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Hi Guys,

I have a 48yr old female who has ball of foot pain in her left foot only. Pain on palpation of intermetatarsal space of 2/3 and also inter-MPJ space of 2/3. Pain also on palp of proximal ends of 2nd and 3rd MPJ. Pain on crunch test. Pain on palpation of interdigital space of 2/3. Burning when sitting in the car for periods of longer than an hour. Pain and burning after 3 hrs on feet at work - checkout operator. Pin pricks in toes when shoes are off and sitting or laying down.
Footwear changed, mobilisation, orthotics and dry needling have not helped.

Ultrasound shows no sonographic cause for the patient's symptoms.

Anyone have any ideas??? I'm heading proximally at the moment for a cause but thought I'd put it out there!

Thanks!
Bec

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Hi Bec,

Does the patient have any lesions over the second or third metatarsal heads?

In my limited experience I have looked at the first when a patient presents like this to see if there is any dysfunction weightbearing and non weightbearing.

May be overloading of the second and third to compensate for dysfunctional first. Thorough examination of the first ray and gait cycle would highlight this.


First post so hope it was of some use and not completely out there

Alan

Hi Alan,
Thanks for your reply!
No lesions over the second or third met heads. We've offloaded them to see if that helps but to no avail.
Bec

Hi Bec,

What was you're original diagnosis and therefore orthotic designs etc?

I would have thought it sounds very much like a neuroma.

Possibility of a dodgy sonographer?

Cheers,

Chris

Hi Bec
We often have negative ultrasound and find a neuroma when we do surgery. We have stopped asking for ultrasound and just use clinical experience. I feel that with the symptoms you state there is not much else that can be causing the problems. If you have tried orthoses and either they have not worked or the patient is unable to use them enough then surgery is a good option with limited complications post op and a pretty quick recovery.

These situations back up the need for good clinical experiece, assessment and diagnosis not just relying on scans, etc. Maybe worth getting a surgical opinion if you have someone you can refer into.

Good luck with your patient

Colin

Hi Colin,

which plane is the scan being done, when you get false positive scans?

Regards,

Peter

__________________
“Body: A thing of shreds and patches, borrowed unequally from good and bad ancestors and a misfit from the start”

Ralph Waldo Emerson

Not sure of which plane just used to send off the request to the local hosptal and get a report back. I did once try to follow up with the department but did not really change anything. So did not go into the details of the process. I did seem to get the impression that they were not really interested in feet. Our most recent case was missed on both MRI and ultrasound and produced a 30x20mm lesion that was showing some worrying changes that had to be further investigated by histology.

I am sure this topic has been discussed before.

Colin

Thanks guys,
My first thought was dodgy sonographer as well. I'm following up that line as well. I usually send my patients to Neil Simmons at Jones and Partners in Adelaide. He's brilliant with feet and ankles!. This patient was unable to get down there so went to the same company closer to us (we are about an hour and a half away from Adelaide). I also have a great surgeon I'll send her to. I just wanted to make sure I had exhausted all my possibilities before I send her. Yes, my diagnosis was neuroma!

Hi everyone,
Update on this patient. I requested another diagnostic ultrasound and they found a very large neuroma!!!!!!
This patient has since had the neuroma surgically removed and is recovering well.
Thank you so much for all your help
xo

Lesson to be learned here? Don't trust a machine to diagnose something that can be easily diagnosed with a knowledge of anatomy, good history taking and good clinical examination techniques.

__________________
Sincerely,

Kevin

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Kevin A. Kirby, DPM
Adjunct Associate Professor
Department of Applied Biomechanics
California School of Podiatric Medicine at Samuel Merritt College

e-mail: kevinakirby@comcast.net

Private Practice:
107 Scripps Drive, Suite 200
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Another lesson to be learned Kevin, is to trust in myself and my skills!!!
I knew it was there!!! I just knew it!! lol

Diagnostic ultrasound has additional value when performed by the examining physician.

The locating of the neuroma second time round would suggest operator error. Some clinicians only examine in the TV plane, whereas a better view is obtained in the longitudinal plane.

__________________
“Body: A thing of shreds and patches, borrowed unequally from good and bad ancestors and a misfit from the start”

Ralph Waldo Emerson

Transverse and longitudinal scans are standard approaches when imaging . Sometimes ultrasound will reveal additional findings such as joint effusions, periosteal elevation, bursas, cartilagineous bodies ,synovitis, foreign bodies, to name a few, which were not evident on xrays,which can contribute to nerve compression .