Diagnosis of Foot conditions
Foot conditions Diagnosis: Book Excerpts
Diagnostic Tests for Foot conditions: Online Medical Books
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FOOT DEFORMITIES:
Ask the Following Question:
(Algorithmic Diagnosis of Symptoms and Signs)
- Are there signs of a neurologic disease? Many foot deformities are associated with neurologic disease. For example, a pes cavus may be associated with a peroneal muscular atrophy, poliomyelitis, and Friedreich's ataxia. Muscular dystrophy produces an equinovarus deformity. Friedreich's ataxia may produce a talipes equinovarus. Amyotrophic lateral sclerosis and progressive muscular atrophy may also cause foot deformities.
DIAGNOSTIC WORKUP
Rather than undertaking an extensive diagnostic workup, it is wise to refer the patient to the appropriate specialist. If there are neurologic signs, the patient should be referred to a neurologist. Otherwise, the patient should be referred to an orthopedic surgeon or podiatrist.
» READ BOOK EXCERPT ONLINE »
Source: Algorithmic Diagnosis of Symptoms and Signs, 2003
FOOT ULCERATION:
Ask the Following Questions:
(Algorithmic Diagnosis of Symptoms and Signs)
- Are there diminished or absent peripheral pulses? The finding of poor peripheral pulses would suggest that the lesion is secondary to ischemia from arteriosclerosis, Buerger's disease, diabetic arteriolar sclerosis, familial hyperlipidemia, and cryoproteinemia.
- Are there abnormalities on neurologic examination? The presence of good peripheral pulses should make one look for a neurologic explanation for the ulcer, and if there is diminished sensation to touch and pain in the periphery, peripheral neuropathy is very likely. Ulcers may also form in paraplegia of any cause, leprosy, and tabes dorsalis.
- Is there a history of diabetes? A history of diabetes makes the diagnosis of diabetic arteriolar sclerosis very likely. Remember, the pulses may be normal in this condition.
- Is there a positive smear or culture? The presence of good peripheral pulses should prompt one to do a smear and culture of material from the lesion, and if this is positive, then the diagnosis is made. We would consider, in addition to the normal bacteria, blastomycosis, sporotrichosis, maduromycosis, and syphilis.
DIAGNOSTIC WORKUP
Diminished pulses is a clear indication for Doppler ultrasound studies. Routine tests include a CBC, sedimentation rate, urinalysis, chemistry panel, VDRL test, and glucose tolerance test. An x-ray of the involved foot should be done to rule out osteomyelitis. A bone scan is even more sensitive to osteomyelitis and other disorders of the bone that may be causing the ulcer. A smear should be made of the ulcer material and a culture done also, not just for the common pathogens, but for AFB and fungi. A dark field preparation may be necessary. Skin testing for blastomycosis and other fungi should be done. A nerve conduction velocity study of the lower extremities will be helpful in differentiating neurologic causes. Femoral angiography may be valuable in determining the exact level of the lesion and whether it can be approached surgically.
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Source: Algorithmic Diagnosis of Symptoms and Signs, 2003
FOOT AND TOE PAIN:
Ask the Following Questions:
(Algorithmic Diagnosis of Symptoms and Signs)
- Is there fever or localized erythema? Localized erythema would suggest phlebitis, gout, osteomyelitis, cellulitis, ingrown toenail, and paronychia. The presence of fever would make one suspect osteomyelitis and cellulitis.
- Is there associated deformity of the foot? Hallux valgus, hammertoe, hallux rigidus, arthritis, and displaced fracture are the main causes of a deformity of the foot.
- Are the peripheral pulses palpable? Diminished arterial pulses would make one think of arterial embolism, peripheral arteriosclerosis, and diabetes.
- Are there associated neurologic findings? The presence of loss of sensation to touch and pain should make one think of peripheral neuropathy and tarsal tunnel syndrome. Numbness or loss of sensation in the 3rd and 4th toes is often associated with a Morton's neuroma.
DIAGNOSTIC WORKUP
Routine diagnostic tests include a CBC, sedimentation rate, chemistry panel, VDRL test, and an x-ray of the foot. If the peripheral pulses are diminished, Doppler studies and angiography should be considered. If there is diffuse swelling and erythema, venography may need to be done. If there are neurologic findings, nerve conduction velocity studies and electromyograms (EMGs) may be helpful. Consider bone scans, CT scans, and arthroscopy if the above tests are negative. An MRI may be needed to diagnose stress fractures. Abnormal weight distribution is diagnosed by quantitative scintigraphs. It is wise to refer the patient to an orthopedic surgeon or podiatrist before ordering expensive diagnostic tests.
» READ BOOK EXCERPT ONLINE »
Source: Algorithmic Diagnosis of Symptoms and Signs, 2003
Hand and Foot Rashes:
Differential Diagnosis
(In a Page: Signs and Symptoms)
- Dyshidrotic eczema (pompholyx)
–Very common idiopathic skin disease
–Affects one or both hands and/or feet in the
thenar eminence, palms and/or soles, and sides of fingers and toes
–Causes itching, scaling, and erythema, and minute vesicles and painful fissures
–Usually chronic and intermittent, and often exquisitely pruritic
- Irritant or allergic hand eczema
–Very common
–Difficult to distinguish from dyshidrosis because both are vesicular and very itchy
–Flares occur during work/hobbies, with improvement on vacation when away from the irritant or allergen
- Tinea manus (hand) and tinea pedis (foot)
–Presents as itchy, diffuse, light scale, and/or maceration; prominent on palmar, plantar (moccasin distribution), and interdigital surfaces
–Erythema is rarely present
–Often “two hands and one foot” or “two feet and one hand” are affected
- Scabies
–Presents as short (a few millimeters), linear burrows and vesicles on the hands and feet (web spaces), belt region, and/or intertriginous spaces
–Intensely pruritic, especially at night
–Often many members of the household unit affected
–Definitive diagnosis made by visualizing the scabies mite in a skin scraping
-
Psoriasis
–Often affects the hands and/or feet
–Well-demarcated, erythematous plaques
with adherent scale, or can present as a focal or diffuse pustular eruption
–Look for associated nail dystrophy or other skin involvement
Reiter's disease
–Uveitis, urethritis, and arthritis
-
Pityriasis rubra pilaris
–Well-demarcated bright salmon or red plaques on the palms or soles
-
Keratoderma
–Focal or diffuse thickening of the skin of the palms or soles
Erythema multiforme
Infection (secondary syphilis, varicella meningococcemia)
Workup and Diagnosis
- History and physical examination
–Note chronic exposure to chemicals or potential irritants at work or in hobbies
–Any family history of psoriasis or allergy/atopy
–Look closely for the presence of small, clear “water blisters” under the skin that may indicate pompholyx
–Examine nails for evidence of coexisting onychomycosis (very common in cases of tinea pedis and manus, and a nidus for frequent reinfection), “oil spots,” or nail pitting (may suggest psoriasis)
–Examine joints for arthritis (psoriasis/Reiter's), eyes (Reiter's), and genitalia (psoriasis/Reiter's)
-
KOH preparation from scale scraped from the palms, soles, or between the toes to determine presence of branching hyphae of tinea or scabies mites
-
Culture any intact pustules
-
Consider performing a patch test to rule out allergic contact dermatitis
-
A punch biopsy may be helpful to distinguish psoriasis or PRP from the other common eczematous diseases of the hands and feet
-
Fungal culture of nail clipping if onycholysis (nail thickening) present
-
Dermatology referral is often indicated in resistant cases
» READ BOOK EXCERPT ONLINE »
Source: In a Page: Signs and Symptoms, 2004
Hand & Foot Rashes:
Differential Diagnosis
(In A Page: Pediatric Signs and Symptoms)
Infectious
-
Enterovirus infection (hand-foot-and-mouth disease, Coxsakie virus, other nonpolio enteroviruses)
-
Kawasaki disease (one of the five criteria)
-
Scabies
-
Tinea
-
Candidal skin infection
-
Ricketsial rash: Rocky Mountain spotted fever (RMSF), murine typhus
-
Mononucleosis (EBV)
-
Measles: Atypical forms start on hands/feet
-
Scarlet fever, post-streptococcal infection desquamation rash
-
Infectious endocarditis: Janeway lesions, Osler nodules
-
Spirochete infection: Secondary syphilis, Lyme disease (acrodermatitis chronica atrophicans)
-
Congenital toxoplasmosis
-
Rat-bite fever (Streptobacillus moniliformis,
Spirillum minus)
Immune-mediated
-
Urticaria: Hands and feet involved in 85% of the cases
-
Juvenile rheumatoid arthritis
-
Systemic lupus erythematosus
-
Raynaud phenomenon (acrocyanosis)
-
Acute graft-vs-host disease
Skin disorders
-
Atopic dermatitis (infantile)
-
Dyshydrotic eczema, pompholyx
-
Chronic allergic contact dermatitis
-
Psoriasis
-
Lichen simplex
-
Papillon-Lefèvre syndrome
-
Olmsted syndrome
-
Acrodermatitis enteropathica (zinc deficiency) can be presenting sign of cystic fibrosis
-
Toxic shock syndrome: Desquamation during the recovery phase; major criteria for staphyloccocal TSS
-
Drugs: Ampicillin, especially in patients with infectious mononucleosis
-
Chronic liver disease: Cirrhosis, hepatoma
-
Metabolic disease: Gangliosidosis
-
Malignancy: Acute leukemia, lymphoma
Workup and Diagnosis
- History
–Season of onset (can be a clue for various infectious
etiologies)
–Patient's age
–Presence of fever, pruritus (typical of urticaria)
–Tick/rat/bat bites (e.g., rat bite fever or Lyme disease)
–Travel (to endemic areas for Lyme, RMSF)
–Sick contacts
–Contact allergen
- Physical exam
–Rash pattern and distribution, desquamation (interdigital, periungal), edema, involvement of other areas of the body
–Other signs and symptoms associated (oral lesions, URI symptoms, arthritis, genital chancre)
–Verify criteria for disease such as Kawasaki, Lyme, juvenile rheumatoid arthritis
-
Labs
–CBC, ESR/CRP
–Serologic testing for RMSF, Lyme, syphilis, toxoplasmosis, SLE
–Throat swabs and stool culture for enterovirus serotype (no therapeutic significance)
–KOH prep for hyphae
-
ECG, echocardiography, and cardiology consult if Kawasaki disease or endocarditis is suspected
» READ BOOK EXCERPT ONLINE »
Source: In A Page: Pediatric Signs and Symptoms, 2007
EXTREMITY, HAND, AND FOOT DEFORMITIES:
Approach to the Diagnosis
(Differential Diagnosis in Primary Care)
It is usually a simple matter to decide whether the deformity is due to neurologic disease or to joint or bone disease. An x-ray film of the hands or feet may be useful in acromegaly and many congenital disorders. Referral to an orthopedic or neurologic specialist is usually indicated if bone or neurologic involvement is probable. An arthritis workup can be done (see page 343) if joint disease is the cause of the deformity.
» READ BOOK EXCERPT ONLINE »
Source: Differential Diagnosis in Primary Care, 2007
FOOT, HEEL, AND TOE PAIN:
Approach to the Diagnosis
(Differential Diagnosis in Primary Care)
Special considerations in the approach to the diagnosis of foot pain include examining the shoes for abnormal areas of wear and tear, measuring the arches, palpating the joints for maximal tenderness, and ordering laboratory tests for joint disease (page 341). Nerve blocks and lidocaine injections in the plantar fascia and other areas of maximum tenderness will assist in diagnosis. Abnormal weight distribution is diagnosed by quantitative scintigraphs. A therapeutic trial of proper-fitting shoes and arches may be indicated. Weight control is essential in the obese. Referral to a podiatrist or orthopedic surgeon is often necessary.
» READ BOOK EXCERPT ONLINE »
Source: Differential Diagnosis in Primary Care, 2007
Clubfoot:
Diagnosis
(Professional Guide to Diseases (Eighth Edition))
Early diagnosis of clubfoot is usually possible because the deformity is obvious. In subtle deformity, however, true clubfoot must be distinguished from apparent clubfoot (metatarsus varus or pigeon toe). Apparent clubfoot results when a fetus maintains a position in utero that gives his feet a clubfoot appearance at birth. This can usually be corrected manually. Another form of apparent clubfoot is inversion of the feet, resulting from the peroneal type of progressive muscular atrophy and progressive muscular dystrophy. In true clubfoot, X-rays show superimposition of the talus and the calcaneus and a ladderlike appearance of the metatarsals. (See Recognizing clubfoot.)
» READ BOOK EXCERPT ONLINE »
Source: Professional Guide to Diseases (Eighth Edition), 2005
Footdrop:
History and physical examination
(Professional Guide to Signs & Symptoms (Fifth Edition))
Ask the patient about the sign’s onset, duration, and character. Does the footdrop fluctuate in severity or remain constant? Does it worsen with fatigue or improve with rest? Ask the patient if he feels weak or tires easily.
During the physical examination, assess muscle tone and strength in the patient’s feet and legs, and compare findings on both sides. Assess deep tendon reflexes (DTRs) in both legs as well. Have the patient walk; inspect his shoes for wear and observe the patient for steppage gait—a compensatory response to footdrop in which the legs are raised abnormally high.
» READ BOOK EXCERPT ONLINE »
Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006
Ankle/Foot Pain:
Differential Overview
(Field Guide to Bedside Diagnosis)
Ankle Pain
❑ Ankle sprain
❑ Fibular fracture
❑ Achilles tendinitis
❑ Acute gout
Foot Pain
❑ Plantar fasciitis
❑ Acute gout
❑ Hallux valgus (bunion)
❑ Sciatica
❑ Metatarsalgia
❑ Metatarsal stress fracture
❑ Tibialis anterior tendinitis
❑ Pes planus
❑ Calcaneal fracture
❑ Interdigital neuroma
❑ Posterior tibial nerve entrapment
❑ Compartment syndrome
Diagnostic Approach
In acute ankle injury, ability to bear weight for four steps and absence of bone tenderness at the posterior edge or the tip of either malleolus rule out a significant fracture (Ottawa ankle rule).
In acute foot injury, ability to bear weight for four steps and absence of bone tenderness at the navicular or the base of the fifth metatarsal rule out a significant midfoot fracture (Ottawa foot rule).
» READ BOOK EXCERPT ONLINE »
Source: Field Guide to Bedside Diagnosis, 2007
Clubfoot:
Diagnosis
(Handbook of Diseases)
An early diagnosis of clubfoot is usually no problem because the deformity is obvious. With subtle deformity, however, true clubfoot must be distinguished from apparent clubfoot (metatarsus varus or pigeon toe).
Apparent clubfoot results when a fetus maintains a position in utero that gives his feet a clubfoot appearance at birth. This can usually be corrected manually.
Another form of apparent clubfoot is inversion of the feet, resulting from the peroneal type of progressive muscular atrophy and progressive muscular dystrophy. With true clubfoot, X-rays show superimposition of the talus and the calcaneus and a ladderlike appearance of the metatarsals.
» READ BOOK EXCERPT ONLINE »
Source: Handbook of Diseases, 2003
Footdrop:
History
(Signs & Symptoms: A 2-in-1 Reference for Nurses)
Ask the patient about the sign’s onset, duration, and character. Does the footdrop fluctuate in severity or remain constant? Does it worsen with fatigue or improve with rest? Ask the patient if he feels weak or tires easily.
» READ BOOK EXCERPT ONLINE »
Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007
EXTREMITY, HAND, AND FOOT DEFORMITIES:
Approach to the Diagnosis
(Differential Diagnosis in Primary Care)
It is usually a simple matter to decide whether the deformity is due to
neurologic disease or to joint or bone disease. An x-ray film of the hands
or feet may be useful in acromegaly and many congenital disorders. Referral
to an orthopedic or neurologic specialist is usually indicated if bone or
neurologic involvement is probable. An arthritis workup can be done if joint disease is the
cause of the deformity.
» READ BOOK EXCERPT ONLINE »
Source: Differential Diagnosis in Primary Care, 2007
FOOT, HEEL, AND TOE PAIN:
Approach to the Diagnosis
(Differential Diagnosis in Primary Care)
Special considerations in the approach to the diagnosis of foot pain
include examining the shoes for abnormal areas of wear and tear, measuring
the arches, palpating the joints for maximal tenderness, and ordering
laboratory tests for joint disease (page 286). Nerve blocks and lidocaine injections in the plantar fascia and
other areas of maximum tenderness will assist in diagnosis. Abnormal weight
distribution is diagnosed by quantitative scintigraphs. A therapeutic trial
of proper-fitting shoes and arches may be indicated. Weight control is
essential in the obese. Referral to a podiatrist or orthopedic surgeon is
often necessary.
» READ BOOK EXCERPT ONLINE »
Source: Differential Diagnosis in Primary Care, 2007
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