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Interesting case / plantar pain

Discussion in 'General Issues and Discussion Forum' started by Kevin Cole, Dec 10, 2009.

  1. Kevin Cole

    Kevin Cole Member


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    Dear Colleagues,

    I would very much value your opinion on the following case.

    A 47 yrs old female patient presented at my office two weeks ago complaining of a great deal of pain in the sole of her left foot, several weeks duration.

    On examination I found the plantar of the left foot (particularly 2-4 MPJt) area to be warm, swollen and tender on palpation. Mild bilateral HAV, left has been surgically corrected. No other obvious foot /ankle pathologies. Digital temp reading of the area indicates between 6/7 degrees centigrade temp differential between surrounding tissues and opposing limb. Patient not febrile. No signs of foreign body/ entry point / punctum / pus. No history of trauma.

    Unremarkable social / medical history. Vascular and neurological status WNL. No medical history of note (other than c/o pain in right TMjt), patient not taking any medication. Pain score reported 7/10. Plays Golf regularly.

    I arranged for x-rays and bloods (ESR, CRP, ANA, Double stranded DNA, Rh factor, serum uric acid). Advised the patient on ICE, pain relief and NSAID’s.

    x-rays have come back showing no abnormalities other than mild HAV. Bloods have shown no inflammatory markers all WNL.

    Any thoughts ladies and gentlemen? The temperature is still elevated and concerns me, my next thoughts are sonographic ultrasound?

    Kind regards,

    Kevin.
     
  2. Hi Kevin.

    Ultrasound sounds like a good idea. Get them to look for a plantarplate tear as well as all the other obvious stuff . Hopefully the ultrasound will help make a diagnosis.
     
  3. Kevin Cole

    Kevin Cole Member

    Thank you for your reply Michael,

    I had thought of a planterplate tear, would that give such a large temp differential? This thing feels like a three bar burner!

    Kind regards,

    Kevin
     
  4. Kevin I´m not so sure about the temp change. It indicate a massive inflammation response even though your blood tests came back negative. I would cosider that Until you can get the ultrasound done it will very hard to diagnos from what you have written and certainly there seems some confusing info ( not what you wrote just the test results)

    that screams inflammation to me but then you write.

    I would tend to ignore the Blood tests for the minute and get the ultrasound done asap so you can make a diagnosis, it could be lots of things

    Continue with this
    but add rest and look at her shoewear as well.

    I tend to look for Plantarplate tears as part of my D/D since reading info from PA.

    Goodluck hope the U/S gives you a cause of the pain would be good to here the results. Maybe someelse willhave some ideas for you
     
  5. Kevin Cole

    Kevin Cole Member

    Thank you again Michael.

    Yes I agree re: confusing about blood results. This one has kept me awake all night, sad as that sounds, thats why I thought I would spread the load! I will let you know how it goes.

    Kind regards,

    Kevin.
     
  6. Kevin:

    Most likely diagnosis:

    Acute plantar plate tear at 2nd metatarsophalangeal joint (MPJ) secondary to iatrogenic shortening/elevation of 1st metatarsal head from previous bunion surgery and resultant increased compression/tension stress at 2nd MPJ

    Treatment:

    -icing 20 minutes/three times a day
    -offloading MPJs with padding/orthosis or camwalker brace
    -Nonsteroidal anti-inflammatory meds
    -possible cortisone injection if no infection is suspected
    -avoidance of any barefoot walking or walking without padding/orthoses in shoes

    Good luck.
     
  7. Kevin Cole

    Kevin Cole Member

    Thank you very much for your reply Kevin. The bunion surgery! Advice from you and Michael much appreciated. Thanks guys.

    Kind regards,

    Kevin.
     
  8. Kevin:

    Most first metatarsal osteotomy procedures for surgical correction of hallux abducto valgus deformity, no matter how expertly they are performed, will result in either some elevation or shortening of the first metatarsal. This elevation and/or shortening of the first metatarsal effectively lengthens the 2nd metatarsal relative to the first metatarsal which will increase the ground reaction force (compression force) acting on the plantar plate of the second metatarsophalangeal joint (MPJ). In addition, the relative lengthening of the 2nd metatarsal will also increase the tensile loading force on the plantar fascial slip to the second digit, which, in turn will increase the tensile loading force on the plantar plate, since the plantar plate serves as a "bridge" between the plantar fascia and the base of the proximal phalanx of the digit. Therefore, increased compression and tensile loading stress on the plantar plate of the 2nd MPJ may lead to an plantar plate tear/rupture which is not an uncommon sequelae from bunion surgery. Therefore, an acute plantar plate tear would always be my first guess as to what has caused a sudden increase in plantar 2nd metatarsal head pain, warmth and swelling in an active patient who had previously had a bunionectomy procedure on the same foot.

    Hope this helps.

    By the way, it would be an interesting teaching case if you could post both AP xrays of her feet (assuming they are weightbearing films) for all of those following along so we could see if, indeed, the first metatarsal had been surgically shortened or not.
     
  9. Kevin Cole

    Kevin Cole Member

    Very interesting Kevin. Certainly something to look out for, I see a lot of post-op bunion surgery patients with pain in that area. A wee review is needed!

    Fortunately the films were taken at a private hospital in Aberdeen so I should be able to get my hands on them. If taken at an NHS hospital you are lucky to get the report never mind the films! If I get them I will put them up.

    Many thanks again.

    Kind regards,

    Kevin.
     
  10. Kevin:

    I have a short chapter in my latest book devoted to plantar plate anatomy, biomechanics, and diagnosis and biomechanical consequences of plantar plate tears (Kirby KA: Foot and Lower Extremity Biomechanics III: Precision Intricast Newsletters, 2002-2008. Precision Intricast, Inc., Payson, AZ, 2009, pp. 105-110).
     
  11. Kevin Cole

    Kevin Cole Member

    Hope my wife appreciates the sentiment if it appears in her Christmas stocking!

    Kind regards,

    Kevin.
     
  12. Nat Smith

    Nat Smith Active Member

     
  13. Nat:

    I don't know if I could answer how common it is since it really depends on what surgical procedure was performed, how that surgery was performed, and the relative loading patterns of the metatarsal heads prior to surgery. However, I would estimate that 20-30% of patients that I see with 2nd MPJ plantar plate tears have had prior bunion surgery on the affected side. I have seen the 2nd MPJ symptoms occur within 6 months of surgery, but generally it occurs over a year after surgery.

    Hope this helps.
     
  14. dgroberts

    dgroberts Active Member

    As an aside. A simple question but how do you physically go about getting those things done? Is it via the GP or do you have direct access to such wonderment?
     
  15. Kevin Cole

    Kevin Cole Member

    Hi Nat,

    Approx 2 yrs.

    Kev.
     
  16. Kevin Cole

    Kevin Cole Member

    Hi, yes well, this drives me nuts.

    I previously worked in NZ and Australia at the pod schools and coming back to Blighty seriously damages your ability to diagnose.

    I have an x-ray licence from NZ, so images from a private hospital not such a drama. However bloods, you have to arrange through GP / or consultant, not usually a problem just a pest. You rarely however get to see the images, just a copy of the report.

    This is one of the most difficult challenges as a practitioner in the UK and quite honestly has to be addressed. I will avoid political comment; however I believe this should be top of the agenda with the profession and the society in the UK. How can you best serve your patients if simple laboratory tests are not routinely available? Rant over! We are working in an imperfect system, which we should change.
    Kind regards,

    Kevin.
     
  17. dgroberts

    dgroberts Active Member

    You're not wrong.

    The answer you'll get from the bean counters will be based on the fact there is no budget for such extravagance, and there will be no real cost/benefit for the patient. In their opinion.
     
  18. martinharvey

    martinharvey Active Member

    Hi Kevin, there are private labs out there for blood and tissue paths if you are in PP. The one I have used for the last few years is : http://www.mullhaven.co.uk/index1.htm

    Steve Mulliner is the chap to speak to there, he is a mine of information. They can supply postal containers and any sundries you need. I usually get simple blood results such as ESR, CR-P etc back by email at the end of the same day he receives them.

    Cheers,

    Martin
     
  19. martinharvey

    martinharvey Active Member

    Oh and just to chuck another differential in - Soft Tissue Gout?, I understand it can happen with normal or even hypo serum UA levels. Just a thought,

    Cheers,

    Martin
     
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