Advice for problem patient

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Promblem patient


Hi everyone,
go easy on me I am a 4th year student just about to graduate!

I have a patient I was watching on placement, who I wish to work out the diagnosis myself but im stuck.

pt is a 23yo female, who studies education and works approx 20hours a week waitressing in cafe
shoes are converse sneakers at work, otherwise, like most qld'ers...thongs!

c/o pain Ld3-5, but cannot pin point where pain is (but said had a feeling it was d3)

pain was a dull ache, usually towards end of day

pain was in DIPJ, PIPJ IPJ of the toes

on palpation, no discomfort anywhere, even at PMA

free movement of MTJ PIPJ etc but heard a 'clunk' when inverting stj

no substantial LLD

muscle strength in both feet was very weak/poor, I actually thought she wasnt trying.
This was with and without resistance.

I asked her if she was clumsy when she was younger and she said yes.

patella and achilles reflexes were normal, as were dermatomes. was treated a while ago by chiro for sciatic pain, but had no problem since

Nothing obvious with her gait

no redness swelling or incident that noticed pain onset.....however did mention a air hostess trolley over the same toes 18mths ago on a plane

pain onset approx 12mths, but is starting to annoy her.


doesnt play any sport


I am sorry if this is a really obvious answer, but ive tried working it out with a couple of mates and we couldnt think of much


any Dx and DDx would be appreciated!!!!

I sent her off with a PMP to splay her toes for some relief :wacko:, but she is comign back shortly

 

Re: problem patint :S

A few questions

1 How is balance now ?

2 does she toe grip when walking ( look on the inside of her old converse )

3 position of STJ axis ?

4 whats PMA in this sentance -on palpation, no discomfort anywhere, even at PMA

if you were meaning Plantar metatarsal arch or distal transverse metatarsal arch. Read the below thread as this in no arch at the heads of the mets. they sit flat like a rake on the ground

http://www.podiatry-arena.com/podiatry-forum/showthread.php?t=7841

If the answers are

1 bad balance and proproreception

2 yes to toe gripping

3 medially deviated

Try low dye taping, get her to wear a more stable shoe, ice her toes when she comes home from work. Review again

If this works then she is toe gripping and when at work is developing inflammation in the ligaments and tendons of the toes.

Dx possible inflammation of flexor tendons and ligaments. ? joint irratation

tx better shoes, icing and orthotic device which may require forefoot posting depending on bx results

Hope that helps and gives you some thing to try next week.

 

Read your list of symptoms.

Standouts: bilateral muscle weakness, "clunk" on STJ ROM, and generalized pain thru the lesser digits.

Differential diagnosis:

1. Neuroma 3rd IS. Check for Mulders sign. Feet are not always as specific for dialing in pain.
2. The clunk in the STJ could represent a tarsal coalition (usually middle facet)
3. Bilateral muscle weakness...hmmm...possibly early signs of MS. Rule out with muscle biopsy or MRI of the brain. Neurologic consult might be helpful.

If you find out what it is...let me know.

Dr. Gary Docks (gwdocks@aol.com)

Good luck!

 

Michael
PMA is abbreviation for Plantar Metatarsal Area!
regards
David

 

And I have been told Plantar metatarsal arch so thats why I asked and then gave the link if it was. Just because you say plantar metatarsal area does not mean the rest of the world does see what does pna stand for thread as an example.

Really podleaner should have said ie plantar metatarsal .... ( pm. ) Then there would be no confusion.

 

Good Point!