25.3: Recognizing Common Musculoskeletal Disorders
By the end of this section, you will be able to:
- Examine musculoskeletal disorders affecting the spine
- Recognize musculoskeletal disorders affecting the wrists, hands, and fingers
- Identify musculoskeletal disorders affecting the feet and toes
The spine offers support for the body, allowing humans upright posture. The structure of the spine also offers protection for the delicate spinal cord. Muscles and other tissues assist the spine with strength and support as well as foster some flexibility and movement. Because the spine provides protection for the delicate spinal cord, it is important for nurses to keep this in mind when assessing patients with any symptoms or deviations from normal spinal structure and/or function. Disorders, deformities, and injuries lead to varying levels of pain and dysfunctions ranging from minor to life threatening.
Variations from the normal curvature of the spine can cause mild, moderate, or severe changes in posture and may lead to pain as muscles and other structures accommodate alterations; limited or absent ability to stand or walk may be or become apparent. The neurological impacts of the spinal cord being moved or squeezed may include paresthesia , pain, or movement limitations, from minimal to total. Patients may be unable to complete ADLs, and have increasing reliance on others for daily care. Changes in tone may become evident, with resultant flaccidity or spasticity associated with the impaired structure and function.
In addition to spinal disorders, there are disorders that affect wrists, hands, and fingers of the upper extremities, and feet and toes of the lower extremities. Some of the common diagnoses affecting these specific regions are important to be explored as they need to be considered as the nurse performs a musculoskeletal assessment. Again, knowing normal conditions and having an awareness of some of the potential abnormal conditions can be very important for the bedside nurse’s contribution to patient care.
Disorders Affecting the Spine
The vertebral, or spinal, column is composed of a sequence of vertebrae, each pair joined by intervertebral disks. The spinal column has flexibility, allowing for movement as well as providing support for the head, neck, and body. The spinal cord runs through openings in the posterior of the vertebrae; the bony structure of the spine protects the spinal cord.
There are normally four curves along the length of the spinal column in adults (Figure 25.14). These curves increase strength, flexibility, and ability of the spinal column to dissipate shock. With certain efforts, like lifting and carrying heavy loads, the spine is under more pressure and accommodates by an increase in the depth of the spinal curves. When the pressure is relieved, for example, by putting the heavy load on the ground, the normal curvature is restored.
C1, or the atlas, is thusly nicknamed because Atlas was the Greek Titan who held the sky above the earth for eternity (GreekMythology.com [1997–2021]). C1, C2 (axis), and C7 are each uniquely shaped vertebrae, with C3 through C6 structurally similar. See diagrams and descriptions of the cervical vertebrae in this video.
There are several disorders that can occur in the vertebral column that affect its normal motion and curvature, causing pain and decreased quality of life. Common conditions seen include flattening of the lumbar curvature, hyperlordosis, kyphosis, scoliosis, and ankylosing spondylitis.
Flattening of the Lumbar Curvature
The lumbar spine normally displays a mild lumbar lordosis , or inward curve above the buttocks, which allows for normal, upright posture, with accompanying ability to look straight ahead. If the lordotic curve is absent, this manifests by a flattened lumbar curve, or “ flatback syndrome .” Patients adjust in order to stand upright, which may be subconscious or conscious, as hips and C-spine are extended, and knees flexed (Burhan et al., 2020). These adjustments are tiring, and by days’ end, patients are often fatigued, and forward stooping is more pronounced (Asher, 2023; Cedars-Sinai, 2023). Pain is also frequently associated with this disorder, also increasing throughout a day of postural adjustments while the patient attempts to complete ADLs and perhaps activities associated with a job and other extended daily activities.
A common cause of flatback syndrome is surgical correction of other spinal disorders, (Figure 25.15). Other associated causes include congenital disorders, degenerative disk disease, trauma, osteoporosis, and compression fractures.
Hyperlordosis
Just as a lack of curve in the lumbar region can cause problems and symptoms, an excessive lordotic curve ( hyperlordosis ) can become an issue (Figure 25.16). The posture of hyperlordosis is characterized by a protrusion forward of the stomach, and rearward of the bottom—this exaggerates the C of the lumbar curve and can cause pain, especially in the neck and perhaps the lower back (Hecht, 2018). Hyperlordosis may also be referred to simply as lordosis, or by the nickname “swayback.” The situation is often temporary and reversible; if the patient maintains flexibility, the impact on mobility is expected to be minor. As stiffness becomes apparent, however, restriction of movement is possible.
Some of the causes of hyperlordosis include obesity and advanced pregnancy, injury to the spine, long-term sitting or standing or wearing high-heel shoes, a weakened core, rickets, or some neuromuscular disorders (e.g., osteoporosis, osteosarcoma, spondylolisthesis, muscular dystrophy) (Cleveland Clinic, 2023; Hecht, 2018). The provider may use radiographic testing such as x-ray, computed tomography, or magnetic resonance imaging, along with physical examination, to assist in diagnosing the cause of hyperlordosis.
Once the diagnosis and likely cause are identified, treatment may include a combination of physical therapy with exercises to increase strength and flexibility and a brace for back support. If the patient has been experiencing pain, anti-inflammatory drugs may be recommended. In extreme circumstances, surgery may be necessary to fuse and straighten the spine (Cleveland Clinic, 2023). Nurses are involved in assessing interventions, including patient willingness and compliance and response to prescribed treatments.
Kyphosis
An exaggeration of the curvature of the thoracic spine is called kyphosis , though it has been referred to by the nicknames “hunchback” and “dowager’s hump” (Figure 25.16). The nicknames are not flattering or scientific and are therefore discouraged. A currently accepted nickname is more descriptively, “roundback.” Like other spinal disorders, causes are varied and include congenital defects, spinal trauma and healing, degenerative disease (e.g., arthritis), osteoporosis, and less frequently, disorders of connective tissue, tumors in the spine, polio, and muscular dystrophy.
Depending on the severity of curvature, symptoms may be absent or mild or may be extreme. During assessment, the nurse may notice unequal shoulder height and shoulders that are rounded; the upper back may have a visible and palpable hump. With these physical alterations from normal, the patient may notice stiffness and/or pain in the upper back or shoulders, and the hamstrings may not be flexible. The patient may tire easily. In severe cases, the patient may notice paresthesias or numbness, urinary or bowel incontinence, or dyspnea from restricted chest expansion (Gabbey & Cohen, 2023). Patients with kyphosis also suffer from poor body image.
Treatment for kyphosis is based on symptoms and limitations relative to mobility and ability to perform ADLs. Nurses interact with patients in outpatient settings while noninvasive interventions are attempted. This may include assessment of pain control measures; strength and flexibility improvement from physical therapy; and ongoing exercises for the core, back, and posture. Some patients may benefit from a back brace, and success or lack of improvement should be evaluated and noted. Surgery is not common, but in cases of respiratory compromise or incontinence, surgery may be necessary.
Scoliosis
A horizontal curvature of the spine is diagnosed as scoliosis (Figure 25.16). This is a common disorder and is often diagnosed during adolescence, although some cases occur and are diagnosed much younger. When a nurse is assessing a patient’s spine, it is routine to have the patient stand facing away from the nurse. This provides an opportunity to inspect the spine while the patient is upright. To further the assessment with scoliosis in mind, the nurse asks the patient to bend forward at the waist, and the nurse observes for shoulder placement. Uneven shoulders in this position are a sign of scoliosis (Mayo Clinic, 2023). Other signs include an uneven waist and hips, a shoulder blade more prominent than the other, or a side of the rib cage that is more forward than the other.
Watch this demonstration of a scoliosis assessment that provides steps and descriptions of normal and abnormal findings. Think about the findings as if you were the examiner.
Scoliosis may be mild, with only a small spinal curvature and mild or no symptoms, or it can be severe, and the patient may be required to use a wheelchair. Symptoms can be anywhere between the two ends of the spectrum. Once diagnosed, healthcare providers usually follow patients on a regular basis, with radiographs and examination, to evaluate any progression of the curvature and symptoms.
Scoliosis is sometimes considered hereditary, with appearances within family lines. Often, the occurrence of scoliosis is idiopathic, with no specific cause identified. In some cases, a diagnosis like muscular dystrophy or cerebral palsy is the cause of the spinal curvature. Other potential causes include spinal infection or trauma, congenital deformity affecting bone development, and diagnosis of a spinal cord disorder. Girls tend to be at increased risk for development of scoliosis, and symptoms tend to appear in adolescence (Mayo Clinic, 2023).
An assessment of the spine for curvature associated with scoliosis is a frequent part of a routine physical examination for an adolescent patient. Manifestations of scoliosis that the examiner looks for include a visible horizontal deviation from the normal straight spinal column, uneven shoulders while standing erect and as seen from behind while bending forward at the waist, prominence of one scapula in comparison to the other, an uneven waist, asymmetrical rib cage, and hip deviation with leg length discrepancy (Mayo Clinic, 2023).
Severe cases of scoliosis may impact respiratory function, as expansion of the lungs may be reduced by size and shape of the thoracic cage. Signs and symptoms are prone to worsening as the spinal curve increases over time. Treatment depends on severity, as mild cases often require no treatment and are simply monitored for changes. Once bone growth is complete, progression is slow; with this in mind, treatments tend to be more effective in growing children (Mayo Clinic, 2023). Application of a brace is helpful in prevention of worsening of the curvature, so this is a common treatment for the growing child, and individual patient response should be assessed at each healthcare visit.
Surgery is an option used to straighten the spinal curve, with hopes of preventing it from worsening over time. Of course, surgery is not without potential complications, including some of the spinal deformities already discussed. Surgeries for treatment of scoliosis include use of a rod (or two) that is adjusted in length with the patient’s growth, every few months (Mayo Clinic, 2023). Another option is spinal fusion , which connects multiple vertebrae to prevent individual movement; this may be done with rods, screws, or pins. Tethering of the vertebral body is another method in which screws are utilized on the outer part of the curve of the spine, and a cord is inserted through them. The spine is straightened as the tether is made taut. Nurses are involved in educating the patient and family throughout diagnosis and treatment, and during postoperative care, frequent assessment of neurological and musculoskeletal function is critical. Additionally, the postoperative patient should be assessed for bleeding at the surgical site. Infection is a risk with any invasive procedure.
Ankylosing Spondylitis
The chronic inflammatory disease ankylosing spondylitis is within the category of arthritis , primarily of the spine and sacroiliac joint (Figure 25.17). The inflammatory process causes abnormal formation of new bone, which leads to fusion (permanently joining together) of involved vertebrae. This produces a flattening of the affected area of the spine, limits movement in the region, and alters posture (Mayo Clinic, 2023). Ankylosing spondylitis may affect other joints as well, and interestingly, it may affect eyes, specifically with a condition called anterior uveitis (Doherty, 2021). The most common symptom is lower back pain; other symptoms include kyphosis, stiffness, heel and other joint pain ( enthesitis —inflammation of the area of attachment of ligament or tendon to bone), and malaise or fatigue, as systemic inflammatory symptoms.
Symptoms may demonstrate differences based on sex, although men and women may experience any or all symptoms (Doherty, 2021). Back pain tends to occur in both sexes as the most common symptom; neck, knee, hip pain, fatigue, and depression are experienced more often in women. Men present more often with foot pain. Nurses should be alert for certain common characteristics of inflammatory back pain, including chronicity, with typically slow onset in patients under 40 years old. Symptoms tend to improve with exercise and not by resting. As a matter of note, symptoms may be even worse at night, severe enough to wake the patient. Because the disorder is inflammatory, drug therapy with nonsteroidal anti-inflammatory drugs (NSAIDs) is often effective.
While rare, a potential neurological emergency for patients with ankylosing spondylitis is compression of the spinal cord. Symptoms the nurse may notice on assessment include a burning pain from buttocks to arms and legs, numbness in extremities, a loss of coordination of the hands, or foot drop (Johns Hopkins, 2023). The cauda equina syndrome may cause loss of bladder or bowel function, increasing leg numbness, and pain. Most spinal cord compression is treated conservatively, with anti-inflammatory drugs (e.g., steroids or powerful NSAIDs) and physical therapy for strength enhancement of the legs and core. Surgery may be indicated for severe situations, and cauda equina syndrome may require emergent surgical intervention (Johns Hopkins, 2023).
A discussion guide about ankylosing spondylitis designed for patients to use in anticipation of an appointment with a healthcare provider gives ideas for questions patients may have. Consider how these can be helpful for nurses who are interviewing and assessing patients with musculoskeletal concerns.
Degenerative Joint Disease
The degenerative joint disease (DJD) , also known as osteoarthritis , is a common disease that occurs with age. Joints, especially those that bear the body’s weight or move in chronic repetitive motion, are prone to inflammation and structural joint damage (American Academy of Physical Medicine and Rehabilitation [AAPM&R], 2024). The constant cycle of inflammation and joint damage leads to a loss of the articular cartilage cushion, creating pain, inflammation, and limited joint movement. In addition to advancing age, other risk factors for DJD are obesity, a family history of DJD, and joint injury or overuse. Women are more prone than men to experience DJD, especially after age 50 years (Centers for Disease Control and Prevention, 2023). While weight-bearing joints (spine, knees, and hips) are more prone to development of DJD, fingers can also be affected.
There is no cure for osteoarthritis, but several treatments can help alleviate the pain. Treatments may include weight loss, low-impact exercise, and medications such as acetaminophen, nonsteroidal anti-inflammatory drugs (NSAIDs), and celecoxib. For severe cases of DJD, joint replacement surgery may be required.
The videos provided here are of the hip and knee, but the degenerative pathophysiology of osteoarthritis is explained here and is the same wherever the joint.
Osteoporosis
The disease osteoporosis causes thin and weakened bones that become fragile and break easily (Figure 25.18). Osteoporosis is common in older women and often occurs in the hip, spine, and wrist. To keep bones strong, patients at risk are educated to eat a diet rich in calcium and vitamin D, participate in weight-bearing exercise, and avoid smoking. If needed, medications such as bisphosphonates and calcitonin are used to treat severe osteoporosis.
Scenario: Miss Nilsen is 60 years old and postmenopausal. She is meeting with the nurse after seeing her primary care provider about her bone density scan results. The nurse has been asked to provide education about osteopenia, osteoporosis, and Miss Nilsen’s next steps.
Nurse: Miss Nilsen, I’m Luisa, I think we’ve met before. I’ve been asked to talk with you about your bone density scan results.
Patient: Dr. Rand says I have weak bones but I don’t have osteoporosis? What’s the difference?
Nurse: Your situation is some bone loss or weakening, called osteopenia. This has not progressed to osteoporosis; the nice thing about finding out now is you can take some steps to prevent it from worsening.
Patient: What do I need to do? Dr. Rand mentioned a medicine.
Nurse: Yes, your healthcare provider is considering starting you on a prescription for alendronate. You had lab work done recently, and your calcium level is fine, but like so many people, your vitamin D is low. Before you can start the alendronate, you should have normal vitamin D, so let’s talk about how much vitamin D to take. Because vitamin D and calcium work together to strengthen your bones, I’ll show you how much calcium to take too. In three months, we’ll have you come to have a retest.
Patient: I can’t start the osteoporosis drug now? I sure don’t want this to get worse.
Nurse: Not until your vitamin D is normal so you have the right building blocks for it to work. First, vitamin D is dosed in international units—you’ll see it on the bottle as IU. Because you are past menopause, the recommendation is for you to have 800 IU of vitamin D every day. Calcium is dosed in milligrams, which on the bottle will be mg. Every day you should take in 1,200 mg. This is between food and fluid intake, and the supplement. I have a list of food and drinks and their usual amounts of calcium and vitamin D; we can circle those you eat regularly and come up with the right amount you need from the supplements.
Patient: Okay, I’m sure glad you’ve got this written down, and we’ll write down the foods and stuff too. This is all a bit confusing.
Nurse: Absolutely! It’s a lot to remember, so you’ll get to take these with you. Do you get any sun? How about exercise?
Patient: I’m so pale, I try to avoid the sun and put on a high number sunscreen, like SPF50, which almost blocks all ultraviolet rays—98 percent (MacGill, 2018). I like to swim, I do that a few times a week.
Nurse: Yes, you are fair, so sunscreen is good to prevent skin cancer. But twenty or thirty minutes of sun daily can help your body produce and use vitamin D. You don’t have to expose your whole body to get the benefit—maybe alternate limbs and expose one at a time for ten minutes, three times a day? Instead of swimming, or in addition to it, could you could do some walking? Exercises that put weight on your bones helps more for making and keeping strong bones.
Patient: Maybe I can walk on my lunch break, so I can get sun and make my bones stronger at the same time.
Nurse: That should help, along with the supplement. Do you think you can add the vitamin D supplement and walking at least three times a week? For three months—until you come in for a repeat blood test?
Patient: I can try. I’ll pick up the supplements on my way home and start tonight.
Disorders Affecting the Wrists, Hands, and Fingers
The small and specialized bones of the wrists, hands, and fingers are prone to disorders, some unique to their locations and some common with other regions. Other musculoskeletal structures, muscles, tendons, and ligaments, can also be impacted by injuries and disorders, whether specific to the region or broader in occurrence. Rheumatoid arthritis, for example, is a systemic autoimmune disorder, so effects can be anywhere and in multiple places. Osteoarthritis is common in the hands (especially fingers) and also the spine, hips, and knees. Similarly, tenosynovitis can occur with tendons around the body. But, De Quervain tenosynovitis is localized to the wrist, with tendon inflammation at the base of the thumb. Carpal tunnel syndrome is another disorder specific to the palm side of the hand. These conditions are further examined in this section.
Rheumatoid Arthritis
In rheumatoid arthritis (RA) , pain, swelling, stiffness, and loss of function in joints is due to inflammation caused by an autoimmune disease. See Figure 25.19 for an illustration of RA. It often starts in middle age and is more common in women (AAPM&R, 2024). Rheumatoid arthritis is different from osteoarthritis because it is an autoimmune disease, meaning it is caused by the immune system attacking the body’s own tissues. In RA, the joint capsule and synovial membrane become inflamed. As the disease progresses, the articular cartilage is severely damaged, resulting in joint deformation, loss of movement, and potentially severe disability.
There is no known cure for RA, so treatments are aimed at alleviating symptoms. Medications such as NSAIDs, biologics, corticosteroids, and antirheumatic drugs such as methotrexate are commonly used to treat RA.
Mrs. Jackson is a 52-year-old female who visits her primary care provider for swollen, sore hands. The nurse, Marcus, interviews Mrs. Jackson and discovers the following:
Personal history of hyperlipidemia, hypertension, obesity, and prediabetes. Family history of hypertension and coronary artery disease in both parents; mother with stiff hands she called “rheumatism.” Mrs. Jackson describes always being stiff in the mornings and that for the past three days she has had no appetite, felt extra tired, and had a bit of fever. Marcus’s assessment includes vital signs: HR 88, BP 140/92, T 99.3°F (37.4°C), SaO 2 95 percent on room air. He notices both hands are warm, with bilateral edema and erythema at the metacarpal phalangeal (MCP) and proximal interphalangeal (PIP) joints; her fingers hurt when touched, and ROM of the fingers is limited by pain. Marcus’s analysis of cues leads to his conclusion that those cues valuable for the next steps of nursing care include the mother’s “rheumatism,” or RA, the patient’s morning stiffness, flu-like syndrome (malaise, low-grade fever, anorexia), and inflamed MCP and PIP joints.
Definition: The nurse incorporates clinical skills, current evidence, and preferences of the patient and family in professional nursing care.
Knowledge: The nurse explains the importance of a professional practice based on evidence.
Assessment of pain and readiness to ambulate are both essential for recovery and are interrelated. Adequate pain control is necessary for patients to reposition, sit and dangle at the bedside, and feel ready to stand and walk. Protocols such as the Enhanced Recovery After Surgery (Zhang et al., 2018) guide practice through evidence relative to the importance of pain control through medication as prescribed, proper positioning, and application of ice packs, and the value of early ambulation in prevention of complications (e.g., deep vein thrombosis [DVT], pneumonia, constipation, and ileus).
Skill: The nurse will maintain a professional practice that includes current evidence-based materials.
- Maintaining currency in practice through continuing education (CE)
- Reading peer-reviewed journal articles relative to professional practice
- Reading and following new protocols as they are established
Attitude: The nurse recognizes the significance of ongoing evidence-based clinical practice development.
Ganglion Cyst
A ganglion cyst is a fluid-filled lump that most often occurs at the back of the wrist, over tendon sheath or joint (Figure 25.20). They can also develop on the end joint or base of a finger. The exact cause is unknown, but they are most common in women, younger people between ages 15 and 40 years, and gymnasts who repeatedly apply stress to the wrist.
Some ganglion cysts disappear on their own with joint rest or splinting of the wrist. In some cases, where there is pain, aspiration of the fluid may help to relieve pain, but the cyst may grow back. Surgical removal can also be done to remove the root of the cyst and the tendon sheath involved (Pidgeon & Jennings, 2022).
Tenosynovitis
Inflammation of a tendon is termed tendonitis ; tenosynovitis is a term for inflammation of not only the tendon but also the surrounding sheath. Such inflammation often affects extensor and flexor tendons of the wrists. It can be caused by autoimmune disorders such as RA or overuse of the tendon. It can also be caused by infection, such as from animal bites, a skin commensal (organism that normally resides on our skin), Staphylococcus aureus , or methicillin-resistant S. aureus (MRSA). Two common types of tenosynovitis seen are De Quervain tenosynovitis and stenosing tenosynovitis.
De Quervain tendonitis occurs on the thumb side of the wrist. Patients feel pain when turning their wrist, grasping, and making a fist (OrthoInfo, 1995–2023). The cause is not known, but repetitive hand and wrist movements can make the pain worse.
Treatments for De Quervain tendonitis include splinting the wrist and hand, NSAIDs, and avoidance of painful activities and positions. Corticosteroid injection is a possible treatment, as is surgical intervention involving release of the tendon sheath.
In stenosing tenosynovitis , nicknamed “trigger finger,” the flexor tendons of a finger or thumb freeze in the bent position (Figure 25.21). The patient may report clicking when bending and/or straightening the finger, as well as pain and stiffness. This type of tenosynovitis is common in patients with diabetes, and the risk for development increases with advanced age.
Treatment includes rest, splinting, NSAIDs, and stretching exercises. Like De Quervain syndrome, steroid injection may be beneficial. Surgery to release the pulley to allow the flexor tendon to glide freely may be performed. Postoperative assessment by the nurse for treatments of tenosynovitis will be the same as for ganglion cyst postprocedure care.
Carpal Tunnel Syndrome
In the wrist, the carpal bones and the flexor retinaculum form a passageway called the carpal tunnel, with the carpal bones forming the walls and floor and the flexor retinaculum forming the roof of this space. The tendons of nine muscles of the anterior forearm and the median nerve pass through this narrow tunnel to enter the hand. Overuse of the muscle tendons or wrist injury can produce inflammation and swelling within this space. This produces compression of the nerve, resulting in carpal tunnel syndrome , which is characterized by pain or numbness and muscle weakness in those areas of the hand supplied by the median nerve.
Classic symptoms of median nerve compression include pain that may be described as burning, numbness, and tingling, which may involve the forearm or entire arm, as it is relative to the sensation of the median nerve. The hand may lose fine motor skills and the ability to grasp and carry things. Being awakened at night with severe arm pain is common, especially if the patient’s wrists are bent forward when sleeping.
Carpal tunnel syndrome happens more often in women, and its occurrence increases with advancing age (AAPM&R, 2024). While repetitive use of the hands has made this common with cashiers and assembly-line workers for many years now, keyboard typing has become a common source of the syndrome. There is also a hereditary component to carpal tunnel syndrome, and as mentioned, position of the wrist (especially flexion) can contribute to the disorder and its symptoms.
Scenario: A 50-year-old female, Mrs. Eldridge, talks to the nurse, LaTonya, prior to a visit with her primary care provider for a painful wrist and thumb.
Nurse: Mrs. Eldridge, how long has this pain been bothering you?
Patient: About three months now.
Nurse: What sort of work do you do?
Patient: Medical coding; I work from home.
Nurse: Nice. That’s computer work, right? Lots of typing?
Patient: Oh yes.
Nurse: Let me see your hand. The one that hurts. [pause] I notice the pad at the base of your thumb, it’s nearly gone. Has that been three months too?
Patient: Yes, it wasted away.
Nurse: Does the pain ever wake you up?
Patient: Every night, I jump up from a deep sleep shaking my hand, it hurts so much! What’s going on with me?
Nurse: Well, the doctor will do a test to be sure, but you might be experiencing carpal tunnel syndrome. At least that’s a starting point. The doctor will be in shortly, and we’ll have a better idea.
Treatment commonly begins with NSAIDs and a wrist and hand brace, which maintains the wrist in a neutral—not flexed—position, which is especially helpful while sleeping. Patients may also choose to wear the brace during activities that tend to cause pain. Corticosteroid injection may help relieve symptoms, at least temporarily; surgery to enlarge the tunnel by dividing the carpal ligament may be recommended (OrthoInfo, 1995–2023). Postoperatively, patients wear an immobilizing brace.
Disorders of the Feet and Toes
There are some musculoskeletal disorders that are naturally associated with the feet, including toes. These may only occur in connection with the feet, or commonly strike feet and toes, but also have the potential to happen elsewhere. This chapter’s exemplars include gout, which can appear in any joint, but is very common in the feet, especially the great toe. Other disorders specific to the feet and toes include pes planus (flat feet), hallux valgus (bunion), and hammertoe.
Gout
A type of arthritis that causes swollen, red, hot, and stiff joints due to the buildup of uric acid is termed gout (Figure 25.22). It typically first attacks the big toe. Uric acid usually dissolves in the blood, passes through the kidneys, and is eliminated in urine, but gout occurs when uric acid builds up in the body and forms painful, needlelike crystals in joints.
Gout is treated with lifestyle changes such as avoiding alcohol and food high in purines as well as administering antigout medications, such as allopurinol and colchicine. Nurses are often involved in patient education, and with gout there may be complicated comorbidities, polypharmacy, and diet and exercise teaching to be done to maximize the patient’s care plan. In extreme cases, especially with frequent exacerbations of gout, surgery may be indicated and may involve joint fusion or replacement (Petrie, 2023). Related nursing assessment will be based on location but includes pain assessment and regional focused assessment.
Nurse:
Monica, RN
Clinical setting:
Home environment
Years in practice:
7
Facility location:
Columbus, Ohio
A 58-year-old patient has just been diagnosed with an acute exacerbation of gouty arthritis. He told me this was the third acute episode he has experienced in four months, then said, “Both my big toes hurt so bad!” As I followed up for more information, I found his father is Italian and his mother German. His father worked the family farm, and his mother was a homemaker. His wife is Irish; she works as a receptionist. He is an accountant and sometimes works long hours, especially at tax time; he doesn’t feel he has time to exercise.
I asked about his involvement in his diet, whether he plans meals, shops for groceries, or cooks meals. He told me that when he was single, his mother did all that, and now his wife does. He tells me his father always enjoyed some red wine in the evenings, and he inherited that habit, usually having three to five glasses. When his wife cooks Italian food from his grandmother’s recipes, she is sure to include plenty of cheese, especially mozzarella and parmesan. He told me his wife sometimes packs him a lunch; his favorite is a summer sausage and blue cheese sandwich, with pickles and sauerkraut, but he’ll eat any lunchmeat-and-cheese combination.
I was pretty concerned about his dietary intake and his lack of exercise. Clearly, his habits have been formed over many years and were well established within his family. I thought about the particular foods he enjoys and, of course, the wine. I knew if I criticized him or his family for their dietary choices, he might be resistant to any suggestions I made, especially since his parents are both still alive, and while they are older, the active lifestyles involved with running a farm may have contributed that. But his lifestyle includes very little physical activity, with excessive food and wine, especially high-purine foods, which are the likely contributors to the rather frequent exacerbations of gout .
I asked him if his wife should join us to talk about food choices and such. He welcomed that idea. With both of them, I outlined foods and beverages that are high in purine and therefore lead to hyperuricemia. I described the pathophysiology of hyperuricemia and its relationship to gout. We talked about some different ways of meal planning. Then I told him he should try to not drink more than two glasses of wine per evening.
That was a huge education session, with a lot of information for both of them. In many cases, it is hard for patients to remember details, so I gave them some written information as well. This included the list of high-purine foods, recommended foods, and some simple recipes for the patient and his wife to try. We scheduled a follow-up appointment in a month to see how he is doing, and whether the new ideas have been successfully incorporated.
Pes Planus (Flat Feet)
Flat feet, termed pes planus , is a common foot deformity characterized by the loss of the medial longitudinal arch of the foot (Figure 25.23). Most babies and toddlers have flat feet and develop a normal arch by age 5 or 6 years. Pes planus is often associated with obesity, posterior tibial tendon dysfunction, excessive tension in the area, or tight Achilles tendon or calf muscle (Raj et al., 2023).
Symptoms are pain noted in the back, leg, ankle, or foot (Raj et al., 2023). The patient will have a visibly flat foot when weight-bearing and may have an abnormal gait.
Treatment may include prescribed NSAID therapy, foot orthotics, and motion control shoes. Patients with higher weight are given weight loss counseling. Surgery to essentially build an arch by moving tendons and fusing other bones into position is done when other interventions have been unsuccessful.
Hallux Valgus
A hallux valgus , or bunion , is a bony protrusion on the medial side of the foot, next to the first metatarsophalangeal joint, at the base of the big toe (Figure 25.24). Over time, this causes inward alignment of the great toe, angling it toward the next toe. Bunions can be hereditary, can be caused by certain autoimmune disorders, such as RA, or can be caused by wearing tight, restrictive shoes.
Assessment findings include the deformed joint and toe(s), erythema, edema, presence of calluses, hammertoes, and difficulty walking. The patient may relay pain and numbness in the affected joint. Osteoarthritis and bursitis may result from bunions, with added symptomatology from these disorders added to the bunion itself. Treatments include NSAID therapy, orthotics, well-fitting footwear, and application of ice to the region. Physical therapy and corticosteroid injections may be helpful for some patients. In severe cases, bunionectomy may be surgically performed.
Hammertoe
A hammertoe is a deformity where the toe bends at the second joint, causing a hammer-type shape (Figure 25.25). This is most common in the second toe but can also occur in other toes. Women tend to experience hammertoe more frequently than men (Petrie, 2023). Causes include traumatic injury, hallux valgus, arthritis, and poorly fitting shoes. In some cases, hammertoe can be congenital. A corn may be seen on the top of the toe, along with a callus on the sole of the foot. Hammertoe can make it painful to walk.
Physical therapy for specific exercises and taping or splinting the toe straight can prevent the deformity from becoming permanent. Applying an ice pack intermittently, taking NSAIDs, or receiving cortisone injections may help with pain and inflammation. In some cases, surgery may be required to straighten the toe joint.