ABSTRACT
The most common presenting symptoms are pain, deformity, swelling and giving way. It is helpful to know whether the symptoms are constant or provoked by standing or walking, or by shoe pressure.
Pain over a bony prominence or a joint is probably due to a local disorder: shoe pressure upon a local deformity, arthritis, tendinitis or – in the younger patient – an ‘apophysitis’ (inflammation over the point where a tendon inserts). Pain across the entire forefoot (metatarsalgia) is less specific and is often associated with uneven loading and muscle fatigue. Always ask whether it started after some unusual activity; metatarsal stress fractures occur even in physically fit athletes, ballet dancers and soldiers on route marches.
Swelling can be diffuse and bilateral, or localized. Swelling over the medial side of the first metatarsal head (a bunion) is common in older women. Bilateral swelling may be due to dependent oedema.
Deformity may be in the ankle, the foot or the toes. Parents often worry about their children who are ‘flat-footed’ or ‘pigeon-toed’. Elderly patients may complain chiefly of having difficulty fitting shoes.
Giving way may be due to pain or instability at the ankle or subtalar joint.
Corns and callosities (thickened, often tender, plaques of skin on the toes or the soles of the feet) are a frequent cause for complaints. They are usually produced by localized pressure and friction – perhaps simply from ill-fitting shoes.
Numbness and paraesthesia may be felt in a circumscribed field served by a single nerve, or more generally in all the toes and both feet suggesting a peripheral neuropathy.
