The painful red foot-inflammation or ischaemia?

Although a recent history of a painful foot may indicate gout or cellulitis, a diagnosis of severe ischaemia should always be suspected, even when the foot is erythematous. Failure to recognise severe foot ischaemia can have an adverse impact on the outcome for the patient —and may have legal consequences for the doctor— as the three cases discussed below illustrate. Case 1 —A 72 year old woman presented with a three day history of pain in her left foot. The pain was worse at night and was described as “throbbing.” The family doctor, who visited the woman, diagnosed cellulitis and prescribed antibiotics. Three days later the condition had not improved. The woman was eventually admitted to hospital by another general practitioner, who believed that she might have ischaemia as he had difficulty detecting a pulse. Physical examination showed that the foot was erythematous while dependent but cool to the touch and pale when it was raised. The patient was investigated by Doppler ultrasonography and arteriography, and ischaemia was confirmed. Femoropopliteal artery bypass surgery was carried out, and this relieved the pain. Case 2 —A 52 year old man presented to his general practitioner with a three day history of pain in his left foot. At that time the forefoot looked red and inflamed. The man was treated with oral antibiotics, but after four days there was no improvement and his toes had become blue and lacked sensation. The patient …