Baffling new patient

[Ozben]

Had a new patient attend saying she had been referred from the pain clinic. No written details except GP's letter saying she had bilateral foot pain and could I please help. Her history was of a long period of evolving pain in both feet. Now at the point where she has great difficulty in ambulating around a supermarket without needing to rest. Objectively she walks flat footed with all her toes extended especially the great toe. She has a marked pes cavus. She is unable to flex her toes. The harder she tries to the more they want to extend. She is extremely tender to gentle palpation to the point of evoking a teary response. She says the pain clinic have prescribed Capadex, but will review her in a few weeks. Seems to me she may have Charcot-Marie-Tooth disease. Is there anyone out there who has any suggestions for management of this lady. I am trying to organise a podiatry referral for her. Regards Ben

Here are a selction of images that will help shed some light on the patient.

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[Physiobase]

Some one with charcot marie tooth diesease would have clear familial history of the process. Although not often diagnosed in the past questioning should provide a, for memory female, relative or two with very unstable ankles! Also the client would have the obvious lack of calf development. peroneal weakness as well as upper limb signs such as additional bone growth on the elbows (pointy olecranon's) and wasting of the intrinsics of the hand. A definative diagnosis is easily established with EMG studies. I have managed several cases and in all instances the later life lead to the permanent use of an AFO (ankle foot orthoses) type device.

Does she have any of the signs apart from the extreme pes cavus? It does appear that she might have a soft tissue problem locally but in addition this might have a more proximal cause. Diagnosis at this stage is imperitive whilst treating the local ?strain? to the soft tissue. She obviously needs rest and supportive footware to cushion the load right now as she walks. Any chance you can take a picture of the lower limbs and feet from front and back and email them to us at physiobase? We can them post them on this forum topic for you. Email us at [email protected]

[Ozben]

Thanks for your interest and reply Bob. I see her next week and will seek her permission to take photos. Must admit I did not pay much attention to her upper limbs--bit overwhelmed by below knee stuff. Did test her reflexes. KJ (L) and (R) hyper with no damping, AJs very hard to elicit. The objective was limited to what described previously because I felt she was not tolerating it too well. Am endeavouring to track her GP down for more info. Trying to arrange podiatry appointment to address the issues of support for the foot. I think her next appointment is eary next week so I will get back to you. Regards Ben

[neving]

I am confused. You say your patient walks flat footed, but also state she has pes cavus, which is a very high arch.
all her toes are extended? in which joints, all of them or only the MTPs with the distal ones flexed?
where exactly is she tender to palpation, plantar or dorsal areas, at which of the phalanges?
RA has been ruled out?
neving

[Ozben]

Thanks for your reply. She walks with small shuffling steps. There is no heel strike or toe off. Her toes extend from the MTP jts, the distal jts are also extended. These joints extend even more with effort including ambulating and even in non weightbearing trying to flex her toes. EDB and EHB are hypertropied. Stretching the toes toward flexion causes extreme discomfort. She is extremely tender in the soles of her feet, particulary under the MTPs, though it was a bit hard to judge specifically as she complains of severe pain throughout the dorsal and plantar surfaces. She lacks a transverse arch. When this is restored manually she is able to flex her toes with considerable effort and discomfort. Further information in the coming week in the meantime I appreciate your questions and any further input you may have. Regards Ben

[neving]

Thanks for your reply, Ben. I have a few more questions. Why did she attend a pain clinic, was it for the foot pain or something differen? Any deformities, eg splaying, any calluses, any weaknesses, has she had x-rays, if so what do they show, any swellings anywhere, what color is the skin, is there a shiny area? You can see what comes to my mind, possibly a stress fracture, a neuroma, Reflex sympathetic dystrophy, some nerve entrapment, etc. Is there a history of any, even a minor, injury. How long has she had this problem?
Very intriguing, I'd like to get more info.
greetings, neving

[Ozben]

Thanks Bob for posting the photos. No sign of RSD, no history of trauma. She attended the pain clinic for the foot pain where XRs were taken. Haven't seen them but the GP says there was some spurring. Also spoke to the clinic physio who thought it was just plantar fascilitis. I spoke to her GP who said she was a "weirdo" who had presented with "many instances of inappropriate illness behaviour in the past". The pain clinic report does tend to focus on her history of anxiety and depression and low education level. There doesn't seem to be much physical assessment in all of this from all the experts. Mentioned C-M-T to GP -- said it hadn't been considered, not considered at the pain clinic either. Was to go back to pain clinic on Sept14 for cortisone injections but has had a gallbladder attack and is having a specialist appointment for that on that date. Podiatry assessment last Friday. The main feature apart from the structure is the hyperactivity of the toe extensors. And she said her father has the same problem.

[Physiobase]

I would rule CMT out all together. Her legs look nothing like a CMT patient and she would have a long history to go with it by now. Looking at the images she definately has collapsed transverse arches and I expect no proximal stability in the hip joints or knees.

I would treat locally and get her into some not so offensive support for the shoes. Perhaps in her case some softer orthotics in the first instance. Do you have access to a good podiatrist? She might be crazy but then this does still look like a physical injury in the making if not present right now. A bit of reassurance might go a long way for someone with a long history of medical complaints.

[friendlypain]

Hey,

I need some more info. How about your results from your neurological examinations. Any signs of the following

Dysergia: Improper co-ordinated function of a muscle group.
Dysmetria: Inability to properly gauge the distance between two points. Tested with finger-to-nose movements.
Dysdiadochokinesia: Inability to do rapid alternating movements.
Scanning Speech: Prolonged separation of syllables, often seen with cerebellar dysfunction.
Clonus: Repetitive, rhythmic contractions of a muscle when attempting to hold it in a stretched state

GAIT Disturbances:

Cerebellar Lesions: Central cerebellar lesion shows unsteady gait, but conventional cerebellar signs may be normal.
Posterior Columns Lesions: Loss of proprioception results in unsteady gait when eyes are closed, but relatively normal gait when eyes are open.
Romberg's Test: Patient can't maintain balance with legs tight together, with eyes closed.
Titubation: Body tremor when standing or walking, sign of cerebellar disease.

Musculosckeletal:
Compartment syndrome anterior and deep

Neurological:
L5-S2 injury
Tibial Nerve Lesion (if left too long a contracture will develop)

Let me know your results
Adamo

[neving]

Hi Ben,
this lady truly exhibits some strange symptoms that are difficult to explain, and considering her seeming history of other strange symptomatology, a mental disorder such as Conversion Disease comes to my mind. According to the "Merck Manual", "weakness and paralysis of muscular groups are common, spasms and abnormal movements less frequent. The motor disturbances are usually accompanied by altered sensibility, especially those involving touch, pain, temperature and position sense. Especially characteristic are the 'glove' and 'stocking' distribution". People suffering from Conversion Disease often also suffer from depression and/or anxiety, and it can run in families.
People suffering from conversion disease truly suffer from their symptoms, their pain and symptoms are very real to them, even if we cannot find a physical reason or explanation for them, and they need to be taken seriously. As your lady has been diagnosed as suffering from depression, she probably has been seen by a psychiatrist already. If so, maybe you can get some info there.
Has TENS been tried, either at the pain clinic or by you? My experience with TENS is that it is pretty useless if applied for short times only, but when left for several hours there seems to be definite pain relief. I usually tell my patients that they need to stay for at least 2 hours the first time I try it, so bring something to read, etc. This also makes the treatment a bit "special"...
Keep us informed of the outcome.
neving