51 year old male , with swelling , foot drop and loss of sensation in the left foot
CHIEF COMPLAINTS
This is the case of a 51-year-old male, farmer by occupation, who presented to the hospital today with chief complaints of
- Swelling in the left foot from the past 3 years
- Progressive loss of sensations in the left foot from 3 years
- Ulcer in the dorsum of the left foot from the past 11 months
the patient was apparently asymptomatic 25 years ago
25 years ago the patient was playing football and accidentally his left foot went into a ditch which lead to diffuse swelling in his left foot up to the ankle joint
The swelling lasted one week, it was associated with Pain and was not associated with fever, change of colour of the overlying skin or loss of body weight.
The pain associated with the swelling was continuous, localised to the left foot below the level of the ankle joint.
The patient was unable to walk, and thus visited a doctor who prescribed him medication for a week, after which the swelling and pain resolved.
3 years ago, while going for a morning walk, the patient accidentally placed the same foot into a ditch and it got twisted. Immediately after, the patient experienced swelling in the left foot, predominantly in the lateral aspect of the dorsum of the foot.
The swelling was associated with Pain and not associated with any change in body weight, fever or change in colour of the overlying skin.
The patient visited a doctor and an X-Ray of the left foot was done, which depicted a crack on the lateral aspect of the plantar of the foot. The patient was advised to undergo surgery, but he didn't and thus continued taking prescribed medication for the next nine months. The patient could walk with a limp. The swelling did not completely subside
A week later, the patient experienced a tingling sensation in the little toe which progressed medially towards the great toe and the patient was unable to flex the great toe towards the dorsum. Later the patient could not flex the foot towards the dorsum. The patient complains that while wearing his slippers, the slippers keep coming off his feet.
11 months ago, the patient developed an ulcer in the lateral aspect of the plantar of the left foot. The patient did not initially notice the ulcer as there was a loss of sensation present at the time. When the patient first noticed the ulcer, it was 1-2 cm in size, on visiting the doctor, the patient was given cadexomer iodine ointment - that did not provide any relief, later in addition to the ointment, the patient was given oral medications, which have been effective in reducing the size of the ulcer. The ulcer is still present.
Past history
The patient is not a known case of DM, HTN, TB, Asthma, epilepsy
Family History
Mother - Breathing difficulty
Father - High blood pressure
Occupation
The patient is a farmer by occupation and works in rice and jute fields.
Personal History
diet - Normal
sleep - normal
appetite - normal
Addictions: chronic smoker for the past 15 years, patient finishes one 10-gram packet in 3 days
No history of allergies
Bowel and bladder movements normal
Drug history
The patient is currently taking
Previous investigations
6 months ago
Previous Imaging
X-Ray- Foot
3 years ago
MRI- lumbosacral spine - 6 MONTHS AGO
General examination
The patient is conscious coherent, oriented to time place and person.
The patient is well built and well nourished.
Absence of pallor icterus cyanosis clubbing koilonychia lymphadenopathy and edema.
Swelling- 
Ulcer
CNS examination :
The patient is conscious , coherent, oriented to time place and person .
Cranial nerve examination- normal
Sensory nervous system -
Absent of pain and fine touch in left foot upto the ankle joint .
Right lower limb sensations normal
Motor system
Right , left
Triceps. Present , present
Biceps. Present , Present
Brachioradial Present, Present
Knee joint. Present , Present
Ankle joint Present , Present
Equine gait
Day 1 investigations
Orthopedic consult
Day 2 Investigations
Nerve conduction studies
MRI
? Nerve sheath tumor
? Mononeuropathy
Treatment
Gabapentin 100 mg thrice daily
Meaxon afternoon
Case discussion
Discussion 1. Are you sure it's common peroneal and not distal to that?
The patient's clinical signs suggest he has got good power in calf muscles as well as sensation over it's dermatome?
Which nerve supplies there?
And which nerve supplies till the dorsum which is the most affected?
Answers :
Sir the calf muscles are being supplied by the tibial nerve and the patient is able to plantarflex . The major part of the sensory supply of dorsum is supplied by the superficial peroneal nerve ( branch of common peroneal) . The sensory supply of the foot also involve other nerves like Sural nerve , Saphenous nerve and distal branches of the Tibial nerve in the plantar aspect .He is not able to dorsiflex due to the involvement of the deep peroneal nerves .
Sir since there is no sensation in the entirety of the foot , could this be a polyneuropathy ?
Peroneal Neuropathies
Disease involving the common PERONEAL NERVE or its branches, the deep and superficial peroneal nerves. Lesions of the deep peroneal nerve are associated with PARALYSIS of dorsiflexion of the ankle and toes and loss of sensation from the web space between the first and second toe. Lesions of the superficial peroneal nerve result in weakness or paralysis of the peroneal muscles (which evert the foot) and loss of sensation over the dorsal and lateral surface of the leg.
Tibial Neuropathy
Clinical features include PARALYSIS of plantar flexion, ankle inversion and toe flexion as well as loss of sensation over the sole of the foot. (From Joynt, Clinical Neurology, 1995, Ch51, p32)
Year introduced: 2000
Suggestive of deep peroneal nerve involvement -
-Absence of dorsiflexion
-loss of sensation in first web space
Suggestive of tibial involvement-
Loss of sensation over sole of foot
Discussion 2 .
Here for this patient, let me begin by asking this basic STEM question :
What is wallerian degeneration and how is it related to infective or any other inflammatory injury including trauma?
How are neurodegenerative disorders different in terms of their neuronal degeneration?
Answer 2.
The characteristics of an efficient innate-immune response are rapid onset and conclusion, and the orchestrated interplay between Schwann cells, fibroblasts, macrophages, endothelial cells, and molecules they produce. Wallerian degeneration serves as a prelude for successful repair when these requirements are met. In contrast, functional recovery is poor when injury fails to produce the efficient innate-immune response of Wallerian degeneration.
Discussion 3
Can you share the examination findings reflecting the current physiological functioning of his left common peroneal and tibial nerve in this patient?
Suggestive of tibial nerve involvement-
1. Loss of sensation over sole of foot
Suggestive of deep peroneal nerve involvement
1. Absence of dorsifelxion of ankle
2. Loss of sensation from first web space between first and second toe
Suggestive of superficial peroneal nerve involvement
1. Inability to evert the foot
2.Loss of sensation over dorsum of foot
https://www.ncbi.nlm.nih.gov/mesh/68020427
https://www.ncbi.nlm.nih.gov/mesh/68020429
So involvement of tibial is only sensory while the involvement of common peroneal is motor sensory?
: Sir the ankle reflex is present and he is able to plantar flex , hence the motor component of the tibial nerve supplying the calf muscles is not involved .
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