Started a private practice in Walton-on-Thames, Surrey

Sold his practice; began teaching at Manchester Foot Hospital (soon absorbed by Salford School of Chiropody)

Became head of the first chiropody programme based at the newly created chiropody school, Huddersfield Polytechnic

Founded the Sussex School of Chiropody at Brighton Polytechnic (later the University of Brighton); taught first cohort of students on the chiropody diploma course

Designed an evidencebased course, introducing research projects in the final year with support from the pharmacy department

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OBITUARY THE S&O 21

with a fu with w fully u equipped operating suite, library, llaboratory, lecture theatre and li main two mai tw i patient areas. It was a resource proud of. to o be pr r Michael invited local medical specialists Mich and staff an staff from the department of pharmacy contribute significantly to the course. to contr r Thankss to the 1988 Education Reform Th Act, which allowed degree courses for A Ac t, wh h professions allied to medicine, Michael p pr ofesss nallyy had the opportunity to design an finally fi evidence-based course. eviden n

Bold d moves Undee his leadership, there were a Under number n nu mb b of significant changes to the three-year diploma programme, including three th e introduction of research projects in the in th n thee final year, the removal of the basic th sciences from year one, the replacement scien sc n basic of b a sciences by physiology – previously topic – and the introduction a second-year secc pharmacology in year two. of p h Bold moves such as these required B negotiations with the Society of n eg g Chiropodists and Podiatrists and the C Ch i Chiropodists Board, while requiring a Chi i strong stro o staff development programme to ssupport the teaching. Michael always encouraged staff to further their studies, en n whether a first degree, master’s or PhD. wh h

Shaping Sh h the future And the changes were to pay off when An degree courses were introduced for professions such as podiatry and

MICHAEL THE MAN Michael was one of a kind; a breath of fresh air; an entrepreneur in the true sense of the word. Always the optimist, always looking for the next challenge in his career.

Generations of patients, podiatrists and healthcare workers owe Michael a great debt of gratitude for the significant impact he had on the development of modern clinical and educational practice. He understood the value of podiatry as a medical specialty and, way ahead of the curve, he strived to instil solid academic and clinical grounds as a basis for research and development, which will be his lasting legacy.

His many colleagues are proud to remember Michael as our humorous, kind, generous and brilliant friend.

physiotherapy. Michael was instrumental in obtaining a grant from the Council for National Academic Awards, the degreeawarding body for higher education institutions. Held with three other schools of podiatry – LFH, Chelsea and Wessex – the grant was used to design a top-up degree for qualified practitioners.

Based on the experience of supervising final-year projects and the top-up degree, Michael and the team at Eastbourne designed one of the first undergraduate degree programmes for podiatry, which started running at the Sussex School of Podiatry in 1990.

And in a happy twist, thanks to Michael’s foresight and planning, the previous year’s graduates were

retrospectively awarded an unclassified degree in podiatry, making the graduates from Brighton Polytechnic the first to graduate in the UK in 1989. All ‘Brighton’ students thereafter graduated with a BSc in podiatry.

Championing evidence Michael’s understanding of the importance of an evidence base for podiatry meant he encouraged staff to engage in research and publish regularly. He secured a personal research grant from Scholl R&D and obtained funding for a full-time PhD scholarship for the department.

He also established an important collaboration with the University of Kent, focusing on the development of a foot pressure measuring system, and supervising a number of PhD students.

This work was recognised when Michael was appointed chair and awarded the title of professor. He was also the youngest professional to receive the Society of Chiropodists and Podiatrists’ Meritorious Award, and held fellowships with the College of Podiatry and the Society of Chiropodists.

He was immensely proud when the podiatry department launched the first MSc in podiatry and a professional doctorate programme, and saw the development and expansion of the top-up degree to countries including Canada, South Africa, New Zealand and Australia.

1990

1992

1994

2001

2002

2007

Sussex School of Podiatry ran its first degree programme; Michael’s 1989 graduates were retrospectively awarded an unclassified degree in podiatry

Appointed dean of the faculty of health at Brighton

Appointed nonexecutive chairman of Worthing and Southlands NHS Hospital Trust

Became founding chairman of BSUH Hospitals Trust; appointed chairman of Brighton Health Care NHS Trust

Contributed to the successful joint bid for undergraduate medicine at what became the Brighton and Sussex Medical School

Retired as professor emeritus from the University of Brighton; became chairman of the Friends of Brighton & Hove Hospitals

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22 THE BIG STORY HIV

PosiƟve thinking

What podiatrists need to know about HIV, from modern drug therapies to manifestations in the feet and lower limbs, and how they can make a difference for HIV-positive patients in their care.

Words Juliette Astrup

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HIV THE BIG STORY 23

t has been 40 years since the first recorded death from AIDS in the UK. Once feared, stigmatised and considered a death sentence, the virus can now be fully suppressed by antiretroviral drugs and modern therapies, to the extent that it is undetectable in the blood. This means the immune system can recover and is protected from further damage – and, crucially, that someone living with HIV cannot pass the virus on.

This fightback is nothing short of remarkable, but how far has knowledge and understanding of HIV, including among healthcare professionals, changed with it? And what do podiatrists need to know about the virus and how it can manifest in the feet and lower limbs?

Images: iStock / Jesper Klausen / Science Photo Library

Transmission impossible Dr Michael Brady, medical director at the Terrence Higgins Trust, says awareness remains ‘variable’, with memories of the ‘bad old days’ still lingering.

‘There are still misapprehensions around risk,’ he says. ‘There is fear that an HIV-positive person may be a transmission risk to them and additional infection control measures are needed.

‘If you are treating somebody living with HIV who is on treatment, where the virus is fully suppressed – and it is the case that for 97% of people on treatment the viral load is undetectable – then there is no concern about transmission and no need for additional precautions. That is a key message for healthcare professionals – there is no risk to you, and you can be confident about treating them in the same way as anyone else.’

‘It is so important podiatrists know this,’ says podiatrist Tim Pursey in Glastonbury, who has treated several patients with HIV. ‘People with HIV are not a cohort of patients that need to be treated any differently – you don’t need to double glove as we were once taught, or see them as the last patient of the day in clinic, for example.’

Steve Jamieson, chief executive at the College, a former HIV/AIDS nurse who led specialist clinics in the 1980s and 1990s, says: ‘The other important thing for members to be mindful of is their

public health role. Podiatrists have that luxury of 20 to 30 minutes spent with a patient other healthcare professionals don’t have. They can build a rapport and create an atmosphere where a patient can open up about HIV or anything else, then signpost on to other services if that person needs more help, or if they think they might be at risk.

‘That means a podiatrist having a good, basic understanding of HIV and also of what services are available locally.’ Having leaflets on HIV or sexual health available in your practice is a good way to open up those conversations, he adds.

There is also the vital element of psychological support, adds Steve. ‘People won’t feel afraid to share their HIV status because they know that their practitioner

will understand and be comfortable with it, and treat them in the same way they would anyone else.’

HIV and feet While HIV-positive patients who are on treatment will not suffer most of the conditions associated with HIV and AIDS, it is still important podiatrists are aware of how the virus might show up in the feet.

Skin conditions are common and are among the early indicators of infection.

They can range from those also commonly seen in people without HIV, such as psoriasis and dry skin, to the rare cancer Kaposi’s sarcoma, regarded as indicative of HIV. Bacterial, fungal or viral skin infections are more common and

Be open, honest and professional Tim Pursey, who owns Tim Pursey Podiatry Services in Glastonbury, has treated several HIV-positive patients.

Some HIV-positive patients who have been on treatment for a long time may develop peripheral neuropathy, which you would pick up in a normal assessment, but many won’t. Some may develop atrophy of the fatty padding to their feet, which can be due to a side effect of their medication.

Many people with HIV still feel there is a stigma about it, so you have got to make it easy for that person to have an open conversation with you. You always need someone’s medical history to ensure you provide effective treatment – you can ask questions, but with care and respect. Ask yourself how you’d want a family member treated.

As podiatry professionals, we need to be comfortable having these conversations, and if we don’t know something, ask the patient, look it up, do some CPD. We don’t need to be ringing their GP or consultant for additional information.

In my experience, people who are HIV-positive are very engaged in their treatment regimen – they know what’s going on better than anyone, and many will have made choices about the medications they take and been asked if they are experiencing any side effects. They will know their viral load, and their CD4 count [number of blood cells per cubic millimetre]. If their CD4 level is above 500 and viral load is undetectable, they are healthy and should respond to treatment as well as the next person; I have performed nail avulsion with phenolisation and verruca needling on HIV-positive patients with successful outcomes.

Remember, you have a person sitting in front of you who has come to you for help and support. They are going to be from diverse backgrounds, as HIV does not discriminate against who it infects. It’s not a life sentence. Due to advances in treatment, HIV-positive people are living long, healthy, successful lives. We may see many more people with HIV as patients as they age and need additional support. Demonstrating our clinical knowledge, and being open, honest and professional will ensure that we provide them with the best care for their needs.

‘It’s not a life sentence. Due to advances in treatment, HIVpositive people are living long, healthy, successful lives’

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24 THE BIG STORY HIV

more severe due to the HIV-related immunosuppression (Smith, 2009).

This systemic disease is also linked to musculoskeletal issues, muscle weakness, stiffness, cramps, fatigue, vascular issues such as deep vein thrombosis, and rheumatic manifestations like Reiter’s syndrome and psoriatic arthritis (Smith, 2011).

Almost a third of people with HIV/ AIDS experience some peripheral nerve damage, which may be caused by the virus itself, certain drugs used to treat it, or as a result of opportunistic infections (Foundation for Peripheral Neuropathy, 2016). Symptoms often include burning, stiffness, prickling, tingling and numbness, or a loss of feeling in the toes and soles of the feet, and can potentially lead to injuries, fractures, foot drop and Charcot foot.

Michael says they often talk to healthcare professionals about indicator illnesses: ‘Conditions that

are not necessarily AIDS-defining, but conditions that are worse or present a bit differently in someone with a weaker immune system.’

He adds: ‘The general rule for allied health professionals when you’re treating a condition you’re used to seeing and it’s not responding to treatment as you’d normally expect – it’s harder to treat, recurring in an odd way – is think about mentioning immune function and encouraging that person to get an HIV test. A verruca is a good example, or any viral or fungal infection that is more severe than you’d expect, getting worse and not responding to treatment – it might suggest immunodeficiency.’

Talking and testing Treatments and preventative strategies, particularly testing, have transformed the landscape of HIV in this country, explains Michael. ‘Our HIV testing is world-leading. Of the 100,000 people

HIV and the homeless Emily Haworth, national education officer for Podiatry Ireland, volunteers with a rough sleeper foot clinic in Cork and Dublin, working with a vulnerable adult group where needle sharing is common and HIV infection rates higher than average.

Dermatological and neurological problems can be seen in HIV-positive rough sleepers – multifactorial dermatological issues, a lot more fungal and bacterial infections, mosaic verrucas, anhydrosis, pruritis, scabies, dermatitis and skin rashes.

Nerve damage is common in HIV-positive rough sleepers and can also be caused by chronic alcoholism and substance abuse, malnutrition and some medication side effects too – polyneuropathy can develop, a bit like a high-risk neuropathic diabetic patient, with gait instability, neuropathic pain, paraesthesia and numbness and plantar pressure high forces.

Guillain-Barré syndrome, an autoimmune disease, can be fairly common; that is something that can be seen early on after HIV infection.

Some service users, in particular those with an HIV diagnosis and mental health involvement and those in active substance abuse, may not be in a position to tell me their status or what medication they are on, so I generally treat everyone the same and have open conversations about risks, especially if there is evidence of injected drug use, such as needle injuries on the feet.

The treatment is about keeping them comfortable with simple interventions – clean socks, footwear, cushioned insoles – doing as much as you can to address pain with as little invasion as possible, because the last thing you want is for them to develop an infection.

As always, it’s not just about treating the feet – it’s about treating the whole person. The key is to be open, to talk, and to be non-judgemental and a great listener.

‘The key is about being open and talking, being a great listener and non-judgemental’

RESOURCES The College's video on working in healthcare during the 1980s: membersarea. cop.org.uk/the-podiatrist-digital Terrence Higgins Trust: tht.org.uk The HIV test finder: test.tht.org.uk National Aids Trust: nat.org.uk Members can direct their HIV-related clinical enquiries to feedback@cop.org.uk

living with HIV in the UK, 94% have been tested and are aware of their diagnosis, and therefore able to access effective treatment, irrespective of what stage of disease they’re at.’

The response to the epidemic is so successful that the target to end HIV transmission in this country by 2030 is now ‘very achievable’, adds Michael, but there is still much work to do to reach that remaining 6%.

‘That is 6000 or 7000 people living with HIV who aren’t yet diagnosed,’ he adds.

But raising the issue outside of a sexual health clinic can be a challenge, says Michael. ‘We talk about “normalising” HIV testing, and one way to approach that is to talk about it as simply an investigation, like a blood test for kidney function. It should be on the list of considerations for many conditions because it can present in many different ways.’

It’s also important not to make assumptions about who is at risk, explains Michael. ‘Everybody is potentially at risk – not just groups traditionally associated with HIV, such as gay men or people from sub-Saharan Africa. And given patterns of testing, we know that people living with undiagnosed HIV are more likely to be older.’

He advises practitioners to make themselves aware of the support and resources available, such as the Terrence Higgins Trust website, which includes a link to an HIV test-finding service (see Resources).

HIV and ageing With the population living with HIV now ageing thanks to effective treatments, there are new things to consider. Michael says: ‘We need to be thinking about

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HIV THE BIG STORY 25

HIV: on the run?

105,200 The number of people living with HIV in the UK in 2019 The number of those who are undiagnosed

18% Diagnoses among gay and bisexual men fell by almost a fifth between 2018 and 2019

U=U Undetectable equals untransmittable (U = U) is a campaign highlighting how, when a person is living with HIV but taking HIV drugs and their viral load stays at undetectable levels (< 200 copies/mL), they cannot transmit HIV to a sexual partner who is HIV-negative.

The U = U slogan was launched by the Prevention Access Campaign in early 2016 and is now seen by many organisations across the globe to be a way to end the worldwide epidemic (Prevention Access, 2021).

treating people with age-related diseases and HIV, polypharmacy and potential drug-drug interactions.’

And there remains a ‘considerable minority of people’ with more advanced HIV, who have had the disease for a long time or were diagnosed late and have more damage to their immune system.

‘They might have foot problems, mobility problems, peripheral neuropathy

In 2019 there was a

drop in new diagnoses compared with 2018 and a

drop compared with 2014 Terrence Higgins Trust, 2019

or stubborn viral or fungal infections in the feet, for example, so there is certainly a role for podiatrists in the ongoing rehabilitation and support of that cohort, although it is a group that is getting smaller.’

Steve adds: ‘Someone who has been HIV-positive for a long while may have peripheral neuropathy, most often in the feet. Because of the numbness, they might slam their feet down as they walk, so podiatrists can have a big part to play in finding the right shoes and the right treatments to help these patients with their gait.’

Julie Day of the Chelsea Podiatry Practice, who while previously working at University College London Hospital published a peer-reviewed paper on toenail surgery in HIV care, says podiatrists need to be informed about the medical and social history of HIV. ‘What an older patient may have lived through medically and socially in the mid-1980s and 1990s can inform what could potentially be happening now,’ she says. ‘These people will now be in

their 50s and 60s and pathologies may start to present. This may be due to living with this medical condition for so long and/or the length of time the patient has been on the antiretroviral medications. They may have come from other countries where treatment may not have been as comprehensive, or their HIV might not have always been well managed.

‘If the patient had a history of a low body weight and a very high viral load, things to consider would be neuropathy – it could be sensory or motor, affecting balance and gait – vascular disease, lipodystrophy, or osteopenia/osteoporosis.

There may be no connection; however, it is about having an awareness of their previous history and if your patient presents with any of these, think “Has their viral load changed and do the drug therapies need to be looked at?”’

Building knowledge While a dedicated HIV specialist podiatrist is not a role you might find, podiatrists with a particular interest and more knowledge are ‘definitely valuable’, both as a point of referral and in the education and training of their colleagues, says Michael. He urges members to access the Terrence Higgins Trust’s new training for healthcare professionals, set to be launched as The Podiatrist went to press. Building on their Can’t Pass It On campaign, it focuses on the message that it can now be said with absolute confidence that people living with HIV and on effective treatment can’t pass the virus on. This is also known as undetectable equals untransmittable (see U = U, left).

The work highlights the need for definitive language to express that fact and the impact this makes on people living with the virus. It will include web-based resources, such as training videos for self-directed learning, as well as resources that healthcare professionals can use when training colleagues.

The College has produced a video for members on what it was like working within healthcare at the start of the HIV epidemic in the 1980s (see Resources).

References are available to view online: membersarea.cop.org.uk/the-podiatrist J U LY/AU G U ST 2 0 2 1 T H E P O D I AT R I ST

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RECRUITMENT

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HEE ROADMAP THE PRACTICE 27

W H AT ’ S H A P P E N I N G O N T H E G R O U N D ?

Pathway to primary care HEE’s Roadmaps to Practice set out a development pathway for podiatrists looking to take up roles in primary care – as encouraged by the NHS Long Term Plan, which aims to provide more integrated and collaborative healthcare.

I

n recent years, before the pandemic, there has been a significant policy focus across all governments in the UK to shift the balance of care from secondary care to primary and communitybased care settings (NHS, 2019).

This shift has brought with it a significant change in where and how resources are spent. Increased funding is now available to support the uptake of roles within primary care by health professionals who have previously worked in other sectors, following a change to the national GP Network Contract Directed Enhanced Service (DES) 2020/21 (NHS England, 2020). Through the subsequent roll-out of the Additional Roles Reimbursement Scheme (ARRS), podiatrists, paramedics, occupational therapists, dieticians and physiotherapists are funded by a national scheme to support the uptake and implementation of these allied health professional (AHP) roles into primary care, thereby meeting the workforce development set out in the DES

at no additional local cost (BMA and NHS, 2019).

To support the introduction of new AHP roles into primary care, Health Education England (HEE) has launched a national multiprofessional training scheme (HEE, 2021a). The scheme, summarised in the Roadmaps to Practice series of documents, sets out a standardised training and development pathway, provides training resources, and signposts trainees to achieve role verification and accreditation with the HEE Centre for Advancing Practice.

The podiatry profession has an unprecedented opportunity to use the national funding, infrastructure and training support available to engage in primary care and contribute our expertise, thereby positively impacting population health across health and care sectors (College of Podiatry [CoP], 2020). There has arguably never been a better opportunity to influence, integrate and impact foot health across the whole health and care system.

DR LINDSEY CHERRY is senior clinical academic at the University of Southampton and Solent NHS Trust.

She is also HEE’s AHP adviser for the Hampshire and Isle of Wight Primary Care Training Hub

LAWRENCE AMBROSE is head of policy and public affairs at the College

The changing primary care landscape Primary care networks (PCNs) have been developed in England to bring general practices together within a local area so they can work at scale (NHS England, 2021). The development of PCNs is a key part of the NHS Long Term Plan (NHS, 2019) and builds upon existing primary care services to enable greater provision of proactive, personalised, coordinated and more integrated health and social care that is also closer to home for patients. PCNs therefore enable GPs to provide a wider range of services to their communities and to integrate into the broader health and care system. There are 1250 PCNs in England, each with an average population size of 48,000 people. More than 99% of general practices are part of a PCN, which then signs up to the DES, detailing core requirements and system-wide entitlements (NHS, 2021).

The newly formed integrated care systems (ICS) offer a way to plan and organise the provision of health and care services in England at a larger scale than PCNs could (NHS England, 2018). Every ICS will ensure that PCNs work with other community staff and use multidisciplinary teams across primary and community care, feeding in and out of secondary care as appropriate. The overall aim is to provide a more integrated system, reduce competition within healthcare provision, and provide service users with a more navigable system than is currently in place (NHS England, 2018).

Private practice providers will continue to offer an additional J U LY/AU G U ST 2 0 2 1 T H E P O D I AT R I ST

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28 THE PRACTICE HEE ROADMAP

element of choice and diversity in the healthcare landscape, and PCN providers can direct service users toward provision within and outside the NHS (NHS England, 2021).

The Additional Roles Reimbursement Scheme In podiatric practice, there is an important distinction to be made between those who work in private practice – for example, who undertake an important diagnostic role in terms of foot health as they may be a first point of professional foot health advice – and those who will be entering into the new first contact practitioner (FCP) or advanced practitioner (AP) roles within PCNs under the ARRS (CoP, 2020). Those in FCP or AP primary care roles have both a diagnostic and safety-netting responsibility, as set out in the DES, and are required to appreciate, use and connect the whole health and

care landscape by signposting or forming onward referrals.

Accordingly, they must have a minimum of master’s level clinical practice, as well as additional primary care-specific training (HEE, 2021a). The values and training ethos relevant to primary care are also strongly reflected in the FCP/AP role descriptors, and there is strong emphasis on advanced communication skills, diagnostic skill, ICS awareness and appreciation of person-centred approaches to health and care.

The ARRS roles are an important addition to the PCN workforce, providing a unique diagnostic and first-contact contribution that complements the work of the traditional GP and nurse colleague roles. The podiatrist FCP would not, therefore, be expected to

provide programmes of treatment, or to offer what may be considered ‘routine’ foot care. For PCNs to be eligible to receive ARRS funding, there is a need to ensure that the roles meet the specification set out in the DES, and duplication or disruption of existing local services is to be avoided.

Definitions of FCP and AP in primary care First contact practitioner

A diagnostic clinician working in primary care at the top of their clinical scope of practice, at Agenda for Change Band 7 or equivalent and above (HEE, 2021a).

Able to assess and manage undifferentiated and undiagnosed lower limb presentations within primary care.

PCNs in England

1250 48,000 PCNs in England

Average population size

> 99%

Image: Shutterstock

of general practices are part of a PCN

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HEE ROADMAP THE PRACTICE 29

Minimum threshold for working as a first point of contact within a PCN environment with people who have undifferentiated undiagnosed conditions.

Must be working at master’s level (academic level 7) or above in their clinical pillar of practice, but may not yet have attained that level of mastery in their research, management or leadership, and education pillars.

Advanced practitioner

Working in primary care, will hold all the attributes described above for an FCP role, but will be demonstrably working at master’s level across all pillars of practice.

‘There has arguably never been a better opportunity to influence, integrate and impact foot health across the whole health and care system’

The role descriptors and levels of practice set out by HEE in the Roadmaps to Practice are similar for all the AHP professions entering PCNs.

The HEE Roadmaps to Practice HEE has worked with the College of Podiatry and its special advisory groups to develop the podiatry-specific Roadmap to Practice in Primary Care.

The roadmap sets out the expected podiatrist FCP and AP capabilities, and describes the range of knowledge, skills and attributes (KSA) expected of post-holders. The KSA elements are cross-referenced to existing national standards and frameworks for podiatrists to ensure consistency across sectors of working.

Roadmap supervision The roadmaps provide guidance on the training required to work in FCP or AP roles in primary care. Supporting resources and signposting to additional sources of training, such as e-Learning for Healthcare online modules, are also included.

Supervision and supervisor verification of a portfolio of evidence demonstrating FCP/AP level of practice is an important element of the pathway to role verification with the Centre for Advancing Practice (HEE, 2021b).

‘Supervision’ has many definitions across healthcare, and there may be variation between professions or regulators in what is meant by the term. To support FCP or AP roles in primary care, supervision is considered in terms of clinical supervision (for example, regular or daily supervision in practice), continued professional development supervision (for example, monthly supervision, and contributing to the requirements for maintaining professional registration) and educational supervision (for example, that related to taught courses) (HEE, 2021a).

The amount of clinical supervision recommended for those transitioning to FCP or AP roles within primary care is considerably higher than that traditionally offered to podiatrists of increasing clinical experience, or who are already working at level 7. HEE recommends the high level of supervision during the training and verification process as part of the podiatrist’s transition into the primary care environment, and in recognition of the unique challenge that working in primary care with people who have undiagnosed/ undifferentiated disease can bring.

Commensurate with this, HEE-verified supervisors must themselves hold a master’s or equivalent and above qualification, be practising as an AP in primary care or a consultant in any healthcare setting, or be a GP, and must have completed a HEE supervisor training course.

Supervisor training courses are typically advertised regionally on PCNs’ training hub websites (HEE, 2021c). Supervision is multidisciplinary, and podiatrists can supervise and be supervised by professionals from different disciplines.

Supporting FCP and AP podiatrists in primary care The College is funding an ongoing project to evaluate FCP and AP podiatry roles.

To find out more about this project or FCP/AP primary care roles, please contact lawrence.ambrose@cop.org.uk To read about one podiatrist’s experience of working in an FCP role, go to page 30.

References are available to view online: membersarea.cop.org.uk/ the-podiatrist J U LY/AU G U ST 2 0 2 1 T H E P O D I AT R I ST

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30 THE PRACTICE FCP ROLE

STRAIGHT TO

THE HEART OF CARE As ffir first irst st c con contact onta tact ct p pra practitioners ract ctit itio ione ners rs e eme emerge merg rge e as tthe he llat latest ates estt pr prov provision ovis isio ion n in h hea ealt lthc hcar are, e, we we hear hear from ffro rom m a podiatrist podi po diat atri rist st working w wor orki king ng in in the the role role healthcare, abou ab outt hi hiss ex expe peri rien ence ces. s. about experiences.

Work/research balance After graduating g fro from rom m th thee Un University of Southampton S outh thampto ton I won an internship with Arthritis UK and the foot and ankle research team at the university, which involved learning about the different research projects happening across the Arthritis UK centres. This led to parttime work as a research assistant on a SPHERE-funded project, alongside part-time practice in the NHS to develop my clinical skills. I learned a lot about the world of research, co-authored a few papers and honed my skills in evidence-based practice.

Route to primary care I then went into private practice with an interest in musculoskeletal (MSK) disorders, with my prior experience providing a strong foundation to build on in primary care.

For the past year I’ve worked across four different surgeries as a

rst Our firs fi rsst contact cont co ntac nt actt practitioner ac p ac pr a ti titi tion ti oner on er ((FCP).

FC CP) P).. Ou ur primary network p pr im mar a y ca care re n ettwo work r ((PCN) rk P N) ccomprises PC ompr om p is pr i es knowledgeable off GP practice a kn know owle ow l dg le dgea eabl ea blee te bl team am o GPs, s, p ract ra ctticce nurses, advanced nurse practitioners nu urs rses es,, ad adva vanc nced ed n u se p ur ract ra ctit ct ittio ione ners ne rs (ANPs), physiotherapists, social (ANP (A NP NPs) Ps) s),, ph hys ysio io oth ther errap apis ists ts,, so ts soci cial al prescribers pharmacists. pres scr crib ib ber erss an and d ph phar arma maaci cist sts. encouraging Thanks to th tthee PC PCN N enco cour urag agin ing g me develop myy sk skills, to d evel ev elop op m skil ills ls,, I’ I’m m al also so sstudying tudy tu dyin ing for podiatry fo or a master’ss degree deg egre reee in advanced adv dvan ance ced d po podi diat atry ry University Brighton work at tthe he U nive ni verssit ity off Brigh ghton h t w to ork or k at practitioner level, an aadvanced dvan dv ance ced d pr prac acti titi tioner ((AP) AP P) le eve vel, l, aass working challenging well as wo work rkin ing g as aan n FC FCP P – a ch halleng gin ing g rewarding journey. but reward din ing g jo jour urne ney. y. becoming The portfolio route to t b ecom ec min ing g an FCP requires self-directed learning and autonomy, but you must also be able to work as part of a wider multidisciplinary team. There are many opportunities for self-development. I see undifferentiated undiagnosed patients and undiag gnosed pa p tients on a dailyy basis, and the beauty of the FCP role is that they can be booked directly with the

‘The portfolio route to becoming an FCP requires self-directed learning and autonomy’

LOUIS MAMODE has be been working as an FCP in Bourne Bou n mouth Bournemouth since sin ce July Ju y 2020 Jul 2020

podiatrist orr ar referred PCN po PCN podi diat atri rist st o aree re refe ferr rred ed by by their their i GP, ANP or other professional within the network.

Professional identity Working in primary care comes with challenges, and working out where I fit in as a podiatrist is one. My first weeks in the role were spent figuring out the different referral pathways, such as highrisk foot, rheumatoid arthritis, MSK triage and orthopaedics, but also establishing links with the independent sector. For example, if I have a patient with diabetic foot who needs urgent referral, I contact the consultant podiatrist to discuss their care until they are seen by the team of specialists and receive swift and appropriate treatment.

Routine care involves knowing where specific to send patients who need specific services. Since all NHS services have

Image: iStock

M

y firs rstt contact cont co ntac actt with wi a podiatrist pod odia iatr ttrris i t was during my AS-levels AS S-lev l vel elss injury, following a footballing inju j ry ry,, and I was fascinated by the level of skill involved. Shadowing a local private podiatrist broader p ivvat pr atee po podi d at atrist st eexposed xp pos osed ed mee to b roader aspects of the profession, from routine routtin inee biomechanics to nail surgery. That year I applied to study podiatry at a number of universities. uni nive vers rsit itie iess.

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FCP ROLE THE PRACTICE 31

eligibility criteria, it’s vital that I know what these require before I make a referral, or refer to the independent sector if appropriate, to avoid delays in the patient’s care.

Pandemic challenges During the Covid-19 pandemic I worked as a vaccinator in primary care, following advice from the College and my PCN regarding training and indemnity insurance. As a podiatrist, it’s been a great experience to work alongside other healthcare teams, and I’ve helped to vaccinate hundreds of people, which is a really rewarding feeling.

For me, the biggest challenge has been recognition by the wider PCN due to limited multidisciplinary team contact during the pandemic. We got around this by meeting individuals in the practices and, slowly but surely, the referral numbers rose. I’ve also been using phone and video for meetings and patient consultations.

Future aims

RESOURCES For the College’s document on podiatrists as FCPs, go to the second policy position listed at cop.org.uk/thecollege/policy-positions

My role as an FCP podiatrist and AP within primary care is still under development.

I have a good relationship with the PCN physiotherapist, where we discuss MSK cases and feed off each other’s expertise.

If there are patients with red flags I confer with my dedicated GP mentor, who is also helping me complete my FCP portfolio.

Working alongside the PCN team, I hope to develop as much as I can. In the future, I see myself working at a level akin to a consultant podiatrist and hope this career path can be forged.

My FCP takeaways In primary care, everything is fast paced.

You’re not expected to know everything but to work within your remit, reflect on cases you’ve seen and build on your existing knowledge using the resources available.

The role provides opportunities to progress and improve your knowledge and skills.

The MSK aspect of the role means you automatically see the benefits of early interventions, such as exercise and prefabricated over-the-counter orthoses, which reduce referral rates and pressure on secondary care.

Join our network The College of Podiatry, in conjunction with Health Education England, have created a First Point of Contact Practitioner network.

Objectives The aim of the network is to bring together those working as first point of contact practitioners in primary care, those with an interest in working in primary care, those managing services and those who wish to know more about this new role and how it works in practice.

Get in touch Join the network to find out about training opportunities, job planning, employment models or just simply to connect with peers with a similar interest.

To be added to the mailing list for future network meetings, contact lawrence. ambrose@cop.org.uk To find out more about being an FCP, go to page 27 for details on the Health Education England roadmap.

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32 THE PRACTICE BUSINESS HOW TO...

THE PATIENT REALLY DOES KNOW BEST

1

All podiatrists should listen to their patients, but it’s particularly important with high-level sportspeople and dancers who know their bodies incredibly well. Although you are the professional, dancers and athletes know their feet much better than you do.

The best thing any podiatrist can do initially is just to talk to them about what they like and don’t like.

Treat dancers and athletes For podiatrists, the world of professional sports and dancing is less about finding marginal gains, and more about ruling out marginal pains, explains Royal Ballet podiatrist Denzil Trebilcock.

Interview Matt Lamy

FORGET CLASSICAL ENUCLEATION

2

Some dancers like to keep a little bit of hard skin because they know that provides protection for them. In dance, there are a lot of shearing forces and friction. If you’re treating someone who is dancing that night and they can’t really put too much padding in their shoe – and you’re going all the way down to a classical enucleation or debridement – then they are going to be quite sensitive after that process. It’s got to be a balancing act of not going too far but still taking enough off to relieve pressure.

NO PROBLEM TOO SMALL

3

Always be aware of any niggling problems and treat them as quickly as possible.

I’ve looked after a world champion boxer. He came to me with something very small and simple to treat, which he knew would affect how he generated his power. At elite level, small issues with the feet can actually lead to major compromises in performance.

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BUSINESS THE PRACTICE 33

DON’T JUST LOOK AT THE FEET

4 DENZIL TREBILCOCK is principal podiatrist with the Royal Ballet and Royal Ballet School.

He practises at Simon Costain’s Gait and Posture Centre in Harley Street, London.

Read more about Denzil on page 16 and at gaitandposture. com

There is a big push for the ‘barefoot generation’. The whole concept is that surely we should be looking at strengthening our feet, and if we strengthen our feet then we never need to worry about orthotics or shoes. But if weekend runners read an article that says they should go running barefoot, and they do it, they’ll simply get injured because they haven’t conditioned themselves for it.

They may argue that if they keep on exercising, then they’ll get stronger. But if you go to the gym and lift weights, and you lift those weights incorrectly, at some point you’re going to create an overwork situation and injury. It’s the same for the foot. If the foot can’t strengthen itself in the correct position, then you may be building some strength, but not necessarily in the areas that you want it.

There may be another reason why a foot isn’t happy. It could be that there is a restriction in the hip, the ankle joint or the knee, or a small limb length differential. Unless you have a more holistic view, either it is going to be a constant problem, or you’re never going to get a great result. So stand back a bit and think about the bigger picture.

USE TECHNOLOGY TO EXPLAIN

5

At our clinic, we use X-rays, pressure analysis and video capture. This helps with our diagnosis but, perhaps even more importantly, it really helps during a consultation to explain what is wrong. When dancers and athletes look for themselves and see how they’re walking, how they’re moving, or see the results of pressure analysis, they’re instantly switched on. So use any technology you have access to as a communication aid rather than just as a diagnostic tool.

Foot-strengthening exercises

Images: Shutterstock

Barefoot cheek

If a patient doesn’t want orthotics, there are exercises they can try instead. If these are followed properly – and it does take some work – at the very least they will reduce the pain being experienced.

Short foot exercises – tense muscles in the feet but keep them flat and try to retract the toes in order to create an arch profile.

Re-engage with the feet – try to abduct the big toe from the lesser digits or try to move the big toe on its own to the midline of the body.

Dorsiflex – lift up the big toe independently of the lesser digits and, equally, try to lift the lesser digits independently of the big toe.

CONSIDER EXERCISES AS TREATMENT

6

Some patients dislike the idea of orthotics, so something I have taken from the ballet is a focus on intrinsic muscular exercises (see Footstrengthening exercises): of powering up the foot and getting the foot core strong.

In the same way people with back pain are encouraged to do exercises to strengthen the musculature around their core, so it is with the foot. The great thing about this with dancers and athletes is that they are used to training. So if you tell them to sit and do eight hours of intrinsic muscle exercises, they will do it and you really will see the changes.

REMIND THEM OF GRAVITY

7

Dancers in particular like to think they can control their feet and manage any problem they may have. But

when they’re walking down the road, talking to friends and they’re thinking about everything other than their feet, the one thing that wins out is gravity. Gravity will always bring them back to base level and if their base level is always in a compromised position, it doesn’t matter how hard they try to fight it.

Highlight the importance of putting measures in place to address foot problems even when they’re not consciously thinking about them.

DON’T TAKE IT PERSONALLY

8

Some dancers or athletes you won’t be able to treat because you simply cannot provide quite what they want. It’s nothing personal, it’s just that dancers and sportspeople are especially particular about issues relating to their bodies.

Equally, though, once a dancer finds a podiatrist that they like, they will always go back to them.

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34 THE PRACTICE APPRENTICESHIPS

A

n ageing population and an increased prevalence in obesity and diabetes means demand for podiatry services is on the up. At the same time, statistics show the number of people choosing to study podiatry is falling, while two-thirds of those practising are already aged 50 or over. So how can the profession tackle this shortfall? A programme of paid apprenticeship degrees in England could be the answer, and is already attracting a new generation of clinicians.

A new route The podiatry apprenticeship standard, launched in September 2019, allows students to earn a salary while studying for a BSc or pre-registration MSc degree – without paying fees. It allows

those interested in either entering the profession or furthering their training to qualify and get a degree, while gaining hands-on, patient-facing experience.

The University of Brighton was one of the first providers to offer the course.

Programme lead Stewart Morrison says: ‘Apprenticeships are a very good route for people who might not consider themselves suitable for degree programmes; it’s a more inclusive way to develop the podiatry workforce.

We’re flexible with our admissions policy to recognise that prior work can be as valuable as academic credentials. It’s about ensuring our approach to developing the workforce is open to everyone.’

Uptake for the three-year course so far has been positive, Stewart says, with a recent recruitment drive for

one apprenticeship post attracting 51 applicants. The University of Plymouth has also noticed a surge in interest across both its three-year BSc and twoyear pre-registration MSc programmes since starting in January this year, with September’s intake set to double.

The university’s BSc programme lead, Philip Hendy, says apprenticeships were vital to increase the number of students embarking on a career in podiatry. ‘People were contacting us wanting to become part of the podiatry profession but either couldn’t afford to go to university or their home life meant they were unable to join a traditional degree programme,’ he explains. ‘Plymouth has designed a portfolio of distance-learning apprenticeships that allow apprentices to work under supervision in clinic from day one, developing their clinical skills, working with patients and accessing specifically designed online distance-learning materials.’

Words Emma Bennett

Learning a lot

ON THE

RIGHT TRACK

For Aaron McCusker, choosing the apprenticeship route to continue his surgical training was a no-brainer.

He is in his first year of studying for a three-year master’s in podiatric surgery at Huddersfield University, working 30 hours a week at Blackpool Teaching Hospitals NHS Foundation Trust.

‘It’s a vast amount of work but I wouldn’t change it,’ says Aaron. ‘The next phase of my training would have cost me £10,000, so accessing the funding through the apprenticeship has massively benefited me.

‘While the commitment can’t be underestimated, working a 30-hour week means I’m learning from other podiatrists and my surgical tutor rather than staring at books all day.

Being able to discuss cases face to face – to go through X-rays

As podiatry grapples with attracting new talent into the profession, could apprenticeships be the key to growing the workforce?

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Image: iStock

APPRENTICESHIPS THE PRACTICE 35

and scans, and talk about complicated patients – is hugely beneficial.’

Aaron qualified as a podiatrist in 2017 and has been interested in podiatric surgery since a surgeon gave a talk to his undergraduate class. ‘It interested me, so I reached out to him on Twitter. He put me in touch with Mr Lee Murphy at the Department of Foot and Ankle Surgery in Blackpool and I ended up going to shadow him in theatre that weekend. I was instantly sold.

‘I’m learning so much from him and have access to a variety of clinics, including new patient assessments, surgical follow-ups, minor surgery clinics, the dressing clinics and, of course, surgery. We have also been helping to cover preoperative assessments where necessary.’

‘The apprenticeship levy money is there and if you don’t use it, you lose it.

Approach your HR team and you’ll probably find they’re keen for you to tap into it’

Removing barriers There are benefits for employers, too, in taking on apprentices. They can attract local talent and develop their own workforce, while accessing government funding to cover the cost of training. But figuring out how to get started isn’t always easy. The College’s Podiatry Apprenticeship Group (see Resources) was formed to provide support for employers and members interested in taking on apprentices.

Emma Stoneman, professional lead for podiatry and deputy therapy lead for East London NHS Foundation Trust, is the group’s chair. She is using her experience of developing the first cohort and apprenticeship programme, in collaboration with the University of East London, to try to remove some of the barriers to employing an apprentice. She says: ‘Each apprenticeship is unique and there can be a lot of work involved for employers – accessing funding, agreeing the job description and salary, recruitment and working with universities. We want to develop standardised guidance to make the process as easy as possible.’

One of the key challenges is helping employers – in both the NHS and

private practice – understand how to access the £24,000 needed to fund a place. For employers with a pay bill of £3m or more – such as large NHS trusts – they can access the apprenticeship levy, with 0.5% of their pay bill going into the pot.

They have 24 months to use that money for training before it goes back to the Treasury.

For everyone else, there are two options. Jennifer Stone, Talent for Care relationship manager for London, explains: ‘There’s reserved funding, where the government pays 95% of the cost and the employer pays the remaining 5% to have access to

Vikki Pestridge RESOURCES For more information about the different apprenticeship programmes, providers, case studies and advice, go to haso. skillsforhealth.org.uk

‘Think about what your service needs and plan apprenticeships into your workforce development plans. Can you make a vacancy into an apprenticeship?

Is there an opportunity to collaborate with others in your region to share placements between employers?’

Jennifer Stone

Go to jobs.nhs.uk and gov.uk/applyapprenticeship to find apprenticeship vacancies in podiatry.

Interested in employing an apprentice? Contact your regional Talent for Care apprenticeship manager or jennifer. stone@hee.nhs.uk to get started.

To find out more about the College’s Apprenticeship Group, email james. coughtrey@cop.org.uk

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36 THE PRACTICE APPRENTICESHIPS

The perfect fit Vikki Pestridge, AHP operational lead for podiatry at Salford Royal NHS Foundation Trust, has two first-year apprentices, including Beth Richardson at the University of Salford. They highlight what other nations – Wales, Scotland and Northern Ireland – as well as the wider profession could learn from England when it comes to apprenticeships.

Vikki: We have a cohort of staff heading towards retirement, so as part of our succession planning we were thinking about how we can build

our future workforce. Beth was working with us as an admin assistant and we knew she had a passion for podiatry. She had worked as a podiatry assistant and wanted to further her career, so her next step was to gain a degree. We needed a local course, so I approached the university while Beth drove it from a student point of view.

Thankfully, it all fell into place.

For us to have somebody we can grow and develop, and offer a job to at the end will be very rewarding. As a trust, you have to be flexible and understand that the timetables are guided by the university. At first, we found it could change with little notice and we had to adapt to release staff quickly. This was challenging but we have regular meetings with the university to

the course. Or you can do a levy transfer where you ask a levypaying organisation to fund the place from their levy. If a private practice in London came to me asking for a levy transfer and I asked a nearby trust to do it, they would jump at it. As the levy expires after 24 months, they would rather it be used in the health and social care sector than expire and be returned to the Treasury.’

While there’s still more to do to make it easier for employers to take on apprenticeships, interest is definitely on the rise, says Emma.

There were just five apprentices studying programmes across England in the academic year 2019-20, with a further 23 joining in 2020-21. ‘Now employers have seen other organisations starting to recruit apprentices and we’re getting feedback on how effective they are, we’re getting a lot more interest,’ she says. ‘Working in the NHS is demanding and complex, and apprentices are learning how to cope with that by being in the work environment.

iron out issues. Developing those relationships with the university is important. While recruitment was up to us, we took advice from the university leads during the interview process. It’s important to understand the apprenticeship is an academic degree and apprentices have to be able to perform at that level.

Beth: While I was working full time as an admin assistant I did a health access course.

There was no guarantee the apprenticeship would go ahead, so I was relieved that it did because I wanted to develop my knowledge and skills. I would never have been able to afford

‘Win hearts and minds. Think about what you can gain from employing an apprentice rather than what you will lose. You can have all the toolkit support you need but unless your team is on board and can see the value of apprenticeships, it won’t work’ Emma Stoneman

They are as good as undergraduates and their clinical progression is faster given their increased exposure to the workplace.’

Business as usual And while Covid-19 may have taken apprenticeships off some trusts’ agendas for a few months, the pandemic has not halted the programmes. ‘They have been invaluable,’ explains Emma, who took on two new apprentices in 2020. ‘They managed all our PPE, they delivered dressing packs for

to do a degree without an apprenticeship, and I can’t study full time as I have children and a mortgage. This way, I don’t pay fees and I’m paid a wage – it’s the perfect fit.

We’re absorbed in the course through work and I have already learned so much. When I came into podiatry I absolutely loved it, and doing this apprenticeship I can see the end goal. Putting the theory into practice is like a puzzle and I’m enjoying seeing the pieces coming together.

The most challenging parts are the exam and assessment, because free time is limited.

I was fully aware we would have to do a lot of work in our own time, but it’s important to find the right balance for family life and be organised coming up to the exam period.

patients in their own homes, helped with developing leaflets and pulling induction packs together, as well as assisting in clinics. Covid-19 has given us the opportunity to showcase what the profession can do.’

University of Brighton apprentice Natasha Bassett says that in many ways it had been business as usual.

‘The diabetic foot clinics still ran, even though there was an increase in DNAs and same-day cancellations,’ she says.

‘So I’ve still gained fantastic experience in wound-care exposure, while others in my cohort were on lockdown and gaining no clinical experience.

‘As all the foot care clinics were cancelled, I spent some time helping our admin team and gained a new respect for all they do. Working through Covid was stressful, but I had the opportunity to continue applying the theoretical knowledge from online lectures to real patients. The whole team at East Sussex Healthcare Trust has helped me at some point throughout this apprenticeship, and the support I’ve had from the managers and mentors during Covid has been second to none.’

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38 THE PRACTICE CAREER DEVELOPMENT

Rebranding to survive When his podiatric surgery role was absorbed into a new department, Damian Holdcroft was faced with a big decision: how to develop his career now? Eminent podiatric surgeon David R Tollafield spoke to him to find out.

employ another podiatric surgeon,’ Damian says.

‘A meeting was set up with the clinical director, foot surgeon and clinical manager of T&O. I outlined how I could be of benefit to the T&O department and there was a general concensus things worked well.’

Ready, willing and able ‘I then discussed working regularly in fracture clinic, where the postoperative dressings clinic for all foot and ankle surgery was held. I told Mr Goswami I could be there and pretty well manage all of the post-op patients once I became an independent prescriber [IP]. I knew this would be the game-changer.’

Path finder DAVID R TOLLAFIELD worked for more than 40 years in the West Midlands as a consultant podiatric surgeon.

He now writes under the brand ConsultingFootPain for Busypencilcase Reflective Communications

At the time, there was no blueprint set out for an ESP used to working in podiatric surgery.

‘I had to make my own path as a podiatrist who had spent years working in surgery, theatres, giving injections, cannulating, going on advanced life support and immediate life support courses, as well as running a nail surgery list within the hospital,’ Damian says.

Image: iStock

F

rom 2011 to 2014, the community department of podiatric surgery at Walsall Healthcare NHS Trust was slowly absorbed by the department of trauma and orthopaedics (T&O) until it ceased to exist. For one member of staff – extended scope podiatrist (ESP) Damian Holdcroft – these developments led him to take an unusual step. Faced with the loss of podiatric surgery, he decided to rebrand himself within the T&O surgery team.

There was no guarantee it would even be accepted. ‘At the time, I thought I should do my utmost to preserve podiatric surgery. I was told by the trust they were unlikely to expand in terms of podiatric surgery and

Damian set out his stall and approached the orthopaedic foot and ankle lead, determined to sell himself.

‘I started off by undertaking some dual clinics with the consultant orthopaedic surgeon and lead in foot and ankle surgery, Mr Goswami. We compared how we would approach different problems. This came about in a friendly and encouraging way.’

Initially, Damian attended theatre with Mr Goswami observing. ‘I informed him that I could perform ankle anaesthetic blocks for the benefit of the patients undergoing surgery,’ he says. ‘Soon I was assisting in theatre and further down the line, suturing and so on. This lead to me taking a supportive role with trauma surgery during the Covid-19 pandemic.

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CAREER DEVELOPMENT THE PRACTICE 39

outlook has paid huge personal dividends. More than ‘just’ an ESP, his role has become almost that of a medical orthopaedic registrar.

‘The professional relationship has gone from strength to strength.

For example, when Mr Goswami is away at another hospital, he often contacts me to find out what’s going on. In this way I can report back to him and take any appropriate action,’ he says.

‘With the advent of Covid-19, some roles had to change. Mr Goswami relied on me as his “registrar” as a number of medical staff were shielding. In theatre, it was just him and me.’

The journey

‘Cascading skills down would be beneficial to individuals and the whole profession’ ‘We had a wide range of drugs we could give, including intramuscular and intravenous, as well as PO [prescription-only] medications.

So my experience was broad.

I could not let that go to waste.’

Even for somebody with all his experience and expertise, instigating change was not without its obstacles.

‘The nurse in charge of the fracture clinic gave me the impression she thought I might get in the way. After a few weeks, she warmed to me because previously she had to do all the suture removal and dressings after foot and ankle surgery. I could offload a lot of her work,’ Damian says.

‘I did the post-op clinic when Mr Goswami was away. My relationship with T&O grew and I found that the orthopaedic team wanted me to just get on and do it.’

Spreading influence Damian’s influence started to grow.

‘In time, the trainees started to come to me with their log books, having had surgical procedures such as osteotomies. After they had undertaken a number of procedures with Mr Goswami, he would suggest I scrub in to support them rather than him. He would say to me “If you run into problems, tell them to stop and then come and get me,”’ Damian says.

‘As I became more involved in the fracture clinic, Mr Goswami would ask me to prescribe medicines. This included drugs such as Clexane to avert a blood clot when patients are immobilised in a below-knee cast.

This helped him enormously if he was snowed under.’

Seven years on, Damian says his decision to expand his professional

So are we ready to develop within the College and its Faculty of Podiatric Surgery the type of work that Damian fulfils in his role working with Mr Goswami?

‘While I understand where podiatric surgery came from, cascading skills down would be beneficial to individuals and the whole profession. The journey made in podiatric surgery is incredible,’ Damian says.

‘Key elements such as IP will give a huge amount of leverage, as well as expanding positively, especially where continuity of care compliments the care pathway.

‘One of my abiding memories comes from a locum consultant orthopaedic surgeon – whom I was assisting in theatre – asking me my grade. I said I was an ESP and he replied that he thought that I was an orthopaedic consultant.’

Damian’s testimony emphasises that, where we once could rely on a linear career, we no longer can expect such stability. It takes courage to change at any time in life, but no less when one has been practising for more than 30 years.

If nothing else, his story is a lesson that could be applied in even wider circles: whatever hurdles you face, there is a route for people with experience and skills.

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40 THE PRACTICE CHARTERED SCIENTISTS

HOW I GOT HERE …

Ambassador for science Aligning podiatry with the scientific community was a strong motivator for achieving Chartered Scientist (CSci) status, as Gafin Morgan explains in our latest instalment.

What prompted you to apply?

I had a few reasons: I wanted to align myself professionally with the Science Council to demonstrate, as a podiatrist, my ability and commitment to the scientific method. I also felt it was a way to recognise the work I’ve done over the years from a service-development and research perspective.

Find out more about applying for CSci status at bit.ly/ CSci-application

How easy or difficult did you find it?

The application process is very clear indeed. Each step can be carried out systematically and saved to your online account as you go. Although it requires the applicant to think clearly about their supporting evidence for each section, particularly in terms of inputs and outputs,

Gafin’s podiatry journey Qualified from the University of Wales in 1997.

Works as an extended scope practitioner podiatrist and foot and ankle clinical lead for NHS Wales University Health Board’s clinical musculoskeletal (MSK) assessment and treatment service.

Is also an MSK sonographer specialising in trauma, interventional, point-of-care diagnostics, ultrasound tissue characterisation and strain elastography.

Has an active research profile.

Works as a consultant podiatrist for Sport Wales, assisting in the management of elite athletes.

there’s plenty of support available with this.

What does having CSci status mean to you?

It’s meant recognition of the various projects I’ve carried out as part of my role, particularly my published research on tendinopathy and stiffness. The application process was rewarding in itself, as it was an opportunity to reflect deeply on my previous activities – research or otherwise.

How would you encourage fellow podiatrists to apply?

Have a look at the Science Council website and read some of the CSci profiles on there for inspiration.

Download the application guidance, take a look through your portfolio and consider what you could use as supporting evidence: you’ll be surprised at how much of your experience is relevant. And don’t be afraid to ask for support from a colleague or another CSci.

Why is it important for podiatry to be seen as a scientific discipline?

Could you be next?

This was an important consideration for my application.

It demonstrates that not only are we aligned with the scientific community in general but we’re committed to the application of the scientific process outside and within our professional role.

To become one of more than 13,000 Chartered Scientists working across all scientific and related sectors, here are the criteria you need to meet:

Tell us more about that...

I’m currently working with our innovation team on the use of 3D technology – scanning, printing and virtual reality across various healthcare sectors. This is an emerging technology within healthcare – particularly the ability to visualise 3D anatomical scans in a virtual environment for surgical planning. With CSci status we can be ambassadors and apply science in all its guises that interest us.

HCPC-registered podiatrist.

Member of the College of Podiatry, holding the MCPod or a fellowship (FCPodM or FCPodS).

BSc podiatry/podiatric medicine or the DPodM or BMedSci podiatry.

Minimum of four years in full-time podiatryrelated employment.

Master’s degree in podiatry (or a cognate discipline) or a doctoral degree, or if not the holder of a master’s degree, the candidate will select the M-level equivalence route.

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D E V E LO P M E N T

CLTI and Covid: a podiatric approach

1-17 CPD JULY AUG_THE PODIATRIST JULY AUG CPD_Podiatry Now.indd 1

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2 THE CPD CLTI AND COVID

The podiatric approach to chronic limbthreatening ischaemia during the pandemic

have diabetes, with its associated peripheral sensory neuropathy. It is a highly morbid disease, associated with increased risks of delayed wound healing, pain, impaired quality of life, amputation and mortality (Conte et al, 2019). In the absence of aggressive treatment and risk-factor optimisation, the prognosis for this cohort is extremely poor, with an estimated mortality rate of 25% within a year of diagnosis (van Haelst et al, 2018; Sigvant et al, 2016).

With the aid of some challenging case studies, we discuss the decision-making process for patients with both chronic limb-threatening ischaemia and Covid-19.

Epidemiology

Summary

MICHELLE MISKELL Clinical lead podiatrist, Stockport NHS Foundation Trust

MICHELLE THURMAN Principal podiatrist, high-risk foot team, Tameside and Glossop Integrated Care NHS Foundation Trust

The aims of this paper are to deliver an overview of chronic limbthreatening ischaemia (CLTI) and to demonstrate how podiatrists can play a key role in the assessment, diagnosis and management of this condition. We have included real-life patient case studies that have taken place during this unprecedented time alongside a case study challenge to help reaffirm your knowledge and skills.

There will also be discussion around the challenges of working within vascular spoke sites, particularly during this pandemic, and the complexity of decision-making for patients with both CLTI and the Covid-19 virus.

C

linicians working routinely within highrisk foot clinics know that patients diagnosed with a critical limb ischaemia are certainly not the only ones who are likely to lose a leg. We have come to understand that people with active foot ulceration, even where there is no ischaemia, are still at significant risk of amputation.

To that end, there has been a small but pertinent modification to how the Society for Vascular Surgery (SVS) asks us to define limbs at risk of amputation. Global vascular guidelines published by the SVS in 2019 recommend using the term ‘chronic limb-threatening ischaemia’ (CLTI), because it better reflects the wide spectrum of disease that we observe (Conte et al, 2019).

CLTI is essentially an umbrella term for a limb presenting with peripheral arterial disease (PAD) of any severity that can delay wound healing and increase the risk of major amputation, accompanied by ulceration, ischaemic rest pain or gangrene (Conte et al, 2019).

People with CLTI are undoubtedly among the more complex and clinically challenging patients that we treat. A large proportion also

The overall prevalence of PAD is estimated to be as high as 20% in people aged over 60 in the UK (NICE, 2012). There is clear evidence of an increasing number of cases that can in part be attributed to the rising prevalence of vascular disease risk factors (see Table 1). There is limited data relating specifically to CLTI, except to say that it accounts for just under 10% of PAD cases (Conte et al, 2019), and with the rising incidence of PAD it is likely that CLTI rates will continue to rise alongside this.

CLTI versus critical limb ischaemia If we consider the familiar diagnostic term ‘critical limb ischaemia’ (CLI), we can appreciate that its definition has useful thresholds that give us confidence in identifying the condition. CLI describes severe end-stage PAD, with the presence of gangrene and/or a two-week history of ischaemic rest pain, with ankle systolic pressures below 50mmHg or toe pressures below 30mmHg (Norgren et al, 2007; Suzuki, 2007).

The SVS guidelines suggest a preference for using the term CLTI over CLI, but, after much scrutiny and many discussions with our vascular-interested podiatry colleagues, we aren’t convinced that we should simply use it instead of CLI. We appreciate that the

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TABLE 1

refer Mr Smith as a non-urgent case. The differentiation in terminology aids a more pragmatic approach to decision-making in such situations.

Sadly, most of the CLTI cases we encounter in real life are more complex and difficult to manage.

But we can also use tools such as the wound, ischaemia and foot infection (WIfI) classification system to help us make sense of them.

Vascular disease risk factors Age: over-60s are at increased risk Sex: prevalence is higher among men Hypertension Hyperlipidemia Diabetes A history of cardiovascular disease

in the context of these factors, it will naturally inform our clinical decisions while helping us to set patient-centred goals and manage expectations (Behan et al, 2017).

WIfI can be used for any patient who has been experiencing foot ulceration for more than two weeks. It is not designed for use in cases of acute limb ischaemia, embolic, trauma or nonatherosclerotic disease including vasospastic disorders or venous ulceration (Conte et al, 2019).

If we consider the WIfI system’s impact on a broader scale, evidence suggests that it has the potential to predict factors such as how long someone is likely to be an inpatient, the cost of treatment, wound healing rates and the need for timely revascularisation (Behan et al, 2017).

If you are not used to the WIfI system, it can appear quite overwhelming to look at initially, but with time and some practice,

Chronic kidney disease Obesity – i.e. a body mass index exceeding 30 Smoking Elevated levels of C-reactive protein (CRP) in the blood A family history of arterial disease Low socioeconomic status Conte et al, 2019; NICE, 2012

condition is better represented as a continuum but with the caveat that there is a point at which more urgent action is required.

The 2012 NICE guideline, which still recognises CLI, supports this stance, while the European Society for Vascular Surgery recognises both terms.

Consider these two examples: Mr Smith attends the high-risk clinic with a non-diabetic foot ulceration on a toe, no deeper structures exposed, an ankle brachial pressure index (ABPI) of 0.57, a toe pressure of 38mmHg, and no infection. He has no necrosis or rest pain.

Mrs Jones attends the clinic with diabetic foot ulceration on a toe, no sign of infection, incompressible ankle vessels, a toe pressure of 23mmHg, ischaemic rest pain, and necrosis.

Both patients have CLTI, but Mrs Jones has a far more serious presentation, which by definition is a CLI. It would therefore be inappropriate for us to treat them the same way. Mrs Jones requires urgent attention from the on-call vascular team, whereas we can

WIfI classification The SVS developed and published this WIfI classification system (see Table 2) to help clinicians deduce where each patient is on the CLTI continuum by accurately staging the threat of a major amputation (Mills et al, 2014). It does so by focusing on the three factors that put the limb at risk: extent of wound, level of ischaemia and grade of foot infection (Mills et al, 2014). If we understand the threat

TABLE 2

The WIfI classification Component W wound

Score 0 1

Small, shallow ulcer on distal leg or foot without gangrene

2

Deeper ulcer with exposed bone, joint or tendon ± gangrenous changes limited to toes

3

Extensive deep ulcer, full thickness heel ulcer ± calcaneal involvement ± extensive gangrene

I ischaemia

ABI

Ankle pressure (mmHg)

Toe pressure or TCP02

≥0.80

>100

≥60

1

0.60-0.79

70-100

40-59

2

0.40-0.59

50-70

30-39

<0.40

<50

<30

0

3 fI foot infection

Description No ulcer (ischaemic rest pain)

0

No symptoms/signs of infection

1

Local infection involving only skin and subcutaneous tissue

2

Local infection involving deeper than skin/subcutaneous tissue

3

Systemic inflammatory response syndrome

2017 ESC Guidelines on the Diagnosis and Treatment of Peripheral Arterial Diseases, in collaboration with the European Society for Vascular Surgery (ESVS) J U LY/AU G U ST 2 0 2 1 T H E P O D I AT R I ST

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you will find it is not difficult to use. We are starting to roll it out in high-risk clinical practice, where it has so far proved insightful and a reliable predictor of amputation risk so far. Its main limitation occurs when falsely elevated ankle/ toe pressures or incompressible vessels are encountered. This can ultimately prohibit the completion of WIfI or lead to a misleading classification, i.e. ABPI or toe pressure suggestive of normal value when the limb is clearly ischaemic.

Based on our experiences and those of neighbouring teams, the introduction of toe pressures has tended to reduce the incidence of this limitation, but we still encounter the odd incompressible toe. This is where experience and competencies in the recognition of various Doppler sounds or visible waveforms is helpful. The question then becomes: ‘Do you believe the result you are presented with?’

If we refer back to Mr Smith and Mrs Jones, we can apply the WIfI classification shown in Table 2 to their presentations and further understand their risk for amputation using Table 3a as follows: Mr Smith: Wound 1 Ischaemia 2 foot Infection 0 = Clinical stage 2 Low risk for amputation at 1 year.

Mrs Jones: Wound 2 Ischaemia 3 foot Infection 0 = Clinical stage 4 High risk for amputation at 1 year.

This system illustrates the difference in urgency between the two cases and shows clearly where each one sits on the CLTI continuum.

Based on the same WIfI scores, we can then use Table 3b to estimate whether revascularisation might be beneficial or required to inform our next decision: Mr Smith has a moderate likelihood that he would require/ benefit from revascularisation.

Mrs Jones has a high likelihood that she would require/benefit from revascularisation.

With a moderate or high likelihood that revascularisation

TABLE 3

WIf I risk score tables a Estimate risk of amputation at one year for each combination Ischaemia - 0

Ischaemia - 1

Ischaemia - 2

Ischaemia - 3

W-0

VL

VL

L

M

VL

L

M

H

L

L

M

H

L

M

M

H

W-1

VL

VL

L

M

VL

L

M

H

L

M

H

H

M

M

H

H

W-2

L

L

M

H

M

M

H

H

M

H

H

H

H

H

H

H

W-3

M

M

H

H

H

H

H

H

H

H

H

H

H

H

H

H

fl0

fl1

fl2

fl3

fl0

fl1

fl2

fl3

fl0

fl1

fl2

fl3

fl0

fl1

fl2

fl3

b Estimate likelihood of benefit of/requirement for revascularisation (assuming infection can be controlled first) Ischaemia - 0

Ischaemia - 1

Ischaemia - 2

Ischaemia - 3

W-0

VL

VL

VL

VL

VL

L

L

M

L

L

M

M

M

H

H

H

W-1

VL

VL

VL

VL

L

M

M

M

M

H

H

H

H

H

H

H

W-2

VL

VL

VL

VL

M

M

H

H

H

H

H

H

H

H

H

H

W-3

VL

VL

VL

VL

M

M

M

H

H

H

H

H

H

H

H

H

fl0

fl1

fl2

fl3

fl0

fl1

fl2

fl3

fl0

fl1

fl2

fl3

fl0

fl1

fl2

fl3

fI foot infection I ischaemia W wound Premises: 1. Increase in wound class increases risk of amputation (based on PEDIS, UT and other wound classification systems).

2. PAD and infection are synergistic (Eurodiale); infected wound + PAD increases likelihood revascularisation will be needed to heal wound.

3. Infection 3 category (systemic/metabolic instability): moderate to high risk of amputation regardless of other factors (validated IDSA guidelines).

Four classes: for each box, group combination into one of these four classes Very low

VL

Clinical stage 1

Low

L

Clinical stage 2

Moderate

M

Clinical stage 3

High

H

Clinical stage 4

Clinical stage 5 would signify an unsalvageable foot

QUICK TIP Download the free SVS guidelines app for a WIfI calculator via the App Store.

could be beneficial, it is clear that referring to our vascular surgery colleagues for their expertise would be recommended in both of these examples. As mentioned in the earlier section, Mrs Jones would be prioritised.

The cardiovascular impact of Covid-19 There is an emerging body of evidence indicating that Covid-19

is not only a respiratory illness.

Studies have shown that the coronavirus can also affect multiple organs through its involvement of the endothelial cells, particularly the cardiovascular system and associated vasculature (Mehra et al, 2020). A paper published in The Lancet last year showed that 40% of Covid-19 deaths are related to cardiovascular complications – and that the virus can infect

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the endothelial cells (Varga et al, 2020).

Understanding endothelial cell function and Covid-19 Endothelial cells form a single layer inside blood vessels; they release proteins that influence blood clotting capacity and help to prevent the development of blood clots and inflammation within the vessel (Alberts et al, 2002). These proteins also help to boost the immune response, which protects the cardiovascular system (Varga et al, 2020).

We can therefore appreciate that, in damaging the endothelium, a Covid-19 infection can potentially result in the inflammation of blood vessels, abnormal clotting, abnormal immune responses and reduced blood flow (Ackermann et al, 2020). Research indicates that people with existing cardiovascular and metabolic conditions, including diabetes, experience more severe cases of Covid-19 because their endothelial cells are already damaged secondary to the effects of these long-term conditions (Ackermann et al, 2020).

Image: iStock

CLTI and the pandemic If we consider the impact of the coronavirus on people with metabolic conditions and cardiovascular disease, it’s perhaps unsurprising that we are observing poor outcomes in our CLTI cohort, who often have widespread atherosclerosis and therefore endothelial dysfunction associated with PAD (Conte et al, 2019; NICE, 2012). Peripheral ischaemia has also been described in critical Covid-19 patients in the context of possible hyper-coagulable state (Zhang et al, 2020). However, due to the novel status of this virus, much of what we know about how the disease affects the high-risk foot is anecdotal at this stage.

Late presentation of the highrisk foot is a familiar problem that has increased significantly during the pandemic. Many of

Blood vessels Artery

Tunica Intima

Vein

Endothelium Subendothelial layer Internal elastic lamina

Tunica Media External elastic lamina

Tunica Externa Valve

Capillary network Lumen

Covid-19’s effect on the skin Lumen

Endothelial cells

Capillary

our patients have attributed their failure to access podiatry services to their fear of contracting the virus, coupled with the government’s advice for people with diabetes or heart conditions to shield. As such, there have been many cases of unsalvageable foot problems often complicated with sepsis. Many patients who presented late were indeed vulnerable due to sepsis and uncontrolled diabetes, and went on to contract Covid-19 as inpatients.

When faced with serious foot infection, it’s hard to discern whether poor limb and life outcomes from serious foot infections have resulted from delayed diabetic foot management or from cardiovascular complications resulting from

Covid-19 (Varga et al, 2020).

Evidence has shown that people with poor glycaemic control who contract the virus have a higher risk of developing complications from it (Zhu et al, 2020). Given that patients with diabetic foot problems generally have a history of poor glycaemic control, this may well explain the increase in mortality that we have witnessed.

QUICK TIP Livedo reticularis is a form of mottled skin discolouration resulting from the disturbance of blood flow to the skin.

‘Many patients who presented late were indeed vulnerable due to sepsis anduncontrolled diabetes and went on to contract Covid as inpatients’

Skin disease, a well-known effect of many viral infections, has been identified in people with Covid-19 (Galván Casas et al, 2020). As podiatrists it is vital we are aware of the different manifestations of Covid-related skin disease, as we could potentially identify skin changes with asymptomatic patients. It’s estimated that between 20% and 70% of Covid-19 cases could be asymptomatic (Black et al, 2020). Some skin manifestations can present in the feet, which could potentially aid with diagnosis and perhaps also give an indication of prognosis.

Bristow and Borthwick covered this subject thoroughly in an article in the Journal of Foot and Ankle Research in June 2020.

Galván Casas et al (2020) observed five cutaneous manifestations of Covid-19. These included ‘Covid toe’, which was seen in 19% of cases and often presented as itchy chilblain-type lesions found in younger patients, lasting 12 days on average. Covid toe was more commonly associated with mild infections and tended to appear later on in their course.

Conversely, a much less common presentation (6% of cases) was a type of necrosis known as livedo reticularis. It took the form of necrotic skin lesions, indicating occlusive vascular disease, and included areas of truncal and peripheral ischaemia. The skin could also show red or blue blotches in a net-like pattern.

It generally appeared in severely ill older patients.

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The pandemic’s effect on vascular multidisciplinary teams Many readers will be familiar with the vascular ‘hub and spoke’ model of care, whereby vascular outreach clinics make initial assessments and refer to central vascular specialist services when further intervention is required.

This model can be inconsistent at times, but for the most part it provides a clear care pathway for our CLTI and CLI patients. These local vascular outreach clinics facilitate the multidisciplinary cooperation of podiatry, diabetes and vascular teams, and helps to safeguard timely investigation and intervention.

The pandemic disrupted many aspects of high-risk foot care and podiatry-led arterial assessment services as it prompted the cessation of vascular spoke site clinics. As we saw the rapid suspension of many NHS services, one of our main concerns was whether access to crucial vascular care would also be limited. Guidance issued during the first peak of Covid-19 infections restricted vascular surgery, with a view to reducing unnecessary hospital exposure, deferring non-urgent cases and reducing inpatient stays (GIRFT and Vascular Society, 2020).

As a profession, we needed to adapt quickly and integrate pandemic-response procedures into our practice to protect patients at most risk of amputation.

The first of these was guidance published by Foot in Diabetes UK on the prevention of lowerlimb amputation during the Covid-19 situation (see Figure 1).

The Getting It Right First Time NHS improvement programme (GIRFT) and the Vascular Society then issued a statement designed to safeguard access to urgent/ emergency lower-limb vascular care, which highlighted how podiatrists and non-medical colleagues would be depended upon during the pandemic.

FIGURE 1

Covid-19 situation v1.3: Lower limb amputation prevention guidance

‘People with CLI and diabetes are especially vulnerable during Covid-19. Where possible, “hot clinics” to minimise emergency department attendance should be kept open, alongside networked hospitals diabetic foot services.

Maintaining open communication with network clinicians, practice

‘Maintaining open communication with network clinicians, practice nurses and podiatrists is essential’

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nurses and podiatrists is essential.

Ideally units should offer non face-to-face consultation (i.e. attend anywhere)’ (GIRFT and Vascular Society, 2020).

As expected, many vascular spoke clinics were cancelled, making the implementation of the new guidance particularly important for podiatrists. Our vascular specialist podiatry colleagues published a CPD article in Podiatry Now in April 2019 (Matthews et al, 2019) outlining how podiatrists could make a vital contribution to vascular assessment in early cases of PAD. Just a few months later, with a shock turn of events, podiatrists have been depended upon to step up and use these crucial skills in the absence of our vascular surgery colleagues.

The traditional ‘peripheral’ role of a podiatrist in the management of PAD – which was true of many

locations – transformed into more of a core diagnostician’s role. We have been delicately edging our way into this arena for years, only to be thrust into it by a viral pandemic that has been shown to directly impact on the cardiovascular system and limb outcomes.

While we are focusing here on the more severe presentations of CLTI, it would be remiss of us not to stress the importance of the podiatrist’s role in recognising a limb that isn’t in crisis and therefore not in need of management in the acute setting.

Identifying lower-risk patients protects them from unnecessary hospital admissions and the higher risk of viral exposure. It also ensures that they can still obtain appropriate, timely care in the community that will prevent their problems from escalating (see Figure 1).

FIGURE 2

A visual aid for determining amputation risk using WIfI Wound 0: No ulcer, no gangrene 1: Small ulcer and no gangrene 2: Deeper ulcer and gangrene limited to toes 3: Extensive ulcer or extensive gangrene

Ischaemia Toe pressure/TCP02 0: >60mmHg 1: 40-59 2: 30-39 3: <30

Foot infection 0: No infection 1: Mild (<2cm cellulitis) 2: Moderate (>2cm cellulitis/purulence) 3: Severe (systematic response/sepsis)

TABLE 4

Key wound assessment principles Patient medical and surgical history Aetiology of wound – e.g. pressure, ischaemia, trauma Duration of wound Location of wound Wound size and depth Wound exudate levels Wound bed tissue type – i.e. the percentage of granulation, slough or necrosis Exposed structures – e.g. bone or tendon Assessment of the surrounding skin’s condition Pain – e.g. visual analogue scale 1 to 10

Wound, ischaemia and foot infection assessment Let’s briefly explore each of the three factors that the WIfI system uses to determine amputation risk.

Figure 2 contains an additional visual aid for WIfI adapted from Mills et al (2014).

Wound assessment When assessing any lower-limb wound, it’s important to take a structured, holistic approach to identify the causes and assess the intrinsic and extrinsic factors that can aid or delay healing (see Table 4). Effective management should include identification of the wound aetiology, as this will ultimately guide the treatment plan (World Union of Wound Healing Societies, 2008). The wound section of WIfI grades the level of tissue loss and necrotic changes so that the level of intervention or amputation required to achieve healing can be anticipated (Mills et al, 2014).

Ischaemia (PAD) assessment To reach a diagnosis of PAD, we must use evidence-based tests such as ABPI and toe pressures, alongside palpation J U LY/AU G U ST 2 0 2 1 T H E P O D I AT R I ST

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of foot to femoral pulses, visual observations of the limb’s condition, interpretation of Doppler sounds and a full pain history. The results of these should be considered along with the patient’s medical history. The 2012 NICE guideline recommends the use of ABPI as a diagnostic for PAD, but this test is sometimes compromised by calcification in vessel walls.

Although toe pressures can be a helpful adjunct and, in some cases, replacement for ABPI, in practice they are yet to feature in the guidance as a recommended test.

This is despite findings that toe pressures can be related directly to whether the ulceration heals or not (Brownrigg et al, 2015).

In this section we have included some of the nuances of ischaemic presentations that can be useful to recognise when the recommended tests are inconclusive.

Buerger’s elevation test. It can be challenging to differentitate erythema associated with cellulitis from that of reactive hyperaemia secondary to ischaemia, particularly when vessels are incompressible. A useful assessment tool to help make this determination is to elevate the patient’s limb to 45 degrees and observe for any change in its colour. Erythema related exclusively to ischaemia will usually drain so that the foot turns white after a minute and,

QUICK TIP Baseline peripheral arterial assessment should include: Pulses Phases Pressures Think: ‘three Ps’.

‘Not all infections progress to sepsis, but all infections have the potential to progress to sepsis’

TABLE 5

IDSA guideline for the diagnosis of diabetic foot infections Grade 0 uninfected

No signs or symptoms of infection.

Grade 1 mild infection

Infection defined as at least two of the following: local swelling or induration; peri-wound erythema/cellulitis >0.5cm to <2cm; localised pain; localised warmth; and purulent discharge or malodour. Mild infection involves only the skin and subcutaneous tissues without involvement of the deeper tissues/ structures and without systemic signs of infection.

Grade 2 moderate infection

Local infection (as described in grade 1) with peri-wound erythema/ cellulitis >2cm; and the involvement of deeper structures than the skin and subcutaneous tissues (e.g. osteomyelitis, abscess, septic arthritis and fasciitis). Moderate infections are without systemic signs of infection.

Grade 3 severe infection

Local infection (as described in grades 1 and 2) with signs of systemic inflammatory response syndrome, which is present as two or more of the following: temperature >38˚C or <36˚C; heart rate >90bpm; respiratory rate >20 breaths per minute; white-cell count >12,000 cells per mm3 or <4000 cells per mm3. Severe infections can be recognised by ulceration associated with rapidly spreading cellulitis and complicated by a collection of pus, wet necrosis or gas in the soft tissues, accompanied by crepitus in the skin. Limb-threatening infection can also be caused by ulcers that probe deep to bone (Bates et al, 2020).

Patients with diabetes, neuropathy and PAD can be immunosuppressed and, as a result, may not respond appropriately to infection, and typical signs/symptoms of infection can be delayed as a result (Edmonds et al, 2008).

after 20 to 40 seconds of being dependent, it will return to dusky pink due to reactive hyperaemia.

This might suggest severe PAD (Norgren et al, 2007). Erythema related to infection will generally be sustained in the elevated position, but it’s important to note that infection and ischaemia can coexist (Edmonds et al, 2008), so the results of this test should be considered carefully alongside other observations before a diagnosis is reached.

Blue toe syndrome. This is characterised by the sudden onset of painful cyanotic or black toe in the presence of palpable pedal pulses, which can often lead clinicians away from suspecting underlying vascular pathology (Poredos, 2004). The most common cause of blue toe syndrome is atheroembolic disease or an aneurysm where a small fragment of atherosclerotic plaque has broken off and occluded the small vessels supplying blood to the toe. It can even be caused by anticoagulant or thrombolytic treatment (Caldwell and Marrochello, 1996).

Urgent vascular investigation to determine the cause and potential location of ulcerated atherothrombotic plaque, along with pain management, is crucial (Poredos, 2004). It is important to be aware of such presentations, which might convince you of either underlying vasospastic disorder (deterring further investigation) or CLI when another type of vascular pathology is actually occurring.

Septic vasculitis. This presents with cyanosed/pre-necrotic or necrotic tissue due to an inadequate supply of oxygenated blood, caused by increased metabolic demands of the infection and reduced blood flow to the skin (Edmonds et al, 2008).

The septic vasculitis response can occur in ischaemic or nonischaemic feet. But in the former case it’s also important to consider that the changes displayed can

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FIGURE 3

SEPSIS SCREENING TOOL COMMUNITY NURSING

01

AGE 12+

START THIS CHART IF THE PATIENT LOOKS UNWELL OR HAS ABNORMAL PHYSIOLOGY

RISK FACTORS FOR SEPSIS INCLUDE:

Age > 75 Impaired immunity (e.g. diabetes, steroids, chemotherapy) YES

COULD THIS BE DUE TO AN INFECTION?

NO

LIKELY SOURCE:

Respiratory Brain

03

Urine Surgical

Skin / joint / wound Other

ANY RED FLAG PRESENT?

YES

KďũĞĐƟǀĞ ĞǀŝĚĞŶĐĞ ŽĨ ŶĞǁ Žƌ ĂůƚĞƌĞĚ ŵĞŶƚĂů ƐƚĂƚĞ Systolic BP ч ϵϬ ŵŵ,Ő ;Žƌ ĚƌŽƉ ŽĨ хϰϬ ĨƌŽŵ ŶŽƌŵĂůͿ ,ĞĂƌƚ ƌĂƚĞ ш ϭϯϬ ƉĞƌ ŵŝŶƵƚĞ ZĞƐƉŝƌĂƚŽƌLJ ƌĂƚĞ ш Ϯϱ ƉĞƌ ŵŝŶƵƚĞ Needs OϮ to keep SpOϮ ш ϵϮй ;ϴϴй ŝŶ KW Ϳ EŽŶͲďůĂŶĐŚŝŶŐ ƌĂƐŚ ͬ ŵŽƩůĞĚ ͬ ĂƐŚĞŶ ͬ ĐLJĂŶŽƟĐ Recent chemotherapy EŽƚ ƉĂƐƐĞĚ ƵƌŝŶĞ ŝŶ ϭϴ ŚŽƵƌƐ ;фϬ͘ϱŵůͬŬŐͬŚƌ ŝĨ ĐĂƚŚĞƚĞƌŝƐĞĚͿ

04

ANY AMBER FLAG PRESENT?

RED FLAG YES

SEPSIS

START BUNDLE

NO

IF UNDER 17 & IMMUNITY IMPAIRED TREAT AS RED FLAG SEPSIS

ZĞůĂƟǀĞƐ ĐŽŶĐĞƌŶĞĚ ĂďŽƵƚ ŵĞŶƚĂů ƐƚĂƚƵƐ ĐƵƚĞ ĚĞƚĞƌŝŽƌĂƟŽŶ ŝŶ ĨƵŶĐƟŽŶĂů ĂďŝůŝƚLJ Immunosuppressed dƌĂƵŵĂ ͬ ƐƵƌŐĞƌLJ ͬ ƉƌŽĐĞĚƵƌĞ ŝŶ ůĂƐƚ ϴ ǁĞĞŬƐ ZĞƐƉŝƌĂƚŽƌLJ ƌĂƚĞ ϮϭͲϮϰ ^LJƐƚŽůŝĐ W ϵϭͲϭϬϬ ŵŵ,Ő ,ĞĂƌƚ ƌĂƚĞ ϵϭͲϭϯϬ Žƌ ŶĞǁ ĚLJƐƌŚLJƚŚŵŝĂ dĞŵƉĞƌĂƚƵƌĞ фϯϲΣ ůŝŶŝĐĂů ƐŝŐŶƐ ŽĨ ǁŽƵŶĚ ŝŶĨĞĐƟŽŶ

Indwelling device

SEPSIS UNLIKELY, CONSIDER OTHER DIAGNOSIS

YES

1 2 3

SAME DAY ASSESSMENT

BY GP/ TEAM LEADER IS URGENT REFERRAL TO HOSPITAL REQUIRED? AGREE AND DOCUMENT ONGOING MANAGEMENT PLAN (INCLUDING OBSERVATION FREQUENCY AND PLANNED SECOND REVIEW )

NO AMBER FLAGS = ROUTINE CARE / CONSIDER OTHER DIAGNOSIS

COMMUNITY NURSING RED FLAG BUNDLE: THIS IS TIME-CRITICAL – IMMEDIATE ACTION REQUIRED:

DIAL 999 AND ARRANGE BLUE LIGHT TRANSFER

COMMUNICATION: Ensure communication of ‘Red Flag Sepsis’ to crew. Advise crew to pre-alert as ‘Red Flag Sepsis’. Where possible a written handover is recommended including observations and antibiotic allergies.

The sepsis screening tool developed by the Sepsis Trust. The tick-box assessment then directs the intervention. (Reproduced courtesy of the UK Sepsis Trust, 2020.)

02

Recent trauma / surgery / invasive procedure Indwelling lines / IVDU / broken skin

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by wound extent and ischaemia, leading to amputation (Conte et al, 2019; Edmonds et al, 2008).

See Table 5 on page 8 for the key manifestations of mild, moderate and severe infection according to the Infectious Diseases Society of America (IDSA) guideline for the diagnosis of diabetic foot infections referred to in the WIfI classification (Lipsky et al, 2012).

be attributed to a combination of worsening ischaemia and infection, indicating an urgent referral to the vascular surgery team. Septic vasculitis affects the small vessels that supply the skin.

The walls of these arteries are flooded by polymorphonuclear leucocytes, which leads to the occlusion of the vessel lumen by septic thrombus (Edmonds et al, 2008). Think of this as an overactivation of the body’s immune response to a severe infection – similar to sepsis, but on a more local scale.

QUICK TIP Download the free NEWS2 app for a calculator to support you with this assessment on the App Store.

Severe foot infection and sepsis Not all infections progress to sepsis, but all infections have the potential to progress to sepsis. Wound infections, particularly in people who are immunosuppressed, have the

Foot infection assessment Infection can cause irreparable damage to the lower limb and is often the main factor, heightened

TABLE 6

The NEWS scoring system Score

Physiological parameter

3

2

1

0

9-11

12-20 ≥96

Respiration rate (per minute)

≤8

Sp02 Scale 1 (%)

≤91

92-93

94-95

Sp02 Scale 2 (%)

≤83

84-85

86-87

Systolic blood pressure (mmHg)

≤90

91-100

Pulse (per minute) ≤40

3

21-24

≥25

Air 101-110

111-219

41-50

51-90

≥220 91-110

111-130

Alert

Consciousness Temperature (oC)

2

88-92 93-94 95-96 ≥97 ≥93 on air on oxygen on oxygen on oxygen

Oxygen

Air or oxygen?

1

≤35

35.1-36

36.1-38

≥131 CVPU

38.1-39

≥39

NEWS thresholds and triggers NEWS score

Clinical risk

Response

Aggregate score 0-4

Low

Ward-based resonse

Red score – Score of 3 in any individual parameter

Low-medium

Urgent ward-based response*

Aggregate score 5-6

Medium

Key threshold for urgent response*

Aggregate score 7 or more

High

Urgent or emergency response**

* Response by a clinician or team with competence in the assessment and treatment of acutely ill patients and in recognising when the escalation of care to a critical care team is appropriate. ** The response team must also include staff with critical care skills, including airway management.

potential to progress quickly to sepsis. This is a life-threatening condition of physiologic, pathologic and biochemical abnormalities that arise when the body’s response to infection results in the injury of its own tissues (Singer et al, 2016).

Sepsis is predominantly secondary to bacterial infections and can be caused by grampositive bacteria including the staphylococci and streptococci commonly found in infected foot wounds (Daniels et al, 2020). It can be identified with fever-like symptoms: temperature >37.5˚C or <36˚C; pulse rate >100bpm; and respiratory rate >20 breaths per minute (Bates et al, 2020).

Septic shock is a sub-element of sepsis whereby profound cellular, metabolic and circulatory abnormalities are correlated with a greater risk of death than with sepsis alone (Singer et al, 2016). See Figure 3 on page 9 for the UK Sepsis Trust’s screening tool (2020).

The National Early Warning Score (NEWS2) system Podiatrists need to be aware of the NEWS2 parameters when assessing and managing a wound infection, particularly if systemic inflammatory response syndrome is suspected.

The NEWS2 system allocates a score to six physiological measurements, reflecting how much each varies from the norm (see Table 6). The higher the cumulative score, the more urgent the required response (Royal College of Physicians, 2017).

Sepsis is a time-critical condition, so early screening, recognition and efficient management decreases morbidity and mortality rates (Dellinger et al, 2013).

An aggregate score of seven or more indicates a medical emergency and can indicate red-flag sepsis (Royal College of Physicians, 2017).

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CASE STUDY 1 This case illustrates the catastrophic impact that diabetic foot infection, coupled with some unforeseen complications, can have on the body. It also gives some insight into the overwhelming impact of Covid-19 on patients such as this one, who probably have substantial existing damage to their endothelial cells, predisposing them to more severe virus-related complications (Ackermann et al, 2020).

Presentation A 45-year-old gentleman presented to A&E two weeks into a nationwide lockdown. Brought in by his father, he had extensive diabetic ulceration to the plantar aspect of his foot. He had a painful leg, his speech was slurred and he reported feeling generally unwell.

His medical history included type 2 diabetes for more than a decade, obesity, asthma, alcohol dependence, hypertension, hyponatraemia (2011), closed fracture of the left humerus (2019), haematemesis (2012), balanitis xerotica obliterans, alcohol withdrawal seizure (2018) and amputation of the left third toe due to gangrene (2019). He also had a penicillin allergy.

Medication included salbutamol, ramipril 2.5mg, gliclazide 40mg, carvedilol 12.5mg, thiamine 50mg, omeprazole 20mg, spironolactone 100mg and metformin 500mg.

He used to consume 40 units of alcohol per week but maintained that he had stopped drinking in October 2019 after his previous admission for severe diabetic foot infection and sepsis. He had never been a smoker.

His HbA1c level was 66mmol/ mol, but before he achieved sobriety he’d had a long history of poorly controlled diabetes.

Examination The left foot and leg were warm and swollen. There was extensive

Figure 1: Case study 1, plantar left foot presentation upon admission to hospital

spreading cellulitis, with minimal exudate from the site. A wound extended from the left first toe toward the first metatarsal, which was visible. There was another wound to the plantar arch. Both wounds were hypergranulated, showing no sign of necrosis. Pedal pulses were palpable, strong and biphasic. Popliteal pulses were also palpable. ABPI was not possible to obtain, due to the pain in his leg from infection. Toe pressures were not possible to obtain either, due to the location of the wounds.

An arterial duplex scan showed patent vessels throughout, with biphasic waveforms. He reported no symptoms of intermittent claudication or ischaemic rest pain. Severe peripheral neuropathy extended to the knee. The attending consultant queried whether the patient’s slurred speech and general demeanour might relate to a lapse in his sobriety, but the patient denied this. Blood cultures showed MRSA bacteraemia. Patient also had acute kidney injury as a result of the infection. X-rays showed acute diffuse osteomyelitis throughout the mid-foot.

His WIfI classification was stage 4, meaning a high risk of

Figure 2: Case study 1, dorsalis left foot presentation upon admission to hospital

amputation at one year (a wound score of 3; unable to determine ischaemia score; and a foot infection score of 3).

Treatment

QUICK TIP Duplex imaging is a non-invasive test that can investigate the flow of blood through arteries and veins. The arterial duplex scan uses ultrasound to create a colour map of the arteries and identify areas of stenosis or occlusive disease within them.

IV teicoplanin was started and the patient underwent orthopaedic surgical debridement and excision of the first metatarsal head. The sepsis worsened, with the onset of rigors and confusion and a C-reactive protein (CRP) level of 210 (0–10 normal), which fluctuated minimally over a week. He was reviewed by the consultant microbiologist as per the 2015 antimicrobial stewardship guidance and his antibiotics were changed to linezolid, clindamycin and ceftazidime.

Several days later, his foot filled with pus and he developed a grossly swollen left arm, which proved to be a secondary infection at his old humerus fracture site. A bestinterests meeting was held with his family to discuss amputation of his leg to save his life. The orthopaedics team performed an incision and drainage of his foot and his arm.

The patient’s foot improved significantly, but he developed a J U LY/AU G U ST 2 0 2 1 T H E P O D I AT R I ST

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cough shortly afterwards. He died of sepsis from Covid-19 and MRSA bacteraemia two days later.

Discussion This patient presented with foot infection involving bone and subcutaneous tissue with erythema (>2cm), coupled with the signs of systemic inflammatory response syndrome. This could be categorised as a severe diabetic foot infection as per the IDSA guideline’s scoring system, which helped us to determine that inpatient management was required. Our usual assessment of arterial circulation using ABPI and toe pressures was not possible, which can be true of many serious presentations, so it became vital for us to consider every other piece of information available to make a pragmatic clinical judgement.

The patient had several cardiovascular disease risk factors, including hypertension and diabetes, which was mostly uncontrolled. He was overweight and had abused alcohol for much of his life, so PAD was certainly possible even though he was relatively young. But his arterial duplex scan was reassuring and the lack of necrosis or ischaemic rest pain gave us confidence that there was no suggestion of CLI. This factor was considered carefully, alongside our findings of strongly palpable and biphasic foot/ popliteal pulses and his history of necrosis in the left third toe, which had occurred through a similar set of circumstances six months previously. Could this indicate small vessel disease? Given his significant history of peripheral neuropathy and strong palpable pulses, it was possible that the previous necrosis had been caused by an occlusion of the vessel lumen due to a septic thrombus otherwise known as a septic arteritis of the digital arteries (Edmonds et al, 2008). A necrotic toe in a neuropathic, well-perfused foot could therefore be easily mistaken for small vessel disease.

Figure 3: Case study 1, plantar left foot post-surgical debridement

Referring to the Foot in Diabetes UK guidance on the prevention of lower-limb amputation during the Covid-19 situation (see Figure 1 on page 6), we could see that the patient had a limb-threatening infection and sepsis but that the situation was not acutely limb- or life-threatening with ischaemia, so we didn’t call upon the vascular surgical team. The decision on whether to involve the team or not was reviewed at every opportunity to ensure rapid escalation if needed.

But in this case we did not have vascular surgery provision at our spoke site and the patient would not have been medically fit to transfer to the hub if necrosis had developed.

Under the WIfI classification system, his classification was stage 4 (high risk for amputation at one year) by wound and infection alone, irrespective of the arterial status. This was certainly a true representation of the prognosis we had suspected clinically. Note that a WIfI grade 3 infection will always produce a moderate to high risk of amputation, irrespective of the grade of wound or ischaemia – and this is validated by the IDSA guideline.

Figure 4: Case study 1, dorsalis left foot post-incision drainage

Conclusion Using WIfI for this case did not reveal an unexpected prognosis, but nonetheless it is a useful tool for keeping the key three factors at the forefront of your mind when determining the severity of the disease, how quickly you need to take certain measures and whom you need to involve in the patient’s care. There will be times when the limb presentation is chronic and WIfI classification might help you to recognise the significance of your findings a little better. It might also support you in imparting risk and therefore engaging your patient in their care more effectively.

Was there CLTI? Based on our clinical findings, we think not. Given that there was no clear sign of PAD and the previous necrosis could be explained by septic thrombus, there was not enough evidence to convince us that PAD was influencing this wound.

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CASE STUDY 2 This case involves one of the many patients we have met in recent months who delayed using health services during the pandemic. It shows the impact of uncontrolled infection in the presence of underlying PAD.

Presentation A 73-year-old gentleman presented to A&E with sepsis after concealing his foot problem for many weeks in a bid to avoid contracting Covid-19.

He arrived reporting extreme pain in his right foot.

His medical history included type 2 diabetes, atrial fibrillation, chronic obstructive pulmonary disease, right CLI (2019), stents in the right distal posterior tibial artery and anterior tibial artery (2019) and partial amputation of the right foot (2019).

His medication included rivaroxaban 20mg, ramipril 10mg, aspirin 75mg and atorvastatin 20mg. He was an ex-smoker who had smoked 25 cigarettes a day for five decades. He had no recent HbA1c reading, but his blood glucose level was historically poorly controlled.

His foot had healed from the previous episode and he was a good attender of podiatry services as part of his foot protection plan.

His latest arterial examination had shown that the right dorsalis pedis had a monophasic pulse, as did that of the right posterior tibial artery. The left dorsalis pedis and posterior tibial pulses were both biphasic. His vessels were incompressible prior to revascularisation in 2019.

on admission showed acute osteomyelitis of the right first toe.

The HRFT podiatrist assessed the man as a hospital inpatient at a vascular spoke site. He had non-palpable pedal pulses. The right popliteal pulse was palpable, as was the right femoral pulse.

Dorsalis pedis and posterior tibial pulses were monophasic and strong on Doppler. Dorsalis pedis was 170mmHg and posterior tibial was 110mmHg. ABPI was suspected to be falsely elevated and therefore unhelpful, particularly with his history of calcification and incompressible vessels, so this test wasn’t pursued any further.

Due to the location of the wounds, it was impossible to complete toe pressures to further clarify the vascular status. His foot was heavily infected, with several sites of spreading wet gangrene.

There was an offensive odour and significant pain. It was not possible to separate rest pain symptoms from infection pain, as the patient was in considerable distress and struggled to articulate his symptoms. He seemed to gain no respite from the pain when hanging his leg down beside his bed. He was

diagnosed with a CLI, complicated with severe diabetic foot infection.

His WIfI classification was stage 4, meaning a high risk of amputation at one year (a wound score of 3; unable to determine ischaemia score; and a foot infection score of 3).

There was no suspicion of a Covid-19 infection at this stage.

A duplex scan was arranged and the case was promptly discussed with the on-call vascular registrar at the hub. Clinical photography was also shared with the vascular hub, which agreed to accept the patient pending his Covid-19 test result.

The duplex and CT angiogram at the spoke site confirmed poor blood flow distal to the right posterior tibial stent, but flow was seen through the anterior tibial stent.

Staphylococcus aureus bacteraemia was confirmed.

Treatment Intravenous flucloxacillin, which had been started on admission,

Examination Secondary care referred the patient immediately to the high-risk foot team, which assessed him within 24 hours. A random blood glucose reading of 27.8mmol/L was taken on admission. His CRP was 143.

His estimated glomerular filtration rate was 66.2 and declining. X-rays

Figure 5: Case study 2, right foot on admission

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was maintained after the above blood-culture findings.

The man was still an inpatient at the spoke site three days later when a urine sample of his tested positive for carbapenemase-producing enterobacteriaceae (CPE). He had to be isolated immediately and barrier-nursed as a result. His Covid-19 swab returned negative, but his transfer to the hub was halted until a side room could be located, as a result of the positive CPE test. His CRP had reduced to 101, his random blood glucose level was down to 12.9mmol/L and he was being swabbed for Covid-19 every two days.

Four days later, the patient was found to be cold and coughing.

His foot condition had worsened, with wet gangrene continuing to spread. The consensus of the multidisciplinary team members was that urgent amputation would be required to save his life. They held a discussion with orthopaedics at the spoke site to start talks between their department and the vascular hub about the feasibility of amputation under orthopaedics instead of vascular, given the patient’s life-threatening condition.

During these discussions, the patient was moved to a Covidpositive ward at the spoke site.

He was given continuous positive airway pressure and treatment for Covid-19 sepsis, but died two days later.

Figure 7: Case study 2, right foot on admission

in more advanced investigations.

In the presence of spreading gangrene and monophasic pedal pulses, CLI was diagnosed.

According to the Foot in Diabetes UK guidance on the prevention of lower-limb amputation during the Covid-19 situation (see Figure 1 on page 6), the patient had a limbthreatening infection and sepsis with a critically ischaemic limb, so discussion with a vascular surgeon was paramount.

Before the pandemic, we would aim for an inpatient transfer to

Figure 8: Case study 2, right foot on admission

the vascular hub within 24 hours if the patient was medically stable with this presentation. Again, we used the WIfI system despite the absence of a reliable ABPI or toe pressure, because the wound and infection gradings alone equated to a stage 4 classification (high risk for amputation at one year). It seemed clear from the initial presentation that the limb was likely to be unsalvageable given the extent of the gangrene and the proximal location of the ankle necrosis.

Discussion This patient presented with severe diabetic foot infection and sepsis as per the IDSA guideline score. As with the previous case study, the usual arterial investigations, ABPI and toe pressures were precluded by vessel-wall calcification and the location of the wounds. The patient had significant cardiovascular disease risk factors, including poorly controlled diabetes. He’d had a previous revascularised critical ischaemia to the same limb, so the expectation was that occlusive disease would be detected

Conclusion This was not a difficult case in decision-making terms. The need for vascular consultation was clear from the first sight of the patient’s limb. In many cases out in the community, ischaemic limbs can be misdiagnosed as cellulitis – sometimes the presence of a black eschar at the tip of a

toe might be overlooked and ischaemic rest pain in the foot even misdiagnosed as arthritis.

Ischaemia aside, it is paramount to monitor the trajectory of infection in such situations. Elevated inflammatory and infection markers including CRP,

neutrophil and white-cell counts are valuable in gauging the severity of infection and judging the clinical response to antibiotics (Edmonds et al, 2008). The usual steps of vascular surgery consultation and planning a limb-salvage procedure become secondary to removing the focal point

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Covid-19 had a significant impact on this patient’s access to urgent vascular care. There were delays because of the need to establish his Covid status before transfer to prevent the spread of the virus to a ‘clean ward’ at the receiving hospital – a crucial measure for the safety of other vulnerable patients, particularly those on a vascular ward. It was further complicated by the positive CPE sample. This bacterium is particularly dangerous because it resists some antibiotics and is sophisticated in its ability to pass on its resistance to other bacteria. It is therefore vital to isolate contaminated patients and apply rigorous hygiene standards to prevent contagion.

It might have been possible to save the patient’s life, albeit with a major amputation, had this episode occurred before the pandemic, but we can appreciate that many unavoidable factors delayed his care because of this unprecedented situation. He was at extremely high risk of developing serious complications in the event of contracting Covid-19, due to his cardiovascular history and poorly controlled diabetes. Because this episode occurred at the height of the first wave of infections, he could easily have contracted the virus at the spoke or, had he eventually been transferred, at the hub.

CASE STUDY CHALLENGE The following case study is for you to work through and answer the questions. Answers will be provided at the end of the paper.

Presentation A 60-year-old gentleman is admitted to hospital with severe diabetic foot infection at the left fifth lateral metatarsophalangeal joint (MTPJ) and suspected sepsis. He reports that he was following advice to walk more in order to improve his arterial circulation and had been successfully increasing his overall walking distance until he wore unsuitable footwear on one occasion, which caused a blister. This de-roofed three days later, resulting in an ulceration that had developed an infection.

The man had been self-caring for this, because he was concerned about contracting Covid-19, and had not sought any podiatric or medical attention until his admission.

His medical history includes type 2 diabetes (HbA1c at 80 mmol/mol in past three months), former smoker (stopped six months ago), hypertension (baseline blood pressure 160/95), chronic kidney disease (stage 2), peripheral sensory neuropathy and PAD with known mild, calcified distal vessel disease.

This man is known to the vascular surgery team. He was seen 12 months before this admission with a history of exercise-induced pain in his left calf. He had reproducible symptoms at a walking distance of about 250m, which was relieved by two minutes’ rest. He was on best medical therapy for his PAD, including atorvastatin 80mg and clopidogrel 75mg in addition to attending the smoking-cessation service.

He was following advice to exercise for 30 minutes three to four times a week to help strengthen his collateral blood supply.

Examination of infection and trying to save the patient’s life. That was not possible in this case, sadly, but it demonstrates how important it is for all multidisciplinary team members to be kept apprised of a severely infected patient’s condition so that they can make crucial changes to the management plan without delay.

The left fifth lateral MTPJ ulcer measures 4cm × 3cm and probes 2cm to bone. The

wound is undermined towards the left fifth proximal phalanx. There is 100% sloughy adherent tissue to the wound bed, with an excessive amount of purulent discharge. There is tracking cellulitis >5cm from the wound with crepitus to the dorsal mid-foot. The left fifth toe is cyanosed and non-blanching.

The patient, who is usually alert with no cognitive impairment, is drowsy and confused. His pulse rate is 110bpm, oxygen saturation is 92%, blood pressure is 110/60, and respiration rate is 20 breaths per minute. He does not have a new, continuous cough, but does have a high temperature (38.2°C). He has been swabbed for Covid-19.

Investigation An X-ray confirms acute osteomyelitis to the left fifth MTPJ and left fifth proximal phalanx. He is referred for an urgent MRI scan to investigate for an abscess or deep collection.

His CRP count is 220. His white-cell count is 20 (>10 is abnormal) and his neutrophil count is 12 (>8 is abnormal).

His estimated glomerular filtration rate is 30 (<60 is abnormal), indicating acute kidney injury stage 1.

Non-invasive clinical lower-limb arterial assessment conducted as per the 2012 NICE guideline produces the following results (see Table 7).

There is evidence of oedema in the left foot and leg. The patient reports no symptoms of ischaemic rest pain.

Treatment The patient is given intravenous flucloxacillin and gentamicin, as per microbiology advice. He is also reviewed by the diabetes foot multidisciplinary team, including the high-risk foot team’s podiatrist, within 24 hours of admission, as per the 2015 NICE guideline.

TABLE 7

Left

Right

Femoral

Palpable

Palpable

Popliteal

Non-palpable/monophasic

Palpable/biphasic

Posterior tibial

Non-palpable/monophasic

Palpable/biphasic

Dorsalis pedis

Non-palpable/monophasic

Palpable/biphasic

Incompressible

Incompressible

ABPI Toe brachial pressure index (TBPI) Toe pressure

0.45

0.70

50mmHg

70mmHg

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CPD questions 1. Does this patient have a CLTI? 2. Does he have a CLI? 3. Given the clinical presentation, what are the possible causes for a cyanotic toe?

4. Calculate the WIfI classification score for this patient and deduce the risk for major amputation at 12 months.

5. Using the National Early Warning Score, calculate a score for this patient and detail what response this would trigger. Refer to the UK Sepsis Trust screening tool and outline what action you might take if you were assessing this patient in the community.

6. In your opinion, does this patient require a referral to the vascular surgery team as a priority?

7. Using the guidance from Foot in Diabetes UK on the prevention of lower-limb amputation during the Covid-19 situation, what is the appropriate pathway for this patient?

8. Does he have any risk factors for developing serious Covid-19 complications if he contracts the virus?

Answers 1. Yes, there is evidence of CLTI, characterised by three factors: • PAD, which is confirmed by a TBPI of 0.45 (<0.64 is indicative of PAD) and a toe pressure of 50mmHg in addition to monophasic sounds. The patient also has incompressible vessels, which suggest

calcification associated with vessel-wall hardening due to diabetes and a history of intermittent claudication. • Diabetic foot ulceration. • Severe foot infection.

2. No, his presentation does not meet the parameters of a CLI at this time. There is no ischaemic rest pain, the toe systolic pressure is not <30mmHg and there is no evidence of gangrene.

3. Pre-necrosis related to a developing CLI, septic vasculitis/embolus or blue toe syndrome.

4. A wound score of 3, an ischaemia score of 1 and a foot infection score of 3 equate to clinical stage 4: a high risk of amputation at one year.

5. The patient’s NEWS2 score is 8 (2 for oxygen saturation, 1 for pulse rate, 1 for systolic blood pressure, 0 for respiratory rate, 3 for confusion and 1 for temperature). This score indicates that the patient needs an urgent or emergency response. Using the UK Sepsis Trust’s screening tool produces a finding of red-flag sepsis, which indicates that the patient would need to go to hospital in an ambulance if identified in the community.

6. Yes, this case requires urgent discussion with the vascular registrar on call and the patient’s urgent transfer to a hospital with a vascular team on site.

7. The pathway entitled ‘Limb-threatening infection or sepsis’.

8. Yes. They are poorly controlled type 2 diabetes and cardiovascular disease risk factors including chronic kidney disease, hypertension and PAD.

Further resources You can refer to the guidance published jointly by the Vascular Society and GIRFT in October 2020 on the resumption of less urgent/elective vascular and endovascular surgery. This document discusses the response, prioritisation and timelines for differing levels of vascular disease, including PAD and CLI, during the Covid-19 pandemic.

The prioritisation table below is taken from the guidance. It is important that podiatrists are aware of this table, as it has lower-limb examples in each priority, which we have highlighted here.

Priority 1a

Emergency operation needed within 24 hours: • Vascular injury/occlusion (including compartment syndrome, mesenteric occlusion and arteriovenous fistula) • Uncontrolled external haemorrhage from any source • Ruptured abdominal aortic aneurysm (AAA) • Surgical revascularisation (embolectomy/bypass) • Interventional radiology thrombolysis for acute ischaemia • Septic/diabetic foot

Priority 1b

Urgent operation needed within 72 hours: • Acute-on-chronic limb ischaemia • Surgical revascularisation (embolectomy/bypass) • Symptomatic carotid disease • Amputation for limb ischaemia • DVT thrombolysis for phlegmasia or end-stage failure (renal/hepatic)

Priority 2

Surgery that can be deferred for up to four weeks: • Chronic severe limb ischaemia, no neurology • Some larger AAAs • Ongoing diabetic foot surgery

Priority 3

Surgery that can sometimes be delayed for up to three months: • AAA >5.5cm (ideally within eight weeks) • Vascular access surgery

Priority 4

Surgery that can usually be delayed for more than three months: • Vein surgery • Arteriovenous malformations without complications • Thoracic outlet syndrome • Claudication

Key messages Think CLTI. We need to start embedding the term into our clinical practice when describing a limb with PAD of any severity with a non-healing leg or foot ulcer of more than two weeks’ duration.

Think WIfI. This is a universal clinical evaluation tool that can be used to classify the severity of wound, ischaemia and foot infection from mild to severe.

Classifications are linked directly to amputation risk at 12 months and the likely benefits/requirements of revascularisation. It can be used to

negotiate the urgency of access to vascular surgery teams.

Clinical skills. Clinicians using the WIfI system need to be both competent and confident in assessing the three factors it covers.

Resources. Refer to Foot in Diabetes UK’s guidance (Covid-19 situation pathway v1.3) and embed it into your clinical practice to help guide your decision-making and ensure appropriate, timely onward referral in the lower-limb multidisciplinary team.

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Bates M, Edmonds V, Kavarthapu C et al. (2020) Diabetes foot care in the Covid-19 pandemic. King’s College Hospital NHS Foundation Trust, London. See: bit.ly/Bates-diabetes-foot-care (accessed 8 June 2021).

Behan S, Kwon E, Reyzelman A. (2017) A closer look at the WIfI classification system for threatened limbs. Podiatry Today 30(5): 14-8.

Black J, Bailey C, Przewrocka J, Dijkstra K, Swanton C. (2020) Covid-19: the case for healthcare worker screening to prevent hospital transmission.

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Brownrigg J, Schaper N, Hinchliff R. (2015) Diagnosis and assessment of peripheral arterial disease in the diabetic foot. Diabetic Medicine 32(6): 738-47.

Caldwell B, Marrochello V. (1996) Microembolization from atheroembolic disease or aneurysm – a case study.

Journal of the American Podiatric Medical Association 86(6): 249-52.

Conte M, Bradbury A, Kolh P et al. (2019) Global vascular guidelines on the management of chronic limb-threatening ischemia.

European Journal of Vascular and Endovascular Surgery 69(6S): 3-125.

Daniels R, Nutbeam T, Berry E. (2020) Sepsis in adults.

BMJ Best Practice. See: bit. ly/sepsis-in-adults (accessed 8 June 2021).

Dellinger R, Levy M, Rhodes A et al. (2013) Surviving sepsis campaign: international guidelines for management of severe sepsis and septic shock: 2012. Critical Care Medicine 41(2): 580-637.

Edmonds M, Foster A, Sanders L. (2008) A practical manual of diabetic foot care (second edition). Blackwell Publishing: Oxford.

Foot in Diabetes UK. (2020) Covid-19 situation v1.3: lower limb amputation prevention guidance. See: diabetestimes. co.uk (accessed 19 May 2021).

Galván Casas C, Català A, Carretero Hernández G et al.

(2020) Classification of the cutaneous manifestations of Covid-19: a rapid prospective nationwide consensus study in Spain with 375 cases.

British Journal of Dermatology 183(1): 71-7.

Getting It Right First Time (GIRFT), Vascular Society.

(2020) Covid-19 response: guidance on resumption of vascular surgery. See: bit.ly/ GIRFT-resumption (accessed 19 May 2021).

Lipsky B, Berendt A, Cornia P et al. (2012) 2012 Infectious Diseases Society of America clinical practice guideline for the diagnosis and treatment of diabetic foot infections.

Clinical Infectious Diseases 54(12): e132-73.

Matthews S, Smith P, Ainarkar S, Jones L. (2019) The podiatric approach to improving awareness and management of peripheral arterial disease.

Podiatry Now 22(4) CPD supplement: 1-15.

Mehra M, Desai S, Kuy S, Henry T, Patel A. (2020) Cardiovascular disease, drug therapy, and mortality in Covid-19. The New England Journal of Medicine 382(25): e102.

Mills J, Conte M, Armstrong D et al. (2014) The Society for Vascular Surgery lower extremity threatened limb classification system: risk stratification based on wound, ischemia, and foot infection (WIfI). Journal of Vascular Surgery 59(1): 220-34.

disease. Podiatry Today 20(4): 54-65.

UK Sepsis Trust. (2020) Community nursing sepsis screening and action tool.

See: bit.ly/sepsis-red-flag (accessed 17 May 2021).

NICE. (2015) Diabetic foot problems: prevention and management: NICE guideline NG19. See: nice.org.uk/ guidance/ng19 (accessed 17 May 2021).

van Haelst S, Koopman C, den Ruiter H et al. (2018) Cardiovascular and all-cause mortality in patients with intermittent claudication and critical limb ischaemia.

British Journal of Surgery 105(3): 252-61.

NICE. (2012) Peripheral arterial disease diagnosis and management: NICE clinical guideline CG147. See: nice.org. uk/guidance/cg147 (accessed 17 May 2021).

Varga Z, Flammer A, Steiger P et al. (2020) Endothelial cell infection and endotheliitis in Covid-19. The Lancet 395(10234): 1417-8.

Norgren L, Hiatt W, Dormandy J et al. (2007) Inter-society consensus for the management of peripheral arterial disease (TASC II). Journal of Endovascular Surgery 33: s5-75.

Poredos P. (2004). Blue toe syndrome. E-Journal of Cardiology Practice 2(18).

See: bit.ly/Poredos-blue-toe (accessed 17 May 2021).

Royal College of Physicians.

(2017) National Early Warning Score (NEWS)2: standardising the assessment of acute-illness severity in the NHS. See: bit.ly/RCP-NEWS2-standardising (accessed 19 May 2021).

Sigvant B, Lundin F, Wahlberg E. (2016) The risk of disease progression in peripheral arterial disease is higher than expected: a meta-analysis of mortality and disease progression in peripheral arterial disease. European Journal of Vascular and Endovascular Surgery 51(3): 395-403.

Singer M, Deutschman C, Seymour C et al. (2016) The third international consensus definitions for sepsis and septic shock. Journal of the American Medical Association 315(8): 801-10.

Suzuki K. (2007) How to diagnose peripheral arterial

World Union of Wound Healing Societies. (2008) Wound infection in clinical practice: an international consensus.

Medical Education Partnership: London. See: bit.ly/Woundinfection-clinical-practice (accessed 17 May 2021).

Zhang J, Dong X, Cao Y et al.

(2020) Clinical characteristics of 140 patients infected with Sars-CoV-2 in Wuhan, China.

Allergy 75(7): 1730-41.

Zhu L, Gang-She Z, Cheng X et al. (2020) Association of blood glucose control and outcomes in patients with Covid-19 and pre-existing type 2 diabetes.

Cell Metabolism 31(6): 1068-77.

The authors acknowledge the support of Naseer Ahmad, consultant vascular surgeon at Manchester University NHS Foundation Trust and clinical director of the Manchester Amputation Reduction Strategy; and Martin Fox, vascular specialist podiatrist at the Manchester Local Care Organisation’s leg circulation service.

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STUDIES IN PODIATRY THE EVIDENCE 43

C L I N I C A L U P D AT E

Research round-up A closer look at the latest reviews and trials from journals around the globe – with insight from the authors.

or even daily? If you think one should be featured in our round-up, get in touch at editorial@ thepodiatrist.co.uk

Behaviour-change approaches for individuals with diabetes to improve foot self-management: a scoping review

Thermal characteristics of rheumatoid feet in remission: baseline data

PUBLICATION: Journal of Foot and Ankle Research

BACKGROUND: Thermography – the non-contact measurement of cutaneous temperature of the body – has been researched to detect areas of inflammation in rheumatoid arthritis (RA). Results have been contradictory.

BACKGROUND: Diabetes-related foot complications are increasing in complexity, frequency and cost. The application of self-management strategies can reduce the risk of individuals developing foot complications. The type, range and nature of the literature focusing on interventions that support patients with diabetic foot self-management is unknown.

AIMS: To identify risky behaviour avoidance strategies and selfmanagement actions within interventions, map the theoretical functions through which these behaviour-change interventions have an effect, and display gaps in the research.

Image: iStock

Are you a PhD or master’s student looking at new research papers weekly

FINDINGS: A core set of behaviour change activities and intervention functions associated with positive changes in behaviour were identified.

This information will be used to provide researchers with a useful basis for developing self-management interventions.

PUBLICATION: PLOS ONE

RESEARCHERS’ TAKEAWAY: ‘To keep patients foot-ulcer free, it is important to help people with diabetes understand the health benefits of foot self-management, and empower them to look after their own foot health. The findings of the review will provide useful information about how to design and deliver foot self-management interventions that have the best chance of success. This collaborative project brought together the expertise of researchers, academics and clinicians with expertise in the diabetic foot and the psychology of behaviour change.’

Joanne Paton, lead author READ THE FULL STUDY: bit.ly/JFAR-behaviour-change

AIMS: To investigate whether the thermal characteristics of the feet of RA patients, in clinical and radiological remission, differ to those of healthy controls.

WANT TO FEATURE ON THIS PAGE? If you would like your work to be featured here, please prepare an 80- to 100-word summary of your research and its take-home messages and send it to us at editorial@thepodiatrist.co.uk

FINDINGS: The authors set out to compare the thermal characteristics of RA feet in remission with those of healthy adults, setting a baseline measurement. The results followed a similar trend to a previous paper in which RA joints showed higher temperatures than healthy joints, although without inflammation.

RESEARCHERS’ TAKEAWAY: ‘This research is continuing, and we hope to develop a tool that would allow for the rapid screening and detection of inflammation in RA.’ Alfred Gatt, lead author READ THE FULL STUDY: bit.ly/PLOS-thermal-RA J U LY/AU G U ST 2 0 2 1 T H E P O D I AT R I ST

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44 THE EVIDENCE CASE STUDY

AQK exclusively affecting the soles

FIGURE 1

Patient A at presentation while the skin was dry, showing only limited exfoliation

Most instances of aquagenic keratoderma affect the hands as well as the feet; the two cases described here were unusual in that only the plantar surface was involved. a

A

quagenic keratoderma (AQK) is a striking but rare skin disorder, most frequently observed in young adults. It presents as rapid wrinkling of the palms and soles when exposed to water, and may be accompanied by pain or itching. The aetiology is unclear, but associations with specific drug therapies and cystic fibrosis are known to exist. The authors present two unusual cases exclusively affecting the plantar surface (unilaterally and bilaterally).

b

FIGURE 2

Patient A plantar surface immediately after water exposure IVAN BRISTOW has 30 years’ experience in the profession, working as a podiatrist at his Hampshire clinic and an academic

Case presentation Patient A was a 28-year-old male.

His chief concern was being embarrassed by his feet, which he described as becoming ‘soggy’ whenever he got them wet when swimming or bathing. He found it particularly difficult on holiday, after swimming in the pool. He described the condition as beginning in his teenage years, but said it had not really improved or deteriorated since. He had sought help from his doctor but no diagnosis had been made or treatment offered. His general health was excellent. He was a non-smoker with a normal BMI of

PAMELA BAXTER has 18 years’ experience as a podiatrist, working at her clinic in North Tynside

Conflict of interest: none declared

24. He was receiving no medication, and had no history of significant illnesses or family history of disease.

Upon examination, his vascular and neurological status were within normal limits. The plantar skin on both feet showed slight hyperhidrosis; no hyperkeratosis was evident but there was some evidence of previous exfoliation (Figures 1a and 1b). The nails appeared normal and there were no problems with the palms.

There was no evidence of tinea pedis or onychomycosis. The patient provided an image of his feet immediately after showering (Figure 2).

Patient B was a 22-year-old male, who contacted his podiatrist via email during the Covid-19 pandemic, troubled by ‘unusual changes’ on the sole of his right foot only, which occasionally itched.

It was at its worst after showering.

He was fit and well, with no

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CASE STUDY THE EVIDENCE 45

Discussion

significant medical or family history.

His palms were unaffected. Emailed pictures of his foot (Figures 3a, 3b and 3c) showed plantar skin exfoliation and hyperkeratosis. He had been using potassium foot soaks daily for five minutes with little effect.

Following the assessment, a diagnosis of AQK was made for both patients. Treatment initially consisted of basic advice: regular washing and thorough drying of the feet. The patients were advised to use antiperspirants on the soles of their feet, twice daily. At a followup, four weeks later, patient A had noticed an improvement in the problem, but it still was evident after bathing. Following discussion with the patient, he was referred to his GP, recommending a referral to the local dermatology department, with a view to receiving a course of iontophoresis.

Patient B had little response to the antiperspirants and was due to return for a further consultation with his podiatrist after the first lockdown (March to June 2020), with a view to being referred to the dermatology department for further assessment and treatment.

feet (Ertürk-Özdemir et al, 2015) around puberty. Unilateral presentations (Ibusuki et al, 2012; Houle et al, 2010; Khuu et al, 2006) and accompanying symptoms of pruritus and pain have also been recorded (Kim et al, 2015). The condition has been reported both as sporadic and familial cases (Nazik et al, 2016).

The diagnosis of AQK is made purely on clinical grounds. In unaffected subjects, research has shown that immersion in water leads to wrinkling in around 11 minutes (Tsai and Kirkham, 2005); for those affected with AQK, wrinkling typically occurs within three minutes of exposure (Gild et al, 2010).

Upon drying, the condition resolves, normally within an hour. Histologically, skin samples from wrinkled areas have demonstrated hyperkeratosis of the stratum corneum and acantholysis accompanied by dilated sweat ducts (Xia, 2012), visible under dermoscopy (Gualdi et al, 2016; Sezer et al, 2012).

Clinically, the condition should be distinguished from hereditary papulotranslucent acrokeratoderma (HPA). This is a rare autosomal dominant condition characterised by translucent papules and plaques on the hands and feet – typically they occur on the weight-bearing surfaces of the soles and are unaffected by water immersion.

A family history of the condition – which does not change when the

AQK (also known as transient aquagenic hyperwrinkling, transient reactive papulo-translucent acrokeratoderma, and aquagenic syringeal acrokeratoderma) is a rare skin condition. It is characterised by the rapid development of transient, oedematous papules and plaques on the palms of the hands and soles of the feet within minutes of immersion in water.

Involvement of the palms is a significant feature of the condition (Megna et al, 2016; Glatz and Muellegger, 2014; Halsey et al, 2011; Davis and Woody, 2004); we present two cases that exclusively affect the plantar surface: an unusual finding in the literature (Xia, 2012).

AQK was first described in 1996 by English and McCollough, reporting two sisters who developed what they termed ‘transient reactive papulotranslucent acrokeratoderma’, or AQK, exclusively on the palms, which appeared after just three to five minutes’ immersion in water, and resolved quickly after drying (English and McCollough, 1996). The authors describe how the condition was accompanied by the sensation of tightening as the wrinkles developed.

Since then, dozens of cases have been reported in the medical literature.

Predominantly, the condition presents symmetrically, typically on the palms and to a lesser extent on the soles of the

Both patients have given consent for use of their histories and images in this paper.

FIGURE 3

Patient B showing wrinkling of the sole (a), apices of toes (b) and residual wrinkling shortly after drying, with hyperkeratosis (c)

a

b

c

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46 THE EVIDENCE CASE STUDY

foot or hand is immersed in water – is suggestive of HPA over AQK. In addition, HPA is accompanied by fine scalp hair and a predisposition to atopic disease in patients (Onwukwe et al, 1973).

From published research, it would seem that many cases of AQK are associated with hyperhidrosis, Raynaud’s phenomenon, cystic fibrosis (CF) and specific medications (Gualdi, 2016). CF is an autosomal recessive disorder resulting from a mutation in the cystic fibrosis transmembrane regulator gene, leading to impaired transport of chloride across epithelial membranes. Association with the condition was reported around 50 years ago, when it was observed that many children with CF had rapid wrinkling of their palms when these were immersed in water, compared with children without the condition (Elliott, 1974). One study of known CF patients demonstrated that time to wrinkling was around three minutes when compared with known CF carriers (seven minutes), and 11 minutes in those without the gene, although not all CF patients show the condition on water immersion. It has been suggested between 44% and 80% of CF patients have AQK (Kaiser et al, 2018; Tchernev et al, 2014). Consequently, it has been proposed that patients presenting with AQK should be offered screening for both CF (homozygous) and heterozygous carrier state (Gild et al, 2010).

This potential link was discussed with both patients in the current case study, and was communicated to their GPs for follow-up. Although neither patient was taking any medication, drugs that have been associated with AQK include cyclo-oxygenase (COX-2) inhibitors (Akin Belli and Dogan, 2016; Carder and Weston, 2002), paracetamol (Glatz and Muellegger, 2014), spirolactone (Uyar, 2014), indomethacin (Gualdi et al, 2016) and aspirin (Khuu et al, 2006).

The pathophysiology of AQK remains incomplete, although observations and studies have led to the development of hypotheses. It has been shown that patients with CF produce more hypertonic sweat secretions (Okuhira et al, 2015; Mishra et al, 2005), which may cause increased water diffusion into the skin (Seitz et al, 2008) leading to rapid skin wrinkling. However, this cannot

explain the anatomical variance in the condition or unilaterality exhibited by some patients.

Wrinkling of the palms and soles is a natural phenomenon in humans when immersed in water for around 11 minutes or more; however, for those with AQK, this process occurs much more rapidly.

Previous research has shown that wrinkling occurs only in patients with an intact sympathetic nervous system (Bull and Henry, 1977). Patients who are post-sympathectomy or with autonomic neuropathy do not exhibit water-induced wrinkling, strongly suggesting that sympathetic nerve activity is a key element of the pathology.

The palms and soles have a higher density of sweat duct openings and sympathetic nerve terminals than other areas. It has been postulated that AQK represents an exaggerated sympathetic vasoconstriction of the skin. Immersion of the palms and soles leads to the rapid ingress of water into the numerous sweat ducts, altering the electrolyte balance and triggering a rapid vasoconstriction mediated by the sympathetic nervous system. Reduction in blood flow, in part, accounts for the skin whitening observed during immersion. Patients with CF and specific drug therapies may have altered electrolyte constituency in their sweat, potentiating this exaggerated, rapid sympathetic response. In addition, intense activity of the sympathetic nervous system could lead to the reported symptoms of itch and pain experienced by some patients (WilderSmith, 2013).

Treatment of the condition relies on avoidance of the trigger factors, particularly avoidance of

‘Predominantly, the condition presents symmetrically, typically on the palms and to a lesser extent on the soles of the feet around puberty’

Key message The authors present two cases of bilateral AQK, unusually exclusive to the soles of the feet (one unilateral and one bilateral case), occurring in two male patients in otherwise good health. Minimisation of exposure to water, and treatment with antiperspirants and potassium permanganate, offered limited relief of symptoms; however, referral for iontophoresis was sought. Further research is required to offer more effective treatments for patients with AQK.

water immersion. The use of topical antiperspirants for both patients was found to be of limited benefit. Aluminium salts contained in antiperspirants work by acid-base chemistry, precipitating in sweat ducts, creating temporary plugs.

Consequently, sweating is restricted, and ingress of water is limited, reducing the symptoms of the condition. Potassium permanganate foot soaks can be undertaken by patients at home to dry the skin. Recommended guidelines (British Association of Dermatologists, 2015) suggest using four litres of warm water to which a tablet of potassium permanganate is added to make the water light pink.

Vaseline is normally applied to the nails to prevent the solution staining the nails dark brown. The feet are then soaked for 10 to 15 minutes before being dried.

The use of iontophoresis for one of our patients was successful, as reported in a previous case (Errichetti and Piccirillo, 2015). Iontophoresis is a technique whereby the soles are placed into a tray containing tap water, and a small electric current of around 25mA is passed across the tray for around 15 minutes, three times a week.

This technique proved effective for patient A, lasting a few months. Other suggested therapies include antihistamines, topical salicylic acid preparations, topical steroids and botulinum toxin injections (Nazik et al, 2016; Houle et al, 2010). However, evidence on effective management is lacking at present.

References are available to view online: membersarea.cop.org.uk/the-podiatrist

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OFF THE SHELF THE END 47

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48 THE END JUST A MINUTE U UTE

My passion has always been wildlife.

My first degree was in zoology and physiology. I saw myself working for National Parks here in Australia, but it was impossible to get a job, so my dad randomly suggested podiatry. I had a meeting with a doyen of podiatry in Australia, John Pickering, and he was very encouraging.

I was always passionate about sports too. I was probably the first podiatrist in the country to join a multidisciplinary sports medicine clinic. Working with orthopods, orthopedic doctors, physios, sports physicians and sports psychologists, I rapidly got a very good grounding in all things to do with sports medicine – I got lucky!

Images: iStock / Shutterstock

My proudest achievement was producing a shoe with footwear brand Salomon, in France, called the Predict.

New Zealand podiatrist Craig Taylor and I basically generated the idea from the ground up – it was very radical, and very successful.

It did remarkable things in terms of taking load off joints.

I’ve been to four Olympic Games.

In Sydney in 2000, I had an infinity pass, which meant I could go absolutely anywhere.

So when Cathy Freeman won

‘We are in a rapidly evolving field, and clinical treatment protocols change all the time’

60 SECONDS WITH...

Simon Bartold A leading light in podiatry and biomechanics, he has worked with elite athletes, and lectured in 42 countries.

the gold medal in the 400 metres, I was standing on the finish line in the stadium. I was within a metre of her. It was just an incredible privilege.

Bartold Clinical started off as a website called Bartold Biomechanics. When I finished my long career with Asics, I packaged my research up and put it online. Much to my surprise, a lot of people were interested. So it’s now evolved into Bartold Clinical, a much better platform. My business partner, Paul Griffin, is also a podiatrist.

So in addition to discussion papers, we do e-books, webinars, podcasts, and updates every day. I love that we can condense complicated information for podiatrists and physios; they can just get a snapshot of it and bang, they’re off.

It’s essential to keep learning. You can’t grow and develop unless you are absolutely on top of your CPD. We are in a rapidly evolving field, and clinical treatment protocols change all the time.

Podiatry should be the go-to profession for any issue from the knee down. And I think we have the tools available to us. The way podiatry will move forward is by having a better educated cohort of professionals. So if we know more, and we’re better conditioned than anybody else, then podiatry will be elevated.

What motivates me more than anything is live presenting. I love talking at conferences, and seeing people’s lights go on, especially with complex issues. That just gives me a fantastic thrill.

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