Kameeldoring tree:A rare Bush injury?

Walking in the Bush can be one of the joys of living in Africa. However, it does have its drawbacks apart from the animals you may encounter!

Last week a young man came in as an emergency, telling me that whilst walking in the bush, a thorn had gone into the inside of his left ankle. The thorn was removed completely and initially there was no pain, but about 4 hours later it was excruciating. The thorn was from a tree called in Afrikaans Kameeldoring, one of the Acacia species, certain of which are poisonous.

A local Doctor prescribed antibiotics for 10 days, but now, the foot was still very painful and only relieved by taking an anti-inflammatory every 8 hours.

Examining the site of entry(parallel to the ground and straight into the medial malleolus – that’s the lump on the inside of your ankle), – there was no inflammation, but lower down towards the arch there was some swelling and inflammation.

Standing on tip-toe was painful so initially thought of damage to the Tibialis Posterior Tendon. However, the pain was described as …”burning and running over the bridge(arch) of my foot.” As I palpated down the foot towards the sole, it was possible to create the pain, which also went “into the foot”.

A Sonar scan was ordered which showed some fluid collection around the tendon when compared to the right foot. No other pathologies were detected, such as a foreign body, thrombus, tendon tear etc.

So what is the provisional diagnosis? Possible trauma to the Tibial nerve. The diagnosis is based on the nature and site of the pain described, plus the fact that the Tibial nerve runs in the area where the thorn penetrated the foot. For the time being the treatment is local ice and continue with the anti-inflammatory.

Undiagnosed Achilles Tendon Tear

When an Achilles tendon ruptures, the patient may tell you they heard a sound like a gunshot and they cannot walk, but with an Achilles tendon tear it is still possible to walk around without knowing your injury.

This week a lady consulted me complaining of pains at the back of both heels and into the calves, which had been there for more 6 weeks. She experienced aching, throbbing and a stretching sensation, especially in the evening. She felt less pain wearing higher heeled shoes. In addition, the pain was worse when she got up after sitting for some time.

There was a history of a right ankle fracture and some persisitent left knee pain. She  also told me that she had been diagnosed with calcaneal spurs many years ago. The lady was overweight and of short height.

During my examination, I could see and feel that both Achilles tendons were swollen and had nodules in them. Her walking stride was short and stamping. There were other significant biomechanical problems too.

Temporary treatment consisted of  in-shoe wedging. I also referred the lady for an ultrasound scan of the Achilles tendons.

Two days later the scan reported the left tendon as having “….an almost full thickness intra-tendon tear ……approximately 2.8mm thick, extending 30mm longitudinally.” On the right “……loss of fibrillar pattern, consistent with fraying.”

There were other features, but this was one lucky lady, because there could have been a rupture at any time. This time she was referred to an orthopaedic foot surgeon.

So whether you are a patient or podiatrist, when managing chronic pain at the back of the heel, consider the benefits of ultrasound scanning to assist in diagnosis and always act quickly, you might discover an Achilles tendon tear.

Foot Pain & Posterior Tibial Tendon Rupture

Never ignore foot pain. A recent case of tibialis posterior tendon rupture is a case in point.

A 76 year old lady was brought to me by her daughter because she could barely walk and was in constant pain. She had been prescribed anti-inflammatories and sleeping tablets for ‘the arthritis.’

At her only previous visit to me in 2003, I had diagnosd the potential for flat foot related problems and made orthotics. The lady never kept any follow up appointments.

This time, the lady described her symptoms as “the left foot is giving me hell. Over the past year, it’s been getting gradually worse and now I can’t wear my shoes.”

When I asked about the previous treatment, she informed me that she gave up with orthotics because they didn’t fit easily into her shoes.

When I examined the foot, it was completely flat and rolled over and the arch was non-existent. The lady was unable to stand for more than a few seconds and she couldn’t manage more than two steps across the room. In addition she was unable to raise up onto tiptoe.

As I traced a path along the inside of the foot up behind her ankle to the lower part of her calf she experienced significant pain. This is the path of the Posterior Tibial Tendon, the main tendon to help form and hold the arch of the foot.

Posterior Tibial Tendon

I immediately sent the lady for X-rays and an Ultrasound scan.  The scan revealed a rupture of the Posterior Tibial Tendon.

Referral for surgery has been completed and now we wait for the outcome, except that she has developed a problem with her eyes that needs treating before any surgery can take place.

The moral of this story? Follow up is vital from both sides of the medical equation. Ignoring foot pain can have serious consequences, so managing it is a team effort.

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