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Severe MIdfoot pain with MRI signs of bone swelling.

Discussion in 'Foot Surgery' started by WalkWithoutPain, Feb 27, 2019.

  1. WalkWithoutPain

    WalkWithoutPain Active Member

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    Hi surgical pods. I have moved this over from general discussion as we weren't getting much traction there. Hope that is ok.

    I would really appreciate help and opinions on a complex case. I have been treating an older woman with severe midfoot pain for around 6 weeks. She has had the pain for approximately 14 months. If I give the pain she has now a score of 10 for reference, it began with a 4, escalating over a month to an 6. She saw a first podiatrist who made some orthotics but not much changed initially. The pain slowly dropped back to a 5 over six months or so which may have been the orthotics or - perhaps more likely - the passage of time. She saw another podiatrist about two months prior to seeing me who (you'll never guess) made a different pair of orthotics. At the review, she reported her pain had not changed. The pod did some forceful mobilisation which caused a lot of pain in during the movement and the pain has been unrelenting since at a 10. She thinks the motion was an inversion / eversion of the midtarsal joint.

    The physical exam of the foot shows it is swollen and heat is radiating from the area. I don't have a measuring device but it was markedly hyperthermic. The pain seems to be experienced around the cuboid area. though most of the lateral half of the rear and midfoot are in trouble. Some tendon pain is present on palpation around the lateral malleolus though this seems secondary.

    The MRI results were a bit startling. The cuboid and lateral cuneiform bones were quite white on the scan but nothing like the base and proximal third of the 3rd metatarsal shaft which is a bright white. This represents extensive bone marrow oedema. No particular joint effusions are present. THe bone shape looks fairly normal. As a diagnostic test after this scan, I injected the joint of the base of the 3rd met / cuneiform joint with Marcaine which had a reasonably positive effect for the day.

    She cannot tolerate a moon boot as it made her very unsteady and I don't want to push her down a flight of stairs or similar. A post op shoe was tolerable as far as her gait went but made the pain worse. She can't tolerate either of the orthotics nor even a small arch pad. I have her in a medial and lateral ankle stirrup brace which is a small improvement. The lady is 77, otherwise in good health. Her bone density status in unknown. She is a very pleasant lady who is obviously in a lot of pain. Attached are a couple of screen shots though the scale of the oedema is not as visible in this photo. If this link doesn't work, they are viewable on https://walkwithoutpain.com.au/mri-pics/

    I have developed a theory of events but would like to hear others opinions on what might have caused such profound bony oedema. Most importantly, what to from here? Whilst I am endorsed to use corticosteroids, I have concerns about the medium and long term outcomes for her healing - are they valid? Would an infiltration into the joint space abutting these oedematous bones have much effect on the bone oedema and repair? Does the base of the 3rd met have a lateral avulsion fracture?

    Hope you can help :) Thanks STephanie
  2. WalkWithoutPain

    WalkWithoutPain Active Member

    Minor update. I had the opportunity to show her MRI scans to a different radiologist who thinks that it is likely that there is a fracture in the base of the 3rd met. I had asked the initial Radiologist to review the area on the films and he reiterated the original 'no fracture-massive oedema' finding. So, not confirmed but certainly in the mix for consideration.

    At this stage, I am getting CRP and white blood investigations to double check that the heat and swelling are not an occult o'myelitis. Following that, my next intention is to go ahead with HCLA (probably...…).

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