Challenging Sociocultural health Disparities: A ...



Challenging Sociocultural Health Disparities: A Collaborative Interdisciplinary Model Podogeriatric Teaching Module

Chapter XI: Foot Pain in the Elderly

Rationale

It is estimated that approximately 74% of Americans will experience foot pain to varying degrees of severity over the course of their lives. Factors such as obesity and improper shoe gear can play a role in the development of foot pain. In addition, comorbid conditions, such as arthritis can add to foot pain and discomfort.

Goals and Objectives

Goal #1 - Recognize the common causes of forefoot, arch, and rearfoot pain.

Identify the signs and symptoms of forefoot, arch, and rearfoot pain

Differentiate between Baxter’s neuritis and plantar fasciitis symptoms

Goal #2 - Develop the necessary knowledge, skills, and attitudes to recognize, manage, and make appropriate referrals when dealing with foot pain.

Master the following psychomotor skills

-Visual inspection of the foot noting any deformities or dermatological

conditions

- Proper palpation of the lower extremity anatomy to determine cause of

foot pain

-Perform the test for neuroma (Mulder’s sign), Tinel’s, Valleix’s and Turk’s test and recognize what a positive test in each case means.

Describe treatment protocols for forefoot, arch, and rearfoot pain, including

medications, injections, physical therapy and surgical intervention.

Demonstrate proper injection techniques including intra-articular injection,

interspace injection and calcaneal injections.

Goal #3 - Demonstrate proper communication skills to effectively communicate with the patient, their families and other health professionals involved in the patient’s care.

Effectively communicate with patients and their families while being sensitive

to their age, culture and ethnic beliefs.

Demonstrate effective and sensitive communication skills with other health

professionals involved in the patient’s care.

Foot Pain in the Elderly

Foot pain is a condition everyone experiences at one point or another. When the elderly patient complains of pain in the foot, it may not be their primary complaint. Very often it is a secondary complaint. They may assume that foot pain is common at their age, or that nothing could be done for their painful foot condition.

When interviewing an elderly patient complaining of foot pain, the clinician should try to direct questions in such a way as to determine exactly what type of pain the patient is feeling. For instance, is the pain sharp or dull, does it radiate either up the leg or down the leg to the toes, is it a burning or tingling pain, is the pain constant or intermittent? Once the patient has voiced his or her complaint, these types of questions, will help you determine whether the pain is musculoskeletal in nature or neurological.

Determining how long the pain has been present and what makes the pain go away can also help you with your differential diagnoses. Did the pain occur suddenly or has it been present for some time? What do they do to make themselves feel better? Does rubbing the foot help? Does sitting down for a while make the pain subside? Are they taking any medications to help with the condition?

Having the patient point directly to where it hurts is also beneficial for you. Does the pain occur over the plantar metatarsal heads, over the calcaneal area, or the medial or lateral side of the foot.

During the lower extremity physical examination, focus in on the vascular, dermatological, neurologic, and biomechanical assessments.

Detailed history taking and a diligent lower extremity exam are crucial to determining the cause of foot pain.

Forefoot Pain

Morton’s neuroma is an impingement of the common digital nerve between the heads of the metatarsals. It is caused by shearing forces across the metatarsal heads. The most common location for this to occur is between the third and fourth metatarsal head affecting the third common digital nerve. It can occur between other metatarsals as well.

Women are more often affected than men. It usually occurs between the 4th and 6th decades of life. Patients will often describe a burning or tingling sensation between toes. In addition they relate that they feel as if they are walking on a small pebble or a wrinkle in their sock. Removing shoe gear and rubbing the foot often seems to temporarily relieve the pain.

While the vascular and dermatological assessments are normal, burning and tingling are clearly signs of a neurologic abnormality. In addition, the examiner can try to palpate a “silent click” called Mulder’s sign. This is done by laterally squeezing the foot with one hand, while palpating between the third and fourth metatarsal heads with the other hand. A palpable click may be felt. Not all neuromas present with a positive Mulder’s Sign, however.

On weightbearing examination, the physician may notice a splaying of the affected metatarsals. This is known as Sullivan’s sign.

Conservative treatment for a Morton’s neuroma consists of non-steroidal anti-inflammatory medication along with padding or orthotics. A corticosteroid injection dorsally to the affected interspace and the involved nerve can also provide some relief. If conservative measures fail, a neurectomy (removal of the nerve) may be indicated.

Mulder’s Sign is the silent palpable click often found in a Morton’s Neuroma

Sesamoiditis is an inflammatory condition associated with excessive pressure at the plantar aspect of the first metatarsal. The etiologies of sesamoiditis are numerous. The primary cause, however, is a plantarflexed first metatarsal. If you were to examine the plantar foot closely, you would notice that all the metatarsals are not on the same plane. Indeed, the first metatarsal would be more plantarflexed. Another common etiology for this condition is inappropriate shoe gear. Very often the elderly will buy shoes without regard to the fact that their foot has changed shape. The foot may be wider now than previously.

On physical examination, the area over the sesamoids may be more edematous and tender to direct palpation. Passively plantarflexing and dorsiflexing the first metatarsal may can pain. With this condition, it is prudent to obtain bilateral radiographs to rule out a fractured sesamoid or a bipartite sesamoid. An AP, medial oblique, lateral, and if possible a sesamoid axial view can help with your diagnosis.

If tolerated, a non-steroidal anti-inflammtory medication can help with sesamoiditis. If the cause is related to the plantarflexed first metatarsal, a functional foot orthotic can help reduce the symptoms. The functional orthotic would elevate the first metatarsal area to the same plane as the other metatarsals. If the problem is improper shoe gear, advising the patient to buy shoes at the end of the day and to be measured both in length and width is helpful. In either case, weight-bearing activities should be limited while healing occurs.

Fat Pad Atrophy is a condition that can cause pain for the elderly patient on the plantar aspect of their feet near the metatarsal heads. This is due to the proximal shifting of the plantar fascia. The plantar fascia normally extends from the calcaneus to the ball of the foot. Over time, however, the fascia can shift proximally making the metatarsal heads more prominent.

The atrophy of the fat pad equally affects men and women usually later in life. Patients will relate that their feet hurt plantarly especially on weightbearing. If you ask the patient to point to the area of maximum tenderness, they will usually direct your attention across the plantar metatarsal heads.

[pic]

Fat Pad Atrophy - notice the small ulcerations across the plantar met heads

Courtesy of the Ohio College of Podiatric Medicine

Upon examination, the physician will note that each metatarsal head can be palpated. The fat pad has shifted and is not providing the needed protection to the metatarsal heads.

Treatment for this condition consists of an accommodative orthotic device, which will provide more cushion and protection to the metatarsal heads.

Stress Fractures can occur at any bone in the foot due to repetitive trauma. The most common areas for stress fractures, however, are over the metatarsal bones. Usually the shaft or neck of the bone is affected.

On examination, there may be pain, edema, and erythema over the metatarsal affected. Radiographs can be helpful. Often a stress fracture will not show up radiographically for a few weeks.

Providing the patient with a cam walker or post-op shoe for all their weight bearing activities can allow the fracture to heal. Normal healing time is approximately 6 - 8 weeks.

Abnormal foot function often contributes to stress fractures. Once the area has healed, fitting and providing functional orthotics to control abnormal pronation or supination can help alleviate further stress fractures.

For additional information on stress fractures, refer to the Exostosis of the Foot and Ankle Module.

Capsulitis usually involves the second, third, fourth and fifth metatarsophalangeal joints. This condition is an inflammation of the capsule surrounding those joints. Patients may or may not have a hammer toe deformity, however, they usually have a plantarflexed metatarsal.

On examination, there will be pain with range of motion of the affected metatarsophalangeal joint. There may be some surrounding erythema or edema.

A course of a non-steroidal anti-inflammatory medication may help. An injection of a corticosteroid may also alleviate the painful symptoms. Orthotics may help as well. If the condition is related to a hammer toe deformity, a surgical correction may be the best course of action.

Metatarsalgia is a very non-specific term referring to pain in the ball of the foot. In fact, many clinicians will define any forefoot pain as metatarsalgia. Rather than using that terminology, it is better to determine through proper history taking and a comprehensive lower extremity examination the cause the forefoot pain.

Metatarsalgia is a non-specific term referring to pain over the metatarsal area.

Arch Pain

Tarsal Tunnel Syndrome is similar to carpal tunnel in the wrist. This is a compression or entrapment neuropathy involving the tibial nerve as it travels beneath the flexor retinaculum within the tarsal tunnel on the medial side of the foot.

The causes of tarsal tunnel syndrome are numerous. Any trauma involving the ankle or foot can lead to this neuropathy. Excessive pronation allows for stretching of the tibial nerve, which can lead to this problem as well. In addition, arthritis and any space occupying lesions such as a lipoma or ganglionic cyst can predispose the patient to tarsal tunnel syndrome. Varicosities in the area can also lead to tarsal tunnel syndrome.

The patient will complain of burning, numbness or tingling over the plantar foot and into the medial longitudinal arch area. Because tarsal tunnel involves the tibial nerve, dermatological and vascular examinations may be normal. The neurological part of the lower extremity examination may reveal a positive Tinel’s sign and possibly a positive Valleix’s sign. The Tinel’s sign is positive when upon palpation of the tibial nerve, tingling is felt distally toward the toes. Similarly, a Valleix’s sign is positive when upon palpation of the tibial nerve, tingling is felt proximally going up the leg. Another test can be beneficial to determine if varicosities beneath the flexor retinaculum are causing the entrapment. The Turk’s test involves inflating a tourniquet proximal to the entrapment site. If symptoms of tingling, burning and numbness increase upon inflation, the Turk’s test is positive. This test is not routinely done.

Tarsal tunnel syndrome is usually treated conservatively. With arch supports and/or orthotics, the excessive pronation is controlled and that may alleviate the symptoms. Non-steroidal anti-inflammatories are also used. A local block with corticosteroids can also provide relief. Care must be taken when injecting into the area so as not to damage or weaken the posterior tibial tendon.

If conservative measures fail or do not provide optimum relief, surgical treatment to release the nerve can provide relief. If the cause of the tarsal tunnel was a space occupying lesion such as ganglionic cyst or lipoma, the lesion should be removed.

Sinus Tarsi Syndrome involves pain on the lateral aspect of the foot near or in the sinus tarsi area. Very often this follows an inversion ankle sprain. In the elderly, lateral ankle instability is common. Walking on uneven ground or lawns and wearing shoe gear that does not provide adequate support for the ankle region can lead to inversion sprains and perhaps sinus tarsi syndrome. Abnormal pronation may also cause sinus tarsi syndrome

While this is often a syndrome involving younger people, sinus tarsi syndrome can also be found in patients with rhematologic problems. The pain is elicited on physical examination lateral to the talar head, near the sinus tarsi. Range of motion of the subtalar joint can cause pain as well.

The most common conservative action is an injection of a corticosteoid into the sinus tarsi itself. Foot orthotics can help with the abnormal pronation and associated calcaneal eversion. Shoe gear that supports the ankle region is important.

If conservative measures fail, surgery may be necessary.

For more information on injection techniques, please refer to the Podiatric Injections and Aspirations Module. For further information on orthotics, please refer to the Biomechanics Module.

Posterior Tibial Tendonitis usually occurs in patients with a pronated foot. The posterior tibial tendon’s major insertion site is plantarly on the navicular. Its action is to invert the foot and help to some extent support the medial longitudinal arch of the foot. With pronation, the tendon becomes stretched at its navicular insertion site. In cases of excessive pronation, marked calcaneal eversion and forefoot abduction, a tear or rupture of the posterior tibial tendon may be suspected.

There will be a notable pain at medial malleoli and at the navicular insertion area on physical examination. Also beneficial on examination, is to have the patient try to stand on their toes. The heels should invert when they do so. If not, tear or rupture of posterior tibial tendon may be suspected.

If inflammation only is suspected, non-steroidal anti-inflammatory medications are helpful. Injections into this area are not recommended because steroids can weaken the tendon. Controlling abnormal pronation with orthotic control is key.

If a posterior tibial tendon tear or rupture is suspected, an MRI would be useful to determine exactly where the insult occurs. Off - loading the patient in a cam walker may help with a tear injury. Surgical correction is necessary if the tendon is ruptured.

Ganglions are defined as benign, unilocular or multilocular mucinoid cysts surrounded by fibrous capsules. They typically communicate with and are fixed to a joint capsule, synovial membrane, or tendon sheath. Ganglions are soft or firm nodular masses that are frequently asymptomatic and commonly found along the dorsal aspect of the foot and ankle or in the region of the sinus tarsi. There are several methods to available to treat ganglions. Surgical excision has been found to have the fewest reoccurrences. However, performing a fine needle aspiration with or without a corticosteroid can also be effective.

When a patient has been diagnosed with a ganglionic cyst that is painful, the clinician should look at the shoe gear. Very often in tie shoes or tight loafer style shoes, the ganglionic cyst can rub against the top of the shoe and cause pain. Educate the patient on different re-lacing techniques, such as skipping an eyelet or two.

Rearfoot Pain

Plantar Fasciitis/Heel Spur Syndrome is a very a common condition, in the elderly, heel pain may result from the gradual atrophy of the plantar fat pad near the calcaneus. Repetitive activity and trauma can result in an irritation and microtears in the plantar fascia. Arthritides, such as gout and rhematoid arthritis can also cause heel pain. Pain is felt by the patient upon initial weight-bearing in the morning or after periods of rest. Once they are on their feet for a period of time, the pain resolves.

On physical examination, the clinician can elicit pain with palpation over the medial calcaneal tubercle. The source of the pain is located in the flexor digitorum brevis muscle that originates above the plantar fascia. Pain may also be felt upon passively dorsiflexing the metatarsophalangeal joints.

Radiographs should be performed to rule out a potential fracture either involving the calcaneus or the fifth metatarsal. Often on lateral radiograph, a small bony spur in seen. This is often asymptomatic. The inflammation lies within the plantar fascia itself.

[pic]

Heel Spur on Lateral view. Courtesy of the Ohio College of Podiatric Medicine

Approximately 80 - 90 % of plantar fasciitis is resolved conservatively. A course of a non-steroidal anti-inflammatory medication may be given if the patient is able to tolerate the medicine. Stretching the foot prior to weight-bearing is very important. Securing a belt around the ball of the foot and pulling the toes toward the nose several times before getting out of bed can alleviate the first painful symptoms. In addition, icing the heel for approximately 10 - 15 minutes per night can be helpful. Patients should be advised never to put ice directly on the skin. Having a towel between the ice and skin is much more comfortable. A heel cup or a pre-fabricated orthotic can help relieve symptoms. An injection of a corticosteroid into the medial heel may help. Usually no more than three injections are given into the area.

Conservative treatment can progress to night splints that will hold the foot in a dorsiflexed position throughout the night. Custom made orthotics may also be prescribed.

If conservative measures fail a surgical release of the plantar fasica may be necessary.

More information regarding plantar fasciitis is discusssed in The Common Pedal Manifestations Module, as well as the Exostosis of the Foot and Ankle Module.

Plantar fasciitis is painful after periods of rest.

Baxter’s Neuritis is very similar to plantar fasciitis. This is an entrapment neuropathy involving the first branch of the lateral plantar nerve, which is the nerve to the abductor digiti quinti muscle. The only significant difference between Baxter’s neuritis and plantar fasciitis is that with Baxter’s the patient will usually experience pain after activity rather than after periods of rest.

Conservative measures of treatment are the same as plantar fasciitis.

For further discussion of Baxter’s neuritis, please refer to the Common Pedal Manifestations Module.

Calcaneal bursitis consists of type types. The first is an adventitious bursa that is located between the Achilles tendon and the skin. This second type is deeper and is called a subtendinous bursa located between the calcaneus and the Achilles tendon.

The adventitious bursa can usually be palpated as a fluid filled mass below the skin over the Achilles tendon. The subtendinous bursa is located superior to the Achilles tendon insertion. In both cases, there may be an exostosis involved as well. When a bony prominence occurs in the area, it is referred to as a “pump bump” or Hagland’s deformity.

When the patient presents with either, an area of erythema or edema may be noted in the posterior calcaneal region. Often the problem is exacerbated by the heel counter of the patient’s shoe. Trauma and sport activities can aggravate the area. The heel is often held in place by the rigid heel counter of the shoe and shearing forces occur along the area. This can lead to the bursa formation.

Heel lifts, non-steroidal anti-inflammatory medications, if tolerated, and rest, ice, compression, and elevation (RICE) are all beneficial conservative methods of treatment. Injections into the area near the Achilles tendon is not recommended as that can lead to weakening of the tendon.

If a Hagland’s deformity is noted, and the conservative methods of treatment are not helpful, surgery to remove the bursa and exostosis may be necessary.

Communications and Cultural Competency Issues

Pain has both individual and cultural correlates that can increase the complexity of management. Individuals have differing pain tolerance. Cultures have differing views about the appropriate expression of pain. Western tradition tends toward a “stiff upper lip” practice, one that supports relatively restrained expression of pain. Some Latin cultures, Italian cultures, and some African-American cultures are likely to be extremely vocal about what appears to the observer to be relatively modest pain.

This can lead to two different kinds of problems. First, while federal law now requires that practitioners inquire about pain and provide appropriate medication, it can be difficult to discern what constitutes appropriate pain management if the patient and the providers have differing experiences of pain and its expression. Under or over medication can result if careful discussion does not occur.

In addition, this is an area in which negative judgment of patients can occur. Providers, the majority of whom tend to be from the more Anglo-Saxon tradition, may find highly vocal patients to be distressing or irritating. This kind of judgment, absent an understanding of the cultural differences in expression of pain, can lead to contentious interaction and inadequate or unsympathetic treatment. Recognition of cultural difference can ameliorate this kind of contentious interaction.

Test Your Knowledge

Choose the best answer

1. Morton’s neuroma usually occurs between what two metatarsals:

A. first and second

B. fourth and fifth

C. third and fourth

D. first and fifth

C is the correct answer. Usually the neuroma referred as “Morton’s” occurs between the third and fourth metatarsals. Neuromas can, however, occur between any metatarsal.

2. Sullivan’s sign is a commonly found in patients with:

A. Sesamoiditis

B. Plantar fasciitis

C. Stress Fractures

D. Neuroma

D is the best choice here. In a neuroma a splaying of the metatarsals is often noted on examination. This splaying is called the Sullivan’s Sign. The other answers are listed as distractors.

3. The elderly often buy shoes:

A. Appropriately

B. Too small

C. Not wide enough

D. B and C

D is the correct choice here. Very often the elderly will present with shoes that are totally inappropriate for their foot type. It is important to educate your patient on the importance of having their feet measured in length and width every time they purchase shoes.

4. To examine for posterior tibial tendonitis, the physician should

A. Look for an abnormal Sullivan’s sign

B. Palpate the lateral side of the foot

C. Obtain an MRI

D. Have the patient stand on their toes and look for heel inversion

D is the best choice here. When a patient presents with posterior tibial dysfunction, have them stand on their toes. When you are positioned behind them, you should notice heel inversion. If the patient cannot perform the test without pain or if the heels do not invert, further testing should be done to see if the tendon is inflamed or ruptures. A is the incorrect choice because a Sullivan’s sign is a splaying of the toes. That would not indicate dysfunction of posterior tibial tendon. B is also incorrect. The posterior tibial tendon is located on the medial side of the foot, not lateral. C may be correct if further testing is needed, however an MRI is not the first choice.

5. Tinel’s sign is defined as

A. Tingling felt distally on percussion of a nerve

B. Numbness felt over the foot in neuropathy

C. Splaying of digits noted on patients with a neuroma

D. Tingling felt proximally on percussion of a nerve

A is correct here. A positive Tinel’s sign is defined as tingling that radiates distally when the nerve is percussed. B is incorrect. C is also wrong. A splaying of the digits is known as a Sullivan’s sign. D is also wrong. When the tingling is felt proximally on percussion of the nerve, known as a positive Valleix’s sign.

6. Which treatment modality for patients with a Haglund’s deformity should be used with caution:

A. Non-steroidal anti-inflammatory medications

B. Surgery

C. Injection

D. Heel lift

C is the correct answer. Given the proximity of a Haglund’s deformity to the Achilles tendon it is important to be careful not to inject into the tendon. Too many corticosteroid injections into a tendon will weaken the tendon. The other modalities listed are appropriate.

7. All of the following are true regarding ganglions, EXCEPT:

A. They are benign cysts surrounded by fibrous capsules

B. Ganglions usually occur at the plantar aspect of the foot

C. Ganglions can be treated with fine needle aspiration or surgical excision

D. Usually they are nodular masses located at the dorsal aspect of the foot.

B is the correct answer. They usually are not found plantarly. The other answers, of course are true regarding ganglions.

8. Most cases of plantar fasciitis are:

A. Treated surgically

B. Never get better even with surgery

C. Successfully treated conservatively

D. Are neoplastic

C is the best choice here. Plantar fasciitis is often treated quite successfully with conservative measures such as stretching, icing, NSAIDs, injection therapy and night splints.

9. When presented with an elderly patient complaining of foot pain, the clinician should

A. Listen, and ask detailed questions and realize that different cultures have different views on pain.

B. Go straight to a physical examination

C. Immediately order blood work and radiographs

D. Dismiss the issue entirely

A is the best choice here. Remember that different cultures have different views on pain. Listen closely to what the patient tells you and ask detailed questions. Speak clearly, slowly and concisely to your elderly patients. B is the wrong answer. You should never proceed immediately with a physical examination without talking to the patient first. C is also wrong. While you may indeed have to order blood work and radiographs, it is not the first thing a clinician should do. D is also wrong. While pain is subjective, it is very real. Never dismiss the issue.

10. Tarsal tunnel and sinus tarsi syndrome are entities that

A. Occur only in the elderly

B. Occur on the medial and lateral side of the foot, respectively

C. Improve only with surgical correction

D. Occur only in certain ethnic groups.

B is the best choice here. The tarsal tunnel is located on the medial side of the foot, while the sinus tarsi is located on the lateral side of the foot. The other answers are listed as distracters.

Bibliography and Recommended Readings

1) Robbins, JM. Primary Podiatric Medicine, W.B. Saunders Company, Philadelphia, PA, 1994.

2) Valmassy, RL. Clinical Biomechanics of the Lower Extremities, Mosby Publishing, St. Louis, Missouri, 1996.

3) Bates, Barbara. A Guide to Physical Examination and History Taking, J.B. Lippincott Company, Philadelphia, PA, 1995.

4) Hetherington, VJ. Hallux Valgus and Forefoot Surgery, Churchill Livingstone, New York, New York, 1994.

5) Watkins, Leon. Pocket Podiatrics, Third Edition, 2001.

6) Oloff LM. Musculoskeletal Disorders of the Lower Extremity. WB Saunders Co., Philadelphia, PA, 1994.

7) Dockery GL. Evaluation and tratment of metatarsalgia and keratotic disorders. In Myerson MS. Foot and Ankle Disorders. WB Saunders Co., Philadelphia, PA, 2000. pp.359-377.

8) Zachariae L, Vibe-Hansen H. Ganglia recurrence rate elucidated by a follow-up of 347 operated cases. Acta Chir. Scand 139: 625-628, 1973.

9) Esteban JM, Oertal YC, Mendoza M, et al. Fine needle aspiration in the treatment of ganglion cysts. South Med J. 79: 691-693, 1986

Challenging Sociocultural Health Disparities:

A Collaborative Interdisciplinary Model Podogeriatric Curriculum Plan

Podogeriatric Module Evaluation

Chapter XI: Foot Pain in the Elderly

Name:___________________________________________Date:______________________

Circle:

Status: PGY-11 PGY-22 PGY-33 Faculty Other__________________________

Discipline: Allopathic Osteopathic Podiatric Medicine Podiatric Surgery

Specialty: Internal Medicine Family Medicine Podiatry Other____________

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By way of clarification for PODIATRY RESIDENTS:

[1] PGY 1=PPMR, POR, RPR

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2 PGY 2=PSR24 (If preceded by 1 year)

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