Case of the Week 6-3-97
from Dept. of Physical Medicine & Rehabilitation, University of Vienna
69 yo man with non-insulin dependant diabetes mellitus, complicated by pedal neuropathy and osteomyelitis in the 5th left metatarsal, requiring resection of the 5th ray and skin grafting, one year previously. Amputation of right hallux several years previously for dysvascularity.
On examination, claw toes II-IV on the left, with hallux rigidus. Ulceration noted over the site of the resected 5th ray. Ankle dorsiflexion reduced to 10° dorsiflexion bilateral, with shortened triceps surae. Subtalar range of motion also very small bilatterally. Soles anaesthetic to Semmes-Weinstein monofilament testing apart from N5.07 over the anteromedial aspects. Body weight 68.4 kg, height 1.69 m.
Technical details
Plantar pressures recorded with EMED-SF pedobarography analyser (Novell, Munich). Normal values recommended by Cavanagh: > 50 N/cm2 regarded as indication for orthotic intervention.
Right foot pedobarography
Left foot pedobarography
Summary of peak pressures
Left
127 N/cm2 (very high!) under area of resection
86 N/cm2 under 4th metatarsal head
44 N/cm2 (normal) under the hallux
Right
63 N/cm2 under 3rd metatarsal head
57 N/cm2 under 5th metatarsal head
Questions
1. What effect has the left hallux rigidus had on the plantar pressure pattern? Comment on the deviation in the centre of pressure.
2. What intervention, if any, would you recommend?
3. How important is the hallux in normal walking?
4. How reliable do you regard EMED pressure measurements?
5. What is the differential cause (biomechanical or other) of a callosity and a corns (clavus): under abnormal pressure what determines which one will develop?
6. What is the reason for the limitation in dorsiflexion frequently seen in diabetic arthropathy?
Case supplied by Dr. Andy Kopf & Andreas Kranzl, AKH-Wien.
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