Something is Afoot

1. A 43-year-old woman presents with progressively worsening bilateral great toe pain that began during pregnancy and increased following the birth of her daughter three years ago. Both of her feet have developed a crescent moon shape, making it painful and difficult to wear normal shoes. This patient has

a) Degenerative arthritis

b) Hallux varus

c) Gout

d) Traumatic sesamoiditis

Diagnosis: Physical exam revealed bilateral hallux varus deformity of the great toe, which was greater on the left foot than on the right (23° and 16°, respectively). The deformities were easily, passively, correctable. Standing radiographs showed evidence of previous proximal osteotomies and well-healed distal first metatarsal osteotomies. Due to unsuccessful nonoperative management, surgical reconstruction was offered.

For further information, see “Bilateral Hallux Varus Deformity Correction With a Suture Button Construct.” Am J Orthop. 2013;42(3):121-124.

2. Following treatment for onychomycosis, this 49-year-old man’s toenails demonstrate inflammation of the medial and lateral nail borders of the hallux and second toes of the left foot. This patient’s diagnosis is

a) Subungual exostosis

b) Primary osteomyelitis of the phalanx

c) Tumors of the nail bed

d) Onychocryptosis

Diagnosis: Onychocryptosis, also known as ingrown toenail, is a rare complication of oral antifungal therapy. As the healthy nail plate advances, it may adhere to the nail bed and cut into the lateral nail folds. In this case, the site of the onychocryptosis corresponded to the proximal clearing of the nail plate. The patient required excision of the nail borders, after which the secondary inflammation resolved. The condition was treated with chemical matrixectomy.

For more information, see “Multiple Onychocryptosis Following Treatment of Onychomycosis With Oral Terbinafine.” Cutis. 2000;66(3):211-212.

3. A 39-year-old man was playing a game of pick-up basketball when he felt a pop, immediately followed by a sharp pain in the back of his ankle and lower leg. He now walks with a limp. The cause is

a) Achilles tendon rupture

b) Medial gastrocnemius tear

c) Calf muscle strain

d) Posterior tibial stress syndrome

Diagnosis: Often diagnosed as an ankle sprain, an Achilles tendon rupture most commonly occurs in middle-aged men from overexertion in sports—usually tennis, racquetball, basketball, or badminton, which involve bursts of jumping, pivoting, and running. Rupture may also occur from a sudden stumble, fall from a significant height, or abrupt step into a hole or off a curb, which causes the tendon to overstretch forcefully.

4. A 60-year-old woman seeks relief for a foot wound of several months’ duration that persists despite use of antibiotics and proper care. The skin over the plantar surface has a full-thickness ulcer, with partial necrosis of the subcutaneous tissue. Her history is significant for diabetes with neuropathy, nephropathy, and retinopathy. The diagnosis is

a) Osteomyelitis

b) Deep venous thrombosis

c) Charcot joint

d) Septic joint

Diagnosis: Charcot joint changes, and an associated stage III pressure ulcer, account for the extensive collapse of the inner arch and “rocker bottom foot” seen on the radiograph. Also known as neurogenic arthropathy, Charcot joint is commonly seen with diabetic neuropathy. In affected patients, secondary degenerative changes to the joints occur with loss of normal muscle tone, proprioception, temperature perception, and pain perception. The joints become loose, enlarged, and boggy. There can be extensive cartilage erosion or osteophyte formation. The normal plantar and heel forces are increased, producing eccentric loading of the foot and leading to microfractures, ligament laxity, and bone destruction.

For more information, see “A disfigured foot with ulcer.” J Fam Pract. 2008;57(5):321-323.

1. A 43-year-old woman presents with progressively worsening bilateral great toe pain that began during pregnancy and increased following the birth of her daughter three years ago. Both of her feet have developed a crescent moon shape, making it painful and difficult to wear normal shoes. This patient has

a) Degenerative arthritis

b) Hallux varus

c) Gout

d) Traumatic sesamoiditis

Diagnosis: Physical exam revealed bilateral hallux varus deformity of the great toe, which was greater on the left foot than on the right (23° and 16°, respectively). The deformities were easily, passively, correctable. Standing radiographs showed evidence of previous proximal osteotomies and well-healed distal first metatarsal osteotomies. Due to unsuccessful nonoperative management, surgical reconstruction was offered.

For further information, see “Bilateral Hallux Varus Deformity Correction With a Suture Button Construct.” Am J Orthop. 2013;42(3):121-124.

2. Following treatment for onychomycosis, this 49-year-old man’s toenails demonstrate inflammation of the medial and lateral nail borders of the hallux and second toes of the left foot. This patient’s diagnosis is

a) Subungual exostosis

b) Primary osteomyelitis of the phalanx

c) Tumors of the nail bed

d) Onychocryptosis

Diagnosis: Onychocryptosis, also known as ingrown toenail, is a rare complication of oral antifungal therapy. As the healthy nail plate advances, it may adhere to the nail bed and cut into the lateral nail folds. In this case, the site of the onychocryptosis corresponded to the proximal clearing of the nail plate. The patient required excision of the nail borders, after which the secondary inflammation resolved. The condition was treated with chemical matrixectomy.

For more information, see “Multiple Onychocryptosis Following Treatment of Onychomycosis With Oral Terbinafine.” Cutis. 2000;66(3):211-212.

3. A 39-year-old man was playing a game of pick-up basketball when he felt a pop, immediately followed by a sharp pain in the back of his ankle and lower leg. He now walks with a limp. The cause is

a) Achilles tendon rupture

b) Medial gastrocnemius tear

c) Calf muscle strain

d) Posterior tibial stress syndrome

Diagnosis: Often diagnosed as an ankle sprain, an Achilles tendon rupture most commonly occurs in middle-aged men from overexertion in sports—usually tennis, racquetball, basketball, or badminton, which involve bursts of jumping, pivoting, and running. Rupture may also occur from a sudden stumble, fall from a significant height, or abrupt step into a hole or off a curb, which causes the tendon to overstretch forcefully.

4. A 60-year-old woman seeks relief for a foot wound of several months’ duration that persists despite use of antibiotics and proper care. The skin over the plantar surface has a full-thickness ulcer, with partial necrosis of the subcutaneous tissue. Her history is significant for diabetes with neuropathy, nephropathy, and retinopathy. The diagnosis is

a) Osteomyelitis

b) Deep venous thrombosis

c) Charcot joint

d) Septic joint

Diagnosis: Charcot joint changes, and an associated stage III pressure ulcer, account for the extensive collapse of the inner arch and “rocker bottom foot” seen on the radiograph. Also known as neurogenic arthropathy, Charcot joint is commonly seen with diabetic neuropathy. In affected patients, secondary degenerative changes to the joints occur with loss of normal muscle tone, proprioception, temperature perception, and pain perception. The joints become loose, enlarged, and boggy. There can be extensive cartilage erosion or osteophyte formation. The normal plantar and heel forces are increased, producing eccentric loading of the foot and leading to microfractures, ligament laxity, and bone destruction.

For more information, see “A disfigured foot with ulcer.” J Fam Pract. 2008;57(5):321-323.

1. A 43-year-old woman presents with progressively worsening bilateral great toe pain that began during pregnancy and increased following the birth of her daughter three years ago. Both of her feet have developed a crescent moon shape, making it painful and difficult to wear normal shoes. This patient has

a) Degenerative arthritis

b) Hallux varus

c) Gout

d) Traumatic sesamoiditis

Diagnosis: Physical exam revealed bilateral hallux varus deformity of the great toe, which was greater on the left foot than on the right (23° and 16°, respectively). The deformities were easily, passively, correctable. Standing radiographs showed evidence of previous proximal osteotomies and well-healed distal first metatarsal osteotomies. Due to unsuccessful nonoperative management, surgical reconstruction was offered.

For further information, see “Bilateral Hallux Varus Deformity Correction With a Suture Button Construct.” Am J Orthop. 2013;42(3):121-124.

2. Following treatment for onychomycosis, this 49-year-old man’s toenails demonstrate inflammation of the medial and lateral nail borders of the hallux and second toes of the left foot. This patient’s diagnosis is

a) Subungual exostosis

b) Primary osteomyelitis of the phalanx

c) Tumors of the nail bed

d) Onychocryptosis

Diagnosis: Onychocryptosis, also known as ingrown toenail, is a rare complication of oral antifungal therapy. As the healthy nail plate advances, it may adhere to the nail bed and cut into the lateral nail folds. In this case, the site of the onychocryptosis corresponded to the proximal clearing of the nail plate. The patient required excision of the nail borders, after which the secondary inflammation resolved. The condition was treated with chemical matrixectomy.

For more information, see “Multiple Onychocryptosis Following Treatment of Onychomycosis With Oral Terbinafine.” Cutis. 2000;66(3):211-212.

3. A 39-year-old man was playing a game of pick-up basketball when he felt a pop, immediately followed by a sharp pain in the back of his ankle and lower leg. He now walks with a limp. The cause is

a) Achilles tendon rupture

b) Medial gastrocnemius tear

c) Calf muscle strain

d) Posterior tibial stress syndrome

Diagnosis: Often diagnosed as an ankle sprain, an Achilles tendon rupture most commonly occurs in middle-aged men from overexertion in sports—usually tennis, racquetball, basketball, or badminton, which involve bursts of jumping, pivoting, and running. Rupture may also occur from a sudden stumble, fall from a significant height, or abrupt step into a hole or off a curb, which causes the tendon to overstretch forcefully.

4. A 60-year-old woman seeks relief for a foot wound of several months’ duration that persists despite use of antibiotics and proper care. The skin over the plantar surface has a full-thickness ulcer, with partial necrosis of the subcutaneous tissue. Her history is significant for diabetes with neuropathy, nephropathy, and retinopathy. The diagnosis is

a) Osteomyelitis

b) Deep venous thrombosis

c) Charcot joint

d) Septic joint

Diagnosis: Charcot joint changes, and an associated stage III pressure ulcer, account for the extensive collapse of the inner arch and “rocker bottom foot” seen on the radiograph. Also known as neurogenic arthropathy, Charcot joint is commonly seen with diabetic neuropathy. In affected patients, secondary degenerative changes to the joints occur with loss of normal muscle tone, proprioception, temperature perception, and pain perception. The joints become loose, enlarged, and boggy. There can be extensive cartilage erosion or osteophyte formation. The normal plantar and heel forces are increased, producing eccentric loading of the foot and leading to microfractures, ligament laxity, and bone destruction.

For more information, see “A disfigured foot with ulcer.” J Fam Pract. 2008;57(5):321-323.