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-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
• 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
• 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
• 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.
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
• 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
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:
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