Painful, Patchy Pallor And Hyperemia In The Feet Of A Completive 16 Year-old Swimmer - Page #1

Author: Brennan Boettcher, DO
Co Author #1: Karen L. Newcomer, M.D.

Patient Presentation:
A 16 year-old competitive swimmer presents with an 11-month history of painful, patchy color changes in her feet following long distance swimming (Pictures 1-5).

Onset was sudden after a 500 m race and has subsequently worsened with similar distance events.
Back stroke and individual medley are the most bothersome. Symptoms are described as "no blood flow in my feet" followed by a sensation of numbness and burning. There are associated blanched patchy skin changes in her feet, which have also times affected the calf and thigh a couple times. Following completion of her event, color change and pain would resolve within 10 minutes.

Negative evaluation elsewhere included MRI of the popliteal artery at the knee, CT angiogram of the legs, post exercise ABI's and rheumatologic workup. Her diagnosis was acrocyanosis. Lisinopril was initiated, and her symptoms worsened. Nifedipine has been subsequently started with questionable decrease in her symptoms. She has been limited in her competition as a distance specialist to only competing in distances 200 m or less. Since her previous workup, she has now intermittently become symptomatic with long distance walking and has had similar symptoms in her hands a few times. Symptoms can also occur with warm ambient temperature.

Physical Exam:
General: Fit-appearing female.
Skin: No discoloration changes or cyanosis at rest. Photographs of symptomatic episodes are presented with alternating areas of hyperemia and pallor. Numerous different episodes are viewed; areas of pallor are not the same in each episode. No skin changes consistent with scleroderma.
Musculoskeletal: Strength normal in upper and lower limbs.
Vessels: DP and PT pulses normal at neutral dorsiflexion. With resisted plantar flexion and knee extended, discoloration comes on. Popliteal pulses are palpable bilaterally.
Neurological: Reflexes symmetric and physiologic. Sensation is normal in the feet.

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