DISEASES AND DISORDERS OF THE FOOT

DISEASES AND DISORDERS OF THE FOOT
Suggestions for Lecturer -1-hour lecture -Use GRS slides alone or to supplement your own teaching materials. -Refer to GRS and Geriatrics At Your Fingertips for further content. -Supplement your lecture with handouts. -See GRS7 questions 53, 75, 119, 252 and 259 for case vignettes on diseases and disorders of the foot. Topic

OBJECTIVES Know and understand:
Changes in the foot associated with aging Common foot problems that occur in older adults Treatment options for common podiatric problems of older adults

TOPICS COVERED Foot Problems in Older Adults
Common Disorders of the Foot The Role of the Primary Clinician in Foot Care Common Deformities of the Feet Skin and Nail Disorders Systemic Diseases Affecting the Foot and Ankle

FOOT PROBLEMS IN OLDER ADULTS
Approximately one third of the geriatric population has some foot pathology, with a higher incidence in patients who are within a medical facility such as a nursing home or hospital Studies of the geriatric population demonstrate that foot complaints can inhibit daily activities such as getting out of a chair, walking, and stair climbing Foot complaints are also associated with increased fall risk in the aging population

THE ROLE OF THE PRIMARY CLINICIAN IN FOOT CARE
Regular assessment of the feet is recommended Practitioners should be aware of their patients’ foot conditions and the complications of systemic diseases Primary practitioners should recognize common foot problems and refer patients for podiatric care Quality of life and the functional capacity of older adults can be significantly improved by early detection and comprehensive management of foot problems

COMMON DISORDERS OF THE FOOT (1 of 7)
Definition or Description Bunion Prominent and dorsal medial eminence of the first metatarsal; associated with hallux valgus Calcaneal spur/heel spur A calcification of the attachment of the plantar fascia, usually at the medial plantar tuberosity of the calcaneus. The spur projects anteriorly and is the consequence of chronic repetitive trauma or stress resulting from biomechanical and pathomechanical change. When ligamentous calcification occurs, inflammation and associated pain at the attachment result. This may be referred to as heel pain syndrome and may be related to plantar fasciitis. Cystic erosion Areas of radiolucency usually noted with arthritic changes, such as rheumatoid arthritis, and usually occurring in the metatarsal heads with associated joint changes Digiti flexus Fixed or flexible flexion at the metatarsal phalangeal joints, ie, hammertoe

Definition or Description Digiti quinti varus Valgus displacement or splaying of the fifth metatarsal, with a resulting varus or inward deviation of the fifth toe Dislocation of lesser metatarsal phalangeal joint Toe joint is out of its socket Entrapment syndrome Occurs when a nerve is compressed by ligamentous or other soft-tissue inflammation, resulting in pain and possibly numbness and neuropathic symptoms. The most common sites are the posterior tibial nerve and the intermetatarsal nerves, plantarly. Equinus Tight Achilles tendon

Definition or Description Haglund’s deformity A hyperostosis of the posterior and superior portion of the calcaneus, enlarging the calcaneus, which can in turn place pressure on the attachment of the Achilles tendon. The presence of the deformity also can produce a pressure area for the heel counter of the shoe. It is easily demonstrated on a lateral radiograph of the foot and can be associated with tendinitis or bursitis, usually resulting from an incompatibility of foot to shoe last. Hallux abducto valgus An alternative clinical diagnosis for hallux valgus, or bunion. There is a varus splaying of the first metatarsal with a valgus and rotational deformity of the phalanges of the great toe. Hallux limitus and rigidus A degenerative joint change involving the first metatarsal phalangeal joint, resulting from dorsal spurs, with a marked limitation or absence of any range of motion. The difference between hallux limitus and rigidus is based on the radiographic interpretation and difference in function.

Definition or Description Hallux valgus Deviation of the tip of the great toe, or main axis of the toe, toward the outer or lateral side of the foot, ie, bunion Hammertoe Muscle tendon imbalance causing contraction of the proximal or distal interphalangeal joint, or both Metatarsalgia Pain in the forefoot near the heads of the metatarsals Morton’s neuroma/Morton’s syndrome A congenital shortening of the first metatarsal shaft, which creates an abnormal metatarsal arc. Excessive weight is placed on the second metatarsal head during gait and stance. The dynamics and pathomechanics of the foot are modified and can lead to hallux valgus, abducto valgus, or rotational deformity of the hallux. Periostitis Inflammation of the periosteum

Definition or Description Pes cavus Higher than normal arch that is commonly associated with neurologic change. In older adults, excessive pressure is usually placed on the metatarsal heads. With atrophy of the plantar fat pad and displacement, pressure is increased, which can serve as a predisposing cause for pain and ulceration. Pes planus A flattening of the medial longitudinal arch, in which the calcaneal pitch on a radiograph is usually below 15 degrees (ie, flat feet) Pes valgo planus Clinical picture same as that of pes planus, with an addition of pronation, demonstrated by a lateral deviation of the Achilles tendon and an outward and rotational deformity of the foot.

Definition or Description Plantar fasciitis Inflammation and pain involving repetitive microtrauma to the plantar fascia, particularly at its posterior calcaneal attachment; associated with biomechanical and pathomechanical changes in the function of the foot. It is related to calcaneal spurs, ligamentous calcification, and tissue atrophy. Subluxation Deviation of a joint’s position Tailor’s bunion Prominence of the dorsal lateral aspect of the fifth metatarsal head Tarsal tunnel syndrome An entrapment neuropathy of the posterior tibial nerve Tenosynovitis Inflammation of the synovial sheath of a tendon complex; sometimes associated with a tendon tear

Definition or Description Tibialis posterior dysfunction Chronic rupture or weakening of the tibialis posterior tendon secondary to long-term pes planus Valgus position Frontal plane position in which pressure is inwardly directed in the foot Varus position Frontal plane position in which pressure is outwardly directed in the foot

COMMON DEFORMITIES OF THE FOOT
Pathologic foot: abnormally distributes weight during gait and creates stress on the musculoskeletal structure of the foot, resulting in pain Physical stress of the foot over a lifetime can result in tissue atrophy, arthritis, and subluxation of joints in the foot Two generalized pathologic foot types create this disability: Collapsing pes plano valgus (low arch morphology) Cavus foot (high arch morphology) Specific associated deformities can develop due to the pathomechanics of the general deformities

Collapsing pes plano valgus
Unstable medial longitudinal arch leading to a ‘‘flat foot’’ The instability can occur in the talonavicular joint, the navicular cuneiform joint, and/or the first metatarsal cuneiform joint Instability causes the forefoot to abduct on the rear foot, and the rear foot to go into valgus attitude in respect to the ankle joint Essentially, the longitudinal arch collapses on the weight-bearing surface during stance, resulting in the subluxation of joints, leading to arthrosis Early in life, collapsing pes plano valgus is usually quite flexible and can be treated with functional orthoses to help support the arch during stance. However, later in life, the foot becomes more rigid and is treated with an accommodative orthotic that absorbs the abnormally high pressure on the pes planus foot type. The deformity can be congenital or acquired, but the extent of the deformity depends on activity level, body type, shoeing, etc. Patients with this type of foot have a number of other associated deformities. These include posterior tibial tendon dysfunction, hallux valgus (bunion deformity), lesser metatarsal phalangeal joint dislocations (chronic dislocation of the toe joints), hammertoes, and neuromas.

CAVUS FOOT The cavus foot type is generally rigid and a very poor shock absorber It also can be congenital; if acquired later in life, it usually has a neurologic origin Cavus foot frequently has a metatarsus adductus (inward orientation of the metatarsal bones) component Older adults with cavus foot generally have loss of the fat pad in the heel as well as in the submetatarsal head region (ball of the foot). Associated deformities include cocked hallux (hammertoe of the great toe), sagittal dislocation of the metatarsal phalangeal joints, metatarsalgia, mid-foot dorsal exostoses (bone spurs), and rigid hammertoe deformities.

EQUINUS The effect of a tight Achilles tendon on the foot
Frequently a component of a pes planus or cavus foot, but it can be seen in a foot that appears grossly normal Tightness of either the gastrosoleal complex or the gastrocnemius muscle complex Can cause various symptomatology, including Achilles tendinitis, plantar fasciitis, metatarsalgia, and hammertoe deformities

Posterior tibial tendon Dysfunction
Defined as the gradual tearing and/or rupturing of the tibialis posterior tendon The loss of this muscle’s function creates significant disability, especially in obese patients The tibialis posterior muscle arises from the posterior aspect of the leg, and its tendon courses posteromedially across the ankle joint and inserts primarily into the navicular joint. It also has small connections to remaining tarsal bones. Dysfunction of the posterior tibial tendon causes collapse of the longitudinal arch, which causes subluxation of the rear-foot tarsal joints and eventually the ankle joint. The dysfunction is divided into four stages. Stage I is a tendinitis of the tibialis posterior tendon without foot deformity. Stage II is tearing or rupturing of the tibialis posterior tendon, which creates a flexible (fully reducible) deformity. Stage III is a stage II deformity that has become arthritic and rigid . Stage IV occurs when the pronatory forces weaken the deltoid ligament, resulting in a valgus ankle deformity. This can be crippling in older patients. Stage 3 posterior tibial tendon dysfunction

TREATMENT OF Posterior tibial tendon Dysfunction
Conservative treatment ranges from orthoses built to place the foot in a supinatory position to bracing with either an ankle-foot orthoses or a Richie brace, a custom brace that provides increased foot control Surgical treatment: Stage I: synovectomy and repair of the tendon Stage II: calcaneal osteotomies and tendon transfers to reconstruct the foot Stage III: arthrodesis of the rear foot Stage IV: pan-talar arthrodesis Studies have demonstrated that stage I and II repairs can improve function and reduce symptoms.

Hallux valgus deformity (bunion)
Subluxation of the first metatarsal phalangeal joint, resulting from the adduction of the first metatarsal and the abduction of the hallux The prominence and subluxation can be painful, especially when the person is wearing shoes, because of pressure at the bunion deformity Treated conservatively by adapting the patient’s shoe to the deformity, ie, wider shoes/toe box and various padding techniques Surgery is considered if the deformity is symptomatic and unresponsive to conservative care One third of people >65 years old have a hallux valgus deformity (bunion). This deformity essentially progresses during a person’s lifetime. There is usually hypermobility of the first metatarsal cuneiform joint. Hallux valgus deformities that have been present for a lifetime frequently are arthritic. Specific surgical procedures depend on the severity of the deformity and on the patient’s health and activity level. Studies evaluating orthopedic quality of life indicators and Short Form-36 after repair have demonstrated reduction of symptoms and a return to shoe gear usually independent of the procedure. These findings were consistent over all age ranges.

Hallux limitus Arthritic condition occurring at the first metatarsal phalangeal joint Occurs with clinical findings of arthritis, including crepitus and a decrease of normal motion, when there is very little motion and the joint is essentially functioning as if fused Traditional treatment: orthoses to prevent motion at the first metatarsal phalangeal joint and relieve pain Surgical approach can vary from removal of bone spurs (cheilectomy) to osteotomies, joint implants, and arthrodesis of the joint Normal motion of the first metatarsal phalangeal joint has been reported from 75 degrees to 35 degrees. The cause of hallux limitus is thought to be from sagittal plane instability (the first metatarsal has increased dorsi and plantarflexion) of the first toe, resulting in hypermobility. This causes elevation of the first toe and thus impingement of the joint. Over time, this process results in an arthritic joint. An alternative treatment approach in patients who still have some motion at the joint is to construct an orthoses with a first ray cut out, thereby plantarflexing the first metatarsal and placing the joint in a mechanically better position as the patient shifts weight from heel to ball of the foot when walking.

HAMMERTOE DEFORMITIES
Buckling (contraction) at the proximal interphalangeal joint (PIPJ) or the distal interphalangeal joint (DIPJ) of the lesser toes ‘‘Classic’’ hammertoe: flexor contracture at the PIPJ Mallet toe: contracts at the DIPJ Claw toe: contracts at the PIPJ & DIPJ Can be flexible and easily reducible, or rigid and nonreducible Rigid hammertoes are generally more painful and create problems when wearing shoes Hammertoes are caused by a muscle tendon imbalance that occurs around the metatarsal phalangeal joint. When hammertoes press against the shoe, a callus or corn is created. This can cause pain and require periodic debridement. Treatment of hammertoes can consist of digital padding, wide toe box in shoes or custom shoes, debridement of callus, or surgical correction of the deformity.

Chronic Dislocated Metatarsal Phalangeal Joint
The end stage of a hammertoe deformity Not uncommon in older adults, caused by long-term biomechanical pathology in the forefoot The toe generally dislocates on top of the metatarsal head, which places pressure on the ball of the foot Patients usually require accommodative shoes with increased toe box height to reduce dorsal pressure When shoes can no longer control symptoms and skin breakdown, surgical reconstruction may be necessary A dislocated metatarsal phalangeal joint is sometimes seen at an earlier age in patients with rheumatoid arthritis. Metatarsal phalangeal joint dislocations are a source of chronic pain and can cause plantar ulcerations, especially in patients who suffer from neuropathy.

Hallux abducto valgus with crossover toe deformity
When a chronically dislocated joint occurs on the second toe, it is usually associated with a hallux valgus deformity and can result in a cross-over deformity.

NEUROMAS Benign growth of a peripheral nerve caused by chronic entrapment Conservative treatment: Metatarsal pads Orthoses Corticosteroid injections Cryotherapy Alcohol injections Surgical treatment: release of the intermetatarsal ligament or primary excision of the neuroma Neuromas are commonly seen in the foot between the third and fourth metatarsal heads, where they are referred to as Morton’s neuromas. It is theorized that the common metatarsal nerve is entrapped by the deep intermetatarsal ligament as it courses underneath the ligament and forms the digital nerve branches. A comparative review of surgical intervention consistently demonstrated favorable results, with 80% of patients reporting a high level of satisfaction.

GENERAL TREATMENT STRATEGIES FOR FOOT DEFORMATIES: ORTHOSES
External devices that are placed either on the foot or into the shoe to accommodate for a foot deformity or to alter the function of the foot to relieve physical stress on a certain portion of the foot Orthoses placed on the foot would include temporary felt padding or silicone/putty spacers to accommodate for structural deformities Orthoses placed in the shoe are either OTC devices or custom made OTC devices are generally made of lightweight polyethylene foam, soft plastics, or silicone, and are produced for a certain size of foot. A custom-made device is constructed from an impression of a person’s foot.

GENERAL TREATMENT STRATEGIES FOR FOOT DEFORMATIES: SHOES
Shoe wear is commonly ill-fitting in older adults and can be a source of foot pain ~75% of people >65 yr wear shoes that are too small Appropriate shoe wear can alleviate foot pain as well as protect the foot from injury Older adults should be advised to purchase a shoe that fits well, has a sturdy heel counter, a firm beveled sole, and good traction Narrow high heels should be avoided. A wide heel <6 cm in height can be appropriate for women who have tight heel cords and have been wearing high-heeled shoes all their lives. Older adults wearing heels >6 cm high are at a greater risk of falls. Proper shoes and inserts that reduce pressure can decrease pain and improve function in older adults.

SHOE TERMS Term Definition or Description Custom-made molded shoes
Made from an impression of the foot either by a plaster cast or foam imprint Extra depth shoe Provides additional space in the toe box Heel counter Back of the shoe that the heel fits in; shoes with a stiffer and higher heel counter have more stability Rocker bottom sole Modification of the sole Shock-absorbing heel Hard but absorbent material that provides shock absorption; good for patients with a cavus foot and obese patients Thomas heel modification A distal medial extension of the heel that provides stability of the arch Toe box Part of the shoe that contains the toes Velcro lacing Hook and loop tape used to secure the shoe closed, rather than conventional laces

Surgical Considerations of Foot Deformities
Foot problems that are not alleviated by conservative methods are amenable to surgical solutions when relief of pain and restoration of function are the goals Most podiatric surgical procedures for older adults can be performed under local anesthesia with monitored sedation, thereby minimizing surgical risk Foot surgery in older adults has become substantially more common in the past 30 years, largely because of the growth of this segment of the population. Studies have indicated that poor outcomes in surgery are generally the result of the overall health of an individual, not chronologic age.

Skin Neoplasms Skin neoplasms on the foot are common in older adults and are rarely malignant The true incidence of skin lesions in the older population is unknown but is likely quite high Suspicious lesions require biopsy See GRS7 pp for an expanded description of the following common benign neoplasms: Keratotic lesions – calluses or corns seen commonly over sites of pressure; common terms are heloma durum (hard corn), heloma molle (soft corn), and tyloma (wide spread callus). Plantar verruca – The most common skin disorder of the foot, this viral infection of the plantar aspect is caused by a strain of the papilloma virus. Lesions are circular, punctate, and flat. Epidermal inclusion cysts – created by a portion of epidermis proliferating in the dermis. Dermatofibromas – flat-topped, raised, and firm lesions; generally not treated unless located across a joint or irritated by shoe wear. A high recurrence rate is noted after excision. Hemangioma – These common vascular tumors contain abundant capillaries and are flat-topped, red lesions typically seen on the plantar aspect of the foot.

MALIGNANT LESIONS Uncommon in the foot but can easily go undiagnosed and generally have a poor outcome: Fully evaluate pigmented lesions of the foot and perform biopsies of any suspicious lesions Characteristics of a potentially malignant lesion are new lesions in a patient >60 years old or lesions that change shape, color, or diameter Lesions not responding to conservative therapy and slow or nonhealing ulceration of the foot should be biopsied to exclude a potential underlying neoplasm Morbidity associated with these lesions increases at age 60 and over. Malignant lesions identified in the foot include basal cell carcinoma, Bowen’s disease, squamous cell carcinoma, and malignant acral lentiginous melanoma.

Malignant melanoma Malignant melanoma, acral lentiginous type, located on the plantar aspect of the forefoot

OTHER SKIN DISORDERS Excessive dryness, or xerosis, is associated with a lack of hydration and lubrication Urea cream or solution (10%, 20%, or 40%) or ammonium lactate (12%) may be helpful A heel sleeve or pad made with mineral oil or a heel cup can help minimize trauma to the heel, thus reducing the potential for complications Eczema is inflamed skin that is not infected Treatment is generally a combination of emollients and steroid creams, with or without occlusive dressings Management of xerosis aims to prevent infection and other complications. Urea and/or lactic acid–based emollients have been shown to be effective but must be used daily and applied after bathing. The most common types of eczema in older adults are xerotic eczema, venous stasis eczema, and drug-induced eczema.

NAIL DISORDERS: Onychocryptosis
Nail disorders are the most common disorders of the foot Onychocryptosis is the incurvation of the edge of the nail plate into the nail groove Generally occurs in the distal portion of the nail groove Secondary to long-term improper nail cutting, narrow shoes, and/or genetically incurvated nail matrixes A chronically ingrown nail is best treated either with a partial nail avulsion or a permanent matricectomy.

NAIL DISORDERS: Paronychia
Localized infection caused by the nail embedding into the nail groove Requires incision and drainage of the abscess with removal of the nail spicule All infected granulation tissue is resected, and, depending on the presence of cellulitis or comorbidities, antibiotic treatment may be needed Toes with chronic paronychias should be radiographed to exclude underlying osteomyelitis, especially in patients with diabetes or peripheral arterial disease

Onychomycosis Nails infected by fungi are often yellow, thickened, and friable, with yellow-brown debris under the nail plate.

ONYCHOMYCOSIS Fungal infection of the nail plate
Causes thickening of the nail  can cause pain Present in ~ one third of older adults; increased incidence in those with obesity, immunodeficiency, diabetes, peripheral arterial disease, chronic tinea pedis, or psoriasis ~80% of infections caused by dermatophytes, the remainder caused by saprophytes or yeast

TREATMENT OF ONYCHOMYCOSIS
For cosmetic concerns, comorbidities (diabetes), or pain Topical antifungal agents not effective Topical ciclopirox: <12% achieve clear or almost clear nails in clinical trials Oral agents, such as terbinafine, fluconazole, itraconazole: Potential for drug interactions Treatment may take 3 to 4 months Relapse rate is high

DIABETES MELLITUS AND THE FEET
The most important disease affecting foot health in older people 50%–75% of amputations in diabetic patients could be prevented by periodic assessment, early intervention, foot health education Ocular complications reduce ability to see ingrown toenails, corns, and ulcers Delayed wound healing is a factor

FOOT ULCERS Most common causes: pressure, venous insufficiency, arterial insufficiency, neuropathy Other causes: tumors, polycythemia vera, self-inflicted improper care Other systemic conditions can impact feet: hypothyroidism, heart failure, renal failure, lymphedema

FOOT ULCER PREVENTION IN DIABETES
Foot examination By clinician at each visit Daily inspection by patient or caregiver is ideal Prevention Management of underlying disease Treatment of peripheral neuropathy, arterial disease, limited joint mobility, elevated plantar pressures, bony deformities, shock, and shear Education: For patient and caregiver, available through national/regional diabetes associations Prevention and early recognition are the most important strategies in managing foot ulcers in older patients with diabetes. Clinicians should ensure that such patients have their feet examined a least annually. It is typical to ask patients with diabetes to remove their shoes at all visits to make a quick visual inspection of the feet and between the toes to ensure no skin breakdown. Patients and caregivers should be instructed in the importance of daily foot inspections. Other preventive strategies include optimizing glycemic control, and monitoring and treating peripheral neuropathy, arterial disease, limited joint mobility, bony deformities, hyperkeratosis, and onychodystrophy. Assessing sensation using the Semmes-Weinstein monofilament and monitoring reflex changes help the clinician assess the risk of development of ulcers and help prevent ulcers in patients with diabetes. Reducing excessive pressure, shock, and shear by accommodating, stabilizing, and supporting deformities by weight diffusion and dispersion is also important in ulcer prevention. Early intervention of high-risk feet with proper shoes and foot care reduces complications, as demonstrated in the LEAP (Lower Extremity Amputation Prevention) program and Medicare LOPS (Loss of Protective Sensation) program.

FOOT ULCER EVALUATION IN DIABETES
Assess location, duration, inciting event or trauma, prior ulcerations, infection, ischemia, neuropathy, wound care, edema, and Charcot joints Evaluate vascular, neurologic, dermatologic systems Identify structural deformities and exclude osteomyelitis by imaging studies Further studies may include: plain radiography, CT, bone scan, MRI, Doppler, and transcutaneous oxygen tension

FOOT ULCER TREATMENT IN DIABETES
Debridement Pressure relief Wound management Treat infection (early antibiotics) Treat ischemia Manage comorbidities Hospitalization and surgery if needed Weight bearing can be modified by the use of crutches and wheelchairs as well as contact casts, walkers, boots, braces, total contact orthotics, modified surgical shoes and boots, and appropriate dressings. A wide variety of dressings and topical agents are available; selection is guided by the nature of the ulcer and its complications. Topical agents include saline, antiseptics, topical antibiotics, enzymes, growth factors, and dermal skin substitutes. Vacuum-assisted closure and hyperbaric oxygen chambers can also aid in the closure of difficult-to-heal wounds in patients with diabetes. Empiric antibiotic therapy should be started early when there is a suspicion of infection. With osteomyelitis or limb-threatening infection, hospitalization is usually indicated. The choice of antibiotic is based on the clinical symptoms, culture and sensitivity, and the presence of deep infection, bone exposure, or sepsis, as well as whether soft tissue or bone is infected.

PERIPHERAL VASCULAR DISEASE AND THE FEET
Older adults with PVD demonstrate many of the same foot signs and symptoms as those with diabetes mellitus In contrast to neuropathic ulcers, vascular ulcers are extremely painful

ARTHRITIS AND THE FEET (1 of 2)
Osteoarthritis Occurs in weight-bearing joints Causes pain, swelling, stiffness, limitation of movement, and deformity Gouty arthritis Most common in the first metatarsal phalangeal joint Early result is intense pain and erythema; later result is joint damage

ARTHRITIS AND THE FEET (2 of 2)
Rheumatoid arthritis Affects the hands and feet equally; usually symmetric in its presentation Can result in muscle wasting, marked deformity Metatarsal phalangeal joints become dislocated or subluxed, causing increasing protrusion of metatarsal heads and painful walking If orthotics and special shoes do not relieve pain, surgery may allow less painful ambulation

SUMMARY Long-term effects of common structural foot deformities, including collapsing pes plano valgus, cavus foot, and equinus deformity, cause significant disability Complete assessment of the skin of the foot is necessary to identify skin conditions and potential malignancies Surgical intervention for treatment of foot deformities can alleviate pain and improve function Systemic diseases can create long-term effects on the foot and ankle

CASE 1 (1 of 3) An active, 70-year-old moderately obese woman reports having a painful left heel over the last few months. She has pain on getting out of bed and after periods of rest. She denies any previous treatments. Her past medical history is unremarkable. Physical examination of the left heel reveals pain at the medial tuberosity of the calcaneus. Dorsiflexion at the ankle joint is decreased but pain-free, and foot structure is normal. A radiograph of her left heel is unremarkable.

CASE 1 (2 of 3) What is the most likely diagnosis? Heel spur
Calcaneal stress fracture Partial tear of Achilles tendon Posterior tibial tendonitis Plantar fasciitis Slide 48 48

CASE 1 (3 of 3) What is the most likely diagnosis? Heel spur
Calcaneal stress fracture Partial tear of Achilles tendon Posterior tibial tendonitis Plantar fasciitis ANSWER: E Plantar fasciitis is a common condition seen after age 40 and is usually diagnosed through symptoms and physical examination findings. Patients typically have pain on rising in the morning and after periods of rest. During periods of nonactivity, the plantar ligament shortens; subsequently, the first few steps cause a sudden stretch, resulting in significant pain that usually decreases as the ligament is lengthened. An associated factor is ankle equinus, or reduction in dorsiflexion of the ankle joint demonstrated on physical examination. This leads to increased stress on the plantar fascia during walking. Pain is usually maximal at the insertion of the plantar fascia on the medial tuberosity of the calcaneus. A pain-free range of motion in the ankle excludes a partial Achilles tear, because this tear is associated with end-range pain. Normal radiographs exclude heel spur and most calcaneal stress fractures; although stress fractures can be missed on plain radiographs, pain due to a stress fracture would not improve with ambulation. A normal foot structure and symptoms not worsening during ambulation (as the medial arch is stressed) exclude tendonitis.

CASE 2 (1 of 3) An active 75-year-old man with no significant medical history presents with chief complaints of chronic itching and scaling of his feet. He says that for >20 years he has had thick nails, starting in the great toes. Over the last few years, this has spread to his lesser digits. Self-care has included nail trimming and OTC hand cream, which he applies a few times a week. Physical examination shows dry erythematous scaling in a moccasin distribution bilaterally, web-space scaling, and thickened yellow nails. Neurovascular examination is within normal limits.

CASE 2 (2 of 3) What is the most likely causative organism?
Candida albicans Microsporum canis Trichophyton rubrum Corneum bacterium Slide 51 51

CASE 2 (3 of 3) What is the most likely causative organism?
Candida albicans Microsporum canis Trichophyton rubrum Corneum bacterium ANSWER: C The incidence of onychomycosis rises with age and often leads to chronic athlete’s feet. It is usually caused by a dermatophyte infection. Trichophyton rubrum has been reported to be the infecting organism in up to 90% of cases. Microsporum canis, another dermatophyte, has been demonstrated to cause onychomycosis, but this type of infection is rare. Yeast infections do not usually involve the toenails, and more commonly cause fingernail infections in patients chronically exposed to water. Bacterial infections do affect the feet but do not present with chronic scaling. Corneum bacterium is associated with pitted keratolysis and presents with moisture and odor limited to web spaces and weight-bearing plantar skin.

CASE 3 (1 of 3) A 72-year-old man with poorly controlled diabetes mellitus complicated by renal disease presents for transfer of care. His feet are now numb, but in the past he experienced a burning sensation.

CASE 3 (2 of 3) Which examination or test is the best test to determine loss of protective sensation? 5.07 (10 gm) Semmes-Weinstein monofilament Electromyography Sharp/dull discrimination Reflex hammer Vibration sense with 128 mH Slide 54 54

CASE 3 (3 of 3) Which examination or test is the best test to determine loss of protective sensation? 5.07 (10 gm) Semmes-Weinstein monofilament Electromyography Sharp/dull discrimination Reflex hammer Vibration sense with 128 mH ANSWER: A Extensive literature has been published that supports the use of the 5.07 Semmes-Weinstein monofilament for determining loss of protective sensation in diabetic patients. This testing is required by Medicare for reimbursement for diabetic foot care and diabetic shoes. Although sharp/dull and vibration testing are routinely performed, their reliability and predictive validity have not been confirmed. EMG testing can determine neuropathy when the neurologic lesion is proximal to the foot, but it does not perform well in patients with neuropathy in a stocking distribution. Deep tendon reflexes can assist in identifying lesions proximal to the foot and thus are not helpful in the diagnosis of diabetic peripheral neuropathy.

Copyright © 2010 American Geriatrics Society
ACKNOWLEDGMENTS Editor: Annette Medina-Walpole, MD GRS7 Chapter Authors: Alfred J. Phillips DPM Douglas A. Albreski, DPM GRS7 Question Writer: Douglas A. Albreski, DPM Pharmacotherapy Editor: Judith L. Beizer, PharmD Medical Writers: Beverly A. Caley, Faith Reidenbach Managing Editor: Andrea N. Sherman, MS Copyright © 2010 American Geriatrics Society

DISEASES AND DISORDERS OF THE FOOT

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