Welcome to the Podiatry Arena forums, for communication between foot health professionals about podiatry and related topics.
You are currently viewing our podiatry forum as a guest which gives you limited access to view all podiatry discussions and access our other features. By joining our free global community of Podiatrists and other interested foot health care professionals you will have access to post podiatry topics (answer and ask questions), communicate privately with other members (PM), upload content, view attachments, receive a weekly email update of new discussions, earn CPD points and access many other special features. Registered users do not get displayed the advertisments in posted messages. Registration is fast, simple and absolutely free so please, join our global Podiatry community today!
If you have any problems with the registration process or your account login, please contact contact us.
I have had an unusual referral that I would be grateful for any input.
Patient presented as an 11 year old boy, with a large apparent blister at the midpoint of the medial longitudinal arch intersection with the plantar aspect of the Left foot. On examination there were three distinct blisters, the largest of which was 5mm across, (see pictures), the blisters are firm to palpate, with no evidence of a liquid sack.
Patient has been getting blisters for past 6 months, located on Left foot. Blisters appear and are then treated by GP, disappear after treatment, but then reappear. Once they develop area is painful to palpate and patient has pain when walking. Current GP treatment is Inadine dressings and Mepore dressings. Although these tend to work it basically is treating the symptoms not the underlying cause.
There is no history of allergies and no evidence of eczema or skin reactions and no history of skin or neurological issues. All neurological responses were normal and sensation was normal, (based on a 10g filament). Both legs exhibit increased external rotation at the hips, (40 degrees ext / 36 degrees int). Passive dorsiflexion at ankle is 10 degrees with foot in neutral alignment. The lunge test gave an angle of 19 degrees. On standing both feet exhibit low arches, but no evidence of midfoot collapse, (x-ray shows normal boney development appropriate to an 11 year old).All foot structures are normal. Positive Hubscher test, (grade 4). Single leg standing showed slow rocking, pronation to suppination followed by pronatary collapse. Elevation of heels showed full correction of feet.Breighton scale 2
Walking in bare feet showed increased pronatary collapse at 2nd rocker, but no other abnormalities.
Footwear is standard Clarke’s school shoes with no shaping in the footbed, (separate sole / heel unit). Patient also wears Addidas trainers with no shaping in the footbed.
My initial conclusion was that the feet were collapsing excessively during 2nd rocker, traumatizing the tissue in the midfoot. But as this has only happened on the left and all comparisons show that left and right are comparable, (patient is right handed so not the dominant side), the right should blister as well.
I have as a test of my theory cast the foot for a custom orthotic with a cutout under the medial longitudinal arch, (which I will infill in clinic with low density compressible material), and rearfoot 5 degree medial post and 50% rearfoot Kirby skive to the cast, (Right foot same device but with no cutout and no Kirby skive). I’m using a 5 degree post, to match what was required to stabilize the foot for single leg standing. To both I’ve added a forefoot 3mm medial compressible post, to allow normal change to high gear but hopefully reduce the speed of the medial collapse.
I would be grateful for any suggestions or if you can identify the blister that would be really helpful.
Thanks for your help
Graham
__________________
It's not that I can't explain it......It's just that you wouldn't understand !
graham, I take your point on the description of the lesion as a 'hard lump', but without that description, that looks very much like a tinea.
__________________ Craig Payne
__________________________________________________ ___________________________________ Follow me on Twitter | Run Junkie God put me on this earth to accomplish a certain number of things - right now I am so far behind, I will never die.
The Following User Says Thank You to Craig Payne For This Useful Post:
graham, I take your point on the description of the lesion as a 'hard lump', but without that description, that looks very much like a tinea.
Hi Craig,
I have to admit I didn't think of tinea, purely because of it's solid nature on palpation.
It feels like plantar fibromatoses, but obviously is in the wrong layer. As I don't have a lot of experience with Tinea, (following your reply I've now updated myself), dosen't that generally have a more general discomfort, as opposed to the point discomfort that is almost specific to the lumps.
And I can't believe that its tinea overlaid exactly on fibromatoses ? or is that logical
Also the rest of the foot is intact with no other syptoms or signs, checked toes and they are fine.
Graham
__________________
It's not that I can't explain it......It's just that you wouldn't understand !
They could be some sort of parasite from the soil, I have seen something presenting very similar , red spots which develop slightly yellowing pustules which dry up but spread out as they appear to dry,symptoms which proved to be sand fly bites, we get lots here. Are they itchy at all? Perhaps the client is rubbing them without consciously thinking about it. Try Mycota cream. Sometimes the explanation and cure can be very simple.
Further, from the pics provided, I would say the blisters may be vesico-pustules and there appears to be some inflammation, both of which can be associated with TP. The dermatophytes usually involved in this type of presentation are Tri-mentagrophytes or Epidermophyton fluccosum. The vesicles are quite superficial, yet can still be uncomfortable, and usually seen on non weight bearing parts of the plantar surface, ie the medial longitudinal arch. They rupture easily with GRF. Hence, they come and go....
I would take skin scrapings for culture, but that`s just me.
"I would take skin scrapings for culture, but that`s just me" ..... That's Bel for you. Not many people know Bel is the Podiatry equivalent of Dexter of television :), just doesn't kill her patients first.!!!!!
Further, from the pics provided, I would say the blisters may be vesico-pustules and there appears to be some inflammation, both of which can be associated with TP. The dermatophytes usually involved in this type of presentation are Tri-mentagrophytes or Epidermophyton fluccosum. The vesicles are quite superficial, yet can still be uncomfortable, and usually seen on non weight bearing parts of the plantar surface, ie the medial longitudinal arch. They rupture easily with GRF. Hence, they come and go....
I would take skin scrapings for culture, but that`s just me.
Cheers,
Bel
Hi Bel,
Thanks for the reply, will get it cultured and let you know.
Graham
__________________
It's not that I can't explain it......It's just that you wouldn't understand !
They could be some sort of parasite from the soil, I have seen something presenting very similar , red spots which develop slightly yellowing pustules which dry up but spread out as they appear to dry,symptoms which proved to be sand fly bites, we get lots here. Are they itchy at all? Perhaps the client is rubbing them without consciously thinking about it. Try Mycota cream. Sometimes the explanation and cure can be very simple.
Hi Heelandtoe,
Reading through my clinic notes, he did rub the foot as he was sitting talking to me - but he was very definite with his - it dosen't itch.
The only thing that makes me think it's not a soil parasite is that patient has a sibling who is two years younger who has no syptoms and I can't imagine that he will not be doing everything big brother is.
Regards
Graham
__________________
It's not that I can't explain it......It's just that you wouldn't understand !
Just wanted to give some feedback and Thanks, following your advice I got scrapings cultured and it came back as Epidermophyton fluccosum, (Tinea Pedis),
and so it's being treated now.
Thank you so much for your advice and help.
Graham
__________________
It's not that I can't explain it......It's just that you wouldn't understand !
The Following User Says Thank You to grahammoore26 For This Useful Post:
Just wanted to give some feedback and Thanks, following your advice I got scrapings cultured and it came back as Epidermophyton fluccosum, (Tinea Pedis),
and so it's being treated now.
Plantar blister
)
Linear Mode
