Differential Diagnosis for Bilateral Foot Discomfort

The patient presents with bilateral foot discomfort, described as feeling like "walking on marbles," with specific symptoms localized to the heel of the left foot and between the digits of the right foot, accompanied by tingling, numbness, swelling, and tenderness. The symptoms have been ongoing for approximately four months, with improvement in pain upon movement but persistent discomfort. Recent lifestyle changes, including cessation of alcohol use and significant weight loss, have led to improvements in blood pressure and overall health.

• Single Most Likely Diagnosis
  • Plantar Fasciitis: This condition is characterized by inflammation of the plantar fascia, leading to pain in the heel and bottom of the foot, which worsens with rest and improves with activity. The patient's description of heel pain, especially after periods of rest, aligns with plantar fasciitis. The recent significant weight loss could also contribute to increased stress on the plantar fascia, exacerbating symptoms.
• Other Likely Diagnoses
  • Morton's Neuroma: This condition involves a thickening of the tissue around the nerves leading to the toes, causing pain, numbness, and tingling, particularly between the toes. The patient's symptoms of tingling and numbness in the second digit of the right foot could be indicative of Morton's neuroma.
  • Peripheral Neuropathy: Given the patient's history of neuralgia and the presence of tingling and numbness, peripheral neuropathy could be a contributing factor. However, the specific localization of symptoms and the improvement with movement make this less likely as a primary diagnosis.
  • Gout or Pseudogout: These conditions can cause sudden, severe joint pain and swelling, often in the feet. The patient's report of swelling and tenderness, along with a history of significant weight loss and potential dietary changes, could suggest a metabolic component to his symptoms.
• Do Not Miss Diagnoses
  • Deep Vein Thrombosis (DVT): Although less likely given the chronic nature of the symptoms and the improvement with activity, DVT must be considered, especially with any history of swelling. The patient's recent significant weight loss and improved mobility might reduce this risk, but it should not be overlooked.
  • Diabetic Neuropathy: Despite the patient's recent health improvements, any form of neuropathy warrants consideration of diabetes as an underlying cause, especially if there are any concerns about glucose metabolism.
  • Infection or Osteomyelitis: Chronic infections of the bone or soft tissue could present with persistent pain, swelling, and tenderness. A history of poorly fitting shoes could potentially lead to chronic trauma or infection.
• Rare Diagnoses
  • Charcot-Marie-Tooth Disease: A group of inherited disorders that affect the peripheral nerves, leading to numbness, tingling, and muscle weakness in the feet and legs. This would be less likely given the patient's age of onset and the specific nature of his symptoms.
  • Erythromelalgia: A rare disorder characterized by burning pain, heat, and redness in the hands and feet. The patient's symptoms do not fully align with this condition, but it remains a consideration in the differential diagnosis of foot pain.