Swollen feet, should I be concerned?

As with any medical problem, understanding the cause or diagnosis is the first step to the right treatment. Swelling or to give it the correct medical term Oedema in the feet and ankles can have many causes. I thought I would talk about some of the more common causes.

There are two general categories of oedema seen in the feet. 1. Pitting oedema is as the name suggests, leaves a pit or indentation when the area is pressed with the finger and will be visible for a little time after you have pressed the area.

2. Non pitting oedema, (I think you can see where this is going) when you press the area with your finger it doesn’t leave an indentation.

Pitting oedema is generally caused by fluid, mainly water accumulating in the feet and ankles. Due to the effects of gravity the pitting oedema will be worse as the day progresses. Pitting oedema is commonly caused by poor circulation or the retention of excess fluids. Some common risk factors that may lead to these problems include sitting or standing in one position for too long, low protein levels, obesity, high salt intake, dehydration, heart failure, varicose veins, cirrhosis and pregnancy.  Some medications may also cause oedema in the feet and legs, some blood pressure medications, steroid therapy, hormone therapy, contraceptive pill and even some antidepressants. All of the above causes are exacerbated by warm weather when we push more blood to the skin to try to lose heat. So I definitely see more pitting oedema in the summer here in Spain.

Non pitting oedema, is most often caused by problems with Thyroid, or the lymphatic system, lymph nodes are sometimes removed as part of cancer treatment which can lead to non pitting oedema. Lipedema ( a buildup of fat under the skin ) also causes non pitting oedema.

Generally speaking all of the above are seen in both feet and legs ( bilateral ) with maybe the exception of where varicose veins are particularly bad in one leg, ( pitting oedema ) or a lymph node is taken from just one side of the body ( non pitting oedema). There are some other non-pitting types of oedema which affect a single foot or leg, these would include, sprains and injuries, infection, and even deep vein thrombosis ( known as DVT or blood clot ). Although most oedema is associated with some discomfort,  injury, infection and DVT are usually associated with acute pain, redness of the skin and heat. Untreated oedema can result in foot and leg ulcers.

Treatment, as stated at the beginning understanding the underlying cause is the most important thing often treating the underlying cause will relieve symptoms. With single foot non pitting oedema treating the underlying condition will resolve the issue.  But treating the swelling with pitting oedema ( once the cause is established ) will fall roughly into three categories: Mild cases should resolve on its own by elevating legs and feet, generally above the the backside or level with the heart is even better. Severe cases diuretic tablets to help eliminate excess fluid via urine. Chronic cases compression stockings are required.

Laser scanning feet

Over the last 30 years there have been various ways of capturing an impression of the feet for making insoles and orthotics.

From foot wax impressions, foam boxes to slipper casting in plaster and plaster sock casting. All have their benefits and drawbacks. I have to say that I have always been a fan of slipper casting in plaster as it is a very accurate technique.

The advantages of this technique is that it can produce a neutral or a semi pronated cast, which basically means capturing the foot in the corrected position rather than the position that it is already in. But of course it is not without it’s drawbacks. It is messy dipping plaster bandage in water then holding the foot in the required position and the casts have to dry a bit before they are sent to the laboratory. The technique requires a high degree of practitioner skill not only to get the cast off the foot but also to be accurate. The resulting casts are delicate and require careful handling and packing to prevent  damage or distortion when they are posted to the orthotic laboratory for manufacture. Plaster sock casting is similar but as the name suggest comes up the foot further and is used when making appliances which come above the ankle or knee and has the same advantages and drawbacks.

Wax impressions have largely been superseded due to problems with accuracy but foam boxes are still popular, particularly here in Spain. One of the problems with these is that it is difficult to get the foot into the corrected position and all too often I hear that the pt was just made to stand normally in the foam box when the cast was taken therefore not capturing the ideal position for the foot. The advantage being that they are not messy.

As with most things in life, technology has moved forward and created a better alternative.

Over the last few years 3D laser scanning the foot has become an accurate way to capture a cast or 3D image of the foot. This can be done with the foot standing in the normal position giving great 3D images of the foot showing increased areas of pressure under the foot known as pressure mapping.This enablies better visualization and diagnosis of what is happening under the foot. The feet can also be captured in the corrected position and of course there is no messy plaster all over the clinic.  The 3D image can be digitally sent instantly to the laboratory with the prescription or instructions if you like of, how the podiatrist want the orthotic or insole made. The whole procedure is speeded up by not having to pack and post delicate casts.

One of the problems of producing orthotics in Spain is that people wear sandals and flip flops of a large portion of the year. With this technology patients can buy specific sandals in shoe shops here and the insole or orthotic and be made to replace the existing insole in the sandal. Or can be used to make a flip flop with a custom foot bed.

Philip Mann Podiatrist/Chiropodist Tel 686912307 or www.footpodiatrist.com