Walking (gait) problems 

Many people with Parkinson’s find their balance, gait, mobility or posture deteriorate.

In ‘normal’ walking, the heel strikes the ground first and the toes are the last point of contact as the foot lifts from the ground again. But in Parkinson’s, stride length is shortened and the ankles may become more rigid, leading to a more flat-footed style of gait. This can result in a shuffling walk which poorly absorbs the impact of the foot when it strikes the ground, potentially causing foot, leg and knee pain.

In contrast, some people with Parkinson’s find they walk on their toes as ankle rigidity and difficultly bending the foot upwards can mean that their feet point downwards. This ‘toe-walking’ adds pressure to the toes and may affect mobility and balance.

Stiffness or cramps in the calf muscles can make it harder for the foot to absorb the impact of it striking the ground when walking. This can lead to pressure problems such as calluses on the soles of the feet.

A podiatrist, often working with a physiotherapist, will be able to give you exercises to stretch muscles and reduce stiffness. He or she can also suggest strategies to correct poor gait, prevent ‘toe-walking’ and ensure a more even stride with your foot flexed to improve heel-to-toe contact with the ground. A podiatrist can also advise on specially tailored devices (orthoses) which are custom-made to fit your foot and help spread the impact of striking the ground across the whole foot. This can improve gait and mobility and allow the muscles in your calves and feet to work properly. 

Dystonia and toe-curling

Dystonia and muscle cramps frequently occur in the feet. Typically, the toes curl into a claw-like position, the foot turns inwards at the ankle (inversion), and occasionally the big toe sticks up (hyper-extension). This position, caused by spasms in the calf muscles, can be very uncomfortable and make it hard to fit feet into shoes. The toes may rub on footwear and pressure problems may arise on areas of the foot not designed to withstand pressure. 

The Achilles tendon may also tighten as a result of dystonia which can cause ‘toe walking’ as the foot is pulled downwards.

Dystonia can be related to your medications, so speak with your doctor, or Parkinson’s specialist nurse if you have one, to see if changing your medications or dosage helps.

Your podiatrist will be able to suggest ways to prevent toe-curling, possibly using devices such as toe splints. These are made of silicone which gives the toes something to grip on when walking. A podiatrist can also make a special mould from quick-setting silicone rubber which forms a casing around the toe to help keep the toes straight. In extreme cases surgery may be necessary.

Swelling (oedema)

Swelling in the feet results from the accumulation of excessive fluid in the tissues. This is more likely to occur if you have slow or reduced movement (bradykinesia) or spend long periods sitting down. Blood circulation relies on the legs muscles contracting and propelling blood back to the heart, so if movement is reduced, veins can become congested and fluid may leak and gather in the feet and ankles. This is known as oedema.

Swelling generally increases during the day but subsides at night. It can be alleviated by lying flat with your legs slightly raised several times a day and keep your legs raised when you are sitting. Your doctor may prescribe a diuretic (a medication which increases the production of urine and stimulates the movement of toxins through the kidneys). 

If you have swollen feet or ankles you should talk with your doctor so that he or she can eliminate other causes, such as heart or renal problems or deep vein thrombosis.

A podiatrist or physiotherapist can help with exercises, such as ankle rotations, to prevent fluid build-up in the legs. As oedema can make it difficult or uncomfortable to wear shoes, a podiatrist can also advise on comfortable forms of footwear, for example shoes that can be loosened during the day if your feet start to swell. Both therapists can also show your carer how to give you a gentle foot or leg massage to improve circulation.

A podiatrist (or chiropodist) is an expert on feet, as well as the way we walk and how this affects other joints. Podiatry is an internationally recognised term for the diagnosis and treatment of disorders of the foot and ankle. There is no difference between podiatry and chiropody – the latter is simply a term used in certain countries only.

The main areas that a podiatrist may be involved in are:

• Biomechanics - looking at how the feet and body work together (often alongside a physiotherapist) and how the way we walk may cause problems with other joints; treating problems such as poor gait with exercises or by using special foot devices such as insole supports; advising on mobility problems and fall prevention.
• Advice on suitable footwear, how to keep feet healthy, and how to deal with minor problems such as corns, bunions and in-growing toenails. A podiatrist can show family members and carers how to care for your feet. He or she can also who you how to safely use instruments such as nail clippers if you experience tremor and other movement difficulties.
• Monitoring and treating a range of foot and lower limb conditions, including injury, ulceration and infected sores.

Depending on where you live and your individual needs, you will almost certainly also be referred to a physiotherapist for foot-related mobility problems and to help prevent falls. For further information see physiotherapy.

What should I expect at a podiatry appointment?

It is a good idea to try to make appointments at a time of day when you are least likely to experience tremor or other involuntary movements as the podiatrist may need to use sharp instruments. It may also be helpful if your carer is with you for the first appointment so that they understand how they can help you between appointments.

The initial appointment will last around 30 minutes, although this will vary depending on where you live. Additional assessment and treatment sessions will normally take between 20-30 minutes.

The podiatrist will take a full medical history, including your Parkinson's and any other health problems, as these can affect your feet. They will need to know what medications you take so make sure you take a list of medications with you.

They will assess your feet, including the condition of your skin and nails, circulation and nerves. They will also watch the way you walk and the position and movement of your feet (gait analysis).

The podiatrist will then suggest a care plan including treatment of any immediate problems, future appointments and day-to-day care such as nail cutting, exercise and the use of creams.

In some countries home visits may be arranged if mobility is very limited.

How do I find a podiatrist?

Your healthcare team may be able to recommend a qualified therapist in your area who has experience of working with Parkinson’s.

Whichever route you take, make sure you see a therapist who is professionally trained and accredited. It is helpful to be seen by someone who has previously treated people with Parkinson’s, and always ask for references and establish the likely costs before treatment commences. In some countries treatment may be state-funded but if not, you can ask to be seen and pay for treatment yourself.

There are a number of ways you can prevent or alleviate foot problems.

Footwear

Well-chosen and appropriate footwear is important for everyone, both for comfort and to prevent pressure points or changes to the foot’s shape. We each have different needs so it is important to speak to a podiatrist or other experienced professional such as a physiotherapist or occupational therapist in order to discuss what is appropriate for you. 

If you experience freezing (your feet suddenly become ‘stuck’ to the ground), leather soles may be helpful as they allow you to slide your feet to aid movement. But slippery soles can make falls more likely. So, if you have a tendency to fall, leather soles are not advisable.

Some people find that rubber soles which grip well are helpful as they force you to properly lift your foot with each step which can help to maintain good gait. But rubber soles may also cause your foot to ‘catch’ on the ground which may make you trip or fall forwards, so take care with this type of sole.

The following recommended shoe features and tips should help you choose suitable footwear.

• Supportive footwear, with cushioning, helps absorb the impact of your foot striking the ground.
• A broad heel, but not too high, will help with stability.
• Fastenings which come high up across the front of the foot, near to the ankle, are supportive.
• Laces provide good support but can be fiddly, in which case Velcro or buckles may be easier.
• Wide-ended shoes with room to wiggle your toes are preferable. Toes should not be cramped in narrow-ended shoes.
• Light-weight footwear require less effort when walking.
• Natural, breathable materials keep feet fresher.
• Try to choose shoes when your feet are at their worst. If they fit in this condition, they should also be comfortable when your feet are in better condition.
• Slippers may be comfortable but they provide very little support so are not generally not recommended.
• Even good fitting slip-on shoes require you to claw your toes in order to keep them on so are not recommended if you have Parkinson’s.

Exercise

Stretching and exercising muscles in the feet can help to reduce or prevent stiffness and rigidity, and improve circulation and the strength of foot arches. A podiatrist will be able to suggest suitable exercises which take only a few minutes and if done regularly can significantly help with foot problems.

The exercises below have been recommended by a podiatrist and may also be useful.

1. Rise on your tiptoes 

Stand with your feet parallel. Hold on to a steady piece of furniture for support and rise slowly up and down on your tiptoes. This exercises the leg muscles and helps strengthen the foot muscles.

2. Extend the sole of your foot

Sitting down, stretch the foot in as straight a line with the leg as possible.

3. Rotate your feet

While still sitting, extend your feet one at a time and rotate slowly at the ankle, as if you are trying to draw the largest circle you can with your big toe. Do this first in one direction and then in the other.

4. Mobilise your toes

Remain sitting with your feet resting on the floor. Move your toes up and down.

General foot care

The following simple tips may help you keep your feet healthy:

• Wash your feet daily in warm but not hot water and dry thoroughly after, including between the toes. If toe-curling is a problem, be careful not to get the towel stuck between your toes - a dry flannel or baby wipe will be easier in this case.
• Avoid harsh soaps or strong antiseptics which destroy the natural oils in the skin.
• Don’t soak your feet longer than you would in a bath as this destroys natural skin oils.
• Keep your feet warm and don’t expose them to extreme heat or cold.
• Exercise your feet to improve circulation.
• Use moisturising creams, lanolin or olive oil if your feet are particularly dry, avoiding the areas between the toes.
• Remove hard skin by using a pumice stone or foot file, applying an emollient cream after and up to twice a day.
• File your toe nails regularly (little and often is best) using a special file with a rounded end or an emery board. Always follow the shape of your nail and don’t cut down at the corners as this can lead to in-growing toe nails.
• If you experience tremor or involuntary movements, or have difficulty gripping foot care instruments, don’t use sharp scissors or nail clippers. Instead use a file or ask your carer or podiatrist for help. A podiatrist can show your carer how to best help with everyday foot-care.
• Seek specialist help for corns, calluses and in-growing toenails to avoid the risk of burns or ulcers resulting from improper use of over–the-counter treatments.
• Contact your podiatrist or doctor promptly if you have any cuts, burns or breaks in the skin as these can lead to more serious problems if left untreated. Also seek advice if you notice any changes in the colour, smell or temperature of your feet.
• Try to wear different shoes each day so that pressures on the foot move around.
• Use shoe horns to help put shoes on (long handled horns may be easier to use) and use special shoe devices - sometimes called ‘shoe trees’ - to keep footwear in good shape and prevent creases when not in use.

Our thanks to Parkinson's UK for permission to use the following source(s) in compiling this information: Foot care and Parkinson’s.