Recognizing, Treating, and Preventing Common Foot Problems

CARING FOR OLDER PATIENTS ROBERT M. PALMER, MD, EDITOR

JEFFREY M. ROBBINS, DPM Professor of Podiatric Medicine, Ohio College of Podiatric Medicine; Director of Podiatric Services, Veterans Affairs National Headquarters; Chief, Podiatry Section, Cleveland VA Medical Center

Recognizing, treating, and preventing common foot problems

ABSTRACT • Fungal disease of the nails and skin The incidence, prevalence, and severity of (tinea pedis) foot conditions increase with age. Teaching • Fungal disease of the nails (onychomycosis) patients simple preventive techniques is • Plantar warts (verruca plantaris) and crucial. Recognition, treatment, and other viral skin lesions prevention of common foot complaints— • Excessive pronation (flat foot) ie, toenail problems, infections, corns and • Functional equinus (toe walking) calluses, injuries, flat feet, bunions, arthritis • Bunion deformity (hallux valgus) of the toes, and toe and joint deformities— • Lesser toe deformities (deformed and are reviewed. contracted toes with or without corns) • Metatarsal deformities (prominent HYSICIANS NEED TO EDUCATE and metatarsal heads with or without cal- encourage patients of all ages to take luses). practical measures to prevent common foot problems. Once foot problems develop, Other problems to look for The patient's physicians can apply treatments aimed at in adult and older patients age dictates retarding the progression of the condition, In addition to the above conditions, watch for relieving pain, and improving function. the following conditions in adult and older the focus This paper reviews the signs and symptoms patients: of the foot of the most common foot problems, preven- • Interphalangeal joint inflammation tion and treatment, and selection of and sublesional bursitis examination footwear. • Metatarsal joint inflammation and sublesional capsulitis • SCREENING FOR FOOT PROBLEMS • Diminished pedal pulses (dorsalis pedis, posterior tibial) Examination of the feet to screen for dis- • Sensory neuropathy, evidenced by lack ease precursors is important throughout of "protection sensation" on the the patient's life. The focus of the exami- monofilament wire test. nation shifts depending on the age of the patient. Monofilament testing for sensory neuropathy What to look for in all patients The 5.07 log (10-g) monofilament test is Examine all patients for the following prob- used to screen for sensory neuropathy in lems: diabetic patients or other patients at risk. • Ingrown toe nails (onychocryptosis) The tip of the monofilament is pressed against the skin until it bends (FIGURE 1). This applies 10 g of pressure to the skin

PATIENT INFORMATION and should normally be felt by the Keeping your feet healthy, page 57 patient. The absence of feeling indicates

FIGURE 1. Monofilament testing. A monofilament is placed FIGURE 2. Onychomycosis. Control the on the skin and pressed until it bends. If no pressure is felt, infection, reduce painful nail thickness, the limb has no protection sensation and the risk for ulcera- and prevent secondary skin infections. tion and infection is increased. Periodic debridement and regular use of topical antifungal creams and powders are recommended. If these are ineffective, that the patient has lost protection sensa- consider oral antifungal agents and per- tion and is therefore at risk for the devel- manent surgical removal of the nail. opment of limb-threatening ulceration and infection. • Superficial white onychomycosis • FUNGAL INFECTION OF TOENAILS affects the superior aspect of the nail and may not affect the nail bed at all. Fungal infection of the toe nails, or ony- Control the chomycosis, is one of the most common foot Treatment infection, conditions and is especially common in older Attempt to control the infection, reduce patients (FIGURE 2). It results from the invasion painful nail thickness, and prevent secondary reduce painful of the nail and nail bed by a dermatophyte. skin infections. Periodic debridement and the nail thickness, The most common organisms causing ony- use of topical antifungal creams and powders chomycosis are Trichophyton rubrum, Tricho- should accomplish this. prevent phyton mentagrophytes, and Candida albicans. If this treatment is ineffective, try oral secondary Signs of fungal infection include onychol- antifungal agents with or without permanent ysis (loosening or separation of all or part of surgical removal of the nail. Oral agents such infection the nail), hypertrophy, and discoloration as terbinafine, fluconazole, itraconazole, and (white, yellow, brown, or green), crumbling, ketoconazole are now available to treat ony- and hyperkeratosis of subungual tissues. chomycosis. Some of these agents can be Onychomycosis is classified according to given in pulsed doses to decrease the potential the level of involvement. for side effects and adverse reactions. • Total dystrophic onychomycosis affects the entire nail and nail bed • INGROWN TOENAIL • Distal subungual onychomycosis affects the distal and sometimes lateral aspects Ingrown nails most frequently involve the hal- of the nail and nail bed initially and often pro- lux nails, although any nail can be affected. gresses to total dystrophic onychomycosis They can be caused by ill-fitting shoes, ony- • Proximal subungual onychomycosis chomycosis, familial incurvated nails, improp- affects the proximal nail fold and nail bed ini- er trimming, and other forms of trauma. The tially and progresses distally if untreated; this nail of the involved margin can lacerate the type is seen commonly in patients with HIV tissues in the nail groove, resulting in infec- infection tion (paronychia). The ingrown nail causes

46 CLEVELAND CLINIC JOURNAL OF MEDICINE VOLUME 67 • NUMBER 1 JANUARY 2000 Downloaded from www.ccjm.org on September 28, 2021. For personal use only. All other uses require permission. severe pain and discomfort and, as does a for- eign body, requires excision.

Treatment Tbis condition is generally benign and is eas- ily treated unless complicated by a systemic condition that places the patient at risk, eg, diabetes, peripheral vascular disease, immun- odeficiency, neuropathy, or any other condition that interferes with wound healing. Initial episodes are treated with partial temporary nail avulsion of the affected side with incision and drainage of paronychia or abscess. This must be followed up with patient education on proper nail cutting to avoid sub- sequent episodes. FIGURE 3. Acute tinea pedis. Treat with topical antifungal In cases involving patients with a compro- agents and warm saline soaks (except in diabetic and other mising condition such as diabetes or severe cel- compromised patients), and encourage proper foot lulitis, an antibiotic can be used in addition to hygiene. Oral antibiotics directed at staphylococcal and removing the nail spicule. If the ingrown nail streptococcal organisms may be used In secondary infec- recurs despite proper nail cutting, permanent tions. Treat chronic tinea pedis similarly but longer. partial avulsion of the nail is recommended.

• TINEA PEDIS patients), proper foot hygiene, and avoidance of trauma that could result in secondary bac- Fungal infection of the skin of the foot, or terial infection. tinea pedis, is classified as acute or chronic In acute vesicular or pustular tinea infec- (FIGURE 3). Signs and symptoms of acute tinea tion, a short course of an oral antifungal agent Infections in pedis may include one or more of the follow- (eg, griseofulvin, terbinafine, fluconazole, diabetic patients ing: macerated web spaces, vesicles, bulla, and itraconazole, ketoconazole) is indicated. If a pruritus that can be severe at times. The secondary bacterial infection is suspected, an should be causative organism is usually Trichophyton oral antibiotic directed at staphylococcal and suspected of mentagrophytes. More severe cases can exhibit streptococcal organisms is recommended. fissures in the web spaces and local erythema In diabetic patients infections should being and cellulitis. When cellulitis is present, bac- always be suspected of being polymicrobial, polymicrobial terial infection must be suspected. and this should guide antibiotic selection. Chronic tinea pedis is characterized by a Treat chronic tinea pedis similarly, but for moccasin-type distribution of scaling and dry a longer time. Following resolution, instruct skin. The web spaces may also be involved. the patient about measures to prevent recur- The symptoms are generally not uncomfort- rence: proper hygiene, daily use of antifungal able to the patient and may persist untreated foot powder, and disinfectant spray (eg, Lysol) for years. The causative organism is usually to shoes at least once weekly. Trichophyton rubrum. Although this diagnosis is most often made clinically, potassium • DEFORMITIES hydroxide slide preparation and culture help to confirm the diagnosis of tinea pedis. The biomechanical effects of years of walking on hard, flat, unyielding surfaces can combine Treatment with inherited foot structure or with years of Treat acute tinea pedis with commonly avail- wearing inappropriately tight or constricting able topical antifungal agents, as well as with footwear, or both—all of which can lead to a local skin care consisting of warm saline soaks compensatory muscular imbalance that results (except in diabetic and other compromised in progressive deformity.

CLEVELAND CLINIC JOURNAL OF MEDICINE VOLUME 67 • NUMBER 1 JANUARY 2000 13 Downloaded from www.ccjm.org on September 28, 2021. For personal use only. All other uses require permission. FIGURE 4. Hammer toe (left) and hallux valgus (right). Treat by protecting the foot, relieving pain, and improving function. Advise patients to consider extra-depth or custom- molded shoes, foot padding, foot taping, foot exercises, nonsteroidal anti-inflammatory drugs, intra-articular injections, physical therapy, or orthotics. Consider surgery only when these measures fail.

Hammer toe, claw toe, mallet toe metatarsal phalangeal joint can result in pain Three distinct types of so-called lesser defor- during movement, restricted range of motion, mity have been identified: hammer toe (FIGURE or joint fusion, making ambulation difficult 4), claw toe, and mallet toe. Lesser toe defor- because of pain. mities are progressive and can begin during early adolescence, but they most often become Tailor's bunion (bunionette) symptomatic only after the third decade of This condition involves the fifth ray, specifi- Walking on life. cally medial migration of the fifth toe and lat- hard, flat, Hammer toe involves extension of the eral migration of the fifth metatarsal. The fifth proximal phalanx on the metatarsal head and metatarsal phalangeal joint is then subjected unyielding flexion of the middle phalanx. The distal pha- to the development of painful bursitis, joint surfaces leads lanx is neither extended nor flexed. arthritis, and loss of normal range of motion Claw toe differs from hammer toe in that and function. to deformity, the distal phalanx is also flexed. trauma, and Mallet toe appears straight, but the distal Treatment phalanx is flexed. Conservative therapy attempts to accommo- infections date deformities, protect the foot, relieve Hallux valgus or bunion pain, and improve function. Conservative Hallux valgus (FIGURE 4) is a deformity of the measures include a change in footwear (eg, first ray (hallux and first metatarsal) and extra-depth shoes or custom-molded shoes), can occur in the transverse, frontal, or sagit- foot padding or taping or both, foot exercises, tal plane. In the transverse plane, the hallux nonsteroidal anti-inflammatory drugs, intra- can deviate laterally, while the first articular injections, physical therapy, and metatarsal migrates medially. In the frontal accommodative and biomechanical foot plane the hallux can rotate. In the sagittal orthotic devices (rigid, semi-rigid, root type, plane the first ray may be extended or UCBL [University of California-Berkeley flexed. laboratory] type). When the first metatarsal phalangeal Surgical intervention is considered only joint becomes prominent, a bursal sac may when conservative therapy fails to relieve develop medially, and this sac can become pain, fails to improve function, or fails to pre- inflamed and painful. Arthritis in the first vent the progression of deformity.

• PLANTAR FASCIITIS taping, NSAIDs, ultrasound, electrical stimulation, and biomechanical orthotic devices. Plantar fasciitis is caused by repetitive Surgical intervention is an option only mechanical trauma and is characterized by after conservative therapy has failed to relieve morning pain and stiffness of the heel and symptoms. plantar fascia, which improves with weight- bearing after getting up in the morning and • HYPERKERATOSIS becomes progressively more painful by the end of the day. Returning to weight-bearing Pressure and friction to the skin overlying after short periods of rest during the day can osseous structures produce hyperkeratotic tis- cause the pain and stiffness to return. sue as the body acts to protect itself. In time, Although often mistakenly nicknamed "heel the subcutaneous tissues develop an adventi- spur syndrome," several other causes have tious bursa, which act as an additional "buffer" been suggested and include prolonged weight- to protect the underlying bone. As this condi- bearing or walking on hard flat surfaces, tion progresses, local nerves can hypertrophy abnormal pressure on the plantar fascia from within both the soft tissues and the capsular such activities as ladder climbing, abnormal structures, causing entrapments and painful subtalar joint pronation, and excessive body ambulation. The presenting symptoms of most weight. hyperkeratotic lesions are pain and discomfort. Hyperkeratotic tissue, by itself, is not Treatment painful. The underlying bursitis of neuroma or Conservative care is directed toward pain neuritis is responsible for the pain associated relief and control of the mechanical causes: with hyperkeratotic lesions. daily stretching exercises, padding, taping, The most common types of hyperkeratosis over-the-counter shoe inserts, ultrasound, are: electrical stimulation, NSAIDs, and biome- • Helomas—corns, usually found on the chanical foot orthotic devices. digits Teaching older Steroid injections should be used with • Tylomas—calluses, usually found patients caution, as rupture of the plantar fascia has under or over metatarsal heads or over other been reported. bony prominence prevention is Surgical intervention is considered only • Intractable plantar keratoma, a cone- especially after all conservative therapy has failed to shaped keratotic plug found within a tyloma. relieve symptoms or improve foot function. important Treatment • NEUROMA Treatment for hyperkeratotic conditions includes wider shoes that reduce pressure and Shoes and abnormal biomechanics of the foot friction on a bony prominence, periodic can lead to excessive irritation of the nerves of debridement, and accommodative or biome- the foot, resulting in benign hypertrophy of chanical orthosis. Foot orthotic devices can the nerve, which can cause distal pain, burn- be especially helpful with plantar lesions, as ing, and tingling in the areas served by the they balance foot pressure on a bony promi- involved nerve. The most commonly affected nence, whereas wider shoes are most benefi- nerve is the intermetatarsal nerve in the third cial for interdigital and lateral fifth toe helo- interspace, although any nerve subjected to ma (corns). chronic irritation can be affected. Surgical intervention is considered only after all conservative therapy has failed. Treatment Treatment for neuroma consists of pain relief • PROMOTING LIFELONG PREVENTION and reducing the size of the neuroma by decreasing trauma to the nerve. Conservative Prevention through foot hygiene and proper management for neuroma includes wider shoe selection should begin in the office of shoes, interlesional steroid injections, padding, the pediatrician and continue throughout

52 CLEVELAND CLINIC JOURNAL OF MEDICINE VOLUME 67 • NUMBER 1 JANUARY 2000 Downloaded from www.ccjm.org on September 28, 2021. For personal use only. All other uses require permission. TABLE 1 Common foot problems in older patients

CONDITION SIGNS, AND SYMPTOMS PREVENTION TREATMENT

Oncychomycosis Thick, crumbling, Daily hygiene Regular debridement discolored nails Antifungal foot powder Topical agents to control infection Disinfect shoes Oral agents to resolve infection Surgical excision of nail and nail matrix

Onychocryptosis Incurvated nail margin, Proper, regular cutting of nails Avulsion of nail margin may lacerate tissues causing Incision and drainage of paronychia, Infection (paronychia) if present Permanent nail repair If problem recurs

Tinea pedis Acute: macerated web space, Daily hygiene Topical antifungal creams vesicles, bulla, pruritis Antifungal foot powder Topical antifungal powders Chronic: moccasin-type Disinfect shoes Oral agents if severe (antibiotics for distribution of scaling secondary infection) and dry skin

Hammer toe, Contracture of toe with or Properly fitting shoes Protective padding for sublesional mallet toe, without hyperkeratosis and during growth and bursitis claw toe sublesional bursitis development Debridement of hyperkeratotic skin Pain, cramping, difficulty Appropriate shoes for activity Extra-depth or custom-molded shoes walking during adult life Surgical repair Biomechanlcal orthotic may prevent this development

Hallux valgus Prominent first metatarsal Same as for hammer toe Extra-depth or custom-molded shoes phalangeal joint, perhaps with Padding, taping inflamed, painful bursal Foot exercises sac medially NSAIDs, intra-artlcular injections Physical therapy Orthotics

the patient's life, in the office of the internist mities than men do. and the geriatrician. Promoting good foot On page 57 is a patient education page health and screening early for problems can that you can copy and give to patients to edu- reduce morbidity associated with foot prob- cate them about proper foot hygeine. lems. Teaching older patients prevention is especially important, because chronic condi- • SELECTING SHOES THAT FIT tions such as diabetes, peripheral vascular disease, and severe arthritis increase the risk In selecting shoes, comfort should come for foot problems (TABLE 1). People over age 65 before fashion. Unfortunately, many of our have more foot problems than the general patients have this backwards, usually out of population, except for infections and concern about fashion trends. Advising injuries,1-10 and women tend to have more patients about proper footwear is best done toenail problems, corns, calluses, bunions, while keeping this psychosocial component arthritis of the toes, and toe and joint defor- in mind.

CLEVELAND CLINIC JOURNAL OF MEDICINE VOLUME 67 • NUMBER 1 JANUARY 2000 13

Downloaded from www.ccjm.org on September 28, 2021. For personal use only. All other uses require permission. FOOT PROBLEMS ROBBINS

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Shoes do not, in and of themselves, cause foot problems, including deformities. Individual foot structure is the chief cause. Furthermore, the normal aging process can result in neuropathy, ischemia, immunopa- thy, and atrophy of the protective plantar fat pad. Improper footwear can exacerbate foot problems related to these processes, and to the chronic conditions mentioned above. On page 57 is a patient education page that you can copy and give to patients whose foot problems you believe are caused or exac- erbated by poor shoe selection. £3

• REFERENCES Let us hear your opinions about the Cleveland 1. Greenberg L. Analysis of foot care data from the 1990 Clinic Journal of Medicine. National Health Irterview Survey, September 1992. HRSA Do you like current articles and sections? 92-204 (P), Rockville, Maryland. 2. Robbins JM, editor. Primary podiatric medicine. What topics would you Philadelphia: W.B.Saunders; 1994. like to see covered and how 3. Helfand AE. Public health and podiatric medicine. Baltimore: Williams and Wiikins; 1987. can we make the Journal 4. Robbins JM, editor. Clinics in podiatric medicine and more useful to you? surgery: peripheral vascular disease in the lower extremity. Philadelphia: W.B. Saunders; 1992. 5. Weber G, Cardile MA. Diabetic neuropathies. In: Weber G, editor. Clinics in podiatric medicine and surgery: neu- PHONE 216.444.2661 rologic disorders affecting the lower extremity II. FAX 216,444.9385 Philadelphia: W.B.Saunders; 1990. 6. Joseph WS. Treatnent of lower exteremity infections in E-MAIL [email protected] diabetics, J Am Podiatr Med Assoc 1992; 82: 361-370. WWW http://www.ccjm.org 7. Joseph WS. Handbook of lower extremity infections. New York: Churchill Livngstone; 1990. CLEVELAND CLINIC JOURNAL OF MEDICINE 8. Fairbairn JF, JuergsnsJL, Spittell JA. Peripheral vascular The Cleveland Clinic Foundation disease. 5th ed. Philadelphia: W.B. Saunders; 1980. 9. Yale J. Yale's podiatric medicine. 3rd ed. Baltimore: 9500 Euclid Avenue, NA32 Williams and Wiikins; 1987. Cleveland, Ohio 44195 10. Levy L, Hetherington V, editors. Principles and practice of podiatric medicine. New York: Churchill Livingstone; 1990.

ADDRESS: Jeffrey M. Robbins, DPM, Cleveland VA Medical Center, 10701 East Boulevard, Cleveland, OH 44106, e-mail jef- [email protected].

CME ANSWERS Answers to the credit test on page 71 of this issue

I E2B3D4C5E6B7B8A9B 10D II A 12C

CORRECTION The answer key to the CME Credit Test in the October 1999 issue contained a typographical error. The answer to question 3 should have been A (ibuprofen), not C (naproxen). We apologize for the error.

JANUARY 2000 49 CLEVELAND CLINIC JOURNAL OF MEDICINE VOLUME 67 • NUMBER 1 Downloaded from www.ccjm.org on September 28, 2021. For personal use only. All other uses require permission.