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Hi I'm new to this forum and was presented with a really interesting case yesterday that I would appreciate member input on.

33 Year old male presented with left 4th and right 2nd and 3rd sausage toes, duration 2 years! Medical history revealed no existing medical conditions, medication or family history of inflammatory arthritides. Onset on both feet was gradual and ibuprofen helps with the pain somewhat. Patient has had a blood test but this showed up nothing. The only medical complaint the patient has is recurrent bouts of genital thrush but the feet are in good health aside from the inflamed toes. No feeling of malaise or stiffness in any other parts of the body. Some lower back pain. Plantar flexion of PIPJ's in affected toes elicits pain and palpation beneath the base of the toes is also painful. The patients job is sailing and he wears trainers on deck and pretty good footwear generally. He also works out in the gym a couple of times a week.

BMX assessment, showed normal ROM in 1st MTP, STJ, MTJ and TCJ. Hamstrings were quite tight and when walking he demonstrated a wide base of gait, flexor stabilisation and low gear propulsion, fairly abducted. Hubscher scores 3 on the right and 2 on the left during stance. Foot posture was pretty normal, right fairly neutral and left mildly pronated.

I am treating the case as biomechanical in orgin, have taped the toes down to stabilise them during gait and have booked the patient in for orthotic prescription as I can't decipher any other cause at this stage. I am also writing to his GP to get a scan done to rule out anything else going on in the joints! Am I missing something??? Has anyone else seen chronic toe swelling in someone so young as a result of poor biomechanics? Please help!

 

Having read posts on fat toes and dactylitis, I have written referral letter to GP for MRI scan to identify any signs of seronegative spondylarthropathies, and blood and urine tests to rule out genitourinary infections or other infections for that matter. Patient fits criteria for Reiters, where dactylitis can occur as a secondary inflammatory response to various STI's and GI's in men between the ages of 20 - 40. Of course it could be caused by something else, I'll have to wait and see! I'm going to hold off biomechanical intervention until test results are back.

 

When you say he fits the criteria are you saying he has had an STI or GITI that would fit the time scale?

 

Hi Active_step

Interesting case. What is the aim of your orthotic prescrption and how do you propose orthotics will help improve this problem.

Have you considered trying taping, padding, shoe modifications etc to see if this would help first before considering orthotic px?

Regards

Daniel

 

According to the reading I've done, reactive arthritis may only cause dactylitis 3-4 months post infection and that once triggered, it can become chronic and continue to cause ongoing flares. The patient had the first 'sausage toe" two years ago and two further toes have become affected since. I have sent the patient for blood and urine tests as well as x-ray to rule out any STI or GI infections. The patient has not reported sufferring with any previous GI or STI but does suffer with recurrent bouts of genital thrush for the past few years, which may or may not be caused by sexual contact, so I felt it best to rule out anything that might be lingering for the patients benefit. However, if the x-ray shows up bony changes suggestive of reactive arthritis or any other for that matter than I will refer him to Rheumatology in order that it can be managed.

 

MRI to confirm Plantar Plate tear ;)

 

Hi PodAus

What would make you think that this could be a plantar plate tear? Do you think this is a typical presentation for a plantar plate tear?

Regards

Daniel

 

Yes, please can you give more detail about why it could possibly be a plantar plate tear. Also, just want to clarify that there are three toes affected, Left 4th and Right 3rd and 4th and they have not occurred at the same time.