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Drop Foot Help Please

Discussion in 'General Issues and Discussion Forum' started by ginger, Jun 19, 2013.

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  1. ginger

    ginger Active Member


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    Hello, I was wondering anyone could help me with a patient I saw today.
    He is a 49 year old male, presenting with unilateral drop foot (left side). He has no noted health problems. His only medication is Ibuprofen taken when required. Strength test 1/5 on dorsiflexion. He also demonstrated weakness when asked to invert and evert the foot against resistance (3/5). The foot was cold to the touch and was significantly colder than the right foot. Appearance was cyanotic. Muscle tone was lacking when compared to the right foot, foot appeared 'floppy'. Pulses were present although the dorsalis pedis was weak. There was presence of hair on his feet and his nails appeared healthy. I tested his light touch (10g monofilament) and vibration sensation (tuning fork), all of which he could feel perfectly. He walks with a steppage gait, using his quads to lift his left foot. He had some slight lower back problems 5 years ago, he did not see the GP and this does not cause him problems any more. Around 7 years ago whilst paint balling, he was hit in the calf with a paint ball which caused significant bruising at the time but again has had no problems since. My patients wife came in with him and noted that "he bruises like a peach". There is a family history of high blood pressure. Also of note, his uncle had a "massive stroke" at the age of 52. My patient was noted to have high cholesterol during an examination for a medical research project 4 years ago but I understand this is now under control.
    Something which is very interesting is that at the exact time the foot drop occurred, my patient also began experiencing problems with his vocal chords. His wife explained that they have been told that his "vocal chords don't meet". I suspect these symptoms have been caused by a CVA or TIA. Do you think this is correct?
    I wonder if anyone has experience of similar presentations? I work privately in a small area so would appreciate some input from colleagues further afield. I hope the information I have provided is helpful. Thank you.
     
  2. ginger

    ginger Active Member

    I should also add that the 'vocal chord problems' have resulted in a very 'rough' voice and my patient also slurrs his speech. He has seen various GP's and is seeing a speech therapist, however only one of 5 GP's has actually examined his foot which was only a brief glimpse from a distance from what my patient and his wife tell me. They are at their wits end as they keep hitting brick walls and no-one seems to have connected the drop foot with the speech issue. If there is a connection to be made...
     
  3. Tuckersm

    Tuckersm Well-Known Member

    While it could be an undiagnosed CVA, it could also be one of a number of Progressive Neurological Disease (MS, PSP, MND, Parkinson's etc.). I would suggest her needs a referral to a Neurologist for a full work up to provide a diagnosis.
    Probably needs a brain CT and nerve conduction studies of both legs.

    How long ago was the 1st onset of symptoms?
    Has there been any progression or improvement since, in either foot power or speech?
    Any swallowing issues?
    Any changes to the other foot?
    How is his hand power / grip strength?
     
  4. ginger

    ginger Active Member

    Hello, thanks so much for your reply. The symptoms began in October last year, there has been no improvement in either speech or his foot. No swallowing issues, as far as I am aware but I will double check at his next appointment. No changes in his right foot, 5/5 in strength tests. Hand power and grip are fine, he works as a mechanic and has not experienced any loss of strength. MS had crossed my mind also, where we live there is a particularly high prevalence of it. I am intending to write a letter to the GP but wanted some other Podiatrists input first. I appreciated your reply, thank you.
     
  5. Tuckersm

    Tuckersm Well-Known Member

    A lot of the progressive Neuro disorders start with a number of non specific problems that need to e linked together to arrive at a Dx
    I am learning more and more about them all having spent the last 6 months managing a PND service, so may have become a bit biased.
    Definitely ask the GP to reffer to a neurologist as they will work out what is causing the issues
    Many of the PNDs take 12 months to be accurately Dx
     
  6. Admin2

    Admin2 Administrator Staff Member

  7. ginger

    ginger Active Member

    Thank you again, I will write a letter tonight asking for a referral. Much appreciated!
     
  8. Vocal chord weakness and drop foot were my mother's initial symptoms prior to being diagnosed with Motor Neurone Disease. Request an urgent referral to your local neurology department.
     
  9. ginger

    ginger Active Member

    Mark, sorry to hear about your mother. I appreciate your input here. I wrote a letter requesting referral last night and have emailed it to the couple so they can take it to their GP today. Thank you.
     
  10. AngieR

    AngieR Active Member

    My first thoughts on the original post was 'MND' as it reminded me of a case I saw many years ago. So I'm glad someone else came up with it.

    I was on a domicillary visit and whilst there, the son in law asked me to look at something on the bottom of his foot, I can't remember the exact nature of the lesion, but it was different, not melanoma type, but odd! He didn't really have any other major symptoms but I advised him to visit the GP for a second opinion and within weeks he was diagnosed! Unfortunately he died about 2 years later having done all those things you wished you'd done but never get round to doing!

    Shows you just never know, he was mid 50s when he died.

    Angie
     
  11. ginger

    ginger Active Member

    Thank you Angie. I will wait and see how they get on at the Neurologist, I hope they get a quick referral. It's not something I have come across before but I won't forget it now!
     
  12. Tuckersm

    Tuckersm Well-Known Member

    MND or ALS and Lou Gehrig's disease as it is known in the US, is an extremely rare condition with an incidence rate of about one in 30,000 per annum, so you wont see it too often. There is no specific diagnostic test (it is usually the Dx given, when there is no other Dx), and there is no treatment (riluzole can extend life for 2-3 months), so treatment is mostly symptomatic, as well as maximising a patients function as the disease progresses.
    Lets hope that in this case it isn't MND
     
  13. Hope not. I think there is now a tissue test being done to Dx MND, Stephen. At least, that was our experience.

    Kind regards
     
  14. Tuckersm

    Tuckersm Well-Known Member

    Mark,

    Just checked with our Neurologist, and there is no specific test for classical MND. Some of the sub-groups (Spinal Muscular Atrophy) have a gene test. A muscle or nerve biopsy can confirm nerve disease / damage and disease progression. but not its cause. Other tests may also be conducted to either rule out, or build a picture consistent with MND.
     
  15. ginger

    ginger Active Member

    My patients wife phoned me yesterday. They had also been to see a private physio who also works part time for the NHS, she agreed with what had been said in my letter and was able to arrange an urgent referral to a neurologist via her boss at the NHS. They also went to the GP surgery on Saturday and are hoping to have a CT scan done within the next 2 weeks. Many thanks for all your help, it has been very much appreciated!
     
  16. ginger

    ginger Active Member

    My patient's wife phoned me yesterday. They had also been to see a private physio who also works part time for the NHS, she agreed with what had been said in my letter and was able to arrange an urgent referral to a neurologist via her boss at the NHS. They also went to the GP surgery on Saturday and are hoping to have a CT scan done within the next 2 weeks. Many thanks for all your help, it has been very much appreciated!
     
  17. ginger

    ginger Active Member

    Hi all, just wanted to update you all. My patient has just been diagnosed with MND after being referred to a Neurologist. Thank you all very much for your input.
     
  18. Sorry to hear that. Best wishes to your patient. Who/where are you btw?
     
  19. ginger

    ginger Active Member

    I'm in Orkney, Kirsten Sinclair. And thank you.
     
  20. You're welcome. Is wee George Rendall still up in these parts?
     
  21. ginger

    ginger Active Member

    He is indeed! He comes up from Edinburgh once a month for a few days.
     
  22. ginger

    ginger Active Member

    Double post, sorry.
     
  23. Give him my best wishes next time you see him, Kirsten. Good luck with your patient..
     
  24. ginger

    ginger Active Member

    I will do Mark. Thank you!
     
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