Assessing the Painful Foot in an Elderly Deaf Patient with Learning Disabilities

Before the Assessment

Preparation and reasonable adjustments (legal and ethical duty)

• Review available records — previous assessments, known communication methods, cognitive/LD level, any formal diagnoses (e.g. Down syndrome, acquired brain injury), sensory losses, and preferred language (BSL, Makaton, spoken English, AAC device).
• Contact the care team/carer/keyworker in advance — establish what communication strategies work best, what the person understands, and whether they can self-report pain.
• Book an interpreter if needed — a British Sign Language (BSL) interpreter for a Deaf patient who uses BSL is a legal reasonable adjustment under the Equality Act 2010. Do not use family members or support workers as interpreters unless in an emergency.
• Consider capacity — apply the Mental Capacity Act 2005 framework. Assume capacity unless there is reason to doubt it. Each decision is assessed separately (capacity is decision-specific).
• Identify appropriate pain assessment tools — standard verbal NRS/VAS is unsuitable. Consider:
  • Abbey Pain Scale — validated for people with dementia/cognitive impairment who cannot self-report
  • DOLOPLUS-2 or Faces Pain Scale – Revised (may be accessible for some LD patients)
  • DisDAT (Distress State Tool) — specifically developed for people with severe communication impairment
  • FLACC scale (behavioural observation)
• Prepare the environment — ensure good lighting (essential for lip-reading and sign language), reduce background noise, remove masks if safe to do so or use transparent masks, position yourself face-to-face at eye level.
• Allocate extra time — do not rush; book a longer appointment slot.
• Arrange a familiar supporter — a known carer/keyworker who understands the patient's baseline behaviour can help distinguish usual from unusual distress.

During the Assessment

Communication strategies

• Face the patient directly at eye level, ensure your face is well-lit and visible.
• Speak clearly and naturally — do not exaggerate mouth movements (this distorts lip-reading). Reduce speech rate slightly.
• Use simple, concrete language — short sentences, one idea at a time. Avoid jargon, metaphors, double negatives.
• Use visual and tactile supports — pictures, diagrams, body charts, Makaton signs, gesture, objects of reference, AAC devices (tablets with symbol software like Widgit or Boardmaker).
• Check understanding actively — do not ask "Do you understand?" (almost always answered "yes"). Instead ask the patient to show or tell you back what you said, or demonstrate a task.
• Give time for processing — cognitive slowing in older age and LD means responses may be delayed; do not fill silences prematurely.
• Watch for non-verbal pain cues — facial grimacing, guarding, withdrawal, vocalisation, altered gait, restlessness, changes in skin colour.
• Use a body map/pain chart — ask the patient to point to where it hurts; augment with picture cards showing pain faces if helpful.

Clinical foot assessment

• History — onset, duration, character, aggravating/relieving factors; adapt questions to yes/no format where needed. Supplement with carer history of observed behaviour changes (limping, reduced mobility, refusing footwear, sleep disturbance, agitation).
• Observe — footwear type and fit (common cause of pain in elderly/LD patients), gait, posture.
• Skin and nail inspection — ulceration, callus, fissures, onychomycosis, tinea, pressure damage. Elderly LD patients are at high risk of undetected wounds due to reduced pain perception and communication barriers.
• Vascular assessment — pedal pulses (DP and PT), capillary refill, skin temperature, hair distribution, ABPI if indicated. Peripheral vascular disease prevalence rises with age.
• Neurological assessment — monofilament (Semmes-Weinstein 10g), tuning fork (128 Hz) for vibration, proprioception. Note that pre-existing neurological impairment in LD can confound findings.
• Musculoskeletal assessment — deformity (hallux valgus, claw toes, Charcot changes), joint range of motion, muscle tone (may be altered in some LD conditions), foot posture index.
• Safeguarding awareness — unexplained bruising, pressure damage, or neglect of foot care may indicate abuse or carer neglect; follow local safeguarding procedures.

After the Assessment

Documentation

• Record all findings clearly and objectively — include behavioural pain indicators used, capacity assessment, communication tools used, and who was present.
• Document reasonable adjustments made — for continuity and so future clinicians can replicate effective approaches.
• Use accessible language in any written materials given to the patient or carer** — easy-read formats, pictures, large print.

Feedback and consent for treatment

• Explain findings in accessible terms — use visual aids, repeat key points, allow questions.
• Supported decision-making — involve the carer/keyworker in explaining options, but ensure the patient's own views are sought and recorded. Do not conflate the carer's preference with the patient's.
• If capacity is lacking — document best-interests decision-making process under MCA 2005, involving those who know the person well.

Onward referral and liaison

• Multidisciplinary working — liaise with learning disability nurses, community LD teams, occupational therapists, orthotists, GP/geriatrician as needed.
• Specialist footwear/orthoses — consider referral for bespoke insoles or extra-depth footwear; compliance may be challenging; involve carers in education.
• Follow-up — shorter intervals may be needed to monitor a patient who cannot reliably report worsening symptoms.
• Carer education — ensure carers know what to look for (red flags: redness, warmth, new swelling, wound breakdown, refusal to weight-bear) and who to contact.
• Safeguarding referral if indicated — do not delay.

Summary Table

Managing Distress and Withdrawal During Assessment

1. Stop Immediately and Prioritise Safety

• Pause the assessment without hesitation. Continuing physical examination against a distressed, withdrawing patient constitutes a potential violation of consent and, in the context of a learning disability, may amount to a safeguarding concern.
• Step back physically — increase personal space, lower your body position (sit or crouch to be below eye level), and adopt open, non-threatening body language. Avoid blocking exits.
• Reduce stimuli — lower your voice, slow your movements, remove any instruments from view, dim harsh lighting if possible.

2. Acknowledge the Distress

• Validate the emotion using the patient's accessible communication method — a simple Makaton sign, picture symbol, or facial expression conveying "I can see you're upset / scared / in pain."
• Do not attempt to override or talk over the distress. Attempting to press on communicates that their response doesn't matter, which deepens anxiety.
• Give time and silence — do not fill the space immediately with more words, instructions, or reassurance. Allow the distress to de-escalate naturally.

3. Involve the Familiar Supporter

• Ask the carer, keyworker, or known person present to take the lead in comforting the patient, using their established relationship and communication approach.
• They can offer comfort objects, familiar phrases, or sensory regulation strategies (e.g. a preferred object, a weighted item, a known routine) that you as a clinician would not know.
• Do not leave the patient alone if they remain distressed, unless their distress is specifically triggered by your presence — in which case stepping fully out of sight briefly may help.

4. Assess the Cause of Distress

5. Consent and Capacity: The Legal Framework

• A person with capacity has an absolute right to refuse assessment or treatment, even if that refusal may harm them. A learning disability does not automatically mean incapacity.
• Reassess capacity in the moment — distress and anxiety can temporarily impair decision-making even in someone who normally has capacity. Apply the MCA 2005 two-stage test:
  1. Is there an impairment or disturbance in the functioning of the mind or brain?
  2. Does that impairment mean they cannot understand, retain, weigh, or communicate a decision about the assessment?
• If capacity is present — respect the refusal. Provide as much safety information as possible through the carer. Document clearly. Plan a return visit.
• If capacity is lacking — move to a best interests decision. Is continuing the assessment in their best interests right now? In most non-emergency foot assessments, the answer will be no — reschedule in better conditions. Forcing a non-urgent assessment on a person lacking capacity, without a formal best interests process and justification, is not lawful or ethical.

6. In a Genuine Emergency (e.g. Suspected Serious Wound, Vascular Crisis)

• Apply the MCA best interests framework or in an acute emergency, the common law doctrine of necessity.
• Use the minimum necessary intervention — examine only what is immediately clinically required.
• Involve a second clinician to support and document.
• Keep the carer/supporter closely involved throughout.
• After the immediate need is addressed, debrief with the carer about what triggered the distress and how to prevent recurrence.

7. After the Incident: What Comes Next

• Document everything — the distress, your response, capacity assessment, whether assessment was completed or deferred, and reasoning. This protects the patient and you.
• Debrief with the carer — find out what the patient's normal response to healthcare contact is, what has worked before, and what to avoid next time.
• Refer to the community learning disability team (CLDT) if not already involved — they can advise on communication passports, reasonable adjustments, and whether an anticipatory care plan for healthcare visits is appropriate.
• Create or update a healthcare/communication passport — a brief, person-centred document that travels with the patient and tells clinicians: how to communicate, what causes distress, what helps, and what to avoid.
• Consider a staged desensitisation approach — for future visits, arrange familiarisation sessions where the patient visits the clinic without examination, meeting the clinician and environment in a low-pressure context.
• Safeguarding review — if the distress suggests possible abuse, trauma, or neglect (e.g. unexplained fear of touch, or injury inconsistent with history), raise a safeguarding concern following local procedures. Do not dismiss distress as simply "the learning disability."

Key Principles to Carry Through

Offloading a Swollen Painful Ankle

Step 1 — Establish the Cause First

Step 2 — Offloading Options (Low to High)

A. Elevation

• The simplest and most immediate offloading intervention.
• Elevate the limb above heart level when at rest to reduce hydrostatic oedema and venous congestion.
• In an elderly patient: ensure safe positioning to prevent pressure injury at the heel or calf.
• Advise not to dangle the leg when sitting — a common habit that dramatically worsens ankle oedema.

B. Crutches / Walking Aids

• Non-weight-bearing (NWB) or partial weight-bearing (PWB) instruction with axillary or forearm crutches.
• In an elderly patient, standard crutches may be unsafe — assess upper limb strength, balance, and cognitive ability to use them safely.
• A wheeled frame (rollator) or knee scooter may be safer alternatives for older adults who cannot manage crutches.
• Wheelchair for NWB if crutches are unsafe.

C. Tubigrip / Compression Bandaging

• Provides mild compression to control soft tissue oedema.
• Not appropriate if arterial disease is suspected — check pedal pulses and ABPI before applying.
• Double-layer Tubigrip (ankle to knee) can meaningfully reduce oedema in mild-moderate cases.
• Contraindicated in active infection, suspected DVT, or if compression worsens ischaemic pain.

D. Ankle Brace / Functional Brace

• Rigid or semi-rigid ankle brace (e.g. Aircast, Donjoy) stabilises the ankle while allowing some ambulation.
• Appropriate for ligament sprains, mild instability, or tendinopathy where full immobilisation is not required.
• Controls inversion/eversion, reduces stress on lateral ligamentous complex.
• Must accommodate swelling — ensure the brace fits over the swollen ankle without creating pressure points, particularly in an elderly patient with fragile skin.

E. Removable Cast Walker (RCW) / Pneumatic Walking Boot

• The most commonly used offloading device for moderate-to-severe ankle pathology.
• Redistributes load away from the ankle joint; limits motion; accommodates oedema.
• Indications: acute ankle fractures (after specialist review), Charcot neuroarthropathy (if TCC not tolerated), severe ligament injury, diabetic foot complications.
• Advantages: removable for hygiene, accommodates fluctuating swelling, adjustable.
• Disadvantage: patient may remove it (reduces efficacy); in LD patients or those with dementia, compliance must be assessed — a carer may need to be responsible for application.
• Fit with a heel raise on the contralateral limb (approx. 15mm) to equalise limb length and reduce contralateral knee/hip strain — especially important in elderly patients.

F. Total Contact Cast (TCC)

• Gold standard for Charcot neuroarthropathy and diabetic neuropathic ulceration.
• Irremovable, custom-moulded, distributes load across entire plantar surface.
• Not appropriate for a simple ankle sprain or oedema alone.
• Requires specialist casting skills — refer to a specialist podiatrist or orthotist.
• In a swollen limb, the cast must be changed frequently (every 3–5 days initially) as swelling reduces to prevent a loose and dangerous fit.
• Contraindicated in active deep infection (until surgical/antibiotic control), severe PAD, or where skin integrity cannot be monitored.

G. Instant Total Contact Cast (iTCC)

• A RCW rendered irremovable by overwrapping with a layer of fibreglass or cohesive bandage.
• Achieves compliance similar to TCC with less technical skill required.
• Useful compromise where TCC casting is not available but compliance with RCW is poor.

Step 3 — Special Considerations for This Patient Population

Step 4 — Adjuncts to Offloading

• PRICE/POLICE protocol (Protection, Optimal Loading, Ice, Compression, Elevation) for acute sprains
• Analgesia — ensure pain is adequately managed; if the patient cannot self-report, use behavioural observation to guide this
• Physiotherapy referral — for progressive weight-bearing rehabilitation, proprioception training, and gait re-education once acute phase resolves
• Orthotist referral — for bespoke ankle-foot orthosis (AFO) if structural instability persists
• Vascular surgery / rheumatology / orthopaedics — depending on underlying diagnosis
• Compression hosiery (once swelling is reducing and vascular status confirmed) for longer-term oedema management

When to Refer / Escalate

• Positive Ottawa ankle rules → X-ray and orthopaedic/emergency review
• Suspected Charcot → urgent specialist podiatry or diabetology
• Signs of infection (warmth, erythema, pyrexia, wound) → urgent MDT
• Suspected DVT (asymmetric calf swelling, tenderness, risk factors) → immediate referral for Doppler USS
• Vascular compromise → urgent vascular surgery
• No improvement after 4–6 weeks of appropriate offloading → review diagnosis and refer