In podiatry, the lower limb is broken down into four systems: dermatological, orthopaedic, neurological and vascular. The vascular or circulation system is further broken down into arterial blood flow into the foot; and venous, which is blood flow away from the foot, back to the heart.
Of the four systems, peripheral circulation problems are potentially the most damaging to the foot. Let’s face it, without proper blood flow to the foot, or impaired circulation away from the foot, the tissues of the foot will suffer, and in some cases die (gangrene).
Unfortunately, as we age, our peripheral circulation to our feet becomes impaired. The degree of impairment will vary from person to person, with factors such as: genetics; lifestyle (smoking, poor diet, lack of exercise); and other disease states (diabetes, hypertension); all contributing to a decreased blood flow to and from the foot.
What does an Examination for Peripheral Circulation Entail?
We note the following:
- – ability to feel pulses and their strength
- – colour and texture of the skin
- – hair distribution; loss of hair may signal a loss of circulation to the foot
- – rashes
- – ulcers
- – venous patterns and enlargement
- – edema (swelling)
- – temperature decreases
- – temperature differences between the two feet. In general, one cold foot is suggestive of poor circulation; two cold feet may be indicative of anxiety, neurological issues, or a cold environment.
Poor circulation may present through:
- – A change in a patient’s recent history, which can give us a clue to circulatory impairment. If a patient complains of rest pain, meaning their feet and legs hurt at night, but find that if they put their feet in a dependent position (sitting), or even standing, the pain subsides, that is highly suggestive of circulatory issues.
- – People who complain of walking a few blocks and experiencing calf pain, finding that if they stop and rest, the pain goes away; only to return when they walk about the same distance, is highly indicative of vascular problems.
- – Changes in the colour of the feet when in a dependent position, compared to when the feet are elevated.
- – Sores on the feet that do not seem to heal timely.
- – Feet and ankles that appear normal in the morning, but progressively swell during the course of the day, may be exhibiting poor venous flow. Keep in mind that there are varying degrees of swelling, but not all are indicative of serious disease. However, alternatively, if one foot is constantly swollen, then circulatory compromise has to be ruled out.
- What is Atherosclerosis?
- The most common cause of poor blood flow into the foot is atherosclerosis, or hardening of the arteries. This is a progressive degenerative process, characterised by the deposit of fatty substances inside the wall of the artery, along with a fibrous thickening of it, resulting in a diminished ability of blood to flow down to the foot.
- This condition in most people will go undiagnosed, until the condition becomes symptomatic. When the initial symptoms of intermittent claudication (pain in the calf after walking a short distance, although to a lesser extent the thighs and buttocks) presents, there is already significant disease present. What is essentially happening, (due to blockages in the blood flow to the feet), is a mismatch between the oxygen being supplied to the extremities, and the metabolic demands of the muscles of the feet and lower legs, upon exertion. Simply stated, when muscles are working, they need fresh oxygen to supply them; any reduction in supply to them, will cause pain (claudication).This condition occurs mainly among men between the ages of 50 and 70 years, and usually starts after age 60 in women. Race and ethnic background also play a role, as persons of African descent have a higher incidence of peripheral arterial disease (PAD), than persons of non-African descent.
- Major Causes of Atherosclerosis
- – Diabetes – It affects both the major blood vessels bringing blood into the foot and the smaller vessels, which actually supply each area of the foot.
- – Hypertension or high blood pressure – Can cause damage to the arteries of the foot and leg, and over time, diminish blood flow to the feet. It’s noteworthy too that some anti-hypertensive medicine can adversely affect the feet, through swelling and discolouration of the extremities.
- – Smoking – May be the worst cause of damage to the arteries, that bring blood to the feet (as well as the heart, brain and kidneys). Smoke from tobacco directly damages the inside of the arteries.
- Treatment of Atherosclerosis
- There are a few different treatments for arteriosclerosis in the lower extremity, which are based on a number of factors. These include the degree of blockage, either by occlusion (calcified plaque); stenosis (narrowing of the artery); the age of the patient; their general overall health, etc:
- – Walking is considered the primary treatment in treating arteriosclerosis in mild to moderate cases. In fact walking works better than oral medication. However, we mean a daily walking program on a graded treadmill for 30 minutes. Initially, that may be impossible for many, so you need to work up to that number. This should be a supervised programme, with clearance from your doctor. Exercise on a regimented, physician supervised program, can reduce the symptoms of intermittent claudication in as little as 6 months in many individuals. The problem here is that many people would rather pop a pill daily, than go out and get some exercise. But statistically, it has been shown that walking is far superior to medication in this situation.
- – Medications used for peripheral arterial disease increase blood flow, by dilating (opening up) arteries.
- – Once a foot has reached this state, exercise or medication is no longer going to cure the problem. Either an angioplasty, stent, or bypass surgery, will be required to bring the foot “back to life”.
- Check next week for part 2 of this topic.
- Your feet mirror your general health . . . cherish them!