clinical assessment ofpodogeriatricpatients · 579.1 tropical sprue 579.9 unspecified intestinal...

Podiatric care can improve the quality of life for senior citizens.

FEBRUARY 2004 • PODIATRY MANAGEMENTwww.podiatrym.com 145

order to accomplish this aim, practi-tioners must think comprehensive-ly, and recognize that team caremust be an essential part of chronicdisease management in the care ofthe older patient. Foot health edu-

cation, including programs devel-oped by the Pennsylvania DiabetesAcademy of Pennsylvania, are avail-able to both patients and profes-sionals, and should be employed. It

By Arthur E. Helfand, D.P.M.

Continued on page 146

Welcome to Podiatry Management’s CME Instructional program. Our journal has been approved as a sponsor of Contin-uing Medical Education by the Council on Podiatric Medical Education.

You may enroll: 1) on a per issue basis (at $17.50 per topic) or 2) per year, for the special introductory rate of $109 (yousave $66). You may submit the answer sheet, along with the other information requested, via mail, fax, or phone. In the nearfuture, you may be able to submit via the Internet.

If you correctly answer seventy (70%) of the questions correctly, you will receive a certificate attesting to your earned cred-its. You will also receive a record of any incorrectly answered questions. If you score less than 70%, you can retake the test atno additional cost. A list of states currently honoring CPME approved credits is listed on pg. 154. Other than those entities cur-rently accepting CPME-approved credit, Podiatry Management cannot guarantee that these CME credits will be acceptable byany state licensing agency, hospital, managed care organization or other entity. PM will, however, use its best efforts to ensurethe widest acceptance of this program possible.

This instructional CME program is designed to supplement, NOT replace, existing CME seminars. Thegoal of this program is to advance the knowledge of practicing podiatrists. We will endeavor to publish high quality manuscriptsby noted authors and researchers. If you have any questions or comments about this program, you can write or call us at: Podia-try Management, P.O. Box 490, East Islip, NY 11730, (631) 563-1604 or e-mail us at [email protected].

Following this article, an answer sheet and full set of instructions are provided (p. 154).—Editor

Goal

The primary goal is to pro-vide an approach for compre-hensive podogeriatric assess-ment and risk stratification tohelp prevent complicationsand improve the quality oflife in the older patient.

Objectives

1) Identify primary footand related complications as-sociated with the older patient.

2) To describe clinicalstrategies to assess and strati-fy the “at risk” patient.

3) To recommend a proto-col for comprehensivepodogeriatric assessment thatstresses referral, education,prevention, and care.

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IntroductionMuch of the ability to remain

ambulatory in the period of aging isdirectly related to foot health. In

Clinical Assessment ofPodogeriatricPatients

G E R I A T R I C P O D I A T R YG E R I A T R I C P O D I A T R Y

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tocol’s application is one primarilyof secondary prevention. Its utiliza-tion also stresses the need for pa-tient and professional education aswell as the need for appropriatemanagement by those licensed toprovide and maintain the highestlevel of quality care and concern.The protocol included a compila-tion of various procedures and clini-cal impressions that also includesMedicare’s “at-risk” criteria for man-agement.

Helfand IndexThe process, protocol, and its

validation were supported with theassistance of a contract from thePennsylvania Department of Healthin cooperation with Temple Univer-sity School of Podiatric Medicine,Pennsylvania Diabetes Academy(Foundation of the PennsylvaniaMedical Society), Philadelphia Cor-poration for Aging, and Thomas Jef-ferson University. The protocol en-hances the ability to document and

stratify risk by the use of an appro-priate clinical assessment to helppatients understand the need forfoot health, and provide educationfor both patients and professionals.The final protocol was termed the“Helfand Index” by the Departmentof Health.

General Information andMethodology

Foot problems associated withaging and as the result of disease,disability, and deformity, as well ascomplications associated with manychronic diseases, represent some ofthe most distressing, disabling andquality-of-life limiting conditionsknown. As society considers thebasic needs of the older populationand those related to chronic dis-eases such as diabetes mellitus, themultiple forms of arthritis, peripher-al arterial disease, as well as thoseconditions which produce sensory,peripheral, musculoskeletal, andmotor deficits, it is recognized thathealth is but one of those needs,and not always the highest in prior-ity. Given an ideal set of circum-stances, there are two importantcatalytic factors that help determinethe patient’s ability to remain as aself-sufficient and reasonably inde-pendent part of society. They are akeen mind and the ability to ambu-late or remain mobile.

Foot problems in the older pa-tient and those with chronic diseaseare a significant health concern,both from a standpoint of incidenceand prevalence. The loss of the abil-ity to walk that result from a focalfoot problem or as the result of acomplication of a systemic disease,can have a significant negative andlimiting impact on the patient’sability to maintain a productive


146 www.podiatrym.comPODIATRY MANAGEMENT • FEBRUARY 2004

Podogeriatric...

is clear that adults with chron-ic disease and older patients are a

high risk for foot related diseaseand should maintain continuingfoot assessment, education, surveil-lance, and care. For this population,the ability to prevent complicationsand maintain mobility and ambula-tion will be reflected in their qualityof life and their ability to remainmentally alert and active in theircommunities.

The initial clinical pedal assess-ment of the geriatric patient hasbeen developed as a comprehensivepodogeriatic and chronic disease as-sessment protocol to augment geri-atric and chronic disease assess-ment. The objective was to developa process to identify foot and relat-ed problems and stratify risk, forthose potential foot problems thatmight develop as complications ofchronic diseases, associated witholder patients. The goal to the pro-

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TABLE 1

Amyotrophic Lateral Sclerosis (ALS) (335.20)Arteriosclerosis obliterans (A.S.O., arteriosclerosis of the extremities,occlusive peripheral arteriosclerosis) (440.20-440.29, 440.9)Arteritis of the feet (447.6)Buerger’s disease (thromboangiitis obliterans) (443.1)Chronic indurated cellulitis (681.10, 681.11, 682.6, 682.7, 682.9)*Chronic thrombophlebitis (451.0, 451.11, 451.19, 451.2)Chronic venous insufficiency (459.81, 443.9, 459.30-459.39)*Diabetes mellitus (250.00-250.93, 648.00-648.04)Intractable edema—secondary to a specific disease (e.g., congestive heartfailure, kidney disease, hypothyroidism) (459.10-459.19, 459.2, 459.30-459.39, 757.0, 782.3)Lymphedema—secondary to a specific disease (e.g., Milroy’s disease,malignancy) (457.1, 757.0)Peripheral neuropathies involving the feet (337.1, 357.0-357.9)

*Associated with malnutrition and vitamin deficiency (266.0-266.9, 357.4)Malnutrition (general, pellagra) (265.2, 357.4)Alcoholism (265.2, 357.5)Malabsorption (celiac disease, tropical sprue) (579.0, 579.1, 579.9)Pernicious anemia (281.0)*Associated with carcinoma (357.3)*Associated with diabetes mellitus (250.6, 357.2)*Associated with drugs and toxins (357.6-357.7)*Associated with multiple sclerosis (340)*Associated with uremia (chronic renal disease) (585)Associated with traumatic injury (959.7)Associated with leprosy or neurosyphilis (030.0-030.3, 094.0-094.87)Associated with hereditary disorders (356.0)Hereditary sensory radically neuropathy (356.2)Angiokeratoma corporis diffusum (Fabry’s) (272.7)Amyloid neuropathy (277.3)

Peripheral vascular disease (356.0-356.9, 443.81-443.89, 447.1, 459.9)Raynaud’s disease (443.0)

Much of the ability to remain

ambulatory in theperiod of aging

is directly related to foot health.


quality-of-life as memberof society.

PodogeriatricsPodogeriatrics is that special

area of podiatric medical prac-tice that focuses on health pro-motion, prevention, and thetreatment and management offoot and related problems, dis-ability, deformity, and the pedalcomplications of chronic dis-eases in later life. Podogeriatricsis a component of healthcare forolder adults. Foot conditionsthat present in older patients re-quire special considerations formanagement as to medical prob-lems for any other system. Theseconditions may be local, the re-sult of complications associatedwith multiple chronic diseases,local foot changes associatedwith the aging process itself, andthe residual effects of repetitiveinjury over the course of an indi-vidual’s lifetime. Older personstend to react to illness, deformi-ty and disease differently thanyounger persons. Care includesan understanding of the specificsyndromes that older patientsexperience and the complexityof being a part of a team thatmanages multiple diseases.

In most cases, podogeriatriccare is provided as a part of atotal approach to patient man-agement that also includes con-sideration of issues that relate tofoot complaints and their rela-tionship to falls, confusion, ne-glect, and the capacity to per-form the simple activities ofdaily living. Social support isalso a consideration in patientmanagement. In many cases, be-cause foot and related problemsare the primary complaint, thepatient seeks podiatric care ini-tially. This initial contact withthe healthcare system may be-come the starting point for totalgeriatric care. Comprehensivepodogeriatric assessment is acomponent of this process. Theability to remain pain-free andmobile is a key element to main-taining an independent qualityof life.


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030.0-030.3 Leprosy094.0-094.87 Neurosyphilis*250.00-250.93 Diabetes mellitus265.2 Pellagra (added July 15, 2002)*266.0-266.9 Deficiency of B-complex components (added July 15, 2002)272.7 Lipidoses277.3 Amyloidosis281.0 Pernicious anemia335.20 Amyotrophic lateral sclerosis337.1 Peripheral autonomic neuropathy in disorders classified elsewhere(added July 15, 2002)*340 Multiple Sclerosis356.0-356.9 Hereditary and idiopathic peripheral neuropathy357.0 Acute infective polyneuritis357.1 Polyneuropathy in collagen vascular disease*357.2 Polyneuropathy in diabetes*357.3 Polyneuropathy in malignant disease*357.4 Polyneuropathy in other diseases classified elsewhere357.5 Alcoholic polyneuropathy*357.6 Polyneuropathy due to drugs*357.7 Polyneuropathy due to other toxic agents357.81-357.89 Inflammatory and toxic neuropathy, other357.9 Inflammatory and toxic neuropathy, unspecified440.20-440.29 Atherosclerosis of native arteries of the extremities440.9 Generalized and unspecified atherosclerosis (added July 15, 2002)443.0 Raynaud’s syndrome443.1 Thromboangiitis obliterans (Buerger’s disease)443.81-443.89 Other specified peripheral vascular diseases443.9 Peripheral vascular disease, unspecified447.1 Stricture of artery (added July 15, 2002)447.6 Arteritis, unspecified (use for arteritis of the feet)*451.0 Phlebitis and thrombophlebitis of superficial vessels of lower extremities*451.11 Phlebitis and thrombophlebitis of femoral vein (deep) (superficial)*451.19 Phlebitis and thrombophlebitis of deep vessels of lower extremities,other*451.2 Phlebitis and thrombophlebitis of lower extremities, unspecified457.1 Other lymphedema (added July 15, 2002)459.10-459.19 Postphlebitic syndrome (added July 15, 2002, truncated October 1, 2002)459.2 Compression of vein (added July 15, 2002)459.30-459.39 Chronic venous hypertension (idiopathic)459.81 Venous (peripheral) insufficiency, unspecified459.9 Unspecified circulatory system disorder (added July 15, 2002)579.0 Celiac disease579.1 Tropical sprue579.9 Unspecified intestinal malabsorption*585 Chronic renal failure*648.00-648.04 Other current conditions in the mother classifiable elsewhere, but complicating pregnancy, childbirth, or the puerperium, diabetes mellitus681.10, 681.11 Cellulitis and abscess of toe682.6 Other cellulitis and abscess, leg, except foot (added July 15, 2002)682.7 Other cellulitis and abscess, foot, except toes682.9 Other cellulitis and abscess, unspecified site (added July 15, 2002)757.0 Hereditary edema of legs (added July 15, 2002)782.3 Edema (added July 15, 2002)959.7 Injury, knee, leg, ankle, and foot

Note: Those diagnostic codes identified by asterisks (*) require that thepatient to have been seen by the physician treating the risk disease, within sixmonths prior to the podiatric visit.

Podogeriatric...

maintain their activities of daily liv-ing. These contribute to the devel-opment of conditions associatedwith disability, from arthritis andulceration. Foot problems are com-mon in the older population as a re-sult of disease, deformity, complica-tions, and neglect, resulting from alack of preventive service, at the pri-mary, secondary and tertiary levels.They contribute to disability andcan reduce an older person’s inde-pendence and quality of life.

Routine Foot CareMedicare may provide coverage

for what is defined as primary “footand nail care” or “routine foot care”if the criteria of vascular and senso-ry deficits are met. There are sys-temic conditions that permit cover-age. The primary chronic risk dis-eases identified by Medicare, thatusually present with pedal compli-cations and coverage in the adultand older population include thoselisted in Table 1.

In addition, Medicare has identi-fied a series of codes that support

coverage requirements formedical necessity listed asTable 2.

Other and equally im-portant chronic diseases orconditions that provide anequal level of risk includethose listed in Table 3 asexamples.

In addition, severalclinical findings, defined asClass Findings of Risk Fac-tors for Medicare, are alsoneeded to qualify patientsfor primary foot care man-agement. They are listed inTable 4 and are also includ-ed as a part of the protocol.

An additional specializedcategory of risks are identi-fied in Table 5 as they usu-ally present with sensoryand vascular deficits.

There are many otherfactors that also contributeto the development of footproblems of the adult pop-ulation, including theaging process itself, as wellas abuse and neglect. Someof these considerations in-clude:

The degree of ambula-tion

The duration of prior hospital-ization

Limitation of activityPrior institutionalizationEpisodes of social segregationPrior careEmotional adjustments to dis-

ease and life in generalMultiple medications and drug

interactionsComplications and residuals as-

sociated with risk diseases.

Assessment ProtocolThe historical evolution of this

assessment protocol began with afederally funded program whichwas conducted by the PhiladelphiaDepartment of Health and St.Luke’s & Children’s Medical Cen-ter (James C. Giuffre Medical Cen-ter) between 1962 and 1965. Theformat was also utilized in a seven-year longitudinal study conductedin cooperation with the Pennsyl-vania Department of Welfare in1967 and 1974 at the South Moun-tain Restoration Center. The proto-col was restructured for two pro-grams in the last ten years and wassupported by the Pennsylvania De-partment of Health, PennsylvaniaDiabetes Academy, and thePhiladelphia Corporation forAging. The assessment instrumentwas designed to provide a reason-able and efficient way of assessingthe most common foot problemsassociated with adult chronic dis-ease and aging, stratify risk, andprovide a means for patient educa-tion and referral for care. The con-cept was based upon the precept ofthe secondary prevention ofchronic disease, i.e. by findingcomplications at their earliestonset, preventing the progress ofdisease to minimize complications,



Podogeriatric...

Foot health and foot care arean important and many time

overlooked component of an olderperson’s overall health and wellbeing. Foot problems may hinder aperson’s ability to be free of painand discomfort, to maintain propermobility, and to enjoy interpersonalrelationships, a positive self-image,and to maintain activity and a highquality of independence and life.Many chronic diseases such as dia-betes mellitus, peripheral arterial in-sufficiency, arthritis, other metabol-ic diseases and conditions whichproduce pain, vascular limitations,and a diminished sensation, aremore prevalent in the older popula-tion with increased symptoms as in-dividuals age. These patients are athigher risk for chronic complica-tions and comorbidities, which in-crease the potential for marked limi-tation of activity, hospitalization,and limb loss.

Foot health has a direct relation-ship to older persons being able to

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TABLE 3

AcromegalyAlzheimer’s DiseaseArthritis—DJDArthritis—RAGoutCerebral PalsyCoagulation Defect—HemophiliaCVAPhlebitisSarcoidosisSickle-Cell AnemiaPrevious Amputation—FootPrevious Amputation—ToeHistory of Prior UlcerPre-ulcerative HyperkeratosisFoot DeformityVascular InsufficiencyReflex Sympathetic DystrophyCoagulation Defects, AnticoagulantsChronic Obstructive Pulmonary DiseaseHypertensionPost-TraumaHansen’s DiseaseMental IllnessMental RetardationHemophiliaPatients on Anticoagulant TherapyPost-Stroke PatientsParalysisAmbulatory DysfunctionParkinson’s Disease

Social support is also a

consideration in patient

management.


DiscussionThe process contains informa-

tion related to demographics; pri-mary medical facilities and manage-ment; a history of present problems;pertinent past medical history; asystems review; current medica-tions; foot dermatologic, foot ortho-pedic, peripheral vascular and neu-rological evaluation; neurologicalrisk stratification; peripheral arterial

risk stratification; footwear evalua-tion; a primary assessment; an ini-tial plan and referral direction; therecording of Medicare’s class find-ings; risk stratification of ony-chomycosis and other related nailconditions; plantar pressure keratot-ic patterns; ulcer classification; andthe classification of mechanical orpressure hyperkeratotic lesions.

The evaluation process may be

limiting ambulation and helpingmaintain a higher quality of lifeand independence.

The current ComprehensivePodogeriatric and Chronic DiseaseAssessment Protocol, Appendix I in-cludes a process to assess and evalu-ate common foot problems, andstratify “at-risk” patients. Once risksare identified and foot conditionsnoted, a direction for care, educa-tion and preventive measures canbe prescribed.

Those notations marked A-1through C-5, denote Class Findingsfor Medicare, which are used asqualifiers for primary foot care cov-erage for those patients with identi-fied “at risk” chronic diseasesand/or conditions.

Those notations marked with as-terisks, denote qualifiers for thera-peutic shoes under Medicare’s pro-gram for “at-risk” patients with dia-betes mellitus. Those criteria in-clude:

History of partial or completeamputation of the foot

History of previous foot ulcera-tion

History of pre-ulcerative callusPeripheral neuropathy with evi-

dence of callus formationFoot DeformityPoor Circulation

Podogeriatric... enhanced by the use ofaccessible instrumentation,such as a C-128 tuning fork;neurologic hammer; percussionhammer; Babinski hammer; bio-thesiometer to determine vibrationperception threshold (VPT);monofilament sensory testing(MFT) devices such as theSemmes–Weinstein 5.07 nylonmonofilament, Norton monofila-ment, or the West enhanced senso-ry test; Tacticon; Doppler; radiome-ter—infrared surface temperaturescanner for skin perfusion assess-ment; oscillometer; and/or plethys-mo-analyzer.

The section on the history ofpresent illness includes primary footproblems and their relationship tochronic disease and activities. Thesection on past history includes themost common systemic diseases,but needs to be augmented by pri-mary and secondary risks as theevaluation evolves. The sections onsystems review and medicationsprovide a cross-reference to poten-tial risk diseases.

Dermatological ExamThe dermatologic section pro-

vides a focus on multiple changesthat affect pressure and mechanicalkeratosis, changes that occur in thetoenail, infections and pre-ulcerativestates. The foot orthopedic sectionhighlights the most common footdeformities and syndromes identi-fied in the older patient and patientswith chronic diseases, such as arthri-tis or hallux valgus. Anterior imbal-ance identifies inappropriate weightbearing and correlates with the plan-tar keratoma pattern noted later inthe examination. Digit flexus identi-fied hammertoes and rotational de-formities and correlates to both im-


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TABLE 4

Class Findings:

CLASS A FINDINGS–Nontraumatic amputation of foot or integral skeletal portion thereofCLASS B FINDINGS–Absent posterior tibial pulse–Absent dorsalis pedis pulse–Advanced trophic changes as: (three required)hair growth (decrease or absence)nail changes (thickening)pigmentary changes (discoloration)skin texture (thin, shiny)skin color (rubor or redness)CLASS C FINDINGS–Claudication–Temperature changes (e.g., cold feet)–Edema–Paresthesias (abnormal spontaneous sensations in the feet)–Burning

Medicare requires one class A, two class B, or one class B and two class Cto meet basic coverage requirements.

TABLE 5

Vascular GraftsJoint ImplantsHeart Valve ReplacementActive ChemotherapyRenal Failure—DialysisAnticoagulant TherapyHemorrhagic DiseaseChronic Steroid TherapyImmunosuppressive States

The evaluation process may be

enhanced by the use of accessible

instrumentation.

SummaryFoot impairment, including

diseases and disorders of the foot,are common in elderly patientsand may impact general healthand functioning of older patients.Periodic comprehensive podogeri-atric assessment is recommendedfor older patients. Practitionersshould be aware of those localconditions and the complicationsof systemic diseases, such as dia-betes mellitus, peripheral arterialdisease, arthritic changes, neuro-logical deficiencies and mentalhealth symptoms that manifestfoot symptoms and signs. Geriatri-cians should recognize the com-mon clinical findings and shouldrefer patients for podiatric careand management in a timely andappropriate manner as indicated.Inasmuch as a majority of geriatricfoot problems cannot be totallyprevented, the concept of sec-ondary prevention, i.e., findingthe disorder or disease at its earli-est manifestation, and managingthe disorder properly, can signifi-cantly improve the quality of lifefor older citizens.

NOTE 1Foot Care services for Medicare

purposes must be provided by prac-titioners who are permitted by statelicense to render examination, diag-nosis, and treatment of foot dis-eases.

NOTE 2Services furnished for the evalu-

ation and management of a diabeticpatient with diabetic sensory neu-ropathy, resulting in a loss of pro-tective sensation (LOPS) must in-clude the following:1. a diagnosis of LOPS2. a patient history3. a physical examination consist-ing of findings regarding at least thefollowing elements:

a. visual inspection of the fore-foot, hindfoot, and toe web spaces

b. evaluation of protective sen-sation

c. evaluation of foot structureand biomechanics

d. evaluation of vascular statuse. evaluation of skin integrityf. evaluation and recommenda-

tion of footwear4. patient education

NOTE 3The Podogeriatric and Chronic

Disease Assessment Protocol(Helfand Index) provides the com-ponents for the existing require-ments provided that state licensurelaws are met.

NOTE 4Feet First, If The Shoe Fits, and

Assessing The Older Diabetic Foot(CD) are available from the Pennsyl-vania Department of Health, Harris-burg, Pennsylvania.

NOTE 5Highmark Blue Shield (Pennsyl-

vania) has identified the followinginformation from the American Di-abetes Association: Foot care—Am-putation and foot ulceration areone of the most common conse-quences of diabetic neuropathy anda major cause of morbidity and dis-ability in people with diabetes. Earlyrecognition and management of in-dependent risk factors can preventor delay adverse outcomes. The riskof ulcers or amputations is in-creased in people who have had dia-betes >10 years, are male, have poorglucose control, or have cardiovas-cular, retinal, or renal complica-tions. The following foot-relatedrisk conditions are associated withan increased risk of amputation:

• Peripheral neuropathy withloss of protective sensation

• Altered biomechanics (in thepresence of neuropathy)

• Evidence of increased pressure(erythema, hemorrhage under a cal-lus)

• Bony deformity • Peripheral vascular disease (de-

creased or absent pedal pulses) • A history of ulcers or amputa-

tion • Severe nail pathology Targeted patient education and

appropriate footwear can reduce therisk of ulceration. For a detailed re-view of the evidence and furtherdiscussion, see the American Dia-betes Association’s technical reviewand position statement titled “Pre-ventive Foot Care in Persons WithDiabetes” (61,62).

Bibliography1. Alexander, I. J. The Foot, Examina-

tion and Diagnosis, Second Edition,



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balance, prominent metatarsalheads and Morton’s syndrome,

which is an anatomical shorteningof the first metatarsal segment pro-ducing improper weight distributionand pressure areas. Soft tissues in-flammation is also noted.

The classification of mechanicalor pressure keratosis is a modifica-tion of the program outlined byMerriman and Tollifield. The ulcerclassification was adapted fromSimms, Cavanaugh and Ulbrechtand provides an earlier identifica-tion of risk. The onychial grades at-risk that was modified and adaptedfrom Strauss, Hart and Winant rec-ognizes earlier risk. This assessmentinstituted to reduce the complica-tions of chronic disease and adheresto the principles of secondary pre-vention of disease.

Vascular ExamThe vascular evaluation identi-

fies those symptoms associated witharterial insufficiency and ischemia.DP refers to the dorsalis pedis pulseand PT to the posterior tibial pulse.Amputation, if present, is noted asabove the knee (AKA), below theknee (BKA), FF (forefoot), and T(toes), which are particularly impor-tant in patients with diabetes andarterial insufficiency. The Neurolog-ical Evaluation identifies primary re-flect and sensory changes.

Vascular and risk stratification isnoted following initial evaluation.Footwear information, assessmentand initial plan are also noted. Classfindings refer to those findings,identified by Medicare, as qualifiersfor primary foot care for those pa-tients with primary risk diseasesnoted in Tables 1, 2, and 3. Itshould be noted that all of the in-formation listed in Table 4 shouldqualify in a similar manner at somepoint in the future. The criteria foronychomycosis débridement cover-age are also mandates of Medicare.

The final impression may not bea final diagnosis, but it identifiesproblems requiring management,surfaces latent risk factors and poten-tial complications, provides a direc-tion for education and prevention,and increases the awareness of foothealth and care as an essential ele-ment for comprehensive patient care.

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HISTORY OF PRESENT ILLNESS___Swelling of Feet ___Infections ___Duration___Painful Feet ___Cold Feet ___Context___Hyperkeratosis ___Other ___Modifying Factors___Onychial Changes ___Location ___Associated Signs & Symptoms___Bunions ___Quality___Painful Toe Nails ___Severity

PAST HISTORY___Heart Disease ___Thyroid ___Hypercholesterol___High Blood Pressure ___Allergy ___Gout___Arthritis ___Diabetes Mellitus ___History: Smoking: OH___* Circulatory Disease ___* IDDM ___* NIDDM ___Family—Social

SYSTEMS REVIEW___Constitutional ___Hematologic ___Neurologic___ENT ___Card/Vasc ___Endocrine___Eyes ___Musculo-Skeletal ___GI___Skin/Hair ___GYN ___Immunologic___Respiratory ___Lymphatic___Psychiatric ___GU

MEDICATIONS

DERMATOLOGIC___* Hyperkeratosis ___Onychodystrophy ___Hematoma___Onychauxis B-2-b ___* Cyanosis ___Rubor___Infection ___Xerosis ___* Preulcerative___* Ulceration ___Tinea Pedis ___Discolored___Onychomycosis ___Verruca

FOOT ORTHOPEDIC___* Hallux Valgus ___* Pes Valgoplanus ___* Prominent Met Head___* Anterior Imbalance ___* Pes Cavus ___* Charcot Joints___* Digiti Flexus ___* Hallux Rigidus-Limitus ___Other___* Pes Planus ___* Morton’s Syndrome Bursitis

VASCULAR EVALUATION___* Coldness C-2 ___* Night Cramps ___* Amputation___* Trophic Changes B-2-a ___* Edema C-3 ___* AKA BKA FF T A-1___* DP Absent B-3 ___* Claudication C-1 ___Atrophy B-2-d___* PT Absent B-1 ___Varicosities

NEUROLOGIC EVALUATION___* Achilles ___* Paresthesia C-4 ___* Burning C-5___* Vibratory ___Superficial Plantar ___Other___* Sharp/Dull ___* Joint Position

RISK CATEGORY—NEUROLOGIC___0 = No Sensory Loss ___* 2 = Sensory Loss & Foot Deformity___* 1 = Sensory Loss ___* 3 = Sensory Loss, Hx Ulceration, & Deformity

RISK CATEGORY—VASCULAR0–0 NO CHANGE * I–4 ISCHEMIC REST PAIN* I–1 MILD CLAUDICATION * II–5 MINOR TISSUE LOSS* I–2 MODERATE CLAUDICATION * III–6 MAJOR TISSUE LOSS* I–3 SEVERE CLAUDICATION

CLASS FINDINGS___A1 Nontraumatic Amputation ___B2e Skin Color (rubor or redness)___B1 Absent Posterior Tibial ___B3 Absent Dorsalis Pedis___B2 Advanced Trophic Changes ___C1 Claudication___B2a Hair Growth (decrease or absent) ___C2 Temperature Changes (cold)___B2b Nail Changes (thickening) ___C3 Edema___B2c Pigmentary Changes (discoloration) ___C4 Paresthesia___B2d Skin Texture (thin, shiny) ___C5 Burning

ONYCHOMYCOSIS: Documentation of mycosis/dystrophy causing secondary infection and/or pain, whichresults or would result in marked limitation of ambulation.

Discoloration OnycholysisHypertrophy Secondary InfectionSubungual Debris Limitation of Ambulation and Pain

CLASSIFICATION OF MECHANICAL OR PRESSURE HYPERKERATOSISGRADE DESCRIPTION

0 NO LESION1 NO SPECIFIC TYLOMA PLAQUE, BUT DIFFUSE OR PINCH HYPERKERATOTIC TISSUE PRESENT

OR IN NARROW BANDS2 CIRCUMSCRIBED, PUNCTATE OVAL, OR CIRCULAR, WELL DEFINED THICKENING OF

KERATINIZED TISSUE3 HELOMA MILLIARE OR HELOMA DURUM WITH NO ASSOCIATED TYLOMA4 WELL DEFINED TYLOMA PLAQUE WITH A DEFINITE HELOMA WITHIN THE LESION5 EXTRAVASATION, MACERATION AND EARLY BREAKDOWN OF STRUCTURES UNDER THE

TYLOMA OR CALLUS LAYER6 COMPLETE BREAKDOWN OF STRUCTURE OF HYPERKERATOTIC TISSUE, EPIDERMIS,

EXTENDING TO SUPERFICIAL DERMAL INVOLVEMENT

PLANTAR KERATOMATA PATTERNLT 1 2 3 4 5 RT 1 2 3 4 5

ULCER CLASSIFICATIONGRADE–0–ABSENT SKIN LESIONSGRADE–1–DENSE CALLUS BUT NOT PRE-ULCER OR ULCERGRADE–2–PREULCERATIVE CHANGESGRADE–3–PARTIAL THICKNESS (SUPERFICIAL ULCER)GRADE–4–FULL THICKNESS (DEEP) ULCER BUT NO INVOLVEMENT OF TENDON, BONE, LIGAMENT OR JOINTGRADE–5–FULL THICKNESS (DEEP) ULCER WITH INVOLVEMENT OF TENDON, BONE, LIGAMENT OR JOINTGRADE–6–LOCALIZED INFECTION (ABSCESS OR OSTEOMYELITIS)GRADE–7–PROXIMAL SPREAD OF INFECTION (ASCENDING CELLULITIS OR LYMPHADENOPATHYGRADE–8–GANGRENE OF FOREFOOT ONLYGRADE–9–GANGRENE OF MAJORITY OF FOOT

ONYCHIAL GRADES AT RISKGrade I NORMAL Grade IV HYPERTROPHICGrade II MILD HYPERTROPHY DEFORMEDGrade III HYPERTROPHIC ONYCHOGRYPHOSISDYSTROPHIC DYSTROPHICONYCHAUXIS MYCOTICMYCOTIC INFECTEDINFECTEDONYCHODYSPLASIA

FOOTWEAR SATISFACTORY HYGIENE SATISFACTORYYES NO YES NO

STOCKINGS: NYLON COTTON WOOL OTHER NONE

ASSESSMENT

PLAN___PODIATRIC REFERRAL ___MEDICAL REFERRAL ___VASCULAR STUDIES ___IMAGING___PATIENT EDUCATION ___SPECIAL FOOTWEAR ___CLINICAL LAB ___Rx

APPENDIX I

PODOGERIATRIC ASSESSMENT AND CHRONIC DISEASE PROTOCOL

DATE OF SERVICE____________________________________________ MR #______________________________________________

PATIENT NAME__________________________________________________________________________ Date of Birth_________________ SOCIAL SECURITY #____________________________________________

ADDRESS___________________________________________________________________ CITY______________________________________________ STATE__________________ ZIP CODE___________________

SEX M F RACE B W A L N A WEIGHT____________ LBS HEIGHT____________IN MARITAL STATUS M S W D SEP

NAME OF PRIMARY PHYSICIAN/HEALTH CARE FACILITY__________________________________________________________________ DATE OF LAST VISIT__________________________________________

16. Helfand, Arthur E., and Bruno, J.,Ed. Rehabilitation of the Foot, Clinics inPodiatry, Vol. 1, No. 2, W B SaundersCo., Philadelphia, PA, 1984.

17. Helfand, Arthur E., Ed. PublicHealth and Podiatric Medicine, Williamsand Wilkins, Baltimore, 1987.

18. Helfand, Arthur E. Ed. The Geri-atric Patient and Considerations ofAging, Clinics in Podiatric Medicine andSurgery, W. B. Saunders, Co., Phila. PA.,Vol I, January 1993; Vol II, April, 1993.

19. Helfand, A. E., The Foot—Geri-atric Overview, Part I, The Foot, 3: 58,1993 and Part II, The Foot, 5: 19, 1995

20. Helfand, A. E., Feet First, Pennsyl-vania Diabetes Academy, Harrisburg, PA.,1991.

21. Helfand, A. E., If the Shoe Fits,Pennsylvania Diabetes Academy, Harris-burg PA, 1995.

22. Helfand, A. E., Assessing theOlder Diabetic Foot, Pennsylvania Dia-betes Academy, Harrisburg, PA., 2002,with Pennsylvania Department ofHealth, Temple University, School ofPodiatric Medicine, and Temple Univer-sity, School of Medicine, Office of Con-tinuing Medical Education

23. Helfand, A. E. & Jessett, D. F.,Foot Problems, Principles and Practice ofGeriatric Medicine, 3rd. Edition, M S JPathy, Ed., 1998, John Wiley & Sons, Ed-inburgh.

24. Helfand, A. E., At The Foot ofSouth Mountain, A Five Year Longitudi-nal Study of Foot Problems and Screen-ing in an Elderly Population, Journal ofthe American Podiatric Medical Associa-tion, Vol. 63, No. 10, October 1973, pp.512-521.

25. Helfand, A. E., Cooke, H. L.,Walinsky, M. D., Demp, P. H., & Phillips,B. S., Foot Pain and Disability in OlderPersons, Pilot Study in Assessment andEducation, Journal of the American Pod-iatric Medical Association, Vol. 86, No. 2,February 1996, pp. 93-98.

26. Helfand, A. E., Cooke, H. L.,Walinsky, M. D., & Demp, P. H., FootProblems in Older Patients, A FocusedPodogeriatric Study, Journal of the Amer-ican Podiatric Medical Association, Vol.88, No. 4, May 1998, pp. 237-41

27. Diseases and Disorders of theFoot, In: Cobbs EL, Duthie ED, MurphyJB eds. Geriatric Review Syllabus: A CoreCurriculum in Geriatric Medicine, 5thed. Ed., Malden MA, Blackwell Publish-ing, for the American Geriatrics Society;2002, page 287-294.

28. Helfand, A. E., Ed., ClinicalPodogeriatrics: Assessment, Educationand Prevention, Clinics in Podiatric Med-icine and Surgery, W. B. Saunders, Co.,Phila. PA., July, 2003.

29 Kozak, George P., Hoar, Carl S. Jr.,Rowbotham, John L., Wheelock, FrankC., Jr., Gibbons, Gary W., and Campbell,

David, Management of the Diabetic Foot,W. B Saunders Co., Philadelphia, PA,1984.

30. Levin, M. E., O’Neal, L. W., &Bowker, J. H., Ed. The Diabetic Foot, FifthEdition, The C V Mosby Co., St. Louis,MO, 1993.

31. Libow, Leslie B. and Sherman,Frederick T., Ed. The Core of GeriatricMedicine, The C V Mosby Co., St. Louis,Mo, 1981.

32. Lorimer, D., French, G., & West,S., Neale’s Common Foot Disorders, Di-agnosis and Management, Sixth Edition,Churchill Livingstone, New York, 2002

33. Merrill, H.E., Frankson, J., &Tarara, Podiatry Survey of 1011 NursingHome Patients in Minnesota, Journal ofthe American Podiatric Medical Associa-tion, 57: 57, 1967.

34. Merriman, L. M & Tollafield, D.R., Assessment of the Lower Limb,Churchill Livingstone, New York, NY,1995.

35. Merriman, L M & Turner W, As-sessment of the Lower Limb, 2nd Ed.,Churchill Livingstone, New York, NY,2002

36. Pathy, M. S. J., Principles andPractice of Geriatric Medicine, Third Edi-tion, John Wiley & Sons, Chichester,England, 1998.

37. Reichel, William, Ed. Clinical As-pects of Aging, Third Edition, Williamsand Wilkins, Baltimore, MD, 1989.

38. Sims, D. S., Canvanagh, P., & Ul-brecht, J. S., Risk Factors in the DiabeticFoot, Recognition and Management,Physical Therapy, 68: 1988, pp. 1887,1902

39. Strauss, M.B., Hart, J. D., &Winant, D.M., Preventive Foot Care, PostGraduate Medicine, Vol. 103, No. 5, May,1998, pp. 233-245

40. United States Department ofHealth and Human Services, USPHS, NIH,Feet First, No. 0-388-126, USGPO, 1970.

41. Yale, Jeffrey F., Yale’s PodiatricMedicine, Third Edition, Williams andWilkins, Baltimore, MD, 1987.

42 Yale, Irving and Yale, Jeffrey F.,The Arthritic Foot and Related Connec-tive Tissue Disorders, Williams andWilkins, Baltimore, MD, 1984.


Podogeriatric...

Churchill Livingstone, New York,NY, 19972. American Diabetes Association,

Preventive Foot Care in People With Dia-betes, Diabetes Care, Vol. 26, Supple-ment, January 2003, pp. S78-S79

3. Baran, R. Dawber, R.P.R., Tosti, A.,& Haneke, E., A Text Atlas of Nail Disor-ders, Diagnosis and Treatment, Mosby,St. Louis, 1996.

4. Benvenuti, F., Ferrucci, L.,Gurlink, J. M., Et. Al., Foot Pain & Dis-ability in Older Persons, An Epidemiolog-ic Survey, Journal of the American Geri-atrics Society, 43: 479, 1995

5. Bild, D. E., et. al., Lower ExtremityAmputation in People with Diabetes,Epidemiology and Prevention, DiabetesCare, Vol. 12, No. 1, January 1989, pp.23-31.

6. Birrer, R. B., Dellacorte, M. P. &Grisafi, P. J., Common Foot Problems inPrimary Care, Second Edition, Henley &Belfus, Inc, Phila., 1998

7. Bowker, John H. & Pfeifer,Michael A., Levin’s & Oneal’s The Dia-betic Foot, 6th. Ed., Mosby, St. Louis,MO., 2001

8. Centers for Medicare& MedicaidServices, Program Manual, Chapter H,Section 2323, Foot Care and SupportiveDevices for Feet, Baltimore MD,03/27/2002 and Highmark GovernmentServices, Medicare Report, Coverage Re-quirements for Routine Foot Care, June2, 2002, Camp Hill PA, pp 33-36,07/14/2002 and P-1 10/01/2002 for 2003

9. Centers for Medicare & MedicaidServices, Transmittal AB-02-096, Cover-age and Billing of the Diagnosis andTreatment of Peripheral NeuropathyWith Loss of Protective Sensation in Peo-ple With Diabetes, Baltimore MD,07/17/2002

10. Centers for Medicare & MedicaidServices (CMS), Department of Healthand Human Services (DHHS), ProgramMemorandum, Carriers, Transmittal B-02-091, Requirements for Payment ofMedicare Claims for Foot and Nail CareServices, December 27, 2002.

11. Collet, B. S., Foot Problems, TheMerck Manual of Geriatrics, Merck & Co,Inc, Rahway NJ, 1990.

12. Evans, J. C. & Williams, T. F., Ox-ford Textbook of Geriatric Medicine, Ox-ford University Press, England, 1992.

13. Harkless, L. B & Krych, S. M.,Handbook of Common Foot Problems,Churchill Livingtone, New York, NY,1990.

14. Helfand, A. E., Keep Them Walk-ing, Journal of the American PodiatricMedical Association, 58: 117, 1968.

15. Helfand, Arthur E., Ed. ClinicalPodogeriatrics, Williams and Wilkins,Baltimore, Md, 1981.

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Dr. Helfand is aProfessor Emer-itus at theTemple Univer-sity School ofPodiatric Medi-cine and Re-tired Chair ofthe Depart-ment of Com-munity Health,Aging, and Health Policy Consultant,Temple University Institute on Aging.


by Medicare per year is?A) 1B) 2C) 3D) 4

7) Which one of the following is not a “class finding” underMedicare?

A) EdemaB) Hallux valgusC) ParesthesiaD) Burning

8) The appropriate term for ex-cessive dryness of the feet of anolder patient is?

A) KeratosisB) HyperkeratosisC) HyperpigmentationD) Xerosis

9) Which of the following is notconsidered as relevant for thecoverage of the débridement ofonychomycosis?

A) Subungual hematomaB) Subungual debrisC) OnycholysisD) Discoloration

10) Which one of the followingtoenail disorders usually indi-cates a prescription for antibi-otics?

A) OnychorrhexisB) OnychodysplasiaC) ParonychiaD) Onychomadesis

11) Which one of the followingdisorders is not a qualifier for“foot care” with class findingsunder Medicare?

A) Alzheimer’s disease


A) Parkinson’s diseaseB) Diabetes mellitusC) Peripheral arterial insuffi-ciencyD) Diabetes with neuropathy

2) Of the following foot deformi-ties, which one is considered as adegenerative arthritis?

A) Plantar fasciitisB) Pes planusC) Hallux rigidusD) Hallux varus

3) Which one of the following isconsidered as an onychodys-trophic change?

A) OnychomycosisB) OnychorrhexisC) OnychiaD) Paronychia

4) Which one of the followingchanges is an associated clinicalfinding in the older diabetic pa-tient?

A) Achilles Reflex LossB) OnychomycosisC) Hallux valgusD) Hallux limitus

5) The primary initial measure-ment for diabetic neuropathy inthe older patient today is:

A) Reflex lossB) Achilles reflex lossC) Loss of protective sensationD) Vibratory loss

6) The number of pairs of “thera-peutic shoes” that are covered

B) LeprosyC) Pellagra with malnutritionD) Arteritis of the feet


A) Buerger’s diseaseB) Chronic indurated cellulitisC) Alcoholic polyneuropathyD) Post-stroke patients


A) Intractable edema associ-ated with congestive

heart failureB) Mental retardationC) Peripheral neuropathy as-sociated with uremiaD) Amyotrophic lateral scle-rosis

14) Which of the following is not a qualifier for “therapeuticshoes”.

A) Hallux valgusB) Digiti flexusC) OnychogryphosisD) Pes cavus

15) Utilizing the Sims, Ca-vanaugh & Ulbrecht Classifica-tion of Ulcers, hyperkeratotic le-sion with evidence of a sub-kera-totic hematoma would beclassed as which grade?

A) 0B) 1C) 2D) 3

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See answer sheet on page 155.


154 PODIATRY MANAGEMENT • FEBRUARY 2004

16) Which one of the following disorders is nota qualifier for “foot care” with class findingsunder Medicare?

A) Arteriosclerosis obliteransB) Raynaud’s diseaseC) GoutD) Diabetes mellitus–Type II

17) Which of the following usually is defined asa “chronic infection”?

A) ParonychiaB) OnychiaC) OnychocryptosisD) Onychomycosis

18) Which of following is usually defined as an“acute infection”?

A) ParonychiaB) OnychomycosisC) OnychiaD) Onychauxis

19) Which of the following is usually defined asan “onychodystrophy”?

A) OnychocryptosisB) OnychiaC) ParonychiaD) Onychogryphosis

20) Which of the following terms is consideredin the listing of Class Findings?

A) OnychiaB) Hallux valgusC) OnychauxisD) Pes cavus

E X A M I N A T I O N

(cont’d)

See answer sheet on page 155.

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E N R O L L M E N T F O R M & A N S W E R S H E E T (cont’d)

LESSON EVALUATION

Please indicate the date you completed this exam

_____________________________

How much time did it take you to complete the lesson?

______ hours ______minutes

How well did this lesson achieve its educational objectives?

_______Very well _________Well

________Somewhat __________Not at all

What overall grade would you assign this lesson?

A B C D

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Additional comments and suggestions for future exams:

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EXAM #2/04Geriatric Podiatry

(Helfand)

1. A B C D

2. A B C D

3. A B C D

4. A B C D

5. A B C D

6. A B C D

7. A B C D

8. A B C D

9. A B C D

10. A B C D

11. A B C D

12. A B C D

13. A B C D

14. A B C D

15. A B C D

16. A B C D

17. A B C D

18. A B C D

19. A B C D

20. A B C D

Circle:

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clinical assessment ofpodogeriatricpatients · 579.1 tropical sprue 579.9 unspecified intestinal...

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