How to manage a patient with a foot X-ray showing calcaneal enthesophytes, hallux callus, and atherosclerosis?

Management of Calcaneal Enthesophytes, Hallux Callus, and Atherosclerosis

This patient requires a comprehensive vascular assessment with ankle-brachial index (ABI) testing, aggressive cardiovascular risk factor modification, proper footwear with callus debridement, and consideration for peripheral arterial disease (PAD) revascularization if symptomatic, all coordinated through a multidisciplinary team approach. 1

Immediate Vascular Assessment

The presence of atherosclerosis on foot X-ray mandates urgent evaluation for peripheral arterial disease, as this represents a high-risk condition that can lead to critical limb-threatening ischemia (CLTI) if not properly managed. 1

• Perform ankle-brachial index (ABI) testing immediately, as many patients with PAD are asymptomatic despite radiographic evidence of atherosclerosis. 1
• Assess pedal pulses bilaterally and obtain a detailed history for claudication symptoms (leg pain with walking that resolves with rest). 1
• If ABI is abnormal (<0.90) or patient has claudication symptoms, refer urgently to vascular specialist (vascular surgery, interventional cardiology, or vascular medicine) for further assessment and potential revascularization. 1
• Regular follow-up at least annually is required to assess clinical and functional status, limb symptoms, and cardiovascular risk factors. 1

Cardiovascular Risk Factor Management

Aggressive medical management is essential as this patient has established atherosclerotic disease and is at high risk for myocardial infarction, stroke, and cardiovascular death. 1

Antiplatelet Therapy

• Initiate aspirin 75-325 mg daily to reduce risk of MI, stroke, or vascular death. 1
• Clopidogrel 75 mg daily is an effective alternative if aspirin is contraindicated or not tolerated. 1

Blood Pressure Control

• Target blood pressure <140/90 mmHg (or <130/80 mmHg if diabetic or chronic kidney disease present) using antihypertensive agents. 1
• Beta-blockers are safe and effective in PAD patients and do not adversely affect walking capacity. 1
• ACE inhibitors are recommended for symptomatic PAD patients to reduce adverse cardiovascular events by approximately 25%. 1

Lipid Management

• Initiate statin therapy for all patients with atherosclerotic PAD regardless of baseline cholesterol levels. 1

Smoking Cessation

• All patients who smoke must be counseled to stop and offered comprehensive cessation interventions including behavior modification, nicotine replacement, or bupropion. 1

Management of Calcaneal Enthesophytes

Conservative management is the first-line approach for calcaneal enthesophytes (heel spurs), with surgery reserved for cases failing 6-12 months of appropriate conservative treatment. 2, 3

Conservative Treatment

• Prescribe well-fitted, cushioned footwear with adequate heel support to redistribute plantar pressure away from the enthesophyte. 1
• Recommend regular physical activity as this may prevent progression of enthesophyte formation. 4
• NSAIDs can be used for pain control and may reduce enthesophyte progression when taken regularly. 4
• Consider ultrasound-guided prolotherapy injection if conservative measures fail after 3-6 months. 5

Surgical Consideration

• Surgery may be indicated if conservative treatment fails, particularly if radiographic measurements show calcaneal spur-to-skin distance <6mm, spur width >7.9mm, or spur height >14mm, as these predict higher failure rates of conservative management. 2
• Surgical debridement involves removal of the retrocalcaneal bursa, calcaneal osteophyte, and any diseased tendon tissue. 3

Management of Hallux Callus

Callus formation indicates areas of increased plantar pressure and tissue damage with potential for breakdown, particularly dangerous in patients with PAD who have compromised wound healing. 1

Immediate Callus Management

• Debride callus with a scalpel by a podiatrist or trained foot care specialist to prevent underlying tissue breakdown and ulceration. 1
• Inspect skin carefully for erythema, warmth, or early ulceration beneath the callus, as these indicate impending breakdown. 1

Pressure Redistribution

• Prescribe therapeutic footwear with cushioning that redistributes pressure away from the hallux—this may include extra-wide shoes, depth shoes, or custom-molded shoes depending on severity of deformity. 1
• If bony deformities are present (bunions, hammertoes), custom-molded shoes may be necessary to prevent recurrent callus formation. 1

Patient Education

• Educate patient on daily foot inspection to identify early signs of skin breakdown, particularly if neuropathy is present. 1
• Instruct on proper foot hygiene including daily cleansing and use of topical moisturizing creams to prevent skin fissuring. 1

Screening for Diabetes and Neuropathy

Given the presence of both callus formation and atherosclerosis, screen for diabetes mellitus if not already diagnosed, as this dramatically increases risk of foot complications. 1

• Perform hemoglobin A1C testing and if diabetic, target A1C <7% to reduce microvascular complications. 1
• Test for peripheral neuropathy using Semmes-Weinstein 5.07 (10-g) monofilament to assess protective sensation. 1
• If loss of protective sensation is present, increase surveillance frequency to every visit with visual foot inspection. 1

Multidisciplinary Team Coordination

Establish care with an interdisciplinary team that should include: 1

• Vascular specialist (vascular surgery, interventional cardiology, or vascular medicine) for PAD management
• Podiatrist or orthopedic foot surgeon for callus debridement, footwear prescription, and enthesophyte management
• Primary care physician or endocrinologist for cardiovascular risk factor optimization and diabetes management (if present)
• Wound care specialist if any skin breakdown develops

Critical Warning Signs Requiring Urgent Referral

Immediately refer to vascular surgery if any of the following develop: 1

• Ischemic rest pain (pain in foot at rest, particularly at night)
• Non-healing wounds or ulceration despite appropriate offloading
• Gangrene or tissue necrosis
• Acute limb ischemia (sudden onset of pain, pallor, pulselessness, paresthesias, paralysis, or poikilothermia)

These represent critical limb-threatening ischemia requiring urgent revascularization within hours to days to prevent amputation. 1