Ingrowing toenails do not require routine microbiological assessment. Most infections in ingrowing toe nails are caused by Staphylococcus aureus and, less frequently, Gram-negative bacteria (e.g. Pseudomonas spp.) and Streptococcus spp.10 Studies have shown that these infections settle without antibiotics after removal of the ingrown portion of the nail and matricectomy.11 In patients with hypertrophy of the nail plate, microscopy and culture of nail clippings are useful to rule out an underlying fungal cause.
Management of an ingrown nail starts with patient education on nail cutting and hygiene. The nail should be cut square to reduce the corners digging into the nail fold. Acute infection may be treated with a short course of oral antibiotics. Should these methods fail to relieve symptoms then referral to a podiatrist or orthopaedic surgeon may be suggested to perform partial avulsion of the lateral edge of the nail followed by surgical or chemical matricectomy. With appropriate training, GPs can perform these procedures without the need for onward referral.
Fungal nail infection is treated with targeted antifungal agents administered either topically or systemically. In the absence of fungal infection, hypertrophied nails are treated with regular cutting or grinding of the nail to debulk it and reduce local pressure symptoms or nail avulsion and ablation of the germinal matrix.
With increasing age, the prevalence of arthritis in the foot and ankle increases. Although it is beyond the scope of this article to describe each arthritic foot complaint, initial management and investigation are similar. Weight-bearing x-rays of the affected foot should be performed. No cross-sectional imaging is required as this would add little information that is not provided by careful review of the x-rays; such imaging is best requested by the orthopaedic surgeon to answer a specific preoperative question.
In older patients, the use of orthotics that support the medial arch of the foot and relieve pressure on the metatarsal heads has been shown to improve mobility and symptoms of foot pain in older women.12 Patients need to be able to accommodate the orthotics within their footwear and to transfer them between their various shoes. Any change in local pressure symptoms or imminent ulceration should prompt review of all orthotics and footwear.
If orthotics and simple oral and topical analgesics are ineffective or not well tolerated then referral to an orthopaedic surgeon should be considered. Image-guided injections of local anaesthetic and corticosteroid may be considered but are often not a long-term solution for patients with advanced arthritis.
Surgical treatment of most forefoot, midfoot and hindfoot arthritis comprises arthrodesis (fusion) of affected joints and removal of associated pressure areas. Management of ankle arthritis is more controversial, with newer joint replacement techniques and implants available (Figures 6a to c), although arthrodesis is still considered the gold standard treatment. Patients must be warned that all surgical treatments will most likely involve a period of enforced nonweight-bearing and use of a plaster cast. For these reasons, many older patients opt to persevere with nonsurgical treatment, as surgery can be more disruptive than their current symptoms.
Foot pain is common in older people and has a variety of overlapping causes. It may significantly affect an older person’s ability to maintain their independence and mobility. Thorough history taking and focused examination are vital to establish a diagnosis and to start treatment in the general practice setting before specialist referral. GPs should maintain a high index of suspicion for diabetes, neuropathy and peripheral vascular disease and investigate appropriately before referring patients to an orthopaedic surgeon. Weight-bearing anteroposterior and lateral x-rays should be the first-line radiographic investigation for all patients with chronic foot pain and deformity.
Exploring the patient’s expectations and concerns may reduce the number of inappropriate referrals to foot surgeons. For many patients with asymptomatic foot deformities, the treatment is reassurance alone. Even in those with complex deformities, simple solutions such as wider fitting shoes, toe sleeves or spacers to stop rubbing of a painful toe may be all that is required. MT