Differential: plantar fascitis, gouty arthritis, others pls help...

Members do not see these Ads. Sign Up.

Patient profile as of 25 July 2011
Male 22 74.1Kg 168cm South East Asian

Case Description
*Inflammation (ususal not always) of either foot with severe pain (7)
Inflammation sites:
ankles
ventral arch (often)
dorsal arch
*Would start as bearable/tolerable discomfort on day 1
*wound progress on days 2-4
*usu on days 4-5 Pt would not be able to walk in the morning due to pain and inflammation
*Pt describes pain as throbbing, sometimes painful even by merely switching positions of foot inflamed or tapping the leg, pt describes pain as "sometimes it feels like I am stepping on a small ball."
*pain migrates/shifts (point of greatest pain, or point that triggers greatest pain)
*usu painful in mid/arch area lower pain towards heels and ankles
*usual pain points/triggers:
Metatarsophalangeal joint compression (pressure exerted on medial MPjoint
opposing pressure exerted on lateral MPjoint) 60-90% of times
Pressure exerted on the three most lateral dorsal part of MPjont
Pressure exerted on medial metatarsal opposing pressure exerted on lateral
metatarsal

Pain is relieved with NSAID
*First instances (type I; with light to moderate pain) were relieved by Mefenamic acid 500 tid onset: May 08 pain duration two to three days
*After several instances (type II) a moderately severe to severe pain which resulted to difficulty in walking with the affected foot was relieved by Celecoxib onset: late 08 pain duration two to four days
*After several more instances (type III) a severe to very severe pain resulting to inability to move and grimaced face was somehow relieved by Etoricoxib and Tramadol+Paracetamol onset: late 09

case severity varies usu Pt would exp type I then after 2-6 weeks type I
and after 4-12 weeks would be either type usu II and III.
Pt was unable to attend Med classes for two days to a week for about 12
instances from Oct 08 to July 10

Early moderate pains and late decreasing pains are decreased by cold pack
Pt tried hot packs several times but pt describes "it would get really red and it feels like I have edema inflammation with less pain, it is better with cold baths/packs"

Medical History
Pt is at 82.6Kg on May 2008
Thought to be caused by increased weight
pt reduced weight over time

May 08 lab results
serum uric acid 0.45 mmol/L
blood urea nitrogen 3.93 mmol/L
Creatinine 88.40 mmol/L
WBC 6.8k/cu mm
RBC 4.6/cu mm
Hemoglobin 14.0g/dL
Hematocrit .42


Sept 08 lab results
serum uric acid 0.40 mmol/L
blood urea nitrogen 3.24 mmol/L
Creatinine 112.67 mmol/L
WBC 8.2k/cu mm
RBC 4.7/cu mm
Hemoglobin 14.4g/dL
Hematocrit .44


Nov 09 lab results
serum uric acid 0.65 mmol/L
blood urea nitrogen 2.86 mmol/L
Creatinine 70.72 mmol/L
WBC 10.5k/cu mm
RBC 4.5/cu mm
Hemoglobin 13.6g/dL
Hematocrit .41


Jan 10 lab results Fam Med
serum uric acid 0.62 mmol/L
blood urea nitrogen 3.21 mmol/L
Creatinine 79.56 mmol/L
WBC 7.5k/cu mm
RBC 4.8/cu mm
Hemoglobin 14.6g/dL
Hematocrit .44


Jan 10 lab results OrthoSur
serum uric acid 0.60 mmol/L
blood urea nitrogen 3.29 mmol/L
Creatinine 79.44 mmol/L
WBC 7.6k/cu mm
RBC 4.4/cu mm
Hemoglobin 14.5g/dL
Hematocrit .42


Dx of diff MDs
Hospital A
May 08 Family Med 1 plantar fascitis
Sept 08 Fam Med 2 plantar fascitis (based on May 08)
Sept 08 rehab 1 plantar fascitis (based on May 08)
Feb 09 Fam Med 3 plantar fascitis (based on May 08)
Nov 09 Rehab 2 plantar fascitis
Jan 10 Fam Med 4 plantar fascitis (did differential dx on osteoarthritis-xray clear; rheumatiod arthritis-RF negative, no fevers, no malaise; did thorough diff on gouty arthritis-very young, xray clear, no specific night pains, no pronounced redness, no to relatively least pain on big toe, blood uric acid level not high enough)

Institute B
May 09 OrthoSurgeon 1 plantar fascitis
Jan 10 OrthoSur 2 plantar fascitis (did xray and re run labs, not osteo, not rheuma, not gouty)
Nov 10 OrthoSur 3 planter fascitis (based on orthosur/fam med 10)
July 11 Ortho Sur 4 (no dx yet wants pt to take colchicine every 2 hrs max 10 tabs/day for 2 days and allopurinol 300mg once a day for 15 days; referred to rheumatologist)
pt not at rest w/ this approach asks me to help research

Hosp C
July Ortho Sur 1 Sprain (LOLs, after 4days wants to run new lab tests thinks arthritis)

please please help

I saw several differentials on
fibroma
posterior tibial tendon dysfunction
DIMCS
radiculopathy
nerve entrapment
PTTD
tear on plantar fascia
tarsal tunnel


pls advise what other tests are better done possible dx for particular result
several confirmatory tests
possibility of comorbid

I am a 2nd year med student not very knowledgable yet pls help me and my friend thanx

 

Re: differential plantar fascitis, gouty arthritis, others pls help...

Hi PlantarPh & :welcome: to Podiatry Arena,

Beautifully presented case study :good:

I would advise that you copy & repost in the General issues & discussion forum as not all members browse the introductions area.

Many thanks for your interesting case question.

Kind regards,

Mandy :drinks

 

PlantarPh

Thanks for a good case with good background info.

One thing lacking is any distinct physical assessment findings (ie vascular, neuro, basic orthopaedic findings).

Sounds like this patient has no pain in or around the plantar fascia, and most of it is related to pain in the tarsal region.

Providing there is no vascular or neurological features to the pain, would suggest closer examination of the hindfoot or midfoot, with some emphasis on postural findings in weight-bearing.

My instinct would be suggest an undifferentiated inflammatory arthropathy, so ESR, CRP, HLAB27 may be useful. Plain weight bearing x-rays initially, possibly followed by Tc99m bone scan potentially.

If possible, post some clinical images +/- radiology, and some of the most eager minds in podiatry can help you out.

LL

 

Perhaps you could give us a geographical location also... I did not Podiatrist among the list of specialists that have been seen.

 

I suggest an immunologic/ rheumatologic profile, some of which was mentioned a couple of posts ago. I did not see any mention of MRI studies---
Why all the repeat diagnoses of fasciitis?
Here in this part of the US, if the x-rays and MRI studies are unremarkable, we would aspirate some joint fluid and look for negative birefringence. A definitive diagnosis of gout is based upon the identification of monosodium urate crystals in synovial fluid or a tophus. All synovial fluid samples obtained from undiagnosed inflamed joints should be examined for these crystals. Using polarized light microscopy, they have a needle-like morphology and strong negative birefringence. A rheumatologist is consulted to investigate other potential sources of arthropathy and possible auto-immune disease-
-John

 

Sorry guys I missed out several more details, most of which I have asked my friend about:

Pt pes planus type
negative RF test made on Jan 2010
Residing in Manila, Philippines
Several MDs/PTs/Chiropractors who checked him are form Poland, Germany, and Philppines

No assessment on vascular and neuro - any suggested tests? Need I advise my friend to consult a neurologist? immunologist? sorry, just finished my examinations am a bit hazy....

==========================================================
while I have posted the case here, my friend continuously seeks med attn
This is the most recent Lab Report

Lab results 26 july 2011
ESR 40.00 mm/hr elevated ref 0-15

Heme 151g/L
Hct .442
RBC 4.91
WBC 10.26
Eos .07 elevated ref .00-.04
Seg .51
Lym .32
Mon .10 elevated ref .00-.07

throm 249K/uL
MCV 90.00um^3
MCH 30.80pg
MCHC 34.20%
RDW 11.70%

uric acid 0.578 elevated ref 0.201-0.413


x rays unremarkable as per ortho MD
I would request if I could upload film pictures

Discussion w/ MD:

current ortho surgeon says it is impractical to extract joint fluids as the affected area is the arch, he says it is hard to obtain fro this area, esp that pt is not on tramadol and etoricoxib max dosage.

MD Rx

20 colchicine tabs, to be taken 1 tab every 2 hours w/o exeeding 10 tabs/day
and
Allopurinol 300mg take once a day for 15 days

MD says if pt is reactive to meds, go to Rheumatologist.
I do no like this approach, maybe I merely could not understand this approach. But, as someone with medical background, meds are prescribed if we think it is highly likely that pt is with this condition. I guess what the MD is trying to do is to cut the diagnostic tests. I have advised my friend not to take colchicine and allopurinol yet. I am researching here and asking several consultants I know as well. - Was it sound judgment to advise my friend not to immediately take these meds?
==========================================================

I have advised pt to proactively ask for MRI, HLA-B27, and CRP

weight bearing xrays were not done, I would advise of this as well.

what would b the use of tcm99 scan, not yet into nuclear med?

is this a possible case of nerve entrapment?

THANX A LOT FOR VERY HELPFUL RESPONSES

 

Sorry if this is a totally silly suggestion but have you considered early Madura foot.If this is a daft suggestion could someone who has seen an early presentation of this tell me what to look out for , I see a lot of asian patients and would like to know what to look out for .I have seen images of late presentation but the situation seems pretty hopless at that stage.
Thanks
Tim

 

Not silly at all. Madura foot is another name for mycetoma, loads of info in the `net on early signs of this. One of my derm books states;

"The earliest sign of mycetoma is a painless subcutaneous swelling. Some patients have a history of a penetrating injury at that site. Several years later, a painless subcutaneous nodule is observed. After some years, massive swelling of the area occurs, with induration, skin rupture, and sinus tract formation.

Nearly 20% of patients with mycetoma experience associated pain, usually due to secondary bacterial infection or, less commonly, bone invasion.

Mycetoma is a chronic subcutaneous infection caused by actinomycetes or fungi. This infection results in a granulomatous inflammatory response in the deep dermis and subcutaneous tissue, which can extend to the underlying bone."

(Dermatology - lecture notes 9th ed R Graham-Brown and T Burns, 2007)

Do you have any pts with this Tim? I`ve never seen it firsthand.

 

I havent yet , But in one of my clinics I have a lot of patients from the Indian Sub continent and have just become aware of Madura foot and I have a strong feeling I will see it and want to be prepared
Tim

 

I go along with previous comments, but would absolutely stress the necessity for an MRI. It seems that there a large number of 'shots in the dark' being taken by his medical advisers eg. Px for gout without a firm Dx. An MRI will give a diffDx that no other test can, and if that is not definitive then further bloods/immunology can be carried out.

Yes, entrapment of the lateral plantar nerve or a branch of that nerve is a possibility and is a good thought. However, if this is the case then the MRI should demonstrate it.

Please let us know how the case proceeds.

All the best

Bill Liggins