Individuals with foot conditions are commonly seen in the family physician’s office, and these conditions can originate from a wide range of chronic conditions. This edition of FP EssentialsTM focuses on common foot conditions that occur in patients with or without underlying chronic conditions, such as diabetes. The monograph should provide information and practical advice to enable family physicians to manage four common foot conditions: heel pain, common surface lesions (corns, calluses, and plantar warts), metatarsalgia, and toenail conditions.
The FP EssentialsTM monograph should be approximately 10,000 words in length, divided into four sections of approximately 2,500 words each, plus a preface, key practice recommendations, a maximum of 15 tables and figures, recommended readings, and references. The monograph should focus on what’s new in each topic and should answer the key questions listed for each section. Each section should begin with an illustrative case, similar to the examples provided, with modifications to emphasize key points. The references listed below include information that should be considered in preparation of this edition of FP EssentialsTM. However, these references are only a useful starting point that should be used to identify additional information to review.
Foot Conditions
Section One: Heel Pain
Example case: Dana, a 45-year-old woman, presents with inferior heel pain that began 2 weeks ago after she began a new running program. The first steps in the morning cause pain. The pain is not present while she is running, but it returns in the evenings. Her foot is tender on the anteromedial aspect of the heel.
Key questions to consider:
Key questions to consider:
- What symptoms, signs, or diagnostic tests best differentiate plantar fasciitis from other causes of heel pain?
- Do stretching, nonsteroidal anti-inflammatory drugs, or foot orthotics improve plantar fasciitis pain or reduce recovery time?
- Does the available evidence support corticosteroid injection as a treatment for plantar fasciitis?
- What new, non-invasive therapies are being used for plantar fasciitis, and have they been demonstrated to be effective?
Initial references to consider:
- Hawke F, Burns J, Radford JA, et al. Custom-made foot orthoses for the treatment of foot pain. Cochrane Database Syst Rev. 2008;(3):CD006801.
- Baldassin V, Gomes CR, Beraldo PS. Effectiveness of prefabricated and customized foot orthoses made from low-cost foam for noncomplicated plantar fasciitis: a randomized controlled trial. Arch Phys Med Rehabil. 2009;90(4):701-706.
- Kalaci A, Cakici H, Hapa O, et al. Treatment of plantar fasciitis using four different local injection modalities: a randomized prospective clinical trial. J Am Podiatr Med Assoc. 2009;99(2):108-113.
- Yucel I, Yazici B, Degirmenci E, et al. Comparison of ultrasound-, palpation-, and scintigraphy-guided steroid injections in the treatment of plantar fasciitis. Arch Orthop Trauma Surg. 2009;129(5):695-701.
- Lee SY, McKeon P, Hertel J. Does the use of orthoses improve self-reported pain and function measures in patients with plantar fasciitis? A meta-analysis. Phys Ther Sport. 2009 Feb;10(1):12-8.
Section Two: Corns, Calluses, and Plantar Warts
Example case: Julian, a 60-year-old man, presents to your office to follow up on hypertension and high cholesterol. He asks if you know of any remedies for calluses or warts. He states that he has had calluses for a long time, but they started to cause pain several months ago. He replaced his shoes, but this did not help. He also has a plantar wart that he has been unsuccessfully treating with over-the-counter products for 2 months.
Key questions to consider:
Key questions to consider:
- What clinical features differentiate corns and calluses from plantar warts?
- What are the evidence-based treatment options for corns and calluses?
- Are there effective strategies for preventing corns and calluses?
- What are the evidence-based, first-line treatment options for plantar warts, including folk or natural remedies?
- Are there characteristics of plantar warts that make one treatment preferable to another?
- What are some options for treating recalcitrant plantar warts?
Initial references to consider:
- Timson S, Spooner SK. A comparison of the efficacy of scalpel debridement and insole therapy in relieving the pain of plantar callus. Br J Podiatr. 2005:8(2):53-59.
- Davys HJ, Turner DE, Helliwell PS, et al. Debridement of plantar callosities in rheumatoid arthritis: a randomized controlled trial. Rheumatology (Oxford). 2005;44(2):207-210.
- Gibbs S, Harvey I. Topical treatments for cutaneous warts. Cochrane Database Syst Rev. 2006;(2):CD001781.
- Park HS, Choi WS. Pulsed dye laser treatment for viral warts: a study of 120 patients. J Dermatol. 2008 Aug;35(8):491-498.
- Salk RS, Grogan KA, Chang TJ. Topical 5% 5-fluorouracil cream in the treatment of plantar warts: a prospective, randomized, and controlled clinical study. J Drugs Dermatol. 2006;5(5):418-424.
Section Three: Diagnosis and Management of Toenail Conditions
Example case: Francis, a 55-year-old woman with type 2 diabetes, presents to your office for a routine follow-up visit. During the physical examination, you notice thickened toenails, and suspect onychomycosis.
Key questions to consider:
Key questions to consider:
- What are the most common toenail conditions seen in the family medicine setting?
- Which toenail examination findings might indicate the presence of a systemic disease?
- What signs and symptoms best differentiate onychomycosis from other toenail conditions?
- What is the availability and accuracy of rapid polymerase chain reaction testing for diagnosing onychomycosis?
- What treatments are effective for onychomycosis?
- How do treatment recommendations differ for patients with diabetes compared to patients without diabetes?
- What are the most effective, conservative treatment options for ingrown toenails?
- Which ingrown toenails need to be removed, and what are the newest removal methods?
- How does radiofrequency ablation of the nail matrix compare with other techniques?
Initial references to consider:
- Shemer A, Davidovici B, Grunwald MH, et al. Comparative study of nail sampling techniques in onychomycosis. J Dermatol. 2009;36(7):410-414.
- Farrelly PJ, Minford J, Jones MO. Simple operative management of ingrown toenail using bipolar diathermy. Eur J Pediatr Surg. 2009 Jun 30. [Epub ahead of print]
- Gupta AK, Lynch LE, Kogan N, et al. The use of an intermittent terbinafine regimen for the treatment of dermatophyte toenail onychomycosis. J Eur Acad Dermatol Venereol. 2009;23(3):256-262.
- Malay DS, Yi S, Borowsky P, et al. Efficacy of debridement alone versus debridement combined with topical antifungal nail lacquer for the treatment of pedal onychomycosis: a randomized, controlled trial. J Foot Ankle Surg. 2009;48(3):294-308.
- Uchida T, Makimura K, Ishihara K, et al. Comparative study of direct polymerase chain reaction, microscopic examination and culture-based morphological methods for detection and identification of dermatophytes in nail and skin samples. J Dermatol. 2009;36(4):202-208.
- Aksoy B, Aksoy HM, Civas E, et al. Lateral foldplasty with or without partial matricectomy for the management of ingrown toenails. Dermatol Surg. 2009;35(3):462-468
Section Four: Metatarsal Pain: Etiologies and Treatment
Example case: Colleen, a 35-year-old woman, presents to your office with pain in the ball of the foot that began several months ago. She describes it as a burning pain that sometimes shoots into the toes. The pain is worse when standing or walking, especially if she is barefoot. Her usual weekday shoes have 4-inch heels and a narrow toe box. You observe that she has a high arch and a bunion.
Key questions to consider:
Key questions to consider:
- What are the common etiologies of metatarsal pain?
- What contributing factors (eg, activities, foot shape, shoe type) increase the risk of developing metatarsal pain?
- What imaging modalities are useful in differentiating among the causes of metatarsal pain?
- Are orthotics helpful for metatarsal pain? If so, for which causes?
- When is an injection likely to decrease pain?
- Which cases should you refer for surgical management?
Initial references to consider:
- Thomas JL, Blitch EL 4th, Chaney DM, et al; Clinical Practice Guideline Forefoot Disorders Panel. Diagnosis and treatment of forefoot disorders. Section 2. Central metatarsalgia. J Foot Ankle Surg. 2009;48(2):239-50.
- Janisse DJ, Janisse E. Shoe modification and the use of orthoses in the treatment of foot and ankle pathology. J Am Acad Orthop Surg. 2008;16(3):152-158.
- Thomas JL, Blitch EL 4th, Chaney DM, et al; Clinical Practice Guideline Forefoot Disorders Panel. Diagnosis and treatment of forefoot disorders. Section 3. Morton's intermetatarsal neuroma. J Foot Ankle Surg. 2009;48(2):251-256.
- Hatch RL, Alsobrook JA, Clugston JR. Diagnosis and management of metatarsal fractures. Am Fam Physician. 2007;76(6):817-826.
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