Help with paresthesia pattern

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Hi all

I wanted to get some more ideas on whether I was on the right lines with a patient.

A 61 y/o female, overweight but tries to do 1-2 miles walk daily. Medication only levothyroxine and no other relevant history.

Onset of pain occurred several months ago with a sudden shooting pain in the right medial heel. There was nothing reported on an x-ray about his time. Over the interval between this and presenting it had become a more diffuse ache, but she had also developed numbness and tingling to her plantar lateral mid to forefoot and 2-5 digits. Perception to 10g monofilament was reduced and altered compared to left side.

History of numbness to 3 and 4 digits which preceded this.

Static stance maximally pronated STJ in rcsp

O/e med deviated STJ axis. Pain on palpation med calcaneal tubercle and peroneus longus insertion and some discomfort over course of p.l.

Non painful areas of oedema lateral foot and ankle overlying peroneal tendons and plantar metatarsal area.

OA at knee worse on right side and marked tenderness over MCL insertion

Gait- Apropulsive with med roll off

Footwear- thin soled and slip-on.

There is obviously multiple connected pathologies, but I'm slightly unhappy with the pattern of parethesia- does not seem quite right for Baxters etc connected with onset of heel pain., is unilateral so not hypothyroidism.
My best guess at moment is lateral plantar nerve entrapment combined with pre existing digital nerve irritation.

She's has had advice on footwear and we'll try some orthotics with rear foot med skive and pad just proximal to 2-4 met heads

Any comments welcome!

 

Hi Ian,

patients with baxters nerve entrapment / neuritis do complain of heel pain. Possibly due to the presence of plantar fasciitis as a complicating factor or vice versa.

I often find they complain of heel pain first then start getting the pain sweeping along the lateral plantar nerve, towards the digiti minimi brevis.

You note it sounds more like lateral plantar nerve entrapment, isn't that what baxters is (its first branch though).

I've often found when i first started treating them that simple orthoses don't help as the posterior portion of the arch fill irritates the nerve further.

Cheers,

George

 

Hi Ian,
Have you considered a diagnostic nerve block? If this works then a steroid injection should help. I agree with George, these cases don't tend to respond to well to Orthoses.

Cheers David

 

Thanks guys

When I was considering baxters I was expecting syptoms more proximal than they are (other than the heel pain around the med calc tubercle but not sure if this is the case. Certainly the pattern of onset starting with heel pain alone and then developing the more distal paresthesia later would be consistent.

The more I think about it the more I think about it the more I'm sure it's multiple pathology confusing things- ie possible baxters with existing digital nerve irritation giving an odd distribution.

I'll be seeing her back to fit orthotics so will do some further testing then and let you know.

I've already warned her the orthotics may not resolve all of her symptoms and if it is a nerve entrapment may require surgery, but her feet and knees are generally a mess so we're not just trying to resolve this alone.

Will keep you posted

 

Saw patient back and did some more checks- palpation of the heel nicely reproduced/aggravated paresthesia to lateral ff and 4/5 digits. Abduction of 5th digit was reduced compared to other side.

Sure it's lateral plantar nreve entrapment so will let you know how treatment progresses.

Thanks
Ian

 

Ian:

You might find this case report paper from 18 years ago of interest that we wrote on a power lifter that I treated with foot orthoses. My patient had similar symptoms and it was determined that his nerve conduction velocity improved with foot orthosis therapy. I believe that this is the only reported case within the medical literature where foot orthoses produced a change in nerve conduction velocity (Johnson ER, Kirby KA, Lieberman JS: Lateral plantar nerve entrapment: Foot pain in a power lifter. Am J Sports Med, 20 (5):619-620, 1992).