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Unusual Case id love some advise on

Discussion in 'Biomechanics, Sports and Foot orthoses' started by adrianjmoore, May 10, 2019.

  1. adrianjmoore

    adrianjmoore Welcome New Poster

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    39 year old male
    137 kgs

    Presented with L forefoot pain 3 mths ago. Started about 6 year ago with pain and numbness in both feet. Worse in L foot. Started at work one day when he was just standing. Nil injury, fall or change in lifestyle. Pain was centre of foot with numb toes. Was treated with orthotics but never really resolved. Has seen several podiatrists since and not much change.
    On initial visit with myself the pain had significantly increased on the L foot. His 1st MPJ and hallux was also significantly swollen and hot. It had been red also in the past. Pain was worse when weight bearing. There was numbness as well as pain. His GP had been treating this as Gout however his blood tests didn’t show any increase in uric acid levels. They have only shown increase in inflammatory markers. He has also trialled cortisone in the past. None of these treatments had helped. Pain killers dulled pain slightly but presently they also do not help.

    Lately the pain is increasing as long as the swelling. It has now spread to 2nd and 3rd mpj and digits.
    He is a fitter and machinist on his feet all day (up 60 hr week). Currently wearing steel blue lace up footwear. Laced very loosely due to swelling. Has even stopped wearing orthotics as they made shoe tighter and more painful. History of hypertension but under control with medication. Family history of TIIDM

    On palpation there is pain at 2nd and 3rd digits/IPJ’s, 3rd and 4th MPJ’s, 3rd and 4th ID space, 1st, 2nd and 3rd metatarsals (middle of shaft) and when mobilising (DF) hallux.
    Visually there is swelling, heat and some redness predominantly around 1st, 2nd,3rd MPJ’s and digits. Swelling and pain goes up till midfoot.

    Ankle ROM is good. 20-40 degrees w/ knee flexed and extended
    Flexible rearfoot with a lot of eversion
    Flexible midfoot
    PF 1st ray
    1st MPJ ROM 40 degrees
    Muscle strength is good

    Initially I thought it was plantar tear and ID nerve irritation but its now not fitting that diagnosis. I then thought it could be periosteal reaction of metatarsals but conservative treatment of this didn’t work too much either.

    Prolotherapy injection in 2/3/4 ID spaces did help initially. But pain returned. Which was to be expected
    I trialled increasing support of orthotics heel added heel posting. Moved met dome to more appropriate location. After this showed minimal results, I trialled plantar plate deflection away from 2nd and 3rd MPj. This initially helped but pain soon returned.
    He had 10 days off in which we gave stiff sole post op shoe. This improved pain when wearing it only.
    Currently he is strapping toes together to stop rubbing on 4th digit.
  2. efuller

    efuller MVP

    Is there any reason that you would think this pain is related to mechanics? High wear patterns in sock liner? Decreased fat pad? Long metatarsals? In the absence of that, and a warm swollen foot with increases in inflammatory markers I'd be worried about autoimmune problems RA etc.


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