Foot problems

Contributed by Dr Philip Marazzi, a GP in East Horsley, Surrey.

Ulcerated tophus


This elderly man has a long history of tophaceous gout. A tophus is a mass of crystals of uric acid. This man had new shoes that seemed to irritate the skin, leading to a secondary infection of the permanently swollen toe. It was treated with oral antibiotics but took some time to settle down. He was advised to restart his allopurinol, which he had stopped taking some months earlier.

Acute gout


This gout sufferer had his first acute attack after gorging himself on his home grown asparagus. He was surprised as he thought that only red wine caused gout. Advice about the range of foods that may trigger acute gout is important. Allopurinol is not generally started after a first attack, but he was advised to keep a small supply of NSAIDs so that he could start treatment immediately if the symptoms recurred.

Heel bump


This man developed a swelling at the site of the Achilles tendon insertion. These lesions, sometimes called Haglund's deformity, are quite common. It is a bony swelling with an overlying bursa. He also had underlying talonavicular osteoarthritis confirmed on X-ray. He needed new running shoes, physiotherapy and, eventually, surgical intervention to reduce the persistent bump.

Post-cryotherapy blister


Patients referred for surgery may be given a long list of risks and the percentage chance of developing these problems. This approach is probably not necessary in a primary care environment, though a warning about likely effects is probably sensible. This woman had vigorous cryotherapy for a verruca and developed this blister five days later. It healed with no problems, with the eventual resolution of the verruca.

Flat feet


This 10-year-old girl has very flat feet with a low arch. This may be a familial condition, but needs careful assessment to exclude more serious underlying structural causes. She was referred to a physiotherapist to provide exercises to try to improve the strength of the foot muscles and improve the arch. This has been successful in reducing her reported problems with exercise.

Ganglion


This child has developed a swelling on her foot which is a ganglion. These lesions are more common in older patients, and around the wrist. As there were no symptoms, treatment was not required. These lesions occasionally disperse spontaneously. If there are persistent problems, aspiration or excision may be considered. It is not unusual for the lesions to recur.

Partial webbing


This woman has a congenital deformity known as syndactyly. It affects both feet and runs in her family. It is rarely associated with some syndromes including Edwards' syndrome. If required, surgical division of the digits is relatively straightforward, although skin grafting may be required to fill the gap. Cases of regrowth have been reported.

Onychomycosis


This is a very common condition. A variety of treatments are available including topical and oral medications. It is recommended that a positive culture is obtained prior to oral treatment, but many laboratories refuse to do cultures, and simple microscopy is often negative. This is usually due to the patient providing an inadequate sample, but may be the case even if a good sample is obtained. Some dermatologists advise treatment regardless of laboratory results.

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