(16) Musculoskeletal Tables Flashcards
(90 cards)
1
Q
Rheumatoid Arthritis: Process
A
Chronic inflammation of synovial membranes with secondary erosion of adjacent cartilage and bone, and damage to ligaments and tendons
2
Q
Rheumatoid Arthritis: Common Locations
A
Hands—initially small joints (PIP and MCP joints), feet (MTP joints), wrists, knees, elbows, ankles
3
Q
Rheumatoid Arthritis: Pattern of Spread
A
Symmetrically additive: progresses to other joints while persisting in initial joints
4
Q
Rheumatoid Arthritis: Onset
A
Usually insidious; human leukocyte antigen (HLA) and non-HLA genes account for >50% of risk of disease; involves proinflammatory cytokines
5
Q
Rheumatoid Arthritis: Progression and Duration
A
Often chronic (in
>50%), with remissions
and exacerbations
6
Q
Rheumatoid Arthritis: Associated Symptoms
A
Swelling: Frequent swelling of synovial
tissue in joints or tendon sheaths; also subcutaneous nodules
Redness, Warmth, and tenderness: Tender, often warm, but seldom red
Stiffness: Prominent, often for an hour or more in the mornings, also after inactivity
Limitation of Motion: Often develops; affected by associated joint contractures
and subluxation, bursitis, and tendinopathy
Generalized Symptoms: Weakness, fatigue,
weight loss, and low fever are common
7
Q
Osteoarthritis (Degenerative Joint Disease) Common Locations
A
Knees, hips, hands (distal, sometimes PIP joints), cervical and lumbar spine, and wrists (first carpometacarpal joint); also joints previously injured or diseased
8
Q
Osteoarthritis (Degenerative Joint Disease) Pattern of Spread
A
Additive; however,
may involve only
one joint
9
Q
Osteoarthritis (Degenerative Joint Disease) Onset
A
Usually insidious; genetics may account for >50% of risk of disease; repetitive injury and obesity increase risk
10
Q
Osteoarthritis (Degenerative Joint Disease) Progression and Duration
A
Slowly progressive,
with temporary exacerbations
after
periods of overuse
11
Q
Acute Gout: Process
A
An inflammatory
reaction to microcrystals
of monosodium
urate
12
Q
Osteoarthritis (Degenerative Joint Disease) Associated Symptoms
A
Swelling: Small joint effusions may
be present, especially in
the knees; also bony enlargement
Redness, warmth, and tenderness: Possibly tender, seldom warm, and rarely red. Inflammation may accompany disease flares and progression
Stiffness: Frequent but brief (usually
5–10 min), in the
morning and after inactivity
Limitation of Motion: often develops
Generalized Symptoms: usually absent
13
Q
Acute Gout: Pattern of Spread
A
Early attacks usually
confined to one
joint
14
Q
Acute Gout: Onset
A
Sudden; often at night; often after injury, surgery, fasting, or excessive food or alcohol intake
15
Q
Acute Gout: Progression and Duration
A
Occasional isolated attacks lasting days up to 2 wks; they may get more frequent and severe, with persisting symptoms
16
Q
Chronic Tophaceous Gout: Process
A
Multiple local accumulations of sodium urate in the joints and other tissues (tophi), with or without inflammation
17
Q
Chronic Tophaceous Gout: Common Locations
A
Feet, ankles, wrists,
fingers, and elbows
18
Q
Acute Gout: Associated Symptoms
A
Swelling: Present, within and around the involved joint, usually in men (have higher serum urate levels); often polyarticular later in course
Redness, warmth, and tenderness: Exquisitely tender, hot,
and red
Stiffness: not evident
Limitation of Motion: Motion is limited primarily
by pain
Generalized Symptoms: Fever may be present;
also consider also septic
arthritis
19
Q
Chronic Tophaceous Gout: Onset
A
Gradual development
of chronicity
with repeated attacks
20
Q
Chronic Tophaceous Gout: Progression and Duration
A
Chronic symptoms
with acute exacerbations
21
Q
Polymyalgia Rheumatica: Process
A
A disease of unclear etiology in people older than age 50 yrs, especially women; overlaps with giant cell arteritis
22
Q
Polymyalgia Rheumatica: Common Locations
A
Muscles of the hip,
shoulder girdle, and
neck; symmetric
23
Q
Polymyalgia Rheumatica: Onset
A
Insidious or abrupt,
even appearing
overnight
24
Q
Chronic Tophaceous Gout: Associated Symptoms
A
Swelling: Present as tophi in joints, bursae, and subcutaneous tissues; check ears and extensor surfaces for tophi
Redness, warmth, and tenderness: Tenderness, warmth,
and redness may be
present during exacerbations
Stiffness: present
Limitation of Motion: present
Generalized Symptoms: Possibly fever; patients
may also develop renal
failure and renal stones
25
Polymyalgia Rheumatica: Associated Symptoms
Swelling: Swelling and edema may
be present over dorsum
of hands, wrists, feet
Redness, warmth, and tenderness: Muscles often tender,
but not warm or red
Stiffness: Prominent, especially in
the morning
Limitation of Motion: Pain restricts movement,
especially in
shoulders
Generalized Symptoms: Malaise, depression, anorexia,
weight loss, and
fever, but no true weakness
26
Fibromyalgia Syndrome: Process
```
Widespread musculoskeletal
pain and
tender points. Central
pain sensitivity
syndrome that may
involve aberrant
pain signaling and
amplification
```
27
Fibromyalgia Syndrome: Common Locations
```
Multiple specific
and symmetric “tender
points,” often
unrecognized until
examined; especially
in the neck, shoulders,
hands, low
back, and knees
```
28
Fibromyalgia Syndrome: Pattern of Spread
```
Shifts unpredictably
or worsens in response
to immobility,
excessive use, or
exposure to cold
```
29
Fibromyalgia Syndrome: Onset
Variable
30
Fibromyalgia Syndrome: Progression and Duration
Chronic, with “ups
| and downs
31
Fibromyalgia Syndrome: Associated Symptoms
Swelling: none
```
Redness, warmth, and tenderness: Multiple specific and
symmetric tender “trigger
points,” often not
recognized until the
examination
```
Stiffness: Present, especially in
the morning—often confused with inflammatory conditions
Limitation of Motion: Absent, though stiffness is greater at the extremes of movement
Generalized Symptoms: Sleep disturbance, usually with fatigue on awakening; overlaps
with depression and other pain syndromes
32
Mechanical Neck Pain: Patterns
```
Aching pain in the cervical
paraspinal muscles and ligaments
with associated muscle spasm and
stiffness and tightness in the upper
back and shoulder, lasting up to 6
wks. No associated radiation,
paresthesias, or weakness.
Headache may be present.
```
33
Mechanical Neck Pain: Possible Causes
```
Mechanism poorly understood, possibly
sustained muscle contraction. Associated
with poor posture, stress, poor sleep, poor
head position during activities such as
computer use, watching television, and
driving.
```
34
Mechanical Neck Pain: Physical Signs
Local muscle tenderness, pain on
movement. No neurologic deficits. Possible
trigger points in fibromyalgia. Torticollis if
prolonged abnormal neck posture and
muscle spasm
35
Mechanical Neck Pain - Whiplash: Patterns
```
Mechanical neck pain with aching
paracervical pain and stiffness,
often beginning the day after injury.
Occipital headache, dizziness,
malaise, and fatigue may be
present. Chronic whiplash
syndrome if symptoms last more
than 6 mo; occurs in 20%–40% of
injuries.
```
36
Mechanical Neck Pain - Whiplash: Possible Causes
Musculoligamentous sprain or strain from
forced hyperflexion—hyperextension
injury to the neck, as in rear-end collisions
37
Mechanical Neck Pain - Whiplash: Physical Signs
Localized paracervical tenderness,
decreased neck range of motion, perceived
weakness of the upper extremities. Causes
of cervical cord compression such as
fracture, herniation, head injury, or altered
consciousness are excluded.
38
Cervical Radiculopathy from Nerve Root Compression: Patterns
```
Sharp burning or tingling pain in
the neck and one arm, with
associated paresthesias and
weakness. Sensory symptoms often
in myotomal pattern, deep in
muscle, rather than dermatomal
pattern.
```
39
Cervical Radiculopathy from Nerve Root Compression: Possible Causes
```
Dysfunction of cervical spinal nerve,
nerve roots, or both from foraminal
encroachment of the spinal nerve (∼75%),
herniated cervical disc (∼25%). Rarely
from tumor, syrinx, or multiple sclerosis.
Mechanisms may involve hypoxia of the
nerve root and dorsal ganglion and release
of inflammatory mediators.
```
40
Cervical Radiculopathy from Nerve Root Compression: Physical Signs
C7 nerve root affected most often (45–60%),
with weakness in triceps and finger flexors
and extensors. C6 nerve root involvement
also common, with weakness in biceps,
brachioradialis, wrist extensors.
41
Cervical Radiculopathy from Cervical Cord Compression: Process
```
Neck pain with bilateral weakness
and paresthesias in both upper and
lower extremities, often with
urinary frequency. Hand
clumsiness, palmar paresthesias,
and gait changes may be subtle.
Neck flexion often exacerbates
symptoms.
```
42
Cervical Radiculopathy from Cervical Cord Compression: Possible Causes
Usually from cervical spondylosis, defined
as cervical degenerative disc disease from
spurs, protrusion of ligamentum flavum,
and/or disc herniation (∼80%); also from
cervical stenosis from osteophytes,
ossification of ligamentum flavum, and RA.
Large central or paracentral disc herniation
may also compress cord.
43
Cervical Radiculopathy from Cervical Cord Compression: Physical Signs
Hyperreflexia; clonus at the wrist, knee, or
ankle; extensor plantar reflexes (positive
Babinski signs); and gait disturbances. May
also see Lhermitte sign: neck flexion with
resulting sensation of electrical shock
radiating down the spine. Confirmation of
cervical myelopathy warrants neck
immobilization and neurosurgical
evaluation.
44
Mechanical Low Back Pain: Patterns
Aching pain in the lumbosacral area; may radiate
into lower leg, especially in L5 (lateral leg) or S1
(posterior leg) dermatomes. Signifies anatomic or
functional abnormality in absence of neoplastic,
infectious, or inflammatory disease. Usually
acute (<3 mo), idiopathic, benign, and selflimiting;
represents 97% of symptomatic low
back pain. Commonly work related and
occurring in patients 30–50 yrs. Risk factors
include heavy lifting, poor conditioning, obesity
45
Mechanical Low Back Pain: Possible Causes
Often arises from muscle and ligament
injuries (∼70%) or age-related
intervertebral disc or facet disease (∼4%).
Causes also include herniated disc (∼4%),
spinal stenosis (∼3%), compression
fractures (∼4%), and spondylolisthesis
(2%).
46
Mechanical Low Back Pain: Physical Signs
```
Paraspinal muscle or facet tenderness,
pain with back movement, loss of
normal lumbar lordosis; motor,
sensory, and reflex findings are
normal. In osteoporosis, check for
thoracic kyphosis, percussion
tenderness over a spinous process, or
fractures in the thoracic spine or hip
```
47
Sciatica (Radicular Low Back Pain): Patterns
Shooting pain below the knee, commonly into
the lateral leg (L5) or posterior calf (S1);
typically accompanies low back pain, often with
associated paresthesias and weakness. Bending,
sneezing, coughing, straining during bowel
movements can worsen the pain
48
Sciatica (Radicular Low Back Pain): Possible Causes
Sciatic pain is sensitive, ∼95%, and specific,
∼88%, for disc herniation. Usually from
herniated intervertebral disc with
compression or traction of nerve root(s) in
people ages 50 yrs or older. L5 and S1 roots
are involved in ∼95% of disc herniations; root
or spinal cord compression from neoplastic
conditions in fewer than 1% of cases. Tumor
or midline disc herniation may cause bowel
or bladder dysfunction, leg weakness from
cauda equina syndrome (S2–S4).
49
Sciatica (Radicular Low Back Pain): Physical Signs
```
Disc herniation most likely if calf
wasting, weak ankle dorsiflexion,
absent ankle jerk, positive crossed
straight-leg raise (pain in affected leg
when healthy leg tested); negative
straight-leg raise makes diagnosis
highly unlikely. Ipsilateral straight-leg
raise sensitive, about 65–98%, but not
specific, about 10–60%.
```
50
Lumbar Spinal Stenosis: Patterns
Neurogenic claudication with gluteal and/or
lower extremity pain and/or fatigue that may
occur with or without back pain. Pain is
provoked by lumbar extension (as in walking
uphill) due to reduced space in the lumbar spine
from degenerative changes in the spinal canal.
Positive LR is >6.0 if pain is absent when seated,
improved with bending forward, or present in
both buttocks and legs. Positive LR is <4.0 if gait
is wide-based and Romberg test is abnormal.
51
Lumbar Spinal Stenosis: Possible Causes
```
Arises from hypertrophic degenerative
disease of one or more vertebral facets and
thickening of the ligamentum flavum,
causing narrowing of the spinal canal
centrally or in lateral recesses. More
common after age 60 yrs.
```
52
Lumbar Spinal Stenosis: Physical Signs
```
Posture may be flexed forward to
reduce symptoms, with lower
extremity weakness and hyporeflexia.
Thigh pain typically occurs after 30 s
of lumbar extension. Straight-leg raise
is usually negative.
```
53
Chronic Back Stiffness: Possible Causes
```
Ankylosing spondylitis, an inflammatory
polyarthritis, most common in men
younger than 40 yrs. Diffuse idiopathic
hyperostosis (DISH) affects men more than
women, usually age ≥50 yrs.
```
54
Nocturnal Back Pain, Unrelieved by Rest: Possible Causes
Consider metastatic malignancy to the
spine from cancer of the prostate, breast,
lung, thyroid, and kidney, and multiple
myeloma.
55
Nocturnal Back Pain, Unrelieved by Rest: Physical Signs
Loss of the normal lumbar lordosis,
muscle spasm, limited anterior and
lateral flexion. Lateral immobility of the
spine, especially in thoracic area improves
with exercise.
56
Low Back Pain Referred from the Abdomen or Pelvis: Patterns
Usually a deep, aching pain; the level varies
with the source. Accounts for ∼2% of low back
pain.
57
Low Back Pain Referred from the Abdomen or Pelvis: Possible Causes
Peptic ulcer, pancreatitis, pancreatic
cancer, chronic prostatitis, endometriosis,
dissecting aortic aneurysm, retroperitoneal
tumor, and other causes.
58
Low Back Pain Referred from the Abdomen or Pelvis: Physical Signs
```
Variable with the source. Local
vertebral tenderness may be present.
Spinal movements are not painful and
range of motion is not affected. Look
for signs of the primary disorder.
```
59
Rotator Cuff Tendinitis (Impingement Syndrome)
Repeated shoulder motion, for example, from throwing or
swimming, can cause edema and hemorrhage followed by
inflammation, most commonly involving the supraspinatus tendon.
Acute, recurrent, or chronic pain may result, often aggravated by
activity. Patients report sharp catches of pain, grating, and weakness
when lifting the arm overhead. When the supraspinatus tendon is
involved, tenderness is maximal just below the tip of the acromion. In
older adults, bone spurs on the undersurface of the acromion may
contribute to symptoms.
60
Rotator Cuff Tears
The rotator cuff muscles and tendons compress the humeral head
into the concave glenoid fossa and strengthen arm movement—the
subscapularis in internal rotation, the supraspinatus in elevation, and
the infraspinatus and teres minor in external rotation. Injury from a
fall, trauma, or repeated impingement against the acromion and the
coracoacromial ligament may cause a partial- or full-thickness tear of
the rotator cuff, the most common clinical problem of the shoulder,
especially in older patients. Patients complain of chronic shoulder
pain, night pain, or catching and grating when raising the arm
overhead. Weakness or tears of the tendons usually start in the
supraspinatus tendon and progress posteriorly and anteriorly. Look
for atrophy of the deltoid, supraspinatus, or infraspinatus muscles.
Palpate anteriorly over the anterior greater tuberosity of the humerus
to check for a defect in muscle attachment and below the acromion
for crepitus during arm rotation. In a complete tear, active abduction
and forward flexion at the glenohumeral joint are severely impaired,
producing a characteristic shrug of the shoulder and a positive “drop
arm” test (see p. 655).
61
Calcific Tendinitis
Calcific tendinitis is a degenerative process in the tendon associated
with the deposition of calcium salts that usually involves the
supraspinatus tendon. Acute disabling attacks of shoulder pain may
occur, usually in patients ages ≥30 yrs, especially in women. The arm
is held close to the side, and all motions are severely limited by pain.
Tenderness is maximal below the tip of the acromion. The subacromial
bursa, which overlies the supraspinatus tendon, may be inflamed.
Chronic less severe pain may also occur.
62
Bicipital Tendinitis
Inflammation of the long head of the biceps tendon and tendon
sheath causes anterior shoulder pain resembling and often coexisting
with rotator cuff tendinitis. Both conditions may involve
impingement injury. Tenderness is maximal in the bicipital groove.
Externally rotate and abduct the arm to separate this area from the
subacromial tenderness of supraspinatus tendinitis. With the patient’s
arm at the side, elbow flexed to 90°, ask the patient to supinate the
forearm against your resistance. Increased pain in the bicipital groove
confirms this condition. Pain during resisted forward flexion of the
shoulder with the elbow extended is also characteristic.
63
Adhesive Capsulitis (Frozen Shoulder)
Adhesive capsulitis refers to fibrosis of the glenohumeral joint
capsule, manifested by diffuse, dull, aching pain in the shoulder and
progressive restriction of active and passive range of motion, especially in
external rotation, with localized tenderness. The condition is usually
unilateral and occurs in people ages 40–60 yrs. There is often an
antecedent disorder of the shoulder or another condition (such as
myocardial infarction) that has decreased shoulder movements.
The disorder may take 6 mo to 2 yrs to resolve. Stretching exercises
may help.
64
Acromioclavicular Arthritis
Acromioclavicular arthritis is relatively common, usually arising from
prior direct injury to the shoulder girdle with resulting degenerative
changes. Tenderness is localized over the acromioclavicular joint. Patients
report pain with movements of the scapula and arm abduction
65
Anterior Dislocation of the Humerus
Shoulder instability from anterior subluxation or dislocation of the
humerus usually results from a fall or forceful throwing motion, then
can become common unless treated or the precipitating motion is
avoided. The shoulder seems to “slip out of the joint” when the arm
is abducted and externally rotated, causing a positive apprehension sign
for anterior instability when the examiner places the arm in this
position. Any shoulder movement may cause pain, and patients hold
the arm in a neutral position. The rounded lateral aspect of the
shoulder appears flattened. Dislocations may also be inferior,
posterior (relatively rare), and multidirectional.
66
Olecranon Bursitis
Swelling and inflammation of the olecranon bursa may result from trauma,
gout, or rheumatoid arthritis (RA). The swelling is superficial to the
olecranon process and may reach 6 cm in diameter. Consider aspiration for
both diagnosis and symptomatic relief.
67
Rheumatoid Nodules
Subcutaneous nodules may develop at pressure points along the extensor
surface of the ulna in patients with RA or acute rheumatic fever. They are
firm and nontender. They are not attached to the overlying skin but may be
attached to the underlying periosteum. They can develop in the area of the
olecranon bursa, but often occur more distally.
68
Arthritis of the Elbow
Synovial inflammation or fluid is felt best in the grooves between the
olecranon process and the epicondyles on either side. Palpate for a boggy,
soft, or fluctuant swelling and for tenderness. Causes include RA, gout and
pseudogout, osteoarthritis, and trauma. Patients report pain, stiffness, and
restricted motion.
69
Epicondylitis
Lateral epicondylitis (tennis elbow) follows repetitive extension of the wrist or
pronation–supination of the forearm. Pain and tenderness develop 1 cm distal to
the lateral epicondyle and possibly in the extensor muscles close to it. When
the patient tries to extend the wrist against resistance, pain increases.
Medial epicondylitis (pitcher’s, golfer’s, or Little League elbow) follows
repetitive wrist flexion such as throwing. Tenderness is maximal just lateral and
distal to the medial epicondyle. Wrist flexion against resistance increases the
pain.
70
Hands: Acute Rheumatoid Arthritis
Tender, painful, stiff joints in RA, usually with
symmetric involvement on both sides of the
body. The distal interphalangeal (DIP),
metacarpophalangeal (MCP), and wrist joints are
the most frequently affected. Note the fusiform
or spindle-shaped swelling of the PIP joints in
acute disease.
71
Hands: Chronic Rheumatoid Arthritis
In chronic disease, note the swelling and
thickening of the MCP and PIP joints. Range of
motion becomes limited, and fingers may deviate
toward the ulnar side. The interosseous muscles
atrophy. The fingers may show “swan neck”
deformities (hyperextension of the PIP joints with
fixed flexion of the distal interphalangeal [DIP]
joints). Less common is a boutonnière deformity
(persistent flexion of the PIP joint with
hyperextension of the DIP joint). Rheumatoid
nodules are seen in the acute or the chronic stage.
72
Hands: Osteoarthritis (Degenerative Joint Disease)
Heberden nodes on the dorsolateral aspects of the
DIP joints from bony overgrowth of OA. Usually
hard and painless, they affect middle-ages or
older adults; they are often associated with
arthritic changes in other joints. Flexion and
deviation deformities may develop. Bouchard
nodes on the PIP joints are less common. The
MCP joints are spared.
73
Hands: Chronic Topaceous Gout
Urate crystal deposits, often with surrounding
inflammation, cause deformities in subcutaneous
tissues, bursae, cartilage, and subchondral bone
that mimic RA and OA. Joint involvement is
usually less symmetric than in RA. Acute
inflammation may be present. Knobby swellings
around the joints ulcerate and discharge white
chalk-like urates.
74
Hands: Dupuytren Contracture
The first sign of a Dupuytren contracture is a thickened band overlying the flexor tendon
of the fourth finger and possibly the little finger near the distal palmar crease.
Subsequently, the skin in this area puckers, and a thickened fibrotic cord develops
between the palm and finger. Finger extension is limited, but flexion is usually normal.
Flexion contracture of the fingers may gradually develop.
75
Hands: Trigger Finger
Trigger finger is caused by a painless nodule in a flexor tendon in the palm, near the
metacarpal head. The nodule is too big to enter easily into the tendon sheath during
extension of the fingers from a flexed position. With extra effort or assistance, the finger
extends and flexes with a palpable and audible snap as the nodule pops into the tendon
sheath. Watch, listen, and palpate the nodule as the patient flexes and extends the fingers
76
Hands: Thenar Atrophy
Thenar atrophy suggests a median nerve disorder such as carpal tunnel syndrome (see
p. 664). Hypothenar atrophy suggests an ulnar nerve disorder.
77
Hands: Ganglion
Ganglia are cystic, round, usually nontender swellings along tendon sheaths or joint
capsules, frequently at the dorsum of the wrist. The cyst contains synovial fluid arising
from erosion or tearing of the joint capsule or tendon sheath and trapped in the cystic
cavity. Flexion of the wrist makes ganglia more prominent; extension tends to obscure
them. Ganglia may also develop on the hands, wrists, ankles, and feet. They can
disappear spontaneously.
78
Acute Tenosynovitis
Inflammation of the flexor tendon sheaths, acute tenosynovitis, may follow
local injury, overuse, or infection. Unlike arthritis, tenderness and swelling
develop not in the joint but along the course of the tendon sheath, from the
distal phalanx to the level of the metacarpophalangeal joint. The finger is held
in slight flexion; finger extension is very painful. Causative infectious agents
include Staphylococcus and Streptococcus species, disseminated gonorrhea, and
Candida albicans.
79
Acute Tenosynovitis and Thenar Space Involvement
If the infection progresses, it may extend from the tendon sheath into the
adjacent fascial spaces within the palm. Infections of the index finger and
thenar space are illustrated. Early diagnosis and treatment are important.
80
Felon
Injury to the fingertip may result in infection of the enclosed fascial spaces of
the distal pulp or phalanx pad of the fingertip, usually from Staphylococcus
aureus. Severe pain, localized tenderness, swelling, and dusky redness are
characteristics. Early diagnosis and treatment, usually incision and drainage,
are important for preventing abscess formation. If vesicles are present,
consider herpetic whitlow instead, usually seen in health care workers exposed
to herpes simplex virus in human saliva.
81
Feet: Acute Gouty Arthritis
The metatarsophalangeal joint of the great toe is the initial site of attack in 50% of the
episodes of acute gouty arthritis. It is characterized by a very painful and tender, hot,
dusky red swelling that extends beyond the margin of the joint. It is easily mistaken for a
cellulitis. The ankle, tarsal joints, and knee are also commonly involved.
82
Flat Feet
Signs of flat feet may be apparent only when the patient stands, or they may become
permanent. The longitudinal arch flattens so that the sole approaches or touches the floor.
The normal concavity on the medial side of the foot becomes convex. Tenderness may be
present from the medial malleolus down along the medial plantar surface of the foot.
Swelling may develop anterior to the malleoli. Flat feet may be a normal variant or arise
from posterior tibial tendon dysfunction, seen in obesity, diabetes, and prior foot injury.
Inspect the shoes for excess wear on the inner sides of the soles and heels.
83
Hallux Valgus
In hallux valgus, there is lateral deviation of the great toe and enlargement of the head of
the first metatarsal on its medial side, forming a bursa or bunion. This bursa may become
inflamed. Women are 10 times more likely to be affected than men.
84
Morton Neuroma
Look for tenderness over the plantar surface between the third and fourth metatarsal
heads, from perineural fibrosis of the common digital nerve due to repetitive nerve
irritation (not a true neuroma). Check for pain radiating to the toes when you press on
the plantar interspace and squeeze the metatarsals with your other hand. Symptoms
include hyperesthesia, numbness, aching, and burning from the metatarsal heads into the
third and fourth toes.
85
Ingrown Toenail
The sharp edge of a toenail may dig into
and injure the lateral nail fold, resulting
in inflammation and infection. A tender,
reddened, overhanging nail fold,
sometimes with granulation tissue and
purulent discharge, results. The great toe
is most often affected.
86
Hammer Toe
Usually involving the second toe, a
hammer toe is characterized by hyperextension
at the metatarsophalangeal
joint with flexion at the proximal interphalangeal
(PIP) joint. A corn frequently
develops at the pressure point
over the PIP joint.
87
Corn
A corn is a painful conical thickening of
skin that results from recurrent pressure
on normally thin skin. The apex of the
cone points inward and causes pain.
Corns characteristically occur over bony
prominences such as the fifth toe. When
located in moist areas such as pressure
points between the fourth and fifth toes,
they are called soft corns.
88
Callus
Like a corn, a callus is an area of greatly
thickened skin that develops in a region
of recurrent pressure. Unlike a corn, a
callus involves skin that is normally
thick, such as the sole, and is usually
painless. If a callus is painful, suspect an
underlying plantar wart.
89
Plantar Wart
A plantar wart is a hyperkeratotic lesion
caused by human papillomavirus, located
on the sole of the foot. It may look like
a callus. Look for the characteristic
small dark spots that give a stippled
appearance to a wart. Normal skin lines
stop at the wart’s edge. It is tender if
pinched side to side, whereas a callus is
tender to direct pressure.
90
Neuropathic Ulcer
```
When pain sensation is diminished or
absent, as in diabetic neuropathy,
neuropathic ulcers may develop at
pressure points on the feet. Although
often deep, infected, and indolent, they
are painless. Underlying osteomyelitis
and amputation may ensue. Early
detection of loss of sensation using a
nylon filament is the standard of care in
diabetes.
```
