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Bit of a head scratcher.....

Discussion in 'Biomechanics, Sports and Foot orthoses' started by Tim VS, Dec 12, 2005.

  1. Tim VS

    Tim VS Active Member

    Members do not see these Ads. Sign Up.
    Thought I'd lob this one in to see if anyone has any ideas.

    Male, 40s, came in with burning sensation and hypersensitivity in all toes, but more acute Hx, 2nd and 3rd. Symptoms are equal bilateral. First noticed this 1 year ago while skiing, but since then has gradually got worse and is now present in all footwear. No obvious surface pathology, inflammation or swelling of digits. No intra-metatarsal pain or Mulders sign. He is over pronating somewhat on RCSP, but has no other foot or lower limb symptoms. He is looking for answers, and so am I!

    I've thought about systemic, such as Raynauds,but nothing seems to fit there. Best I can come up with is some kind of metatarsalgia/neuritis, secondary to misalignment & hypermobility, but equal/bilateral??

    I've put him in in a pair of Slimflex with FF varus posts, to see if that might make a difference, but I'm not confident. He is returning this week, so I'd appreciate any advice.


  2. Pass him through the pathological sieve. Anatomically what is there? Look, feel, move. look for capsular/ non-capsular movement patterns. Check movement, passive, active and resisted. Remember, common things are common, rare things are rare. It is more likely to be something common with a slightly unusual presentation, than something rare. Get some imaging.
  3. Craig Payne

    Craig Payne Moderator

  4. LuckyLisfranc

    LuckyLisfranc Well-Known Member

    By definition of the pain alone, you should be thinking neurological; - it is equal and bilateral. Therefore it is peripheral neuropathy of unknown cause until proven otherwise.

    Hence the top aetiologies are (in no order): diabetes, alcohol, nerve compression/tarsal tunnel, hypothyroidism, Guillain-Barre, nutritional deficiency eg B12, toxicitiy/heavy metals, drugs such as amiodorone, porphyria, iodiopathic, sarcoidosis, et al.

    Start with the tarsal tunnel first me thinks...
  5. Tim VS

    Tim VS Active Member

    Thanks for your replies, guys. Craig first.

    If the pain is caused by pinching of the nerves at the met heads due to forefoot instability, then stabilising the forefoot might, I hope, relieve the symptoms. However, I don't think it is that, so I'm really only doing it to rule it out.
    I gave him a reasonably thorough work out I think Simon, but I may have missed something. I'll check one more time.
    I tend to go with you Lucky. Think I'm going to give up on this one and refer him on to a Neurologist. Is tingling in the toes an early sign of MS? Hope not. :(

    Thanks again,

  6. Peter

    Peter Well-Known Member

    I would get his forefoot Ultrasound scanned. Mulders sign is not always present. Pain in Ski-Boots? Neuritis via compression? If your forefoot post makes it worse, you are looking at this issue.
  7. davidh

    davidh Podiatry Arena Veteran

    Hi Tim,
    Since this is equal bi-lateral, and has been present for a year, logic suggests that the cause is probably not just local (ie something like footwear which is directly affecting the foot or feet) but may be due, at least in part, to something systemic.

    My initial thoughts are:
    Biomech dysfunction, possibly coupled with:
    Drug reaction. eg Certain anti-hypertensives will produce burning in the feet in some patients.
    Early signs of neurological or rheumatological disease.
    Could also be a combination of several factors.
    Let us know!
  8. DaFlip

    DaFlip Active Member

    Orthotics hey! So sorry for being so very negative again but why wouldn't you have chosen answer c) orthotics and heel lift. Sorry but couldn't resist.
    Lets be serious for a second, just one. Bilateral neural symptoms in all digits. Get outside the foot. Forget the worst case scenarios, like MS, and just look for the more common conditions. Conditions such as nerve root compression from posteriocentral disc should be first suspicion, L5/S1. Not that common to get bilateral conditions originating in the foot such as tarsal tunnel syndrome, since the most common causative factor is vascular occlusion. Mechanical causes of the TTS are not that common either, the other main cause is trauma and it's not that common bilat.
    Suggestion is to run through neural assessment in particular of L5/S1, ensure patency of reflex, sensory etc and dynamic nerve evaluation. If not comortable wth this type assessment refer patient out to someone who can run through neuro assessment and if necessary organise diagnostic imaging of the lumbosacral spine.
    Now Kev i am happy today and appear to be over my short burst of negativity. :) Its is amazing what a real hard 2 mile run over an hour will do for you!
    DaFlip :mad:
  9. yehuda

    yehuda Active Member

    unless you are running on your hands 2 miles in over an hour is verrrrrrrrrrrry slow and not very hard :) :) but i agree going out for a run definetly sorts out most problems :D and i havent run in 3 days coz my hip is killing me :mad: )
  10. stevewells

    stevewells Active Member

    He's a bit young but dont forget spinal stenosis - you didnt say what the pattern of presentation of symptoms were now
  11. Laurie Foley

    Laurie Foley Member

    "First noticed this 1 year ago while skiing,..." Is there a possibility of an jury here? Say in relation to his long flexors. I would respectfully suggest checking for any triggerpoints of the long flexors.
  12. summer

    summer Active Member

    I have to agree with Steve Wells on this one, if the pain is somewhat bilateral and symmetrical I would think spinal stenosis possible at the L3 L4 level as that is where the dermatome runs. Suggest a nerve study to the patient.
  13. DaFlip

    DaFlip Active Member

    It does depend a little on which text you use and also the specific mapping pattern of the individual. There is a significant difference between persons with regards as to the dermatomal and radicular referral patterns of the lumbar spine. Since the most common condition in those under 50 years is a herniated disc it would appear more likely to be this condition. Whilst posteriocentral disc lesions are not as common as posterolateral pathology it is more likely to be a radicular pattern from a posteriocentral disc path at L5/S1, then L4/5, then L3/4 then spinal stenosis unless the patient has history of congenital defect, DJD, or pathology. Basic radiographic analysis may suggest a measurement of less than 12mm of cross sectional area for the canal as an indicator if SS is suspected. I would use MRI if the back was suspected and forget NCV tests as these are rarely used for this type of assessment. It appears the US, Australia and NZ are a few of the only countries who routinely utilise these as they are very non specific for location of pathology. That is they will tell you which nerve is impacted but not where the problem is occurring. If you suspect back go to the back.
    The other option to thow in is chemical radiculopathy. Worth reading about as it may be a significant cause of many referral patterns but won't be readily picked up by many people.
    the west is won, the rest is next. Bring those Broncos home!
  14. DaFlip

    DaFlip Active Member

    Personally i am a little offended by the above statement. 2 miles per hour rocks. I have a rare condition which i have termed 'supreme fast twitch capacity'. It enables me to reach lactic threshold within 10 yards of the start. Normally this would take me about 15.8 seconds to achieve. I know i am boasting a little but the ego i have is due to my elite standing in the sport. I then recover for 12.5 minutes at a slow pace and really let rip again until i hit LT. I repeat this cycle for an hour or so and really find this a great work out. It may well be the secret to my phenomenal success in T&F over the last few years. With a messed hip up like yours, you should give it a try. You to might find it enables you to achieve an elite standing within the sport and travel the world competing for your nation. Obviously i do other training like aquarobics and ballet for mobility. However you may find this inappropriate to fit in with your schedule. Give it a try and don't laugh at my splits until you can achieve equal or better without hitting LT.
  15. dgroberts

    dgroberts Active Member

    I run a bit and don't understand a word you just said :confused:

    PLease let us know what happens with this guy anyway.
  16. yes,yes,yes

    and DaFlip, those 2mile stats.. impressive!! if no-one else has grabbed ya, if youre looking for a manager/sponsor.. i'm yours baby
  17. John Spina

    John Spina Active Member

    If there is something equal and bilateral,it can be systemic.I have diabetics with distal polyneuropathy which has not gone proximal.Think of a spinal etiology.Other oddballs:sarcoidosis,HIV(I have had HIV+ folks with neuropathy and resulting ulcers),MS,et al.But these are rare.Look for the horses first,then if that fails,look for zebras.A blood test should help.
  18. Tim VS

    Tim VS Active Member

    Thanks for your replies - just back from hols. Awaiting reports from physio referral as suggested. Chairside orthoses with FF varus posts have improved his symptoms 10% approx, but there is clearly more going on here. Subject to physio's report I may send him up the road to the neurologist. I await with interest and will post as I get more news.



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