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Feature Article

Foot problems in older people

Paul Dearden, Andrew Wines
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Abstract

Age-related fat pad atrophy, bony deformities such as hallux valgus (bunions) and hammer, claw and mallet toe, Morton’s neuroma, toe nail disorders and arthritis are common foot problems in older people. Resulting foot pain, deformity and loss of function can significantly compromise an older person’s mobility and independence.

Key Points

  • Most foot problems in older people can be improved by shoe modification and use of cushioned insoles.
  • The most useful investigation for patients presenting to their GP with foot problems is a weight-bearing anteroposterior and lateral x-ray series; cross-sectional imaging of the foot has limited value in general practice.
  • Neuritic or burning type pain radiating to the third and fourth toes is a classic symptom of Morton’s neuroma.
  • Generalised numbness or pain radiating down the leg to the foot suggests either peripheral neuropathy or nerve root compression.
  • Toe nails that are thick and crumbly raise the suspicion of fungal nail infection, and nail clippings should be sent for microscopy and culture.
  • Rapid progression of deformity in a person with known or suspected diabetes warrants urgent referral to an orthopaedic surgeon or at-risk foot clinic.

    Picture credit: info.Michaelheim-photographer.com/DepositPhotos Model used for illustrative purposes only

With our ageing population, painful conditions of the foot are becoming more prevalent. Foot pain, progressive deformity and loss of function after a lifetime of loading are seen by many as a natural consequence of getting older. However, age-related loss of natural soft tissue fat cushioning, loss of skin elasticity, bony deformity and difficulty with basic foot care can lead to significant problems that may compromise an older person’s ability to maintain their independence.1 In many cases, these foot issues contribute to multifactorial problems that can increase falls risk, with its well-documented associated morbidity and mortality.2 It is estimated that foot pain affects one in four older people, with forefoot pain affecting two- thirds of those patients.3

This article describes common conditions of the foot seen in older people and summarises the recommended general practice management, imaging, referral route and, if required, eventual surgical management.

Lesser toe deformities

Deformities of the lesser toes are among the most prevalent problems in the older population presenting to foot and ankle surgeons. These deformities may be an isolated problem or seen in combination with other forefoot deformities such as hallux valgus or first metatarsophalangeal (MTP) joint arthritis. In the early stages of development of lesser toe pathology, deformities are likely to be flexible rather than rigid, and be fully correctable. Loss of normal lesser toe function increases forefoot pressure during the late stance phase of gait, leading to forefoot pain or metatarsalgia. By the time patients seek medical attention, the deformity has usually become painful with a degree of stiffness. Often, painful forefoot deformity and metatarsalgia occur together, with pain arising from the level of the MTP joint of the toe, the metatarsal head or the interphalangeal joint deformity.

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History and examination

A thorough history should include screening questions for diabetes, rheumatoid arthritis and peripheral vascular disease. Decreased sensation in the foot is common in people with diabetes and can lead to ulceration in the presence of even minor deformity. If peripheral vascular disease is present then it may be prudent to investigate this and discuss management with the vascular team before considering foot surgery to correct the deformity.

The examination should start with inspecting the feet with the patient standing, looking for deformities of the lesser toes and callosities. Lesser toe deformities include:

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  • hammertoe – a flexion contracture of the proximal interphalangeal joint (Figures 1a and b)
  • claw toe – hyperextension of the MTP joint and flexion of the proximal and distal interphalangeal joints
  • mallet toe – a flexion contracture of the distal interphalangeal joint.

Lesser toe deformities may be associated with dorsal callus overlying the flexed joint or over the tip of the toe. A callus in the web space between the lesser toes is a soft corn, caused by pressure from the bony prominences of the neighbouring toes.

Next, the sole of the foot should be inspected with the patient sitting. Callus under the forefoot indicates a site of increased pressure or the presence of a swelling or lesion. Callosity beneath the metatarsal head and overlying the proximal interphalangeal joint may be associated with a hammer toe deformity. Callosity or corns may develop over the tip of the toe in claw toe or mallet deformity. As toe deformity progresses, the MTP joint may dislocate and thicker callus may develop. A callus that develops beneath one or more of the lesser metatarsals in this situation is termed an intractable plantar keratosis.

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It is also important to assess the patient’s peripheral circulation and sensation as inadequate peripheral perfusion or lack of protective sensation can cause wound complications following corrective surgery.

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Dr Dearden is a Postgraduate Orthopaedic Foot and Ankle Fellow at the Mater Hospital, Sydney. Dr Wines is an Orthopaedic Foot and Ankle Surgeon at Royal North Shore Hospital, North Shore Private Hospital and Mater Hospital, Sydney, and Dubbo Private Hospital, Dubbo, NSW.