When we as foot specialists examine a foot, we break it down into four systems: dermatological, orthopedic, neurological and vascular. The vascular or circulation system is further broken down into arterial blood flow into the foot and venous which is blood flow away from the foot back to the heart.
Of the four systems, peripheral circulation problems are potentially the most damaging to the foot. Lets face it, without proper blood flow to the foot or impaired circulation away from the foot the tissues of the foot will suffer and in some cases die (gangrene).
Unfortunately, as we age our peripheral circulation to our feet does become impaired. The degree of impairment will vary from person to person with factors such as genetics, life style (smoking, poor diet, lack of exercise), and other disease states (diabetes, hypertension,) all contributing to a decreased blood flow to and from the foot.
When the foot is examined in regards to peripheral circulation we note the following:
The most common cause of poor blood flow into the foot is atherosclerosis or hardening of the arteries. This is a progressive degenerative process characterized by the deposition of fatty substances inside the wall of the artery along with a fibrous thickening of the artery wall resulting in a diminished ability of blood to flow down to the foot.
Below is a diagram of the arterial flow into the foot.
This condition in most people will go undiagnosed until the condition becomes symptomatic. When the initial symptoms of intermittent claudication (pain in the calf after walking a short distance, although to a lesser extent the thighs and buttocks) presents, there is already significant disease present. What is essentially happening, due to blockages in the blood flow to the feet, there is a mismatch between the oxygen supply being supplied to the extremities and the metabolic demands of the muscles of the feet and lower legs upon exertion. Simply stated, when muscles are working, they need fresh oxygen to supply them. Any reduction in this oxygen supply to a muscle will cause pain (claudication).
This condition occurs predominately among men between the ages of 50 and 70 years and usually starts after age 60 in women. Race and ethnic background also play a role as African Americans have a higher incidence of peripheral arterial disease (PAD) than non-African Americans. Studies have also shown that Hispanics present with more advanced lower extremity vascular disease and have worse outcomes, which includes a higher amputation rate after revascularization, than non-Hispanic whites. (Lower Extremity Review, March 2013). An estimated 8-12 million Americans have this condition. Fifty percent of people with PAD (peripheral arterial disease) are asymptomatic and usually go undiagnosed.
Major causes of atherosclerosis include:
Abnormal causes of atherosclerosis
Although atherosclerosis is generally associated with middle age and elderly individuals, there are instances where young people are affected.
A 17 year-old Irish dancer developed discomfort in her toes as well as discoloration and swelling over a one year period. She was an otherwise healthy individual, not taking any medication. An MRA (magnetic image angiogram) was performed and revealed fibrotic bands of the dorsalis pedis artery which is the artery on top of the foot that runs from the ankle all the way down to the toes.
An ultrasound was then performed that found the fibrous bands were impinging flow of blood through the dorsalis pedis artery when the foot was plantarflexed (pointed downward). Essentially her circulation was being cut off.
Surgery was performed to resect the bands and bounding pulses returned to her feet.
The lesson learned here is that even young people can develop vascular compromise. The majority of these cases are usually from external damage to the arteries through overuse injuries.1
There are a few different treatments for arteriosclerosis in the lower extremity and treatment is based on a number of factors including the degree of blockage either by occlusion (calcified plaque) or by stenosis (narrowing of the artery), the age of the patient, their general overall health, etc.
Below is a picture of very poor circulation into the foot. Notice how pale, thin and shiny the skin is along with sores that have developed on the foot.
The most common cause of poor blood flow out of the foot is varicose veins. This is a very common disorder seen twice as often in women than men and the prevalence increases with age.
Below is a diagram of the venous system in the foot.
symptoms of venous insufficiency (poor venous flow)
Increased humidity, obesity and the cyclic premenstrual period may exacerbate the symptoms.
The first is apple cider vinegar. Soak a cheesecloth bandage in apple cider vinegar and use it to wrap the affected area for thirty minutes. Make sure you legs are reclined above the level of your heart. Do this twice a day. Vinegar is believed to encourage varicose veins to contract. Some people also suggest drinking two teaspoons of apple cider vinegar in a cup of warm water after each session.
The second is bromelain. This collection of enzymes found in pineapples has anti-inflammatory properties believed to inhibit the unattractive swelling around varicose veins. Take 500-1000mg with each meal. Bromelain is available in health food stores.
In more severe cases of venous insufficiency the leg can become chronically swollen and inflamed. The leg is now much more susceptible to ulceration and infection.
Below is a picture of severe venous stasis. Notice the swelling and discoloration of the leg. A complication of this condition is a venous stasis ulcer.
Deep venous thrombosis is also a medical emergency. This is a blood clot that has occurred in a vein in the leg. The classic example is severe tenderness in the calf upon pressing the area with the foot simultaneously being dorsiflexed (foot bent upward); this is known as Homan's sign.
Other symptoms include persistent or unexplained swelling usually in only one lower leg. Additionally, the leg may also be red in color. This should not be confused with intermittent claudication, which generally results in calf pain after walking and no swelling in the foot and ankle.
The diagnosis is usually made with the use of a venogram, and more recently with duplex venous ultrasound. In patients who exhibit shortness of breath, fever, rapid heart beat or dizziness, a pulmonary embolism also has to be ruled out.
Factors that increase the chance of a deep venous thromobus (DVT) consist of:
People with any of the above mentioned conditions which may lead to a DVT should be very careful when contemplating foot or ankle surgery and should make their doctor aware of any of the above problems. Hopefully your surgeon will take a proper history and these problems will become known during the interview.
Most cases of DVT following lower extremity surgery is associated with major orthopedic procedures involving the hip and knee but a blood clot can form after foot and ankle surgery so it is imperative both patient and doctor are aware of the possibility.
Below is a picture of DVT, deep venous thrombosis of the right leg.
This condition requires hospitalization and anticoagulant medication to break up the clot. Without treatment there is a very high incidence of the clot breaking loose and causing a pulmonary embolism, which is a life-threatening situation. This type of clot is also known as (VTE) or venous thromboembolism.
A more common condition with less potential complications is a superficial phlebitis. This is an inflammation of one of the superficial veins such as on top of your foot that forms a clot and inflammation ensues.
This is usually a benign and self-limiting condition. Typically, a patient will present complaining of a painful, red area on the foot or lower leg with a lump underneath the skin. The lump is cord-like in its appearance. They can occur spontaneously or after trauma directly to the area.
Treatment consists of warm compresses and anti-inflammatory medication.
NOTE: there are many more conditions of peripheral circulation that have not been discussed. For example, see my discussion on blue toe syndrome.
One vascular problem affecting both the arteries and veins that I would like to mention is a condition known as Buerger's disease or thromboangitis obliterans. I have seen one such case and that was during my residency, but found it to be fascinating.
Buerger's disease is a condition that affects medium sized arteries and veins leading to the hands and feet. It is an inflammation of either the arteries or veins which thus causes a blockage of blood flow usually into the fingers and toes. It is a condition that has a predominance in jewish and asian populations affecting men three times as much as women. The incidence in the United States is estimated to be 12-20 cases per 100,000 population. The disease is most prevalent during the ages of 25-40 years.
No immunologic or toxic basis has been identified as the cause of this condition, but there is a very strong correlation with tobacco use. Tobacco itself has the propensity to thicken the inner lining of blood vessels as well as cause vasoconstriction (clamping down) on vessels further diminishing blood flow.
Thromboangitis obliterans has two stages:
Early Stage- where there is periodic episodes of inflammatory reactions which essentially inflame the internal lining of arteries and veins causing a diminished flow of blood into the fingers and toes and obstruction of veins by thrombosis which does not allow for proper blood flow from the fingers and toes back to the heart.
Late Stage- constriction of arterial flow to the point where ulceration and possibly gangrene set in at the ends of the fingers and toes. Thrombophlebitis of the venous system resulting in medical emergency as well as formation of ulcers along the course of the veins.
Diagnosis is made by taking a thorough history with any admissions of tobacco use. Once this condition is suspected, it can be confirmed through a multitude of vascular testing. This includes doppler studies of the arteries as well as plethysmography which measure blood volume in the fingers and toes. Ultrasound studies measuring venous flow are also performed, as well as nuclear imaging.
Treatment options for Buerger's disease include cessation of smoking, although in the one case I have observed, the patient continued to smoke even as his toes were being amputated one by one. Anticoagulants may be used for any thrombophlebitis that may develop. Anti-inflammatory medication is also used in sub-acute incidences of phlebitis. Vasodilators which attempt to open up vessels for increased blood flow are used in early stages to reduce the vasospastic component of the condition. Lastly, in many cases amputation is necessary if any ulceration becomes grossly infected or if gangrene has set in.
The more serious conditions described above are generally diagnosed with sophisticated testing such as arteriograms and venograms along with dopplers and nuclear imaging. Inspecting the area can give us an idea of the problem but testing confirms them. These conditions are best diagnosed and treated by vascular surgeons, however, the local treatment of any foot manifestation is usually best in the hands of a podiatrist.
Cutting Edge News
Over the last year or so, the pomegranate has been the subject of a lot of research in health as a potent antioxidant. An article from the Life Extension Foundation discusses recent research revealing
how not only does pomegranate slow down atherosclerosis but it actually may reverse it.
To read the entire article, click
1 Foot Claudication with Plantar Flexion as a Result of Dorsalis Pedis Artery Impingement in an Irish DancerSmith BK, Engelbert T, Turnipseed WD, (University of Wisconsin Hospital and Clinics, Madison, WI)
J Vasc Surg 2013 Jul;58(1):212-214
J Vasc Surg 2013 Jul;58(1):212-214