FOOT, HEEL, AND TOE PAIN

Many patients presenting with pain in the foot or toes have joint disease (see pages 341 and 343 for a discussion of these differentials). Other anatomic components of the foot and toes may cause pain as well, so a consideration of the differential diagnosis of foot and toe pain must include diseases of these structures.

FOOT, HEEL, AND TOE PAIN

Let us develop our list by moving from the skin inward. Many of these conditions are illustrated on page 224 (Table 30). Painful conditions of the skin include warts, calluses, bunions, and corns, conditions often caused by bad posture and poor-fitting shoes. Ingrown toenails may be found. Herpes zoster in this location is unusual. Moving to the subcutaneous tissue and fascia, cellulitis and plantar fasciitis are suggested. In plantar fasciitis, a spur of the calcaneus will be found on the x-ray. Achilles bursitis and tendonitis are suggested in this layer. The veins may be involved by phlebitis and hemorrhage.

The arteries may be inflamed in Buerger disease and periarteritis nodosa; they are painfully obstructed in the arteriolar sclerosis of diabetes mellitus and arteriosclerosis. Emboli may be a cause of foot pain. Raynaud disease may also affect the foot. The nerves of the foot may be involved by the many causes of peripheral neuropathy, as well as herniated lumbosacral discs and cauda equina tumors; the radiation of the pain should suggest the latter two conditions. Trapping of the plantar tibial nerve may cause pain just like the carpal tunnel syndrome in the hand. Metatarsalgia may be caused by a plantar digital neuroma. Tracing the arteries centrally will suggest Leriche syndrome, whereas tracing the nerves centrally will suggest a thalamic syndrome.

Finally, the bones may be involved by fractures, by deformities such as pes planus, pes cavus, talipes equinovarus and hallux valgus, and by many postural defects. Kohler disease is aseptic bone necrosis in the calcaneus (considered under the section on joint pain, page 341).

Approach to the Diagnosis

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.

Other Useful Tests

1. X-ray of the feet (fracture, dislocation)
2. Doppler studies (arterial and venous insufficiency)
3. Bone scan (osteomyelitis, fracture)
4. EMG and NCV (peripheral neuropathy)
5. Angiogram (arteriosclerosis)
6. Venogram (deep vein thrombosis)
7. CT scan (fracture, tumor)
8. MRI (stress fracture)
9. CT scan or MRI of lumbar spine (herniated disc)
10. Arthritis panel

Book Source Details

• Book Title: Differential Diagnosis in Primary Care
• Author(s): R. Douglas Collins
• Year of Publication: 2007
• Copyright Details: Differential Diagnosis in Primary Care, Copyright © 2007 Lippincott Williams & Wilkins.

Other Book Chapters Related to Heel pain

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Copyright Details: Differential Diagnosis in Primary Care, Copyright © 2008 Williams & Wilkins.

More About Causes of Heel pain

• Back to symptom: Heel pain: Introduction (review 15 causes)
• Next Book Extract About Heel pain: FOOT, HEEL, AND TOE PAIN (Differential Diagnosis in Primary Care)
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More About This Book: Title: Differential Diagnosis in Primary Care Authors: R. Douglas Collins Publisher: Lippincott Williams & Wilkins Copyright: 2007 ISBN: 0-7817-6812-8

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