Clavus Clinical Presentation

  • Author: Nanette Silverberg; Chief Editor: Dirk M Elston, MD   more...
 
Updated: Apr 9, 2010
 

History

A clavus forms because of inappropriate distribution of pressure onto a specific site, usually of the foot. A localized callosity of the soles, which do not resolve, are termed plantar callus, heloma, tyloma, keratoma, or plantar corn. When callosities occur over one or more lateral metatarsals, they are termed intractable plantar keratoses.

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Physical

Clinically, all variants of clavus lesions look like hyperkeratotic or thick skin; maceration and secondary fungal or bacterial infections are a common overlying feature in heloma molle and diabetes. Plantar helomas tend to have a central keratin plug, which, when pared, reveal a clear, firm, central core. The most common sites for clavus formation are the feet, specifically the dorsolateral aspect of the fifth toe for heloma durum, in the fourth interdigital web of the foot for heloma molle, and under the metatarsal heads for calluses.

  • Examination of patients should include assessment of the types of footwear worn, activities performed, gait, and current home therapy or previously prescribed therapy.
  • Lesions should be palpated and pared to look for underlying blood vessels (black dots or pinpoint bleeding), which are seen in warts, and to look for underlying ulcerations, as seen in neurovascular ulcerations (especially in patients with diabetes).
  • Paring of callosities or corns, as opposed to plantar warts, should reveal normal dermatoglyphics.[17]
  • Callosities are generally more painful with direct pressure, whereas warts are more painful with lateral pressure.[18]
  • Pedobarographic studies are pressure assessments that may be used to detect an altered distribution of foot pressure. MRI may delineate diabetic foot problems more clearly.
  • Biopsy of lesions reveals hyperkeratosis and, occasionally, mucin deposition.
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Causes

Conditions associated with clavus formation

Faulty mechanics: Irregular distribution of pressure and repetitive motion injury (especially in athletes) are believed to be the main inciting causes; however, inappropriately shaped or constrictive footwear in the presence of bony prominences (eg, talar bone prominences[24] ) may exacerbate clavus formation. Furthermore, some disorders may alter the shape or sensation of the soles of the feet. Bony prominences and faulty foot mechanics then allow clavus formation to continue.[25, 26, 27, 28, 29]

  • Rheumatoid arthritis[30] : About 17% of patients with rheumatoid arthritis present with intractable foot pain. Chronic arthritis leads to foot deformities and consequent callus formation. Bleeding into callosities in patients with rheumatoid arthritis may be a sign of rheumatoid angiitis.
  • Diabetes mellitus with associated peripheral neuropathy[31] : In patients with diabetes, chronic callosities in the presence of neurovascular deterioration may lead to ulcerations and superinfections.
  • Obsessive-compulsive disorder (pseudo-knuckle pads)
  • Ectopic nail
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Contributor Information and Disclosures
Author

Nanette Silverberg  MD, Assistant Clinical Professor, Department of Dermatology, Columbia University College of Physicians and Surgeons; Director of Pediatric Dermatology, Department of Dermatology, St Luke's Roosevelt Hospital Center, Maimonides Medical Center and Beth Israel Medical Center

Nanette Silverberg is a member of the following medical societies: American Academy of Dermatology, American Academy of Pediatrics, American Association of University Women, American Medical Association, American Medical Women's Association, Dermatology Foundation, International Society of Pediatric Dermatology, Phi Beta Kappa, Sigma Xi, Society for Pediatric Dermatology, and Women's Dermatologic Society

Disclosure: Nothing to disclose.

Specialty Editor Board

Smeena Khan, MD  Private Practice, Adult and Pediatric Dermatology Associates

Smeena Khan, MD is a member of the following medical societies: Alpha Omega Alpha and American Academy of Dermatology

Disclosure: Nothing to disclose.

David F Butler, MD  Professor of Dermatology, Texas A&M University College of Medicine; Chair, Department of Dermatology, Director, Dermatology Residency Training Program, Scott and White Clinic, Northside Clinic

David F Butler, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American Medical Association, American Society for Dermatologic Surgery, American Society for MOHS Surgery, Association of Military Dermatologists, and Phi Beta Kappa

Disclosure: Nothing to disclose.

Jeffrey J Miller, MD  Associate Professor of Dermatology, Pennsylvania State University College of Medicine; Staff Dermatologist, Pennsylvania State Milton S Hershey Medical Center

Jeffrey J Miller, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, Association of Professors of Dermatology, North American Hair Research Society, and Society for Investigative Dermatology

Disclosure: Nothing to disclose.

Glen H Crawford, MD  Assistant Clinical Professor, Department of Dermatology, University of Pennsylvania School of Medicine; Chief, Division of Dermatology, The Pennsylvania Hospital

Glen H Crawford, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American Medical Association, Phi Beta Kappa, and Society of USAF Flight Surgeons

Disclosure: Nothing to disclose.

Chief Editor

Dirk M Elston, MD  Director, Ackerman Academy of Dermatopathology, New York

Dirk M Elston, MD is a member of the following medical societies: American Academy of Dermatology

Disclosure: Nothing to disclose.

Additional Contributors

The authors and editors of eMedicine gratefully acknowledge the contributions of previous Chief Editor, William D. James, MD, to the development and writing of this article.

References

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Screwdriver operator's callus (ie, clavus).
Table. Clavus Formation Named for Specific Etiology or Location
Vernacular Term Location Association
Jeweler's callus, cherry pitter's thumb,[4] cameo engraver's corn[5] ThumbDigital changes, including callosities related to repetitive use of fine jeweler's instruments, which also may be seen with the use of cherry-pitting tools
Weight lifter's callus[6] Callosities over the palmar metacarpophalangeal jointsCaused by the friction of weight-lifting apparatus (This also may be seen in athletes who participate in crew.)
Prayer callus[7, 8] Callosity on the foreheadFrom kneeling prayer with the hands on the forehead
Cigarette lighter's thumb[9] Hyperkeratosis of the radial aspect of the thumbCaused by excessive cigarette lighter flicking
Knuckle pads[10] Hyperkeratosis over the knucklesCaused by boxing training
Russell sign[11] Callosities of the dorsum of the hand over the metacarpophalangeal and interphalangeal jointsCaused by the friction involved with self-induced emesis in bulimia nervosa
Screwdriver operator's clavus[12] Palmar surface of the handOccurs at the site of contact with a screwdriver handle
Spine bumpsHyperkeratosis over the spinal columnCaused by dancing with spinning on one's back
Hairdresser's handFirst finger on dominant handCallus formation at the site of friction caused by scissors around the first finger on the dominant hand
Sucking calluses[13] Lip, hand, or foot of a newbornCallus formation at the site of an area of suction on the lip, hand, or foot of a newborn
Vamp disease[14] FeetClavus formation due to wearing tight high-heeled shoes
Table 2
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