Disorders of the Foot may be caused by poorly fitting shoes that may distort normal anatomy while inducing deformity and pain. Dermatologic problems also commonly affect the feet with fungal infections and plantar warts.
- Patients with diabetes are prone to corns and peripheral neuropathies with diminished sensation, leading to diabetic ulcers at pressure points of the foot.
- Patients with Peripheral Vascular Diseases (PVD) and Arteriosclerosis complain of burning and itching feet, resulting in scratching and skin breakdown.
- Rheumatoid Arthritis (RA) may result in foot deformities.
- Obesity can cause a host of foot anomalies, including adult onset of pes planus (i.e. “fallen arches”) and plantar fasciitis.
Foot Strain
- Foot Strain is treated with rest, elevation, physiotherapy, supportive taping, and orthotic devices.
- The patient must inspect the foot and skin when using pads and orthotic devices to observe for pressure and skin breakdown daily. The same is true for shoes that have been windowed.
- Active foot exercises promote circulation and help strengthen the feet. Walking in properly fitting shoes is considered the ideal exercise.
Callus
A thickened area of skin that has been exposed to persistent pressure or friction. Faulty foot mechanics often precede the formation of a callus.
- Treatment: eliminate the underlying causes; painful calluses require treatment by a podiatrist. A keratolytic ointment may be applied.
- Prevention of the callus is ideal, done with proper attention to well-fitting shoes and socks. Padding relieves and prevents pressure. Orthotic devices may be used to remove pressure from the bony prominences, or the bone prominences themselves may be excised.
Corn
An area of hyperkeratosis (an overgrowth of a horny layer of epidermis) produced by internal pressure (the underlying bone is prominent because of a congenital or acquired abnormality, commonly arthritis) or external pressure (ill-fitting shoes). The fifth toe is often involved, but this may occur in any toe.
- Treatment: corns are treated by a podiatrist by soaking and scraping off the horny layer, by application of a protective shield or pad, or by surgical modification of the underlying offending osseus structure. Early intervention is required for patients with diabetes.
- Soft corn located between the toes, kept soft by moisture, is treated by drying the affected spaces and separating the affected toes with lamb’s wool or gauze. A wider shoe and toe box may be helpful.
Hammer Toe
A flexion deformity of the interphalangeal joint, which may involve several toes. Tight socks or shoes may push an overlying toe back into the line of the other toes. They are often pulled upward, forcing the metatarsal joints downward. Corns develop on top of the toes, and tender calluses develop under the metatarsal area.
- Treatment: conservative measures including open-toed sandals (except in diabetes), round-toe or foot-shaped shoes, carrying out manipulative exercises, and protecting the protruding joints with pads.
- An osteotomy (surgical cutting of the bone) may be used to correct the deformity.
- There is little evidence to support treatment of hammer toe when the patient is asymptomatic.
- Attention should be given for diabetic patients as the deformity may result in friction points, causing wounds.
- Prevention: orthotics may be used to prevent deformity in people with high foot arches.
Onychocryptosis
An ingrown toenail, where the free edge of a nail plate penetrates the surrounding skin. Secondary infections or granulation may develop. This is caused by improper self-treatment, external pressure (tight shoes or stockings), internal pressure (deformed toes, growth under the nail), trauma, or infection.
- Treatment: washing the foot twice a day and relieving the pain by decreasing the pressure of the nail plate on the surrounding soft tissue.
- If infection is present, warm wet socks help drain the infection. If infections are recurrent, a toenail excision may be done by a podiatrist.
- Prevention: proper nail trimming (clipping straight across, filing corners along with contour).
Pes Cavus
“Clawfoot” refers to a foot with an abnormally high arch and a fixed equines deformity of the forefoot. The foot shortens, and calluses form from the increased pressure on the metatarsal area and on the dorsum of the foot. Common causes include Charcot-Marie-Tooth disease, diabetes, and progressive neurologic disorders are common causes.
- Management: exercises are prescribed to manipulate the forefoot into dorsiflexion and relax the toes.
- Orthotic devices alleviate pain and can protect the foot.
- Arthrodesis (fusion) may be used for severe cases, reshaping and stabilizing the foot.
Hallux Valgus
Commonly known as a Bunion, literally meaning “big toe deviated laterally”. There is a marked prominence of the medial aspect of the first metatarsophalangeal joint. There is also osseous enlargement (exostosis) of the medial side of the first metatarsal head, over which a bursa may form (secondary to pressure and inflammation). Acute bursitis symptoms include a reddened area, edema, and tenderness. Factors contributing to the formation of a bunion include (1) hereditary, (2) ill-fitting shoes, (3) osteoarthritis, (4) and aging, which involves lengthening and widening of the foot.
- Treatment depends on age and severity:
- Uncomplicated cases involve wearing a shoe that conforms to the shape of the foot to prevent pressure on the protruding portions.
- Acute inflammation may be controlled through corticosteroid injections
- Advanced cases may require surgical removal of the exostosis and toe realignment to improve function, appearance, and symptoms. At least three months of rest after surgery is required before resuming strenuous activities, such as in athletes.
Morton Neuroma
A plantar digital neuroma, neurofibroma is a swelling near the third (lateral) branch of the medial plantar nerve. Microscopically, digital artery changes cause an ischemia within the third intrametatarsal (web) space. The result is a throbbing, burning pain in the foot that is usually relieved with rest and massage.
- Treatment: consists of inserting innersoles and balance the foot posture. Local injections of a corticosteroids and a local anesthetic may provide relief.
- If the previous fails, surgical excision of the neuroma is necessary. Pain relief and loss of sensation are immediate and permanent with surgery. The risk of falls increases because of the loss of all sensation.
Pes Planus
“Flatfoot”, a common disorder in which the longitudinal arch of the foot is diminished. It may be caused by congenital abnormalities or associated with bone or ligament injury, excessive weight, muscle fatigue, poorly fitting shoes, or arthritis. Signs and symptoms include a burning sensation, fatigue, clumsy gait, edema, and pain.
- Management: exercises to strengthen the muscles and to improve posture and walking habits. Additional support may be given by foot orthoses.
Plantar Fasciitis
Plantar fasciitis is an inflammation of the foot-supporting fascia, presenting as an acute onset of heel pain experienced with the first steps in the morning. The pain is localized to the anterior medial aspect of the heel and diminishes with gentle stretching of the foot and Achilles tendon.
- Management: stretching exercises, wearing shoes with support and cushioning to relieve pain, orthotic devices (heel cups, arch supports, night splints), and corticosteroid injections for inflammation.
- Unresolved plantar fasciitis may progress to fascial tears at the heel, and eventual development of heel spurs.
Nursing Process
Patients Undergoing Foot Surgery: patients may require foot surgery due to various conditions, including neuromas and foot deformities (bunion, hammer toe, clawfoot). These surgeries are generally performed in an outpatient basis.
Preoperative
- Assess patient gait, balance, and neurovascular status of the foot.
- Consider the availability of assistance at home and the structural characteristics of the home in planning for care following the surgery.
Postoperative
- Neurovascular assessment of the exposed toes every 1 to 2 hours for the first 24 hours is essential in monitoring the function of the nerves and perfusion of tissues. Educate the client and family about assessment for edema and neurovascular status.
- Edema is expected: elevation of the foot on several pillows when sitting or lying is helpful. Support the entire limb under the knee.
- Ice packs are applied to the surgical area intermittently for the first two days to reduce edema and pain.
- Oral analgesics may control pain. Educate the patient on the use of medication.
- Bulky foot dressings and a light cast will be in place after surgery. Varying weight-bearing limitations are put in place.
- Assistive devices may be required. Options depend on the patient’s general condition and balance and on the weight-bearing prescription. Safe use of assistive devices must be ensured through education and practice before discharge.
- Venous Thromboembolytic Risk due to lower extremity immobility.
- Patient education concerning aseptic wound care and pin care may be necessary if percutaneous pins are used.