Hi,
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I feel the need to sound this case on this forum, as otherwise I'd be in danger of consigning it to the crazy/impossible patient bin and I really don't like doing that.
I saw a lady in our practice today who saw the previous owner 3 years ago. She complains of stiffness in the forefoot area bilaterally and weakness in both feet & ankles.
She takes ibuprofen for arthritis, although this seems to be a self diagnosis & treatment. It doesn't seem like she's seen a GP in a long while. She takes no other medications.
She is quite anxious and lacks confidence in walking to the extent that her daughter now helps her walk everywhere. There is no history of cardiac disease, no history of degenerative disease or thyroid problems. However, given her reluctance to see a GP I didn't read too much into that. She has experienced no significant changes in weight in recent years, she is overweight but not what I would call obese.
Ankle ROM is OK. Laterally deviated STJ axis. Plantarflexion power OK. Dorsiflexion, inversion & eversion power negligible. All forefoot jt ROM good. Some tenderness palpable around the sinus tarsi bilaterally. She complained when I prodded around her peroneal muscles early in the exam, but then didn't when I prodded again later. Some tenderness at the base of 5th met. Lateral compression of the forefoot was painful bilaterally & there was some localised tenderness between 3/4 & 2/3 MtP joints.
RCSP shows a cavoid position for both feet. Gait is ataxic and pronated throughout.
Neurological testing on both feet showed no sensory neuropathy. Babinski reflex was OK. Ankle & knee reflexes seem OK, possibly dulled but inconsistent would be a better description. Foot pulses are all excellent. There is some mild oedema at both ankles.
She's had orthotics from a couple of Podiatrists in the past, both EVA. She doesn't wear either now. The 1st pair incorporated a met dome but otherwise a fairly neutral shell. The second pair added a lateral heel wedge to the prescription on the assumption that she had a peroneal tendonopathy at the time.
I tried some heel wedges in her shoes to see what happened to her symptoms. Lateral wedging changed nothing, medial wedging she found quite uncomfortable.
I couldn't really get her to describe her pain beyond a constant stiffness. She seemed quite vague in general and asked the same questions several times.
I feel like I'm missing something, as her symptoms don't fit nicely into any diagnosis. Any thoughts?
Julian
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