Advice needed for 1st MPJ pain

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I’m a new graduate and would like advice on this particular case-

Initial presentation-
Female, 30’s
history –temporary loss L leg sensation post epidural approx 10y ago-unable to weight bear-sensation slowly returned eventually leaving lastly the dorsum of the L foot - which then disappeared from this location ( in the same location as the current complaint)
...Reports sciatica like pain sometimes
FW –non supportive low heels (had previously been wearing high heels prior to foot pain)
R.Arth family hx
Physical activity “minimal”... low BMI.
Complaint-Left foot pain,
Had problem i.e. 1st met pain for 3mths –>arthritis like pain dorsally & medially over 1st met
- Then in past 2weeks heavy object rolled over same foot (MTJ location) ...& Pt. said foot was a bit swollen & bruised :hammer:
Sensations pt. is currently experiencing is Pins and needles- (through 1st 4 digits up to dorsum of foot)
Blankets= pressure on foot which the pt. notices/finds somewhat irritating
Ok for self to touch foot, couldn’t weight bear entirely post trauma -antalgic gait
Saw GP -treatment =ice NSAIDS strapping & NON-WB x-rays
X-rays showed - calcification mild around the 1st MPJ & the report said osteochondritis (which I could barely see myself) of 2nd MPJ
Vibration & monofilament= within normal limits & no pain from tuning fork
No Tinels sign elicited
Short 1st met bilaterally
Initial treatment= (allergy to tapes inc. micropore) SCF Valg pmp with u to 1st in L shoe padding in both shoes wearing (nothing else was really practical with the pt’s narrow flat shoes)
I suggested to continue RICE & wear most supportive fw to work (sneakers)
I said we will wait another week at least before another x ray (WB) is taken to allow time to see results of initial treatment .
Follow up-
Reviewed padding etc.
Padding was helpful for a couple of days until pt. found it to have become compressed hard and uncomfortable.
pt. did not find sneakers comfortable & turned up to the clinic in another pair of loose flats:bash:
My touch which was very light dorsal surface of MTJ region-now producing pins and needles down to toes dorsally (except 5th)
Pins and needles pains she is getting regularly is very generalised over the l forefoot (medial to dorsal excluding the area of the 5th toe
NWB movement was painful for the entire L foot
Pt. felt as though just the air was painful (the ‘breeze’ even in closed doors where there is none)
L foot pain wakes her up at night-movement/sheets
No swelling or discolouration. Cool feet
Proprioception- dorsiflexion movements were not indentified/felt
Whilst inverting the L foot ( by pressing on the 5th metatarsal) this created generalised pain in the left foot
Pt. practically in tears about the situation
Had been using a compression stocking on left foot as believed to help the pain- I said if that if it was helping relieve the pain than that was fine
Preferred shoes with a heel lift- I said if those shoes are comfortable than it’s ok to wear them as long as they’re supporting your foot efficiently (I think pt. is used to heels but I didn’t want to add a heel lift as I was concerned about forefoot pressure)
X-rays ordered-(WB...) AP , Lat , MO.
Applied SCFVL pmp with u to 1st in L shoe again & continue RICE
I suggested to the patient that the GP may want to order an MRI (which I think most likely cheaper with GP referral?)
& she may also need a referral to a neurologist soon (nerve conduction studies?) with the ‘pins and needles pains’ she is getting
I said to pt may need to go to a pain clinic if it continues/worsens despite treatment...
Dorsal nerve entrapment, CRPS/RSDS?, stress F#... :craig:
Please let me know if you think I’ve missed something. Any input would be greatly appreciated. Thank you!

 

Re: foot pain

Hello:

Trying to wade through all this....sounds like 1st MTPJ arthritis then a direct trauma to dorum resulting in neurological symptoms.

You didn't mention if there are any spurs palpable at Lis Franc's or mid tarsal.

My first impression is simple neuritis of a sup peroneal branch from direct trauma, perhaps predisposed due to underlying osteophytes at one or several locations.

The most common location for this is the 2nd Met-cuneiform due not only to biomechanical reasons but to the location of the neurovascular bundle.

I would suggest, if this sounds like it fits your patient, a small amount of Marcaine/decadron (or other anesthetic/steroid of choice) given at the most proximal point of your tinel's sign.

All this assuming you have ruled out a fracture.

Good Luck

Steve

 

My thoughts would be early CRPS

 

Thank you for the input guys.
Steve-
As I have not had the pt. back yet with those x rays, I’ve not yet been able to eliminate a fracture.
I like the idea of anaesthetic injection. Unfortunately no one in the practice that I work at does nerve blocks like the one you suggest- apart from digital blocks. We get plenty of palliatives. I have no experience other than (from a uni in Oz) with plantar infiltration & digital blocks so I wouldn’t feel comfortable doing that dorsal region without proper training. Shame. So I believe referral to a neurologist will have to do.
As for palpable spurs, (in initial examination) I did not want to hurt the patient too much during examination so I didn’t poke around too heavily. Mind you, I didn’t feel/see anything protruding.
Colleagues have agreed with referral to a neurologist & suggested for support- to make a PPT valgus with a met dome beneath the 2nd met- as a more permanent option.

You mentioned that-
The most common location for this is the 2nd Met-cuneiform due not only to biomechanical reasons but to the location of the neurovascular bundle.
Would you be able to explain the biomechanical reasons?

Thank you

 

This is a woman who went from high heels to flats daily. She appears to note that she is much better with an elevated heel. Considering this, the pain is likely secondary to a fibula related ankle equinus and secondary peroneal inhibition. Manipulation of the ankle (and likely the cuboid) are the treatment of choice. Works wonders in cases such as this.

Howard