Loss of feeling in both feet

[Kubrick123]

I have a patient who has this strange problem. For the last 2 months she has no light feeling sensation (can't fell light touch but can feel pressure) through the region of medial malleolus, medial border of the foot to Ist digit in both feet.
All the reflexes and muscular strength is normal without any deviations. The skin is well nourished. Patient is young in her early 20s.
Do you have any idea what is causing this symptoms?

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[gcoe]

Hi kubrick123

Even though reflexes and strength are normal this is a potentially highly concerning situation with the possibility of serious cord pathology or other neurological or orthopaedic disease I think you sould refer on and the patient should be imaged. You should have things like tumours in or impinging on the cord, and central disc trespass, ruled out - and remember this could be at the cervical or thoracic levels not just lumbosacral. Bilateral objective Neuro signs should always raise alarm bells. If something sinister is happening at the posterior cord or adjacent posterior nn root then you may have no motor signs and it is entirely possible for just the dorsal column/mediai lemniscal tract responsible for light touch to be involved and not the anterolateral sensory tract responsible for deep pressure as the geography is quite distinct. And as she is young tumours can be very aggressive - so i wouldn't waste time. Better to be overly cautious even if it creates a bit of a flap. You never know when you may save a life or severe disablement. BTW when you say reflexes are normal did you include testing for Babinski and clonus? And I take iy that gait is normal?

[Kubrick123]

Yes, both Babinski and clonus are not present. As for the gait it is entirely normal in all phases, with even beter than normal muscular strenght - she is a competitive swimmer.
I've advised her she should consult a neurologist and do an MRI but for that we'll have to wait a couple of days.
Apart from a tumour what else do you think it could be?
And how could it be concerning the upper spine without any signs from the upper limbs and neck?

[gcoe]

Sounds a good plan. BTW I am not saying she has something serious. But best to be sure. The bilateral nature of the symptoms does tend to point to something more central - the probability of simultaneously developing symptoms in both feet due to localized pathology in each foot is Less likely.

Due to the the somatotopic organization of the sensory and motor tracts in the spinal cord a space occupying lesion in the cervical area, for instance, could impinge just on nerves supplying the lower limbs and spare the upper limbs. That is why gait disturbance and bilateral paraesthesia or numbness in the lower limbs are special questions you should always ask when examining the neck.

[jordanloughlin]

Did you palpate the posterior tibial pulse? Or better still if you have access to doppler, use that. Are symptoms variable? mechanical in nature, get worse with certain activities etc?

Jordan

[Kubrick123]

@gcoe - but it would be strange to have such symptoms without any ailments even in the thoracic area, right?
As for the neuroanatomy, the symptoms go along the line of medial dorsal cutaneous nerve but strangely in both feet..
@jordanloughlin - pulse is palpable without any disturbances. Symptoms are constant, without any change during activities.

[gcoe]

@gcoe - but it would be strange to have such symptoms without any ailments even in the thoracic area, right?

Not quite get your point here. Do yu mean it would be strange not to have any other symptoms? yes probably. The nervous system is so well protected by pain sensitive tissue it is hard to get damage without pain. One exception is a a tumour or other pathology that originates within the nervous system tissue itself - in this case there can be a lot of nervous system destruction before pain is experienced due to the anaesthetic nature of the the CNS.

As for the neuroanatomy, the symptoms go along the line of medial dorsal cutaneous nerve but strangely in both feet..

...yes maybe - but not sure from what you described it matches up that way. Wouldn't the area possibly also include the saphenous nerve, and medial platar nerve? Of course there can be a lot of anatomical variation in superficial nerves. I f you can do put up a diagram. If it is the medial plantar nerve then tarsal tunnel syndrome is the most common neuropathy but usually this is also very painful - usually you get burning pain and as you say that doesn't explain the bilateral nature of the symptoms. But a superficial nerve could possibly explain the difference in sensory modalities

Another stab in the darK - has she changed shoes recently? A superficial neuropathy caused by tight fitting shoes can happen but again usually very painful and P&Ns to start off with. But this could explain the bilateral nature. Haven't heard of a nerve entrapment caused by shoes in that area.

another stab in the dark - aren't swimmers more prone to spondylolisthesis? (not a sports physio here so may be out of line here) A significant slip could possibly cause such symptoms but again probably be accompanied by pain. Is there any history of back pan

All guess work at this stage.

[Dr Damien]

is this patient an unknown diabetic? If we have discussed a neurological explanations perhaps vascular possibilities should be considered...I agree with gcoe the age of this client makes this situation a little concerning, and a space occupying lesion at the dorsal column could be responsible...either way an MRI is good idea...

I would consider ruling out diabetes also...this is another condition wherein all central neuro tests will be ok when tested...

She needs to be fully examined, blood work and all...to be honest

[gcoe]

Good point Dr Damien re diabetic europathy

Let us know how your patient gets on Kubrick 123. It is always informative to know the actual diagnosis and outcome

[msk101]

as a swimmer myself there can be a tendency for hyper-extension of the lumbar spine predisposing to spondylolisthesis if the core strength isn't sufficient and depending on stroke and technique (female butterfly swimmers are the most at risk). however red flags do fly with the patient's age, bilateral symptoms and onset.
i am very interested in MRI results but would also like to see lumbar neutral, flexion and extension standing plain xrays to determine if there is a dynamic spondylo component (ie not evident in neutral, exaggerated in full extension and reduced in full flexion).

keep us informed
cheers,
msk 101