Welcome to the Podiatry Arena forums

You are currently viewing our podiatry forum as a guest which gives you limited access to view all podiatry discussions and access our other features. By joining our free global community of Podiatrists and other interested foot health care professionals you will have access to post podiatry topics (answer and ask questions), communicate privately with other members, upload content, view attachments, receive a weekly email update of new discussions, access other special features. Registered users do not get displayed the advertisements in posted messages. Registration is fast, simple and absolutely free so please, join our global Podiatry community today!

  1. Have you considered the Clinical Biomechanics Boot Camp Online, for taking it to the next level? See here for more.
    Dismiss Notice
Dismiss Notice
Have you considered the Clinical Biomechanics Boot Camp Online, for taking it to the next level? See here for more.
Dismiss Notice
Have you liked us on Facebook to get our updates? Please do. Click here for our Facebook page.
Dismiss Notice
Do you get the weekly newsletter that Podiatry Arena sends out to update everybody? If not, click here to organise this.

Advice please - Forefoot ? scrunched up sock sensation

Discussion in 'General Issues and Discussion Forum' started by Salanne, Jun 9, 2012.

  1. Salanne

    Salanne Member


    Members do not see these Ads. Sign Up.
    Please could I ask the members for advice on a condition that I have been unable to identify, treat or resolve - and I would value any guidance from the expereinces of others on the site.

    My patient is male, age 67 fit and active, retired and is in good health.
    Meds: He has taken statins for 4 yrs and had to increased them 2 yrs ago as his GP was concerened about his cholesterol levels - this is now managed well.
    He is approx 2.5 overweight but losing weight currently.

    Pt came to me complaining of " a pain/sensation under my toes on both feet but more so on my right side. It started about 18 months ago but was particulary bad after dancing all night on last New Years eve in hard sole shoes. The pain then spread over the sole of my foot for that one time. It feels as if my socks have rucked up under the toes and it is very uncomfortable - I can now feel it most of the time. It started after I had been working walking on the rafters in my loft.

    Exam:

    BF has no signs skin infection/inflammation
    Pt initially felt if the feet were cool it was helpful, however now he feels that was a false positive
    There is some distally movement of the MPJ fibro-fatty tissue under the lesser toes - however not severe
    There is no pain or unusual sensation when all lesser toes joints are palpated
    Pt has not know neurological conditions
    Doppler BF PT/DP triphasic
    Monofiliment BF 10/10
    Neurotip BF 3/3
    BF pale in colour normal temp gradient
    No callous/soft tissue issues
    No excessive clawing of lesser toes

    Discussion:

    As my first thought was that it could be the distal movement of the MPJ fibro fatty pad which was creating this feeling -
    I tried a silicon toe prop - the pt reported that this made the discomfort worse
    Using emmollient (skin disorders) - made the feeling worse
    Surgical Spirit initially helped - no effect now I had considered whether he had a sweat glad disorder
    Changing footwear - no effect
    Walking barefoot - no effect

    Although I have not completed a full BMX evaluation he does not present with any obvious disorders.

    D/D ? plantar plate disorder, capsulitis, gout, ligaments.........

    HELP!

    At this stage I am at a loss and my thoughts are to ref him back to the GP (who referred him to me as he did not know what it was either) for further tests.

    Can anyone through any light onto this problem - the patient is at a stage where he feels that he should be resigned to the fact that it is unknown - but he like myself would at least like to know what it might be.

    AS my experience is still growing as having only qualified in 2009 I would be very grateful for any suggestions.
    :sinking:
     
  2. Craig Payne

    Craig Payne Moderator

    Articles:
    8
    'Screwed up sock" sensation is a often described symptom of those with any one of the many causes or peripheral neuropathy. They need a more complete neuro work up.
     
  3. Salanne:

    Many patients with plantar plate tears/metatarsophalangeal capsulitis subjectively describe that they feel as if they are walking on a "bunched up sock" or have "something stuck to the bottom of their foot". This subjective sensation is likely due to the edema plantar to the metatarsophalangeal joint (MPJ) that commonly occurs due to this condition.

    http://www.podiatrytoday.com/current-insights-treating-second-mpj-dysfunction

    Even though you wrote up a good history and physical on this patient, here are some exam tips for this condition. The tenderness from plantar plate pathology is 95% of the time localized not so much plantar to the metatarsal head but rather more at the insertion of the plantar plate onto the base of the proximal phalanx of the affected digit where, in nearly all instances, the tear in the plantar plate actually occurs.

    http://www.ncbi.nlm.nih.gov/pubmed/22381345

    I have also attached one of the better papers on the correlation of ultrasound to MRI findings and histologic examination in plantar plate tears (Gregg JM, Silberstein M, Schneider T, Kerr JB, Marks P: Sonography of plantar plates in cadavers: Correlation with MRI and histology. Am. J. Roentgenology, 186:948-955, 2006).

    One thing that helps differentiate symptomatic plantar plate tears is that they nearly always are painful on manual plantarflexion of the affected digit at the MPJ. I call this test the "digital plantarflexion test". The probably reason for the pain with the "digital plantarflexion test" with plantar plate tears is that the area of the plantar plate tear is compressed onto itself with this test. The vertical drawer test of the digit will also be positive with a more severe plantar plate tear. Often times the plantar edema is so obvious so that it can be seen from across the exam room but nearly always, to the careful and experienced clinician, plantar MPJ edema can be easily palpated even in the mildest cases of plantar plate pathology.

    Try examining again much more closely to find the area of maximum tenderness at the affected MPJ. Sometimes you must press very firmly to find the area of maximum tenderness. Another test I use to determine which MPJ is most symptomatic is what I call the "metatarsal head compression test". With the patient in relaxed bipedal stance barefoot on the floor, take your index finger and press firmly downward onto each metatarsal head to see which plantar MPJ is the most painful with this "metatarsal head compression test". The MPJ with the plantar plate pathology will alwaysbe the most painful with the "metatarsal head compression test".

    After you have determined which MPJs are most affected, then make an accommodative pad for the MPJ(s) so that the patient cab start walking all the time in this pad. Also have the patient start doing icing therapy 20 minutes twice a day and have them avoid any barefoot walking or walking in thin-soled shoes. You may try plantarflexion taping of the digit to reduce the tensile stress on the plantar plate especially if digit has started to dorsiflex due to the loss of MPJ plantarflexion moment from the plantar plate tear. Modified over-the-counter foot orthoses or custom foot orthoses are probably the best way to treat these pathologies long-term on a conservative basis.

    Hope this helps.:drinks
     
  4. Salanne

    Salanne Member

    Thank you very much for all the information I am very grateful - I have just contacted the patient to call them back for further tests and I will report back on the findings.

    You never stop learning but some days you just need to discuss it with others to see it from a different perspective.

    Thank you again

    Salanne
     
  5. Lorcan

    Lorcan Active Member

  6. Tkemp

    Tkemp Active Member

    Kevin,

    Thank you so much for that information and the articles.
    Even before the first coffee of the morning I could follow the techniques in my mind.

    Will now convince my colleague to practise :)

    Cheers,
    Tracy
     
  7. Salanne:

    It would most helpful for everyone following along, including myself, to hear back from you on a regular basis on your continued treatment of this patient, including your exam findings, treatments and your patient's response to those treatments over time. This type of followup by the clinician is what makes these cases so clinically valuable for the hundreds of clinicians around the world who frequent Podiatry Arena on a daily basis to improve their clinical skills.

    Thanks for keeping us informed of your patient's progress.:drinks
     
  8. Bev Ashdown

    Bev Ashdown Welcome New Poster

    A scrunch up sock sensation if often the way in which patients describe pain from a Mortens neurima, have you performed the Mulders Click test?
     
  9. Salanne

    Salanne Member

    Thank you Kevin I really value the help and support from you, Craig, Lorcan and Tracy and my apologies for the slow response - I have only just had the patient back in to see me however I am pleased to report the results of the examination...

    The patient was pleased to hear from me especially as he felt that if he went back to the GP the health service probably would not take it too much further (previous experience). Neverthe less he was still not convinced that we would be able to establish anything.

    Exam and clinical tests.

    1, "Metatarsal head compression test"
    RF no tendereness/discomfort was felt under R1245 but mark difference on R3 which proved a postive for tenderness/?pain/discomfort (patient was very pleased when I removed the pressure)
    LF was the same but not so tender - this was fitting in with the picture as it had always been the right foot that had been more symptomatic.

    2. Trauma/Edema
    The originating trauma had been caused by working on narrow rafters in the attic over 18 month ago standing/crouching on the "ball of his feet" - Edema is not particularly evident upon examination - however the patient has quite fleshy feet (patient is about 2.5 stones overweight) so I was unable to clearly identify.

    3. Plantar flexion of lesser toes
    This part of the examination was a little more tricky - when just plantar flexing the toes on BF the patient reporting no differences - I then went back and grasp the MPJ head with thumb and fingers on one hand and the phalanx in my other and plantar flex which I hope Kevin is the vertical drawer ? the patient report some differences with the BF 3's being the target area.

    4. Mortons Neuroma
    I did also perform again the 'Mulders Click' test just to recheck that there was no interdigittal nerve compression - this proved negative


    Patient discussion

    Although not conclusive, in view of the current findings my feelings are that the patient has a plantar plate disorder -
    My concerns are that the 'postives' were not outstanding - the key points for debate are:-

    The condition is now chronic so possibly symptoms such as edema and acute pain might not be so clear cut (sorry cannot thing of another way of putting that)

    My inexperience of performing the tests have left some area inconclusive
    ( I did try to look at any utube clips on these tests beforehand) however being shown by an experienced practitioner in real life is the preferred way of being sure that you are getting reliable results.

    Treatment Plan

    The most important thing to say at this time is that after a lengthy discussion with the patient that I had not given up on his case and that I had been seeking further advice from my 'colleagues far and wide' - and also clearly showing him what we were testing for and why he is a lot more confident.

    This has helped enormously with developing a treatment plan with him as he is keen to see if we will get any improvements - we are working as a team and patient compliance is sometimes the best medicine of all.:empathy:

    I have asked him to change footwear/not too walk barefoot
    To use the icing technique for 20 mins per day
    I also used soft tissue moblisation once which he reporting back that it gave him some short term relief

    I wanted to take this one stage at a time so I have the patient coming back in 2 weeks to see if there are any improvement after changes in footwear etc - we will then introduce padding and taping

    Or go back to the drawing board............

    Kevin - Sorry this is so lengthy and please excuse any lack of correct terminology (although I am very pleased to be corrected on anything again it is the only way to learn) - I felt it was important to reflect the case clearly in hope that it helpful to others.

    Craig thank you for your reply - unfortunately any further neurological evaluation/tests would have to referred as I did not have any access to any other procedures. Mind you I did not do a reflex test but he does not exhibit any other symptoms. He is not a regualr alcohol drinker.

    Thank you Lorcan for your help I used some of the images to show the patients the area we were testing and what for helped alot when I ran out of words.....

    Looking forward to any comments - and I will continue to post results

    Thank you

    Salanne
     
  10. Salanne:

    I am very proud of you. You have taken the advice of those who have commented, have applied that new knowledge to the examination and treatment of your patient and, even better, you have taken the time to give us a very thorough description of your examination findings which will absolutely help many, many others do the same. Awesome!:drinks

    Here is what I would do for treatment now that your patient is likely suffering from a plantar plate tear/contusion and metatarsophalangeal joint (MPJ) capsulitis.

    1. Make an accommodative pad for the 3rd MPJ using 3-5 mm adhesive felt, EVA, korex or other suitable accommodative insole material. Also you should try adding a metatarsal pad so that the distal edge of the metatarsal pad ends approximately 15 mm distal to the metatarsal neck (some like the pad, others do not). I have attached one of my illustrations for doing a similar technique to an orthosis for the 2nd MPJ which you should be able to easily modify to accommodate only the affected 3rd MPJ.

    2. Have the patient wear this modified insole all the time. Initially, no barefoot walking, no squatting, no climbing ladders and no jumping or running should be allowed.

    3. Have the patient ice the plantar aspect of the MPJs of the affected foot with an icepack, 20 minutes twice a day, onto bare skin. I will have the patient use a ziplock bag full of crushed ice, or a bag of frozen peas/corn or a reusable ice pack, put it directly on the ground and then have them sit down and put their forefoot onto the ice pack for 20 minutes, twice daily. This single treatment should make a huge difference for the patient in ridding them of much of their plantar MPJ edema which creates the "bunched up sock" sensation.

    4. Consider making a foot orthosis for the patient with the anterior orthosis edge 5 mm thick, with an MPJ accommodation for the 3rd MPJ (e.g. 3 mm korex plantar to met heads, 1,2, 4, & 5). This is the best long term solution to prevent further damage to the plantar plate.

    5. Use plantarflexion taping of the affected digit to limit excessive dorsiflexion of the digit if the digit is starting to dorsiflex due to a signficant plantar plate tear. This plantarflexion taping will reduce the tensile force on the plantar plate during propulsion which will help not only the pain will also promote more rapid healing of the plantar plate injury. I have attached the classic paper by the late Gerard Yu on "predislocation syndrome" which thoroughly reviews this technique and the pathology (Yu GV, Judge MS, Hudson JR, Seidelmann FE: Predislocation syndrome: Progressive subluxation/dislocation of the lesser metatarsophalangeal joint. JAPMA, 92: 182-199, 2002).

    Good luck with treatment and please keep us informed of your progress.
     
  11. Salanne

    Salanne Member

    Thank you Kevin I really value the help and support from you, Craig, Lorcan and Tracy and my apologies for the slow response - I have only just had the patient back in to see me however I am pleased to report the results of the examination...

    The patient was pleased to hear from me especially as he felt that if he went back to the GP the health service probably would not take it too much further (previous experience). Neverthe less he was still not convinced that we would be able to establish anything.

    Exam and clinical tests.

    1, "Metatarsal head compression test"
    RF no tendereness/discomfort was felt under R1245 but mark difference on R3 which proved a postive for tenderness/?pain/discomfort (patient was very pleased when I removed the pressure)
    LF was the same but not so tender - this was fitting in with the picture as it had always been the right foot that had been more symptomatic.

    2. Trauma/Edema
    The originating trauma had been caused by working on narrow rafters in the attic over 18 month ago standing/crouching on the "ball of his feet" - Edema is not particularly evident upon examination - however the patient has quite fleshy feet (patient is about 2.5 stones overweight) so I was unable to clearly identify.

    3. Plantar flexion of lesser toes
    This part of the examination was a little more tricky - when just plantar flexing the toes on BF the patient reporting no differences - I then went back and grasp the MPJ head with thumb and fingers on one hand and the phalanx in my other and plantar flex which I hope Kevin is the vertical drawer ? the patient report some differences with the BF 3's being the target area.

    4. Mortons Neuroma
    I did also perform again the 'Mulders Click' test just to recheck that there was no interdigittal nerve compression - this proved negative


    Patient discussion

    Although not conclusive, in view of the current findings my feelings are that the patient has a plantar plate disorder -
    My concerns are that the 'postives' were not outstanding - the key points for debate are:-

    The condition is now chronic so possibly symptoms such as edema and acute pain might not be so clear cut (sorry cannot thing of another way of putting that)

    My inexperience of performing the tests have left some area inconclusive
    ( I did try to look at any utube clips on these tests beforehand) however being shown by an experienced practitioner in real life is the preferred way of being sure that you are getting reliable results.

    Treatment Plan

    The most important thing to say at this time is that after a lengthy discussion with the patient that I had not given up on his case and that I had been seeking further advice from my 'colleagues far and wide' - and also clearly showing him what we were testing for and why he is a lot more confident.

    This has helped enormously with developing a treatment plan with him as he is keen to see if we will get any improvements - we are working as a team and patient compliance is sometimes the best medicine of all.:empathy:

    I have asked him to change footwear/not too walk barefoot
    To use the icing technique for 20 mins per day
    I also used soft tissue moblisation once which he reporting back that it gave him some short term relief

    I wanted to take this one stage at a time so I have the patient coming back in 2 weeks to see if there are any improvement after changes in footwear etc - we will then introduce padding and taping

    Or go back to the drawing board............

    Kevin - Sorry this is so lengthy and please excuse any lack of correct terminology (although I am very pleased to be corrected on anything again it is the only way to learn) - I felt it was important to reflect the case clearly in hope that it helpful to others.

    Craig thank you for your reply - unfortunately any further neurological evaluation/tests would have to referred as I did not have any access to any other procedures. Mind you I did not do a reflex test but he does not exhibit any other symptoms. He is not a regualr alcohol drinker.

    Thank you Lorcan for your help I used some of the images to show the patients the area we were testing and what for helped alot when I ran out of words.....

    Looking forward to any comments - and I will continue to post results

    Thank you

    Salanne
     
  12. drsarbes

    drsarbes Well-Known Member

    In addition to the fine advice given already;
    I have found many patients with the FOLDED sock or SCRUNCHED sock feeling have an early Tarsal Tunnel syndrome.

    If you find no forefoot pathology or generalized neuropathy, I would see if your patient has a positive tinnel's sign on percussion of the Tarsal Tunnel. Frequently they will have radiation to the forefoot where they are experiencing symptoms. If so, inject 1cc plain dexamethasone intra-tarsal tunnel.

    If they get relief then I would make the Dx of TT syndrome.

    Steve
     
  13. Salanne

    Salanne Member

    Thank you Drsarbes I had not thought of tarsal tunel syndrome I will test for this when he next comes in.
     
  14. Mart

    Mart Well-Known Member

    Hi Salanne

    Couple of thing I would add to thread so far.

    Absence of Mulder sign doesn't rule out early so called “Morton’s neuroma” - MN

    pain from MN is likely caused by plantar digital neuritis - PDN

    PDN may also be caused by inter-metatarsal space bursa enlargement compressing adjacent to plantar digital nerve

    PDN can also be caused by overly narrow foot-wear

    PDN in early stages may manifest as altered sensation typically (feeling like a bunched up sock or similar idea)

    When foot-wear is a factor and symptoms are mild, modifying footwear habits in my experience will resolve problem completely often when recalcitrant to many other interventions.

    Many people believe that their foot-wear fits well when it can actually be seen to constrict forefoot

    I find a good test is to have patient rapidly transfer entire body wt from one foot to the other whilst standing upright shod. Look at the behaviour of the shoe at medial and lateral forefoot and see if there is significant shoe bulging with this manoeuvring. If there is I think we can infer that there is likely reduction in available inter-metatarsal space whilst at the same time applying a deforming forefoot force; this will then reduce headroom to avoid irritating compressive stress to interposed structures including neurovascular bundle and perineural incompliant mass (MN).

    I would expect provocative testing with barefoot single limb stance heel raise to result in metatarsalgia in someone with a symptomatic plantar plate injury

    Generally I find those with PDN will have sensitivity, often pain radiating distally or proximally with careful palpation dorso-anteriorly into inter-metatarsal space just proximal to metatarsal heads. You can isolate stress from the plantar plate and joint capsule at this site; I believe it is reasonably specific. When observing with ultrasound you can see how this compresses the inter-metatarsal space fat tissue down against the bursa to the neurovascular bundle.

    hope that helps a bit in thinking about this common complaint

    Cheers

    Martin
     
  15. David Smith

    David Smith Well-Known Member

    Salane

    This is a common symptom and can be quite difficult to reduce, however I once had a male patient who was elderly (70yrs) and had this pain that I could not resolve with extensive orthotic therapy etc, a orthopod consultant prescribed haemorroid cream and that resolved the problem. I don't know the diagnosis but one might imagine vasculitis, varicose vein or similar.

    Regards Dave Smith
     
  16. Edema is not the most important exam finding, plantar plate tenderness is the most important exam finding. My guess is that you simply are not using enough force with your thumbs on the plantar plate to find the most tender area of the foot. Imagine how much force this large man has on his foot with each step and then try to reproduce that force/surface area (i.e. pressure) with your thumb on the plantar plate, especially at its distal attachment to the proximal phalanx base. If you are worried about a false positive, use the same manual pressure on another MPJ's plantar plate of the patient and you will find if your manual pressure elicits tenderness on even the unaffected MPJs. This gives you a better idea of just how hard you much press on some of the bigger feet to reproduce the plantar pressures which cause the plantar plate symptoms in these patients.

    With the patient non-weightbearing on the exam table, I grasp the distal aspect of the dorsal proximal phalanx shaft with the tip of my thumb and then, while stabilizing the plantar aspect of the forefoot with the other hand, push very firmly on the dorsal proximal phalanx to try to plantarflex the digit approximately 20-30 degrees past the "plane of the ground". If there is a more symptomatic plantar plate tear, this will always produce increased pain and you will feel increased resistance to MPJ plantarflexion (increased MPJ plantarflexion stiffness) when performing this test. In more severe plantar plate tears with MPJ dorsiflexion adaptation, you will not be able to plantarflex the digit past 0 degrees due to pain and increased MPJ plantarflexion stiffness. If there is a mild plantar plate tear and little plantar edema, then the test may produce no pain and little increase in MPJ plantarflexion stiffness.[/QUOTE]
     
  17. N.Knight

    N.Knight Active Member

    Hi,

    I am currently writing some guidelines on the treatment of plantar plate injuries, as well as the papers Kevin has posted up I have attached another one I found useful. I do not know if you are NHS or PP, but if you have limited access to immediate orthoses, I tend to issue a slimflex with a met dome ad medial heel post, then a more permanent device as Kevin described.

    Also I know it was mentioned in a recent thread; however I feel it explains the reverse windlass mechanism very well.

    Nick
     

    Attached Files:

  18. Good papers Nick. Here is an illustration I did a few years ago specific for the modification used to treat 3rd MPJ plantar plate injuries which is probably more specific to the case presented by Salanne.
     
  19. Salanne

    Salanne Member

    Thank you all for so much help I will report back on suggested treatment plans soon as I have the patient in again.

    Just to clarify I am in private practice but as I am still building experience and confidence with orthotics I normally approach the procedure by using something like slim flex with adaptations to see if it is working beneficially for the patient. Also this give me opportunity to educate patients into suitable footwear which can be an uphill battle ......

    Back to reading the posts/threads again.

    Thank you all for so much information it has really helped me to approach this problem with a greater understanding.
     
  20. Here is another illustration which I made a few years ago to describe the anatomy and function of the plantar plate and plantar fascia for my "Ten Functions of the Plantar Fascia" lecture. Note that the plantar plate is actually an extension of the plantar aponeurosis, mechanically connecting each slip of the central component of the plantar aponeurosis to the base of the proximal phalanx of each digit. Plantar plate tears will lessen the passive metatarso-phalangeal joint (MPJ) plantarflexion moment since the plantar aponeurosis will, with the plantar plate tear, not be able to plantarflex the MPJ and digit toward the ground as effectively as before the plantar plate was injured. Plantar plate tears are a very common cause of hammertoe deformities in, especially, the 2nd and 3rd lesser digits.
     
  21. Ray Anthony

    Ray Anthony Active Member

    As far as I can see, no member has recommended radiographic imaging to make a definitive diagnosis of the patient's chief complaint. If there is a high suspicion of a definitive lesion, an MRI is likely to identify it, and then you can tailor your treatment plan accordingly.
     
    Last edited: Jun 19, 2012
  22. Mart

    Mart Well-Known Member

    Hi Ray

    Imaging may confirm clinical suspicion in this kind of presentation but just as likely may be confusing since identification of a lesion may be moot for symptom. What example could you identify which radiographic exam or MR might be helpful in this case?

    I cant think of any role for radiographic exam.

    MR might identify early so called “Morton’s neuroma”, inter-metatarsal space bursa enlargement adjacent to plantar digital nerve or flexor tenosynovitis (unlikely to be definitive) or plantar plate defect (common but not necessary cause of symptom). Other mechanical cause of peripheral neuropathy I would think unlikely to show on MR.

    US would be worthwhile if done by clinician - I can give example of anyone interested.

    Cheers

    Martin

    Foot and Ankle Clinic
    1365 Grant Ave.
    Winnipeg Manitoba R3M 1Z8
    phone [204] 837 FOOT (3668)
    fax [204] 774 9918
    www.winnipegfootclinic.com
     
  23. Ray Anthony

    Ray Anthony Active Member

    Martin,

    I have to say, I'm surprised at your reluctuance to employ imaging in this case. Do you not think it might be worth ruling out fracture as the aetiology of the patient's symptoms -- there is certainly a history of increased activity? What about a relatively long 3rd metatarsal as the aetiolgy of mechanical overload -- worth a look, perhaps? There's two very basic reasons for an x-ray study for a start.

    To my mind, your comment ". . .identification of a lesion may be moot for symptom" is a very tenuous approach. Of course, there's always the possibility that a lesion discovered on an image may not be the cause of the symptoms. But as we have all been taught, we don't just treat radiographic findings. At this stage, Salanne has a high suspicion (a provisional clincial diagnosis) of plantar plate disruption. Would it be "moot" if an US or MR scan showed a definitive plantar plate lesion? What if the MR scan showed the third strip of FDL to be oedematous and the other strips normal? Would this be "moot," or do you think it might provoke Salanne to re-think her provisional diagnosis and her proposed treatment programme?

    Sincerely,

    Ray Anthony
     
    Last edited: Jun 19, 2012
  24. Mart

    Mart Well-Known Member

    Hi Ray

    I would not expect # to cause feeling of bunched up sock, normally even stress # would be painful and accompanied by edema, possibly ecchymosis if acute.

    If physical exam, as Kevin outlined, was +ve for plantar plate defect, I'd feel that this would not warrant MRI since PE is pretty specific for this problem. I would do US to confirm this since I have that on hand but wouldn't order test unless problem did not respond to first line therapy.

    Long 3rd metatarsal needing radiographic exam? Essentially if foot-wear is not issue I would want to look for evidence of alternative cause of mechanical plantar digital neuritis. In absence of this, as Craig mentioned, consider an alternative explanation for peripheral neuropathy.

    If there was metatarsalgia (which doesn't seem to be case here), if metatarsal parabola issue were seen as important I would treat empirically with foot orthoses to offload; I cant see that radiographic exam would alter initial approach.

    Cheers

    Martin


    Foot and Ankle Clinic
    1365 Grant Ave.
    Winnipeg Manitoba R3M 1Z8
    phone [204] 837 FOOT (3668)
    fax [204] 774 9918
    www.winnipegfootclinic.com
     
Loading...

Share This Page