Hi all,
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I have a case that is baffling me a little that I'm hoping for some advice with. Complicating the issue is that the patient is a friend's father who lives 8 hours away, I see him only occasionally. He has seen a podiatrist where he lives who I regard as very competent.
HISTORY
58 year old male
No significant medical history
Osteoarthritis right knee
Has had left heel pain (plantarfasciitis) which was resolved with orthoses and
acupuncture
Wears orthoses daily at work (mine site)
CURRENT ISSUE
Occasional severe burning in 2nd toe only right foot. Location is the two distal phalanges, possibly isolated to the distal interphalangeal joint.
Not an obvious pattern (timing of symptoms) except it usually occurs twice each day, once in the morning and once in the late afternoon. I have not seen the patient while the toe was sore.
Does not swell or change colour
No initiating factor obvious (eg: injury, change in footwear / activities)
5 months duration
Occurs despite wearing orthoses plus the recent addition of a metatarsal dome. Is not worse when without orthoses. Is not worse when OA knee is particularly sore.
Acupuncture (one event) no help
EXAMINATION
No toe deformity
No reproduction of symptoms on movement of IPJs and MPJ through range of motion
Mild discomfort to palpation of 2nd/3rd plantar webspace. No Mulders sign. I would expect something a bit more definitive to make me suspect a neuroma.
Mild discomfort to plantar 2nd MPJ and plantar proximal phalanx
First ray is not excessively compliant to dorsiflexion
FPI +5 bilaterally
Lunges reveal no limitation of ankle joint dorsiflexion, but the feel (nonweightbearing dorsiflexion) is there is increased stiffness.
Very dry skin, reduced elasticity of skin and plantar fat pad
DIFFERENTIAL DIAGNOSES
1. Intermetatarsal neuroma - most likely due to the definite burning symptom. Although orthoses with met dome and calf stretches haven't helped, diagnostic ultrasound to confirm.
2. Osteoarthritis of the IPJs - although no pain on range of motion, radiographs will rule out.
3. Dorsal interosseus trigger point - unlikely as acupuncture did not help
4. Sausage toe - unlikley as no swelling or colour change
PLAN
1. Check with you guys to make sure there is nothing I've missed - don't you hate it when friends / family come to you with something curly and you feel like a dill because you don't immediately know what it is and how to fix it!
2. Radiographs - have requested
3. Diagnostic ultrasound once radiographs confirmed negative with a view to ultrasound guided cortisone injection if neuroma demonstrated.
Thanks in advance for your help. The patient is in town for the next week (though he has forgotten to bring his orthoses with him).
Rebecca
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