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My 4th day of work and I'm already stumped!

I have a 47 yo female patient who came into the clinic with numb forefeet, only relieved when she wears her shoes.

- Reports of no medical/surgical history and no medications
- Started 3 years ago, and was only in her toes (both feet)
- Has since spread to metatarsophalangeal joints
- Describes sensation as "numbness" - no tingling/burning/pins and needles, and does not radiate (localised to specifically from MPJs to toes)
- Pain only relieves when wearing shoes (regardless of shoe type); quickly returns after taking them off. Even as she was sitting in the clinic chair, she could feel it/
- Pain especially bad during the night and when she's lying down
- No history of Reynaud's or rheumatoid arthritis
- No traumatic/emotional event that may have triggered symptoms
- Pain is present all year round - does not alter with weather
- She's had some back problems near the cercival/top thoracic area
- VAS - 8/10

She's previously had some imaging done:
- Ultrasounds for morton's nuroma negative (also, nil neuroma click and lateral squeeze)
- Doppler ultrasounds show no abnormality

Biomech assessment:
- right shoulder drop
- R ASIS higher than L ASIS
- moderate cavoid foot type
- neutral calc
- tight Achilles
- limited ankle dorsiflexion during gait
- abductory twist

Doppler sounds normal - bi/triphasic, strong and regular

I tried taping her feet to supinate it and relieve the tension under the flexor retinaculum but no symptom relief.

This is my first time seeing the patient. But I believe the other podiatrist has tried met pads, which didn't help.

Today we gave her some tubigrip to apply in the evening, and wrote to her GP asking for a referral to the neurologist.

Is it just me, or is this a tricky case?

Cheers, Loraine

Forgot to add (but probably quite obvious), would muchly appreciate any help/suggestions on what it could be, and what I can do! At first I was thinking Reynauds, Tarsal Tunnel Syndrome, Neuroma but then none of them seem to fit.

Forgot to add:
- negative Tinel's sign
- negative exacerbation with passive pronation

Loraine:

This is likely a forefoot pressure neuropathy, also seen commonly in people who use elliptical trainers on a regular basis and sometimes in cyclists. The shoes with a heel will reduce forefoot pressure due to her tight Achilles tendon. Put her on three times a day gastrocnemius and soleus stretching exercises, have her wear shoes with at least a 1/2" heel height differential initially then as the Achilles tendon becomes more compliant over time with stretching, she should be able to walk barefoot without much less pain. Expect the symptoms to start improving after about 2-3 weeks of regular stretching. Foot orthoses with the anterior edge left full thickness (3-6 mm thick) also helps greatly in many cases.

I don't believe forefoot pressure neuropathy has been previously described in the medical literature. This is the name I have given this diagnosis and it seems to be much more common in those individuals who are heavier than normal, have higher arched feet and who have a limitation of ankle joint dorsiflexion.

Hope this helps.

__________________
Sincerely,

Kevin

**************************************************
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
Sacramento, CA 95825 USA
My location

Voice: (916) 925-8111 Fax: (916) 925-8136
**************************************************

Thanks Kevin! I've prescribed her some stretches. I'll give her a call in a few weeks time to see if there's any improvement. Will get back to you on how it goes!

Hello Zol,

Instead of trying to strap her feet to roll your patient out/ support her arch. May I suggest 2-3 low dye plantar straps and then 3-4 ankle stirrups. When doing the ankle stirrups, instead of pulling up on the inside, pat down on the inside of the ankle and pull up on the outside. This will serve to pronate this foot a bit better and dissipate some ground force - cavus feet in geneeral do poorly to absorb shock. Just a thought.

With the met pads, think perhaps for every action there is an equal and opposite reaction and the pads are perhaps increasing GRF (if it is positioned directly under the met heads). Perhaps, try a pre-metatarsal dome of small to medium (with a slight grind) nature.

Loraine:

How is she doing?? We all are anxious to find out!

__________________
Sincerely,

Kevin

**************************************************
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
Sacramento, CA 95825 USA
My location

Voice: (916) 925-8111 Fax: (916) 925-8136
**************************************************

If she gets relief with shoes on I would think this paraesthesia might be more like a hypersentivity issue. Is it worse with vibrations i.e. when driving does she have increased paraesthesia with the vibrations under the gas pedal.


If it is really impacting her lifestyle has she tried medication like Endep to see if this relieves it. This would be interesting.

Is she very anxious i.e can't sleep because she is always worried about things.

Otherwise my 'dark horse' would be L5 issues. Rare I know because no limitation or back pain has been described but just a gut feeling.

Cheers,
Con

Hi everyone!
Thanks for all your input. I've previously asked her how her emotional/personal well-being was, and she said she was good - no anxiety issues.
I gave her a call today, and she said that her symptoms are still there (i.e. no pain in shoes, and sudden onset of numbness when she's out of her shoes). She tells me she's been doing her stretches, and she generally is very compliant. She reports that the only relief she gets when she's out of her shoes is when she puts on her tubigrip. In fact, she reports that she has trouble sleeping without it on.
She has an appointment with the neurologist on April 30th - will be interesting to see what he/she says.

Hmmm... Given that she experiences no symptoms in her shoes, are met domes/correcting foot posture with orthoses justified?

Con - also thinking possible hypersensitivity (or would it be more like hyposensitivity?). I'll be giving her a call back after her visit to the neurologist. Watch this space!

Cheers, Loraine

Did you check vibration and monofilament response?

__________________
My location

I did monofilament when I first saw her and no problems there. Didn't do vibration though.

Hi everyone!
Thought I'd give you an update on my patient. I've just gotten off the phone with her - she saw the neurologist about 2 weeks ago.
She's getting several blood tests done. Some interesting initial results that she's gotten back already is that she's low in iron and extremely low in B12 (her levels are at 50; apparantly, normal ranges are around 500). I only have a very basic understanding that B12 can lead to nerve damage and neuropathy. The neurologist has put her on B12 supplements that may either reverse her symptoms, or at least stop the progression of symptoms. Her neurologist has also thrown in celiac disease as an additional diagnosis.
So, there you go! I've "discharged" her, but she'll keep me informed on how things go.

Sorry - amendment. She is having B12 injections, not supplements.

Hi Loraine,

Yes it is commonly known that B12 deficiency can cause neuropathy but what really suprises me (if indeed it is the cause of the forefoot numbness) is the 3 year duration. You see I would have thought that bloods would have been ordered by the GP early on in the piece for not only these symptoms but considering longevity of symptoms (at some point in time) and also considering age of patient.

Don't want to sound critical....just suprised.

Hope for your patient's sake a full recovery is made and thanks for your update post.

Cheers,
Con