Chronic ankle pain

Chronic talalgia of undetermined nature
Short Summary

A 58 years old male. 4 years ago the patient was hospitalized due to acute thrombosis of the right femoral-iliac axis. The patient was treated succesfully with locoregional intra-arterial fibrinolytic therapy. A follow-up arteriography, revealed sub-occlusion of the common iliac, occlusion of the right superficial femoral artery in Hunter’s canal. PTA + stent of the iliac was carried out with excellent final angiographic result.
10 days after thrombosis, the patient reports appearance of painful symptomatology at the right heel. During the last 4 years the patient undervent numerous examinations (US, EMG, X-rays of his right foot, MRI, CT), as described below, without getting any specific diagnosis or efficient treatment.

Patient's Questions

1) What, according to your opinion, is the main diagnosis? A medullary edema could be assumed to be the cause?
2) What therapy do you suggest?
3) Any centers of excellence in Italy or in Europe?
 

Medical Background

A 58 years old male.
4 years ago the patient was hospitalized due to “Acute thrombosis of the right femoral-iliac axis in chronic obliterated arteriopathy of the distal femoral region.” During hospitalization, a locoregional intra-arterial fibrinolytic therapy was carried out obtaining in 24 hours the recanalization of the right femoral-iliac axis. Following this recanalization the presence of a stenosis of the common iliac artery was revealed. The lesion was, therefore, corrected by means of PTA and stenting.
A follow-up arteriography, one week later revealed sub-occlusion of the common iliac, occlusion of the right superficial femoral artery in Hunter’s canal. PTA + stent SMART (8x40 mm) + Dinalink (8x38 mm) of the iliac was carried out with excellent final angiographic result.

10 days after thrombosis, the patient reports appearance of pain at the right heel, therefore, he begins to carry out medical tests:
- Right foot X-rays: “Right valgus big toe with associate metatarsal-phalangeal arthrosis.”
- Muscles-tendons ultrasound scan: within normal limits.
- Right foot NMR: “Inflammatory pain of moderate importance at the level of the calcaneus insertion of the Achilles tendon that, also keeping a substantially regular thickness, shows a slightly dishomogeneous signal due to a modest edematous imbibition with little edematous after-effect also of the near superficial soft tissues. Signs of inflammatory pain of moderate importance are noticeable also at the level of the calcaneal insertion of the plantar fascia without evidence of rough calcaneal bone spurs.”
- Lower limbs EMG: “Reduced motor conduction speed of the right common peroneal and tibial nerves, with reduction in extension of the motor response potentials. Unexcitable right sural nerve. The EMG examination shows deficit in recruitment of the motor units in right pedidius and gastrocnemius muscles, in the absence of signs of denervation. On the whole, the electroneurography findings indicate concomitant pain of the right common peroneal, tibial and sural nerves.”
- Repeat of right foot X-ray (10 months after the previous rt.foot x-ray): “Valgus of the big toe. Presence of small cyst formations at the level of the extreme distal region and of the 1st phalanx of the 1st finger. "
- Lumbosacral spine NMR: “Diffuse degeneration of all the lumbar intersomatic discs but mainly in the inferior segment of the spine where they are connected to inter-apophysis arthrosis and spondylosis abnormalities. The L4-L5 disc protrudes posterolaterally to the right with compression on the proximal portion of the L5 radicular pouch of this side.”
- Lower limbs CT scan with contrast medium: “Regular morphology and flow of the large arterial afferences distally to the abdominal aorta at level of iliac bifurcation. Presence of moderate angiosclerosis phenomena with calcific deposits of the iliac and the superficial femoral arteries. On the right, the posterior tibial artery is assessed. Its flow is shown up to the tarsal tunnel level where it gains a progressively thin morphology.”
- Repeat right foot NMR (performed year and a hhalf after the previous NMR): “Moderate and dishomogeneous edematous infarction of the soft tissues that surround the distal end of the third and the fourth metatarsal bone, consistent with a functional overload syndrome of the forefoot. Moderate degenerative pain at the calcaneal insertion of the Achilles tendon and of the plantar fascia, in the absence of rough calcareous deposits or of insertional sinovial bursa. Nothing to report on the sinus tarsi and the sub-astragalic joints. Signs of diffuse degenerative joint pain, with greater expression involving the tarsal and the metatarsal-phalangeal joints of the ray, with associated deviation in the big toe valgism.”
- Lower limbs follow-up EMG (2 years after the first EMG): “The study of the right posterior tibial gives evidence of a meaningful reduction in extent of the motor response, if compared to the previous examination. On the contrary, a slight improvement in the distal latency can be observed. These findings give evidence of a meaningful axonal damage.”
- Lower limbs follow-up EMG (3 months after the previous EMG): “Marked reduction of maximal motor nerve conduction velocity of common peroneal nerves and right tibial nerve and right median nerve. Instrumental findings consistent with protopathic pain of the muscle cell.”

On completion of the information related to the diagnostic examinations it is advisable to indicate, on the date preceding the symptomatic beginning, the following examinations:
Right upper limb EMG that was performed 15 years ago:“Myotonic discharge, at the insertion activity, extended.”
Subsequently, molecular analysis on peripheral blood through non-radioactive Southern blot was performed and showed expansion of the CTG codon in myotonin gene (Steinert’s disease).
The extent of the expansion was assessed in the range:
E1 (50-500 codons)
E2 (500-1000 codons)
E3 (>1000 codons)
The result is compatible with the diagnosis of Steinert's disease.”

For the pain management in calcaneal region the patient, following the doctor’s advice, used, without taking any benefit, each time painkillers of various types, among which:
Contramal, Lyrica, Tachidol, Tauxib, Efferalgan, Coefferalgan, Nicetile, Colibri and Tramadol.
The patient also used various types of arch support without getting any benefit.
He carried out 7 infiltrations with corticosteroids as well as acupuncture treatment for the pain therapy.
Moreover, shock wave courses, laser therapy, ultrasound water and non-water treatments were carried out.

In the course of the years the patient underwent an operation for the plantar fasciitis, without achieving any subsequent symptomatic relief and, then, those of the neurosurgeon who performed an operation of “Tarsal Tunnel” , as per the results of EMG examination (findings strongly indicative of compressive pain of the tibial nerve posterior to the tarsal tunnel) with return of the algic symptomatology after a short period of time.
At last, upon the neurosurgeon’s advice, a pharmacological therapy with Lamictal and Laroxyl was carried out showing satisfactory pain mitigation. Unfortunately this therapy was suspended since it created signs of mental derangement in the patient.
One of his treating physiasians is currently assessing the possibility to make use of medullary stimulation.
 

Expert's Opinion

This is a 58 years old male with chronic talagia.
4 years ago the patient was hospitalized due to “Acute Thrombosis of the right femoral-iliac axis in chronic obliterating arteriopathy of the distal femoral region.” During hospitalization, a locoregional intra-arterial fibrinolytic therapy was carried out obtaining in 24 hours the recanalization of the right femoral-iliac axis. Following this recanalization, the presence of a stenosis of the common iliac artery was revealed. The lesion was, therefore, corrected by means of PTA and stenting.
A follow-up arteriography, revealed sub-occlusion of the common iliac, occlusion of the right superficial femoral artery in Hunter’s canal. PTA + stent SMART (8x40 mm) + Dinalink (8x38 mm) of the iliac was carried out with excellent final angiographic result.
After 10 days from thrombosis, the patient reports appearance of painful symptomatology at the right heel.

His imaging workout included:
1. US of the tendons and muscles that was reported as normal.
2. X-rays of his right foot X2 Reported per the attached history
1st examination: "“Right valgus big toe with associate metatarsal-phalangeal arthrosis.”
2nd examination: “Valgus big toe. Presence of small cyst formations at the level of the extreme distal region and of the 1st phalanx of the 1st finger. Small calcaneal arthropathy.”
3. MRI x2 ( I reviewed the attached images of the first examination).
4. CT of the lower limbs: “Regular morphology and flow of the large arterial afferences distally to the abdominal aorta at level of iliac bifurcation. Presence of moderate angiosclerosis phenomena with calcific deposits of the iliac and the superficial femoral arteries. On the right, the posterior tibial artery is assessed. Its flow is shown up to the tarsal tunnel level where it gains a progressively thin morphology.”
The attached MRI  is only a part of the examination (area included and the sequences). It is difficult for me to see the inflammatory changes of the Achiles tendon or in the calcaneal insertion.
The attached images of his CT angiography of the pelvis and lower extremities is of good quality. The stent in the Rt common Iliac artery is patent. There are atheromatous changes with calcifications of his pelvic vessels and both SFA. The popliteal arteries and calf arteries are within normal limits.

In my opinion, his problems are not arterial. His arterial vessels below the knees are normal and I expect to find normal pulse examination and normal ABI (ankle –brachia index). I can't exclude inflammatory changes in the achiles tendon and at the calcaneal insertion, though he was treated for without success.
Regarding additional imaging- I don’t think that there is much to add. PET CT will be influenced from the surgeries and treatments he underwent,and US, CT and MR are of little added value.
The main diagnosis, unfortunately is not clear, the pain is probably of neurologic origin, which I can't put my finger on. The medullary edema (which I didn't see) is probably not the cause.
I would ask for opinion of neurologists and orthopedists specialize in the foot and get idea for additional therapy.
 

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