Unknown diagnosis - neuro?

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Hi All

Just thought i would post this interesting chap i have just had in to see if anyone had any ideas.

49 year old man, guest house owner. Relatively tall, slim build.

4 year history of generalised foot pain. Which began with a lot of cramping in the leg muscles in various places. He now complains of pain around the anterior ankle area where EDL crosses.

On palpation both Tib post are tender, lateral/anterior ankle/STJ area tender.
Also some tenderness under some MTPJ's.

Right plantar fascia and TA insertion tender.

You can also see faint bruising along the line of Tib ant and EHL tendons anterior to the ankle joint.

In stance left foot increasingly pronated compared to left and during gait. On examination right LLD evident about 12mm. Also both considerable plantarflexed 1st rays.
He has had blood tests and was messed around an awaful amount with referrals etc and took months to get any appointments. he has seen rheumatology and had nerve conduction studies etc carried out, still with no diagnosis.
His last blood test in Oct 2010 showed raised CPK levels and patient aware of associated muscle wasting all over the body.

He has had a very poor patient experience and is obviously very worried about his health and is in pain. I have treated him mechanically today the best i can.
But would like to know if anyone has any other suggestions.

Many thanks everyone

Cheryl

 

Any familial history?

 

No familial history, he did mention also he had an electric shock about 4-5 yrs ago after trying to fix something and he was thrown across the room and he think s he may have broken his shoulder at this time.
He doesnt personally feel any significance here

 

Hi Cheryl

You might be dealing with seperate issues here or not.

But I would suggest try as hard as you can using mechanical (orthotics) and physical to make him more comfortable.

Get the patient to start icing
Suggest ask his GP re NSAIDS

What orthoitic are you thinking off ? - with the info we have maybe something like

Medial skive 4-5 mm
Good arch contour
FF valgus post
Some thing quite stiff ie 4-5 mm poly

Get a shoe built up for the LLD - not a heel lift once you get the right get more done

Find a good physio to start strength training program

Good luck

Hope that helps

 

Thanks for that, im seeing him quite soon so will let you know how things are going and will try your suggestions.

I do agree that there a couple of separate issues here

Cheryl

 

Hi,

Evaluate his calf muscles...
Just a guess: he may need gastrocnemius stretch

Regards

 

Baypod,

"bruising on the anterior ankle" are you sure he is not tying his shoe laces tight? assuming your patient is not on warfarin or has chronic renal failure (both has a tendency to cause non-traumatic bruising).
high ankle lace-up shoes, laced up tight has a "superior influence" on the subtalar joint (Prof.Kirby discussed this concept earlier in this forum). If this patient being a care taker do spend considerable time on ladders or in positions which involves loading the forefoot he is more likely to dorsiflex the forefoot on rearfoot, causing compression within the dorsal joints of the midfoot and subsequently increased strain on the plantar ligaments. As M.Weber suggested supporting the foot plantarly through orthosis would minimise these forces within the foot and gast-sol stretches as Romeu suggested.

You should ask your patient what his work involves? what type of shoes he wears? does he smoke? is he diabetic? or has any systemic diseases? has he got PAD? has he had any back injury? (could cause tightness in the calf aften reported as cramp, Your pt had a fall???)

May be you might have covered all this but has failed to report in your post. Its important to have all the information to give an opinion or a suggestion.

(Read-up on cycling biomechanics and Medial Dorsal Interossei Compression Syndrome by Prof. Kevin Kirby)

Regards

David

 

If the 1st ray is plantarflexed would a forefoot varus posting not be more suitable for this patient
gary

 

Gary,

Why would a forefoot varus post be more suitable for a plantarflexed 1st ray in this patient?

Are you a proper Paisley buddy?

Baypod,

Definately sounds less like something mechanical(not that you shouldn't treat mechanical problems - just perhaps expect limited success)

I take it that vitamin/mineral deficiencies and fibromyalgia have been checked out. Also depression - chronic pain syndrome. Sounds a bit left field but I have had similar patients who have responded well quite recently to such interventions.

Tough one

Robin

 

hi
being a novice in this area if the 1st ray is plantarflexed excessively then a varus forefoot post would decrease this 1st ray force vector as long as it did not prevent normal 1st ray plantarflexion and normal hallux dorsiflexion

Gary
willing to lean more as an eager buddy even from an islander:hammer:

 

cant tell from the OP but is there any X-ray done?sorry for my ignorance if there was

 

I am an Islander now but I'm originally from Barrhead (for those not in the know, Barrhead is like Cannes/Biarritz/Nice ) and my father is a buddy.

As I haven't seen the patient, I can't really say what would be appropriate. However, normal 1st ray plantarflexion is a difficult one to quantify.

If we assume that your forefoot varus post is higher under the neck of the 1st metatarsal than it is under the 5th metatarsal, then it will certainly resist plantarflexion of the first metatarsal/ray. Will it allow "normal" hallux dorsiflexion by comparison to a ff valgus post - probably not

The difficulty here is that the OP does not really diagnose a biomechanical problem. Pronated foot, more on one side than the other. Plantarflexed 1st rays statically(?) If there is no great 1st ray dorsiflexion stiffness, this may not be significant

Forefoot varus posts will shift the centre of pressure medially. The effect will be dorsiflexion of the 1st ray and subsequently less likely for the Windlass mechanism to "engage". Tension on the plantar fascia will increase and the 1st MPJ will become more stiff(increased dorsiflexion stiffness) This will probably increase the internal compression force at the 1st MPJ which is rarely a good thing (in my opinion).

Forefoot valgus posts will shift the COP laterally and allow the 1st ray to plantarflex. 1st MPJ dorsiflexion stiffness should be reduced. This should allow more normal Windlass function which should resist pronation moments.

I thought I was going to write something really concise. This is not. However, hopefully someone will come along in a minute and give you the same information in 1 sentence. Where is Isaacs when I need him?

Regards,

Robin