Case 104: Ten-Toe Rest Pain Relieved and Patient Restored to Ambulatory State

This 76 year old non-diabetic female was referred from a nearby University Medical Center with a 14-year history of poor circulation. She had rest pain in all ten toes. Her cardiologists felt her cardiac reserve was insufficient to allow her to undergo possible bilateral femoro-iliac bypasses. Her pulse volume curves were flat at the ankles, detectable at the calves and low in the thighs. She was hospitalized for aggressive boot therapy over two weeks.

Rubor on dependency was especially prominent in the toes. The left 1st toe was infected.

In her case, toe temperatures and transcutaneous PO2 measurements were followed. The temperatures were obtained in a 20 degree C constant temperature room with the patient covered with blankets and heating pads except for her bare toes, which were exposed to the room air (a standard vasodilatation test). Temperatures under 25 degrees C are thought to be incompatible with healing. The temperatures in her right 1st toe (24.4) and right 3rd toe (26.2) rose respectively to 30.2 and 29.5 by the end of her hospitalization. In the left foot, the temperatures in the 1st toe (23.7), 3rd toe (23.6) and 5th toe (23.8) rose respectively to 29.8, 27.8 and 27.1 degrees C. Her PO2 polarographic readings on the dorsum of her feet at the base of the first and fifth toes rose respectively from 9% and 49% in the right foot to 31% and 62% of the maximally vasodilated arm. In the left foot, the values rose from 9% and 27% to 30% and 38% respectively. At the time of discharge, her rubor had receded, her feet were pain free and her left big toe was healing. She was given weekly outpatient booster treatments for several weeks. Thereafter, she received treatments once or twice a month in part depending on how her legs felt to her. She remained fully ambulatory and pain free until a hospitalization three years later for a brain tumor which took her life.

Hospitalized now for her brain tumor, the skin color of her feet was normal and her toenails were healthy. The imprint of her slipper is seen on the dorsum of the right foot.

Comments: This lady had few skin lesions and no neuropathy. Diffuse arteriosclerosis caused her ischemic pain. Bypass surgery could not have provided her with a more successful outcome. One wonders whether the HMO of today would have allowed the hospitalization felt necessary to perform her aggressive boot therapy.