Help: Case Study

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Hey Doc's, I could use some help. [a photo should be attached...I hope it shows up...] Note the flushing of skin on the symptomatic body part, in this case the foot of a 75 year-old (former) tri-athlete -see the photo below (weightbearing). His chief complaint was foot pain of 2-1/2 years duration that has become progressively worse. On exam, his foot would go flush intermittenly. Periferal pulses were in tact. He also has mild, left SI, hip, and lateral thigh symptoms there were not provoked by mechanical challenges or isometric challenges, but were dull and infrequent, and don't wake him from sleep. His plantar foot, especially inferomedial to the MTC and navicular, was quite tender. He favors the foot, with recent symptoms causing him to use a walker. Past medical history is replete with a variety of conditions, most minor, and one major, a lymphoma he recovered from decades ago. He is hypertensive and controlled with meds. History of seropositive arthritides was absent. He is not diabetic. Further past medical and social history was unremarkable or non-contributory. Primary sensory and motor exam was normal, with pinwheel sensation in tact, but with loss of vibration sense at the great toe. Spine palpation tenderness was notable only at the left SI joint, and absent at thoracic and lumbar segments. There was no spasm. Fascial lesions were few. Further isometric muscle testing demonstrated grade 5/5 strength to hip flexor and extensor muscles, but a 4/5 weakness to the right hip abductors and left hip TFL (combined abduction, flexion, and internal rotation of the hip). Knee examination was normal, with no signs of meniscal, capsular, or other ligamentous disruption. Allis’ sign was positive (though mild) for a short left femur.

He brought me two pairs of rigid orthotics, one made by an orthopedic foot specialist 16 years ago (they look like old Langer Lab's) and one made recently by a podiatrist that was graphite and composite, rigid, and with bilateral extrinsic forefoot posting. He does not tolerate the new orthotics, and now no longer tolerates the old ones. XRay Summary: Some mild soft tissue swelling about the ankle. The ankle mortis is intact. There is no joint effusion, fracture, or dislocation. Extensive vascular calcification is noted. Some erosions at the 1st cuneiform. Some loss of joint space of 1st cuneiform and 1st metatarsal. Some hypertrophic spurring also identified at the 1st cuneiform and metatarsal joint. Some mild spurring identified in the superior posterior aspect of the navicula. Vascular calcifications are again identified. No periosteal reaction or reabsorption... Old pelvic xrays show multiple vascular calcifications.

My thoughts on the flushing skin were RSD or some variant on it. My concern regards the potential for vascular disease. Despite clean lab's, and before I order MRA, would you simply consider this flushing a concern?
FYI: I re-casted him and plan to fabricate softer, more accomodative orthotics via Langer Labs. Any thoughts would be appreciated.

Thanks,

Scott
___________________________________________________
Scott F. Gillman, DC, DACBSP
Diplomate: American Chiropractic Board of Sports Physicians
www.drgillman.com

 

I would be interested in learning more about the timing, frequency and nature of the flushing - it certainly rings vascular alarm bells. Although peripheral pulses are present, further vascular assessment would seem warranted (non-invasive examination such as Doppler, ankle-brachial index etc). The presence of calcified vessels on plain film radiographs would point to the possibility of underlying atherosclerotic disease.

In regard to RSD, has there been any trauma (other than being a triathlete!) in the past?

I saw a lovely chap the other day who had bilateral flushing of the feet - after we exhausted every other diagnosis, we actually settled on the old 'trench foot/immersion foot'. He had been a milkman for most of his life and his feet had been severely cold and wet every morning. Eventually he ended up with a vasomotor disorder, although his macrovasculature was reasonably intact.

An LA Block more proximal to the foot might knock out the sympathetic system long enough to evaluate the potential of a vasomotor diagnosis.

Meanwhile - good luck!

cheers,

Felicity

 

Scott,

This looks like CRPS. I doubt that the primary problem is vascular in nature given the intermittant presentation and lack of hs pain. This could have been triggered by DJD type pain. One does not need a severe traumatic event to develop CRPS. Vascular pain, in my experiece, does not present with significant unilateral foot pain that requires a walker. The vessel calcification could be age related changes.

Keep us posted.

Nick

 

Nick, Felicity, thanks for your responses to this. I also agree that it's a CRPS/RSD type of issue. I taped his foot today and hope his new orthotics arrive soon. His hip and thigh symptoms were notably better following his initial visit where I did some joint manipulation and Graston Technique.

'Regards,

Scott