Wide feet or something else?

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All, I am due to see a patient on Saturday who was referred to me by a colleague. Today, I received in the post a letter from the patient together with a questionnaire he had completed for another clinic/ company and some photo's of his feet- he thought this might be helpful. I'd like to know what your thoughts are, not about the questionnaire design, about his responses and condition. The following is copied verbatum from his completed questionnaire (questionnaire in bold, his answer italic):

1. Define exactly what the patient is complaining of (this can be difficult with some patients!). Some patients insist on telling you what previous doctors, chiropodists etc have said is wrong with them. Insist that they tell you first what actual problems they are having. Don't accept previous diagnoses at face value- find out on what basis they were made and re-assess their validity

(This answer, though accurate, does little to describe the impact the problem has on every aspect of my daily life)- Discomfort, pain and various odd sensations (tingling, twitching (actually visible on left foot behind baby toe), stinging, burning) all confined to a small area on the sides of the feet behind baby toes and big toes from "bunion" joint to tip of big toe.

Describing the pain at its worst imagine having something like dried peas (but smaller) taped to the sides of the toes and then trying to wear shoes. the worst "sensation" happens when walking and feels like a nerve (or something) is being pinched and "shocked" with every step taken. The worst "pain" happens when standing in shoes, especially after a couple of hours shopping (in the shoes I wear this is confined mainly to the area of the baby toe joint and I've marked this (and the area of discomfort around the big toe) in red on one of the pictures although it applies to both feet).[He had drawn onto the pictures by hand- basically medial border of hallux from base of nail to 1st MTPJ and dorsolataral aspect of 5th MTPJ-Simon]

(Also recently started getting occasional sharp pain underneath feet (marked the approximate location on the foot outlines over the area)- [This is approx medial tubercle of calc- Simon] but that has only recently started and seems mainly connected to footwear and doesn't last long (rarely happens when barefoot and seems to lessen/improve/go away with walking).)


2. How the problem first started

Always had problems finding wide enough footwear (as far back as my teenage years). Think the current problem first began when I believe my feet spread with age and well fitting shoes could not be found.

3. How long has it been going on

Certainly recall having current problems to a lesser degree more than 10 years ago and probably had for years before but only when directly caused by squeezing the foot into unsuitable footwear.

4. Initiating, exacerbating and relieving factors (in the foot this should include the effects of walking, running, work and footwear)

Any activity will trigger and even sitting with just socks on can feel odd if not actually uncomfortable. Best relief is had be going barefoot (in soft socks) and walking on carpet (with an underlay!). Worst is standing in my only pair of shoes- the discomfort/ pain is lessened for a short while if I keep walking but eventually feet become so "painful" I have to find somewhere to sit (the time this takes varies and can be as long as a couple of hours to as little as less than an hour). Haven't been able to run for 20+ years and walking for pleasure/ exercise now impossible and if I stil worked i don't know what I would do- and once my only (and uncomfortable) shoes eventually wear out.........?

5. Course of the condition (getting better or worse, or staying the same)

In the past two to five years has got quite a bit worse (it's been a couple of years since I was able to walk for pleasure- and even then uncomfortably) and was just about as bad two years ago as it is now.

6. How is it affecting the patient's life: work, sport, hobbies, social activities

Work- I can't see how I could even if I had to. Sport (activities for exercise) I can't do anything on my feet (I can cycle (uncomfortable) and swim but rarely have the opportunity). Hobbies- wife and I both really enjoyed serious walking but not in the last 10 years and never in proper "walking" shoes for me.

7. What treatment has been tried and with what result. Again clarify exactly what treatment has been tried- "physiotherapy" or "chiropody" are not enough any more than "an operation" is- find out what modalities of treatment were used, for how long and by whom. Ask about partial or temporary success of treatments- this can be a useful guide to diagnosis as well as possible alternative treatment.

Other than painkillers and anti-inflamatories (which do not work) nothing has ever been suggested.

8. What has the patient been told and what does s/he understand (not necessarily the same thing!)- who told them?

Musculo/skeletal specialist believes there's nothing mechanically wrong but said I should see a rheumatologist. rheumatologist said there was nothing he could suggest as the cause and that I'm probably one of those cases which defies diagnosis. Doctor has performed a range of blood tests and ruled out everything he can think of.

9. What does the patient believe is likely to happen to them

Honestly, I've just about given up all hope and sometimes wonder if I'll become virtually housebound and restricted from doing anything which can't be done barefoot! And this is why:-
-baffled doctor
-3 previous podiatry appointments
-neither musculo-skeletal specialist nor rheumatologist able to help
-tried having shoes made (after 2 attempts maker said I should try to get the problem treated)- although I'm not sure the shoes were right but for them I travelled 500 miles and spent nearly £300 (which I luckily got refunded)
-I visited the Cosyfeet shop in Street which stocked Hotter shoes and Padders and have also tried every other wide fitting shoe i could find and none provide the fit I need (that is width at the right place, accommodations for big toes and sufficiently cushioned and padded and free of seems).
But how can I be sure different footwear would help if I can't get the problem diagnosed in the first place?

10. What sort of treatment do they expect and want

I've no idea- but want to identify the cause and then, hopefully something can be done.

11. If there has been a perceived injury, is there litigation going on?

N/A

12. Does the patient have any other relevant medical or psychological conditions

Other things which I have mentiond have only taken attention away from my feet even though the musculo-skeletal specialist originally said I should not be focusing on my feet as he thought the problem was a wider one (possibly arthritis)- the rheumatologist did not seem to agree. The only thing confirmed, and thought might be relevant was an early stage arthritis which was found in my writsts.


13. Is s/he on any medication?

No

14. What is his/ her overall level of fitness?

Have become out of condition over last 10 years and not getting any better- I know I could be feeling a lot fitter if I could do the activities I enjoy.

15. Do they have a family history of this or related conditions?

No

16. In the foot and ankle particular note should be taken of

a. occupational and sporting factors None
b. The effect of shoewear-what shoes does the patient wear- do they fit.- See above and shoes
c. Effects on gait and mobility- see 8 above

[what happened to questions 17-19?- Simon]

20. All patients with foot and ankle problems should be asked about
a. Diabetes doctor has tested for
b. inflammatory arthropathy- ??????
c. Neurological disease- ?????? (I have recently wondered)
d. Vascular disease-??????
e. Trauma- None unless badly fitting shoes counts

Looking forward to your thoughts on this case.

 

Simon:

Any patient that sends me photos of their feet or brings me in a long history of their injury preprinted with pictures means, generally, that I will probably be able to do very little to help them. And you have to see this patient on a Saturday?!....what a way to spend the weekend!

I tend to doubt this patient's pain is caused by shoes or "wide feet" but it could very well be some type of peripheral neuropathy. Generally neuropathic pain in the feet will be worse when the patient is at rest or trying to go to sleep at night and is better while walking around and/or while the mind is occupied "doing other things". This seems to be a quite consistent characteristic of pedal neuropathic pain. His description doesn't exactly fit a neuropathy but the "tingling, stinging, burning pain" sounds exactly like a neuropathy. I would suggest a neurologic consult and EMG/NCS if you think it is nerve-related and/or neuropathy.

I see probably 5-10 patients a year that have been diagnosed with idiopathic peripheral neuropathy, which is a diagnosis of exclusion (i.e. after having ruled out neuropathy from diabetes, alcoholism, Vit B12 deficiency, etc). http://www.clevelandclinicmeded.com/DISEASEMANAGEMENT/neurology/pneuro/pneuro.htm Ask about exposure to odd chemicals in the past, types of medicines/drugs/ he may have been on in the past, chemotherapy, or heavy metal exposure. http://www.mayoclinic.com/health/peripheral-neuropathy/BN00046 Sometimes these poor individuals just have it and no one can determine how or why they got it. If peripheral neuropathy is the diagnosis, then topical capsaicin works for some patients but I have had better results with oral Neurontin (gabapentin) to help relieve the "tingling, stinging, and burning pain". Unfortunately, Neurontin causes somnolence in many patients and is best taken sparingly during the day with the highest dose before sleep at night.

Hope this helps. Good luck and let us know how your Saturday adventure goes.

 

Hi Simon
My thoughts for what they are worth...
I have had a few patients they have presented with similar symptoms and I would not rule out that the simple diagnosis of wide feet.
The appearance from the photos suggests prominance along the 5th ray- this can easily cause compression along the border of the shoe. This of course would be exascerbated if he tends to pronate and therefore the forefoot is abducting on the rearfoot.
Skiers often have these kind of problems as their boots are certainly not very forgiving- I have felt this pain skiing and it becomes almost unbearable- relief is by taking off the boots and pressure off the feet. Biomechanical control makes a great difference for skiers in these cases, much more so than blowing out the shell of the boots to increase the width.
I would certainly want to see what intereventions had been attempted previously to be satisfied that this possibility has been accounted for.
Is it possible that this sort of mechanical pressure could cause some low grade local nerve irritation?? I have had a few confounding cases that have defied a diagnosis, but responded to simple biomechanical offloading- nerve conduction tests had not shown anything, but the symptoms did seem to have a 'nervy' component.
Just another idea... hope it helps!

 

Hi guys,
I have played with fitting ski boots and walking shoes for years and have seen feet with enlarged 5 th met head (tailors bunion), usually associated with uneven tension and lax tension (between 4 and 5) of DTML which is often associated with neuroma type symptoms. When coupled with steep rear foot axis and increased transverse plane motion the lateral side of the foot "bangs " on the inside lateral surface of footwear even when it is wide enough. Not an easy combination to get relief....have used really major lateral column support focussed under the cuboid and where possible a shim or pad down the lateral inside (of shoe) that begins back near cuboid and stops before 5th head. Have also played with shaft elevators and domes to get feedback about effects.
Good luck
regards Phill Carter
ex Uni...now country bumpkin rural practitioner

 

I like the questionnaire, particularly this question 1...

Some patients love to give you some medical jargon, second hand from another practitioner or other source. Little do they know that they are not helping one iota.

How difficult is it to just say what you feel?

 

It's always wonderful when patients bring in a long list of their various aches and pains. I always remember one chap who presented me with four sides of close-typed A4 paper, detailing his full medical history dating from 1953. This included every prescription, investigation and procedure he had experienced, including his penile prosthesis...

It's often difficult for some individuals to find shoes that fit their particular foot shape and proportions, which makes me wonder who this patient saw to have the shoes manufactured - £300 sounds quite cheap for full bespoke shoes. It could be that this chap might need a modular orthopaedic shoe, which would give him more space on the medial and lateral aspect. I do however think that there's a neurological component to this problem - tingling, stinging and burning are the signs I'd expect.

Regards,
Martin Nunn
Podiatry Service Manager
Hotter Comfort Concept

 

Having spent an hour and half with this chap last Saturday I honestly believe he needs psychiatric help.

 

I fully sympathise. When I first started working at Boots, both the dentists and myself were swamped with all manner of odd characters. We soon realised that these individuals had been seen by every other practice in the town, and we were the only one that would offer them an appointment . We were then stuck with them until we could persuade them to go elsewhere...

 

I was asked approx 2 years ago by the Chief Clinician of our Service to assess a pt.

After approx 1 hour of conducting every clinical exam technique I could remember, I could not put my finger on the problem.

I walked out with a headache. My Manager asked me how it went, which confirmed her own suspicions that the pt was probably insane, but wanted a second examiner to assess the pt without any pre-conceptions gleaned by discussing the case prior to exam.

I believe the pt is now in long term care in a Psychiatric establishment.

If anybodys remotely interested, the pts complaint was that when he stands in the base of gait, he felt he had to turn his pelvis, spine and head to one direction, as his body felt it was pointing differently to his head.

NB, please don't tell me this is a recognised clinical condition or Im a goner.

 

We all have to have a few of these patients. Frustration makes us stronger (alledgedly). The Question" BUT WHERE DOES IT ACTUALLY HURT!!!! "causes lots of people real problems!

I do love it when they come in with a second hand diagnosis from another podiatrist / GP / Physio / Surgeon / Guru / Man in the pub who have told them what it is and that it will be easily cured with an Insert-name-of-orthotic-here. Strangly the refferer always stops short of actually DOING anything, leaving you trying to explain to the patient that they're not getting better because they're a 52 stone fire walking, sky diving, jogger rather than because you did'nt make the orthotic right or that you don't understand what the bloke in the shoe shop meant.

However regarding the relevance of the penile prosthesis (don't know what that is, and I don't want to!) i did have a similar case once.

56 YO Male with a fairly bog standard Planter Fascitis. Had been improving nicly with orthotics. Suddenly started having relapses where he would wake up first thing in severe pain (much as he had in the beginning). These episodes lasted only a half day or so and appeared to be completely at random a few times a week. Try as i Might i could not match the attacks with anything relevant in the mechanical history, they did not correlate with any increases in activity, footwear etc.

It was the patient who finally cracked the riddle. The problem was occuring the morning after he used Viagra. Increased blood flow, inflammation, kinda makes sense (or it could have been from swinging off the chandeliers i guess).

Interestingly he elected not to discontinue his medication!


Regards
Robert

 

Simon:

Like I said, any patient that brings me in that much information (i.e. typewritten, illustrated with diagrams or photos of their feet) has been, in my experience, someone I will rarely be able to help. He may need psychiatric help or he just may have a disease process that can't be cured or helped. The best we can do is be sympathetic and try our best to help them.

 

Now there's a red flag. Someone made him some custum shoes and gave him his money back. In the shoemakers head: "what is worth to me to make this guy go away?" The shoemaker chose to not get paid for the materials and hours of work that went into the shoes. Maybe we should call this the "Spooner sign" for a difficult patient


Cheers,

Eric

 

I did try to talk to him about the red flags (and even used this terminology) within his letter and I did offer numeous solutions to his problems. I was sympathetic and caring throughout. But, I was left with the feeling that this man wanted to be a "medical puzzle" and untreatable and moreover, took some kind of weird pride in it. He didn't like it when I was able to point to a number of things which may be responsible for his symptoms and even less provide potential solutions to these problems. Interestingly, he doesn't work but is of working age. Hmmmmmm. I sent him down to a local store that deals in extra width footwear, since this was the only thing he was really interested in (interestingly, his only pair of "comfortable shoes" were a pair of standard off the shelf Clark's gibson shoes!- in answer to his question- "what will I do when these shoes wear out?"- my response: go and buy some more identical ones from Clark's). Feedback from them was that he spent less than five minutes there and "didn't want to know."

Spooner's half time verdict: cock. Glad to see him walk out of the door and out of my life, no lost sleep, no big deal. Some may think: harsh. But y'all weren't there. I say fair. Result: Spooner 1 - 0. To quote the brilliant and much missed Bill Hicks: "K? K!" He was sent to me as someone elses problem in the first place, and here's a lesson for some of you students out there. Ready? Wait for this................ Drum roll: tthrudddddddddddddddd. Shocking news just in: some people don't want to get better. Think about that in your psychology class tomorrow. Have a nice day.

 

Certainly have also seen my share of these types of patients also. To quote a surgeon that I know (while he was standing face to face with a patient in the hallway of his office when the patient was loudly arguing with the doctor that he had done nothing for his pain): "The only cure for your pain will be for you to hold a 44 to your head and pull the trigger." ......all done with a smile on the surgeon's face. A classic and a true story.

 

What about some sort of RSDS/CRPS?

 

have to not misjudge your audience, a woman recently won a £44,000 setlement from a clinic over here after a doctor saw her having a cigarette outside following childbirth and commented "you've just seen your daughter born, if you give up smoking you may see her get married"

 

After reading the answered questionnaire - it seemed logical that there were more psychological issues in there than physical. Almost as though he had given up on the medical system, and was asking for more help when his expectations was to have no help in the first place. Spooner you were there and you dealt with it - pat on the back deserved. I suppose sometimes we just have to take a step back and let some people deal with their problems the way they would like, as any input we place in will cover our butts legally but in reality they may not choose to listen.

At the end of the day, it's him who is in pain and not you. At least you have peace knowing that you've done all you can to cover your grounds.

- As for the Regional pain syndrome, neuropathy, and neurological diagnosis they may be possible and may require a neurology referral for confirmation or testing.