Painful lump, plantar surface of foot

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I would be very grateful for any advice or suggestions regarding a patient of mine.

She is a 40 year old active female, no relevant PMH. Two weeks ago she jumped out of bed and noticed pain under her left foot as it hit the ground - by the time she had got down stairs it had become extremely painful and she was unable to weightbear on it. She describes a feeling of something having popped and a lump appeared just proximal to the 2nd/3rd MTP joints. The following day it had not improved so she pushed the lump upwards into the foot and experienced relief of symptoms for a few hours before the pain and the lump reappeared. She has tried repeating this but is unable to alleviate the pain again. No findings on xray and was given a tubigrip at A&E. Over the past 2 weeks there has been no improvement in pain or symptoms, although the bruising took a week to appear.

On examination yesterday there is significant bruising in a circular area just proximal to the MTPjoints. There is a palpable lump which feels 'gristly' and is moveable and exquisitely painful to touch. No pain is elicited on extension of the toes alone, however dorsiflexion of the entire forefoot causes a 'stretching' type pain in the area.

As the pain only occurs when the foot is placed on the floor and tension applied across the plantar surface I have applied low-dye taping which brings much relief and enables the patient to ambulate much more normally.

I haven't come across anything like this in the past. I have written to her GP to request further investigation as the patient is unable to work or drive and due to the complete lack of improvement in her symptoms. Until then I would be very grateful for any feedback - many thanks in advance.

 

Hi JPod,

If X-Ray rules out any bony involvement then you might want to consider some diagnostic imaging of the soft tissues - I'm mulling over the possibility of a plantar plate tear from your description perhaps?

http://www.podiatry-arena.com/podiatry-forum/tags/index.php?tag=/plantar-plate/

(Then again if I'm honest ever since I read an excellent chapter regarding plantar plate tears in a book I recently purchased I have been looking for it more than usual!)

Ian

 

Thanks Ian - that was certainly my first thought and her GP is certainly happy to refer her on for an MRI, however waiting list is currently 3 weeks so thought I'd check I wasn't missing anything obvious or over reacting!

 

I concur with Ian, sounds like a plantar plate tear/2nd/3rd capsular tear.

Icing dorsally 3x daily for 20 mins and Plantar metatarsal pad with 'u' to 2nd/3rd met with met bar immediately proximal to site of injury should help symptoms.Rigid soled shoe will reduce the bending moment at the mtpj's too, avoid flimsy shoes will little support.

A tight tubigrip bandage may increase interdigital pressure due to lateral compression so might not be such a good idea.

MRI should conclude

Scott

 

Thanks Footdoctor - lateral compression produced no discomfort and distracting/twisting the toes similarly caused no pain so that probably rules out capsular involvement. I will definitely try the plantar pad. The tubigrip given by A&E (there's nothing wrong with it - it says so on the x-ray etc!) was discarded immediately...

 

JPOD

I would not suspect the plantar plate if the lump and pain are proximal to the 2nd 3rd MTP joints (MPJ's). In my experience and from reading, plantar plate tear is usually painful when palpating at the met toe sulcus, proximal phalanx and met head and when plantarflexing the relevant toe. There can also be vertical instability of the joint.

E.G.
A 45-year-old female presented with a three-month history of
left forefoot pain. There was no history of trauma although the
patient reported a rapid onset of pain whilst walking. The pain
was localised to the plantar surface of the base of the left
second digit. Since the initial onset of pain the patient had
noticed a gradual deviation and retraction of the digit with
dorsal pressure occurring between the proximal
interphalangeal joint (PIPJ) and the toe box of her left shoe
(Figure 1). The patients presenting complaint concerned both
the irritation to the dorsal surface of the PIPJ as well as the
continued pain in the base of the second toe.
A diagnosis of rupture of the plantar plate was made
through the use of a vertical stress test, plantar palpation, toe
position and medical history. With the disruption of the
retaining mechanism to stabilise the proximal phalanx and an
alteration in the alignment of the pull of the flexor tendons
(Australasian Journal of Podiatric Medicine 2003; Vol 37, No.2 : 43-46)

The plantar plate origin is just proximal to the met head of the lesser digits and inserts into the prox phalanx. It seems unlikely that there would be a contraction of the Plantar plate rupture that would manifest proximal to the met heads IMO.



Can she actively plantarflex the 2nd or 3rd, is the 2nd or third metatarsal more compliant to dorsiflexion than other rays? Is there pain on plantarflexion of 2nd or 3rd digits? Are those toe joints unusualy plantarflexed or dorsiflexed? Does the lump more easily move toward the heel of toward the toes when palpated? Does flexion of the other toes cause the lump to move? Could it be a rupture of the flexor tendon? or the plantar fascia slip. Seems the most likely. It could be a swannoma that has popped out of the space it was occupying between the mets but there would be no bruising I would think. Or plantar fascia cyst/fibromatosis that has been there a long time but has only recently become painful.


The plantar plate of the foot is formed by the plantar aponeurosis
and plantar capsule. The plantar plate arises from the
distal plantar aspect of the metatarsal neck and inserts on the
plantar aspect of the proximal phalangeal base. This thick plate
supports the undersurface of the metatarsal head and resists
hyperextension of the metatarsophalangeal joint (MTPJ) [1].
Plantar plate rupture may present as lesser metatarsalgia (the
lesser metatarsals are the second through fifth), occasionally
with exuberant synovitis. Plantar plate derangement also plays
a central role in the genesis of the common hammertoe [2, 3].
Rupture or degeneration of the plantar plate destabilizes the
MTPJ, allowing dorsal subluxation of the proximal phalanx. The
resulting “cock-up” deformity at the MTPJ shortens and compromises
the action of the extensor digitorum longus tendon,
contributing over time to a flexion deformity at the mnterphalangeal
joints. AJR i994;163: 641-644 Yao et al

Just my contribution

Dave

 

Hi David

Many thanks - that's very interesting. I am seeing her again this week so will investigate further bearing in mind what you have said. I await her MRI results with interest.

 

Hi have only briefly read all popstings, Ultrasound with a good sonographer will show plantar plate tear. This is often easier to acess and much cheaper. I have seen taping the toe down and padding under the area give immediate BUT not complete relief. This can show you you are on track until the results come through.

Cheers

 

Given your Hx of acute trauma and acute onset with ecchymosis, sounds like a localized hematoma or possible hematoma with tendon rupture. MRI not indicated unless it fails to resolve.


SIDE NOTE:
So, you have to wait 3 weeks for an MRI??????? I'm sure as Obama's socialized medical plans take over here in the states we'll have the same situation. As of now, my small town of 115,000 people have no less than 6 MRI centers to choose from (immediate scans available.)

Steve

 

Hi Steve - 3 weeks minimum... Thanks for your thoughts - she has now been of work for a month with pretty much no change to her symptoms - I would have thought a tendon rupture would at least have started to heal by now?

 

Well, perhaps.
A complete tear with proximal retraction will not "heal".....the surrounding tissue damage (if any) may resolve, but the tendon will not reunite when retracted.

My other thought is a previous existing mass that perhaps was unappreciated until she traumatized it.

3 weeks, not much change - MRI.

Steve

 

I'm thinking that a pre-existing mass may be likely due to the lack of trauma involved in the traumatic onset. Assuming the "jumping out of bed" she describes was, in fact, just that...

 

just to help recalibrate for you drsarbes, in my small country town of 7,000, we have one XRay machine and a single slice CT scan that should have been thrown away by now. In my large state of 4Million we have only about 6 MRI centres. A mobile MRI on a truck comes here once a week. A machine costs millions and if I rock up and pay for an MRI it will cost me about $A300. I wonder what an MRI costs in your town? and I wonder how all those numbers effect the level of service and costs?
regards
Phillip

 

Routine foot or ankle MRI without contrast runs around $800-1,000 US.
Many of the centers have contracts with insurance providers so they most likely get a bit less.

MRIs are VERY common here, not only because they are so helpful, but because there are so many lawyers!

Steve

 

Just had a letter back from the surgeon reporting that he suspects this is a glomus tumour. The patient ended up paying to see him privately in the end as she was told there was an 11 week waiting list to be seen on the NHS, despite being unable to weight bear/work and having a palpable mass. She has now been referred back to the NHS for urgent diagnostic ultrasound with a view to surgical intervention.

Many thanks again all for ideas - an interesting case indeed.