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HPI: The patient is a 62-year-old who presents with a painful left foot. The patient relates to significant history of pain that is predominately associated with a left foot bunion and with the significant callus formation that she has on the “ball of her left foot.” The patient relates to difficulties with ambulation due to the painful lesions on her left foot, and relates to having attempted previous conservative therapy including offloading in custom molded shoes. The patient has a long history of Rheumatoid arthritis (RA) and has previously required surgical correction of the right foot approximately five years prior.
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by Ryan Fitzgerald, DPM
PRESENT RI Associate Editor
Washington Hospital Center
Washington, DC
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PMH: Rheumatoid Arthritis, Diabetes, HTN
FMH: Diabetes, HTN
SOCIAL: Denies ETOH, Tobacco, or drug usage
ALL: NKDA
MEDS: Predisone 7.5mg daily, Methotrexate 2.5 mg po q12 hrs x3 doses q week, Lantus 25 U q am, Folic acid 1mg daily, Cozaar 25 mg po BID.
Physical Exam: The pedal pulses are weakly palpable at the DP and PT with a CFT <5 seconds noted to the digits. There are varicosities noted along the anterior and medial ankle which are non-pulsatile. The protective threshold is grossly intact to the Left utilizing 5.07gm SWMF, and vibratory sensation intact. There is a significant HAV (fig. 2) noted which is track-bound with limited range of motion in dorsiflexion. The lesser digits demonstrated fixed contractures and subluxation at the MTPJs with significant retrograde plantarflexion of the metatarsal heads that are palpable plantarly. There is general atrophy of the skin noted, and the patient demonstrates significant plantar hyperkeratosis formation sub-1,2,5 metatarsal heads which are exquisitely painful (fig. 3). Muscle strength is +4/5 with DTR at B/L at patella and achilles noted to be +2/4.
Radiographs: Radiographs (fig.1) demonsrates significant HAV formation with dorsal subluxation of the lesser digits. Bone is noted to have decreased bone density.
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Fig. 1: X-rays of the left foot demonstrate significant HAV with cystic changes to the metatarsal head. The lesser digits are contracted and dorsally subluxed at the MTPJ. |
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Fig. 2: Clinical view of left foot demonstrates significant HAV deformity which is track-bound and limited in dorsiflexion. The lessor digits demonstrate fixed contractures. A painful plantar lesion is also visualized. |
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Fig. 3: Plantar view of left foot demonstrates significant painful hyperkeratotic lesions as well as significant HAV deformity to the left foot. |
Considering the radiographs presented, history, and physical exam, how would you proceed with this case? Please Reply with your thoughts and perspectives and we will share them in a future RI.
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