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Unusual presentation of Burning and Tingling

Discussion in 'General Issues and Discussion Forum' started by pod87, Sep 9, 2016.

  1. pod87

    pod87 Member


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    Hi All,

    I have been racking my brain as to this patient with quite an unusual presentation. Please help if you have any insight :)

    42yo male, healthy, active
    L foot burning + tingling since 1.5yrs.
    R foot burning + tingling since 1 year.
    First noticed after skiing Jan 2015 - tight boots
    May have been mainly toes when it first began
    Plantar surface of feet seem HOT to patient
    Used to be intermittent, now more constant and both feet
    Occurs mainly at night during sleeping. Wakes patient up.

    No awareness of family history of burning feet
    Has not noticed swelling, excessive sweating on feet, no changes in skin temperature
    Occasionally tingling sensation - back of the arches bilateral
    Usually a disconnect between feet - one is not always as sore/burning as the other
    No joint pains

    Improved by exercise eg. cycling & walking
    Aggravated by sleeping

    Alcohol consumption- 1 glass of wine or beer/day
    Had BSLs taken - WNL - non-fasting though

    Using Scholl gel insoles - do not improve or aggravate symptoms
    Sport/Activities: walking 2km/day, mountain biking 1x/week 10-20km

    Traumas/Injuries:
    Occasionally gets pain in lower back, manages by being active

    Medical history:
    Atrial fibrillation (1998)
    Meds: Pradaxa, diovan, Linoxin

    Tenderness palpated at peroneus longus near peroneal head and tibial nerve at tarsal tunnel.
    Patient notes burning at proximal medial longitudinal arch/distal to medial calcaneal tubercle
    Patient notes tingling lateral legs

    Toes warm initial visit, cool to cold second visit
    Pedal pulses palpated - strong
    No abnormal temperature gradient
    Monofilament WNL

    Footwear:
    - Daily: RMW boots or lace-up oxfords, slip on loafers
    - Sporting: "Specialist" bike shoes

    Foot Posture: R planus, L neutral
    Rearfoot: R everted slightly, L neutral
    Gear: R low, L high
    Single Leg Lunge: VMOs WNL
    Glutes: WNL
    Calves/ ankle ROM: 12cm + bilateral
    Functional Hallux Limitus: R 35 deg, L 15 deg
    Supination Resistance: moderate
    Body Posture: posteriorly displaced COG - shoulders behind hips
    Gait: posteriorly displaced COG - shoulders behind hips, abducted feet, L>R abductory twist
    Orthotics: gel insoles

    Diagnosis: ????

    Treatments performed:
    First visit:
    Rigid Low Dye taping applied to R, flexible longitudinal arch taping taping applied to L

    Results: Night of taping - L foot felt better
    When woke up in morning R foot felt better than L
    Thinks feet felt better with tape on first day (but not significantly better)
    Did not notice a difference in sensations when took tape off
    Night after removed tape burning returned to normal

    Second Visit:
    Dry needles applied to L peroneus longus + L tarsal tunnel

    Issued neural stretch to be performed for 1 minute daily both legs

    Results: Noted no difference in burning sensations after dry needling. Patient thinks that no intervention has really helped so far.

    Patient went bike riding last weekend 18km, 25km steep incline
    Feet were sweating profusely, seemed to be "swimming" in socks

    I keep thinking is this vascular?? Is this neurological?? I don't think it is biomechanical but maybe a combination?
    I have been meaning to give COG exercises to patient but I do not think this is related to his night pain anyway.

    Please help :)
     
  2. Dieter Fellner

    Dieter Fellner Well-Known Member

    Consider a diagnosis of spinal stenosis and / or pseudostenosis
     
  3. PostMortem

    PostMortem Active Member

    Have a look at the recent post by toeslayer re: erythromelalgia. Your patient is in the right ball park and history for the development of this condition. I have seen one severe case of this and it is amazing to see how it can affect the limbs, an absolute nightmare for the patient!
     
  4. Ros Kidd

    Ros Kidd Active Member

    Has he mentioned this to his cardiologist? Atrial Fibrillation since being 24yo makes me think along the lines of pharmacologically induced neuritis. Just a thought.
    Ros
     
  5. pod87

    pod87 Member

    Thanks team. I will look into all 3 of these. Hopefully get some more leads.
    :)
     
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