Introduction

Geriatric Essentials

• Foot disorders may be particularly problematic because they interfere with ambulation (and thus social interactions) and increase the risk of falls.
• Risk factors for many common foot disorders (eg, degenerative musculoskeletal changes, obesity, inactivity, diabetes) become more common with aging; consequently, many common foot disorders are prevalent among the elderly.
• Elderly patients should be regularly evaluated by a podiatrist, who should check their feet for skin and nail problems and trim toenails.

Age-related changes in the feet include hair loss, brown pigmentation, and dry skin. Thickened, callused, hyperkeratotic lesions commonly develop, particularly in patients with deformities or arthritis-induced bony changes.

Foot disorders are common and involve various parts of the foot (see Table 56-1). These disorders often begin early in life. Many factors, such as heredity, gait patterns, level of activity, terrain, quality of foot care, and shoe styles and fit affect the development of foot disorders. For example, tight or ill-fitting shoes may injure the feet, legs, or hips, as well as cause falls or worsen lesions that are slow to heal because of peripheral arterial disease or diabetes mellitus.

Symptoms and Signs

Symptoms and signs vary by disorder (see Table 56-2). Several disorders cause heel pain; its location varies by disorder (see Table 56-3). Initial symptoms and signs of certain systemic disorders may occur in the feet (see Table 56-4).

Diagnosis

Most physicians do not examine the feet carefully and are not trained to treat many common foot problems. Routine foot care is more commonly provided by podiatrists. Podiatric visits should occur at least every 60 days for patients at high risk of developing foot disorders and yearly for other elderly patients. Elderly patients with any risk factor for foot problems should have their toenails trimmed by the podiatrist rather than doing it themselves. Physicians usually become involved when a patient has a specific symptom or is referred to them by a podiatrist who has found alarming signs.

Pain is the most common foot symptom. Any clinician, when evaluating foot pain, should record its location, date of onset, duration, and severity. Relevant economic, psychologic, and social factors should be recorded. The clinician should attempt to elicit symptoms by palpation and range-of-motion testing while the patient is at rest. The clinician should also determine whether the patient's shoes are tight or fit poorly.

Complete inspection of the feet includes checking for hyperkeratotic lesions or excrescences, deformities, changes in long-standing lesions (eg, bleeding, discoloration), evidence of a bacterial or fungal infection, dry skin, ulcers, and warts. The feet and legs should be inspected for trophic changes consistent with loss of vasculature (eg, slowed hair growth; red, shiny, atrophic skin; brown pigmentation). The toenails should be inspected for signs of hypertrophy and fungal infection. Missing nails, changes in color and continuity of the nail plate, foot odor, temperature of the feet, varicosities, and edema should be noted. The pedal pulses (eg, dorsalis pedis, posterior tibial) should be palpated. If patients have diminished pulses, peripheral arterial disease, or diabetes, the ankle-brachial index should be determined.

Postural deformities, physical limitations, and the position of the foot at heel strike and through the gait cycle are identified by watching the patient walk. The degree of pronation or supination should be determined, especially when orthoses (orthopedic inserts to prevent or accommodate deformities) are being considered.

Neurologic examination includes evaluation of motor function. The Achilles tendon and superficial plantar reflexes should be elicited. Vibratory sensation and sensitivity to temperature and touch should be evaluated. Sensitivity to pinprick should be assessed at least on the volar surfaces of the great toe and the 1st, 3rd, and 5th metatarsal heads; hypoesthesia at these locations increases risk of developing foot ulcers.

X-rays may be taken to check for bone changes (eg, osteoporosis, demineralization, previous fractures, arthritis). Indications for x-rays include progressively increasing pain with ambulation, suspected injury, and deformity.

Treatment

The goals of treatment include preventing foot problems before they develop (mainly in younger patients), preventing them from worsening, preventing secondary problems, minimizing pain, and maximizing function. Patients are advised to follow general guidelines for optimal foot care (see Table 56-5). Patients at high risk of infection and its complications (eg, patients with diabetes or peripheral arterial disease) must adhere to these guidelines scrupulously and examine their feet daily for wounds. If patients have difficulty bending to see the plantar aspect of the foot, they can use a plastic mirror placed on the floor.

Shoes should provide adequate support and have a wide toe box to compensate for age-related orthopedic deformities. Patients should not wear shoes that are misshapen or that have worn-out soles or heels. Correct size and fit should be determined at a reliable shoe store. Oxford-type shoes that have shoelaces are preferable to loafers or slip-ons, which may be constrictive and do not allow for possible swelling as the day progresses. Patients who have impaired hand dexterity and who cannot tie shoelaces may benefit from shoes with touch fasteners (eg, Velcro) or shoes with elastic laces, which can remain tied. Patients who have difficulty bending down to put their shoes on may benefit from using extended-length shoe horns. Often, orthoses can be fashioned to cushion vulnerable areas. For patients with painful or preulcerous foot lesions, shoes can be custom-made and fitted with orthoses made of polyethylene foam.

Some disorders causing foot pain can be treated with injections of local anesthetics, corticosteroids, or both. Commonly used local anesthetics include 0.5 to 0.75 mL of 1% lidocaine and, for more prolonged relief, bupivacaine. Corticosteroid injection, particularly superficial injection, can have adverse effects (eg, depigmentation, atrophy, ulceration), especially in elderly patients with peripheral arterial disease. Thus, corticosteroid injection is limited to patients with inflammation (which is not present in most foot disorders) or with scar tissue. Commonly injected corticosteroids include 0.25 mL of a solution containing 6 mg of betamethasone/mL or 0.25 to 0.5 mL of a solution containing 40 mg of sustained-release methylprednisolone/mL; the corticosteroid is mixed with 0.5 mL 1% lidocaine. The foot should be immobilized for a few days after tendon sheaths are injected. Unusual resistance to injection suggests injection into a tendon, which, if it occurs repeatedly, weakens the tendon, predisposing to subsequent rupture, and should be avoided.

This topic was last updated May 2006.