51M with Foot Drop, Loss of Sensation and Swelling in Left Foot

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NOTE: THIS IS AN ONLINE E LOGBOOK TO DISCUSS OUR PATIENT'S DE-IDENTIFIED HEALTH DATA SHARED AFTER TAKING HIS/HER GUARDIAN'S SIGNED INFORMED CONSENT. HERE WE DISCUSS OUR INDIVIDUAL PATIENT'S PROBLEMS THROUGH A SERIES OF INPUTS FROM THE AVAILABLE GLOBAL ONLINE COMMUNITY OF EXPERTS INTENDING TO SOLVE THOSE CLINICAL PROBLEMS WITH COLLECTIVE CURRENT BEST EVIDENCE-BASED INPUT.


A 51M, a farmer by occupation, complains of: 
  • Loss of pain sensation and swelling in his left foot since 3 years, 
  • Ulcer on dorsum of little finger of left foot since 11 months.
  • Tingling sensation in his sole of left foot


HISTORY OF PRESENTING ILLNESS:

The patient was apparently asymptomatic 21 years back

In 2019, the patient sprained his little toe (left foot) on a morning walk and noticed swelling. An x-ray showed joint displacement and he was recommended surgery. Since he couldn't afford surgery, he was given medications to decrease the pain. He went to a different doctor who prescribed different medications. 4 months later, the gap filled up.

Few days later, he started experiencing tingling sensation in his left foot. He tried physiotherapy, but there was no improvement. He visited a neurologist, got an MRI done, which showed nerve compression. This later progressed to foot drop. He was advised to use Vit D tablets and a special shoe made of hard plastic.

Few weeks later, he lost all pain sensation in left foot (4 inches above ankle to toe). He noticed this at the following incidences:
  1. Nail peeled while working in the field
  2. Burn injury to foot
  3. Shoe (made of hard plastic) caused skin to peel 
He can walk for 1-2km without any issue, but faces difficulty walking on uneven land.


In 2021 Nov, he noticed a crack on the sole of his left leg which he ignored. This used to get exposed to mud and water every day. He noticed that the crack was getting deeper and opening up. Around March, he went to the doctor, who prescribed him an ointment. After 3 months of using it, the crack did not heal completely. He then started using Lizoforce and A-Z tablet, after which he says it healed almost 95%. 

He still experiences a tingling sensation in his left sole around 2-3 days every week. It lasts for 2-3 hrs if he is resting and only 5-10 mins if he is walking.


HISTORY OF PAST ILLNESS:

26 years ago, the patient's left ankle got caught in a ditch. There was immediate swelling and pain which were relieved on taking medication

4 years later (22 years ago), the patient injured his left foot while playing football. There was swelling and pain which were relieved on taking medication.


FAMILY HISTORY:

Father - experienced a similar tingling sensation in his foot. 
            - There was no issue with walking.
            - Passed at 70

Elder brother - experienced a similar tingling sensation. 
                         - There was no issue with walking.
                         - 1 MI incident

Mother - Smoker
              - SOB
              - Passed at 65


PATIENTS TAKE ON PaJR:

Patient believes that PaJr was very helpful for him to track health reports and treatment. He joined recently so he feels it was better meeting the doctor offline too.



DRUG HISTORY:

The patient is currently taking 


PREVIOUS INVESTIGATIONS:

6 months ago 





PREVIOUS IMAGING:

X-Ray- Foot

3 years ago



MRI - 6 MONTHS AGO 






GENERAL EXAMINATION:

The patient is conscious coherent, oriented to time place and person. 

The patient is well built and well nourished. 

Absence of pallor icterus cyanosis clubbing koilonychia lymphadenopathy and edema. 






Swelling- 



Ulcer 



CNS examination : 

The patient is conscious , coherent, oriented to time place and person . 

Cranial nerve examination- normal 

Sensory nervous system - 
Absent of all sensations in left foot upto the ankle joint . 

Right lower limb sensations normal 


Motor system 
                    Right , left 
Triceps.      Present , present 
Biceps.        Present , Present 
Brachioradial Present, Present 
Knee joint.   Present , Present 
Ankle joint  Present , Present 


Equine gait 
 



Day 1 investigations 





Orthopedic consult 






Day 2 Investigations 





Nerve conduction studies 



 

HARD PLASTIC SHOE:





DISCUSSION:

[9/12, 7:00 PM] Dr. Rakesh Biswas General Med: Well done @⁨Rishika KIMS⁩ 👏👏 Please upload today's twist in the case where the neural ultrasound is suggesting a neural sheath tumor. 

[9/14, 8:18 AM] +91 94933 40818: https://jnnp.bmj.com/content/76/suppl_2/ii23. This is one article on NCS with beautiful description sir. Almost read 75% mostly will complete in 30 min sir

[9/14, 8:24 AM] Dr. Rakesh Biswas General Med: 👍Will be looking forward to your sharing the relevant portions with particular focus on this patient. 

[9/14, 9:56 AM] Dr. Rakesh Biswas General Med: Good. In the diagnosis you need to mention the involved nerve and the fact that it is a mono neuropathy

[9/14, 9:58 AM] Dr. Rakesh Biswas General Med: Check out the video of another mononeuropathy published by our elective students long back here 👇https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4785487/

[9/14, 10:35 AM] Dr. Rakesh Biswas General Med: Are you sure it's common peroneal and not distal to that? The patient's clinical signs suggest he has got good power in calf muscles as well as sensation over it's dermatome? Which nerve supplies there? And which nerve supplies till the dorsum which is the most affected?

[9/14, 11:41 AM] Riya KIMS: Sir the calf muscles are being supplied by the tibial nerve and the patient is able to plantarflex. The major part of the sensory supply of dorsum is supplied by the superficial peroneal nerve ( branch of common peroneal) . The sensory supply of the foot also involve other nerves like Sural nerve , Saphenous nerve and distal branches of the Tibial nerve in the plantar aspect .He is not able to dorsiflex due to the involvement of the deep peroneal nerves .

[9/14, 11:42 AM] Riya KIMS: Sir since there is no sensation in the entirety of the foot , could this be a polyneuropathy ?

[9/14, 11:42 AM] Rishika KIMS: https://www.ncbi.nlm.nih.gov/mesh/68020427

Peroneal Neuropathies

Disease involving the common PERONEAL NERVE or its branches, the deep and superficial peroneal nerves. Lesions of the deep peroneal nerve are associated with PARALYSIS of dorsiflexion of the ankle and toes and loss of sensation from the web space between the first and second toe. Lesions of the superficial peroneal nerve result in weakness or paralysis of the peroneal muscles (which evert the foot) and loss of sensation over the dorsal and lateral surface of the leg.

[9/14, 11:42 AM] Rishika KIMS: Tibial Neuropathy

Clinical features include PARALYSIS of plantar flexion, ankle inversion and toe flexion as well as loss of sensation over the sole of the foot. (From Joynt, Clinical Neurology, 1995, Ch51, p32)

Year introduced: 2000

https://www.ncbi.nlm.nih.gov/mesh/68020429

[9/14, 11:45 AM] Rishika KIMS: Yes sir

[9/14, 11:47 AM] Rishika KIMS: Suggestive of deep peroneal nerve involvement -

-Absence of dorsiflexion 

-loss of sensation in first web space 

Suggestive of tibial involvement-

Loss of sensation over sole of foot

[9/14, 8:53 PM] Dr. Rakesh Biswas General Med: Thanks. Well analyzed both of you 👏

So do we have the findings in this particular patient that we have now reviewed in terms of general knowledge? 

We know our patient has findings of PARALYSIS of dorsiflexion in his ankle and toes and loss of sensation from the web space between the first and second toe suggestive of deep peroneal? 

But have we checked for paralysis of the peroneal muscles (which evert the foot) and loss of sensation over the dorsal and lateral surface of the leg that would also suggest superficial peroneal nerve? 

I guess his tibial nerve is intact? 

So now we come to the question of nomenclature. When would we call it mononeuropathy? What if the entire sciatic nerve is involved? Will that still be a mononeuropathy or polyneuropathy?


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