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Plantar blister

Discussion in 'Biomechanics, Sports and Foot orthoses' started by grahammoore26, Apr 12, 2011.

  1. grahammoore26

    grahammoore26 Member

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    Hi All,

    I have had an unusual referral that I would be grateful for any input.

    Patient presented as an 11 year old boy, with a large apparent blister at the midpoint of the medial longitudinal arch intersection with the plantar aspect of the Left foot. On examination there were three distinct blisters, the largest of which was 5mm across, (see pictures), the blisters are firm to palpate, with no evidence of a liquid sack.

    Patient has been getting blisters for past 6 months, located on Left foot. Blisters appear and are then treated by GP, disappear after treatment, but then reappear. Once they develop area is painful to palpate and patient has pain when walking. Current GP treatment is Inadine dressings and Mepore dressings. Although these tend to work it basically is treating the symptoms not the underlying cause.

    There is no history of allergies and no evidence of eczema or skin reactions and no history of skin or neurological issues. All neurological responses were normal and sensation was normal, (based on a 10g filament). Both legs exhibit increased external rotation at the hips, (40 degrees ext / 36 degrees int). Passive dorsiflexion at ankle is 10 degrees with foot in neutral alignment. The lunge test gave an angle of 19 degrees. On standing both feet exhibit low arches, but no evidence of midfoot collapse, (x-ray shows normal boney development appropriate to an 11 year old).All foot structures are normal. Positive Hubscher test, (grade 4). Single leg standing showed slow rocking, pronation to suppination followed by pronatary collapse. Elevation of heels showed full correction of feet.Breighton scale 2

    Walking in bare feet showed increased pronatary collapse at 2nd rocker, but no other abnormalities.
    Footwear is standard Clarke’s school shoes with no shaping in the footbed, (separate sole / heel unit). Patient also wears Addidas trainers with no shaping in the footbed.

    My initial conclusion was that the feet were collapsing excessively during 2nd rocker, traumatizing the tissue in the midfoot. But as this has only happened on the left and all comparisons show that left and right are comparable, (patient is right handed so not the dominant side), the right should blister as well.

    I have as a test of my theory cast the foot for a custom orthotic with a cutout under the medial longitudinal arch, (which I will infill in clinic with low density compressible material), and rearfoot 5 degree medial post and 50% rearfoot Kirby skive to the cast, (Right foot same device but with no cutout and no Kirby skive). I’m using a 5 degree post, to match what was required to stabilize the foot for single leg standing. To both I’ve added a forefoot 3mm medial compressible post, to allow normal change to high gear but hopefully reduce the speed of the medial collapse.

    I would be grateful for any suggestions or if you can identify the blister that would be really helpful.

    Thanks for your help

    Attached Files:

  2. Craig Payne

    Craig Payne Moderator

    graham, I take your point on the description of the lesion as a 'hard lump', but without that description, that looks very much like a tinea.
  3. marjfra

    marjfra Member

    I agree with Craig. My initial reaction on looking at the photos was tinea!
  4. Mr C.W.Kerans

    Mr C.W.Kerans Active Member

    Anything between the toes indicative of tinea?
  5. grahammoore26

    grahammoore26 Member

    Hi Craig,

    I have to admit I didn't think of tinea, purely because of it's solid nature on palpation.
    It feels like plantar fibromatoses, but obviously is in the wrong layer. As I don't have a lot of experience with Tinea, (following your reply I've now updated myself), dosen't that generally have a more general discomfort, as opposed to the point discomfort that is almost specific to the lumps.
    And I can't believe that its tinea overlaid exactly on fibromatoses ? or is that logical

    Also the rest of the foot is intact with no other syptoms or signs, checked toes and they are fine.

  6. healandtoe

    healandtoe Member

    Hi Graham
    Does your client live in a coastal area, these look similar to sand fly bites. They can cause horrible blisters and take ages to heal.
  7. grahammoore26

    grahammoore26 Member

    Hi Mr Kearns,

    There is nothing anywhere else on the feet or toes, the firm lumps and skin breakdown are localised to the one specific area.

  8. grahammoore26

    grahammoore26 Member

    Unfortunetly no and they haven't been on holiday recently.

    But thanks for the thought
  9. healandtoe

    healandtoe Member

    They could be some sort of parasite from the soil, I have seen something presenting very similar , red spots which develop slightly yellowing pustules which dry up but spread out as they appear to dry,symptoms which proved to be sand fly bites, we get lots here. Are they itchy at all? Perhaps the client is rubbing them without consciously thinking about it. Try Mycota cream. Sometimes the explanation and cure can be very simple.
  10. blinda

    blinda MVP

  11. blinda

    blinda MVP

    Further, from the pics provided, I would say the blisters may be vesico-pustules and there appears to be some inflammation, both of which can be associated with TP. The dermatophytes usually involved in this type of presentation are Tri-mentagrophytes or Epidermophyton fluccosum. The vesicles are quite superficial, yet can still be uncomfortable, and usually seen on non weight bearing parts of the plantar surface, ie the medial longitudinal arch. They rupture easily with GRF. Hence, they come and go....

    I would take skin scrapings for culture, but that`s just me.

  12. Ian Linane

    Ian Linane Well-Known Member

    "I would take skin scrapings for culture, but that`s just me" ..... That's Bel for you. Not many people know Bel is the Podiatry equivalent of Dexter of television :), just doesn't kill her patients first.!!!!!
  13. grahammoore26

    grahammoore26 Member

    Hi Bel,

    Thanks for the reply, will get it cultured and let you know.

  14. grahammoore26

    grahammoore26 Member

    Hi Heelandtoe,

    Reading through my clinic notes, he did rub the foot as he was sitting talking to me - but he was very definite with his - it dosen't itch.

    The only thing that makes me think it's not a soil parasite is that patient has a sibling who is two years younger who has no syptoms and I can't imagine that he will not be doing everything big brother is.
  15. grahammoore26

    grahammoore26 Member

    Hi All,

    Just wanted to give some feedback and Thanks, following your advice I got scrapings cultured and it came back as Epidermophyton fluccosum, (Tinea Pedis),
    and so it's being treated now.

    Thank you so much for your advice and help.

  16. blinda

    blinda MVP

    Cool. Thanks for letting us know the outcome.

    Enjoy the sun!

    Bel (AKA Dexter Morgan ;))

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