Right foot pain
Short Summary

38-year-old female started to suffer pain in her right foot on without a notable trauma. She was examined by several orthopeadic doctors and she got different opinions. The first diagnosed medium sprain of right foot and slight tumefaction on forefoot, and suggested her paracetamol administration that was with no benefit. The second specialist diagnosed sesamoiditis and right plantar fasciitis with 3rd degree cavus-valgus feet and recommended Depomedrol + Lidocaine, Pennsaid drops and NSAIDs. As part of the examinations she underwent an MR with and without Gadolinium. Currently, she continuous to feel warmth in the affected area and to suffer from a slight pain which is present all day long.

Patient's Questions
1)    What diagnosis do you infer?

2)    What therapy do you suggest? In particular, do you think surgery is necessary or a simple shoe sole application or other physiotherapeutic intervention would be sufficient?

3)    Centers of excellence in Italy?
Medical Background

Patient's History
 
Sex: F, Age: 38
Diagnosis
:
Right foot pain
 
Medical history:
Laparoscopic surgery for endometriosis and laparotomic surgery for uterus mioma;
Microlaryngoscopy to remove vocal cords nodules.
Sideropenic anemia in abundant menstruations.
 
Case history:
Beginning of painful symptomatology affecting her right foot during the weekend of February 2008 whilst the patient was at the seaside. After 2–3 days the pain increased becoming unbearable. The patient went therefore on February 2008 to the Emergency Unit of ULSS – TV Hospital Trust of the Veneto Region, where, following a radiological examination, she was diagnosed with “right foot sprain” and she received an intramuscular injection of 1 vial of painkiller Toradol.The final report of the orthopedist is as follows:medium sprain of right foot.Rx negative for fracture.Slight tumefaction on forefoot.6 days rest without load on the right side, then clinical follow-up”.
 
At the follow-up on Feb, the following blood tests were performed:
Uric acid                                            3.5 mg/dl                    2.0 – 5.0
Rheumatoidfactor                          10.3 UI/ml                   < 20   
A.S.L.O.                                             322 UI/ml                   < 200
 
Thereafter, because of the persisting painful symptomatology, the patient contacted an orthopedic specialist who did not find anything pathological. He, therefore, suggested a “plaster cast” of the right foot which was rejected by the patient; the specialist then suggested the patient to take Tachipirina (paracetamol) for a couple of days and then to visit her again.
Following paracetamol administration with no benefit, the patient contacted privately another orthopedist, a former hospital unit director who visited her on 02/2008 and reported the following:
 
Diagnosis:
sesamoiditis of 1st ray of right foot in bipartite sesamoid and right plantar fasciitis at the proximal intersection in patient with cavus-valgus feet (3rd degree).
 
It is recommended:
Local infiltration of Depomedrol + Lidocaine is performed on the painful areas (to be repeated in a week);
Pennsaid drops -> 15-20 drops 3-4 times/daily, on the painful plantar region of the forefoot.
NSAIDs if necessary”.
 
An MR without contrast of the right foot was performed on 02/2008, the report of which is as follows: “Achilles tendon within normal limits and conservation of tarsal sinus with no alteration of its ligament. No lesion in the talar dome and tibio-peroneal sydesmosis within normal limits. Moderate effusion in the tibiotalar joint. Moderate edema of the metatarsal-phalangeal joint of the first toe with signs of edema also on the soft tissue parts surrounding the joint; the appearance is of uncertain significance, and should be better investigated, eventually with the use of contrast agent. No alteration of peroneal tendons, and flexor and tibial tendons within normal limits.”
 
A further infiltration was performed on 02/2008 by the same specialist, then a follow-up visit was made on 03/2008, the report of which is as follows:
Diagnosis:
Rebelliuos painful tumefaction on plantar side of the metatarsal-phalangeal joints of right big toe and first metatarsal head, in patient with 3rd degree cavus-valgus feet.
It is recommended:
The painful symptomatology is only slightly improved following medical treatment and infiltrations prescribed.
It is therefore recommended to perform an MR with contrast of the right foot (to examine soft tissue parts)”. 
 
Said exam was performed on 04/2008 and the report is as follows:
“ currently, following IV injection of contrast agent, presence at the first metatarsal interspace of a signal alteration area with a diameter measuring 10-15 mm presenting high hyperintensity after GDTPA injection and highly accentuated vascularization in the images after IV injection of contrast agent; the alteration is of uncertain significance and is surely not referable to Morton’s neuroma (phlogosis? other?); the lesion itself appears poorly defined in its margins even after IV injection of contrast agent.
The other metatarsal-phalangeal and interphalangeal joints are within normal limits.
A short-time follow-up is recommended”.
 
Currently, after 3 months from the acute phase, the patient continuous to feel warmth in the affected area and to suffer from a slight pain which is present all day long, even though she only wears low shoes since she is not yet able to wear heels.

Expert's Opinion

I looked profoundly at the pictures of the MR and I think that the diagnosis for her problem lays in that examination.
It can be seen that the Lateral Sesamoid bone is completely inflamed and not regular in its shape. My diagnosis is AVN = Avascular Necrosis of that Sesamoid bone.
Usually we start treatment conservatively, utilizing insoles within the shoes. Some times it does not help and surgery is needed.
 
The patient can find help at:

Prof. Sandro Giannini 
 
 
 
 
 

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