Teenage boy presents with painful ingrowing toenail for 4 months
Richard has had two courses of antibiotics. Not able to wear closed-in shoes. Presents with an inflamed big toe. There is a tendency to bleed from this area. On examination, the nail is clearly deep within the side of the toe and very painful to pressure. Although it is sometimes possible to simply cut back the nail and allow the area to settle, it was necessary to remove the nail edge under local anaesthetic and apply a chemical to prevent regrowth of this section. After the first two days, he had a redressing and then commenced with daily wound-care. He reported no discomfort following the procedure and, as he looked after the area well, it healed within 4 weeks.
Woman presents with a pain in the ball of her left foot that radiated to two toes on walking
Marianne's foot pain seemed to be aggravated by certain footwear. On assessment, symptoms presented on squeezing the forefoot and placing pressure within the toe-webbing. A diagnosis of Morton's neuroma was made and x-rays did not show any bony or joint problems. An ultrasound scan revealed a neuroma and overlying this a bursitis. This was injected with steroid and this settled her symptoms for 3 months. Unfortunately her symptoms recurred and she decided to undergo surgery. A large neuroma was excised. At 3-months' post-op, Marianne is pain-free and happy.
Woman presents with a long history of pain in big toe-joint
Mrs P was seen elsewhere and advised that she had a bunion and needed surgery which involved breaking and re-setting the bones. She came to see us for a second opinion. On assessment, the great toe was in good alignment and a bony prominence was seen over the top and to the side of the joint. An x-ray confirmed good alignment of the great toe and first metatarsal; however, degenerative changes within the great toe and the bony prominences were part of the wear-and-tear process and they were causing a bony block to movement. The main symptoms were from impingement and prominences causing discomfort in footwear. She underwent a cheilectomy procedure. This improved the big toe movement and overall she has greatly improved and has returned to normal activities. She has occasional discomfort in the joint and this is due to the degenerative changes. However, the procedure should give many more years of comfortable walking.
Man presents with pain in the ball of his foot which has been present for 6 months
Mr X has no history of injury. Pain was worse on standing following rest and also with prolonged periods of walking. He describes this as "walking on a golf-ball" with a "burning, aching pain" within the third toe-joint. A diagnosis of Morton's neuroma was made elsewhere. On assessment, swelling was noted around the third toe-joint with pain on movement. X-rays revealed erosive changes within the third toe-joint and a diagnosis of inflammatory arthropathy was made. This is now being managed by a Rheumatologist. However, the patient returned to us because of on-going pain which was greatly improved with a steroid injection to the joint and using orthotics for protection.
Man presents with a 12-month history of heel pain
Robert's pain was worse on standing following rest, eased with gentle movement only to become painful with prolonged walking. This was described as "a sharp pain" and "an aching/dull throb" under the heel area. Our assessment found that the focus of pain was on the inside heel area. Calf muscles were tight. On standing, flattening of the arches was noted but these corrected. An x-ray showed a small heel spur but no other abnormalities. A diagnosis of plantar fasciitis was made. Management included calf stretches, plantar fascia stretches, deep soft-tissue massage to the tender area, use of a night splint (made in the clinic) and off-the-shelf supportive orthotics with a heel cushion. At a later date, custom orthotics were fitted. At 6 weeks, there was a 60% improvement in symptoms. The patient continued to complain of a sharp pain on walking and this was preventing a return to running. Nicholas injected steroid to the focus of pain in the heel. After an initial 2 days of increased discomfort, his symptoms settled. He was advised to continue with the daily stretches for a further 4 weeks and then, to prevent recurrence, to carry on three times weekly and to use orthotics.
Woman presents with shin pain
Caroline presented complaining of shin pain. A keen runner she had intensified her training prior to the onset of symptoms in preparation for a triathlon. She was managed for shin splints by a physiotherapist for 3 months. Pain presented on running, mainly on impact. The pain increased in severity with exercise and then she had to stop. Over time, her symptoms also presented when walking. On assessment, the tender area is over the shin. An x-ray showed possible slight bone injury which was confirmed on the MRI scan as a small stress fracture. As she was starting to have discomfort on walking, she was placed in an Aircast boot for 4 weeks. She was advised not to return to impact for 3 months and, thereafter, to have conditioning exercises from a personal trainer and gradually return to running.
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