Tricky new patient

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Hi, this is my first post on podiatry arena - looking for some advice on a new patient I saw today!

78year old woman presented complaining of “intense” pain in her feet. This pain has been present 18 months, and is painful during walking, whilst standing and during rest. Up to 8 or 8 out of 10 on VAP scale
Bilateral - L worse than R

She has no history of fractures.

She reports no diabetes (yet to be confirmed with fasting glucose test)
She does however has a history of an “unknown virus” affecting her 10 years, following an illness with glandular fever, and a trip to the Northern Territory.

This was suspected, as ruled out as being Malaria, Dengue Fever and Legionnaire’s Disease. It was also suspected to be something along the lines of bird flu.

She experienced surging temperatures, which would peak (at unknown temperature) and leave her with violent shaking of her whole body); followed by temperature plunges.

By her account, she was not treated with medications or antibiotics.

Recent x-rays indicate Charcot neuroarthopathy.
Pain is greatest with active/passive dorsiflexion with and without resistance. Jack's test is painful to assess.
Most painful point of gait cycle is end of midstance/early toe-off.
Feet are not red or hot. Nil temperature difference.
Swelling noted L > R

I am organising for a fasting glucose test to rule out diabetes. Thinking aetiology of Charcot may be something to do with this virus? or undiagnosed lupus??
Trialling low dye strapping (rearfoot eversion and midfoot collapse noted in gait) also trying 4mm bilateral heel raises to reduce pain during dorsiflexion in gait.
Considering adding rocker-soles to her footwear (Brooks Addiction) to aid propulsion.

Anyone seen anything like this or have any advice???

Thanks!
Alison

 

Hi Alison, 1st :welcome: to Podiatry Arena.

Now to your patient.

Lots of info, but you have missed the most important bit. Where is the pain?

we have

so we have her feet.

we have left worse than right.

But we still don´t have where the pain is and what joint your dorsiflexing
Sorry if that sounds harsh but it´s quite hard to help with a patient you have never seen.

From your post it seems to be biomechanical related. So what we need to do is find out what tissue is stressed and then workout why then treatment plans can be discussed.

Hope you come back with some more info maybe I can help ?

 

http://www.podiatry-arena.com/podiatry-forum/showthread.php?t=22144

 

You stole to Ctrl + C off my keyboard Ian

 

Neuropathy???? If not neuropathy, why does she have a charcot joint? Knowing the answer to that could change the recomendations. Folks who have loss of protective sensation and then feel pain can have something really bad going on.

Eric

 

Apologises for missing the location of the pain!
Pain is diffuse, dorsally, overlying proximal midfoot.
Pain present with resisted muscle testing during inversion, eversion, plantarflexion, and dorsiflexion. Greater pain noted with dorsiflexion (both active and passive, as well as resisted)

Radiology report says (bilateral ankles and feet):
Collapse and fragmentation is demonstrated at the joint between navicular bone and cuneiforms on both sides. There are multiple subchondral cysts and sclerosis as well as loss of joint space.
The changes are suggestive of Charcot joint.
Mild osteoarthritic changes are present elsewhere in the feet
The ankles joint are unremarkable bilaterally.

I actually have not yet completed a neurological assessment, which I will do when I review her in 2 weeks.
I'm worried that I'm not on the right track with management; since I would expect her feet to be red and hot, as well as swollen.
I rang her back later that afternoon to ask if since her virus (from initial post) she had experienced and recurrance/relapse of same/similar symptoms...she has not.
She also did not experience any joint pain or skin rashes during illness with virus, only headaches.
Am I getting stuck on the wrong bits of information?!

 

Also!
Medical history includes restless legs syndrome; allergies - sulphur based medications.

 

I think that I would be erring on the side of caution and if the radiology report is suggesting a charcot joint then immobilise it with a cast or cast boot until you get a definitive answer - assuming the Charcot is stage 1.

They are not all swollen and hot - I have seen one diagnosed where there was very little in the way of inflammatory markers

Robin

 

I would make the following suggestions:

1. A recent history of viral illness whilst travelling in tropical Australia suggests either Barmah Forest or Ross River Virus, though other similar arboviral infections are also possible. The classic feature of these viral infections is a predilicition towards small joint (hands, feet) arthralgia, that can last up to 12-18 months. Treatment is supportive, and symptoms usually fully resolve in time. Prebaricated orthoses, supportive shoes, and simple analgesics are usually sufficient. Typically patients can be screened for anitbodies to these infections very easily. Malaria and the other infections you mention are less likely in that part of the world.

2. In the absence of peripheral neuropathy of any cause (did you do a basic neurological assessment?) then I think the diagnosis of Charcot joint is highly unlikely. I have periodically seen radiologists confuse severe Lisfranc or Chopart osteoarthritis with the radiogrpahic features of neuroarthropathy. Be suspicious of this diagnosis in the absence of other clinical signs and positive neuropathy history.

3. If the diagnosis is leaning more towards OA (aggrevated by post viral arthralgia) than Charcot, then obviously treat this as aggressively as you feel necessary. I would avoid a surgical consult for at least 12-18 months.

LL

 

If the patient has active Charcot destruction of the joints, no matter what the etiology proves to be, non- weight bearing is what she needs stat. DANG THERAPIST is a good mnemonic for the causes of peripheral neuropathy. Facebook Podiatry Boards has a discussion of this from Zier. Dwight L. Bates, DPM, DABPS

 

Alison - if O/A is the cause read this thread will give you some ideas - http://www.podiatry-arena.com/podiatry-forum/showthread.php?t=1980&highlight=Dorsal+midfoot+compression

 

Thanks so much to everyone for their advice. She is in for review shortly, so will be doing further assessment.
My only concern is her potential for offloading, since her symptoms are bilateral.
Even if I offload the worst foot (left), won't that just place the right at greater risk of deformity/degeneration, provided it definitely is charcots?
Will keep you updated with further finding
Thanks!

 

That's why you need a diagnosis.

Dig deeper. Do a more thorough history and physical examination. Get more imaging. Don't assume anything that any other health provider has said is correct.

LL
LL

 

You can shift load from one foot to the other or you can shift the load from one location to another within a foot. For example, if the disintegrating joint was the first met cunieform, you could shift weight from the first metatarsal head to the lesser metatarsal heads with a reverse Morton's extension. You need to know which structure(s) are damaged.

Eric

 

Hello Allison:

You may have failed to mention, other than the level of the deformity, if there is any recurvatum of the foot, or complete collapse of the midfoot into a negative angle, such as a negative calcaneal inclination angle.
In the absence of any suspected rheumatological, or diabetic neuropathic condition, a 75 yo person with such a clinical scenario will probably suffer from a collapsing pes plano valgus with a midfoot leve of deformity that may have started with posterior tibialis tendon dysfunction grade 1 or 2.
Conservative treatment will not help this patient if the deformities are rigid.
Again, screen this patient thoroughly for the presence of metabolic or rheumatologic disease.
She may be a candidate for a medial column fusion with bone grafting and possible a CROW walker to support her post-operatively.
Good luck!
Narmo L. Ortiz, Jr., DPM, FACFAS, CWS