Vague symptoms, vague diagnosis.

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Hi,

I feel the need to sound this case on this forum, as otherwise I'd be in danger of consigning it to the crazy/impossible patient bin and I really don't like doing that.

I saw a lady in our practice today who saw the previous owner 3 years ago. She complains of stiffness in the forefoot area bilaterally and weakness in both feet & ankles.

She takes ibuprofen for arthritis, although this seems to be a self diagnosis & treatment. It doesn't seem like she's seen a GP in a long while. She takes no other medications.

She is quite anxious and lacks confidence in walking to the extent that her daughter now helps her walk everywhere. There is no history of cardiac disease, no history of degenerative disease or thyroid problems. However, given her reluctance to see a GP I didn't read too much into that. She has experienced no significant changes in weight in recent years, she is overweight but not what I would call obese.

Ankle ROM is OK. Laterally deviated STJ axis. Plantarflexion power OK. Dorsiflexion, inversion & eversion power negligible. All forefoot jt ROM good. Some tenderness palpable around the sinus tarsi bilaterally. She complained when I prodded around her peroneal muscles early in the exam, but then didn't when I prodded again later. Some tenderness at the base of 5th met. Lateral compression of the forefoot was painful bilaterally & there was some localised tenderness between 3/4 & 2/3 MtP joints.

RCSP shows a cavoid position for both feet. Gait is ataxic and pronated throughout.

Neurological testing on both feet showed no sensory neuropathy. Babinski reflex was OK. Ankle & knee reflexes seem OK, possibly dulled but inconsistent would be a better description. Foot pulses are all excellent. There is some mild oedema at both ankles.

She's had orthotics from a couple of Podiatrists in the past, both EVA. She doesn't wear either now. The 1st pair incorporated a met dome but otherwise a fairly neutral shell. The second pair added a lateral heel wedge to the prescription on the assumption that she had a peroneal tendonopathy at the time.

I tried some heel wedges in her shoes to see what happened to her symptoms. Lateral wedging changed nothing, medial wedging she found quite uncomfortable.

I couldn't really get her to describe her pain beyond a constant stiffness. She seemed quite vague in general and asked the same questions several times.

I feel like I'm missing something, as her symptoms don't fit nicely into any diagnosis. Any thoughts?

Julian

 

manmantis,
How old is this lady and can you give some more info about her occupation/lifestyle ?

Thanks

Catfoot

 

Hi,

You've indicated that the patient is self-treating for O/A, has a high anxiety level, and her daughter has to walk her everywhere etc.

I would document your findings and refer her, with her agreement, to her GP for a complete medical check.

 

From memory I'd say she's in her mid/late 70s. Certainly no older. Her husband is dead & she's retired & living alone. As I said, she's not very active at all as she lacks the confidence/ability to walk anywhere.

The treatment was prompted by her daughter who's a registered nurse. The daughter was wondering about TIAs, but we discussed her symptoms & recent history and that really doesn't sound likely. I questioned about dementia as well and that line of enquiry went down like a lead balloon.

I'm going to speak to her GP in the morning to thrash her symptoms about with him. I made an appointment with him for her at the end of the consult. Would be nice to sound a little less vague.

 

I think this is exactly right. Your post certainly wasn't vague, so it's unlikely you'll come across as vague to the GP.

Let us know the outcome.

Cheers,

David

 

Does sound a little like phantom type of pain. I would be considering the "pain" is more of a mental side of things .

 

Hello manmantis,
I had seen cases like this where an elderly person (usually female) appears unable to walk unaided due to lack of confidence or just refuses to walk altogether.
In the absence of any apparent physical cause I would suspect that it was a manifestation of an anxiety state coupled with a degree of agoraphobia. However, as this area is outside our remit as pods, a chat with the GP might be very useful.
Sadly, the cases I have seen have not been resolved. I hope this one has a more sucessful outcome.

regards

Catfoot

 

I concur with this, the vagueness of the symptoms was quite frustrating. I pretty much decided it was a psychological issue of some description, I just don't like those sort of open-ended consults.

I was confused about the loss of inversion/eversion & dorsiflexion power though. Plantarflexion was quite good bilaterally. If she was "putting it on" I would have expected it all to be weak. And that seemed to sort of fit with the ataxic gait. I say "sort of", because I was expecting some evident foot drop as she swung her feet and there wasn't any.

I ought to let this go really!

 

Sitting & reflecting on this at length it seems likely to me that this is probably a combination of a spino/cerebellar ataxia and some anxiety/confidence psychomotor issues.

Plausible?