Help with an unlucky patient!

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Hi There

I have a lady in her 30's who is having severe problems with her feet.
GP - had xray done, revealed only a calc spur. He then referred her to me

Symptoms were highly suggestive of neuroma b/f so i referred for US.

US reveals 3 mortons neuroma - just a little smaller than 1cmx1cmx1cm. Also bursitis and synovitis. Radiographer recommending MRI

Personally i feel her pain cannot be managed with orthotic therapy and footwear adjustments ( or should i say i wouldnt be confident doing so) So i need to refer her somewhere.

Im new to Australia and have no idea of good surgeons etc. She is in Brisbane so recommendations would be good please.

I was also led to believe that a dorsal excision is the way to go as opposed to plantar. Is this true?

If i refer to a podiatry surgeon in Australia is it purely private or covered by medicare? Would she have to pay for an MRI if one is required.

Thanks for your help in advance. This lady is in extreme pain.

many thanks

Rebecca

 

Rebecca Contact the Australin Podiatric surgeon assoc.

http://www.acps.edu.au/

They should be able to help you out with all your questions.

The only thing I may add is I beleive Dorsal excision is the way to go, but I´m not a surgeon but someone at acps will be able to help I´m sure.

Goodluck

expat Australian in Sweden

 

Thanks for the info Michael. Ill look into it.

I dont know how to put this without offending anyone given the current climate (orthopods vs pod surgeons). So ill just say it!

If surgery is recommended for her and a dorsal excision is the best option, then i want her to have this....what i dont want is for her to end up lets says in Orthopaedics and end up with some nice scars plantarly which may give her grief in the long run.

Personally im not really bothered if she sees an Orthopods or Pod Surgeon as long as they good job.

Also word of mouth recommendations usually hold some value

 

Hello Rebecca

Normally, (ie if indicated) Podiatric Surgeons will carry out neuroma excision through a dorsal incision. This may not be the case if a stump neuroma is the problem in question.

I'm sure that you have had excellent advice of Mike, but would suggest that you refer to a Podiatric Surgeon in preference to an Orthopaedic Surgeon. Why? Because a Podiatric Surgeon is your colleague, will work closely with you, and will have experience and expertise of foot surgery. That is not to say that there may be some Orthopaedic Surgeons who are competent when dealing with feet, simply that Podiatric Surgeons have been trained to deal with feet from the outset, are knowledgeable concerning the mechanics of the foot, likely relevant adverse outcomes and are used to dealing with the presenting pathology. Orthopaedic Surgeons are generalist and have not received specific training with regard to foot pathology and, I suspect are much less likely to involve you. The situation may be different in Oz.

All the best

Bill

All the best

Bill Liggins

 

Thank you Bill

I whole heartedly agree with what you have said and this is the info i have given to patients whilst working in the UK.

I have contacted the receptionist of a Podiatric Surgeon here. The situation in OZ is more or less purely private with a little back on consults through private health insurance companies. Ive been told they will not pay much or indeed anything on the procedure itself.

I will put this to here tomorrow and then make her choice as to which path she wishes to take

Incidently - how common is it to have 3 neuroma?? and do you agree that managing this purely Podiatrically would be difficult?

Regards

Rebecca

 

I think its more likely to have 3 intermet bursitis than neuroma. US cannot distinguish between neuroma and bursitis. Cystic lesions tend to be hypoechoic, whereas solid lesions eg scar tissue tend to be hyperechoic.
My Rx plan would be to put her into a stiff-soled shoe/boot with adequate toe-spring/roll-off, possibly with a met bar/dome.

 

Hi Peter

The report says she has both?? Is that possible?

It also states synovitis of the 1st mpjts

Xray - calc spur.

She does have numbness of the 3rd and 4th digits

She says he was pretty sure they were neuroma... the report recommends MRI

Pain is enough to bring tears to her eyes!!

Would bursitis give a postive mulders click??

thanks for you advice

 

You can have both i'm certain. US is a very dynamic investigation, and can be hard to demonstrate on still slides the movement of tissues you see when undertaking the dorsal intermetatarsal sqeeze towards the probe. On US, the hypoechoic lesion may be seen to clearly compress easily, suggestive of bursitis (and given the synovitis present, one might think this the case with your pt). Also the 3rd and 4th metatarsal spaces are often very closely approximated, casting acoustic shadowing, and causing intermet neuritis, without neuroma in some cases.
One would expect on US to find a non-compressible structure to be more represantative of a neuroma.
I have had some pts with a Mulders click have bursitis, i don't think its pathognomic as much as some folk think (in my experience).

My Rx plan would however still be the same...........

 

Thanks Peter (am i right in thinking youre a salford lad too??)

Ill speak to her tomoz and talk her into an mri

Tried a met dome
Tried a PMP
Tried trainers

Only thing she is comfy in is thongs (flip flops)which she cant wear for work.

She also have large HAV stage 3. The availability of affordable footwear here is a big issue. Yeah there are decent shoes here but the cost is very high and choice limited.

Your thoughts on those rocker soled trainers????
Will have a look around for a stiff soled shoe - she may have to buy a blokes!!!

ta

Rebecca

 

Trained at Durham, but originally from the Midlands.
Rocker soled trainers would be good, provided they don't have to much of a soft heel/negative heel.

Reebok classics with a midsole carbon fibre stiffener would be an option.
and Anti-Inflammatories

Have you thought about a series of intermet injections with long-acting LA?

 

Ah, good to have another Mercian on the site!

I agree with Peter. It is possible but unusual to have 3 true neuromata. However, if that's what the Radiologists say it's certainly worth an MRI to show up pathology that the US does not.

Might be worth trying L.A./depo-medrone injections initially.

All the best

Bill