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Patient presented with wife over concern of foot posture, and recent trip injury? (vague memory of injury) on left foot.

Hx:
57 y.o. Male
Factory worker
Psoriatic Arthritis (15 years Hx)
Peripheral Neuropathy

Meds:
Glucosamine

Exam:
- Completely Rigid Rearfoot both feet (STJ, TC)
- Ridgidity of mid foot.
- Sever Oedema of both ankles and erythema. Very localised around malleoli, firmer than usual oedema.
- mid foot collapse - appeared similar to a charcot foot
- Neuropathic foot slap in gait. lack of controlled motion.

Wasn't sure what was going on with bones and articulations, so decided to get X-rays. Especially due to neuropathy and the charcot-like appearance.

X-RAYs:
Results came back with arthritic fusions (posterior sub talar) and multiple 'rat bite lesions' of the rearfoot, and poor bone density.
Appearance of bone density and joints of the forefoot looked non-pathological.

There was a large circular lesion in the calcaneus of the left foot, with clear margins, taking up approx 2/3 of the calc. The cortical bone of the calc planterly and medially looks like an EGG SHELL!

The radiographer has suggested it may be a interosseous calcaneal lipoma or bone cyst. I have never seen a bone cyst so big?

The patient is coming in tomorrow and I plan to refer on to GP -> Radiographer as I dont feel competant in managing this lesion. I will indicate the need for future support in accomodative orthotics and monitoring due to PN.

Any thoughts will be most valued if you have experienced similar. I will follow up with any info.

Well it seems either nobody is interested in this thread, or everybody was unsure, as I was.

I have referred this patient for further examination through the GP and will keep you posted on outcomes.

Quite strange, I had a very similar thing happen last week, a man with similar medical problems (including severe rheumatoid arthritis and previous bilateral met. head resections) who was complaining of a sore ankle, which swells with activity. I was also concerned about Charcot or a stress fracture, so sent him off for x-rays, and was completely stumped by the large lucent area in the body of his calcaneus, with similar fragements on the plantar surface.

I sent him off to his GP for a CT, the radiologist I spoke to and asked for a verbal opinion suggested imterosseous lipoma, a 'pseudo-cyst' appearance from a healed previous fracture, or osteomyelitis.

Are you in Melbourne? haha maybe same patient.

I referred my patient to a GP (he was reluctant to go as he has a poor opinion of medical practitioners due to various experiences, but has great trust in me which is good :))

The GP did no further testing, just sent straight to an orthopaedic surgeon. The patient refused to go so showed up to me again. So I have referred for some MRI's to discover what tissue the cyst is consisting of.

After discussion with a podiatric surgeon, he was of the opinion it may have been a long standing lesion that has only been found by chance, or a bone cyst.
He thought surgery would probably not be warranted as the procedure usually entails removing the cyst and replacing it with a bone graft or bone cement, and a long recovery time.

Will be interesting to see out come of MRI which is being done next week. Will keep you posted.

Sally

Hi Melb:

Sounds like your patient has problems. The edema you see is most likely induration.

First, you never told us what his chief complaint was other than "foot posture"... is he in pain?

Second, you state he has peripheral neuropathy. What is the etiology?

Large cysts in the os calcis are not too uncommon, most are UBCs.
Assuming it is in fact a cyst (benign) and there are no symptoms or fractures through it, I would leave it alone.

Sounds to me like he has long standing Charcot rearfoot (maybe complicated from psoriatic arthritis).
Given the fact that you didn't mention Diabetes, I would suggest possible complications of alcoholism.

Let us know

Steve

__________________
DrSArbes
Fellow American College of Foot & Ankle Surgeons
Board Certified Foot & Ankle Surgery, ABPS
Green Bay, Wisconsin, USA

No, there is no significant pain other than the long standing pain he associates with the psoriatic arthritis.

No diabetes or alcoholism. It seems after some lit reviews, that peripheral neuropathy can be caused by psoriatic arthritis in some individuals.


After MRI if the tissue is benign, this is my plan.

He has never been a big drinker.

Thanks Steve, will keep you posted on the outcome.

Sally

"sounds like he has problems".
What I meant was given his Peripheral neuropathy, Rigid rear foot, rigid Midfoot, psoriatic arthritis, bilateral edema, induration, midfoot collapse and foot "slap" - well...to me, it sounds like he has problems! :-)

Steve

__________________
DrSArbes
Fellow American College of Foot & Ankle Surgeons
Board Certified Foot & Ankle Surgery, ABPS
Green Bay, Wisconsin, USA

I definitely agree with that Steve!!
Will keep you posted on his progress. firstly will get diagnosis on the calcaneal "lesion".
Then will begin management of supporting the rest of the foot to prevent further deterioration.

:)

MRI results show large bone cyst of the calcaneus, surrounded by bone oedema.
synovial cyst also present surrounding FHL and PT tendons. (possible cause of neuropathy with irritation to PT nerve.)
Pt happy no malignancy.
As for management I will issue a supportive EVA style device to limit further deterioration of foot and minimise risk of trauma to calc causing fracture.

thanks for all your advice

Sally

Sounds as though this patient is a "cyst former"

If they are getting a secondary tarsal tunnel due to cyst pressure you should aspirate and see if the symptoms resolve. If symptoms improve then obviously the prognosis depends on how long it takes for the cyst to refill. Short duration leads to surgical removal.

As for the calcaneal bone cyst, unless they are symptomatic, you can leave it alone.

Good luck

Steve

__________________
DrSArbes
Fellow American College of Foot & Ankle Surgeons
Board Certified Foot & Ankle Surgery, ABPS
Green Bay, Wisconsin, USA