This week I will be presenting an interesting case study for your review.  I will give you some of the background and findings along with some clinical photos.  Give it a read and see if you can arrive at the proper diagnosis.  Next week we will present the answer and a discussion of that diagnosis…

A 44 y/o Caucasian male presents to the ED with c/o severe pain and swelling to his right foot x 2 days.  The patient states that he has had dull pain in his arch of the same foot for several years and it seemed to be getting worse over the past 3 months.  He sought care and an MRI showed a fluid filled mass in his medial longitudinal arch.  3 days prior to his presentation in the ED, he was seen in his physician’s office and a needle aspiration was attempted but did not produce any aspirate.  The patient states that he noticed the severe pain and swelling to his foot approximately 24 hours after the attempted needle aspiration.  He is a newly diagnosed type 2 diabetic with no other significant past medical history.

The patient is admitted to the hospital and receives IV antibiotics, posterior splint, and extremity elevation overnight.  With no improvement noted, the next morning the patient is taken to the OR for surgical exploration with the working diagnosis of abscess, hematoma, or compartment syndrome.  Upon incision there is a large coagulum that is evacuated and no signs of infection are found.  After lavage, a grey soft tissue mass is noted deep to the abductor hallucis muscle and this is carefully dissected, ligated, and excised.  Photos of the lesion and its histopathology slides are seen below…what is your best guess?  Send in your responses to jsteinberg@podiatry.com

If you have something you would like to suggest for a topic for a future Residency Insight, please email it to me at jsteinberg@podiatry.com