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Confused about a diagnosis for foot pain

Discussion in 'General Issues and Discussion Forum' started by suresh, Oct 9, 2007.

  1. suresh

    suresh Active Member

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    21 year old male came with pain right ankle,2 days , more since this evening.
    no trauma, no fever, severe pricking type of pain.
    afebrile, diffuse swelling around the ankle , but tenderness only around the medial malleolus.local warmth present. x rays normal.

    ? cellulitis, acute syanovitis ,....

    confused about the clincal diagnosis.
    recently i got these kind of clinical presentations
    how can i approach these kind of cases?
  2. markjohconley

    markjohconley Well-Known Member

    obvious, WHITE POINTER! ......... stay out of the water suresh
  3. drsarbes

    drsarbes Well-Known Member

    Hi Suresh:
    I think most of "these" tend to point to a Dx via History. Are you sure it's intraarticular?

    This particular patient; any previous arthritic conditions; Gouty arthritis comes to mind. Non-crystalline arthropathies; septic arthritis; repetitive stress / stress Fx; etc......
    Acute synovitis generally a non specific term and "usually" anterio-lateral.
    Blood work would be indicated......
    Let us know
  4. suresh

    suresh Active Member

    even though swelling around the ankle, clinically seems to be extra articular, tenderness around the medial malleolar soft tissue. no previous episode pain like this.normal uric acid level. ASO titer 400 IU. other blood parameters with in normal limits.

    i gave him posteror splint and analgesics on observation observation .
    i let you know the progress of this patient.
  5. drsarbes

    drsarbes Well-Known Member

    "tenderness around the medial malleolar soft tissue"
    Is that posterior over the Tarsal tunnel/post tibial t. area or anterior over the ant. tibial t area?
    OR - right on the malleolus?
    As you are aware, not too much right ON the medial malleolus that would not show up on plain films other than possible acute periostitis. Great Saph V. pathology which would be unusual in this age patient.
    No break in the skin? bites, etc...?
    Neoplasm would be my next DD.
    You might aspirate some ankle joint fluid for assay and culture.

    I'd also go over his history again and look for some initiating factor he might have failed to describe if nothing makes itself apparent soon.

    Keep us posted

  6. Mart

    Mart Well-Known Member

    This might raise the wrath of those who don’t like resorting to the use of “toys” but in this instance having a high res US machine at hand would be very useful and narrow down DD very quickly.

    I’d do this right away and feel confident to give you a pretty narrowed down DD within 5 mins.

    As Steve mentioned are you sure this is intra articular?

    US will give you this info instantly; unless joint effusion is extensive radiographic exam might lack sensitivity.

    DD as mentioned might include;

    With any form of Talocrural arthritis, US would give you instant info regarding joint effusion, synovitis and possibly joint debris, although not completely specific, differentiates inflammatory vs non inflam if you have power doppler.

    Cellulitis – US would identify position of cause of swelling, oedema and cellulitis have fairly characteristic US appearance.

    Tib Post. FDL or FHL tenosynovitis, you could evaluate this with physical exam but US is much more specific for location and degree.

    Periostitis has characteristic US presentation, unlikely to find this given lack of trauma.

    VV difficult to pin point without US, likewise space filling lesion (though this unlikely given speed of onset and warmth).

    Skeptics please challenge my viewpoint because I am currently attempting to definite indications for US for podiatric use .



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  7. When I lecture to podiatry students, I recommend that when they present their patient to me or another consulting podiatrist, that they attempt to describe the history and physical examination of the patient completely and accurately so that the greatest amount of information is provided to me to be able to come up with a good list of differential diagnoses. In other words, Suresh, you have not provided us with.....

    1. What is the color of the skin? Are there any defects, evidence of lesions at the area of the most swelling?

    2. What is the history of the increase in symptoms? How long did the swelling take to come on? Did the swelling and pain come on simultaneously?

    3. During clinical exam, what area of the medial ankle is most tender? You only have a few choices, but you should know your anatomy well: medial malleolus, PT tendon, FHL tendon, FDL tendon, PT neurovascular bundle, deltoid ligament, greater saphenous vein, saphenous nerve.

    4. Does resistance testing of PT, FDL or FHL muscles cause increased pain?

    5. Does walking increase pain? Does range of motion of the ankle cause pain?

    6. Does elevation decrease pain? Does icing decrease pain? Do meds decrease pain?

    7. What was he doing the day before or day symptoms began? Was he wearing socks that covered his medial malleolus? Was he in an environment where he could have been exposed to a spider bite or insect bite/sting?

    My guess is this is a spider bite or insect bite/sting, especially if there is erythema at the site of tenderness on the medial malleolus. However, you haven't given us enough information otherwise to make the diagnosis for you.

    I suggest having the patient ice the ankle 20 minutes, 3X/day. Keep the foot elevated as much as possible for 2 days, stay off the foot as much as possible and take NSAIDS until a proper diagnosis can be determined.

  8. Martin:

    To the podiatric surgeon, everything looks like it can be fixed with a scalpel.

    To the podiatric biomechanics clinician, everything looks like it can be fixed with foot orthoses.

    However, to the podiatrist with a diagnostic ultrasound, everything looks like it can be diagnosed better with their magic wand.:pigs:;):pigs:
  9. Mart

    Mart Well-Known Member

    Hi Kevin

    I assume we respect each other as rational and intelligent people, I certainly do you

    So I am baffled by your magic wand reference :confused: and suggestion that I might have narrow diagnostic approach.

    I agree entirely with your list of requirements for proper PE which you mentioned in your last post.

    I can only anticipate that you will say that with good PE and history US is not neccessary.

    Good deductive reasoning for this ankle problem will NOT give you visible structural evidence, this can be arrived at very quickly with skilled US use.

    Granted if you have it you might be inclined to use it, you have hands, eyes, a nose, an educated mind, you use it. If you had X ray vision or a 6th sense would you avoid using it?

    I have a nice high tech US machine, which I have invested heavily in learning and cost. It is not a Gimmicky toy which I have seen disparigingly refered to in popular podiatric media and would love to defend this view if anyone cares to seriously consider this.

    I have been curious regarding its utility and continue to evaluate this, and add it to my tool box when it seems like it might be helpful.

    I remain open minded regarding its value, I am not lacking in self awareness to miss that I might rationalise using it because I don't wish to feel I have wasted my efforts.

    I did invite some dialogue not simply a :pigs: dismissal - so lets do that, I regard myself as having an honestly scientific mind not an evalgelist's

    look forward to your learning about your aversion, I love learning :dizzy:


  10. Martin:

    It was a joke, Martin!! Sorry about my attempt at humor about your posting. When you have the high tech diagnostic machine that you do have, I can see why you are excited about it. Maybe I'm just jealous because I don't yet possess the magic wand.:drinks

    Seriously, I love your postings regarding the benefits of diagnostic ultrasound and am learning a lot about this diagnostic modality because of your excellent and thorough posts. Who knows, because of you, I may be considering purchasing a diagnostic US machine some day for my office?!
  11. Mart

    Mart Well-Known Member

    Hi Kevin
    Oops I did not see the winking emoticon between the flying pigs.

    Sorry for allowing my inflamed ego to get the better of me. :eek:

    I am somewhat defensive regarding my use of technology in areas where the value remains unclear. This is why I was curious to defend my position with you since I prefer to do this with someone whose opinion I respect.

    Anyhow ego inflammation nicely resolved (this did not show up on US, perhaps with PET it would have but I do not have the budget for that :)).

    When I get time, I will follow up on the chronic plantar fasciosis/inflammation discussion thread, I have been trying high intensity therapeutic US (against the evidence based consensus, and I have some discussion on this to follow too) on selected patients and doing pre and post treatment US exams with power doppler with interesting observations. Need to get more than n=1 before putting this up for grabs so will wait till I can do this.

    Cheers Martin :drinks

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