Feet of an older adult showing many of the conditions that can happen with aging. Xerosis is present on both legs and feet. Onychomycosis is present bilaterally. Hallux valgus (bunion) is noted on the left foot. Digiti flexus (hammertoe) is present in the right second toe.
Pruritis is common in older patients and may be related to dry skin and cold weather. The patient may complain of itching and scratching, and the foot examination may reveal excoriations. An examination should be done to rule out tinea, urticarial, or other skin lesions.[7] Treatment of pruritis consists of skin lubricants and topical steroids if warranted. If needed, antihistamines can be helpful, but they have side effects that can be dangerous in older patients.
Venous stasis dermatitis is caused by venous insufficiency and can manifest as edema, induration, discoloration, and ulcerations of the skin. It starts most commonly in the medial aspect of the ankle. Management includes elevation and compression stockings to improve venous return and manage edema. Emollients and topical corticosteroids can help to manage the dermatitis. Antibiotics may be indicated when infection is present.[8]
Hyperkeratotic lesions
Hyperkeratotic lesions such as tyloma (callus) and heloma (corn) are thickened and hardened areas of the skin that have developed over time due to constant friction or pressure or over bony prominences.[9] Ill-fitting shoes may be a factor in the development of these lesions. Other factors include contractures, gait changes, deformities, loss of skin tone and elasticity, loss of soft tissue with age, and atrophy of the plantar fat pad.[10] Generally, these are not harmful, but patients often present with pain, ulceration, or infection that can limit their ambulation.[11] Patients with vascular or neurologic disorders will need to examine their feet frequently to check for signs of skin irritation, ulceration, and bone infection.[9]
It is often hard to differentiate corns and calluses. Corns are usually smaller than calluses and have a central core that is surrounded by irritated skin. Corns are often painful with pressure. On the other hand, calluses are rarely painful and often larger. These usually develop on the stratum corneum, the outermost layer, on the soles of the feet, under the heels or balls.[12] It is important to differentiate corns and calluses from verruca (warts) or other similar appearing lesions.[10]
Treatment for hyperkeratotic lesions is dependent upon the patient and the effect on function. The primary focus should be placed on removing pressure and preventing ulceration or further injury. Considerations for treatment include padding, shoe modification, emollients, debridement, and orthoses. When the lesion is on the plantar aspect of the foot, treatment should be aimed at dispersing the weight.[9] The lesions can be treated with salicylic acid plasters and debulking.[12] Surgical revision may be indicated in some cases. The problem may be recurrent or persist because of the residual deformity and underlying conditions such as diabetes.[11]
Ulceration
An ulceration is a soft tissue injury that leads to an open wound or sore that is difficult to heal. It can result in complete loss of the epidermis and may go as deep as the dermis and subcutaneous fat. There are several different stages of ulcers. Risk factors for ulcer development include lack of mobility and prolonged stress on the tissue.[13] Ulcers can lead to poor quality of life, high mortality due to sepsis, and increased hospitalization.
There are three types of ulcerations that need to be taken into consideration: arterial, neurotrophic, and venous stasis ulcers. The ulcers are defined by their appearance, location, and the surrounding tissue.
Arterial (ischemic) ulcers are often on the heels, tips of the toes, between toes, or anywhere there are bony prominences. Patients complain of severe pain worsening at night. Patients often feel better after hanging the leg over the side of the bed.[14] There is usually very poor circulation causing poor tissue granulation and color changes (pale white/yellow, gray color when the leg is elevated, and redness reappears when the leg is dangling).[9]
Neurotrophic ulcers are usually located on the bottom of the feet beneath pressure points or hyperkeratoic lesions. There is often no pain associated with this type of ulcer. There is an increased incidence with elderly who have diabetes due to a loss of foot sensation and changes in the sweat-producing glands. Patients often complain of tingling, numbness, or burning sensation. The ulcers appear punched-out with a calloused, white fibrotic rim.[9]
Venous stasis ulcers occur in patients with poor venous circulation in the leg. They primarily occur below the knee, just above the ankle. Due to the poor circulation, risk of infection and prolonged healing often occur.[13]
Treatment should be focused on reducing pressure to the area and preventing infection. Pressure reduction can be obtained with dressings, orthoses, shoe modifications, and special depth shoes. In order to prevent infection of the ulcerated area, wound care is essential. The wound must be kept clean, and the wound base must be healthy to permit healing. Appropriate wound care may include debridement and/or antibiotics (when indicated). Vascular ulcers may warrant further evaluation with a vascular specialist. It is essential to improve vascular supply to the area and minimize worsening of conditions.[10]
Onychomycosis
Onychomycosis is one of the most prevalent nonbacterial diseases of the toenail. It is usually caused by dermatophytes (Trichophytum rubrum or T. mentagrophytes).[15] Other causes include yeasts and nondermatophyte fungi. Factors that contribute to this disease can include occlusive footwear, repeated trauma, sports participation, comorbid diseases such as diabetes, peripheral vascular disease, genetic predisposition, and foot hygiene.
The incidence of onychomycosis increases with age.[16] As the population ages, the nails also change. The nail calcium concentration decreases along with iron. Blood circulation diminishes and nail growth becomes retarded, increasing the susceptibility to infection.[15]
The patient often presents with discoloration and increased thickness in the toenail (see Figure 42.1). The infection may cause distal subungual, white superficial, proximal subungual, or total dystrophic changes. The superficial variety does not involve the nail plate, whereas the distal and proximal kind affect both the nail bed and the nail plate. When the nail plate is involved, hypertrophy and deformity is the result, and external pressure to the nail may cause pain.[10] It is important to rule out any other diseases that may mimic onychomycosis such as trauma, lichen planus, and psoriasis. Only approximately half of the suspected onychomycosis is truly due to a fungal infection and the other half is due to other causes that may lead to variation of nail morphology.[17] Therefore, confirmation of a fungal infection is imperative.
Diagnosis can be made based on laboratory confirmation with potassium hydroxide smear, culture, nail biopsy and less frequently immunohistochemistry, restriction fragment length polymorphisms, and polymerase chain reaction assays. It is important to get the correct specimen sampling and to use proper technique to prevent false negatives.[16]
After diagnosis is confirmed, management includes systemic and topical antifungals, keratolytic agents, debridement, photodynamic therapy, and surgical removal. Elders often do well with serial nail debridement as this decreases chances of infection, ingrown toenails, corns, and ulceration.[9] Treatment is often challenging because treatment is lengthy as the infection is usually embedded within the nail and difficult to reach. Factors that can indicate poor prognosis include the amount of nail involvement, nail dystrophy, mold, dermatophytoma, immunosuppression, and poor circulation.[16]
Tinea pedis
Tinea pedis, otherwise known as athlete’s foot, is also caused by contagious dermatophytic fungal infection, such as T. rubrum or T. mentagrophytes. It affects the skin and causes scaling, flaking, and itching. It can be an extension of onychomycosis. In most cases, the disease is transmitted in warmer and moist communal areas where people walk barefoot, such as locker rooms and showers.[7]
Tinea pedis can occur in the interdigital spaces and on the sole of the foot. The diagnosis can usually be made clinically through thorough history and physical. Treatment consists of conservative measures such as allowing the feet to ventilate and remain dry with good hygiene. Topical antifungal medication is usually the treatment of choice such as clotrimazole, miconazole nitrate, and terbinafine hydrochloride. For severe or refractory infections, oral terbinafine is most effective, but it is important to be aware of the side effects that may occur with any oral medications.[15]
Other nail disorders
Ingrown toenail (onychocryptosis) is an incurvation of the edge of the nail into the nail groove. This is usually due to poor self-care (nail cutting) or narrow fitting shoes.[15] When this occurs, an abscess or an infection may result. If treatment is not initiated, periungual granulation tissue forms and complications such as deformity and involution may be the outcome. Treatment may include excision, partial avulsion, fulgeration, desiccation or caustics, and astringents.[11]
Paronychia is a localized infection involving the lateral or medial nail wall, most often caused by a spike of ingrown nail. This requires incision and drainage of the abscess with removal of the nail tissue. Antibiotics may also be necessary if there is surrounding cellulitis or if the patient is diabetic. Nonhealing granulation tissue in the nail groove may be an indication for a biopsy as Kaposi sarcoma, melanoma, and squamous cell carcinoma can present in this manner.[9]
There are many nail dystrophies that can occur in the older adult. They are usually the result of repeated trauma, underlying diseases, or degenerative changes. These nail conditions can be a source of pain, ulceration, and infection. Treatment should be individualized and may include specialized shoes, orthoses, debridement, and possible excision.
Subungal hematomas are common in the elderly secondary to microtrauma. However, when pigmented lesions are noted under the nail, it is important to rule out melanoma.[9]
Common foot disorders in elderly
Forefoot
Hallux valgus
Hallux valgus, commonly known as bunion, affects one-third of people over age 65. It is characterized by subluxation of the first metatarsal phalangeal joint and lateral deviation, greater than 15 degrees, of the great toe toward the lesser toes (see Figure 42.1).[18] The tissues around the joint may become swollen and sore. It may lead to restricted movement and thickening of the skin. Patients often complain that it is difficult to wear shoes or find shoes that are comfortable. Bunions may eventually lead to bursitis, which is inflammation of small fluid-filled pads (bursae); hammertoe, a bend in the middle joint of the toe, usually the one next to the big toe; and metatarsalgia, which is inflammation of the ball of the foot. Conservative management may include adaptive shoes (wider shoes or shoes with wider toe), proper padding and taping, anti-inflammatory medication, and applying ice. In some cases, the patient remains symptomatic and may require surgical management. Bunion surgery has been found to reduce symptoms and improve patient ability to comfortably wear shoes.[19]
Digiti flexus
A digiti flexus (hammertoe) or contracted toe is a deformity arising from increased extension at the metatarsophalangeal joint (MPJ), flexion of the proximal interphalangeal joint (PIPJ), and hyperextension of the distal interphalangeal joint (DIPJ) of the lesser toes causing it to be permanently bent, resembling a hammer (see Figure 42.1).[15] Two other types of toe deformities are claw toe and mallet toe. Claw toe deformity is an extension contracture of the MPJ and flexion of both PIPJ and DIPJ. Mallet toe consists of flexion at the DIPJ only. A “crossover” second toe deformity occurs when the hallux valgus deformity crosses over the second MPJ causing subluxation.[20] Hammertoes are often painful and may be associated with hyperkeratotic lesions from abnormally shaped toes rubbing on shoes.
Treatments should be focused on alleviating pain and caring for keratotic lesions. Management may be nonsurgical or surgical. The conservative approach includes physical therapy, proper-sized shoes (wider and deeper), padding, and orthotic devices. Debridement of hyperkeratotic lesions can also be beneficial along with corticosteroid injections to decrease inflammation or bursitis. Taping and splinting mild crossovers to prevent further worsening of conditions may be helpful. Surgical correction may be necessary for more severe cases.[20]
A hammertoe deformity may progress to metatarsal-phalangeal dislocation. This is a dislocation of the phalanx on top of the metatarsal head. This can result in chronic pain and possibly a source of callus or ulceration. Treatment usually consists of shoe accommodation (wide toe shoes) or surgical correction of the joint.[5]
Sesamoiditis
Sesamoiditis is inflammation of the sesamoid bones and usually affects those that are under the first metatarsal joint of the hallux. There are normally two sesamoid bones and may be comprised of two separate pieces. The function of the sesamoid bones is to act as a hinge for the flexor tendons, which allows the big toe to bend downward.[21]
Sesamoiditis is caused by repetitive motions, sudden bending upward of the big toe, direct trauma, osteoporosis, or osteoarthritis. Treatment involves rest, proper-fitting shoes, and padding with proper arches to prevent continual impact to the sesamoid bones. Anti-inflammatory medications, corticosteroid injections, and immobilization may also be used.[21]
Fracture of phalanx/stress fracture
Stress fracture can develop from overuse and occurs in the weight-bearing bones of the foot. It is more common in patients with chronic inflammatory arthropathies, severe osteoporosis, joint deformities, or chronic corticosteroid injections.[20] This happens when overused muscles are unable to minimize the shock of repeated impacts and thus transfer the stress to the bones, leading to small fractures. The most common sites of stress fractures are the second and third metatarsals of the foot.[20] The patient may complain of gradually increasing pain and swelling on top of the foot. The patient may also notice bruising. A stress fracture is often difficult to see on an x-ray and may require a bone scan, magnetic resonance imaging (MRI), or computed tomography (CT) scan.
A conservative approach is to wear proper footwear and orthoses. It is important to immobilize and modify activities. Normal activities can be resumed after adequate healing which may take six to eight weeks.[20] Strength training and physical therapy will be of great benefit for these patients after recovery.
Other fractures may occur from falls or trauma in older adults. This may be due to instability or neuropathy. When there are fractures of the phalanges, this can affect the balance and ambulation of the patient.[22] Referral to a specialist may be necessary, depending on complications such as osteomyelitis and displacement. If the fractures are nondisplaced, often buddy taping and immobilization with boot or cast are appropriate. A displaced fracture may be reducible or irreducible. If reducible, a cast will be placed to prevent movement. If irreducible or open fracture, open reduction may be required.
Morton’s neuroma
Morton’s neuroma is a benign lesion that involves the compression of the common digital nerve occurring in the third intermetatarsal space. The patient will complain of numbness and tingling, and/or radiating, shooting, or burning pain on weight bearing. Occasionally the pain may be described as “walking on a lump.”[23] It may be relieved by removing or changing the footwear. The symptoms may be replicated with direct pressure at the intermetatarsal space. A click may be felt or heard with compression to the forefoot and applying plantar pressure, known as Mulder’s sign. Other maneuvers that can be used are Grauthier’s test (applying medial to lateral pressure of the forefoot) and Bratkowski test (hyperextending the toes, rolling the thumb over the symptomatic area and feeling a mass).[20]
It is important to differentiate Morton’s neuroma from other diseases such as stress fracture, osteoarthritis, neoplasm, bursitis, or capsulitis. An x-ray, ultrasound, or MRI may be helpful to rule out other musculoskeletal pathology.[24] Initial treatment should be focused on orthoses and corticosteroid injections to decrease pressure and irritation of the nerve. For some patients, this may not be enough, and surgical neurectomy or nerve decompression could be considered. Cryogenic neuroablation is an option to preserve structures, but is less effective on large neuromas.[23]
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