Because many common foot conditions are incapacitating, easing the pain and restoring normal function are important aspects of primary care. Appropriate treatment of foot problems often results in immediate improvement and grateful patients. Geriatric patients are especially susceptible to foot pain and deformity that the primary care physician can usually manage without recourse to more costly-and perhaps more distant-specialist care. A number of common foot problems that often respond well to primary care are discussed here.
A bunion-hallux valgus, a protuberance at the head of the medial metatarsal bone-is usually, but not always, a painful condition that causes the skin to redden. The disorder causes a lateral or valgus displacement of the great toe with deviation of the sesamoid bones. The cause in many patients is age-associated splaying of the foot and confinement in narrow shoes; the condition may be familial. The pain generally arises when shoe pressure results in a bursa that becomes inflamed. The spectrum of pain ranges from nagging to severe. Patients may say they cannot get their foot back into a shoe or bear the weight of bed sheets on the bunion.
Older persons are more vulnerable because their feet tend to spread with aging. Women are somewhat more frequently afflicted than men because they tend to wear tighter, more pointed shoes. Young people are rarely affected, although bunions sometimes occur in individuals as young as 10-13 years. Stiff, tight shoes are a factor, but even persons who do not wear shoes may get bunions. Arthritic conditions such as rheumatoid arthritis may occasionally provoke hallux valgus.
Most bunions are easy to diagnose, the most conspicuous feature being the prominence at the medial metatarsophalangeal (MTP) joint. Bursitis revealed by pain and reddened skin is a common characteristic. The lesser toes may also be deformed. Although severe arthritis with associated bony spurs is rarely confused with a bunion, the prominence in such a case tends to arise on the dorsal surface of the joint rather than on its medial side.
A bunion that appears at the lateral head of the fifth metatarsal is called a bunionette, or tailor’s bunion. Management Conservative therapy is directed at taking pressure off the bunion. Patients should be encouraged to wear laced shoes with a wider toe box. Conventional shoes such as these are also wider at the rear, however, and patients often find that the foot slips out of the shoe at the heel when walking. Shoes that are made to order on a combination last provide more room up front and sufficient snugness at the rear.
Another common solution is to wear shoes made of soft leather, such as suede; inexpensive shoes are often much less stiff than expensive ones. A number of manufacturers are now mass-marketing softer, roomier pumps with cushioned insoles for women. Some patients may be able to wear sandals with cross straps, athletic shoes, or roomy, cushion lined, soft-leather boots (snow boots, all weather boots, or dress boots), at least for part of each day or in certain seasons. Where appearance is of less importance, as with a geriatric patient in severe pain, slitting open or cutting patches out of the leather may provide greater comfort. Stretching shoes may be effective. In most cases, the patient with a bunion must choose between comfort and cosme even if corrective surgery is performed.
Orthotics, which are designed to correct abnormal movement, may be of value for the patient who is in pain but has no severe bone abnormality. If roentgenography is called for, as in a surgical candidate, the study should be done with the patient putting weight on his or her feet. Non-weight-bearing films do not provide enough information for determining joint alignment.
Surgery may be appropriate for patients who obtain insufficient relief from conservative measures. A bunionectomy usually consists of reducing the bony protuberance; an osteotomy involves making an incision in the bone and shifting the head or base of the metatarsal laterally. Many different procedures to correct bunions are performed by foot surgeons. Success rates for bunion procedures vary considerably, but the majority of patients appear to experience relief. Follow-up by the primary care physician is important. Many patients must temporarily keep weight off the affected part, usually by means of crutches.
Foot surgery may be performed by orthopedic surgeons and by podiatrists, who are licensed as surgeons in all states, although the kinds of procedures they are permitted to do vary from state to state. Experts advise checking the training and experience of foot specialists before referring patients.
Corns and calluses
Corns and calluses result from shoe pressure during standing and walking. They may appear on weight-bearing surfaces, such as the ball of the foot, or on nonweight-bearing surfaces, such as the arch or the top of the toe.
Corns and calluses are easily recognized as thick-skinned areas. Diagnosis is simplified by identifying areas where pressure is applied when the patient wears a stiff or tight shoe or when he stands or walks on hard surfaces. A hard corn commonly develops on the distal interphalangeal (DIP) or proximal interphalangeal (PIP) joint; a common site is the PIP joint of the little toe. A callus on the arch is generally caused by a foreign body, a wart, or plugged sweat glands (porokeratosis). If any doubt exists, debridement or excision may be diagnostic; the corns and calluses generally do not bleed, whereas warts bleed from many small points when tiny vessels are cut. Management Doughnut-shaped pads for corns may be effective when the toe is flexible enough to bend; but if the toe is rigid, the pad may only increase the pressure already being applied to the painful area. (A rigid toe may be an indication for bone surgery.) A pad in the sole of the shoe may alleviate pain. Roomier shoes-larger shoes, open shoes, shoes that have been cut open, laced shoes-may be helpful in any of these circumstances.
Perhaps the best therapy is trimming the corn or callus with a scalpel, a procedure that many patients attempt on their own with a razor blade or other edged tool. Elderly patients, however, are often unable to trim thickened skin because they lack the manual dexterity or visual acuity. Careful trimming by a primary care physician, podiatrist, or dermatologist provides immediate relief, but the benefits may be transient. Trimming may also be useful for certain patients with pain and infection if pus is evacuated during the procedure.
Many acid preparations are available for reducing corns and calluses. A commonly used prescription preparation is a mixture of salicylic and lactic acids and collodion (Duofilm, Salactic Film, Viranol, etc.).* The over-the-counter (OTC) acids are weaker than their prescription counterparts, such as trichloroacetic acid, 80% (Tri-Chlor). But such preparations may be more harmful than helpful because the bony prominences of the toes have such thin coverings. Be very cautious in recommending OTC preparations to patients, who may apply them injudiciously and cause irritations, burns, or infections that are as serious as the corn or callus problem. Acids are contraindicated for diabetic patients and are not advisable for individuals with impaired sensation or the elderly with thin skin. Be careful about applying acids too generously to weight-bearing areas where skin damage may aggravate the pain and cause infection.
Surgery may be indicated for corns or calluses if abnormally positioned bone is exerting pressure on the skin. An example is a declinated, or dropped, metatarsal that produces a callus on the ball of the foot.
Virus-initiated plantar warts (verruca plantaiis) may sometimes be confused with the thickened skin of calluses. Plantar warts, however, tend to have sharp margins and often grow inward because of pressure, unlike the outwardly growing warts on non-weight-bearing areas of the body. Warts are most common among adolescents but may occur at any age.
Squeezing the growth is ordinarily more painful than pushing on it if it is a wart, and pushing is more painful than squeezing if the lesion is a callus or foreign body. In addition, warts cut by a scalpel bleed freely from end arterioles perpendicular to the plantar surface, whereas calluses are avascular.
Many warts-perhaps up to 50%-disappear spontaneously, and thus some treatments may be undeservedly credited with cure. The most familiar therapies are directed at destroying the warty tissue: topical application of acids, cryotherapy with liquid nitrogen or carbon dioxide, electrocauterization, or laser therapy. Some practitioners are successful with injections that are thought to sensitize the growths or interfere with growth at the interface of normal skin and the wart.
Conservative therapy is the first consideration, and in all situations therapy should avoid aggressive removal that may produce scarring and pain at weight-bearing surfaces. Mild acids, such as those used for corns and calluses, may be effective in some cases, and patients often try such OTC preparations before seeing a physician. Patients who use acid preparations should be cautioned against damaging their skin when removing tape containing the acid. Stronger prescription acids in the range of 40-60% applied by a physician may be appropriate for stubborn individual warts.
Because warts thrive in a moist environment, patients whose feet perspire excessively should be instructed to keep their feet dry. Otherwise, warts may multiply or recur quickly after excision. One way of dealing with hyperhidrosis is to apply talcum powder directly to the skin if the warts are situated between the toes. Soaks in an astringent solution, made from preparations such as Domeboro powder or tablets or Bluboro powder, may be helpful for multiple warts. Soaps promoting dryness may also discourage the growth of warts.
Freezing of warts should be done cautiously because the fluid-filled blisters that may result are very painful, especially on weight-bearing surfaces such as the ball of the foot or the heel.
Cauterization, too, should be done with care. It may produce scar tissue if done too extensively, or it may remove only the superficial portion of warts that tend to grow inward in areas where pressure is applied to the foot. The remaining portion may survive to grow again.
Injecting multiple warts with lidocaine HCI Xylocaine HCI)* intradermally has the apparent effect of disrupting growth and is used when warts multiply; this therapy, however, is controversial. Intralesional injection of bleomycin sulfate Blenoxane)* may cure even stubborn warts, although scleroderma may result. Viral contamination can occur if a needle used at one site is used again at another; switching to a sterile needle is recommended.
One of the most desirable methods of eradicating warts is blunt dissection, after the area is anesthetized. Specialists are likely to use a curette. Suturing should be avoided because it can promote scar tissue and may propagate the causative virus where the skin has been perforated.
Recurrence is frequent with all techniques, but if warts reappear after several treatments, it may be advisable to obtain a biopsy specimen. A troublesome lesion is sometimes malignant.
Although the relevant terms are often used interchangeably, abnormal flexion of a toe at the PIP joint is usually called hammer toe; the DIP joint may be abnormally extended as well. Claw toe is similar: The PIP joint is always flexed but, in addition, the MTP joint is extended. Mallet toe is characterized by persistent hyperflexion of the DIP joint, causing an L-shaped toe. In all these conditions, corns or calluses develop where joints or the ends of toes rub against hard shoe surfaces.
Investigators have suggested a number of causes for these deformities, such as abnormalities of joints, muscles, or other soft tissues, or tight shoes. Persons with flat feet or high arches seem to be more susceptible, and heredity plays a role.
The position of the toe is diagnostic in each case. Corns or calluses are commonly found at pressure points, and the patient often complains of pain at those points. Sometimes the ball of the foot is painful in patients with hammer toe. Involved toes may or may not be flexible. Management If a toe deformity is asymptomatic, therapy is probably unnecessary. If a painful toe is flexible, padding such as moleskin over corns or calluses provides pain relief. Lamb’s wool can cushion a painful digit without sticking to the skin, which may be a problem in older patients. A pad with a strap that fastens around the toe can reduce pressure by straightening the toe. Roomier shoes may be helpful if the patient is willing to wear them, and prescription footwear may reduce discomfort. Orthotic devices are not recommended for adults, but may occasionally be useful in children who are still growing. Tapping a toe to derotate it is appropriate only in children younger than 4 years. Surgery may be indicated for adult patients whose toes become constantly irritated at pressure points or for children whose deformed toes may be corrected by release of the tendons.
Plantar fasclitis is a painful condition not yet fully understood or well defined. The term is broad, and specialists perceive it variously as an irritation of the fascia, caleaneal spur, heel bursitis, trapped nerve, stress fracture of the heel, or inflammation of the bursa. It may be due in part to overuse inflammation. * One common element is pain along the arch or on the plantar surface of the heel.
This condition is characterized by plantar-surface hindfoot pain that severely afflicts an individual on arising, worsens with activity, and may also appear at the end of the day or even after rest, but the diagnosis may not be immediately clear.
A calcaneal spur is sometimes the cause of plantar fasciitis, it sometimes only contributes to the pain, or it may be asymptomatic. A spur is usually revealed by roentgenogram, but the size of the spur does not correlate with pain severity. A spur can grow for several years before causing discomfort; it often begins to cause pain as the foot flattens or the individual puts more pressure on the foot with the spur than on the other foot.
Padding or cushioning may be helpful in relaxing the taut or inflamed plantar fascia. A gel-filled heel pad may be more comfortable. Orthotics may be useful in relieving plantar fasclitis, especially if they are not too firm. A simple arch support, or scaphoid pad, often helps.
Nonsteroidal anti-inflammatory drugs (NSAIDs) such as naproxen (Naprosyn), ibuprofen (Advil, Medipren, Motrin, etc.), and sulindac (Clinoril) are often given for plantar fasclitis. * NSAIDs are nonspecific in their action, however, and may only mask symptoms without ameliorating the abnormality. Furthermore, patients may fail to comply with an oral regimen, and NSAIDs occasionally cause gastrointestinal bleeding. An alternative to giving an NSAID is injecting into the affected area a corticosteroid mixed with an anesthetic for more specific pain relief. One choice is triamcinolone acetonide (Kenalog), 0.25 mL, or methylprednisolone acetate (Depo-Medrol), 0.25 mL, combined with lidocaine HCI Xylocaine HCI), 0. 25 mL. Although many practitioners inject through the thick skin under the heel, this route may produce severe, almost unbearable pain. A better route is from the side of the heel or arch, preferably from the medial side. A slender needle, 27- or 30gauge, should be used, and the volume of material injected should not exceed 0.5-1.0 mL. The area to be injected should be sprayed with a topical anesthetic beforehand.
Most patients respond to these therapies, but referral to a specialist is advisable if symptoms persist. A physically active patient, such as a runner, who experiences symptoms only after activity, is also a candidate for referral, as is an obese patient, whose weight is a factor in heel pain.
If a spur is discovered on roentgenogram and is believed to be the source of pain, therapy can begin with a soft heel pad or cup. For some patients, a tailor-made orthotic device may be helpful. NSAIDs or injected corticosteroids may also be therapeutic. Most patients find relief in such nonsurgical approaches, but referral is indicated for persistent pain. Surgery is rarely appropriate. Postsurgical rehabilitation requires 3months.
Morton’s, or interdigital, neuroma is a misnomer because this condition is no truly neoplastic; neuritis might be a more appropriate term. It is a benign swelling of tis sue beneath a nerve sheath, most commonly between the heads of the third and fourth metatarsals. The etiology is unclear, but nerve degeneration or trauma may account for the abnormal growth.
The most marked symptom is severe, persistent pain, which may be described as a burning, cramping, or aching sensation. A patient may liken it to stepping on a nail or a pebble. The pain may become so intense during driving that the patient has to pull off the road. It usually abates if the shoes are removed and the area massaged. There are no visible signs such as skin inflammation or swelling. Gentle squeezing between the heads of the metatarsals may elicit pain, but the response should be compared with that produced by squeezing between other toes. Rolling the thumb across the heads of the metatarsals on the plantar surface may reveal an unnatural growth.
Conservative treatment often suffices. A patient may reduce the pain by avoiding tight shoes or high heels or by placing pads beneath the involved heads of the metatarsals. The physician may choose to inject corticosteroids between the heads; up to three injections will satisfy most patients for a year or more. Although injections may be repeated, they may produce complications such as deviating toes. If pain persists, excision of the affected nerve and fibers branching into the toes is indicated. Surgery is successful in 80-95% of patients, although all should be warned that they will experience a certain degree of numbness in the affected area.
Sever’s disease, also known as calcaneal apophysitis, occurs most commonly in children 8-16 years old and more often in boys than girls. It may be an overuse phenomenon, following intense or repeated physical activity. Cartilage in the epiphysis of the posterior calcaneus may be damaged by jumping or other stressful physical activities, resulting in inflammation and pain.
The most marked symptom is pain on the plantar and posterior surfaces of the heel. Pressing on the area with the fingers elicits pain. The history may reveal strenuous physical activity, especially in walking, running, or jumping. X-ray films may reveal a fracture at the epiphysis. Heel pain caused by other conditions, such as rheumatoid arthritis, should be ruled out.
Sever’s disease is self-limiting and may require only modest therapy. Keeping pressure off the heel can be accomplished in any of several ways. Placing pads or cushions around the heel may help elevate it and rest the epiphyseal area, as may taping the foot to angle it downward at the toe. Sending the patient to a shoe repair shop to have the heel built up may also be effective: The shoe heel can be built up in stages to raise the heel of the foot about 2 inches above the ground. The shoe heel should be left at that level for 3-4 weeks and then cut down by degrees to normal height. Healing may require up to three months.
Some practitioners add an NSAID to the regimen, but this is often unnecessary and adds to treatment costs. Putting youngsters on crutches for long periods is impractical, but running and jumping should be restricted for several months. In a few cases in which pain is severe and the child is disabled, immobilizing the foot in a cast is an option.