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A 14 year old boy presented to a physiotherapist and to myself this week, using an air cast and two crutches.

HISTORY PRIOR TO PRESENTATION TO PODIATRY
In February 2006, after a skiing trip with no incident, he started to develop a sore ankle, progressing over a couple of weeks into an incredibly painful and swollen foot (left). He had an xray showing a healed (?) 5th met fracture site. He had an MRI showing swelling around his cuboid. He had a bone scan showing a hot spot at the base of his calcaneus. He was assumed to have osteomyelitis by his consultant (but no apparent portal of entry for infection, no fever/tiredness/illness) - see below infection history. Developed a hugely swollen foot (photos) but 3 month later foot is improved but very swollen (particularly dorsal foot and base of calcaneus). At worst, patient had severe night pain and had to wear his aircast boot in bed. He was put in a plaster cast too but found that too painful.

5 months previous, patient had an infected ingrown toenail on his right hallux caused by an exostosis. Exostosis was removed surgically, site was infected, patient developed septicemia/septic arthritis/sacroilitis in opposite side to IGTN(left) and was hospitalised for IV antibiotics but was 100% by October 2005. Returned to normal activity until as above in February. ? red herring.

Pt has had mild back aches but never sought treatment and usually associated to playing cricket.

Pt has had no major illness.

Pt has had blood tests and seen a rheumatologist. Slight raise in WBCs. No other abnormalities detected.

CURRENT HISTORY
- gross midfoot collapse
- gross gait changes (externally rotated foot, gross pronation and valgus foot placement)
- still huge amount of swelling across tarsals/dorsal midfoot and at base of calcanus.
- severe pain with pressure to tarsal area
- pt describing arch pain
- generalised foot pain
- limp
- mother and son depressed as has seen 6 consultants without diagnosis
- still taking antibiotics, improving slightly so consultants currently assuming antibiotics are the way to continue

TREATMENT COMMENCED
- endeavouring to return normal function (without crutches) through physio
- trying to improve foot position through temporary padding (which patient is finding very comfortable)
- trying to organise case manager

QUERY
Has anyone seen anything like this?
Being treated as an infection without other signs of infection including no xray confirmation of osteomyelitis/fever/illness/portal of entry (or can it be a bug still evident from septicemia in opposite foot 5 months prior).
Swelling and pain quite generalised. No injury history. Bloods normal except slightly high WBC.
If scans hadn't come back relatively normal, I'd be suspecting a nasty bony pathology with such severe swelling, foot changes and night pain.

Any suggestions welcome!

Thanks
Kath

Kath

Do you have any digital photos of weight-bearing plain x-rays you could post onto a message? The lateral would be good to see.

My "gut" feeling is this is more mechanical than related to his history of infection, but could also represent an underlying undiffentiated systemic arthritis???

LL

Kath

photos would be great, also can you find out the results of all the blood work carried out by the rheumatologist?

mark

Hi Mark/LL,
Thanks for responses. I am in the process of trying to get all the specifics together as unfortunately I haven't seen the scans myself (just was given the reports...) and obviously want to check over all tests/results but to date, my understanding is that all arthritic conditions have been ruled out, the patient has been discharged by rheumatology and all that was shown on the bloods was a slightly elevated white blood cell count which was assumed to be due to infection.
More info when it comes to hand! Cheers, Kath

Reflex Sympathetic Dystrophy?