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A 47 year old lady presented to the clinic today with severe HDs, sub B/2nd and L/4th MPJS, with thick HK sub R/4th MPJ. These HDs are very deep and the size of a small pea (sorry for no exact dimensions)

The patient has no medical history and these HDs presented only in the last 3years. There is a strong family history of RA with her mother and grandmother.

Her foot structure is unremarkable, only slight largening of her 1st MPJS, but nowhere near as severe enough to alter her biomechanics detrimentally to create such large HDs.

I have been unable to provide her with a reasonable explanation for the severity of these HDs. After seeing her today, I have considered taking Xrays however is that the right place to start or is this a simple case with a simple solution that I am overlooking?

Any feedback/advice would be greatly appreciated for the patient and also myself!!

Accessory Ossicles?

Is she a smoker?

Hi.

Interesting case. It raises two questions for me.
You said:
"but nowhere near as severe enough to alter her biomechanics detrimentally to create such large HDs"

Is your pt quite certain they' (the lesions) have only been present for 36 months?
Your supposition that the biomech has been altered. Altered from what?
Or did she, like most of the patients and research subjects I've seen over the years, already have biomech features which were not great for hard, flat surfaces, and have simply worsened with time?

Regards,
david

Hi David,

The lesions have definately been there for that period of time only.

Her biomechanics do not alter greatly from the 'norm'. Her slightly enlarged 1st MPJS cause a decrease in ROM at that joint however the patient seems to be compensating with an abductory twist. It still leads me to the point that if this is quite a common foot type with common compensations then why do we not see these sized lesions more often?

I feel there is something more sinister going on!

Kirsten

Hi,
Associated factors may be:
Smoking (as Peter suggested), pt-weight, pt activity-level, pt-shoegear.
I think, too, that "the normal", when it comes to feet and biomech, embraces many different types. So there could, for example, also be a variation in met length and/or lig laxity.

I understand that you are sure these lesions have only been present for three years. If this was my pt I would start by questioning this, and go on from there.
As I said - interesting case!
Regards,
david

Sounds daft .... but possibly warts. I have (in frustration) blunt dissescted a few and sent for histology only to return with a pathology of mixed hyperkeratosis with rete pegs and associated viral elements.

Try biopsy and see what you get.

another vote here for warty lesion, Ive seen a couple of these in the last year, the patient having been refered for surgery consult as a last resort, having spent time in orthoses dept, electro surgery and generalist clinics.

histology returned viral elements

good luck

s :)

try a skyline view x-ray and look for plantar movement of met heads also do bloods and look for hla b27 and/or rh factor.
good luck.
Grahame Mann FCPod S Podiatric Surgeon

Any chance of a genodermatosis? It's very late in the day to display the clinical signs, and you don't mention any family history, but stranger things have happened.....

What medications has she been on? Any chance of arsenic exposure?

What shoes does she wear? Nails in funny places?