Swelling of dorsal foot

[Xue Heng]

Hi, Steve. This was today’s case.
The patient was a 53-year-female, with swelling and tenderness of dorsal foot for 2 weeks.
Without injury, she developed this symptom, and she had difficulty in dorsiflexion.
The skin surface looked normal.
A heterogeneous mass with clear margin was observed superfical to the cuboid bone.
It had no blood flow, but the surrounding tissue was swelling and hyperechoic with increase blood flow.
I had completely no idea about this case, and turn to you for help.
Thank you, Steve, you always give me powerful support.

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[Stephen Bird]

You are finding the tricky stuff today Xue,

I think the hypo echoic area is in fact the muscle belly of extensor digitorum brevis.

There is certainly some inflammatory change surrounding the muscle.

This one will benefit from an MRI assessment I think,

I would suggest it could be an inflammatory arthritic event of some sort in the articulation beneath the muscle belly. I would include gout in my differentials.

You said there was no trauma, however what about increased use?

Gout would be more common in a male, however it still remains on my list of possibilities.

A stress reaction is another possibility.

Another completely different interpretation could be that the hypo echoic area is not in fact the EDB muscle but is the Gruberi Bursa which sits immediately deep to that muscle in this location.

It could be an inflamed Gruberi bursa.

It looks as if the inflammatory change extends into the medial aspect of the sinus tarsi which is where the Gruberi bursa is located.

Let me know what the MRI report says !

So I have :

Stress reaction
Gout
Other inflammatory arthritis event
Gruberi bursa inflammation
I guess you can’t exclude something sinister like a sarcoma, however it would be less likely.

Steve.

[Xue Heng]

Hi, Steve.
In your webinar, I heard the term “Gruberi Bursa”, but I didn’t know what is it.
I search the literature, and found that it is an anatomic bursa found in the dorsolateral ankle termed the “sinus tarsi bursa of Gruberi”.
After your remind, I think “Gruberi Bursitis” may be the most likely diagnosis.
I forgot to ask her history of overuse, and did not compress the lesion.
Once she provided the history of increased use (or friction maybe), and the lesion was comprssible, the diagnostic confidence of “Gruberi Bursitis” would increase.
Thank you very much!

[Stephen Bird]

Nice one mate.

Steve

[Xue Heng]

Hi, Steve. Here is another similar case.
The patient was a 48-year-male, with swelling dorsal foot for 1 year.
One year ago, he fell from the tree, since then he began to develope medial dorsal foot swelling, with tenderness.
The swelling might sometimes resolve spontaneously.
A heterogeneous mass was observed superfical to the anterior tibialis tendon.
The mass and the surrounding tissue had increased blood flow.
A hyperechoic free body could also be observed.
I had no idea about this case, what would be the diagnosis?
Thank you for your help, Steve.

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[Stephen Bird]

HI Xue,

Tricky one !

The question in my mind is “did the tree fall cause the pathology or was that event a coincidence”

If the tree fall had nothing to do with it we could be looking at a rheumatoid patient.

But you said there was a hyperechoic free body. Did this look like a foreign body?

If it was a splinter from the tree are we looking at a chronic infection?

There is certainly a lot of inflammation in the soft tissues. The question is whether it is synovial proliferation from something like rheumatoid or a chronic infection from the fall.

he extender digitorum brevis muscle is lateral to this location so I don’t think it has anything to do with it.

There is a bursa under the tib ant tendon and it could be a chronic bursitis of that bursa.

It looks like it is getting worse as I notice you have sent me films from 2 dates.

So :

Rheumatoid
Gout
Foreign body – chronic infection
Bursitis

Steve

[Xue Heng]

Thank you, Steve.
This was another patient from previous one.
The hyperechoic free body was not a foreign body because he had intact sole when falling from the tree.

[Stephen Bird]

I think then we go for:

Rheumatoid
Gout
Bursitis

Steve.

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