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hi, i need a little bit of advice. I have recently been asked for some advice off a 56 year old woman who has been suffering with dorsal pain from 1-5 met head area for at least 2 years and the pain was getting worse. on examination both feet are pes planus, both 1st hallux abducto-valgus, crepidus felt in both 1st on assessment of range of motion, both 2nd toes are hammered, both feet planta fibrofatty pads have migrated distally. her footwear are court shoes. no history of rheumatoid arthritis diagnosed previously. i carried out the mulders click to establish if mortons neuroma was present- this was negative.
my advice to her was:
1- change footwear- advice given on apprioprate footwear for foot type
2- it was possible osteoarthritis (OA)
2- as well as possible metatarsalgia along side OA.
she was advised to see her doctor for further tests.
this is where it became interesting to me as a podiatrist.
she told her doctor that i had stated that she definately had OA and that she wanted referred for more tests. her doctor became angry and said i was not in a position to diagnose, assess or treat her complaint and the only information i got right was to change her footwear.
to cut a long short her doctor sent her for x-rays. the results as stated by her smug doctor was that there was no evidence of OA at all in the feet, the doctors diagnosis was that the problems were as a result of her foot type and the way her bones were placed!!!!!! no follow up treatment was needed.
now i feel a right idiot. i feel as if the doctor may be trying to be a little less truthfull and wanted to make me feel an idiot.
if anyone can give me another explanation or differential diagnosis please feel free as this is a big concern to me.
"has been suffering with dorsal pain from 1-5 met head area for at least 2 years and the pain was getting worse. on examination both feet are pes planus, both 1st hallux abducto-valgus, crepidus felt in both 1st on assessment of range of motion, both 2nd toes are hammered, both feet planta fibrofatty pads have migrated distally. her footwear are court shoes. no history of rheumatoid arthritis diagnosed previously. i carried out the mulders click to establish if mortons neuroma was present- this was negative."
Has the forward metatarsal arch inverted?
Mulder's click is elicited within the foot by manipulating one ray against another - I carried out the mulders click is hardly podiatry!
Re: Differential diagnosis for dorsal metatarsal pain
Quote:
Originally Posted by kerryflo
hi, i need a little bit of advice. I have recently been asked for some advice off a 56 year old woman who has been suffering with dorsal pain from 1-5 met head area for at least 2 years and the pain was getting worse. on examination both feet are pes planus, both 1st hallux abducto-valgus, crepidus felt in both 1st on assessment of range of motion, both 2nd toes are hammered, both feet planta fibrofatty pads have migrated distally. her footwear are court shoes. no history of rheumatoid arthritis diagnosed previously. i carried out the mulders click to establish if mortons neuroma was present- this was negative.
my advice to her was:
1- change footwear- advice given on apprioprate footwear for foot type
2- it was possible osteoarthritis (OA)
2- as well as possible metatarsalgia along side OA.
she was advised to see her doctor for further tests.
this is where it became interesting to me as a podiatrist.
she told her doctor that i had stated that she definately had OA and that she wanted referred for more tests. her doctor became angry and said i was not in a position to diagnose, assess or treat her complaint and the only information i got right was to change her footwear.
to cut a long short her doctor sent her for x-rays. the results as stated by her smug doctor was that there was no evidence of OA at all in the feet, the doctors diagnosis was that the problems were as a result of her foot type and the way her bones were placed!!!!!! no follow up treatment was needed.
now i feel a right idiot. i feel as if the doctor may be trying to be a little less truthfull and wanted to make me feel an idiot.
if anyone can give me another explanation or differential diagnosis please feel free as this is a big concern to me.
My advice would be this;
In future if you want a positive responce from another practioner make sure that that they get accurate information which conveys your concerns, impressions and if established a Tx Plan.
I would guess that most of us have experienced poor comunication by patients about what others have said and also negative viewpoint regarding podiatrists opinion.
After getting to know my own ego and also recognising that there are some truly crap podiatrists around I realised that if I wanted the respect and cooperation from other professionals I needed to make sure that they understood my clinical reasoning and also was prepared to have it questioned if not sound. Professional respect needs to be earned and is sometimes hard one if you are dealing with a primary care physician who has previously had to deal with wazok podiatrists. Of course this offer no guarantee but would logically reduce the risk of the scenario you paint.
The best way to do this is of course to write a decent report to whoever you want to work with not just tell your patient to go back and ask for more tests.
The history and physical exam presented so far I assume is heavily truncated, there is so much vital information lacking to start to really make any useful recommendations, perhaps you could give us a complete HX and PE to go on further with this.
hope this helps you make some progress
cheers
Martin
The St. James Foot Clinic
1749 Portage Ave.
Winnipeg
Manitoba
R3J 0E6
phone [204] 837 FOOT (3668)
fax [204] 774 9918 www.winnipegfootclinic.com
Re: Differential diagnosis for dorsal metatarsal pain
Thank you for your response. I am a newly qualified podiatrist so a little brand new, however this does not excuse my behaviour. I do appologise that there is a lot of information missing from my previous thread.
My previous thread was based upon observation and the very limited 1st range of motion. As stated the person in question wanted advice and was unwilling to be given a full biomechanical assessment . The reason behind this was that she had saw another podiatrist with 5 years experience 6 months previously with the same symptoms. The podiatrist issued her with a pair of insoles that cost her a lot of money and had been no benefit to alleviating her pain nor had the podiatrist explained what her was foot problem or offered a follow up insole review. She stated that she had no faith in private podiatrist.
As this put me in a situation, I offered my advice of the possible causes but asked the person to see her doctor for advice more tests or a referal to an NHS podiatrist for which I thought her faith maybe restored.
This has been a huge learning curve, I feel as if I have contributed to the lost faith of podiatrists by this person but also I have become involved in the previous podiatrist lack of accountability for his actions. I know i let this person down but at least my advice did not come with a £ attached.
I have taken your valued advice on board and will use this in the future
Thank you
Last edited by kerryflo : 12th November 2007 at 10:45 AM.
Reason: CAPITAL
Re: Differential diagnosis for dorsal metatarsal pain
Quote:
Originally Posted by kerryflo
thank you for your response. i am a newly qualified podiatrist so a little brand new, however this does not excuse my behaviour. i do appologise that there is a lot of information missing from my previous thread. my previous thread was based upon observation and the very limited 1st range of motion. as stated the person in question wanted advice and was unwilling to be given a full biomechanical assessment . the reason behind this was that she had saw another podiatrist with 5 years experience 6 months previously with the same symptoms. the podiatrist issued her with a pair of insoles that cost her a lot of money and had been no benefit to alleviating her pain nor had the podiatrist explained what her was foot problem or offered a follow up insole review. she stated that she had no faith in private podiatrist.
as this put me in a situation, i offered my advice of the possible causes but asked the person to see her doctor for advice more tests or a referal to an NHS podiatrist for which i thought her faith maybe restored.
this has been a huge learning curve, i feel as if i have contributed to the lost faith of podiatrists by this person but also i have become involved in the previous podiatrist lack of accountability for his actions. i know i let this person down but at least my advice did not come with a £ attached.
i have taken your valued advice on board and will use this in the future
thank you
Kerry Flo:
Does the shift key on your keyboard not function properly?
__________________
Sincerely,
Kevin
**************************************************
Kevin A. Kirby, DPM
Adjunct Associate Professor
Department of Applied Biomechanics
California School of Podiatric Medicine at Samuel Merritt College
Differential diagnosis for dorsal metatarsal pain
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