Foot Problems in Elderly

-Podogeriatrics-
Associate Professor: Doha Rasheedy
Geriatrics and Gerontology Department
Faculty of Medicine
Ain Shams University
 Objectives
Know and understand:
1. Normal age-related
changes in the foot
structures.
2. Systematic evaluation
of foot
3. Primary foot problems
and their management
4. Foot disorders
associated with
chronic diseases
Clinical key points
1. Provide a comprehensive clinical
assessment of the foot and related
structures (especially for at risk patients)
2. Provide patient information and education
that includes hygienic and preventive
components, footwear, and orthotic
recommendations
 The etiology of foot problems in
elderly
1. The aging process itself, years of use and abuse
2. Repetitive stress
3. Neglect
4. Foot deformity
5. The presence of multiple chronic diseases, such
as diabetes mellitus, peripheral arterial diseases,
rheumatoid arthritis and degenerative joint
changes, musculoskeletal disorders, neurologic
deficits and sensory loss.
6. Onychial and dermatologic conditions.
7. Altered biomechanics and pathomechanics.
Physiological changes
in the ageing foot
 Physiological changes
in the ageing foot
Integumentary system
• Epidermis and dermis
• Nails
Plantar soft tissues
Peripheral vascular system
• Arteries
• Capillaries
• Veins
Peripheral sensory system
Skeletal system
• Bone
• Joints
• Tendon and ligament
Muscular system
• Ankle muscles
• Foot muscles
Integumentary system
Epidermis and dermis

1. The thickness of the epidermis does not change

appreciably with age.
2. the dermal–epidermal junction becomes flattened
3. the rate of production and turnover of keratinocytes may
reduce to only 50% of that of a young person. this delay in
turnover time,
4. the moisture content of keratinocytes is reduced, which,
combined with the reduction in sweat gland density,
contributes to the dry, scaly appearance of elderly skin
5. Epidermal Langerhans cells, dermal macrophages and mast
cells, which play an important role in the immune function
of the epidermis, decrease dramatically with age, resulting
in a reduced rate of sensitization to microorganisms
• Elastin fibers, decrease in number and become
fragmented. (loss of elastic recoil)
• The collagen fibers decrease in number and
become thicker and stiffer and undergo a
haphazard cross-linking process (decrease
wound healing). These processes alter the
mechanical properties of the skin, leading to
increased fragility
• significant reduction in the number of capillary
loops in the papillary dermis, increased porosity
of endothelial cells and a thickened basement
membrane, all of which contribute to a less
efficient superficial blood supply
• Hair loss
• Atrophy follows with the skin appearing
parchment like and xerotic.
• Brownish pigmentations are common and
related to the deposition of hemosiderin.
• Hyperkeratotic lesions when present are
associated with keratin dysfunction
(hypertrophy and hyperplasia), a residual to
repetitive pressure, atrophy of the
subcutaneous soft tissue, and/or acting as
space replacement as the body attempts to
adjust to the changing pressure placed on the
foot.
 NAILS
1. the rate of growth of the nails decreases by up to
50%.
2. Older nails exhibit an increase in calcium and
reduction in iron content, increased size of
keratinocytes and degeneration of elastic tissues
beneath the nail bed, The formation of longitudinal
grooves and an overall increase in thickness
(onychauxis), often leads to a marked loss of
translucency.
3. periods of arrested growth due to periods of systemic
illness may also manifest as transverse ridges known
as Beau’s lines. These changes are exacerbated by the
presence of arterial insufficiency and low-level
chronic trauma from ill-fitting footwear
 PLANTAR SOFT TISSUES
• The metatarsal pads of fat progressively decrease in
thickness and undergo compression of 10–15% when
standing and up to 46% during gait, increased stiffness,
dissipate more energy when compressed and are
slower to recover after the load is removed.
• Heel pad: the collagen fibers within the septa increase
in number and size and appear more fragmented. As a
result, the septa may become distorted and rupture,
leading to a leakage of fat cells, leading to less
compressibility slightly stiffer and dissipated more
energy.
 PERIPHERAL VASCULAR SYSTEM
1. The size and shape of endothelial cells become more
irregular
2. the overall thickness of the intima and media increases
as a result of collagen cross-linking and invasion of
smooth muscle cells.
3. Elastin fibers in the media of large arteries break down
and stiffen, resulting in a reduction in elastic recoil
4. capillaries become even narrower and their porous walls
increase in thickness, because of basement membrane
thickening and collagen deposition. As a result of these
changes, ageing is associated with an overall reduction in
capillary blood flow, particularly in the lower limb
5. Advancing age is also significantly associated with
perforator vein incompetence, which may result from the
accumulation of collagen fibers around valves.
 PERIPHERAL SENSORY SYSTEM
• With advancing age, there is a generalized decline
in the size and number of axons, and the myelin
sheaths surrounding the axons undergo
significant deterioration, leading to a reduction in
nerve conduction velocity.
• Merkel discs and free nerve endings are not
affected by age
• however, Meissner and Pacinian corpuscles
considerably reduce in density and the receptors
that remain exhibit a number of morphological
alterations
BONE
• Reduced osteoblastic activity, bone density
Cartilage:
• gradual reduction in the amount of chondroitin
sulphate and oligosaccharides, and a corresponding
increase in keratan sulphate. Collagen fibril width and
cross-linking increase with age, and the water content
decreases
TENDON AND LIGAMENT
age results in significant increases in collagen fibril
concentration and diameter, and increased spacing and
cross-linking of collagen molecules.
• Non-collagenous components of tendon show decrease
in the water content of glycosaminoglycans and
increases in lipid content
AGE RELATED CHANGES IN MUSCULAR
SYSTEM
• ↓ total muscle mass
• ↓ muscle cross sectional area
• ↓ the size of type II fibers.
• motor unit remodelling, a process in which
type II fibers are denervated and then
reinnervated by collateral branches of type I
fibers, resulting in the formation of large,
slow-twitch motor units
 THE INITIAL ASSESSMENT INTERVIEW
1. Medical and social history
2. Medication use
3. The presenting complaint
4. Systematic examination
5. Diagnostic imaging
• A comprehensive assessment and risk stratification process
was developed for The Pennsylvania Department of Health
under contract with the Temple University, School of
Podiatric Medicine. (Helfand index)
http://www.podiatrym.com/cme/feb04cme.pdf
 Medical and social history
1. Current overall health status
2. Diagnosed medical conditions
3. Current medications
4. Previous medical history
5. Previous surgeries
6. Usual activity level, sport pattern
7. Occupational history
8. Footwear history
Aim: Identify at risk patients eligible for regular
foot care
 Present complaints
E.g.
1. Swelling of feet
2. Painful feet, location, quality, severity, duration,
context, modifying factors
3. Hyperkeratosis
4. Onychial changes
5. Bunions
6. Painful toenails
7. Infections
8. Ulcerations
9. Cold feet
 Examination of the Foot
1. Vascular Assessment
2. Neurological Assessment
3. Dermatological Assessment
4. Musculoskeletal Assessment
5. Gait
6. Footwear
7. Functional Assessment
8. Pain assessment
 Vascular Assessment

 Assess for trophic changes

 Pedal pulses: palpation of the dorsalis pedis and posterior
tibial pulses. If pulses are not present, the popliteal and
femoral pulses should be identified.
 Temperature Gradient
 Edema
 A history of night cramps, intermittent claudication
(related to arterial insufficiency disease),edema,
atrophy, varicosities, and atrophy
 Neurological Assessment
• Sensory changes
– Vibration
– Proprioception
– Tactile

• Motor changes
– Reflexes
– Muscle power
 Dermatological Assessment
• Assess the nails
 Changes to nail growth, condition, shape
• Assess skin of the lower limb
• Dorsum, plantar and interdigital
• Hyperkeratotic lesions
• Tissue breakdown
• Assessment of skin dryness
 musculoskeletal
1. Deformity
2. Tenderness
3. ROM
 Pain Assessment
1. Site
2. Severity
3. Impact on QoL
 Functional Assessment

1. Identify patients capabilities and limitations

2. Maintaining hygiene
3. Touch and inspect feet
4. Change a dressing
5. Diminished visual acuity
6. Decreased manual dexterity
7. Reduced flexibility of the back, hips and knees
 Footwear Assessment
• Footwear fit :This can be very simply and effectively demonstrated by making a tracing of the patient’s
bare foot on a piece of paper, and using the same piece of paper to trace around their shoe
• Length
• Width
• Heel height
• fixation
• Girth
• Toe box
• Stability
• Appropriate for activity
• Footwear at home
• Those who wore shoes narrower than their feet were
more likely to have corns on the toes, hallux valgus
deformity and foot pain, whereas those who wore shoes
shorter than their feet were more likely to have lesser toe
deformity. Heel elevation in women’s shoes was
associated with both hallux valgus and plantar calluses.
 Imaging
1. plain radiography [weight and nonweight
bearing studies]
2. computed tomography [CT]
3. bone scan
4. Magnetic resonance [MR] imaging
5. bone density
 Other studies
• Doppler evaluation
• pulse volume recording
• ankle-brachial index
• Oscillometer
• skin surface thermometer and scanner
• digital subtraction angiography
• MR angiography
• C-128 tuning fork
• biothesiometer
• vibration threshold meter
• percussion hammer; neurological hammer; Babinski hammer
• monofilament sensory testing such as Semmes-Weinstein, Norton, or West; Tip Therm,
• two-point discriminator
• goniometer (foot and ankle and digital)
• ultraviolet light (Wood light).

biothesiometer
• detect vibration threshold
ultraviolet light (Wood light)
• . special examination lamp which
illuminate the skin and/or hair with
different fluorescent colour in order
to detect and analyse the changes
and its meanings.
 Summary of findings
clinical findings include as examples:
• exquisitely painful or painless wounds, slow healing or nonhealing
wounds, trophic ulceration, necrosis, changes in texture and turgor,
pigmentation (hemosiderin deposition), chronic pruritus, excoriations,
neurogenic and/or emotional dermatoses, contact dermatitis, footwear
related allergic dermatoses, stasis and atopic dermatitis, eczema, xerosis,
recurrent infections (paronychia, tinea pedis, onychomycosis, pyoderma,
and/or cellulitis), keratin dysfunction, keratotic lesions with
(preulcerative) or without hematoma (such as tyloma [callus], heloma
durum [hard corn], heloma millare [seed corn], heloma molle heloma
neurofibrosuum [neuritic], heloma vasculare [vascular], onychophosis
[callus in the nail groove], and intractable plantar keratosis), poroma,
verruca, psoriasis, fissures, hyperhidrosis, bromidrosis, maceration, skin
turgor, and tropic changes. Other considerations include seborrheic warts
(basal cell papilloma—stucco keratosis), solar keratosis, melanoma, and
basal and/or squamous cell carcinoma.
 Onychial findings
• onychatrophia (atrophy)
• onychia sicca (dryness)
• onycholysis (freeing from the free
edge
• subungual hyperkeratosis,
• onychexallis (degeneration)
• onychodystrophy, onychogryphosis
(hypertrophy with deformity),
• onychia (inflammation),
• paronychia (bacterial infection),
• onychitis (inflammation),
• onychalgia (pain),
• subungual abscess,
• subungual heloma (keratosis),
• subungual exostosis or spur,
• onychomadesis (freeing from the
proximal portion),
• onychoschizia (splitting),
• onychyphemia (hemorrhage),
• onychomalacia (softening),
• onychoptosis (shedding),
• periungual ulcerative granulation
tissue,
• onychodysplasia (involuted or
pincer nails),
• onychorrhexis (longitudinal
ridging),
• Beau’s lines (transverse growth
cessation),
• pterygium (hypertrophy of
eponychium),
• Hippocratic nails,
• koilonychia, leukonychia,
• onychoclasis (fracture
• diabetic onychopathy
 orthopedic findigs
• hallux valgus (bunion)
• hallux abductor valgus
• hallux rigidus and/or limitus,
• anterior imbalance
• Morton syndrome,
• digiti flexus (hammertoes, claw
toes, and mallet toes),
• bursitis,
• pes planus,
• Tarsal tunnel syndrome,
• prominent metatarsal heads and
prolapse,
• pes valgo planus,
• Charcot joints,
• pes cavus,
• bony prominences,
• rearfoot varus,
• valgus rearfoot,
• forefoot spinatus,
• everted or valgus forefoot,
• ankle equinus,
• leg length discrepancies, and other
musculoskeletal deformities.
• The foot type,
• muscle strength
• ranges of motion
• atrophy and/or displacement of the plantar
fat pad and subcutaneous so􀁸 tissue
• spur formation (including calcaneal
 Gait findings
• a steady or unsteady gait
• use of mobility aids (cane, crutches, or
wheelchair)
• if the patient is able to reach and see their
feet
• Gait speed and balance
 The prevalent physical manifestations in the foot
associated
with mental health disorders in older patients include
1. Hysterical paralysis
2. psychogenic tremors
3. localized neurodermatitis, pruritus, and hyperhidrosis.
4. Covariant conditions that are affected by emotional
disorders result in exacerbation of the disease or
disorders such as gout, diabetes mellitus, obesity, vascular
insufficiency, psoriasis, urticaria, and atopic dermatitis.
5. The older patient may be using his or her foot complaint
as a cry for “help” and as a means to seek attention,
expecting relief through some form of physical treatment
• Foot problems
1. Primary foot problems.
2. Systemic Diseases Affecting The Foot and
Ankle
Classification of primary foot problems
1. Foot deformities
2. Neuromas
3. Planter fasciitis and heel pain
4. Skin and Nail Disorders
5. Foot pain
SKIN LESIONS
 Xerosis
• Associated with lack of hydration and lubrication and
keratin dysfunction
• Fissures and ulceration may result from dryness and
associated stress on the heel
• Risk factors for xerosis include
– ageing,
– Friction
– low humidity
– open backed shoes
– use of soaps
– Xerosis also presents as a symptom of cutaneous conditions such
as psoriasis, dermatitis and ichthyosis
– Diabetes, hypothyroidism, PVD are associated with higher risk
• Treatment goals: Prevent infection and further complications
1. an emollient following hydration
2. Mild keratolytic agents: 20% or 40% urea solution,
12% ammonium lactate
3. Heel sleeve made of mineral oil
4. Heel cup to reduce trauma
• Deep heel fissure require debridement of
callous edges and applying cyanoacrylate
adhesive to seel fissure till healing
 Pruritus
Risk factors:
• dryness, scaliness, decreased skin secretions, keratin dysfunction, environmental
changes, and defatting of the skin that is usually aggravated by the use of warm
foot soaks.
Clinical presentations:
1. Itching
2. Scratching and excoriations
3. more severe in the colder weather
Differential diagnosis:
• Chronic tinea,
• Allergic, neurogenic, and/or emotional dermatoses
Management
• hydration, lubrication, protection
• topical steroids if indicated
• and judicious use of antihistamines.
• If excoriations are infected, antibiotics should be utilized early on as indicated.
 hyperhidrosis and bromidrosis
Control excessive perspiration and odor:
1. topical hydrogen peroxide, isopropyl alcohol, and astringents
2. Neomycin powder will help control the odor by reducing the
bacterial decomposition of perspiration.
3. footwear and stocking modifications:
1. by rigorous hygiene. A different pair of shoes should be worn each
day with clean socks,
2. the socks must be changed three times a day.
3. Socks made of cotton and hemp absorb foot moisture better than
nylon.
4. A 10% boracic acid powder on the foot and in the shoe used daily is
effective in diminishing the offensive odor.
5. For persistent cases, X rays may be utilized, which will result in a
decrease of the glands.
 Dermatitis
Contact dermatitis Stasis dermatitis
• is associated with reactions to
chemicals used in shoe • associated with venous
construction, such as nickel, insufficiency and chronic
footwear fabrics, and/or ulceration with dependent
stockings. edema.
• Skin lesions and clinical
findings are limited and • Management:
usually bilateral in distribution. 1. Elevation
• Skin testing can identify the 2. mild wet dressings
primary irritant.
3. topical steroids
• Management includes:
4. antibiotics or antifungal as
1. removing the primary indicated,
irritant
5. supportive measures
2. mild wet dressings needed to manage the
3. the use of topical steroids. venous disease.
 Tinea pedis
• Tinea pedis is most commonly caused by Trichophyton rubrum
• Risk factors:
– Poor foot hygiene
– A hot, humid, tropical environment and prolonged use of occlusive footwear,
– underlying conditions (eg, immunosuppression, diabetes)
– Due to spead of onychomycosis

• Clinical picture: pruritic, scaly soles and, often, painful fissures between the
toes. Less often, patients describe vesicular or ulcerative lesions
• Types:
1. Interdigital tinea pedis
2. Chronic hyperkeratotic tinea pedis
3. Inflammatory/vesicular tinea pedis
4. Ulcerative tinea pedis
Diagnosis:
direct potassium hydroxide (KOH) staining for fungal elements
• Complications
– Secondary cellulitis, lymphangitis, pyoderma, and even osteomyelitis can result
1. Health education
– reinfection can occur. Old shoes are often sources of
reinfection and should be disposed of or treated with
antifungal powders.
– When occlusive footwear is worn, wearing cotton socks and
adding a drying powder with antifungal action in the shoes
may be helpful.
2. Treatment:
– Topical agents are used for 1-6 weeks
• Clotrimazole, Econazole, Ketoconazole, Luliconazole, Ciclopirox ,
terbinafine
– Oral antimycotics should be considered in patients with
extensive chronic hyperkeratotic or inflammatory/vesicular
tinea pedis.(itraconazole, terbinafine, Fluconazole) till
symptoms subsides
– Topical urea is esed to decrease scaling in patients with
hyperkeratotic soles
– Ammonium lactate lotion is used to decrease scaling in
patients with hyperkeratotic soles.
Interdigital tinea pedis vesicular tinea pedis

Ulcerative tinea pedis Chronic hyperkeratotic tinea pedis

 Keratotic disorders: calluses and corns
Calluses (also known as tylomas)
 present as a broad-based, diffuse thickening of the stratum corneum and
are most commonly located under the metatarsal heads
Corns (also known as heloma )
• are a more discrete, circumscribed area of thickening with a central core
that may penetrate into the dermis. Three subtypes of corn have been
recognised: hard corns (heloma dura), soft corns (heloma molle) and
seed corns (heloma milliare).
 In response to repetitive friction or pressure, normal healthy skin
undergoes accelerated keratinization and a decreased rate of
desquamation, resulting in an increase in the thickness of the stratum
corneum.
Posited risk factors for the development of keratotic lesions
 Intrinsic  extrinsic
Increased age Footwear
Female sex Narrow toe box
Obesity Elevated heel
Comorbidities Textured insoles (‘health sandals keratosis’)
Diabetes mellitus Occupational/lifestyle factors
Rheumatoid arthritis Prolonged weight bearing
Cerebrovascular accident Prolonged bed rest
Systemic sclerosis Prayer posture (‘Mecca foot’)
Foot deformity
Hallux valgus
Hallus limitus/rigidus
Lesser toe deformity
Pes planus and pes cavus
Foot surgery complications
Reduced range of motion

 Mechanically induced lesions will appear on weight bearing areas or bony

prominences subjected to pressure from footwear,
 whereas keratotic lesions due to other causes are generally more widespread
and associated with similar lesions on the palms.
1. sharp debridement or enucleation with a
scalpel
2. the underlying cause should be addressed
3. shoe modifications
4. Topical treatments: chemically
debride keratotic lesions and inhibit their
regrowth: salicylic acid, silver nitrate, silicone
and hydrocolloid wound dressings
5. Injection therapy: intralesional or sublesional
injection , including sodium chloride, alcohol
and liquid silicone
 If left untreated, keratotic lesions can cause
considerable damage to deeper layers of the skin,
particularly in people with diabetes. Indeed, the
presence of plantar keratotic lesions is a strong
predictor of foot ulceration in people with diabetic
peripheral neuropathy
DD:
 verrucae (warts), and indeed longstanding warts may
develop a thick covering layer of hyperkeratosis.
However, verrucae do not generally form on weight
bearing areas, are more acutely painful when lateral
pressure is applied to the lesion, and will exhibit
characteristic pinpoint bleeding when debrided
because of the presence of thrombosed blood vessels
within the lesion itself.
Toe nail disorders
1. Toenails undergo degenerative trophic changes
(onychopathy),
2. thickening (onychauxis and onychogryphosis),
3. and/or longitudinal ridging (onychorrhexis)
– related to repeated microtrauma, disease, and
nutritional impairment.
4. Deformities of the toenails become more
pronounced and complicated by xerotic changes in
the periungual nail folds as onychophosis
(hyperkeratosis) and tinea unguium
(onychomycosis). These conditions are usually
longstanding, chronic, and very common in the
elderly and, in the case of onychomycosis, present
a constant focus of infection.
 Fungal nail infection (onychomycosis)
• The most common of all nail disorders, affecting 24% - 41% of
people over the age of 60 years
risk factors:
• Old age, male sex, obesity, cigarette smoking, peripheral vascular
disease, immunosuppression, concurrent interdigital tinea pedis,
psoriasis and diabetes
C/p:
• pain, difficulty walking and footwear limitations
• Infection from dermatophyte fungi, including Trichophyton,
Epidermophyton and Microsporum species. By far the most
common organism isolated from mycotic nails is Trichophyton
rubrum, present in between 67% and 82% of cases
• onychomycosis in older people may be more likely to be caused
by a combination of organisms.
patterns of infection:
1. Distal subungual onychomycosis is the most common presentation and
is caused by the fungus, usually Trichophyton rubrum, invading the distal
edge of the nail, leading to a white–yellow discoloration of the nail and
hyponychium.
2. Proximal subungual onychomycosis, also caused by Trichophyton
rubrum, is much less common and results from infection of the proximal
nail fold, possibly triggered by trauma to the nail in
immunocompromised patients.
3. White superficial onychomycosis is commonly caused by Trichophyton
mentagrophytes and leads to a superficial discoloration that coalesces
to cover the entire nail plate
4. The fourth presentation, Candidal onychomycosis, is caused by Candida
albicans and has three subtypes: (1) Candida paronychia, characterised
by swelling and erythema of the proximal and lateral nail folds, (2)
Candida onycholysis, characterised by separation of the nail plate from
the nail bed, and (3) Candida granuloma, characterised by thickening of
the nail plate
5. Any of these four types of onychomycosis can further develop into total
dystrophic onychomycosis, in which there is little distinction between
the nail plate and the underlying hypertrophic nail bed
Total dystrophic onychomycosis
DD:
• Psoriatic nails, onychogryphosis or trauma
Investigation:
• culture of nail specimens: After cleansing the
area with alcohol, full-thickness nail clippings
from the actively infected region should be
obtained using a scalpel or curette, direct
microscopy with 10% potassium hydroxide
(KOH),
• Isolation of the pathogen, however, requires 4–
6 weeks of inoculation of the sample on
Sabouraud’s agar or dermatophyte test medium
 TREATMENT
• oral treatment of • topical treatments
onychomycosis is far more including the azoles (such
effective than topical as clotrimazole,
therapy and should ketoconazole and
therefore be considered the
gold standard of care miconazole), allylamines
• terbinafine has documented
(such as terbinafine),
interactions with some • These agents are often
antidepressants, combined with 20–40%
antipsychotics, urea cream to facilitate
anticoagulants, beta- penetration into the nail
blockers and antiarrhythmic plate
medications
• 12 weeks • 48 weeks of treatment
 Surgery
1. Severely thickened, dystrophic onychomycosis
may be extremely painful and resistant to both
topical and oral treatment.
2. Complete avulsion of the nail under local
anaesthetic, followed by topical and/or oral
antifungals while the new nail grows back.
3. longstanding cases of dystrophic onychomycosis
may cause irreversible damage to the nail
matrix, so there is no guarantee that the
infection-free nail will be of normal shape or
thickness. If dystrophic regrowth is considered
likely, complete avulsion of the nail followed by
matrixectomy is advisable
Preventing recurrence (very common)
1. discarding infected footwear and hosiery
2. avoiding barefoot activity in public places
3. keeping the feet cool and dry
4. Wearing absorbent cotton socks
5. detecting and treating tinea pedis before it spreads
to the nail
6. applying antifungal powder to footwear at least once
per week.
7. Footwear should also be carefully examined, as
trauma to the nail by ill-fitting footwear may also
trigger relapses.
INGROWN TOENAILS
(ONYCHOCRYPTOSIS)
 Ingrown toenails (onychocryptosis)

• Is predominantly a condition that affects young adults but has been reported to
occur in 5–10% of people aged over 65 years
• Because of age-related reductions in peripheral vascular supply and the increased
propensity to infection, onychocryptosis has potentially serious consequences
such as ulceration and cellulitis.
• If left untreated, a pulp of overhanging hypergranulation tissue may develop that
bleeds in response to minor trauma. At this stage, the condition can be exquisitely
painful
The condition develops when a spicule of nail penetrates the nail sulcus, leading to
erythema, swelling and secondary infection.

Factors thought to be associated with

onychocryptosis include:
1. ill-fitting footwear, tight socks, hyperhidrosis,
incurvated/ involuted nails, pronated foot type,
hallux valgus,
2. incorrect cutting of nails and variations in toe
length
3. may develop secondary to several other
disorders of the nail unit, including benign and
malignant tumours of the nail bed, dystrophic
onychomycosis, traumatic subungual
haematomas and subungual exostosis.
4. Several medications have also been reported to
lead to onychocryptosis, including indinavir (a
medication used in the treatment of HIV
infection. oral retinoids, cyclosporin
In each case, the medication appears to increase the
risk of onychocryptosis by causing paronychia and
promoting the development of hypergranulation
tissue.
1. The diagnosis of onychocryptosis is
straightforward, and is based on the classical signs
and symptoms of redness and swelling of the toe
and quite severe, sharp pain in response to lateral
pressure.
2. In stage 1, the toe appears red and swollen and
there is pain on direct pressure to the nail and
while walking.
3. In stage 2, there is evidence of infection, slight
pressure to the toe will cause considerable pain,
and the patient may have difficulty walking.
4. In stage 3, hypergranulation tissue has developed
over the edge of the nail plate
 Conservative ttt:

• clearing the sulcus of hyperkeratotic debris (onychophosis),

removing the offending spicule of nail with a scalpel and smoothing
the edge of the nail. This may be undertaken without anaesthesia;
however, if the pain is severe, local anaesthesia may be necessary.
• Inserting a small piece of cotton wool or foam beneath the edge of
the nail may prevent recurrence by slightly elevating the nail plate.
• In cases where the nail is being compressed against the adjacent
toe, taping techniques, or the use of foam toe spacers to separate
the toes may also be useful
• Advice on appropriate nail cutting may assist in preventing
recurrence
• Orthonyxia, the gradual correction of incurvated nails using bracing
techniques, is no longer commonly used but may have a role in the
prevention of onychocryptosis in older people for whom surgery is
contraindicated.
 Surgical intervention
• is often required for recurrent onychocryptosis
• nail avulsion combined with phenolisation is
more effective than surgical excision in the
treatment of ingrown nail
• Prevent recurrence:
– Proper Toe nail cutting
– Fitting shoes toe box
Thickened nails (onychauxis or
onychogryphosis).
 Abnormally thickened nails (onychauxis
or onychogryphosis).
• onychauxis refers to hypertrophy of the nail plate. This
condition affects approximately 65% of older people
• Risk factors, including:
1. subungual exostosis
2. a history of trauma to the nail
3. compression from footwear
4. reduced peripheral circulation.
5. Onychauxis is also frequently observed in conjunction with
onychomycosis
• longstanding onychauxis is generally irreversible as
permanent damage occurred to the nail bed and nail
matrix.
Onychogryphosis (also referred to as Ram’s horn nail or
Ostler’s toe)
• the nail plate is grossly thickened and deformed. The
nail appears yellow to dark brown and develops a
curved or hornlike shape. In severe cases, the nail
may penetrate the soft tissue of adjacent toes.
• Onychogryphosis is caused by the same aetiological
factors as onychauxis but is most likely to result from
a major traumatic event such as severely stubbing the
toe. This damages the nail matrix, causing it to
produce nail in an irregular manner. Onychogryphosis
may also result from long-term neglect of older
people.
Onychogryphosis
Treatment of onychauxis and onychogryphosis involves
1. clearing the sulcus of keratotic debris and reducing
the thickness of the nail with a file or motorised burr.
2. Foam or silicon gel toe sleeves may help alleviate
pressure from the toe,
3. footwear should be carefully examined for suitability
and replaced if necessary.
4. Total avulsion of the nail should be considered in
symptomatic cases, as both conditions are indicative
of permanent damage to the nail matrix and will
invariably recur.
5. non-surgical nail avulsion may be a useful alternative
for frail elderly: This requires the application of 40%
urea cream to the nail plate, occluding the toe with
adhesive tape or waterproof dressing. Dressing
changes need to be undertaken twice per week. The
urea cream gradually macerates the nail plate,
enabling debridement of the entire nail.
SUBUNGUAL EXOSTOSIS AND OSTEOCHONDROMA
YELLOW NAIL SYNDROME
CLUBBING OF THE NAILS
PINCER NAILS
NAIL DISORDERS ASSOCIATED WITH SYSTEMIC DISEASES AND MEDICATIONS

OTHER NAIL PROBLEMS

 Subungual exostosis
• uncommon benign tumour of trabecular
bone that most commonly develops on
the distal phalanx of the hallux
• an Repetitive trauma to the toe is thought to
lead to periostitis and an outgrowth of
cartilage that eventually ossifies.
• The presence of the exostosis may cause the
nail plate to become incurvated or elevated
at its distal edge and, in severe cases, the nail
plate may become eroded and the nail bed
ulcerated
• Osteochondromas are benign tumours that Subungual exostosis
have a similar clinical presentation to
subungual exostoses,
• Both subungual exostoses and
osteochondromas need to be differentiated
from malignant tumours of the nail bed,
including squamous cell carcinoma, basal cell
carcinoma and malignant melanoma

osteochondromas
 Treatment of subungual exostoses and
osteochondromas
• involves protecting the toe from further trauma
by the use of foam or silicon gel toe sleeves
• fitting footwear.
• Surgical excision may be necessary, which
involves partial or total nail avulsion (depending
on the size and location of the lesion), followed
by removal of the growth using a bone chisel.
• recurrence is uncommon (less than 10%);
however, distal onycholysis and subungual
hyperkeratosis may develop postoperatively.
 YELLOW NAIL SYNDROME
• an uncommon condition characterised by the triad of:
1. thickened, incurvated yellow nails (both fingernails and toenails),
2. lymphoedema
3. respiratory disease (including asthma, tuberculosis, pleural effusion,
bronchiectasis, chronic sinusitis and chronic obstructive pulmonary
disease
• The condition has also been reported in association with several other
conditions, including rheumatoid arthritis, various forms of cancer,
thyroid disease and sleep apnoea
• The nail dystrophy associated with the syndrome is thought to be due to
lymphatic obstruction in the nail region, which causes a markedly
reduced growth rate (as slow as 0.12– 0.27 mm/week), with an inversely
proportional increase in nail thickness
• development of onychophosis and paronychia is common, and complete
separation of the nail plate (onycholysis) may occur
• The condition can be easily differentiated from nail discoloration
associated with onychomycosis, as the discoloration is generally uniform
and the nail plate is considerably harder.
1. Yellow nail syndrome is treated
in the same manner as
onychauxis and
onychogryphosis
2. There is preliminary evidence
that oral and topical vitamin E
or oral zinc supplementation
may improve the appearance of
the nail; however, the
mechanism is not fully
understood.
3. Interestingly, spontaneous
recovery of yellow nail
discoloration and dystrophy has
been noted in response to
treatment for other
comorbidities, including
rheumatoid arthritis, diabetes
mellitus and tuberculosis.
PINCER NAILS
• a form of involuted/incurvated nail
deformity in which the transverse
curvature of the nail plate becomes
more pronounced distally, producing
an almost cylindrical structure
around the distal pulp of the toe
• Pincer nails frequently present with
onychocryptosis, onychophosis and
paronychia, and in severe cases the
nail bed may become ulcerated.
• The aetiology of pincer nails is not fully
understood. It has been hypothesised that the
formation of osteophytes on the proximal
aspect of the distal phalanx causes a widening
of the proximal nail matrix but, because the
unaffected distal nail matrix is narrower, the
nail plate assumes a conical shape as it
progresses distally
Toes deformities
HALLUX VALGUS
• Genetic factors play a role
• Women: men=9:1
• Progressive sublaxation of first metatarsophalangeal
joint.
• frequently accompanied by a painful soft tissue and
osseous prominence on the medial aspect of the
first metatarsal head, commonly referred to as a
‘bunion’
• It impairs alignment and function of the lesser toes,
resulting in hammer toe or claw toe deformities,
• altered weight bearing patterns and the
development of plantar keratotic lesions.
• Pressure from footwear may also lead to the
formation of an adventitious bursa over the joint,
which may become inflamed.
• impact on balance and gait patterns and is an
independent risk factor for falls
The aetiology of hallux valgus is not well understood. There is some evidence that the condition is
an autosomal dominant trait
• The most commonly proposed aetiological factors for hallux valgus are footwear,
metatarsus primus varus, long first metatarsal, metatarsal head shape, muscle
dysfunction and foot pronation.
• secondary to several other systemic conditions, including
1. a range of inflammatory joint diseases (e.g. rheumatoid arthritis, gout and psoriatic arthropathy),
2. conditions associated with ligamentous laxity (e.g. Ehlers–Danlos syndrome, Marfan’s syndrome and Down’s syndrome),
3. neuromuscular disorders (e.g. cerebral palsy, poliomyelitis and Charcot–Marie–Tooth disease).
4. Iatrogenic hallux valgus may also develop secondary to surgical removal of the tibial sesamoid

• Conservative management of hallux valgus includes:

1. measures to obtain pain relief,
2. addressing the associated nail and skin conditions,
3. Extra-depth and wider-fitting footwear may need to be prescribed and fitted
4. toe splints, mobilisation and manipulation, and foot orthoses

• Surgical intervention for hallux valgus is frequently indicated with variable outcomes
• Common complications associated with hallux valgus surgery include ongoing pain,
transfer lesions (the development of lesions at previously lesion-free sites because
of changes in foot function), joint stiffness, stress fractures, ‘floating hallux’ (loss of
function of the hallux due to plantarflexion weakness) and irritation from internal
fixation devices (K-wires and screws
HALLUX LIMITUS AND HALLUX
RIGIDUS
• Hallux limitus is a condition in which
there is a restriction in the range of
motion of the first
metatarsophalangeal joint. If this
progresses to complete fusion of the
joint, the term hallux rigidus is used.
• developed in response to trauma
(e.g. stubbing the toe) or ill-fitting
footwear.
• overlap between hallux
limitus/rigidus and OA of the
first MTP joint.
• Associated with rheumatoid
arthritis, gout and psoriatic
arthropathy
• Patients with hallux limitus/rigidus typically present with
complaints of pain and stiffness in their big toe joint that
increases with activity and is alleviated by rest.
• Paraesthesia may be present because of compression of the
dorsal digital nerve of the hallux
• the first metatarsophalangeal joint may be swollen and
erythematous and in long-standing cases there will be a dorsal
exostosis overlying the first metatarsal head

management of hallux rigidus includes:

1. measures to obtain pain relief,
2. addressing the associated nail and skin conditions,
3. Extra-depth and wider-fitting footwear may need to be
prescribed and fitted
4. Intra-articular injection and manipulation
5. Orthotics
6. surgery
 common lesser toe deformities
1. A hammer toe: a flexion contracture at the
proximal interphalangeal joint. An extensor
contracture at the metatarsophalangeal joint
may coexist.
2. A mallet toe is contracted at the distal
interphalangeal joint,
3. a claw toe is contracted at both
4. Retracted toes: MTP hyperextended that distal
phalanx don’t touch floor
5. Overriding and under riding second toe to cope
with hallux valgus
LESSER TOE DEFORMITIES
• The most common problem associated with these
deformities is the formation of corns dorsally over
areas of prominence and medial and lateral, and
interdigitally
• Women more affected
• Lesions with remaining ROM(flexible deformity)
• Limited ROM(rigid deformity)
management of lesser toes deformity
includes:
1. measures to obtain pain relief,
2. addressing the associated nail and skin conditions,
3. wider-fitting footwear
4. Physiotherapy
5. Surgical (such as tendon lengthening and transfer)
TAILOR’S BUNION (bunionette)
• is an enlargement of
the lateral aspect of the
fifth metatarsal head
• long periods sitting
cross-legged with the
lateral border of the
foot compressed
against the floor
HALLUX VARUS
• hallux is adducted relative
to the first metatarsal
• Congenital or iatrogenic
after surgical treatment of
hallux valgus.
• Conservative treatments,
such as splinting and
strapping techniques, are
generally of little use, so
most cases will require
revisional surgery.
 Differential Diagnosis of Heel Pain
Arthritic Neuropathic
1. Gout 1. Lumbar radiculopathy
2. Rheumatoid arthritis
2. Nerve entrapment (branches of posterior
3. Seronegative spondyloarthropathies
tibial nerve)
Infectious 3. Neuroma
1. Diabetic ulcers 4. Tarsal tunnel syndrome (posterior tibial
2. Osteomyelitis nerve)
3. Plantar warts
• Trauma
Mechanical
1. Plantar fasciitis/fasciosis • Tumor (rare)
2. Heel spur
• Ewing sarcoma
3. Calcaneal stress fracture
4. Nerve entrapment • Neuroma
5. Achilles tendinopathy
6. Retrocalcaneal bursitis • Vascular (rare)
7. Posterior tibialis tendinopathy
8. Tarsal tunnel syndrome
 Plantar fasciitis
 Plantar fasciitis is one of the most common causes of heel pain.
 caused by biomechanical overuse from prolonged standing or
running, thus creating microtears at the calcaneal enthesis
(fasciosis not faciitis)

 Risk Factors for Plantar Fasciitis

 Excessive foot pronation (pes planus)
 Excessive running
 High arch (pes cavus)
 Leg length discrepancy
 Obesity
 Prolonged standing/walking occupations (e.g., military personnel)
 Sedentary lifestyle
 Tightness of Achilles tendon and intrinsic foot muscles
 Clinical Diagnosis
 Most patients have heel pain and tightness after standing up from bed in the
morning or after they have been seated for a prolonged time.
 Typically, the heel pain will improve with ambulation but could intensify by day's
end if the patient continues to walk or stand for a long time.
 Palpation of the medial plantar calcaneal region will elicit a sharp, stabbing
pain
Differential Diagnosis of Plantar Heel Pain
1. Achilles tendinitis
2. Plantar fascia rupture
3. Calcaneal stress fracture
4. Tarsal tunnel syndrome
5. Medial calcaneal and abductor digiti quinti nerve entrapment

 Subcalcaneal spur on lateral foot radiography does not support the diagnosis of plantar fasciitis.
Previous studies show that subcalcaneal spurs are also found in patients without plantar fasciitis.
 Ultrasonography used to rule out soft tissue pathology of the heel. Findings that support the
diagnosis of plantar fasciitis include proximal plantar fascia thickness greater than 4 mm and
areas of hypoechogenicity
 Magnetic resonance imaging is a valuable tool for assessing causes of recalcitrant heel pain.
 Plantar fasciitis, a self-limiting condition, usually improves within one year regardless of treatment.
treatments
o rest
o activity modification,
o ice massage
o acetaminophen or nonsteroidal anti-inflammatory drugs
o weight loss
o stretching techniques
o deep myofascial massage
o arch supports, heel cup, full-length shoe insoles
o Night splints prevent plantar fascia contracture by keeping the foot and ankle in a neutral 90-degree
position, preventing foot plantar flexion during sleep
o Corticosteroid injections are commonly used in the treatment of acute and chronic plantar fasciitis and have
proven effective
o If at least six months of conservative treatment is ineffective, a trial of extracorporeal shock wave therapy or
plantar fasciotomy can be considered. Extracorporeal shock wave therapy is used to promote
neovascularization to aid in healing degenerative tissue found in plantar fasciitis. Plantar fasciotomy can be
performed when all conservative measures have been ineffective.
 TARSAL TUNNEL SYNDROME
 Compression of the posterior tibial nerve most commonly occurs as it
courses through this tunnel, causing neuropathic pain and numbness in
the posteromedial ankle and heel which may extend into the distal sole
and toes
 Patients often report worsening of pain with standing, walking, or running,
and alleviation of pain with rest or loose-fitting footwear. Physical
examination may reveal a pes planus deformity, which increases tension
of the nerve with weight bearing, or muscle atrophy in more severe cases.
 Pain can be reproduced by tapping along the course of the nerve (Tinel
sign) and with provocative maneuvers to stretch or compress the nerve
(dorsiflexion-eversion test, plantar flexion-inversion test
 Electromyography and nerve conduction studies may be useful to confirm
the diagnosis
 Treatment is mostly conservative, with activity modification, orthotic
devices, neuromodulator medications (tricyclics or antiepileptics), or anti-
inflammatory medications. Corticosteroid injections into the tarsal tunnel
may also be beneficial. Surgery is available if conservative measures are
ineffective
 INTERMETATARSAL NEUROMA (MORTON’S
NEUROMA OR MORTON’S METATARSALGIA
 C/P:
1. severe, neuritic pain in the third or fourth intermetatarsal space that radiates
towards the toes, exacerbated by long periods of weight bearing and
alleviated by rest or removal of footwear
2. pain, paresthesias, and numbness in the forefoot.
 Risk factors:
 female sex, increased body mass index, reduced space between the
metatarsals, excessive foot pronation, elevated plantar pressures and the
wearing of tightly fitting shoes
 neural fibrosis, oedema, demyelination and degeneration of the
intermetatarsal nerve(thick nerve)

 Investigations:

1. Ultrasound imaging is considered to be the most appropriate diagnostic

modality neuromas appear as elliptical hypoechogenic structures running
parallel to the metatarsals that are integrated with surrounding nerve tissue
2. MRI technology and applications continue to evolve and can provide reliable
information
 A provocative examination (see the
image ) involves manually compressing the
forefoot and simultaneously palpating the
affected web space between the fingers of
the other hand. The compression may
result in the Mulder sign, which is a painful
and palpable click that reproduces the
symptoms

 Conservative therapy:
o Shoe modification Wide toe-box shoes are preferred to relieve pressure across the metatarsal
heads. High-heeled and narrow shoes should be avoided.
o The use of a metatarsal pad orthotic device can help keep pressure off the nerve
o Corticosteroid or local anesthetic injections
o Alcohol sclerosing injections should be used with caution, in that they have not been shown to be
reliably effective
o Nonsteroidal anti-inflammatory drugs (NSAIDs) or antiseizure medications such as gabapentin or
pregabalin
 Surgery: decompressing or resecting the nerve
 Recurrent or persisting symptoms after surgical intervention may relate to a number of
factors and can be difficult to treat. Patients who have had the decompression type of
procedure may continue to have problems if the decompression was incomplete or if the
nerve simply remains irritable. Those who have had neurectomy may develop a stump
neuroma that may be even more painful than the original problem.
 REASONS TO REFER TO A PODIATRIST
1. Signs suggesting generalized disease include neuropathy,
vascular disease, infection, and focal neoplastic disease
2. In those cases where concomitant therapy is indicated
3. Where initial management is not effective
4. In the presence of skin, nail, postural, and joint deformities
of the foot and related structures
5. In the presence of diabetes mellitus, neurosensory,
peripheral vascular, and other risk diseases
6. In the presence of foot problems combined with walking
problems and/or a history of falls
7. Where orthotics are indicated
8. If the patient is unable to obtain and/or provide foot care
9. If the patient complains of a foot problems or has specific
questions about care including information on footwear
THANK YOU