Swollen foot - ddx??

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Hi guys, I have a colleague has a tricky patient and was just wanting to know if anyone has any more thoughts on what the patients condition could be.

She is a woman aged 45, has spinal stenosis at L5 and has had pain in her foot for 2 years. The swelling started on the medial side of the foot posterior to the medial malleolus and slowly spread over the entire dorsum of the foot.

Initially she had a full blood test done, with negative results, and has had massage, physiotherapy, acupuncture and vascular testing performed. All have not yeilded any results or helped.

On examination there is non-piting edema on the entire dorsum of the foot, with no pain palpable anywhere, no pain on resistance of any muscles or passive joint movement. The swelling becomes uncomfortable sometimes after walking for prolonged periods of time, and at night it can sometimes throb.

X-ray results revealed osteophytic changes on the dorsum of the navicular and the middle cuneiform. We have sent her for another full blood as the last one was done 2 years ago, otherwise we will send for an MRI.

Does anyone have any ideas?

Thanks!

 

Hi Jess :welcome: to Podiatry Arena posting.

Did the MRI show any changes to the Posterior Tib ? the reason I ask is the Navicular boney changes.

Also some more biomechanical information can be good ie STJ axis position etc.

I´m sure others will be along soon.

Good luck

 

She hasn't yet gone for the MRI and a bmx evaluation hasn't been performed as she is seeing an osteopath in the same clinic as me. She will be coming in to visit me next week so I can give you a more updated overview of her feet on Monday

 

Sorry reading to fast for the brain again. let us know the results of MRI and Biomex exam.

 

Hi Jess,
Although difficult to make guesses without more details of the assessment of the patient.
My initial thoughts with swelling posterior to the medial malleoli (other than the obvious post tib injury/tendonitis) would be are the venous return? Is there variscosities? Varicose veins? history of thrombosis etc?
I have had patients being examined by other health professionals for an inflammatory explaination to swelling and it ended up being a result of venous insufficiency.
Woth ruling out of the Ddx anyway!

Good Luck

 

Any allodynia, sweating previous trauma.

What bloods has she had done - Just inflammatory markers?

Is the area warm and red?

Whe you says she has had tested vascular testing has she has done?

An ultraound scan should show up any superficial soft tissue problem responsible for the problem but you will need to be give a small target area. You can also check for vasriscosities which can be masked by the retinaculaum on the medial aspect of the ankle.

If you have gone all through all these options please forgive me but there are too many possibile diagnoses based on the information here. An MRI would be a good idea.

Best wishes Simon

 

Just a thought

Have you considered Reflex Sympathetic Dystrophy or Complex Regional Pain Syndrome as it is now known ?

Cornmerchant

 

Jess,
The dorsals pedis vascular bundle courses close to the observed bony proliferation on the navicular. That bundle is tightly bound and close to the bone and prolifferation of navicular bone may be pressing on the vein in that bundle and causing the problem. If that were so, Vascular testing (by a PAD I presume) would not pick up the problem. An arterogram might but an arterogram would be contrindicated in the face of a normal PAD test. However, the pulsing/throbbing at night and the unilateral swelling really lends hints to a vascular problem somewhere, albiet an unusual one.
Dave C. Omaha NE

 

Hi Jess:
Reading through all this, how tricky is this patient? haha
Seriously, what stands out from your initial post is "non-pitting edema" -

If it is truly a non-pitting area I would see if your radiology department can perform a lymphogram.

Steve