Case Study On Pathophysiology Essay

Question:

Discuss about the Case study on Pathophysiology .

Answer:

Background

The symptoms reported in the case study indicates that the patients is suffering from Plantar plate Tearing. Planter plate tear is a common problem occurred in forefoot and can be associated with Neuroma. This can be occurred due to lack of attention (Baravarian, Thomson, Nazarian, 2011). The injuries occurred in foot area can be considered as damage of supporting ligament of a toe. It includes inflammation, reduction of strength in that particular area, and rupture, Crossover in second most toe deformation. Women are older than 50 years affected more by plantar plate tear. This can be caused by excessive pressure on second metatarsal by using footwear like high heeled shoes which caused peak pressure on second most metatarsal, footwear like flocks caused excessive sweat which causes skin infection. Sometimes, patient feels tearing sensation and feel like walking on stones. Plantar plate is a ligament like structure provides strength to joints of metatarsal when there is excessive pressure occurred on that area it results plantar plate tearing and further caused low stability and dysfunction in planter plate (Camasta, 2015). It can be diagnosed by analysing symptoms like pain and instability occurred in metatarsal area, swelling on metatarsophalangeal joints and skin infection. Some physical diagnosis methods can be used are: X-rays, MRI

Case study Information

Subjective history (initial assessment)

  • The initial information provided in case study stated that the patient is a theatre nurse
  • Suffering from burning pain in left second metatarsal region from 12 weeks.
  • She is an old age women with body mass index of 28 kg/m2.
  • Goes to gym three times per week and wears clogs for work.
  • Reported to feel pain every day after work and stated that it feels like walking in stones.
  • Used to do gardening in free time.
  • Has a history of HAV and Diabetes type two.
  • She is taking Metformin medicine to control BGL.
  • No vascular complication.
  • Having no pain in first metatarsophalangeal joints. The picture of left foot of patient showed inflammation near first toe, dislocation of second toe towards first toe and skin infection can be seen.

Objective history (findings)

  • Most of the symptoms that are reported in initial case study are similar as symptoms occur in plantar plate tear.
  • Faulty structure of foot like hammertoe is examined in picture
  • Swelling in left foot near first toe which is also called bunion
  • Second toe is floating and little bit upward.
  • First toe is leaning toward second toe
  • Fungal infection and calluses can be seen on base of the foot.
  • Swelling on the base of foot and because of this toe is floating

Planter plate Tear

Plantar plate is the disruption of plantar plate of foot occurs at distal lateral border of the plantar plate. A plantar plate is a ligament that is situated on the underside of the metatarsal phalangeal joints ay the ball of the foot (Pogo Physio, 2017). It is mostly occurs in women’s of middle age and causing persistent pain and swelling in that area. It is associated with bunion and hammer toe. It can be categorized as Acute and Chronic. If it is not treated in acute stage may reach to chronic and cause worse painful situation.

Grading

Grade

Variables

Description

0

Alignment

The is no deformity

Physical analysis

Swelling of MTPJ, pain

1

Alignment

Some misalignment, medial toe deviation, transverse distal tears (TDT) <50%

Physical analysis

Pain, swelling,

2

Alignment

Moderate misalignment, TDT 50 to 100%

Physical analysis

Pain reduction of swelling,

3

Alignment

Severe misalignment, overlapping toes, flexible hammertoe,

Physical analysis

Pain, little swelling, dislocated MTPJ, hammertoe

4

Alignment

Severe deformity, dorsal toe dislocation, fixed hammertoe

Physical analysis

Pain, dislocated MTPJ, hammertoe fixed

Epidemiology

  • Problem related to plantar plate is an important public health disorder
  • It is the most common cause of foot pain in patients
  • Nearly ten per cent of the total populations probably suffering foot pain
  • Among all the fracture treated n primary care, around 12 % are related to second metatarsal
  • Problems occur in metatarsal bones accounts for 3.7% of all sports injuries.
  • Around 20% athletes suffered with metatarsal injuries once in a life.
  • The second toe deformity was originally described in 1987.since than great number of patients has been diagnosed with this faulty foot problem.

Risk factors

  • Age
  • Sex
  • BMI
  • WEIGHT
  • Footwear
  • Unusual Walk Or Foot Position
  • Heavy Weight Exercises

Differential diagnosis

Differential diagnosis in plantar plate tear includes Morton’s neuroma, capsulitis, stress fracture, flexor tendinopathy and avascular necrosis.

Diagnosis

Symptoms

Footwear

BMI

Risk factor

Morton’s neuroma

Feeling of standing on pebble, burning pain, tingling in toes

Yes

No

(Pearl, 2016)

Age, mostly women’s, Any tight fitting shoe causes stress on foot, sports, foot deformities (DoveMed, 2018)

Capsulitis

Pain on ball of foot, Swelling in pain area and base of toe, Difficulty in wearing footwear , pain when walking

Yes

Yes

(Tighe & Oakley, 2008)

Gardening, climbing ladder, wearing non supportive footwear, playing sports, some medical conditions like Rheumatoid arthritis, Osteoarthritis

Stress fracture

Pain, swelling, tenderness, bruising ( Mayoclinic, 2015)

Yes

Yes

Age, mostly women’s, race, alcohol and tobacco use Certain sports.

Flexor Tendinopathy

Stiffness, swelling, weakness, tenderness

Yes

Yes (Castro, Skare, Nassif, Sakuma, & Barros, 2016))

Age, gender, Acute injury, fallen arches.

Avascular necrosis

Joint pain, redness and swelling on toe area, stiffness

No

Yes

Age between 20 -50, Injury, pancreatitis, radiation treatment, alcohol use

Plantar plate tear

Pain, swelling, skin infection, feels like pebbles in shoe

Yes

Yes

(McAlister & Hyer, 2013)s

Age, overweight, diabetes, certain exercise

Assessment

Physical examination

  • The patient is complaining of pain on the dorsal and plantar area of MTPJ, and describes pain as walking on pebbles.
  • Weight bearing activities increasing pain, specially walking, exercise etc.
  • Bunion and inflammations on first toe
  • Swelling on the base of the foot
  • Patient complaint pain in second metatarsal and no pain in first metatarsal.
  • Elevation of first toe toward second toe and second toe is floating

The physical examination of patient indicates that the patient is suffering from 8/10 pain and the symptoms are found to be more similar to plantar plate symptoms. Further diagnostic tests are done to make sure whether the situations are planter plate tear or not.

Figure 1. The exact location of stretch or tear in second metatarsal. (Brindabella Podiatry, 2015)

Lachmans Test

It is the most valuable test to determine instability in second metatarsal of toe also called dorsal drawer test described by Thompson and Hamilton. The head of the metatarsal is stabilizing with one hand and the proximal phalanx is stabilizing with other hand, vertical force is applied to examine if there is any pain and translocation.

Scoring system for Lachman’s test

Stages

Description

Stage 0

There is no dorsal translocation present of the proximal phalanx.

Stage 1

The bases of the phalanx, will not dislocate, however may sub lux.

Stage 2

Flexible dislocation can be found on the base of the phalanx.

Stage 3

Fixed dislocation is found in phalanx base and first toe.

Result - The patient is diagnosed with stage 3.

Imaging

Arthrogram and MRI is used to diagnose plantar plate tear. Arhtogram is very helpful to determine the integrity of the ligament structure surrounding the joint. A needle is injected into the joints and radiography dye is injected to see if any fluid leaks out. MRI of foot allows direct visualization of plantar plate. Joint alignment is viewed by using x rays.

Radiographic criteria for instability

  • Lack of concentration of joint.
  • Lateral or medial deviation of proximal phalanx >5 degree.
  • Clawing on lateral radiograph.

Patient is also gone through MRI and Arhtogram test of second MTPJ. Plantar plate and collateral ligament tears diagnosed.

Management or intervention in planter plate tear

Planter plate tear can be diagnosed by analysing the symptoms and complications occurred in foot are, by X-rays, magnetic resonance imaging (MRI) and arthrogram.

Non operative Interventions

Divide according to the type of injury. Like acute and chronic injury. Acute injury is examined by surgeon to determine if surgery is necessary or not. If the surgery is not essential than the toe will be taped and splinted to get it heal. Some of the cases required casting and crutches if the symptoms occurred more than 8 weeks before.

Simple interventions

  • wear footwear that are supportive to the foot , avoid using high heels
  • arch support will be effective
  • shoes with wide toe box should be used
  • periodic callus care should be considered

Footwear modification

Footwear like high heels and flexible minimalist shoes tends to increase risk of plantar plate injury. Some of the other footwear like open toe shoe and flip flops also associated with this problem. Risk of developing the problem will be reduces after using recommended shoes, the patients is using clogs that are causing skin infection on foot. By avowing these shoes the infection will also be reduced. According to Moore (2018) a long, softer shoe can reduce the direct and indirect stress on second metatarsal.

Anti- inflammatory medicine

As patient reports inflammation on the first toe area it is essential to reduce it for relief. Anti-inflammatory like aspirin, ibuprofen and naproxen will be prescribed in this case. Anti-inflammatory medicines are helpful to decrease the inflammation and relief pain in affected area (Frank, 2015).

Stretching/ strengthening

Applying stretching on foot muscle that are tight and lack of strength. To provide strength and flexibility to the muscles. Daily strengthening and stretching workouts helps to treat plantar plate tear (Bishop, 2017).

Icing

By applying ice directly on affected area of foot. Icing is the oldest methods to treat musculoskeletal injuries. It can reduce inflammation, swelling and pain (Camasta, 2015).

Orthoses

It is an artificial external device used to support foot; a metatarsal dome is proximal to the second metatarsal head with extension and cur out around the MTPJ area. It is helpful to offload plantar plate while walking (Goom, 2017).

Operative management

Most of the injuries treat through no operative methods it not treated with these methods than surgeries applied to them are for instant relief form the painful situation there are two types of surgeries:

Plantar plate tear surgery

In this method the surgery is applied to the affected area to repair plantar plate tear. It directly treats or repair plantar plate. It is totally depends on time of injury reason of tear and the physical structure of the foot

Surgery assisted in earlier problem

This is also called primary repair to the metatarsal and it is done by directly apply a cut on the skin and the displaced parts treated, is some of the cases plastic surgery is applied.

Chronic surgery to treat plantar plate

Planter plate tear needed to be examined before doing chronic surgery it is also called secondary surgery. It is applied in chronic cases where the pain is not treated with primary treatments. It is especially assisted in the case of dislocated toe or hammer toe.

Health outcome measure

Foot and Ankle Ability Measure

Foot and Ankle Ability Measure (FAAM) have been used to analyse the current condition of foot. It contain twenty one questionnaires related to difficulty in walking, standing Squatting, personal care, heavy work, daily lining activities. Score has been categorized as no difficulty, slight, moderate, extreme difficulty and unable to do and not applicable. And at the end they asked to give percentage related to their level of functioning during usual activities (Martin, Irrgang, Burdett, Conti, & VanSwearingen, 2005).

Before the treatment patients scored 62/100 that revealed patient had difficulty to do normal daily work. After using Supportive pads, recommended shoes, applying ice and doing stretching. Patient again asked to fill the FAAM questionnaire and she scores 95/100. That means the treatment were successful.

Pain examination

VAS (Visual Analogue Scale) is a measurement instrument. It is used to evaluate the pain intensity. It is usually a horizontal line, 100 mm in length labelled with word description at both end as 0 to 10. Zero means no pain and 10 means extreme pain. This was applied to the patient before the treatment and the score reported was 8, which indicated severe pain. After treatment patient scored 0-3 which means the intervention provided to the patients were appropriate and effective (Wewers and lowe, 1990).

For self-reported satisfaction patient has been asked to answer about their satisfactions and efficacy of the treatment on the scale of 0 to 4. Zero means unsatisfied and 4 means very satisfied. It was found that patient was satisfied with the services provided to her.

References

Baravarian, B., Thompson, J., & Nazarian, D. (2011). Plantar plate tears: A review of the modified flexor tendon transfer repair for stabilization. Clinics in podiatric medicine & surgery, 28(1), 57-68.

Bishop, B. (2017). Plantar plate (ball of foot) pain. Retrieved from:

Brindabella podiatry (2015). Plantar plate injury. Retrieved from:

Camasta, C. A. (2015). Emerging concepts in plantar plate repair. Podiatry today, 28(2). 32-42.

Castro, A. D. A. E., Skare, T. L., Nassif, P. A. N., Sakuma, A. K., & Barros, W. H. (2016). Tendinopathy and obesity. Scielo analytics, 29(1),107-110.

DoveMed (2018). Morton’s Neuroma. Retrieved from:

Frank, C. (2015). Plantar plate rupture. Retrieved from:

Goom, T. (2017). Plantar plate injury, assessment and management. Retrieved from:

Martin, R., Irrgang, J., Burdett, R., Conti, S., & VanSwearingen, S. (2005). Evidence of validity for the foor and ankle ability measure. Foot and ankle internastional, 26(11). 968-983.

Mayoclinic (2015). Stress fracture. Retrieved from:

McAlister, J. E., & Hyer, C. F. (2013). The direct plantar plate repair technique. Foot & ankle specialist, 6(6), 446-451.

Moore (20100. Plantar plate tears injuries: New surgical procedures. Retrieved from:

Pearl, J. (2016). Contributing factors leading to Morton’s neuroma. Retrieved from:

Pogo Physio (2010). What is a plantar plate tear and what is the treatment?. Retrieved from:

Tighe, C. B., & Oakley, J. W. (2008). The prevalence of a diabetic condition and adhesive capsulitis of the shoulder. Southern medical journal, 101(6), 591-595.

Wewers, M. E. & Lowe, N. K. (1990). A critical review of visual analogue scales in the measurement of clinical phenomena. Research in Nursing and Health 13, 227-236

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