wk 12- revision Flashcards
transmission routes for infectious agents and their respective PPE
contact- direct or indirect (contaminated surface), PPE: gown and gloves
droplet- particles that can travel within a 1.5 distance, PPE: surgical mask
airbone- particles that can travel larger than 1.5m distance (suspended in air), PPE: n95 or P2 mask
when do you need to do hand hygiene? 5 moments
before touching patient
before procedure
after a procedure
after touching patient
or patient surroundings
why do podiatrists have to be good with chain of transmission?
because most patients have comorbidities or immunocompromised
hand washing (initial hand wash procedure)
- rub in palm to palm
- palm to back of palm with fingers interlaced and reverse
- palm to palm with fingers interlaced
- fist to palm and reverse
- thumbs x2
- fingers circling palm x2
- rinse hands and dry completely with paper towel
how long are hand wash after the initial one?
15-30 seconds
what do you need to always ask the patient in regards to gloves?
are you allergic to latex?
Donning PPE order
hand hygiene
gown
mask
eyewear
hand hygiene
gloves
doffing PPE order
gloves
hand hygiene
eyewear
gown
mask
hand hygiene
what is an autoclave? and what is the temp, pressure and hold times
steam sterilising (after cleaning) of semi critical and critical instruments
134 celcius, 203kPa, 3 minutes (general use)
121C, 103kPa, 15 mins (occasional use)
what is the cambridge-calgary observation guide? 5
- initiating the session- prep, establish rapport, identify reason for consult
- gather info- explore biomed, patient problems and context
- physical info- assessments
- explanation and planning- correct amount and type of info, aid recall and understanding, shared understanding
- closing session- ensuring appropriate point of closure and forward planning
how can you involve patient and be culutrally sensitive?
-share thinking
-explain rationale for assessments
-explain process and ask for consent/understanding
Vascular assessment- general examination (2)
visual inspection
-risk factors (BMI, smokers staining, age)
-nail quality/shape
-skin colour
-swelling
-hair growth
-lesions/ulcers/ varicose veins
-asymmetry of limbs
clinic biomed tests
Vasuclar assessment- risk factors (patient history)- 9
-family history
-age (over 60)
-hypertension
-dyslipidaemia
-smoker
-obesity
-diabetes
-sedentary lifestyle
-medications (NSAID, oral contraceptive -risk of blood clots, CVD)
symptoms of vascular problems- arterial and venous specific
Arterial:
pain (on exertion- arterial)
Thin, shiny, hairless skin
Ulcers on toes
Red/pallor colour skin
Cool temp
Asymmetry (thin legs)
Venous:
cramping (night cramps relieved by getting up)
Swelling
Ulcers around ankles
Dark/blue skin colour
Made better with elevation of limbs
Asymmetry (muscle bulk)
signs and symptoms of PAD (3 main)
- intermittent claudication- pain on exertion, gets better with rest. time to pain correlates with stenosis/occlusion, felt in thigh, calf or buttocks.
- rest pain (usually in calves that is eased by standing
- non-healing lesions (typically on toes)
Clinical assessments for vascular
- pulses
- perfusion
- capillary refill time and possibly elevation, dependency
- doppler and possibly ABI
venous condition visual signs on limbs (4 main)
- varicose veins
- oedema
- haemosiderin deposits
- telangiectasia
assessment of oedema (2)
Venous:
Press firmly with your thumb for at least 2 seconds on each extremity
1. Over the dorsum of the foot
2. Behind the medial malleolus
3. Lower calf above the medial malleolus
Record indention recovery time in seconds
0- no oedema
1- 2mm or less indent
2- 2-4mm
3- 4-6mm
4-6-8mm indent
Lymph:
Stemmers sign
Pinch the skin on the dorsum of foot at 3rd MTJP, if unable = lymphoedema
classifying PAD into 4
- asymptomatic
- claudication
- critical limb ischaemia
- acute limb ischaemia
6 P’s for acute limb ischaemia (PAD)
pain- worse during movement
paralysis- motor nerve damage
paresthesia- sensory nerve ischaemia
pulselessness
poikilothermia- perishing cold
pallor
what does pallor or white tell us ?
cold, anaemia, raynauds phenomenon, cardiac failure, insufficient arterial supply, occlusion
what does blue tell us?
cold, raynauds phenomenon, venous stasus
what does blue with central cyanosis tell us
cardiac, respiratory failure
what does hazy blue tell us
infection, necrosis, bruising
what does red tell us
heat, extreme cold (vasodilation), inflammation, infection (cellulitis), a dusky red - severe vascular deficiency
brown?
haemosidorin deposits, necrosis, melanoma, gangrene, bruising
black
bruising, shoe dye, necrosis, melanoma, gangrene
minimal vascular assessment 7
- history of modifable and non-modifiable risk factors
- palpation of foot pulses
- skin, temp and other visible clinical features
- intermittent claudication and ischaemic rest pain identification
- differential diagnosis of common leg symptoms
- identification of rterial ulceration and severity
- identification of venous disease, oedema, and lymphedema
what are the pulses for braadycardia and tachycardia? infection is associated with which?
B- less than 60BPM
T- more than 100BPM- infection
when is buergers elevation test useful?
severe PAD
vascular calcification due to incompressible leg arteries or high ankle pressures
what are the triphasic responses?
-First sound is the loudest and of a higher pitch – ventricular bolus from
the heart
-The second and third sounds are the diastolic sounds due to the reversal
of flow caused by the elastic distension in the arteries and final forward
flow as the arteries rebound
what do monophasic and biphasic sounds show?
M-blood flows in one direction and doesnt cross baseline
B- two directions
which can indicate disease (obstruction)
what are ABI and ASP ranges?
ankle brachial index: 0.9-1.3, ankle systolic pressure >100 = normal
ABI<0.9, ASP <100 = Abnormal
ABI<0.4, ASP <50 = severe limb ischaemia
bi>1.3 Or non compressible, >200 = vascular calcifiction
what are TBPI and TSP ranges? and when to use it?
toe brachial pressure index >0.7, TSP >95 = normal
TBPI <0.7, TSP <95= abnormal
TBPI <0.3, TSP <30 = severe limb ischaemia
TBPI >1.1 = suspect vascular calcification
use to asses further in people with known or suspected leg artery calcification or foot ulceration
organisation of nervous system
NS - CNS (brain and spinal) and PNS (somatic, autonomic)
PNS:
somatic- efferent motor and afferent sensory
autonomic - efferent (sympathetic and parasympathetic) and afferent
how many cranial and spinal nerves in the PNS?
12 pairs of cranial
31 pairs of spinal
Neuro assessment- general examination
visual inspection-
muscle bulk
asymmetry
autonomic - sweating/ dryness
affecting sensation or movement
deformity
tremors
state of consciousness- speech, gait, facial
main features of upper motor neurone lesions
more muscle contraction = spasticity
more muscle tone = hypertonicity
more muscle reflexes = hyperreflexia
more disuse = disuse atrophy
babinski sign = toes go up
main features of lower motor neurone lesions
less muscle contraction = flaccid
less muscle tone = hypotonicity
less muscle reflexes = hyporeflexia
loss of innervation = denervation atrophy
babinski sign = toes go down
sensory deficits may arise from?
damage to the parietal cortex (receptors or ascending pathways)
neuro clinical tests test what?
large and small fibres
what is a dermatome?
area of skin that is mainly supplied by a single spinal nerve
where is L1, 2, 3 derm?
L1- top of thigh
L2- mid thigh
L3- medial femoral condyle, above knee
where is L4, L5, S1, S2?
L4- medial malleolus
L5- 3rd met dorsum of foot
S1- lateral calc
s2- back of knee
what tests do you conduct in dermatomes? how is it usually conducted and what is the point of this?
light touch and sharp dull discrimination tests
test each key sensory area in each derm and then two other sites within the derm
the key sensory area (dermatome only) tests for radiculopathy (compression of nerve at spinal root)
within the dermatome (cutaneous nerve region) tests for peripheral nerve entrapment
nerve root segments for femoral, obturator and sciatic nerve
femoral L2-l4
obturator L2-l4
sciatic L4-S3
what cutaneous nerves supply the foot
plantar:
medial(toes 1-3 and half of the 4th)/lateral plantar nerves (toes 5 and half of the 4th toe)
sural (lateral foot)
saphenous (medial foot)
calcaneal (from tibial nerve)
dorsal:
medial and lateral plantar nerves (same as plantar)
saphenous (medial foot)
sural (lateral)
deep fibula nerve (in betwwen 1/2 toes)
superficial fibula nerve (dorsum of foot)
what is the difference between dermatomes and cutaneous innervation?
dermatome- area of skin supplied by a single pair of spinal nerves (eg L4), a problem here would indicate a problem at the nerve root
cutaneous innervation- areas innervated by specific peripheral nerves (nerves that track off the nerve roots) eg lateral cutaneous femoral nerve, this indicates a problem further down in a specific peripheral nerve
how can you test radiculopathy?
straight leg testing, lay them flat and raise a leg to see if any pain is felt in back to suggest nerve root entrapment
normal is greater than 90 degrees, depends on age
the slump test, seated and clasps hands behind back, they slump forward to put their spine in flexion, the client also extends out their knee and flexes their foot. this puts tension on the spinal cord and nerves
assessment of motor nerve function tests which roots (hip, knee, ankle, 1st met)
hip
-flexion L2, L3
-extension L4, L5
knee
-flexion L3, L4
-extension L5, S1
ankle
-dorsiflexion and inversion L4, L5
-plantarflexion S1, S2
-eversion L5, S1
1st met
-dorsiflexion L5, S1
-plantarflexion S2, S3
difference between dermatomes and myotomes
derm- nerve root that innverates an area of skin
myo- nerve root that innervates a group of muscles
what to rememeber about myotomes
move down a joint, move down a nerve root
front movement before the back movement (flexion, extension)
hip- L2: L2-L5
knee- L3: L3-S1
ankle L4: L4-S2
1st met L5: L5-S3
Muscle tone assessment
hip- patient lying straight, roll knee side to side
knee-hand behind knee and lift rapidly and watch heel
ankle- hold ankle dorsiflex and plantarflex foot
assessing muscle tone tells us what?
hypertonia- abnormal and increased tension of the muscle
hypotonia- reduced tension of the muscle shown in increased flexibility, poor posture, low muscle endurance and strength
tonus
partial contraction of normal muscle, normal state of balanced muscle tension in the body which makes posture movement and coordination possible
dystonia
neurological movement disorder characterized by unintended muscle contractions that cause slow repetitive mvoements or abnormal postures
myotonia
rare neuromuscular condition where there is a delayed relaxation of skeletal muscles after voluntary contraction. associated with pain, weakness, fatigue, hypertrophy or underdeveloped muscle
what can affect reflexes
age \
skin sensory apparatus defect (after surgery)`
what root is the patella reflex?
L3, L4
achilles reflex root
S1, S2
what does absent ankle reflexes mean
-if normal patella reflexes then could be peripheral neuropathy
-age (over 70)
-if only absent on one side then S1 root lesion
what are the sensory receptors
mechanorecptors- touch and pressure
thermoreceptors- temp
nocioceptors- pain
proproceptors- position
classifications of peripheral nerve fibres
large diameter fibres (heavily meylinated) - mediate motor strength, vibration, light touch and 2 point discrimination
medium diameter fibres (myelinated)- carry info to muscle spindles (stretch reflex)
small diameter fibres- cold, pressure, pain (unmyelinated)
how can you test A-b (beta) fibres
cotton wool- light touch
tuning fork-vibration
2 point
monofilament - pressure
large diameter fibres
how can you test A-A (alpha) fibres
neurotip- sharp blunt discrimination
large diameter fibres
how can you test C type fibres
menthol, capsaicin- chemical pain
pinch, neurotip- pain/deep pressure
small diameter fibres
how can you testA-d (delta) fibres
hot and cold
why should you check skin areas before testing
-infection control (unbroken skin)
-reduction in results due to callous or thickening
what order do you test neurological areas?
distally to proximal
if theres known areas of sensory loss then start there and work toward areas of sensory sensation
what numbers on the RSTF show decrease and almost complete loss of sensation
4- decrease
2-almost complete loss
10g monofilament requires what amount of force to buckle?
10g
why arent thermorecptors often tests?
because if pain perception is normal theres not much need as it tests similar things
how can you assess dusfunction on the cerebellum
-posture
-balance
-difficulty speaking
-inability to perform rapid muscle movement
-tremor
-gait (wide base of gait, ataxic, deviate to one side)
MSK assessment- general examination
look:
-skin/nail changes (callous)
-muscle bulk
-swelling
-deformity (vagus or valgus, clawing)
-alignment (foot arch)
-posture
-symmetry (left and ride, check insoles)
feel:
-back of hand feel temp across joint line forefoot, midfoot and ankle
-assess swellings for mobility
-palpate areas for tenderness/pain
spinal malalignments (4)
-Lordosis: increase in forward curvature of the
spine, particularly observed in the lumbar
region in the sagittal plane
* Kyphosis: increase in outward curvature of the
spine, particularly observed in the cervical region
in the sagittal plane
* Scoliosis: lateral curvature of the spine in the
frontal plane
* Kypho-scoliosis: combination of kyphosis and
scoliosis (i.e outward and lateral)
what is genu varum
Physical deformity marked by outward bowing of the lower leg in relation to the thigh
genu valgum
Physical deformity where the thighs angle inwards
and the knees touch
genu recurvatum
knee hyperextension
flexed deformity of knee
inability to straighten the knee
what movements occur in the sagittal plane?
Flexion, extension, dorsiflexion and plantarflexion
what movements occur in the frontal plane
abduction/adduction, inversion and eversion
what movements occur in the transverse plane
internal and external rotation, foot adduction/abduction
triplanar motions
pronation- dorsiflexion, eversion abduction
supination-plantarflexion, inversion, adduction
what is a close packed joint position?
maximum contact between the two surfaces which allows for max stability but minimum mobility
what are you assessing for joints
- sign of inflammation
-red,heat, pain, swelling, loss of function - joint movement
-direction of motion
-range
-symmetry
-quality
-pain
-end feel
if theres pain/restriction noted in the same direction for both active and passive motion this means
damage to articular tissue (non contractile), ligs, tendons, nerves, bursae, joints etc
if theres pain/restriction noted in opposite direction for both active and passive motion eg active ankle dorsiflexion and passive ankle plantarflexion this means
damage to extra articular tissue (contractile) such as muscle
classifying muscles (3)
local stabilizers- low levels of contraction for long periods of time, typically deep muscles close to joint.
global stabilizers- control range of movement, typically superficial and control eccentrically to decelerate motion of joint
global mobilizers- produce movement, active in specific directions, typically in the sagittal plane
types of lesser toe deformities and how are they formed
hammer toe- flexion at the proximal IPJ
mallet - flexion at the distal IPJ
claw- flexion at both IPJ
retracted toe- off the ground
absent toes
dorsally displaced
syndactyly - toes joined, webbed
fan toes
macrodactylia
digital gigantism
microdactylia
digital dwarfism
clinodactylia
overlapping toes
Davie’s law
soft tissue will elongate when put under unremitting tension
when soft tissue remains in a loose state, they will gradually shorten
joint positions for hammer toe
MPJ- DF
PIPJ- PF
DIPJ- neutral
joint positions for claw toe
MPJ- DF
PIPJ- PF
DIPJ- PF
joint positions for mallet toe
MPJ- neutral
PIPJ- neutral
DIPJ- PF
key features of pes planus
-flat foot
-low arch
-hypermobile foot
-pronated
key features of pes cavus
-high arch
-supinated
-hollow foot
-less ground contact
function of skin
-largest organ in body
-provides protection
-permits sensations (touch, thermo, proprio, etc)
-metabolic functions
-part of immune system
-absorpton functions
dermatology assessment- general examination
look
-skin/nail changes
skin assessment
nail assessment
list of primary lesions
macule
patch
papule
nodule
plaque
vesicle
bulla
pustule
cyst
wheal
list of secondary lesions
scales
crusts
erosions
ulcers
excoriations
lichenification
atrophy
scars
fissures
what are primary lesions
caused directly by the disease process
recognise and define skin/nail pathologies
classification of callus’
- 0 - no lesion
- 1- diffuse or pinch callous
- 2 - circumscribed well defined callous
- 3 - seed corn or hard corn with no callous
- 4 - callous with corn
- 5 - extravasation, maceration, early
breakdown under callous - 6 - complete breakdown extending to dermis
what is verrucae pedis
-begins as papule
-affects stratum spinosum
infection progression of dermtology
primary site
2. cellulitis
3. lymphangitis
4. lymphadenitis
5.bacteraemia
6.septicaemia
7.death
what is the difference between bacteraemia and specticaemia
Bacteraemia is just the simple presence of bacteria in the blood and Septicaemia is the blood poisoning caused by the
presence and multiplication of the bacteria in the blood. Septicaemia is dangerous and life-threatening than bacteraemia.
difference between lymphadenitis and lymphangitis
dentitis- inflammation of lymph nodes due to infection
angitis- inflammation of lymph vessel due to infection
what is melanoma
a malignant tumour of melanocytes usually in the epidermis
explain the clark levels of skin cancer
- Clark Level I, the cancer is in the epidermis only.
- Clark Level II, the cancer has begun to spread into the
papillary dermis (upper layer of the dermis). - Clark Level III, the cancer has spread through the papillary
dermis into the papillary-reticular dermal interface but not into
the reticular dermis (lower layer of the dermis). - Clark Level IV, the cancer has spread into the reticular
dermis. - Clark Level V, the cancer has spread into the subcutaneous
tissue.
features of a melanoma
A- asymmetry
B- border irregularity
C- colour variation
D- diameter >0.5mm
E- evolution in size, shape, colour, elevation, bleeding, itchiness, crusting
age related changes to the skin
decreased:
1. production of keratinocytes
2.density of sweat glands
3.number of langerhans cells
4. number of dermal collagen and elastin fibres
5. capillary loops in papillary dermis
and increased:
1. thickness and stiffness of dermal collagen fibres
what do age related changes cause as complicatons?
- drness (fissuring/hyperkaratosis)
- decreased wound healing
- bruising
- risk of infection
what are nail changes that occur due to age
decreased nail growth rate
increased nail plate thickness
age related changes to peripheral vascular system
increased:
collagen cross linking
thickness of intima and media
stiffness of arterial walls
capillary wall thickness (reduced blood flow)
and
decreased diameter of veins
implications of age related changes of peripheral vascular system
decreased skin temp
increased risk of PAD and VI
what are the best 3 tests with the highest senistivity and specificity scores for peripheral sensory system (neuropathy)?
- achilles reflex
2.vibration sense at the hallux (dissipation method) - position of the hallux (proprioception)
footwear assessment- 4 F’s
Fit
- Does the footwear adequately fit your patients foot and accommodate any deformities or
orthotics?
Function
- Is the shoe appropriate for the intended use? (ie: pt may need steel caps for warehouse work,
appropriate indoor shoes for a falls risk, running shoes for marathon running etc
- Does it function appropriately for the intended use? (ie: an inappropriate running shoe for the
patients foot or gait)
Features
- Eg: Does the shoe have appropriate fastenings for the patient? Is it made out of an appropriate
material? Does it need a rocker?
Fatigue
- eg: Has the shoe fatigued past its lifespan? Is there a wedge worn into the sole? Is the last
broken?
review shoe fit
hemiplegic gait is
spasicity in one leg, swing at hip and knee with leg circumduction
diplegic gait
spasticity in both legs, narrow base with dragging and circumduction of legs
neuropathic gait
high step, foot flop, scrapping of toes
myopathic gait
side to side swing/drop of hips with each step- weakness of muscles
choreiform gait
random uncontrolled twitching/jerking of the arms, trunk, legs
ataxic gait
uncoordinated gait, wide base because of poor balance
parkinsonian gait
shuffling, feeling of being stuck (freezing), leaning forward, sometimes no arm swing
sensory ataxia gait
high stepping gait/foot slapping, unbalanced without ground contact
what do you assess for standing posture? (3)
spinal malignments (lordosis, kyphosis, scoliosis, kyphoscoliosis)
joint deformities (varum, valgus, recuravatum (hyperextension), flexed knee)
muscle bulk and symmetry
skin assessment for dermatology involves look and feel examination for (9)
texture
colour
temp
humidity
elasticity
hyperkeratosis
hair
dermatoses
surgical intervention
assessment of nails involves (4)
shape
contour
texture
pain
flat, localised area of colour change
macule- primary
a large macule >10mm in diameter (flat, localised area of colour change)in
patch- primary
elevated solid lesion, could be flat topped or dome shaped <5mm in diameter
papule-primary
a larger papule >5mm (elevated solid lesion), can be fluid filled or solid in any layer of skin
nodule-primary
plateau like elevated lesion, collection of papules that are >10mm in diameter and <5mm in height
plaque-primary
a papule (elevated solid lesion) with clear fluid, <5mm in diameter
vesicle-primary
a larger >5mm in diameter vesicle (elevated solid lesion with clear fluid)
bulla-primary
a papule (elevated solid lesion with pus)
pustule-primary
a nodule (large >5mm elevated solid lesion) with fluid or semi solid material, subdermal layer
cyst-primary
transitory elevated lesion, oedematous (can be plaque or papule)
wheal-primary
flakes of dead epidermal cells from stratum corneum
scale- secondary
accumulation of serum (yellow), blood (brown/red) or purulent (white/yellow) excudate dries on the skin
crust-secondary
a defect or kiss if epidermis only, superficial form of ulceration, heals without scarring
erosion-secondary
a skin defect or loss of tissue extending into the dermis or deeper, always heal with scar
ulcer
destruction or removal of the surface skin, caused by scratching, scraping or chemicals
excoriation
thickening of the epidermis causing exaggeration of creasing
lichenification
wasting of layers of the skin
atrophy
fibrous tissue replacement of normal tissue
scar
linear like cleavage of skin
fissure
a subcutaneous spot of bleeding >10mm diameter (bruise)
ecchymosis
small red or purple spot caused by bleeding into the skin
petechiae
rash of purple spots caused by internal bleeding
purpura
permanently dilated capillaries and venules in skin
telangiectasia
superficial reddening of the skin caused by injury or irritation (dilated blood capillaries)
erythema
development of patches of brown/yellow deposits as a by product of breakdown of red blood cells
hemosiderin deposits
causes of hyperkeratosis
- mechanical stress- pressure, shear, friction
- skin disease
psoriasis, dermatitis, fungal, etc
difference between callous and heloma
callous- diffuse, even thickening of str corneum
heloma- corn, concentrated area of hyperkeratosis with deep centre
heloma durum
hard corn, deep centre, painful on pressure
heloma molle
soft corn, interdigitally it occurs, macerated tissue, painful on pressure
heloma milliare
seed corn, shearing stress/dry skin
heloma vasculare
hard corn- vascular
heloma neurovasculare
hard corn- vascular and neural
soft tissue infection at nail fold
paronychia
uniform thickening of the nail plate without any gross deformity
onychauxis
what footwear advice would you give someone with onychauxis/ onychogryphosis
deep toe box
thickening of nail plate with deformity (typically perpendicular)
onychogryphosis
transverse ridges or retardation of growth on nail plate
beau’s lines
localised or diffuse hyperkeratosis in nail folds/sulcus
onychophosis
footwear advice for onychoposis
avoid tight toe box
growth of bone from distal phalanx beneath nail plate
subungal exostosis
fungal infection of nail
onychomycosis
higher curvature of nail than usual (cuts into skin folds)
involution
ingrown nail, penetrating sulcus resulting in inflammation
onychocryptosis
longitudinal ridging and fissuring of nail plate
onychorrhexis
spooned nails
koilonychia
separation of nail plate from nail bed
onycholysis
white, opaque discolouration of nail plate
leukonychia
shedding of nail at proximal end
onychomadesis
split in nail plate, looks like christmas tree
canalifomis
abnormal colour of nail plate
chromonychia
increased convexity of nail fold
clubbed nails
shortening of nail length
brachyonychia
veruccae pedis
HPV infection causing benign tumour
affect stratum spinosum
begins as spongy papule
covered in callous often and oainful
lateral pressure more painful
difference between verruca and heloma
V-
protrusion from skin
paring down produces dark punctate spots of thrombosed capillaries
skin lines deviate around lesion
infection from HPV
painful on lateral pressure
H-
cone shaped
paring down produces decreasing cone of hyperkeratosis
skin lines pass through lesion
shear/friction
painful on direct pressure
par
4 diagnostic features of verucca pedis
capillary spots and bleeding
interuption of skin striations
pain on lateral pressure
cauliflower appearance
5 classifications of OM
- Distal or lateral subungual onychomycosis
(DLSO) - Proximal subungual onychomycosis (PSO)
- Superficial white onychomycosis (SWO)
- Total dystrophic onychomycosis (TDO)
- Candidal (CO)
the ideal shoe
ØLaces have at least 3 eyelets
ØLow, wide heel
ØWidth for toes
ØDeep toe box (reinforced)
ØHeel stiffener/counter
ØCurved back for close fit at heel
ØShaped topline - deep enough to secure
instep
ØLeather upper
ØHard wearing synthetic sole
ØGood fit and condition
