Foot Pain Disasters

Thu, 04/08/2021 - 6:00am
Author: 
Karen O'Brien, DO
Editor: 
John Cafaro MD

Case 1 

  • 52 yo F bilateral foot and leg pain for 1 day, worse with walking, no numbness, weakness, skin/color/temperature change 
    • Vital signs normal 
    • Differential: DVT vs. superficial thrombophlebitis vs. Cellulitis vs. MSK pain (diagnosis of exclusion)
    • Normal ESR, CRP, CBC, BMP, Coagulation Panel
    • Duplex ordered at triage, no DVT 
    • Discharged with NSAIDs and PCP follow up 
  • One Month Later: returrns with right foot pain worse and became discolored over past 3-4 days 
    • +Paresthesias 
    • Cool, purple 
    • Vascular emergency at this point: Acute Limb Ischemia!  
  • She had a complete anterior tibial artery occlusion and was emergently taken to the OR à revascularized but still ended up with amputation 

Pearls from Case 1:

  • 6 Ps:
    • Pain
    • Pulselessness (late)
    • Pallor
    • Paresthesia
    • Poikilothermia
    • Paralysis 
  • Claudication  
  • Compare both feet! 
  • Pain at rest is concerning  
  • Presence of a pulse does NOT mean there’s not acute limb ischemia 
    • Stage I of ALI = you have an audible pulse by Doppler!

Case 2:

  • 50y F RLE pain x 3hrs, hx of previous DVT 
    • Vitals normal, no calf tenderness or edema, normal ROM, no skin changes 
    • US Duplex = negative for DVT 
  • 48 hours later 
    • R foot pain x 2 weeks worse when walking on it 
    • Limited dorsi and plantarflexion secondary to pain, no calf tenderness, skin warm dry no skin changes 
    • Given muscle relaxant and post op shoe 
    • Diagnosed with Plantar fasciitis 
  • 24 hours later presented to another hospital…  
    • Blue foot 
    • Dx via CTA with tibioperoneal trunk occlusion 
    • Management: Thrombectomy, fasciotomy, eventually amputation  

Pearls from Case 2:

  • 2 types of ALI with two different presentations 
    • Embolic = acute severe cold pale foot can be otherwise healthy pt 
    • Thrombotic = usually has comorbidities such as HLD DM CAD smoker 
      • These patients have developed collaterals so not as obvious/acute in onset à can develop over hours or weeks 
    • Often only present with pain 
    • Easy to miss 

Algorithm:

  • "Other Stuff" refers to ABI
    • > 0.9 is normal
    • < 0.4 is "chilly flipper"
    • Between 0.4 and 0.9 should prompt arterial US with toe pressures vs. CTA & a consult to Vascular Surgery