Advice on tricky case with night pain

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Hey guys,

Im hoping to get a little bit of guidance with a recent patient, please have a read and any responses will be much appreciated:

- 57 year old female
- overweight but not obese
- Moderately active, lives on farm. Works as medical receptionist.
- water aerobics 2 x per week for last year.
- usual footwear are flat boot, flat dress shoe (subjective) wore in to clinic a
non-supportive strappy sandal.


Medical Hx:
- bilateral knee arthroscope (could not elaborate) pain in knees currently mild
- Nil Medications



Presenting Complaint:

- 2 month Hx of severe pain in 2nd toe Right foot. Pt is unsure of onset (gradual or sudden). Pain from MTPJ to apex, dorsal and plantar.
Reports also having some pain in 3rd toe, and 1st webspace continuing onto 1st toe.
- Pain is present weightbearing and NonWB, reports pain whilst in bed.
- Reports pain through pushoff period in gait around MTPJ area.

Originally she thought she must have stubbed her toe and not realised, but when it continued sho got x-rays and ultrasound though GP which reported no abnormalities.
Pt went to a clinical Massuer and found some immediate releif.
Has since been to a chiro who manipulated the foot, with no relief in symptoms.


ASSESSMENT:

- I had trouble localising the pain to any specific structure. EDL tendon at base of 2nd was tender but no pain in muscle belly.
- Pain with passive planterflexion of the foot and toes.
- weakness in actively flexing toes.

DDX:
- tendonitis of EDL
- Neuroma
- Stress fracture of 2nd met?

TREATMENT:

Pain was most significant with any flexion of 2nd toe. So for immediate treatment I applied taping to limit flexion of the digit and will reassess if this changed pain levels in 2 days.

Thanks,

Sally

 

Re: tricky case with night pain

Hi Sally

Have you requested x-rays? Night pain is one of those things that rings scary alarm bells, I think it would be a good idea (if you haven't already) to order these to rule out the presence of malignancy and check for stress fractures while you're at it...

Regards

Donna

 

Does asprin helps? nIght pain and asprin relief leads to osteiod osteoma???? Also look for Friebergs dxs? Xray sure will help

 

Xrays were taken ~1 month ago. Nothing significant seen.

 

Sally:

Sounds like a plantar plate injury to me which is also known as metatarsophalangeal joint (MPJ) capsulitis, pre-dislocation syndrome and MPJ stress injury. Plantar plate injuries often are very painful with forced plantarflexion of digit which is an excellent test for these injuries and may hurt at night if they are acute enough or if the pericapsular swelling has irritated the intermetatarsal nerve. Plantarflexion taping of the digit, direct icing to plantar foot 20 minutes twice daily, accommodative padding/orthoses, avoidance of barefoot walking/standing and cortisone injections will all help. When hoofbeats are heard, first think horses, not zebras.

Hope this helps.

 

I agree kevin,

Plantar plate injury immediately came to mind for me as a diff dx. One thing I have seen in patients with a confirmed plantar plate rupture by diagnostic ultrasound is the ability dorsiflex and plantarflex the MTPJ relatively independently of the neighbouring joints although it feels like you need to have 3 hands to do this. Might be worth a try on review but this is just my experience in a few cases.

I would suggest ultrasound to investigate further and have nothing to add on the run down of treatment options kevin mentioned.

 

US had previously been undertaken with no significant findings. However I did not see the US, just the report.

Can Plantar Plate injury cause dorsal pain around EDL tendon.

After rereading my post, yes plantar plate does seem a definite possibility.

Thanks everyone for your input.

Will reassess and keep you posted.

Sally

 

I would agree with Kevin and others views Sally on the plantar plate tear as the more obvious reason for the symptoms. Great phase by the way Kevin re horses and zebras, i will be using that line in future no question. My point is in regard to night pain and stressing the importance of magnitude of pain, any night pain should be a red flag but more do do with the pain either stopping the patient from sleeping or waking the patient up, in these situations futher imaging becomes a priority. I have tried to attach the case study in PPT form of a female age 30 who attended one of my Physio colleagues back in 2007. Fascinating story and i became involved with the subsequent rehab issues with gait following the endo prosthetic replacement (EPR) on the distal end of the femur. The moral to the story i guess is review the images where possible as the patients initial x ray was reported as normal (hard to believe but thats what the radiology team reported).

The outcome in this respect was always going to end up in resection of the distal femur and a EPR but a failure to be suspicious because of the degree of night pain may have led to further problems.

What i find as interesting is in the patients that i see post oncology managment for neoplastic involvement their symptom description often mimicks our regular MSK complaints and often the dividing line can be the degree of night pain the patient complains of.

Can anyone tell me how i can attach the powerpoint?

regards

Mark

 

Sally:

I did a flexor transfer 2nd digit hammertoe surgery a few years ago on one of the orthopedic surgeons I have worked with for over 15 years. He had a plantar plate tear with partial dorsal dislocation of the proximal phalanx base relative to the 2nd metatarsal head which was causing nearly all his pain and tenderness to be dorsal at the MPJ rather than plantarly. Check for a vertical drawer test at the MPJ to see if there is any dorsal instability at the joint that could indicate a more significant tearing of the plantar plate.

For the night pain, have the patient try icing the dorsal and plantar aspects of the 2nd MPJ about an hour before retiring to bed. This should reduce or eliminate the night pain. If it doesn't, and the other mechanical therapies I mentioned earlier don't help, then an MRI would be indicated to rule out other pathologies.

 

Hi MelbPod,
I recently had a pt with a very similar presentation (2nd MTPJ, also). After taking a HX and following my examination i intitally thought it was a plantar plate tear. So, i strapped the 2nd digit as we do for Plantar plate tears, advised rest, good f/w, and sent the pt off for X-ray and U/sound and reviewed the pt following the imaging results.
The X-ray showed no abnormalities............................however, the u/sound showed a focal osteophytosis (which did not show up on the X-ray) with associated oedema.

This may be something to consider. Hope this helps.

FD