How to document a callused area over the plantar surface of the first metatarsal in a patient's medical record?

Medical Documentation of Plantar First Metatarsal Callus

Document this finding as "hyperkeratosis overlying the plantar aspect of the first metatarsal head" with specific measurements of size, location, and associated features to enable proper tracking and risk assessment. 1

Essential Documentation Components

Anatomic Location and Characteristics

• Record the precise anatomical location using standardized terminology: "plantar surface of first metatarsal head" or "plantar first metatarsophalangeal joint region" 1
• Measure and document the lesion dimensions in millimeters or centimeters (length × width), as this enables other clinicians to assess healing progress over time 1
• Describe the lesion type using appropriate terminology:
  • "Diffuse callus" (callosity) if thickened without a central core 2
  • "Heloma durum" (hard corn) if a central keratin plug is present causing focal pain 2
  • "Roll-off hyperkeratosis" if located on the medial aspect of the first metatarsophalangeal joint, which is the most common pattern (12% of all plantar lesions) 3

Critical Associated Findings to Document

• Probe the lesion depth after debridement using a sterile blunt metal probe to assess for underlying ulceration, as bone contact has a characteristic stony feel and indicates osteomyelitis risk 1
• Document surrounding tissue quality: presence of erythema, warmth, edema, or cellulitis, as these indicate impending tissue breakdown or infection 1
• Record any underlying wound: if debridement reveals ulceration beneath the callus, document wound size, depth, drainage characteristics (color, odor, quantity), and tissues involved 1
• Note pain characteristics: whether the patient describes pain as "walking on a small stone or pebble," which is typical of corns with central keratin plugs 2

Risk Stratification Documentation

Neuropathy Assessment

• Test and document protective sensation using 10-g Semmes-Weinstein monofilament at the first metatarsal head and surrounding sites, recording the number of sites where sensation is absent 1
• Loss of protective sensation at 2 or more of 3 tested sites defines clinically significant neuropathy 1

Vascular Assessment

• Palpate and document pedal pulses (dorsalis pedis and posterior tibial); if diminished or absent, document ankle-brachial index values 1
• An ABI <0.5 or ankle pressure <50 mmHg indicates ischemia requiring urgent vascular evaluation 1

Biomechanical Factors

• Document associated deformities: hallux valgus severity (mild/moderate/severe), as moderate to severe hallux valgus increases risk of medial first metatarsal head lesions by 2.95-fold 3
• Record lesser toe deformities (hammertoes, claw toes), as these correlate with specific callus patterns 1, 3

Documentation Pitfalls to Avoid

Critical Distinctions

• Never document as simply "callus" without specifying location, size, and depth assessment, as this provides insufficient information for risk stratification 1
• Distinguish from plantar warts by paring the lesion: pinpoint bleeding (thrombosed capillaries) indicates wart rather than mechanical hyperkeratosis 2
• Rule out neurovascular hyperkeratosis before aggressive debridement, as this rare variant (<1% of cases) bleeds profusely and causes severe pain with normal debridement 2
• Consider biopsy documentation if the lesion is resistant to treatment or has atypical features, as squamous cell carcinoma can mimic hyperkeratosis 2

High-Risk Patient Documentation

• In diabetic patients, explicitly document the presence or absence of infection signs (purulence, warmth, tenderness, induration) and whether imaging is indicated 1
• Document footwear assessment: whether current footwear contributed to the lesion, as "the foot should never return in the same shoe that caused the ulcer" 1

Recommended Documentation Template

A complete note should include:

• Chief complaint: "Painful thickened skin plantar first metatarsal head"
• Physical examination: "3.0 × 2.5 cm area of hyperkeratosis overlying plantar aspect of left first metatarsal head. No central keratin plug identified. No erythema, warmth, or drainage. After debridement, no underlying ulceration detected. Probe-to-bone test negative."
• Neuropathy status: "10-g monofilament: protective sensation intact at 3/3 sites tested"
• Vascular status: "Dorsalis pedis and posterior tibial pulses 2+ bilaterally"
• Associated findings: "Moderate hallux valgus deformity present"
• Assessment: "Plantar hyperkeratosis, first metatarsal head, associated with hallux valgus and pressure loading"
• Plan: Document debridement performed, pressure redistribution strategy, and follow-up interval 1

This structured approach ensures comprehensive documentation that facilitates continuity of care, enables outcome tracking, and supports appropriate risk stratification for complications. 1, 2