FOOT, HEEL, AND TOE PAIN
Many patients presenting with pain in the foot or toes have joint
disease (see pages 284 and 286 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.
Let us develop our list by moving from the skin inward. Many of these
conditions are illustrated on page 185 (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.
FOOT, HEEL, AND TOE PAIN
|
| M
| I
| N
| T
| S |
|
| Malformation
| Inflammation
| Neoplasm
| Trauma
| Systemic Disease |
|
Skin
| Ingrown toenail
| Herpes zoster Cellulitis
| | Callus Bunion
| |
Subcutaneous Tissue and Fascia
| | Cellulitis Plantar fasciitis
| | | |
Arteries
| | Vasculitis
| | Hemorrhage Contusion Aneurysm
| Diabetes Periarteritis nodosa Buerger disease |
Veins
| Varicose vein
| Thrombophlebitis
| | Hemorrhage
| Buerger disease |
Nerves
| Hypertrophic polyneuritis Peroneal muscular atrophy Plantar entrapment syndrome
| Tuberculosis of spine
| Neuroma Cauda equina tumor
| Contusion Compression Laceration
| Diabetic neuropathy |
Bones
| Pes planus Pes cavus Talipes equinovarus
| Osteomyelitis Kohler disease
| Primary and metastatic neoplasms
| Fracture
| Hyperparathyroidism Sickle cell anemia |
Joints
| | Rheumatoid arthritis Gout Osteoarthritis Pseudogout
| | Traumatic synovitis
| Gout Rheumatic fever Reiter syndrome |
|
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 in the section on joint pain, page 284).
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 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.
Other Useful Tests
-
X-ray of the feet (fracture, dislocation)
-
Doppler studies (arterial and venous insufficiency)
-
Bone scan (osteomyelitis, fracture)
-
EMG and NCV (peripheral neuropathy)
-
Angiogram (arteriosclerosis)
-
Venogram (deep vein thrombosis)
-
CT scan (fracture, tumor)
-
MRI (stress fracture)
-
CT scan or MRI of lumbar spine (herniated disc)
-
Arthritis panel
Pictures
Book Source Details
- Book Title: Differential Diagnosis in Primary Care
- Author(s): R. Douglas Collins MD, FACP
- Year of Publication: 2007
- Copyright Details: Differential Diagnosis in Primary Care, Copyright © 2007 Lippincott Williams & Wilkins.
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Copyright Details: Differential Diagnosis in Primary Care, Copyright © 2008 Williams & Wilkins.
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