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572651 tn?1531002957

OT - Mystery Diagnosis for my Foot

We haven’t had a good old mystery diagnosis lately so I thought I would offer up my case history and get your feedback.  This is not MS related because it is not a CN problem  

Pt history:
MS
Left foot Bunionectomy April 2012
Pulmonary embolism August 2012
Hammer toe – left foot developed 2013

Sx (that’s for symptoms and not sex)-

Pain in left foot – got orthotics for relief from hammertoe – helped temporarily but then started to worsen over  past six months.  
Pain worse over the past month or so.
Difficulty/impossible to push to standing position without using arms of chair or whatever I could grab to get up.  Positioned walker in restroom so I could get off the toilet.  Left leg would not push – has since resolved and standing from sitting position no longer a problem
Sharp pain in left calf, since resolved, but sent for ultrasound in February 2014 to rule out blood clot.  Negative for DVT
Swelling in left ankle & foot after prolonged sitting, began to happen more frequently the past six weeks
Pain increased in intensity in left foot  - swollen foot, primarily across the top at the base of the toes (mainly 2nd & 3rd metatarsal bones)
Foot NOT hot to touch
Foot NOT red or inflamed
Painful to touch swollen area, rest of foot does not hurt
NOT Painful while sitting or sleeping.  
Only hurts while standing and bearing weight (like walking)

Tests I have had so far:
Blood work – CBC normal, no infection
Bloodwork – uric acid in normal range,  not likely to be gout
Xray – negative
CT Scan – negative
MRI is scheduled for Friday.
Currently wearing a compression sock and one of those sexy post-surgery black boots to immobilize the foot

So is there a Dr. House in the crowd who might venture a guess?   I am stumped and so is the podiatrist  for now.   If you have any ideas, I would love to hear them.  And you can send me the bill for the house call.

Of course i will let you know if/when I get an answer... I see the dr again on Monday





26 Responses
Avatar universal
Okay, here's my fearless assessment, offered as one who lives with--in the words of my old PCP--Crappy Feet Syndrome. I suspect your bunionectomy was somehow botched. A millimeter here, a millimeter there, and the whole balance of your foot and leg are thrown off.

It's amazing how such tiny deviations can snowball into almost life-changing problems. Because A and B have now been shifted ever so slightly, you may be putting more weight on C during certain movements, which strains D, which then compensates by pushing closer to F, and on it goes.

I had a double bunionectomy by age 40, so already had developed the crappy feet well before then. Fast forward quite a lot of years with no particular problems, and then began experiencing pain in my left foot that ultimately had me walking more on the outside edge of the foot, which then too became painful. It was determined that the main joint in the big toe had developed hallux limitus. All that means is that it couldn't move up and down properly because of bony deposits.

So then a podiatrist decides this should be corrected by surgery that slightly shortened the first metatarsal. Right in theory, maybe, but wrong in practice. In short, he took a millimeter too much out. So then my weight shifted ever so slightly when walking, eventually causing a huge and painful callus on the ball of that foot.

Exit podiatrist. He'd had his chance and blown it big time, costing me weeks in a cast and a major if temporary adjustment in my whole lifestyle, especially since I live in a garden-style condo, no elevator, with a pooch needing care, etc. Enter orthopedic surgeon, who had to correct the podiatrist's correction by ever-so-slightly shortening the next two metatarsals, thus evening things up a bit, and not coincidentally making my whole left foot just a bit shorter than the right. That worked, at a cost of much more time, aggravation and life adjustment. I now have 5 screws in that foot.

Oh, he also corrected hammertoe in 4th toe, which now splays out when I walk, almost like something featured in a cat cartoon. If I walk barefoot for more than a short while, the third toe goes numb, no doubt from displacement due to 4th toe no longer doing its job.

Then a few years back I took a bad MS-related fall and broke all 3 bones in my right ankle, sort of mangled them. Surgery and a week in the hospital was followed by 5 months of PT, which didn't help all that much, and I now have 'post-traumatic arthritis' in that ankle (pain and swelling), along with 11 screws and a plate. Can't really blame anyone but myself for that, but I have learned to beware of doctors bearing scalpels.

The ortho who did that surgery would like nothing more than to get in there with a knife again and either fuse the ankle or replace the entire joint. Things will have to get a whole lot worse before that happens. Meanwhile another podiatrist who is making me orthotics at ruinous expense (luckily covered 90% by insurance) has been looking greedily at my Achilles tendons and their shortened state (may be an MS thing) and wants to do either surgery or a special series of laser treatments, not covered by insurance. Like that is ever going to happen. His beady little eyes got a frustrated look in them when I told him I had largely solved the pain problem in my left calf by the simple expedient of getting rid of a pair of ankle boots I'd been wearing most of this past winter of endless snow. If ever I do need surgery for the Achilles stuff, which would be a last resort after meds and PT, it ain't gonna be by a podiatrist.

Sorry that story veered off into me me me, but it does illustrate the fact that millimeters can well be what it's about. I wouldn't necessarily trust the opinion of the doctor who may have started the whole thing. Have you seen an orthopod?

Well, it's the middle of the night, and I just got up to get something to drink, so now I think I'll try lullaby land again.

Keep us posted on developments.

ess
572651 tn?1531002957
Ess, you know I NEVER select a *best answer* until this morning - I so appreciate you taking the time to write out all of this.  It makes a lot of sense, and esepcially that i could really lose 50 pounds to begin with to really give my foot some relief.  

The good news is it only hurts when i walk on it, so sleeping and sitting are not a problem, for now.

I'm glad you made it about you, you, you - it helps me to see the bigger picture.  i hope you got back to sleep - it appears we are passing in the night.

hugs, Laura
Avatar universal
I do love a good mystery! :-)

Might not hurt to be checked for diabetes and I am guessing your blood pressure isn't high because that can sometimes cause weird swelling.

Also, I know my mother had foot and leg swelling and wears compression stockings due to severe arthritis in her back.

My father also used the stockings the last decade of his life due to a really aggressive case of lymphedema so I am praying there is nothing seriously wrong.

I hope you get an answer soon,
Corrie
572651 tn?1531002957
Thanks, Corrie.  Yes, my sugar can be boderline but I have been pretty good lately but that thought came to mind.  

A local neuro at a talk last night asked if I had seen a rheumotologist, which fits your arthritis question.  I hate to add another 'ologist' to my stable of docs.

Some form of edema also crossed my mind, but I have to wonder about that because the pain/discomfort is ONLY when I am standing on it.  It does't hurt when i sit or sleep.

You have some good suggestions there.
hugs, Laura
1689801 tn?1333986916
I´m sorry your feet are hurting so much Laura. You have got a really good theories from both Ess and Corrie. I smiled when you said doctor House, because I gave my new neuro "my story" in writing (a little different version than you have seen in English) and I talked about needing some doctor House to help me figure this out :) there should be much more off "House´s" out there! We need them!

I hope will get your doctor House soon, so you will get better.
Hugs,
Dagun
572651 tn?1531002957
Thanks, Dagun.  the good news is I had a massage today and had her work almost exclusively on my legs.  She did some lymphatic work and got the fluid moving some and I can now wiggle my toes, which I couldn't do before.

stay tuned for the next chapter
Laura
751951 tn?1406636463
I'm thinking gout, until the blood test --" likely "-- ruled that out.  Then maybe just too much fluid in the tissues, a la COPD type of thing, though not necessarily COPD.  CHF is related, is it not?  Did you mention your salt intake?  A wild guess tells me you're fastidious about that.   Electrolyte levels checked?
572651 tn?1531002957
Thanks, PD, for weighing in on this one.  Gout doesn't fit the profile because it is not sensitive to touch, only hurts when it is weight bearing.  But I understand there is always ana exception to everything medical.

I had my MRI done yesterday - I have never seen such a small machine and will post a picture.  We talk here a lot about the strength of the MRI being significant for MS dx  - this one is 0.3T  yes, Zero.point.three.  The pictures are interesting and clearly show my hammertoe malformation but i don't know what else I might be looing at.  i'll post some pictures of the machine and the results because I know we all find this intersting.  ;-)

My appt for followup is Monday morning - I can't wait to hear what he says now.

hugs, L
147426 tn?1317269232
HERE I COME TO JOIN THE FRAY!!!

Yes to all Ess said and I, too, am sad you have joined the Crappy Feet Corps.  I all of the following problems are at play here.

First off - I have the same thing you have, but on the right foot.  Some excruciating pain in the 2nd and 3rd metatarsals with localized swelling and agonizing pain to pressure.

Osteoarthritis - already discussed, but I believe the bunions and hammertoes themselves start the process of redistributing the balance and smooth functioning of the enormous numbers of bones, nerves, ligaments, tendons......ad nauseum.

Surgery and injuries - both of these can disrupt the micro blood flow and the lymph drainage of the feet.  Then nothing is as healthy as it was before.  The best advice is to never, ever injure your feet and ankles and surgery should be done only when absolutely necessary and things are often not improved or other things are made worse.

MS - Yes, I believe this is also an MS problem.  You suffered a relapse involving the strength of your left foot.  This indicates a lesion in the left sided motor tract of the spinal cord.  The strength returned, but doubtfully to the level of before the relapse.  We know that the left-sided sympathetic nerve tract runs right alongside the motor tract.  When one is affected by a lesion, the other is often caught within it.

The sympathetic tract governs the vascular status of the lower limbs and thus affects the temperature, color and health of the leg and foot.  The bones and soft tissues may suffer in their health from inappropriate constriction of the vascular flow.

Your MS has affected your gait and weight distribution for a lot of years.  This alone has done damage to small structures.

I also have suspected that I have stress fractures in my metatarsals, but they have not shown up.

weight - 'nuff said (may she who is without sin throw the first stone)

It is all at fault.  Our feet were not made to handle the amount of trauma that life and MS (MS not being include in life, of course) has placed on them.  They are damaged and wrenched and misaligned and too much is asked of parts of the feet that are not up to the task.

Has your podiatrist plotted all the lines from heel to toe that need to be correctly in their relationships?

Crappy Foot Core - ***** majorly doesn't it.
572651 tn?1531002957
It's always nice to see

MIGHTY QUIX IS ON HER WAY!!  LOL

(i'm not sure who in this corp is old enough to get the pop culture reference but it made me smile)

After consulting with the fine experts here and also with Dr Google, and looking at my MRI pics, I am farly certain that this is a problem that will be  ongoing because amputation is not an option.   I would rather have magic surgery to correct it than learn to live with slowing down.

As we all know, not everything that goes wrong with us can be fixed, and this is probably one of those.  

Thanks for weighing in.






5509293 tn?1428535075
The mighty Quinn song !!
Just wanted to say how much I hope you get a solution, Lulu. Take care.
Avatar universal
Lu,I so agree. I used to love walking, got loads of exercise that way, and so did my pup. When every step is painful, we're often willing to try anything to get back to so-called normal.

Sometimes that doesn't work (me). Sometimes it does (also me). Surgery is a pain in the -err- foot, but watcha gonna do?

ess
Avatar universal
Oh yeah! Something like

Come all without, come all within
You'll not see nothin' like the mighty Quix
(or maybe, Quinn)

There aren't many here in the right age group, and I think that at least currently, I'm the leader of that Corps  :-)

ess

147426 tn?1317269232
LOL
751951 tn?1406636463
I was thinking more along the lines of Mighty Mouse.

Kids.  What can ya say?
Avatar universal
I've had bunion surgery on both feet. On my left the bunion is coming back and though it is still "smallish" compared to before surgery it is much more painful along the scar.  So scar tissue/ a touch of arthritis from the previous surgery and the bunion coming back causes pain! sleeping on my side with my foot on its side is painful again... argh hate having bad feet.  I just dropped 150 dollars on new running shoes and foot still hurts! Bought anothe pair of new running shoes a few months ago and can't wear them as they rub the scar and are to painful
751951 tn?1406636463
I am very, very careful in buying shoes.  Several months as a retail greeter were disastrous for my feet, and ever since, I've been among the world's slowest shoe shoppers.

For one thing, the old dogs have very high arches, so much so that I must buy EEEE width, in order to get enough leather to lace together up on top of the foot.  When I shop for shoes, I will then try 1st to determine what the store has in my size.  If anything, I try to start at the bottom of the price range, working my way up until something aesthetically acceptable feels unlikely to torture me in the first week.

LauraLu, we will continue to pray that you find relief.
751951 tn?1406636463
My "then" belongs in the next sentence following the one in which it appeared.  Smart phone, my foot.
572651 tn?1531002957
I was thinking might mouse, too, PD.  

My update -

It is no surprise - I definitely have a stress fracture in my left foot - 3rd metatarsal if that means anything to you.  I also have a rupture of the synovium  on the 2nd metatarsal bone.  That is the pocket of fluid that cushions the joint when we walk.


For now my plan is to see if we can do a temporary patch job but the reality is eventually it will have to be surgically repaired .  I am now in a full boot up to my knee to stabilize the foot and allow the stress fracture to heal - that will be rechecked in 4 weeks.  They will get me in yet this week to do an injection in my toe - much like the stuff they put into knees when the cushion is worn down.   I'm hoping I can do one or two of these and get to fall or early winter and then do the surgery, if not later. That one involves absolutely no weight bearing for 6 weeks or so and I'm not so sure about rolling around on one of those knee scooters with my balance.    


The podiatrist said the rupture comes from the hammertoe and the stress fracture comes from the 2nd metatarsal pushing into the 3rd and causing that much pressure.  


so that's the news for now, unfortunately.

Laura
5112396 tn?1378021583
Oh, Laura. I do hope that the healing of the fracture will at least take some of your pain away, likewise the injection. I'm sorry to hear it's down to multiple issues and that a surgery with such a challenging recovery period is in your future.

Thank you for updating us. Please keep us in the loop about your follow-up appointment this week. I'm thinking of you.
572651 tn?1531002957
This is going to be a long four weeks.  The podiatrist said i don't have to restrict my activity in this boot  

BUT

he obviously doesn't understand MS fatigue.  Today was horrendous and it was all i could do to come home from work early and take a nap.  I know this leg brace/boot is only maybe three pounds at most but it might as well be twenty ... it makes my leg feel that weak.  I'm hopeful that I get accustomed to this anchor but with the rounded rocker bottom it might be difficult to find my balance and strength.  

They got the injection scheduled for Friday - i wish it were sooner but he only does procedures on Thursday and Friday and that's when they could find an opening in the lab schedule.

So enough whining from me - time to s*ck it up and get on with it- at least for four weeks. thanks eveyrone for the kind words - I have a feeling I might need to come back for more before this is over.
738075 tn?1330579444
Ugh!  The foot problems with MeSsy stuff thrown on top for good measure... Not fun!  I hope the four weeks pass fast. Speedy recovery, Laura!!
Avatar universal
I'm hunkered down with stomach spasms, but holding down water today, but I noticed PD's comments and my brace widens my shoe and now one foot is bigger than the other!

Sending you hugs Laura, that the 4 weeks pass in a hurry.  Hubby gets his first week check up Friday on his cataract surgery and pup and I are still recovering.  Hopefully will have a new infusion center next week, heck you didn't want to hear my ranting, you need encouragement, hush Sarah, and wish Laura the best……….and a speedy recovery!
Avatar universal
Guess it'll be a while before you're footloose and fancy free again, but  hang in there. At least it's a time-limited thing, even if it is a real drag now. If surgery is really inevitable long term, I think I'd bite the bullet and get it over with. Maybe, though, this conservative approach will do the trick long term. Hope so.

Reminds me of when I got a hairline fracture in a 5th metatarsal, just by twisting it quickly in a way nature didn't intend, I suppose. Another manifestation of crappy feet. I didn't realize I'd done it, at first, but after a week or so of moderate pain, I had it looked at. Yup, x-ray showed the tiny fracture. Didn't need a brace or anything, but they made me come back over and over for subsequent x-rays till it finally healed completely.

They said extremities take longer to heal because blood flow is less. I'm not sure if this is valid. Anyone know? Lu, here's hoping yours heals fast. But if you do wind up with a knee scooter, you'd be surprised how well they work, especially the smaller ones. Having had lots of practice over the years, I'm a real roller derby champ. Can't do crutches at all because of balance. I'd fall on my face for sure.

Good luck to you.
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