What is the recommended evaluation and management approach for a 62-year-old female with foot pain, plantar pain, bilateral ankle deformity, bilateral toes deformity, hyperkeratosis, and backache?

Evaluation and Management of Foot Deformities with Plantar Pain and Hyperkeratosis

This patient requires urgent evaluation for inflammatory arthropathy, particularly seronegative spondyloarthropathy, given the constellation of bilateral foot deformities, ankle valgus, finger deformities, and backache in a 62-year-old female.

Immediate Diagnostic Workup

Essential Laboratory Investigations

• HLA-B27 testing to evaluate for ankylosing spondylitis, which has an incidence of approximately 5 cases per 100,000 person-years in females aged 25-44 years, though lower in older age groups 1
• Inflammatory markers: ESR and CRP to assess for active inflammation 2
• Rheumatoid factor and anti-CCP antibodies to exclude rheumatoid arthritis, despite absence of nodules 2
• Fasting glucose and HbA1c to rule out diabetes, as diabetic neuropathy can present with foot deformities and pain 3
• Vitamin B12 levels as deficiency can cause neuropathic foot pain 4

Critical Physical Examination Components

• Neurological assessment: Perform 10-g monofilament testing with at least one additional assessment (pinprick, temperature with 128-Hz tuning fork, or ankle reflexes) to evaluate for loss of protective sensation 4
• Vascular assessment: Palpate pedal pulses and assess ankle-brachial index if pulses are diminished, as an ABI <0.9 indicates peripheral arterial disease 3
• Spine examination: Assess for reduced lumbar flexion (Schober's test) and sacroiliac joint tenderness given the backache 2
• Gait analysis: Document walking pattern and pressure distribution, as this facilitates diagnosis and guides management 3

Imaging Studies

• Weight-bearing radiographs of both feet to assess degree of deformity, joint space narrowing, and rule out Charcot neuro-osteoarthropathy 3
• Spine radiographs (AP and lateral lumbar/sacroiliac views) to evaluate for sacroiliitis or spondylitis given the backache 2
• Consider ultrasound of plantar fascia if thickness >4mm suggests plantar fasciitis, though hyperkeratosis pattern suggests mechanical pressure rather than fasciitis 5

Immediate Management Priorities

Footwear and Orthotic Intervention

Immediate referral to a podiatrist or foot care specialist is essential for this patient with multiple foot deformities and hyperkeratosis 3

• Therapeutic footwear prescription: The shoe should be 1-2 cm longer than the foot, with internal width equal to the width at the metatarsophalangeal joints, and adequate height for toe accommodation 3
• Custom insoles or orthoses to redistribute plantar pressure away from areas of hyperkeratosis and accommodate the valgus ankle deformity 3, 6
• For significant ankle instability: Consider below-knee customized devices such as ankle-foot orthoses or Charcot Restraint Orthotic Walker (CROW) if inflammatory arthropathy is confirmed 3

Hyperkeratosis Management

• Professional debridement of the hyperkeratotic lesion on the right 2nd toe by a trained foot care specialist, as calluses should never be cut by patients themselves 3
• Regular podiatry visits for ongoing callus management, as hyperkeratosis in older females is associated with hallux valgus and toe deformities (60% prevalence in this age group) 7
• Avoid chemical agents or plasters for corn/callus removal 3

Pain Management Algorithm

First-line pharmacological therapy (if neuropathic component identified):

• Pregabalin 75 mg twice daily, titrating to 300 mg twice daily as needed, as it is FDA-approved for neuropathic pain 4
• Alternative: Gabapentin 300 mg at bedtime, gradually increasing to effective dose 4

If inadequate response after 4-6 weeks:

• Switch to alternative first-line agent or consider duloxetine (SNRI) 4
• Avoid tricyclic antidepressants in this 62-year-old due to dose-limiting anticholinergic side effects in patients ≥65 years 4

For mechanical pain from deformities:

• NSAIDs with gastroprotection given age
• Metatarsal pads or bars to offload pressure areas 6, 8

Specific Deformity Management

Hammer Toe (Bilateral 2nd Toes)

• Toe sleeves or padding over the proximal interphalangeal joints 6
• Metatarsal off-loading insoles to alleviate symptoms 6
• Avoid tight-fitting or high-heeled shoes 6

Hallux Varus (1st and 2nd Toes)

• Toe spreaders to maintain alignment 6
• Bunion shields if pressure areas develop 6

Flat Foot with Ankle Valgus

• Medial arch support in custom orthoses 6
• Ankle stabilization with appropriate bracing if instability present 3

Critical Pitfalls to Avoid

1. Do not assume this is simple osteoarthritis: The bilateral symmetric nature, finger involvement, and backache suggest inflammatory arthropathy requiring disease-modifying therapy 2

2. Do not delay podiatry referral: Patients at high risk for ulcers (foot deformities, hyperkeratosis) require specialist foot care to prevent catastrophic outcomes 3

3. Do not perform surgical debridement of hyperkeratosis without vascular assessment: If pedal pulses are absent, debridement risks non-healing wounds 3

4. Do not prescribe off-the-shelf footwear: This patient requires custom therapeutic footwear due to multiple deformities 3

5. Ensure daily foot inspection education: Given sensory changes may develop, teach patient and family to inspect feet daily for blisters, cuts, or pressure areas 3

Rheumatology Referral Indications

Urgent rheumatology consultation is warranted if:

• HLA-B27 positive with inflammatory back pain pattern 1
• Elevated inflammatory markers with progressive deformities 2
• Evidence of sacroiliitis on imaging 2
• Multiple joint involvement suggesting systemic inflammatory disease 2

Longitudinal Surveillance

• Annual comprehensive foot evaluation including inspection, neurological assessment, and vascular assessment 3, 4
• Regular podiatry visits (every 4-8 weeks initially) for callus management and footwear assessment 3
• Monitor for ulcer development: History of foot deformity is a major risk factor for ulceration 3