Hi All,
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I have had an unusual referral that I would be grateful for any input.
Patient presented as an 11 year old boy, with a large apparent blister at the midpoint of the medial longitudinal arch intersection with the plantar aspect of the Left foot. On examination there were three distinct blisters, the largest of which was 5mm across, (see pictures), the blisters are firm to palpate, with no evidence of a liquid sack.
Patient has been getting blisters for past 6 months, located on Left foot. Blisters appear and are then treated by GP, disappear after treatment, but then reappear. Once they develop area is painful to palpate and patient has pain when walking. Current GP treatment is Inadine dressings and Mepore dressings. Although these tend to work it basically is treating the symptoms not the underlying cause.
There is no history of allergies and no evidence of eczema or skin reactions and no history of skin or neurological issues. All neurological responses were normal and sensation was normal, (based on a 10g filament). Both legs exhibit increased external rotation at the hips, (40 degrees ext / 36 degrees int). Passive dorsiflexion at ankle is 10 degrees with foot in neutral alignment. The lunge test gave an angle of 19 degrees. On standing both feet exhibit low arches, but no evidence of midfoot collapse, (x-ray shows normal boney development appropriate to an 11 year old).All foot structures are normal. Positive Hubscher test, (grade 4). Single leg standing showed slow rocking, pronation to suppination followed by pronatary collapse. Elevation of heels showed full correction of feet.Breighton scale 2
Walking in bare feet showed increased pronatary collapse at 2nd rocker, but no other abnormalities.
Footwear is standard Clarke’s school shoes with no shaping in the footbed, (separate sole / heel unit). Patient also wears Addidas trainers with no shaping in the footbed.
My initial conclusion was that the feet were collapsing excessively during 2nd rocker, traumatizing the tissue in the midfoot. But as this has only happened on the left and all comparisons show that left and right are comparable, (patient is right handed so not the dominant side), the right should blister as well.
I have as a test of my theory cast the foot for a custom orthotic with a cutout under the medial longitudinal arch, (which I will infill in clinic with low density compressible material), and rearfoot 5 degree medial post and 50% rearfoot Kirby skive to the cast, (Right foot same device but with no cutout and no Kirby skive). I’m using a 5 degree post, to match what was required to stabilize the foot for single leg standing. To both I’ve added a forefoot 3mm medial compressible post, to allow normal change to high gear but hopefully reduce the speed of the medial collapse.
I would be grateful for any suggestions or if you can identify the blister that would be really helpful.
Thanks for your help
Graham
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Lesiones en el pie en el ámbito laboral
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How to Remove a Topcover Without Really Trying
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Lesiones en el pie en el ámbito laboral
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Kirby Pepper Jar Technique:
How to Remove a Topcover Without Really Trying
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