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Help with forefoot pain

Discussion in 'General Issues and Discussion Forum' started by shiralee, Jun 25, 2011.

  1. shiralee

    shiralee Member


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    Hi All,
    I would appreciate any comments/advice regarding a patient with acute forefoot pain. He is a 40y.o runner who has experienced 3 acute episodes of forefoot pain, approx L dors 2/3 mets, while running. He described it as a sharp stabbing pain that caused him to stop running immediately, and he could not continue running. The first episode occured in March, swelling and bruising appeared dorsally immediately, but pain (which was felt dorsally and plantarly), swelling and bruising abated within days and he was "back to normal". He resumed running soon after and had another episode about at month later, which occured in exactly the same manner. However, this time it did not resolve quickly. He had an ultrasound exam the following day, but nothing showed. I saw him a couple of days after the 2nd episode and used some temporary SCF padding to offload the 2nd met, but this was not tolerated. It was painful dorsally and plantarly to palpate and I could also elicit pain with med/lat compression. He has a pl fl 1st ray, and a slightly cavus type foot. All muscle testing and ROM WNL.
    The pt went to a sports physician 2-3weeks ago. A bone scan, ultrasound and MRI ordered by the sports physician, were all -ve. The sports physician gave the "presumptive diagnosis of transient synovitis of the 2nd MTP" and administered a corticosteroid injection, asked the pt to rest for 2 weeks, then resume running very slowly. He also suggested the pt come back to me for orthotics.
    I saw the pt 2 days ago (he was pain free) and gave him ICB's with a met dome with instructions to wear them in slowly and not to run with them until he was used to the orthoses walking.
    He ran for the first time the following day (yesterday, without orth) for only 10 mins and the same acute pain/swelling/bruising stopped him yet again.
    I've tried to attach a photo the pt took of his foot following the 2nd episode.

    Looking forward to some ideas!
     

    Attached Files:

  2. Plantar plate tear thread

    This should help - with all the scans etc -ve have they looked for a plantar plate tear - I would put my money on that

    Hope it helps
     
  3. shiralee

    shiralee Member

    Thanks Mike, I'll look into that.
    Appreciate your help!
    Shiralee
     
  4. Frederick George

    Frederick George Active Member

    Dear Shiralee

    The bruising is the strange thing. Bone scan would have shown a stress Fx, and by now it would be healed and pain free. The scans should have shown a plantar plate tear, as the structure is more discrete, and radiologists are pretty aware of this diagnosis. Neuromas are missed more on scans, and clinical exam is more accurate. The lateral squeeze pain points to that, and the bruise is centred over the 2nd interspace. But neuromas don't usually bruise, even though they have their own vascularity.
    In a plantar plate tear, by now you might see beginning dorsal location (early dislocation) of the base of the proximal phalanx.
    Trying to offload the 2nd met head with aperature padding would put more pressure on a neuroma.

    Is the pain discrete and localised on palpation? Is it under the mpj or in the interspace? By gentle palpation you can often discriminate this.

    An injection unfortunately isn't discrete enough to confirm the diagnosis.

    Over time either the toe will dorsally dislocate, or the pain will go away, or, if a neuroma, the pain will worsen and change, becoming sharp, burning, tingling, numb, "thick" feeling, or any of the above.

    Not much help, I'm afraid.

    Cheers

    Frederick
     
  5. LuckyLisfranc

    LuckyLisfranc Well-Known Member

    This erythema is troubling.

    I would rule out a septic arthritis or soft tissue infection related to the steroid injection. There has been a recent court ruling against a GP for a steroid injection related infection which has almost every medical practitioner now fearing litigation unless these injections are done under full glove/gown and absolute sterile conditions.

    I have never seen a plantar plate tear/soft tissue injury or stress fracture cause erythema like this.

    Beware.

    LL
     
  6. Ive seen 1 and may have looked at another yesterday I´ll see what the scans tell.
     
  7. shiralee

    shiralee Member

    Thanks everyone.
    The erythema/bruising occurs almost immediately at the time of pain onset and gradually disappears over the following few days. The photo I posted was taken hours after his 2nd episode of pain. There hasn't been any erythema post injection that I'm aware of apart from it appearing when the acute pain does when running.
    I probably haven't been careful enough in isolating the pain, but it appears to be dorsal and plantar on palpation and I can elicit it with lateral pressure too. The pt seems to complain mostly about plantar pain in the following days as it begins to abate. There is no movement of the digit so far.
    It seems like the sharp pain and erythema now occurs most times the patient runs, which hasn't been often recently because he has been resting until pain free before trying again.
    I have referred the patient for another ultrasound with some more specific "instruction" for the ultrasonographer, and I'm yet to see those results. He has been wearing the orthoses I gave him and is wearing them for a few hours each day, and so far is comfortable with the orth.
    Shiralee
     
  8. HansMassage

    HansMassage Active Member

    Interestingly I get pain in the same location. I attribute it to repetitive stress due to altered right arm swing caused by right clavicle menubrium tear. I often have to put a magnet on the origen of the dorsaflexor for that toe to calm down the muscle and prevent an agonist antagonist fight. I also use a magnet under the joint for dual support.
    http://reflexposturology.weebly.com/
    http://magnet-therapy-how-why.com
    Hans Albert Quistorff, LMP
    Antalgic Posture Pain Specialist
     
  9. Lab Guy

    Lab Guy Well-Known Member

    There has been a recent court ruling against a GP for a steroid injection related infection which has almost every medical practitioner now fearing litigation unless these injections are done under full glove/gown and absolute sterile conditions.

    That is a shame. Sounds like the GP misdiagnosed the patient and gave a steroid injection into an area with an underlying bacteria infection. Steroids suppress the cell-mediated immune response so the bacteria were free to multiply with the body's defenses out to lunch.
     
  10. shiralee

    shiralee Member


    Thanks Hans, not something I would have though of!
    Shiralee
     
  11. LuckyLisfranc

    LuckyLisfranc Well-Known Member

    No - the case revolved around infection due to the introduction of pathogenic skin flora into the joint/bursa. The risk in the literature is reported to be very small, but the ruling suggested that these procedures should be only done under full aseptic operating theatre conditions, otherwise litigation will favour the complainant. This has caused an uproar in the GP community, and has direct implications for podiatrists who undertake injection therapy.

    LL
     
  12. Frederick George

    Frederick George Active Member

    Ahhh . . . America. Don't you just love it?

    Become a doctor, support a lawyer.

    Cheers

    Frederick
     
  13. LuckyLisfranc

    LuckyLisfranc Well-Known Member

    The case was in Australia.

    LL
     
  14. Frederick George

    Frederick George Active Member

    Well, I used to be an American, so I guess I just made that assumption.

    Oz really has "a seat at the big table" (George Bush) now don't they? Becoming a bit imitative. When I go there, it always feels like a step closer to America.

    What a ridiculous idea, full sterile conditions for an injection. Should be in a laminar air flow Sx theatre as well, I suppose.

    Cheers
     
  15. Lab Guy

    Lab Guy Well-Known Member

    No - the case revolved around infection due to the introduction of pathogenic skin flora into the joint/bursa. The risk in the literature is reported to be very small, but the ruling suggested that these procedures should be only done under full aseptic operating theatre conditions, otherwise litigation will favour the complainant. This has caused an uproar in the GP community, and has direct implications for podiatrists who undertake injection therapy.

    We should also debride mycotic nails, ingrown nails, deep seated calluses/corns and of course diabetic ulcers under full aseptic operating theatre conditions. Anything less would not be the standard of care as the risk of introducing pathogenic bacteria flora to the deeper tissues is greater.

    Steven
     
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