Pain in the Foot:

A 52 yo man in misery

Christie Seibert, MD
September 21, 2005
No financial disclosures.
The Patient
52 yo man w/o sig PMH
2 mo ago: sudden onset of 8/10 pain in
his R great toe and sole of foot, spreading
toward his ankle. Occurs with rest and
exertion. Worst when elevates R leg.
Treated with NSAIDS, which gave partial
relief.
The Patient
3 wks ago: Same sxs in L foot. Also, R
foot developing red-blue discoloration at
toes, dorsum of foot.
Pain so severe that he is unable to work
and has sig diff sleeping. Sleeps sitting in
a chair.
Treated with NSAIDs again, ruled out for
DVT.
The Patient
PMH: Nephrolithiasis x 1. No meds.
SH: Works for a uniform rental company.
Smokes 1ppd x 36 yrs. 3-4 beers/wk.
Occasional marijuana.
FH: No FH of cancer, CAD, VTE.
ROS: Had URI about 2 wks prior to sxs.
The Exam
VS: Afeb, BP 112/66, P 78
General: Comfortable with feet on floor
CV, Lungs, Abd WNL
MSK: no synovitis, no limits in ROM
EXT: Non-pitting edema of both feet to
mid calf. 2+ PT and DP pulses
Skin Exam

UptoDate.com
Accessed 9/6/05
Differential Diagnosis
Embolic Disease
Peripheral Vascular Disease (arterial
insufficiency)
Vasculitis
Cryoglobulinemia
Buergers Disease
Diagnostic Testing
CBC, LFT, Cr
ESR, CRP
ANA, RF, C-ANCA, P-ANCA
Hep B and C
Antiphospholipid antibodies
ECHO
 MRA of Lower
Extremities:
Iliac, femoral and
popliteal circulations
are widely patent.
Several short segment
moderate stenoses in
posterior and anterior
tibial arteries.

Warfel, JH. The Extremities, 5th edition 1985

 Skin Biopsy
Multiple small, highly cellular, inflammatory
thrombi
Relative sparing of the blood vessel wall
No vasculitis
No evidence of atherosclerosis
Buergers Disease
(Thromboangiitis Obliterans)
First described in 1879
In 1908, Leo Buerger described pathologic
findings in 11 amputated limbs
Worldwide distribution
Prevalence: Middles East/Far East >
North America/Western Europe
12.6 per 100,000 in Olmstead County
Pathophysiology
Nonatherosclerotic segmental
inflammatory disease of small and
medium-sized arteries (skip lesions)
Distinguished from other vasculitis
Sparing of blood vessel wall
ESR, CRP normal
Autoantibodies negative
Diagnostic Criteria
Typically age less than 45 years and male
Current or recent history of tobacco use
Distal extremity ischemia in the absence
of proximal disease
Exclusion of autoimmune and
hypercoaguable diseases
Clinical Features
Usually presents as claudication, rest pain
Features Atherosclerosis Buergers Ds
Age > 40yo 20-45yo
Other risk factors +++ no
Upper extremity
rare Up to 90%
involvement
Proximal vessel
+++ rare
involvement
Pulse exam decreased preserved
Superficial
no Up to 40%
Thrombophlebitis
Skin Exam

UptoDate.com
Accessed 9/6/05
 Allen Test (+ in 65%)
Patient makes a fist
Examiners thumbs occlude
radial and ulnar arteries
Patient opens hand into relaxed,
partially flexed position
Pressure on ulnar artery is
released while radial artery is
compressed
Normally, hand should turn pink
because of intact interconnecting
arteries
Can be repeated releasing
pressure of radial artery
NEJM,2000;343(12):867.
Treatment
Absolute abstinence of smoking
40% who continue to smoke will require
amputation, compared to 5% who quit
Not amenable to surgery
Negative studies regarding thrombolytic
therapy
Oh by the way, doc
Cannabis arteritis first described in the
1960s.
Mainly case reports and series.
Clinically and pathologically like Buergers
disease, occurring rarely in young adults.
Objectives
Recognize Buergers disease
Describe diagnostic criteria and clinical
features of the disease
Describe the Allen Test
Know that complete smoking cessation is
the only treatment
References
Szuba a, Cooke JP. Thromboangiitis obliterans: An update on
Buergers disease. West J of Med 1998;168(4):255-61 .
Olin JW. Thromboangiitis Obliterans (Buergers Disease). NEJM
2000;343(12):864-9.
Mohler ER, Olin JW. Thromboangiitis Obliterans (Buergers
Disease). Up to Date.com. Accessed 9/6/2005. Last updated
11/15/2004.
Combamale P, Consort T, Denis-Thelis L et al. Cannabis arteritis.
Br J Dermatol 2005;152(1):166-9.
Disdier P, Granel B, Serratrice J et al. Cannabis arteritis
revisited;ten new case reports. Angiology 2001;52(1):1-5.