A total of 255 respondents completed the survey, two of whom indicated that they were completing the survey on behalf of their child aged under 18 years. Most respondents (n=249) were from the United Kingdom, although responses were also received from Oman (n=3), Spain (n=1), Guyana (n=1), and Australia (n=1). A summary of respondent demographic characteristics is shown in table two.
Most respondents (n=193, 75.7%) reported foot symptoms which had been present for four weeks or longer, but 49 respondents (19.2%) noted a new problem. The duration was missing for 13 (5.1%) respondents.
Pain was the most frequently reported symptom, (n=139 (54.5%)). Change in appearance to the foot was also commonly reported (n=122, 47.8%), often alongside reporting the presence of swelling. Most foot problems were musculoskeletal (n=123 (48%)). A summary of response frequencies for other categories is shown in table three. Additionally, n=8 (3.1%) respondents reported having had an infection which required antibiotic prescription.
Emergence of qualitative themes and an explanatory framework demonstrating the impact of COVID-19 upon foot health
A total of five themes and 11 subthemes were identified (figure one). The full thematic analysis summary, including itemisation of the 49 derived codes and representative quotations, is available in appendix one.
Integrative analysis identified one over-riding explanatory contextual theme, that of lockdown as a disruptor to support networks integral to maintaining foot health. Using an integrated analysis approach, an explanatory framework demonstrating the impact of COVID-19 upon foot health was developed (figure two).
Theme 1. Foot pain is a constant companion for many during lockdown
Fifty-five percent of participants reported foot pain (n=139). Pain was more common amongst those reporting musculoskeletal foot conditions than others (X2= 12.00, p=0.001). Foot pain was less common amongst those who did not report an integumentary condition (X2= 10.61, p=0.001) (table 4). The specific pathologies causing foot pain was largely unclear from survey responses. However, the impact of foot pain was highly evident within the qualitative text and there was a sense that those with MSK complaints accepted foot pain as inherently part of the condition.
Qualitative findings also illustrated associations between experience of pain and physical signs of poor foot health, such as swelling or deformity.
“even though I had surgery on all my toes for bunion joint and dropped joints, this was some years ago and I am now suffering with pain in some toes and difficulty walking as 2 little toes on right foot turn right under, so they get sore when walked on” (participant #5).
There were numerous references made by respondents to the negative consequences associated with persistent pain and observation of how COVID lockdown exacerbated such beliefs.
“I have had foot pain for over a year caused by an injury (likely stress fracture/ligament damage) that causes aggravation to mid-foot during exercise/walking. Too much aggravation leads to me not being able to walk on that foot without limping. I have not been able to do much exercise since working from home and losing out on the movement throughout the day seems to have made things worse” (participant #78).
In addition to foot problems limiting activity during COVID lockdown, respondents also noted a range of negative emotions associated with foot pain, including fear of movement, reduced motivation to exercise, and finding walking and mobility harder.
“I find I'm less motivated to go out for walks as not sure how much the pain may flare up and then I find it difficult and painful to walk home. If I do go out, I try to use the car or make sure it's short distances from home”; "Pain is making me reluctant to move about and no reason to push myself because of the shielding" (participant #85).
The lack of routine and a structured day associated with COVID lockdown also appeared to impact typical pain coping mechanisms and in particular sleep patterns:
“The pain causes… I am sleeping a lot in the daytime but up in the night, sitting in my recliner chair for 1-2 hours, usually around 4am" (participant #177).
Similarly, one respondent also noted the potential link between a change in lockdown diet, weight gain and foot pain:
“I have also put-on weight through lack of exercise (and easy access to unsuitable food!) but feel the excess weight may have contributed to my foot pain" (participant #176).
There was only a single response citing direct association between testing positive for the COVID-19 virus and foot pain:
“Five days after testing positive, I developed a fever, this lasted on and off for 4 days. During that time the pain in my feet was incredible and they were cold to the touch. My feet health has improved over the last several weeks and continued to do so. But they have not returned to normal. I did not have issues prior to testing positive” (participant #42).
Theme 2. Self-care continues during lockdown but does not sufficiently prevent deteriorating foot health
During the COVID lockdown 192 (78.05%) respondents reported attempting to undertake self-care to support their foot health. The proportion of those undertaking self-care did not differ between those with long-term (over 4 weeks) and those with a new (within 4 weeks) foot problem (X2=0.03, p=0.856), (Table 5).
From a qualitative perspective, self-care was a frequently referenced activity of great importance to respondents. There was a particular emphasis on undertaking skin or nail self-care and in some cases, this extended to the treatment of nail or skin infection:
“I remove as much fungus as I can with a nail-file or small knife”; “I wear wound covers on my blisters to stop infection” (participant #91).
Strategies to support self-care described as effective included use of over-the-counter products, massage, use of hot/cold therapy, rest and/or elevation of the foot, use of footwear and insoles, exercise, and use of medications:
“Swelling makes skin more red and very dry. Difficult to keep feet clean as can’t reach them. Bought a gadget to try to apply moisturiser” (participant #149); “occasionally when it's bad will get a cold bottle from the freezer to roll under my feet” (participant #85); “Raising leg as often as possible (during working hours not so easy as sat at dining room table to work” (participant #87).
In contrast, several respondents also reported detrimental impact of ineffective skin or nail self-care, and these observations were typically in relation to inability to manage callus or nail growth, or uncertainly around product use, in particular when they usually relied upon professional advice or treatment:
“get a lot of build-up of callus under my metatarsals. This is usually removed every 6 weeks but, because of lockdown, is building up (in spite of my trying to get rid of it)” (participant #125); “I had an infected blister. Which was treated with antibiotics. This didn’t resolve it so I had to have another round and then strangely I got a blister on the other foot, then another on my ankle and for two weeks or so it felt like they were going to spread over my feet and a small knock would create a red mark” (participant #198).
The contrast in views about effectiveness of self-care appeared to be concordant with the contrast in overall emotive expression of either stoicism or helplessness that is amplified by experiences in lockdown, as discussed in theme three. Here, the overall theme of disruption to support networks became evident. Forty-four (17.81%) respondents were receiving some form of help or support for their foot health during the lockdown period, 30 of whom (68.18%) reported this support was meeting their needs. However, 204 (84.3%) respondents reported an intention to seek external help or support for their foot health once the lockdown period ended and they were able to do so, suggesting that whilst self-care was prevalent, it was not sufficiently addressing health needs.
Theme 3. Lockdown restrictions force the emergence of a cope or crumble scenario
A typically polarised response to the challenge to living with poor foot health during a period of COVID lockdown emerged. Finding personalised solutions and adjustment to daily routines or activities appeared to provide the greatest sense of coping and stoicism. The support networks underpinning a person’s ability to find solutions or adjustments to cope with poor foot health appear to be intricately linked to the emergence of a cope or crumble scenario. The strong sense of stoicism described appeared to be driven by a wish to prioritise physical activity above pain avoidance, or the potential to cause more physical harm to the foot:
“I do try to walk even with the pain but the pain beats me in the end” (participant #165); “I push through the pain and limp if need be” (participant #166).
Conversely, whilst some respondents described adjustments to daily living, for others there were notable expressions of concern or inability to cope:
“I worry about the long-term effect of my bones getting so out of alignment. I am normally an active person” (participant #88).
Theme 4. Lockdown restrictions do not change future intent to access health professionals
A reliance upon informal support networks was reported by many respondents. However, several participants also noted their reliance upon formalised support networks and healthcare professionals, reporting their intention to access support as soon as it becomes available again:
“…under current circumstances trying to look after feet is extremely difficult due to medical conditions… have to wait until major problems before can be seen which will probably mean more visits – not cost effective and potentially not safe for me to attend and means more time for staff” (participant #24); “it has been unusual circumstances and IF we weren’t where we are, I would have looked for help and been getting it by now either NHS or private” (participant #65).
There were no examples of respondents finding new self-care strategies, support networks or solutions that meant that they no longer intended to access healthcare professionals in the future. However, there were some respondents who expressed a wish for greater resources to support self-care to be made available:
“wish to access general education information and what is available for foot health care and mobility improvement. What is out there?!” (participant #30).
Theme 5. Poor foot health limits people’s ability to participate in recommended daily physical activity
Important emphasis was placed upon participation in daily activity, both in continuing public health messages of the time and in mainstream media. However, 151 (59.2%) of respondents reported a reduction in physical activity, with 57 (22.4%) reporting similar amount and 46 (18.0%) reporting increased activity (n=1 missing). Notably, 128 (50.2%) respondents cited their poor foot health as affecting their ability to remain active during the COVID-19 lockdown (n=5 missing). Quantitative analysis revealed a significant relationship between (a) pain and (b) musculoskeletal foot conditions and reduced physical activity (X2=6.6, p=0.010), suggesting these to be the key drivers.
For those living with a pre-existing long-term condition affecting the foot, the impact of the COVID lockdown appeared to amplify physical restriction. For example, one respondent with rheumatoid arthritis wrote:
“It’s harder to get the joints moving and my toes are a bit swollen. The process of gardening, bending at the ankles, balancing etc. is causing more foot pain… people who have been shielding have been far less mobile than usual and we need to get back on track again, ASAP!” (participant #11).
The opportunity for enthusiastic increased activity in early lockdown resulted in new injury for some:
“I wish I’d taken running easier to start with – ‘going for a run’ seems so ubiquitous and easy… but if out of condition it’s not!” (participant #55).
Amongst people with a new foot problem, the disruption to support networks caused by COVID lockdown was also reported: having sustained an acute foot injury there was notable frustration at the lack of support or guidance available to aid recovery. Thus, the importance of support needed to recover or maintain foot health does not appear to be weighted toward either acute or long-term conditions and instead is common across both groups.
The reasons given for foot health restricting physical activity were thematically grouped into physical or emotive restrictions. Reported physical restrictions included reduced ability to walk a certain distance, being slower, moving or standing differently, or sensations of tightness, weakness, or pain:
“I have developed a pain in my ankle and heel which limits my ability to walk comfortably since late April. Worse after a period of inactivity” (participant #175); “Too much aggravation leads to me not being able to walk on that foot without limping. I have not been able to do much exercise since working from home and losing out on the movement throughout the day seems to have made things worse” (participant #78).
Reported emotive restrictions included fear of movement or lacking motivation:
“Pain is making me reluctant to move about and no reason to push myself because of the shielding” (participant #117).