Overview and history of trench foot

Introduction

Did you know that Trench foot remains a concern today, despite its historical connotation as a wartime condition? Knowing the causes and risk factors can help you prevent this serious condition. Trench foot, as the name suggests, is a condition that impacts your feet and is caused by long exposure to cold, damp environments between 0-15°C, or unhygienic conditions.¹ Symptoms occur in phases and include:

History

Trench Foot (also known as non-freezing cold injury - NFCI) has a lengthy history that traces back to World War I, particularly during the winter of 1914-1915.² During this time, nearly all soldiers were affected by this condition, with estimates suggesting that over 20,000 British soldiers received treatment for trench foot, and approximately 75,000 British soldiers and 2,000 American soldiers lost their lives due to it.¹ Medical authorities at the time quickly identified this condition and classified it as a new type of disease caused by the waterlogged trenches and wet socks that they could not change because of their tight footwear.^3,4 Initially, soldiers experienced itching, numbness, tingling and pain in their feet, which eventually led to sore, swollen feet that could double in size, followed by blisters and open sores. The soldier’s feet would change colour, and if it was left untreated, gangrene would often occur, resulting in amputation.^1,4 Soldiers were required to adhere to several health measures in order to treat and prevent Trench Foot, which included:

• Foot inspections
• Changing their socks twice daily
• Applying whale oil, which helped to keep their feet cool
• Mechanical pump to minimise flooding

This all proved helpful in drastically reducing the number of cases.⁴ Despite the fact that trench foot is historically linked to unsanitary wartime conditions, it still remains relevant today, especially for those who spend time in wet, cold environments, such as outdoor enthusiasts, homeless individuals or military personnel. It is especially important for these groups of people to maintain proper foot hygiene.¹ 

Biological impact of trench foot

Blood circulation and tissue damage

Trench Foot mostly affects blood circulation and causes major tissue damage in the feet due to moisture and constant pressure. The presence of water compromises the skin’s barrier, which increases infection risk and can lead to inflammation and blood vessel damage.⁵ In response, blood vessels constrict to retain heat but later dilate to restore warmth in the feet.⁵ This restricts blood flow to the feet, damaging capillaries and depriving tissues of nutrients and oxygen, resulting in tissue damage.⁶ 

High-risk groups in modern settings

Available research and statistics online regarding trench foot in modern settings are limited and still being evaluated. However, the condition still remains well-documented as its causes and risk factors closely resemble those observed during wartime in the waterlogged trenches. 

Outdoor workers and hikers

Those who work outdoors are more likely to develop trench foot due to their frequent exposure to water, dampness, or cold conditions. Construction workers, for instance, often perform tasks and work in harsh, unsanitary conditions, such as excavating in cold, muddy waters for hours, which increases their likelihood of developing the condition.⁷ Agricultural workers are among the most affected by trench foot due to their daily work conditions. As a result of the demanding requirements of their occupation, they often stand in water or wet, muddy environments for long hours without taking sufficient breaks in order to dry their feet or change their socks, which increases their chances of developing trench foot.⁸ The same risk applies to fishermen who work long hours on boats, fishing docks, or coastal areas where they are constantly exposed to these conditions. Their feet are frequently in contact with water, and the long hours at sea can make it extremely challenging to remove wet socks, dry their feet, or access drying facilities. Additionally, waterproof gear can trap moisture, preventing it from escaping due to the material’s design. 

Trench foot is more common among hikers than most people realise, especially for those who trek for long periods without the necessary breaks needed for proper foot hygiene. Outdoor enthusiasts engaging in recreational activities are also at higher risk if they don’t change out of wet socks or shoes.¹⁰ This condition is known to rise during certain seasons and environments when weather conditions are bad, such as high rainfall, flooding, snow and cooler temperatures.

Military 

Military personnel are among the most affected by trench foot due to their harsh living conditions and prolonged exposure to extreme environments during training and operations.¹¹ A study conducted by Johns Hopkins University, Imperial College London and the University of Oxford examined active-duty service members and veterans with trench foot. The research found that many suffered from long-term complications, including a significant reduction in nerve fibres in affected areas, which led to chronic pain, restricted physical activity, and in some cases, loss of employment.¹² 

Glastonbury 2007

There have been several reported instances at music festivals where the conditions contributed to cases of trench foot among a number of attendees.¹ During the Glastonbury festival in 2007, the heavy rainfall and severe weather created unsanitary conditions, resulting in widespread wet, muddy, and flooded areas where thousands of people had gathered. The adverse weather persisted throughout the entire event, causing many attendees to spend long periods in waterlogged fields while wearing wet socks and shoes, which created an ideal and perfect environment for the development of trench foot. Numerous reports of Trench Foot symptoms emerged during and after the festival, which emphasises that even modern-day activities can still pose a significant risk for trench foot if wet conditions continue and risks are ignored. This situation highlights the importance of maintaining good hygiene and ensuring that feet remain clean and dry during such activities.

Diagnosis, treatment and prevention for trench foot 

Diagnosis

Trench foot is usually diagnosed clinically by professionals, who will conduct the appropriate assessments to determine how it developed, as well as carry out a detailed foot examination to confirm the diagnosis. It is important for them to rule out any other infections that might be present, which may require a full white blood cell count. Medical professionals will ask about any recent exposure to cold or damp environments and the duration of contact with such conditions. Additionally, inflammatory markers such as erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) can provide further insight. If osteomyelitis (a bone infection) is suspected, a bone scan or X-ray might be necessary for further evaluation. These tests will help them in examining the health of blood vessels and nerves in the feet before providing treatment.¹

Treatment

There are many home treatments available and recommendations to help treat trench foot; however, these treatments will have a better outcome if they are started early. 

Rewarming

Avoid trying to rewarm feet quickly, as this can often lead to severe swelling and pain. Instead, slowly rewarming your feet has proven to be a lot safer, by soaking them in warm water for a minimum of 5 minutes or by applying warm packs, which will help restore the warmth.¹³

Elevating your feet

Attempt to elevate your feet above heart level whilst resting or sleeping to help reduce any risk of blisters and open wounds developing. 

Medical care

After diagnosis, a healthcare provider will usually clean and dry your feet in order to keep them warm. They may also prescribe antibiotics to treat and prevent infections. In some cases, they may also recommend a tetanus booster.

Medication

Acetaminophen, nonsteroidal anti-inflammatory drugs (NSAIDs), or amitriptyline may be given to help relieve pain.¹⁰

After treatment, it is extremely crucial for patients to follow prevention guidelines. This will ensure proper healing and also prevent the condition from worsening. 

Prevention

The most effective way for individuals to manage trench foot is through prevention. Being able to keep your feet protected and dry is essential to avoid developing the condition. Some key preventative measures include:

• Maintaining good foot hygiene - Ensuring that your feet are always clean and dry by regularly changing wet socks and shoes will help prevent prolonged exposure to moisture¹³
• Choosing adequate footwear - Wearing breathable shoes that fit you well will help prevent moisture buildup, which will also decrease the likelihood of circulation issues occurring
• Managing excessive sweating - For those prone to excessive sweating, applying an aluminium-based antiperspirant or powder on your feet can help reduce moisture

Summary

Although trench foot is mostly associated with and remembered for its historical context during wartime, caused by the poor living conditions and waterlogged trenches soldiers had to live in, it remains a modern issue. Those who spend long hours outdoors in damp environments, like farmers, fishermen, construction workers, military personnel, and outdoor enthusiasts, are still at high risk.

While recent research, literature, and statistics on trench foot in modern settings are limited, it is still well-documented that certain populations, including individuals who are exposed to prolonged moisture or wet conditions, often face similar risks to the soldiers who encountered trench foot during wartime. For those at risk, strictly following prevention and treatment guidelines is important to help reduce the chances of developing this condition.