HELP PLEASE with painful lesions

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Hi All - 1st time poster looking for advice.

Bilateral foot pain on medial aspect of feet - see photos identifying area.
1 year ago pain started after pt got up off sun lounger and stood up. Felt a pain in arch of foot on RF only. Pain persisted to a point where they were having to sleep with their foot in a dorsiflexed position and stretch out the fascia as it was so tight. The pain didn't improve as the day wore on and at night time there was a tender spot on the plantar aspect across anterior border of calc. Treatments of anti inflammatories, ice, rest had little effect although strapping provided some relief.

8 months on pain so severe causing sleep deprivation and depression. Pt had gone from walking regularly, approx 35- 45 miles per week, to nothing. MRI scan showed slight thickening of posterior attachment of plantar fascia into calc and nothing else reported. Pain also started LF approx 8/52 ago. Lumps present over areas shown on pics, painless on palpation, circumscribed, but paraesthesia/neuropathic type discomfort present. Edges can become inflammed and veins prominent. T/t has consisted of; physio, core stability exercises, ultrasound, osteopath (to address L/hip pain), orthotics (bespoke and off shelf), footwear appropriate. Pt has seen orthopaedic consultant who has diagnosed plantar fasciitis even though symptoms atypical!! Pt was offered steroidal injection which they have declined, as the orthopod could not offer any evidence based success rates and did not remove shoes or socks which did not instill confidence in the patient.

Any diagnosis and cure greatly appreciated!

Many thanks.

Julie :drinks

 

Hi Julie,

No pics I'm afraid - go to the manage attachments section and you should be able to do it there. Might be an idea to get the patients MRIs if possible to post up here - some of the brainier folks on here might be able to spot something else.

Robin

PS Welcome to Podiatry Arena!

 

Hi there,
Sounds a bit enigmatic, we need x-ray vision sometimes. Just a few questions.
What kind of pain? Throbbing, aching, stabbing, burning. Any history of neurological problems or spinal problems? Any history of tissue disease such as Ledderhose disease or weight gain. Pregnancy? Foot wear compliant (high heels/ flat flip flops and mountain walking)
Ditto welcome
Lizzy

 

The pain was initially a sharp nerve type pain at times along with an ache but symptoms are now parathesia/ neuropathic type discomfort, and depending on the activity levels which are not massive will result in the lesions swelling but not painful to palpate. X ray showed no problem. Pt very compliant with footwear, not overweight.

look forward to any help..........
JM

 

Please find attached MRI report and images.
First two images are number 6's and second two are number 10's

Also added a Plantar image showing abductor hallucis muscle, Does this look abnormal ?

REPORT:


"There is some thickening in the posterior portion of the plantar fascia
(arrowed on slice 10 of 24 of the sagittal series and 6 of 24). No
abnormality of the subcutaneous fat or muscles in the foot. No abnormal
signal is seen relating to these areas on the fat suppressed images. No
abnormality of marrow signal seen throughout the scans.

COMMENT: Apart from thickening in the plantar fascia, not significant
findings."

 

You may have already ruled this out ,but perhaps consider PTTD or inflammation of tendon sheath? If you haven't already done so try pressing on the navicular tuberosity, follow the route round the medial malleolus, and up into the muscle body. If your getting postive signs of discomfort with these that could indicate the above.
Just my tuppence worth.
Michael

 

I agree with Michael re PTTD the insertion of the pt tendon is not shown but it doesnt look quite right to me
Do you have a view of the Spring ligament - an increased thickness of this may be present, also a t2 would show bone oedema if present
Also have you considered medial calc nerve entrapment because of the neurological symptoms? And of course the old RSDS - chronic regional pain disorder.
Just some ideas to ponder sorry couldnt be more helpful
Sue

 

There is no pain at the navicular and if i palpate back along the PT I only elicit discomfort if i palpate really hard. I am still stumped as to what else i can do ??

 

When u say it "doesn't look quite right" can you elaborate please?
cheers

 

hI to me the tendon insertion was difficult to see well, but hte main thing was the higher signal around the tendon itself , which may indicate some fluid around the area of the tendon or in the tendon sheath
Sue

 

The area highlighted in the clinical picture is the porta pedis.

This corresponds to the distal aspect of the tarsal tunnel, where the medial and lateral plantar nerves exit through the medial expansion of the plantar fascia as it wraps up towards the abductor hallucis. It is a common site of distal tarsal tunnel nerve entrapment.

By your description of the symptoms, this is clearly a neurological problem, and sleep disturbance is common with advanced cases of tarsal tunnel syndrome. MR findings will typically be negligible.

Thorough clinical examination is required to determine if this is truly a case of bilateral distal tarsal tunnel syndrome, or referred froma more proximal point. Percussion of the tibial nerve through the medial ankle is essential. See if the patient can abduct their 5th toes, or if there is a pattern of sensory loss in the plantar aspect of the foot and toes.

Although bilateral tarsal tunnel is less common, it is entirely possible, and I have seen it seeral times.

I would refer to an experienced foot surgeon, as in my experience a neurology consult is less than helpful since nerve conduction velocities are notortiously inaccurate in the foot. It ultimately is a surgical solution, but the success rates can be quite variable.

LL