Medscape is available in 5 Language Editions – Choose your Edition here.


Intractable Plantar Keratosis Workup

  • Author: Noah S Scheinfeld, JD, MD, FAAD; Chief Editor: Jason H Calhoun, MD, FACS  more...
Updated: Jan 20, 2016

Laboratory Studies

Standard preoperative tests are indicated.

Pedobarography provides numeric information regarding dynamic and static foot pressure. However, one study found the diagnostic validity of pedobarography to be low for intractable plantar keratosis (IPK) related to metatarsophalangeal (MTP) dislocation in rheumatoid arthritis.[25]


Imaging Studies

Weightbearing radiography should be performed for IPK. Anteroposterior (AP), lateral (LAT), and forefoot axial (FtAx) projections are best. Images are reviewed for possible fractures, metatarsal avascular necrosis (AVN), or accessory sesamoids. The metatarsal parabola should be noted, as well as the sagittal plane of the metatarsal heads on the FtAx view.

A radiopaque marker can be used to indicate the exact location of the lesion in the soft tissue.

If the lesion is overlying the first MTP sesamoids, the FtAx view is useful for evaluating for fracture of the sesamoid, as well as for gauging the overall size of the sesamoid.

A Harris mat can be used to determine pressure areas.


Other Tests

Nerve conduction studies, electromyography (EMG), and noninvasive vascular testing may be used if indicated on the basis of the clinical history. As a rule. these tests are rarely indicated in the workup of IPK.


Histologic Findings

Analysis of a biopsy specimen of IPK will show hyperkeratosis and inflammation.

Contributor Information and Disclosures

Noah S Scheinfeld, JD, MD, FAAD Assistant Clinical Professor, Department of Dermatology, Weil Cornell Medical College; Consulting Staff, Department of Dermatology, St Luke's Roosevelt Hospital Center, Beth Israel Medical Center, New York Eye and Ear Infirmary; Assistant Attending Dermatologist, New York Presbyterian Hospital; Assistant Attending Dermatologist, Lenox Hill Hospital, North Shore-LIJ Health System; Private Practice

Noah S Scheinfeld, JD, MD, FAAD is a member of the following medical societies: American Academy of Dermatology

Disclosure: Serve(d) as a speaker or a member of a speakers bureau for: Abbvie<br/>Received income in an amount equal to or greater than $250 from: Optigenex<br/>Received salary from Optigenex for employment.


Christopher F Hyer, DPM, FACFAS Foot and Ankle Surgeon, Director, Advanced Foot and Ankle Surgery Fellowship, Orthopedic Foot and Ankle Center

Christopher F Hyer, DPM, FACFAS is a member of the following medical societies: American College of Foot and Ankle Surgeons, American Podiatric Medical Association

Disclosure: Received consulting fee from Wright Medical Technology for consulting; Received royalty from Wright Medical Technology for consulting; Received consulting fee from Amniox for consulting; Received consulting fee from Stryker for none; Received consulting fee from Biomet for none.

Mark Loebenberg, MD, FAAOS Consulting Staff, Department of Orthopedic Surgery, Assaf HaRofeh Medical Center

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Chief Editor

Jason H Calhoun, MD, FACS Department Chief, Musculoskeletal Sciences, Spectrum Health Medical Group

Jason H Calhoun, MD, FACS is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American College of Surgeons, American Diabetes Association, American Medical Association, American Orthopaedic Association, American Orthopaedic Foot and Ankle Society, Michigan State Medical Society, Missouri State Medical Association, Southern Medical Association, Southern Orthopaedic Association, Texas Medical Association, Texas Orthopaedic Association, Musculoskeletal Infection Society

Disclosure: Nothing to disclose.

Additional Contributors

Heidi M Stephens, MD, MBA Associate Professor, Department of Surgery, Division of Orthopedic Surgery, University of South Florida College of Medicine; Courtesy Joint Associate Professor, Department of Environmental and Occupational Health, University of South Florida College of Public Health

Heidi M Stephens, MD, MBA is a member of the following medical societies: Alpha Omega Alpha, American Academy of Orthopaedic Surgeons, American Medical Association, American Orthopaedic Foot and Ankle Society, Florida Medical Association

Disclosure: Nothing to disclose.

  1. Mann RA. Pain in the foot. 1. Evaluation of foot pain and identification of associated problems. Postgrad Med. 1987 Jul. 82(1):154-7, 160-2. [Medline].

  2. Canale ST, Daugherty K, Jones L. Lesser toe abnormalities. Canale ST, ed. Campbell's Operative Orthopedics. 10th ed. St Louis: Mosby; 2003. 4068-72.

  3. Khoury V, Guillin R, Dhanju J, Cardinal E. Ultrasound of ankle and foot: overuse and sports injuries. Semin Musculoskelet Radiol. 2007 Jun. 11(2):149-61. [Medline].

  4. Carmona FJ, Huerta JP, Toledo JH. Plantar epidermoid inclusion cyst as a possible cause of intractable plantar keratosis lesions. J Am Podiatr Med Assoc. 2009 Mar-Apr. 2:148-52. [Medline].

  5. McKay C, McBride P, Muir J. Plantar verrucous carcinoma masquerading as toe web intertrigo. Australas J Dermatol. 2012 May. 53:e20-2. [Medline].

  6. Ghani S, Fazal MA. An unusual cause of intractable heel pain. J Foot Ankle Surg. 2011 Nov-Dec. 50(6):744-6. [Medline].

  7. Mann RA, DuVries HL. Intractable plantar keratosis. Orthop Clin North Am. 1973 Jan. 4(1):67-73. [Medline].

  8. Hatcher RM, Goller WL, Weil LS. Intractable plantar keratoses: a review of surgical corrections. J Am Podiatry Assoc. 1978 Jun. 68(6):377-86. [Medline].

  9. Dreeben SM, Noble PC, Hammerman S, et al. Metatarsal osteotomy for primary metatarsalgia: radiographic and pedobarographic study. Foot Ankle. 1989 Apr. 9(5):214-8. [Medline].

  10. Young DE, Hugar DW. Evaluation of the V-osteotomy as a procedure to alleviate the intractable plantar keratoma. J Foot Surg. 1980 Winter. 19(4):187-9. [Medline].

  11. Mann RA, Wapner KL. Tibial sesamoid shaving for treatment of intractable plantar keratosis. Foot Ankle. 1992 May. 13(4):196-8. [Medline].

  12. Unlü RE, Orbay H, Kerem M, Esmer AF, Tüccar E, Sensöz O. Innervation of three weight-bearing areas of the foot: an anatomic study and clinical implications. J Plast Reconstr Aesthet Surg. 2008. 61(5):557-61. [Medline].

  13. Plascencia Gómez A, Vega Memije ME, Torres Tamayo M, Rodríguez Carreón AA. Skin disorders in overweight and obese patients and their relationship with insulin. Actas Dermosifiliogr. 2014 Mar. 105(2):178-85. [Medline].

  14. Kang JH, Chen MD, Chen SC, Hsi WL. Correlations between subjective treatment responses and plantar pressure parameters of metatarsal pad treatment in metatarsalgia patients: a prospective study. BMC Musculoskelet Disord. 2006 Dec 5. 7:95. [Medline]. [Full Text].

  15. Kiviniemi VJ, Leppilahti J, Jalovaara P. Study of straight metatarsal osteotomy for the treatment of plantar callosities. Ann Chir Gynaecol. 2000. 89(4):309-12. [Medline].

  16. Kitaoka HB, Patzer GL. Chevron osteotomy of lesser metatarsals for intractable plantar callosities. J Bone Joint Surg Br. 1998 May. 80(3):516-8. [Medline]. [Full Text].

  17. Idusuyi OB, Kitaoka HB, Patzer GL. Oblique metatarsal osteotomy for intractable plantar keratosis: 10-year follow-up. Foot Ankle Int. 1998 Jun. 19(6):351-5. [Medline].

  18. Grimes J, Coughlin M. Geometric analysis of the Weil osteotomy. Foot Ankle Int. 2006. 27(11):985-92. [Medline].

  19. Kennedy JG, Deland JT. Resolution of metatarsalgia following oblique osteotomy. Clin Orthop Relat Res. 2006 Dec. 453:309-13. [Medline].

  20. Spence KF, O'Connell SJ, Kenzora JE. Proximal metatarsal segmental resection: a treatment for intractable plantar keratoses. Orthopedics. 1990 Jul. 13(7):741-7. [Medline].

  21. Pontious J, Lane GD, Moritz JC, et al. Lesser metatarsal V-osteotomy for chronic intractable plantar keratosis. Retrospective analysis of 40 procedures. J Am Podiatr Med Assoc. 1998 Jul. 88(7):323-31. [Medline].

  22. Vaseenon T, Wattanarojanaporn T, Intharasompan P, Theeraamphon N, Auephanviriyakul S, Phisitkul P. Foot and ankle problems in Thai monks. J Med Assoc Thai. 2015 Jan. 98(1):71-6. [Medline].

  23. Garcia Carmona FJ, Pascual Huerta J, Hernandez Toledo J. Plantar epidermoid inclusion cyst as a possible cause of intractable plantar keratosis lesions. J Am Podiatr Med Assoc. 2009 Mar-Apr. 99:148-52. [Medline].

  24. Ferguson K, Thomson AG, Moir JS. Case study: Epidermoid cyst following percutaneous Topaz coblation for plantar fasciitis. Foot (Edinb). 2012 Mar. 22(1):46-7. [Medline].

  25. Choi YR, Lee HS, Kim DE, Lee DH, Kim JM, Ahn JY. The diagnostic value of pedobarography. Orthopedics. 2014 Dec 1. 37(12):e1063-7. [Medline].

  26. Zhao M, Zhao Q, Bao T. Dong's extraordinary points combined with pelvis adjustment for 21 cases of refractory calcaneal pain. Zhongguo Zhen Jiu. 2015 May. 35(5)::459-60. [Medline].

  27. Rawicki B, Sheean G, Fung VS, Goldsmith S, Morgan C, Novak I. Botulinum toxin assessment, intervention and aftercare for paediatric and adult niche indications including pain: international consensus statement. Eur J Neurol. 2010 Aug. 17 Suppl 2:122-34. [Medline].

  28. Jain K, Murphy PN, Clough TM. Platelet rich plasma versus corticosteroid injection for plantar fasciitis: A comparative study. Foot (Edinb). 2015 Dec. 25(4):235-7. [Medline].

  29. Malal JJ, Shaw-Dunn J, Kumar CS. Blood supply to the first metatarsal head and vessels at risk with a chevron osteotomy. J Bone Joint Surg Am. 2007 Sep. 89(9):2018-22. [Medline].

  30. Garg R, Thordarson DB, Schrumpf M, Castaneda D. Sliding oblique versus segmental resection osteotomies for lesser metatarsophalangeal joint pathology. Foot Ankle Int. 2008 Oct. 29(10):1009-14. [Medline].

  31. Roukis TS. Clinical outcomes after isolated periarticular osteotomies of the first metatarsal for halluxrigidus: a systematic review. J Foot Ankle Surg. 2010 Nov-Dec. 6:553-60. [Medline].

All material on this website is protected by copyright, Copyright © 1994-2016 by WebMD LLC. This website also contains material copyrighted by 3rd parties.