1
Best Foot Forward: reviewing the literature on the prevalence
of foot pathology in older people
Professor Jackie Campbell and Jane Evans, University College Northampton
Introduction
This literature review is part of a larger research project undertaken by Ray
Jones, Jackie Campbell et al from the University of Plymouth and University
College Northampton.
The project was commissioned by Help the Aged to examine the level of
unmet need among the older population and explore innovative methods of
providing foot-care services to older people. The full report, Best Foot
Forward: older people and foot care, published in August 2005 by Help the
Aged, is available from Help the Aged Publishing (tel. 020 7239 1946 for
credit card orders) at £8.00 plus £1 postage and packing (cheques payable to
Help the Aged should be sent to 207–221 Pentonville Road, London N1 9UZ).
1 Methods
To obtain statistics on the prevalence of foot pathology in older people, a
search was made of bibliographic databases, and websites for health
collections, gateways, organisations and services.
Bibliographic databases
Ingenta
AMED
Assianet
BioMed Central
BioMedNet
Reviews
British Nursing
Index
CINAHL
Cochrane Library
Embase
Emerald
Highwire
Kluwer
Medline
Recal
Science Direct
Swetswise
Web of
Knowledge
Your Journals @
Ovid
Zetoc
1
2
Websites for health collections and gateways
BUBL
Health on the Net
Foundation
Medline Plus
MedWeb
National Electronic Library
for Health
National Research Register
NMAP
Organising Medical Networked
Information
UK Health Centre
Websites for organisations and services
Alberta Podiatry Association
American Podiatric Medicine Association
Department of Health
Foot and Ankle Institute
Foot and Ankle Library
Institute of Healthcare Management
International Working Group on the Diabetic Foot
Podiatry Online
Society of Chiropodists and Podiatrists
The Wellcome Trust
World Health Organisation
Websites for UK national statistics
House of Commons Hansard
National Statistics Online
2 Search strategy
In the bibliographic databases, the search strategy varied according to the
rules for truncation, the existence of a thesaurus, and the size of the
database, but broadly the strategy was to search for a combination of the
three facets of the topic:



Podiatr? OR chiropod? OR foot
Prevalence OR incidence OR epidemiology OR frequency
Elderly OR geriatric OR aged OR old?
Modifications to the strategy had to be made where the number of references
retrieved was too great, i.e. sometimes the age facet had to have ‘aged’
removed because it retrieved too many ‘aged 18’ etc. Similarly, sometimes
‘NOT child?’ had to be entered to avoid retrieving the wrong ages. Where too
many hits were related to the diabetic foot, ‘NOT diabet?’ had to be entered.
2
3
3 Types of literature retrieved
The literature contains two types of surveys of the elderly: those covering foot
health in general and enumerating the various conditions identified, and those
dealing with specific foot conditions. The former are sometimes difficult to
compare because (a) the conditions are not described in exactly the same
way and (b) the conditions are sometimes clinically observed by a podiatrist
and sometimes as perceived by the elderly person. It has also been noticed
that many older people may consider foot disorders an inevitable part of the
ageing process and therefore do not report them to health professionals
(Menz and Lord 1999).
The surveys noted have been carried out not only in England, but also in Italy,
the Netherlands, Sweden, Australia, Canada and the USA.
In the present research into the unmet need for podiatric care of the elderly, it
is of course important to consider the predicted growth in the elderly
population. The proportion of older people continues to rise, death rates are
continuing to fall and the average life span is increasing by an average of two
years every decade (UK Central Council for Nursing Midwifery & Health
Visiting 1997). Between 1979 and 1994 the number of elderly people over the
age of 85 years increased by 50 per cent (Office of Population Censuses and
Surveys and General Register Office for Scotland 1993). The number of
people over 85 years of age was projected to increase by 15 per cent from
1995 to 2019 (UK Central Council for Nursing Midwifery & Health Visiting
1997). Giving a more European perspective on the issue, Woolf predicts that
by 2025 25 per cent of Europeans will be aged over 65 (Woolf and K.
Akesson 2003).
Menz described the difficulty in establishing the prevalence of foot problems in
older people when he referred to the lack of consensus as to what actually
constitutes a foot problem, the variations in the populations that have been
assessed, and the variety of approaches used to collect the data.
Foot problems in older people may result from age-related decreases in joint range of
motion, dermatological conditions, detrimental effects of footwear, and systemic
conditions such as peripheral vascular disease, diabetes mellitus and arthritis.
Furthermore, the definition of a foot problem may also include an individual's inability
to maintain basic foot hygiene (e.g. cutting toenails) or [have] difficulty in purchasing
comfortable shoes. (Menz and Lord 1999)
In order to meet the requirements of the present study, foot conditions were
prioritised by a panel of podiatry service managers so that low-risk ones were
scored from 1 to 10, 1 indicating where professional interventions are most
desirable, 10 where intervention is least indicated.
The top five were:
Corns
Callus/tyloma
Plantar neuroma
1
2
3
3
4
Ganglion/bursa
Fissure
Abrasions/trauma
Symptomatic nail pathology
4
4
5
5
The bottom five were:
Heel deformity
Mid-tarsal deformity
Hallux valgus/rigidus
Lesser toe deformity
Exostosis
Fungal infection – skin
Anidrosis/xerosis
Hyperidrosis
Fungal infection – nails
Asymptomatic nail pathology
Maceration
6
6
7
8
8
9
9
9
10
10
10
Medium risk is presented when increasing discomfort or pain are noted in lowrisk conditions.
High-risk conditions are listed as:
ulceration
tissue breakdown
infection
neoplasm
inflammation
cellulitis
gangrene
Charcot joint.
At any level of risk, the presence of a relevant medical condition may make
professional intervention essential. These medical conditions are:
neuropathy
oedema/edema
rheumatoid arthritis
osteoarthritis
diabetes
hypertension (with relevant complications)
peripheral vascular disease/peripheral arterial disease
cardiovascular conditions
malnutrition
compromised immunity
medication factors
scleroderma
lupus
arteritis
4
5
gout
Raynaud's disease
Charcot Marie tooth syndrome
cerebral vascular accident.
The prioritisation eliminated, from this paper, a certain amount of research
found in the original literature review. The studies here are only included
because they refer to the top five low-risk and high-risk conditions.
The research studies to be considered are described by:
researcher – date of research – place researched – no. of subjects – age of
subjects – type of residence (i.e. in the community or in care home) – type of
assessment.
Where necessary, results presented in the original papers by age and sex
have been put together to create overall percentage rates for the 65+ age
group.
The studies are arranged in three sections:



General surveys (of 60+ or 65+ age group) and within that by region
(England and Wales, Europe, Australia and USA)
General surveys but with the subjects pre-selected according to a
particular criteria, e.g. aged 75+ or living in nursing homes, and within that
by region (England and Wales, USA)
Surveys of a specific disease arranged by region (Europe, Australia, USA
and Canada). (These are not always restricted to the 60+ age group.)
4 General surveys of 60+ or 65+ age group
4.1 Research in England and Wales
Cartwright, A & G Henderson – 1985 – England – 543 – 65+ – in
community – self-assessment + by chiropodist
In England in 1986 a project was undertaken by the Department of Health and
Social Security to do almost precisely what the present project seeks to
achieve. A search of the UK Data Archive located a database describing
unmet needs of the elderly for chiropody (Cartwright and Henderson 1986). A
random sample of people aged 65 and over was selected from the electoral
register in ten representative parliamentary constituencies in England. The
number of people taking part in the study was 543 (76 per cent of the elderly
people identified). Foot examinations were carried out in the participants’
homes by state-registered chiropodists.
This study is very significant in any review of podiatric conditions because it
has a broad base; the sample was scientifically selected, and 76 per cent of
the elderly people approached were willing to take part. The elderly people
were a sub-sample systematically selected from a random sample of 1,026
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Systematic Review of the Literature: General Surveys of 60 or 65+ age group
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elderly people who had already been identified for the ISSMC Elderly People:
their medicines study. The original study was carried out in ten parliamentary
constituencies chosen with a random starting point after stratification by the
proportion of people of pensionable age, with probability proportional to the
number of electors. In each of these areas a systematic sample of 500 people
was selected from the registers published in February 1984.
The patients were examined by a chiropodist as well as giving a selfassessment, so the results are particularly interesting. They reveal the
existence of what is known as 'the iceberg effect' (Hannay 1979) (Lisdonk
1989; Lamberts, Brouwer et al 1991) (Vetter, Jones et al 1986; Kees,
Kuyvenhoven et al 2000). Just over half the elderly people (52 per cent)
initially reported some trouble with their feet, and more detailed questioning
revealed that 86 per cent had some foot condition, problem or deformity.
Examining chiropodists assessed that 84 per cent had some foot problems,
describing 4 per cent as having major ones, 22 per cent moderate problems
and 58 per cent minor ones. Roughly one in seven of the people had feet that
were entirely problem-free. These findings bear out the evidence in Menz that
elderly people do not always report foot problems (Menz and Lord 1999).
The data from this study were released in 1986 and so it is somewhat dated
and does not reflect any changes in the health of elderly people's feet which
may stem from improved lifestyle or better treatment over the last 20 years.
Nevertheless it is a very relevant, useful study for the purposes of this
research.
Cartwright, A & G Henderson (1986)
Initial reports of foot problems
Reports after more detailed
questioning
Reports of difficulty cutting toenails
Chiropodists’ assessment of foot
problems
Major foot problems
Moderate
Minor
None
Dorsal corn/callus
Apical corn/callus
Interdigital corn/callus
Ungual corn/callus – definite
Ungual corn/callus – possible
Plantar corn – definite
Plantar corn – possible
Plantar callus – severe
Plantar callus – moderate
Cuts, bruises or abrasions
Ingrowing or involuted toenails –
52%
86%
50%
4%
22%
58%
16%
33%
27%
9%
10%
28%
20%
12%
3%
19%
3%
9%
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Systematic Review of the Literature: General Surveys of 60 or 65+ age group
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severe
Ingrowing or involuted toenails –
slight
Thickened toenails
Other nail problems
Pain or discomfort with feet
Severe
Moderate
Minor
None
Foot ulcer – infected or not
infected
38%
45%
19%
7%
18%
13%
62%
2%
In the low-risk conditions, corns, calluses and symptomatic nail pathology are
a significant problem. As the prevalence of corns and calluses are reported by
site and severity of the individual conditions, it is not possible to combine
these rates to arrive at an estimate of the proportion of older people with these
problems. This is because some people will have corns on several sites, for
instance. However, other studies have estimated the proportion of people with
multiple foot pathologies (e.g. Crawford et al 1993, Sinacore, 2000) and this
may be used as a rough guide to the extent of double-counting that may be
present in these figures. Moderate or severe pain/discomfort with feet is also
surprisingly common at about 25 per cent. Of the high-risk conditions listed,
only ulceration and infection were covered in the survey – under the heading
'Foot ulcer – infected or not infected'. The proportion is 2 per cent.
Brodie, BS, CS Rees et al – 1983 – Wessex – 200 – 65+ – in community -–
self-assessment + by chiropodist
Also from the early 1980s, this survey is regionally based in Wessex and
involved 700 people randomly selected in seven age groups. For the over18s, the sample was based on the electoral register, with 50 males and 50
females from every age band. (These included bands for 65–74 and 75+.)
The authors of the study ensured that interviewers were trained to achieve as
uniform an examination as possible, and the questionnaires were confined to
the general and more obvious conditions which might be found, in order to
satisfy the constraints of time and subject co-operation.
The interviews were conducted by chiropodists who also investigated the
respondents' feet. The results were analysed in fairly general categories, and
the ones considered in this paper are listed in the table below. They include
only corns, calluses and nail pathologies. The proportions in this study are
similar to those in Cartwright and Henderson (1986). It must be noted that the
survey involved 100 65–74-year-olds and 100 people aged 75+, hence a
higher proportion of those aged 75+ than in the Cartwright study.
The authors concluded their study with reference to a subsequent volume in
order to report on the implications of the research on chiropody staffing needs
and norms.
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Systematic Review of the Literature: General Surveys of 60 or 65+ age group
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Brodie (1983)
65+
Reporting
foot problem
Difficulty in
cutting
toenails
Medical
conditions
predisposing
towards
need for
chiropody
Corns
Calluses
Nail
pathologies
65–74 years
75+
Men
Women
Men
Women
%
62
%
56
%
58
%
58
%
76
67
62
48
78
80
50.5
42
48
56
56
30
41.5
41
24
42
38
36
48
34
20
26
52
40
50
40
Elton, PJ & SP Sanderson – 1986 – Manchester – 1,153 (i.e. the 66 per
cent who were willing to take part and could be contacted out of
potential 1746) – 65+ – in community – self-assessment (154) + by
chiropodist (999)
This survey, again from the 1980s, is restricted to the population of an urban
area. The sample of 1,746 was taken from the GPs' age/sex registers in North
Manchester. Of those selected, 66 per cent were willing to take part, but not
all were examined by a chiropodist. Those not attending the clinic constituted
9 per cent and, in the main, were just interviewed without being examined.
The accuracy of the sampling is therefore flawed because self-assessment is
not a reliable measure, as has been suggested by Cartwright, and the fairly
high proportion of those unwilling to take part may either reflect reasonable
foot health or a dissatisfaction with the service and a consequent reluctance to
participate. The survey particularly probes whether patients in need were
receiving treatment, and whether need was being properly assessed by GPs.
Three low-risk conditions were listed – corns, calluses and nail pathology, and
the percentage rates match fairly closely those of the previous two studies.
Heel pain was also mentioned, the rate being 4 per cent.
Elton (1986)
Chiropodial conditions (%)
Both sexes
Male
Female
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Systematic Review of the Literature: General Surveys of 60 or 65+ age group
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26
17
31
42
30
49
66
65
66
49
56
50
61
25
34
4
5
Corns
Hard skin, ball of
foot
Nail conditions,
first toe
Onychauxis
53
Onychophosis
Nail conditions, lesser toes
57
Onychauxis
31
Onychophosis
4
Heel pain
Harvey, I, S Frankel et al – 1988–91 – South Glamorgan – 560 (i.e. the 71
per cent who responded out of potential 792) – 60+ – in community –
assessment by chiropodist
This study, like Elton's, is predominantly concerned with assessing how
chiropody care is rationed out and deduces that foot morbidity is not an
independent determinant of receipt of care. The random sample was of 792
patients from GP registers in South Glamorgan in about 1990. The positive
response rate was similar to Elton's study, being 71 per cent, and patients
were examined by a chiropodist for fairly common low-risk conditions – corns,
calluses, symptomatic nail pathology and toe deformities. The proportions for
each condition are not given as the authors were more interested in the
number of foot problems found in each patient. The table shows that 53 per
cent had three or more of these problems. (N.B. The deformities are not
included in the top five low-risk conditions in this paper.)
Harvey (1997)
Foot morbidity score (range 0–5, 1 point scored for each problem present, on
either foot)
Foot problems examined were for toe deformities (hallux valgus and lesser
toe deformities), corns and callosities, in-growing toenails and toenail
thickening.
Mean foot index scores
2.5 (index 1) and 1.1 (index 2)
Three or more foot problems
53%
Garrow, P, AJ Silman et al – 2004 – Cheshire – 3,417 – age 18–80
population survey – self-assessed + follow-up interviews and
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Systematic Review of the Literature: General Surveys of 60 or 65+ age group
10
professional examination on 231 respondents with ‘disabling foot pain’
and 50 with no disabling foot pain
This very recent study was designed to estimate the prevalence of disabling
foot pain, broken down by age and sex, and any associations with foot
pathology, regional pain and other general health indicators. It was conducted
initially by postal questionnaire to a large random sample (n = 4780) of
patients aged 18–80 selected from the lists of two general practices in
Cheshire – one from a small market town and the other a commuting suburb
of Manchester. There was a very high response rate (84 per cent). The paper
does not give information on the age profile of the respondents. Respondents
who reported having had foot pain in the last month had foot pain on the day
they competed the questionnaire and reported at least one disability arising
from foot pain (as measured by the Manchester Foot Pain and Disability
Index, Garrow et al, 2000) and were defined as having ‘disabling foot pain’.
This group were invited for an interview and professional foot examination,
together with a control group of respondents who did not report disabling foot
pain.
The following prevalence of self-assessed foot problems (not broken down by
age) was reported.
Self-reported foot problems in the previous six months, by gender
Foot problems
Total %
Male %
Female %
(n = 3047)
(n = 1357)
(n=1690)
Any foot problem 63.2
57.5
68.0
Corn or callus
30.7
20.2
39.2
Nail problem
23.7
23.5
23.9
Swollen feet
12.0
6.2
16.7
Bunions
8.0
2.6
12.2
Verrucae
4.6
4.0
5.0
Overall, 24 per cent of women and 20 per cent of men reported foot pain
during the last month lasting at least one day. The prevalence of disabling foot
pain was 11 per cent for women and 8 per cent for men, but increased with
age, more steeply for women than for men, reaching a peak at age 55 to 64
(15 per cent women, 12 per cent men) after which it decreased to
approximately 10 per cent for both sexes at age 75–80.
Only 16 per cent of the overall study population had received foot treatment
from a healthcare professional in the last six months (36 per cent with
disabling foot pain, 14 per cent with no disabling foot pain). This rate
increased with age, with 40.5 per cent of the over-65 age group receiving
professional foot care.
Those who underwent the professional examination as part of the study
showed that, in most cases, the prevalence of clinician-diagnosed problems
was greater than the self-assessed rates. This was examined by foot problem
and the following sensitivity (proportion of foot problems identified by self-
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Systematic Review of the Literature: General Surveys of 60 or 65+ age group
11
assessment that were also identified by the clinician) and specificity
(proportion of absence of foot problem reported by self-assessment that were
also reported as absent by the clinician) results were reported.
Sensitivity and specificity figures, comparing self-reported with
clinician-diagnosed foot problems
Foot problem
% Sensitivity (95%
% Specificity (95%
confidence interval)
confidence interval)
Nail problems
51.7 (44.4–58.9)
79.2 (70.3–85.9)
Corns and callosities
47.4 (41.4–53.8)
91.4 (80.1–96.6)
Bunions
29.2 (22.9–36.5)
96.3 (90.9–98.6)
Verruca
33.3 (13.8–60.9)
97.7 (95.5–98.9)
Swollen feet
57.3 (47.9–66.1)
87.5 (81.7–91.7)
4.2 Research in Continental Europe
Benvenuti, F et al – 1995 – Italy -– 459 (i.e. the 73 per cent who were
willing to co-operate and have medical assessment out of a potential
628. The 73 per cent were similar in age, gender, level of disability to
group refusing medical assessment) – 65+ – in community –
assessment by physicians
Two studies in continental Europe – Italy and the Netherlands – are of
interest. Benvenuti in 1995 assessed 459 people over 65 in a small town in
Italy. The positive response rate is similar to that in England and Wales, being
73 per cent (out of 628). The group who took part were similar in age, gender
and level of disability to the group who refused to participate. The assessment
was reliable, being a standardised medical examination by a geriatrician. The
particular emphasis in this study was to assess the association between foot
pain in older people suffering from pathological conditions of the foot with
disability. The list of conditions evaluated is more extensive than in Elton and
Brodie. It is not easy to compare the prevalence rate of corns and calluses
with the English rate because Benvenuti puts them together in one
percentage figure, but if the two English rates are added together, the rates
are in fact similar.
Benvenuti (1995)
Prevalence of foot problems according to gender and age
Men
Women
Total
65–74 75+
65–74 75+
population
yrs
yrs
Variables
%
%
%
%
%
Corns or calluses 64.8
49.6
65.5 75.9
70.2
Hypertrophic nails 29.6
27,8
35.2
19.9
40.4
Prevalence odds-ratio
Women vs 75+ vs
men
65–74
2.3
(1.5–3.3)
0.9
(0.6–1.3)
1.1
(0.8–1.7)
2.0
(1.3–3.0)
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Systematic Review of the Literature: General Surveys of 60 or 65+ age group
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Onychocryptosis
5.4
4.0
6.8
6.4
4.8
Pain only when
standing
Pain also at rest
21.8
17.5
23.9
41.1
41.4
9.6
3.2
5.5
11.4
18.3
1.1
(0.5–2.5)
2.7
(1.8–4.2)
3.8
(1.8–7.8)
1.1
(0.5–2.5)
1.2
(0.8–1.7)
3.8
(0.9–3.3)
Kees, JG et al – 2000 – Netherlands – 5,689 (i.e. 79 per cent response
rate out of potential 7,200) – 65+ – in community – self-assessment by
postal questionnaire
The Dutch study by Kees et al was conducted in 1997 among a very large
random sample of people aged over 65. The selection was based on
community registers in an urban district and the positive response rate was
very high – 79 per cent. As with Benvenuti, the prime motive was to discover
whether foot complaints are risk factors for limited mobility and poor perceived
well-being. The response rate may have been particularly good because
people who did not reply were sent a reminder after two weeks and if
necessary were telephoned two weeks after that. The assessment, however,
was possibly not reliable because it was based on a postal questionnaire.
Comparisons with the English studies are made difficult because the
questionnaire combined common foot complaints together, defining them as
complaints not owing to an accident and lasting longer than four weeks. On
the face of it, the percentage rates are lower than in England, but this could be
a result of the survey being based on self-assessment. Of the 20 per cent of
people with non-traumatic foot complaints of over four weeks’ duration, 80 per
cent had musculo-skeletal problems related to the forefoot, thus giving an
average figure of 16 per cent for musculo-skeletal problems. Foot
osteoarthritis is singled out, and the percentage rate is 8 per cent.
Kees (2000)
General characteristics of the study population (N = 5,689)
Characteristic
% of respondents
Female
58
Age 75+
38
Foot osteoarthritis
8
Foot complaints, non-traumatic of
20 (men: 14%; women: 24%)
4+ weeks duration
Of these, non-traumatic complaints:
Foot pain
60 (i.e. 12% of total)
Malpositioning of toes or toenail
20 (i.e. 4% of total)
problems
Numbness or swelling
12 (i.e. 2.5% of total)
Skin problems
8 (i.e. 1.6% of total)
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Systematic Review of the Literature: General Surveys of 60 or 65+ age group
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4.3 Research in Australia and USA
Munro, BJ & JR Steele – 1998 – Australia – 128 (i.e. 46 per cent of the
276 eligible who answered the phone researchers) – 65+ – in community
– self-assessment by postal questionnaire
A study was conducted in Australia in 1998 to assess the prevalence of foot
problems among older people and the rates of utilisation of chiropody
services. The random sample comprised only 128 people and was based on a
random selection of 1,715 phone numbers which were then narrowed down to
those eligible for the survey (276). Two hundred people were willing to
participate, but the response rate was in fact only 64 per cent. The
assessment was based on a postal questionnaire, and the results were
checked against what was expected. The questionnaire was said to be
reliable. The categories do not quite fit the ones listed in this paper as
priorities, e.g. there is a general category of ‘skin problems’.
The purpose of the study was again to provide evidence that elderly people
need to be educated about foot problems and the need for foot care in order
to maintain their mobility and well-being. So views were also elicited on any
treatment sought and received.
Specific foot problems reported by respondents
Foot problem
Total %
Men %
Corn
17
8
Callus
13
11
Skin problem
19.5
9
Ingrown toenail
13
12
Hard, thickened
26
28
nail
Foot pain
52
45
Swollen feet
17
9
Arthritis
22.5
23
Other
14
13
None reported
29.5
40
Female %
26
15
30
14
30
59
25
22
15
19
Diagnosed medical conditions reported by respondents
Condition
Total %
Men %
Female %
Leg circulation
20
18
23
problems
National Health Interview Survey – 1990 – USA – 119,631 all ages
(number of 65+ not known) – 65+ – in community – assessment by
untrained observers
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Systematic Review of the Literature: General Surveys of 60 or 65+ age group
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In the United States the National Health Interview Survey in 1990 is
particularly large, covering about 120,000 people within age bands. It is not
known how many were in the 65+ age band, and assessment was by
untrained observers. Greenberg analyses this survey, comparing it with
another one (of 1,000 people aged over 65) run by Bruskin/Goldring Research
in 1992 (Greenberg 1994). The tables show how the categories of problems
are very broad and limited. Also the latter study made assessments only by
telephone interview. The low figures seem a mystery unless they reflect the
untrained assessment procedure and a bias in the selection of participants.
Foot condition
Corns and calluses
Toenail problems in the last year
Foot infections
With foot problem in the last year
%
10
10
5
31
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Systematic Review of the Literature: General Surveys of 60 or 65+ age group
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Bruskin/Goldring Research – 1992 – USA – 1,003 – 65+ – in community –
assessment by telephone interview
Foot condition
Corns and calluses
Toenail problems in the last year
Foot infections
With foot problem on any occasion in
whole life
%
12
8
less than 1%
38
Helfand, AE et al – 1998 – USA – 417 – 60+ – in community – method of
assessment unclear
This American study was far more precise and scientific than the two previous
large-scale ones mentioned above. It was conducted between 1995 and 1998
among 417 people over 60 years old, living in the community in the city of
Philadelphia. It is not clear how they were selected. Helfand writes that higherrisk patients tend to be receiving care already so it was not expected that the
number of such patients in the study would be significant. He thus indirectly
suggests that the selection process was for volunteers from those who were
not receiving care. The results will therefore be affected by a prevalence of
low-risk conditions. The assessment is so precise that the observers must
have been trained, although it is not stated whether they were podiatrists.
Assessment is made even more reliable because the participants were
educated in some depth about foot health. The results show the widespread
prevalence of foot problems among older people, and are quite similar to the
findings of Cartwright.
Helfand (1998)
Prevalence of foot conditions
Condition
Heloma (corns)
Tyloma
Hyperkeratosis
Prominent plantar metatarsal heads,
with soft-tissue atrophy
Onychauxis
Onychodystrophy
Painful toenails
Clinical hallux limitus
Painful feet
Cold feet
Bacterial infection
Foot ulcerations
%
33
26
48
24
28
31
28
17
45
12
2
2
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Systematic Review of the Literature: General Surveys of 60 or 65+ age group
16
Sinacore, DR – 2000 – USA – 81 (19 men, 62 women) – 51+ – in
community – assessment by podiatrist
The study by Sinacore is much smaller than Helfand’s and the sample was
self-selected, being in response to requests for volunteers. Of the 81
participants (over 50 years old), 62 were women. Women have been shown to
be more prone to foot problems than men, so the results of the study will be
biased. Asking for volunteers is likely to have attracted those with problems,
so with the sexual bias as well, the results are not very reliable. The
categories are very broad, e.g. ‘skin and callus’ and ‘foot deformities’, so
comparisons with other studies are difficult.
Prevalence of most common foot impairments in the elderly
%
Foot impairment
Skin and callus
46
Foot deformities
36
With 2 or fewer impairments
45
With 3–5 impairments
53
With 6+ impairments
2.5
5 General surveys with specified sub-populations (i.e. not just 60 or
65+)
Research in England and Wales
Campbell, J et al – 2002 – Cambs & Hunts – 343 (assessed as low-risk
and discharged from NHS podiatry service) – 65+ – in community –
assessment by podiatrist
This study took place in Cambridgeshire in 2002 to assess the effect on older
people who were discharged from NHS podiatry services in two health
authorities because they were assessed as low-risk during a disinvestment
programme. The 343 patients included were therefore not a totally random
sample, having had low-risk foot problems within the past one to three years.
The authors made a random selection within this group of people and after
encountering anger in the responses on account of reaction to the cutbacks,
they had to reword their letter of invitation to assure patients of the
independence of the study. Every effort was made to ensure uniformity of
assessment, which was carried out by two podiatrists. Sometimes the same
patient was assessed by both to check the validity of the results.
The purpose of the study was to find out how much foot health deteriorated
after discharge and what factors were involved. The results are in broad
categories. Their fairly high percentage rates may reflect the fact that all
patients had been assessed as low-risk within the previous three years.
16
Systematic Review of the Literature: General Surveys of 60 or 65+ age group
17
Campbell (2002)
Percentages of moderate/severe pathologies receiving only home care
12–18 months after discharge
Moderate/severe nail pathology
30
Moderate/severe hyperkeratosis
42
Moderate/severe pain
49
Moderate/severe inflammation
40
Unilateral/bilateral oedema
37
Insensitivity to touch
26
Insensitivity to vibration
33
Crawford, VLS et al – 1993 – South Belfast –248 – 75+ – in community –
assessment by podiatrist. NB Foot problem percentages are based on
the 128 (52 per cent) needing treatment
This study is similar to Campbell’s in that the prevalence rates of foot
conditions are based on a sample who are currently receiving podiatry
treatment. (Campbell’s sample had been receiving treatment within the
previous one to three years.) Therefore the rate may be higher than in a
normal population. On the other hand, some surprisingly low prevalence rates
such as those for ingrowing toenails (7 per cent) may be owing to the fact that
appropriate podiatry treatment was being received.
The group is aged over 75 and living in the community. The sample was
based on a random selection of one in ten of those eligible and living in south
Belfast – i.e. 730 individuals. The number was reduced to 248 on account of
various factors, e.g. being institutionalised or not traceable. Only 52 per cent
of these were studied because the study required them to be in contact with
podiatrists. The assessment was by a podiatrist. The prevalence rates of
corns and hard skin are surprisingly high considering that podiatry treatment
was being received, but the age band (75+) would account for this. As
mentioned above, the rate of ingrowing toenails is unusually low. Crawford
points out, however, that a similarly low prevalence rate was found in a study
by Salvage of a group of over-75s in South Glamorgan in 1988 (see below).
No present contact with podiatrist
Needing treatment
% based on those needing treatment
Having 1 foot problem
Having 2 foot problems
Having 3 foot problems
Having 4 foot problems
Foot problem treated
Hard skin
Corns
Infections
Nails – cutting
48%
52% (males 26; females 102)
23%
48%
23%
6%
36%
48%
2%
96%
males: 35%
males: 39%
males: 0%
males: 96%
females: 36%
females: 51%
females: 2%
females: 96%
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18
Nails – thinning
Nails – ingrown
6%
7%
males: 8%
males: 4%
females: 5%
females: 8%
Salvage, AV et al – 1988 – South Glamorgan – 251 (i.e. the 69 per cent
who were willing to participate and could be contacted out of potential
362) – 75+ – in community – assessment by interview
In a South Glamorgan community, 370 subjects over 75 were randomly
selected. Of these, 69 per cent (251) could be contacted and were willing to
participate. In the last year, 37 per cent had seen a podiatrist, which may
explain the low rate of ingrowing toenails. Assessment was by a podiatrist.
%
Foot condition
Ingrowing toenails
Unable to cut own toenails
Able to cut own toenails with difficulty
7
38
19
White, EG & GP Mulley – 1989 – Leeds – 96 (i.e. the 95 per cent who were
willing to be examined out of potential 101) – 80+ – in community –
assessment by chiropodist
This group was also quite narrow, covering people over 80 and living at home.
From a GP’s age/sex register in Leeds, 106 people were selected and of
these 96 were willing to participate. As with all these studies, the proportion
currently receiving podiatry treatment (in this case nearly 50 per cent) affects
the reliability of the figures, as foot health may be better in those who are
being treated and the level of podiatry care varies from health authority to
health authority. Assessment was by a podiatrist. The study is also similar to
other research cited in that the effects of not being able to cut one’s own
toenails is seen as a source of potential nail pathology and foot pain. The
prevalence rates seem high but can be accounted for by the high age group.
White (1989)
With foot problem
With foot pain
Difficulty in cutting own toenails
Corns or calluses
Nail pathology
94%
30%
77%
68% (men: 44% women: 76%)
56% (men: 68% women: 52%)
6 General surveys with groups pre-selected (i.e. not just 60 or 65+)
Research in USA
Black, JR & W Hale – 1987 – USA – 733 – 72+ – in community – selfassessment by questionnaire with nurse or technician
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19
It is not stated how the sample was selected in this study. It took place in a
community in Florida in 1987 with a high proportion of retired people. The
number of people who participated was 733, and the youngest was 72.
Assessment may have been flawed because it was done by the participants
on the basis of a questionnaire with a nurse or technician subsequently
helping to complete any questions that had presented difficulty. The low
prevalence rate for corns may reflect the difficulty in distinguishing between
calluses and corns experienced by the older participants.
Black (1987)
Frequency of foot problems
Foot problem
Total %
Toenail problems 22.5
Calluses
20.2
Corns
16.1
Swelling
9.8
Decreased
9.1
activity
Burning spells
5.4
Loss of feeling
3.7
% Men
17.3
9.8
4.7
5.1
5.2
% Women
25.1
25.7
22.1
12.3
11.2
2.4
2.4
7.1
4.4
Hannan, MT et al – 2001 – USA – 56 – 65+ – in nursing home and
ambulatory – assessment by podiatrist
The group studied in this research were residents of a nursing home. The
study took place in 2001 in the USA. The number of participants was quite
small – 56. They were all ambulatory, and assessment was by a podiatrist.
The choice of categories seems odd because there is no mention of corns or
calluses. The list provided covers the eight most frequent foot problems, only
one of which comes in this paper’s list of priorities.
Hannan (2001)
Prevalence of most frequent foot problems
Dystrophic nails
78%
Foot vibratory lack of sensation
57%
Varicosities
25%
Ankle edema
9%
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7 Surveys on specific diseases/foot problems
The literature review listed several foot diseases and related medical
conditions on which research had been carried out, but only one area falls
within the list of priorities to be discussed in this systematic review –
ulceration.
Leg and foot ulcers
Research in Europe
Ebbeskog, B et al – 1996 – South Stockholm, Sweden – 241,804 – all
ages, with age bands – in community – questionnaire for clinical staff
Four very large studies have been reported in Sweden – in South Stockholm
(1996), Malmo (1992), Skaraborg county (1991) and Blekinge county (1998).
The populations studied ranged from 151,610 to 270,800. Assessment was
done by a questionnaire sent to clinical staff, and the response rate was high
at over 90 per cent. The prevalence rates cover anyone with leg or foot ulcers
undergoing treatment, but the vast majority (85 per cent and 92 per cent in
two of the studies) are elderly patients. The rates of 0.12 per cent, 0.19 per
cent and 0.33 per cent are better than the 2 per cent rate reported in
Cartwright’s and Helfand’s studies.
One of the Swedish studies was by Oien, and he makes the interesting
suggestion that the ulcers were being treated more successfully since the
annual questionnaire was introduced in 1986. (The annual questionnaire was
the basis for his research in Blekinge county.) It encouraged staff to make
more accurate diagnoses of ulcer aetiology and he presumes, therefore, that
they give more effective treatment. Ulcers with a duration of over two years
decreased from 44 per cent to 27 per cent and treatment time per ulcer from
2.1 to 1.7 hours per week.
Ebbeskog (1996)
Prevalence of leg and foot ulcers
Age
All ages
Over 65
Commonest cause
Venous insufficiency
Pain reported with venous ulcer
Pain
%
0.12%
92%
42%
47%
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21
Lindholm, C et al – 1992 – Malmo, Sweden – 264,959 (i.e. circa 95 per
cent response rate) – all ages – all types of residence – questionnaire to
clinical staff
Prevalence of leg and foot ulcers
With leg or foot ulcer
0.12%
Nelzen, O et al – 1991 – Skaraborg county, Sweden – 270,800 (with
response rate of 92 per cent) – all ages, with age bands – all types of
residence – questionnaire for clinical staff
Prevalence of leg ulcers
With active leg ulcers
Median age of patients with leg ulcers
Patients with leg ulcers over 65
0.33%
76.5 years
85%
Oien, RF – 1998 – Blekinge county, Sweden – 151,610 – all ages – all
types of residence – questionnaire for clinical staff
Prevalence of chronic leg and foot ulcers
With chronic leg or foot ulcer
0.19%
Commonest cause
Venous ulcers
38%
Leg and foot ulcers
Research in Australia
Johnson, M – 1995 – Australia – 1,050 – 65+ – in community – method of
assessment not given, with mention of studies in Sweden and North
America
No source for prevalency rates given.
A study in Australia found slightly higher prevalence rates (1 per cent) than
those in Sweden, based on a population group of 1,050 in a large city.
Johnson points out that despite low prevalence rates, the condition involves
major health costs with frequent nursing visits, therefore preventive measures
and screening for venous and arterial vascular disease are cost-effective.
Johnson (1995)
Prevalence of chronic leg ulcers
All ages in an Australian town
Over-60s in Swedish survey
Over-60s in North American survey
1%
1%
1%
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Leg and foot ulcers
Research in USA and Canada
Harrison, M et al – 1999 – Canada – total number not given – all ages,
with age bands – all types of residence – clinical assessment
The research by Harrison in 1999 covered a whole region in Canada and
used clinical staff as a source of information on prevalence. Harrison
mentions a study by Nelzen in 1996 which suggests that a significant
proportion of people with leg ulcers may be self-managing their condition.
(Nelzen 1996) Harrison’s study therefore also includes a mechanism for selfreferral (advertisements in 15 local and community newspapers). She does
not give details of the response rate to these advertisements. The prevalence
rate of 1.8 per cent is similar to that in Cartwright and Helfand. Nearly 75 per
cent of the cases were in people over 65.
Harrison (1999)
Prevalence of leg and foot ulcers
With leg or foot ulcer
Within this patient group, % of over65s
Within this patient group, with a leg
ulcer (all ages)
Within this patient group, with both
leg and foot ulcer
Within this patient group, with a foot
ulcer
Within this patient group, with history
of leg or foot ulcers
Within this patient group, with 2 or
more leg or foot ulcers
Within this patient group, with
moderate to severe pain from ulcers
1.8%
nearly 75%
50%
15%
35%
45%
over 40%
over 35%
Paletta, C, Professor, Dept. of Plastic Surgery, St Louis University, USA
– in eMedicine 2003
Review of research in Ireland, Australia and Sweden
No source for prevalence rates given.
This review by Paletta (2003) reports that the prevalence rate of ulcers in the
USA is not known. He refers to studies in Ireland and Australia, finding the
prevalence rate of chronic leg ulcers to be about 1 per cent. He also mentions
a telephone survey in Sweden which shows that over time, in people over 70,
the prevalence rate for both healed and non-healed ulcers is 9.8 per cent. No
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further details are given, although he suggests that 80 per cent of leg ulcers
are caused by venous disease and 20 per cent by arterial disease.
Current chronic leg ulcers in Ireland
and Australia
Healed & non-healed ulcers over time
in over-70s in Sweden (telephone
survey)
1%
9.8%
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