Foot/Lower Limb Pain

[benhughes]

Hello, I am a recent physio grad from Uk and like most am struggling for any experience, this was until my dad constantly complained of foot and lower limb pain so I thought bonus Ill keep up my assessment and management skills here! However not having much knowledge of disorders of the lower limb/feet, I am struggling to diagnose the cause of the pain much to my embarrassment and I therefore need some help if possible from you more experienced physios!!

PC - 50 year old, no history of any trauma. Right foot ‘burning’ pain very localised on plantar surface around head of 1st metatarsal (sesamoids?) and more recently anteromedial pain up to about ¾ the way up the lower leg. C/o ‘burning’ sensation especially on head of R 1st metatarsal and planages. No numbness or altered sensation. He’s recently changed job (approx 3 months ago) which is around the time of onset, job is predominantly office based but he has to drive 2 hours each way. Aggravating factors include pressing accelerator while driving for more than ½ hour and easing factors include wearing new boots with higher instep inside. No difference between morning/night.

Observation – fair loss of longitudinal arches/pes planus foot pattern
?Poor circulation – dry skin and ‘cold’ to palpate

No pain/stiffness on AROM or PROM and these were all full with no restricted movements in any direction. Muscle strength Gd 5 and L=R. Performed quick assessment of knees, hips and lumbar spine but indicated nothing.

Hypothesis – Plantar Fasciitis – due to possibly overuse injury

However, this does not explain the anteromedial pain ¾ of the way up the lower limb and also the pain on the foot is very localised and Im at odds to explain this.

So far, I have suggested seeing the doctor for anti-inflammatories and purchasing insoles for every pair of shoes. However I am reluctant to manually treat (i.e frictions etc) until im sure what the diagnosis is so sorry for the long winded patient assessment but hope someone out there may offer some explainations especially concerning the anteromedial lower limb pain.

Thanks!!

[sdkashif]

Your assessment findings indicates that pain is most probably due to the pes planus. If you have doubt about the plantar fasciitis, please check the tenderness on heel especially at the plantar spur site.i.e. attachment of plantar fascia at heel. Please, remember any painful condition of foot gives rise to pain in the leg. However, the differential diagnosis of leg may be :

Leg Pain:

Osteitis or other infections
Bone tumour
Stress Tibia fracture
Brodie 's abscess
Anterior Comartment syndrome
Shin Splints
PID and spinal Stenosis
Vascular insufficiency
Thrombopholibitis
Paget's disease
Ruptures plantaris tendon
Painful conditions of foot
Syphilis

Foot Pain:

Plantar Fasciitis
Flat Foot
Plantar Neuroma
Anterior Metatarsalgia
Kohler's disease
Cuneiform exostosis
Tight shoes and stockings
March fracture
Freiberg's disease
Pes cavus
Verruca Pedis
Bunion
Hallux valgus and regidis
Osteoarthritis
Rheumatoid arthritis
Gout
Tarsal tunnel syndrome
Plantar Neuroma

However, if the problem is pes planus, use foot insole, strengthening exercise for foot intrinsic muscles and stretching exercises for tight muscles around lower leg especially calf muscles.

[alophysio]

Hmm,

Would pes planus make driving painful?

I am going to go out on a limb and ask you to assess his L/S particularly his L5/S1 segment. No numbness or altered sensation yet he has "burning pain"...

I note that referred pain is not in your lists sdkashif. But it is possible...The pes planus can change the way the pelvis and L/S relate and aggravate the pain...

Good luck

[sdkashif]

I do agree that referred pain from lumbosacral pathology could be the cause but as you note from his examination findings that hips, knees and lumar spine was normal or unremarkable. So any possiblity with lower leg or foot problems could be there.

[alophysio]

Hmm, I missed that on the first read - I should be more careful.

That said, benhughes, what about neuro examination? The various versions of the SLR to test different nerve branches?

Just remember that "a prophet is without honour in his home town" - it was always going to be hard to treat family! I always get one of my staff to treat my family, it always seem they get better with them than me!

Thanks

[benhughes]

Thanks for the ideas everyone, I think you are right I should just get him seen by someone else!! But Ill have a closer look at his L5/S1 jt and look closer at foot intrinsic musculature and maybe give exercises for that as well when I can get 5mins spare with him!

Thanks everyone again!