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Podiatry

• Foot surgery to remove benign tendon shealth tumor results in chronic pain syndrome.
  
  
• Metatarsal (foot long bone) fracture, chronic pain syndrome, and then ankle pain with a bone cyst discovered.

Foot surgery to remove benign tendon shealth tumor results in chronic pain syndrome.

At age 17 this patient had a painful small lump on the bottom of her left foot. The pain had become worse after she had a foot massage by her boyfriend.

She saw a Podiatrist who recommended treatment by injecting an anti-inflammatory (steroid) medication, but she preferred surgery. He had her sign a very detailed consent form that warned her of many risks including a worsening of her condition, and even death.

Surgery took place in his office under local anesthesia, and he described removing a 1-centimeter (2/5-inch) nodule through a one inch incision on her foot. The Pathologist confirmed the 1-centimeter lump (in pieces) of fibrous flesh (fibroma) of the tendon sheath (covering).

She received crutches and proper office care. The operative site healed without infection. Her pain initially persisted for three weeks, and they urged her to limit weight bearing. By six weeks she was "doing well, minimal swelling. She's still wearing her surgical shoe, it feels more comfortable. The wound is healing nicely. There's some swelling and some mild tenderness, but overall seems to be improving nicely. I'm going to go ahead and dismiss her. She may return to shoes and activity to tolerance. To return if she has any further problems."

By five months after surgery she developed much more pain, and temperature changes in her foot and when she saw a physician specializing in rehabilitation medicine, his impression was: "Possible early left foot reflex sympathetic dystrophy." And he said: "I believe this patient will improve and not require additional intervention."

Reflex sympathetic dystrophy is a bizarre reaction of the "sympathetic nervous system" to any injury or correctly performed operation, which she had. Fortunately she did not need the lumbar sympathetic block (deep needle into the sympathetic nerves next to her aorta and iliac arteries), or an implantable spinal nerve stimulator.

Based on all of the above, she accepted the operation instead of a local injection of steroid medications, had correctly performed surgery that healed, but resulted in her reflex sympathetic dystrophy painful condition.

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Metatarsal (foot long bone) fracture, chronic pain syndrome, and then ankle pain with a bone cyst discovered.

At age 36, on 8/18, this patient had a heavy steel flywheel fall on her right foot. It caused a nondisplaced fracture of the distal (near the toes) area of her second metatarsal (long midfoot) bone. This was not at all near her ankle, and all the examinations by different physicians noted point tenderness at only that site.

She was seen in the emergency room, examined, x-rayed, and treated conservatively, since these injuries usually heal uneventfully without weightbearing. She received crutches and correct instructions for ice and elevation.

Her physician, Dr. #1, followed up, and repeat x-rays on 8/20 were unchanged showing "faint visualization of a nondisplaced fracture involving the distal shaft of the second metatarsal bone." This is excellent alignment and an optimum chance for total healing.

She was referred to an Orthopedic group and came under the care of a Podiatrist, Dr. #2, on 8/25. He prescribed an Equilizer cam walker, and subsequently a cast. On 11/3, the x-ray revealed a fracture line, therefore healing was still incomplete. By mid-November she had episodes of severe pain and color change. This is consistent with reflex sympathetic dystrophy (RSD), a chronic pain syndrome which can be caused by any injury or surgery and occurs unpredictably, and is not from negligent care. Initially it disappeared on its own and nothing further had to be done at that time.

Because of a delay in healing of the fracture (delayed union), Dr. #2 prescribed an electrical (EBI) bone stimulator to aid healing. Again, good care.

Because (on 1/26) her foot pain had increased: "She has global symptoms throughout the entire foot and ankle. She also states at times the foot becomes very red with color changes." Dr. #2 promptly referred her to Dr. #3, a Pain Management Specialist, to "rule out RSD." This, again, is excellent care.

Dr. #3 saw her on 2/3 and noted: "She continues to complain of pain which is situated on the dorsum (top) of the foot. Mainly between the second and third toe." The physical examination noted the pain at only that site. And he injected it with a local anesthetic and cortisone (steroid anti-inflammatory medication), again, standard good care. He also prescribed nortriptyline, an antidepressant often tried for RSD pain relief.

On 3/3, she noted the previous injection had been helpful, so Dr. #3 re-injected again.

X-rays on 7/13 showed the fracture had healed.

A bone scan on 7/23, using radioactive "dye," revealed activity at the second metatarsal bone, and her right ankle and big toe joint at the foot.

On 7/25/99, Dr. #2 noted: "She has some discomfort over the second / third metatarsal region. No specific pain emanating from the ankle or talus. Relatively good motion of the joints." The bone stimulator was continued. All this is good care.

She missed the 10/21 appointment.

On 9/28, she saw Dr. #4, an Orthopedic Surgeon who reviewed her foot medical history and noted: "She has some tenderness over the anterior ankle and a little tenderness over the base of the first and second metatarsals but exquisite tenderness on pressure over the distal third of the second and third metatarsals. He obtained x-rays of her ankle (because of some ankle pain) and noted: "The x-rays of the ankle demonstrate that she has a fracture of the dome of the talus (foot bone near the heel/ankle joint) along the medial (inner) margin, which is nonhealed with an in situ body like an osteochondritis dessecans (a bone cyst from growth, not the flywheel crushing the distal second metatarsal bone), and I am sure this is causing some of the symptoms in her ankle." A CAT scan on 10/12 revealed "An osteochondral (bone and cartilage) lesion is identified involving the medial talar dome which measures 7 mm (one-third inch) in transverse dimensions and 3 mm in depth. At least two small ossific (bone) fragments are identified." There was no fracture.

On 11/15, Dr. #4 performed arthroscopic surgery and removed the loose piece of cartilage, scraped out this bone cyst cavity, and drilled into normal bone to allow it to heal and fill in over time. With time and physical therapy she had full range of ankle motion and 70% of bone filling in that cavity.

Her distal second metatarsal fracture was properly treated by all her physicians, including the Podiatrist. She had an unusually severe pain syndrome (RSD) which was treated and fortunately resolved. Sometimes the chronic pain becomes so severe that patients demand amputation. After the fracture had healed (aided by the bone stimulator), another doctor noted "some tenderness over the ankle," obtained an x-ray of her ankle (not previously indicated), and found the bone cyst. She rushed into surgery rather than extensive physical therapy to aid of ankle motion, stiff from prolonged immobilization from her painful and delayed metatarsal fracture healing. That was her option, but in no way does that make her Podiatrist negligent for his excellent care of her problematic second metatarsal fracture.

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