Reproduced by Sabinet Gateway under licence granted by the Publisher (dated 2012)
C L I N I C A L CASE R E V I E W
MANAGEMENT PROBLEMS IN GENERAL PRACTICE
A 50-year-old woman with
a swollen, tender foot
Clinical problem
We present here a clinical
problem encountered in general practice together with a
commentary from an expert in
the field. If you meet an interesting or puzzling case you.
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Commentary
•
In a d d r e s s i n g a p r e s u m a b l y
menopausal woman with a history
such as this, one would need to
consider osteoporosis, diabetic
neuropathy, gout and the most
likely cause — a sprain of mildly
osteoarthritic t a r s o m e t a t a r s a l
joints. The X-ray could well show
no sign of such arthritic changes,
A technetium bone scan woiild
reveal microfractures in the midfoot if the injury was due to osteoporosis, or occiilt fractures associated with midtarsal disruption if
due to neuropathy. Possibly, the
localized periarticular changes of
gout or early tarsal osteoarthritis
would be seen.
A uric acid test and, if indicated,
a 24-hour urine test would eliminate the possibility of gout if there
was a suspicion of this condition.
U!"inalysis and possibly a random
blood sugar analysis would confirm or exclude a diagnosis of late
Commentary by Professor Edward Bates,
MB BS, FRCS, FRACS, associate
professor of paediatric orthopaedics.
University of New South Waies, and
Chairman, department of paediatric
surgery. Prince of Waies Chiidren's
Hospital, Sydney, New South Wales,
Australia. This article was written specially
A 50-year-old w o m a n presents with a swollen, tender foot.
Her foot h a s b e e n this w a y for around six w e e k s since s h e
s t u b b e d h e r t o e . At n o t i m e h a s t h e d i s c o m f o r t b e e n
f o c u s e d in t h e toe; rather it is in t h e m i d d l e of t h e foot
over all five metatarsals. No abnormality is f o u n d o n Xray but there is a definite swelling w h i c h is improved by
resting the foot. Is this related to the initial injury? H o w
should this condition be treated?
onset diabetes, although most
cases of neuropathic feet do not
present acutely and have a fairly
gradual onset of symptoms.
All of these conditions would be
associated with swelling and tenderness. Disuse and dependency
would aggravate this swelling.
If the medical alternatives to
simple midfoot sprain have been
excluded, traumatic aggravation of
subclinical osteoarthritic joints
would be the most Kkely and certainly the most common cause of
this not uncommon, but rather
vague, clinical scenario.
Treatment at six weeks shoiild
comprise analgesics, probably slow
release NSAIDs and/or paracetamol, in conjunction with elevation
and compression bandaging of the
foot and a physical therapy programme to restore strength and
mobility. A moulded sponge-rubber inner sole with medial arch
support might provide symptomatic relief
This condition is related to the
stubbing of her toe. I do not feel
that the ubiquitous reflex sympathetic dystrophy syndrome shoiild
be considered in this clinical context. •
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for MODERN MEDICINE.
6 2 IVIODERN MEDICINE OF SOUTH AFRICA / AUGUST 1996
Reproduced by Sabinet Gateway under licence granted by the Publisher (dated 2012)
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