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CARE OF ANAESTHETIC FEET IN LEPROSY
FOOTWEAR FOR ANAESTHETIC FEET IN LEPROSY
OUR MAIN WEBSITE WITH MANY LINKS TO LEPROSY
One of the main characteristics of Leprosy is that it can result in anaesthesia of the feet. In this brief study, we shall not discuss what causes the anaesthesia. The causes will be dealt with separately so, if you wish to receive further information, kindly email me.
During the course of my training at the Schieffelin Leprosy Research and Training Centre, Karigiri, India, I was privileged to sit at the feet of the Superintendent of that institution - Dr. Ernest P. Fritschi, M.B.D. Orth, FRCS (Edin). At the time, Dr Fritschi was one of the leading specialist reconstructive surgeons and leprologists with extensive experience in producing special footwear for leprosy sufferers. The following are extracts from the notes I received in his lectures and those also of another distinguished leprologist and surgeon - Dr. R.Handel Thangaraj. I am indebted to both these specialists in the field.
When a foot never has had a ulcer, it takes a great deal of wear and tear to give it the first ulcer, but after one or two ulcers it becomes increasingly easier. The important thing, therefore, is to prevent the first ulcer.
1. Principles of Protective Footwear.
1. A covering
A covering to prevent injury from heat, sharp stones and thorns etc.
2. Padding
Padding is necessary to lessen the effect of the muscle-wasting and to give a soft surface for any hard, bony projections which can be felt.
3. Moulding
Moulding of the sole to increase the weight-bearing area and to take weight off the danger spot.
4. Rigidity
Rigidity is necessary to reduce the effect of sheering stress, to stabilise the foot and correct mobile deformity.
THE COVERING of the foot to prevent outside injury is served by almost any footwear. The only requirement is that the sole should not have any nails in it. Nails can penetrate the patient’s foot without him knowing. If the sole is soft rubber, it should have a layer of hard rubber (old tyre) stuck on the lower surface to prevent thorns from penetrating. The simplest and cheapest is a layer of car inner tube rubber, using old tyre for the sole. .
PADDING is usully provided by a layer of soft rubber. The recommended material is “Microcellular Rubber (MCR)” of the grade 15 shore. This has proved very satisfactory in practice as, generally, it is neither too hard nor too soft. It is relatively cheap and readily available. This is the material used in good quality “thongs”. Another material sometimes used is “Plastazole” but it is very expensive and less durable than MCR, except in one particular application . Rubber tends to perish when it comes into contact with oil but “Plastazole “ does not. “Plastazole” is recommended, therefore, for those patients whose work brings them into contact with oil on floors. The purpose of making a soft surface for the foot is to make up for the loss of padding by muscles which have become paralysed and wasted and also for the loss of fat under the scar of the previous ulcer. Padding is only necessary in a flat shoe, NOT in a moulded shoe.
MOULDING is the term used when the upper surface of the sole of the shoe is not flat but is made to fit the wearer’s foot (contour of the sole) . This is perhaps the most useful modification of footwear because :-
a. It increases the area of weightbearing by transferring some of the weight to the arch of the foot which, normally, does not touch the ground.
b. It can be adjusted to take the weight completely off the place where there is a hard, bony prominence felt.
c. It can be made to extend up the sides of the foot for 1cm. on the outer side and about 3cm on the inner side, thus making a still greater area of pressure bearing. Moulded shoes need not have a soft insole.
RIGIDITY is particularly important when a moulded shoe has been prescribed. The foot is normally a little mobile and this may be worse in some forms of early damage of the foot. Every normal foot will bend at the metatarsophalangeal joint when the person walks. By doing this, heavy pressure is applied to the metatarsal head area. If the shoe is made rigid by inserting a steel or rigid plastic strip between the insole and the tyre sole, this pressure is avoided. However, in order to make it possible for the person to walk, it is necessary to provide a rocking effect or else the patient will have to walk with an uncomfortable, flat foot gate. I am sorry that I do not have a scanner by which I could send to you a sketch of the necessary curved, rigid rocker sole which prevents hyperextension of the Metatarsophalangeal joint during walking, hence reducing stress under this joint.
Rigidity helps to protect the joints and bones of the foot. It reduces the sheering stress in forefoot thrust and prevents undue stess between normal skin with fat and scar tissue which is fixed to the bony prominence.
The principle of rigidity is applied also in the case of a Fixed Ankle Brace Walker (F.A.B.). This is a rather big appliance which keeps the whole foot, including the ankle joint, immobile, even when the patient is walking. In this way, any possible damage to the ankle bones is avoided. This can be further modified by transferring a part or even the whole of the weight of the body of the patellar tendon where there may be sensation. In this case, the appliance is called “Patellar Tendon Bearing” (P.T.B.) shell . These two appliances are ugly, heavy and expensive and are only used for very badly deformed feet.
THE PRESCRIPTION OF SUITABLE FOOTWEAR.
There are three kinds of footwear commonly used and these are prescribed for different kinds of feet.
1. Flat soled Microcellular ( 15 shore MCR) padded slippers /chappals or sandals These are used for anaesthetic feet which either have had no previous ulcers or in which there have been only one or two simple ulcers which have quickly healed with a minimum of tissue destruction. It is important that this type of sandal have a back-strap or a closed-heel like in a shoe. This is because the foot, which has lost its intrinsic muscles, is unable to keep a slipper on, because the toes do not function properly. Also, the front strap of the sandal should not press the toes together.
2. The Low Moulded Shoe with “Arch Support and Metatarsal Pad” (A.S.M.P.)
This shoe is basically the same as the previous one but it has an additional piece of microcellular rubber cut out and ground into a suitable shape and stuck into the sole under the arch. This improves the flat sole by increasing the pressure-bearing area and taking the weight off the metatarsal heads. It is suitable for the foot where there is no change of shape but where there have been ulcers in the forefoot. This is probably the cheapest and most useful modification. It is essential that a heel-strap or heel counter is provided.
3. THE METATARSAL BAR is a simple alternative which is used in similar feet. Its only advantage is its simplicity and the fact that any local shoe-maker can fit it, but without using nails. The position of the bar is very important; it should be behind the metatarsal heads and NOT under them.
4. THE MOULDED BOOT is used in badly deformed feet where there are many scars but where the bony structure of the mid and hind foot is not broken down. It is rather expensive and is only required in a relatively few feet which have been neglected for many years
5 THE F.A.B. WALKER AND P.T.B. SHELL which already have been mentioned are for use in very bad feet which cannot be kept ulcer free by simpler methods. The alternative to this type of footwear usually is amputation. If there is a fixed deformity, this should be corrected surgically before prescribing these appliances.
THE FOLLOWING TABLE MAY BE HELPFUL IN PRESCRIBING FOOTWEAR.
GRADE 1 - Anaesthesia and small muscle paralysis with one or two soft scars >>
Prescribe MCR sandals with heel counter or heel strap.
GRADE 2 - Several forefoot scars. Some metatarsal heads felt. Soft heel scar >>
Prescribe MCR sandals with heel counter and MCR Arch Support and Metatarsal Bar (A.S.M.P.)
GRADE 3 - Loss of bone - forefoot deformity and several scars and hard, bony prominences, hard heel scars. Some shortening - less than one third. >>
Prescribe High Moulded Shoe.
GRADE 4 - Mobile Inverted Foot - large scarred areas. “Hot Foot” after treatment. Instability of mid foot. Hind foot shortening. >>
Prescribe High moulded shoe with F.A.B.Walker of P.T.B. Shell
GRADE 5 - Gross structural deformity; less than one third of normal plantar skin. Gross instability with repeated recurrance of ulcers. >>
Prescribe P.T.B. Shell or amputation.
It should be remembered that leprosy is totally curable and all the deformities and ulcerations fully preventable. No one, therefore, needs to suffer the deformities mentioned here. With proper Health Education and early treatment (MDT), there is no suffering whatsoever. Please email me for any further information about the disease, its diagnosis and treatment. You are also welcome to visit my Home Page at :-
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