"My toe hurts!"

One of the many best things about being a doctor is that I can be first responder to medical complaints and questions from friends and family. I don't know what your average adult daughter of an elderly parent would do if Mom or Dad complained of a sore toe, but I sat her right down and pulled off her shoe and sock. Here's what I found:

All the toes on the foot, especially the big one, were a dusky red. As I raised her foot for a closer inspection, the color changed to a waxy white. Oh-oh, dependent rubor! That's medical shorthand for the color change that occurs in limbs with arterial insufficiency. When they're hanging down or dependent, gravity pulls red, oxygenated blood into the capillaries. When they're hoisted up, the capillaries empty out, and the foot pales.

Next step, I compared sore foot with other. Both feet were swollen, and have been for several weeks. That's a different story for a different post (venous insufficiency). But painful right foot was cool and shiny, relatively normal left foot was pink and warm, and the skin had a normal texture. Normal feet have two palpable pulses where arterial pulsation can be felt. I checked her dorsalis pedis pulse (top of the foot) and posterior tibial pulse (just behind the ankle bone on the big toe side) and found no pulses at all.

I then pulled out my reading glasses for a closer inspection. No ulcerations on any of the toes, but the tip of the big toe was especially tender to touch. The nails were thick and deformed, another sign of not enough blood flow.

So why did Mom complain of big toe pain while walking? The muscular activity in her leg called for more blood flow, and her aging arteries just couldn't deliver blood all the way to the tip of the toe. As soon as she sat down, she had enough blood to toe to relieve the pain.

So all the wiser for my exam, but what to do? I called the nurse and showed her what was going on. I asked her to leave my Mom in slippers through the day to reduce pressure and trauma to her foot. She hardly walks at all, so hopefully her sore toe, which is only sore on walking, will not be a bother to her. She's not a candidate for revascularization or bypassing narrowed arteries in her leg (a big deal operation with big deal complications for little old people), so it's just another step in the downward road.