Cold Feet

Muriel complained of cold feet but they felt warm to me. Martha’s cold feet had bluish, red blotches on most of her toes, which hurt so much she begged for pain medication. Mary’s feet were cold with steadily darkening blue toes and they hurt so much she refused to wear shoes.

In each of my clinics I have a pocket Doppler, good for recording peripheral blood pressures and listening to fetal heart tones. That little device has made it easier to triage the symptom of cold feet.

Muriel’s calf blood pressures, recorded at the posterior tibial artery with my Doppler, was 160, greater than in her arms. “Water pressure in the basement is usually higher than on the top floor”, I always explain as I do the procedure. But she had decreased monofilament sensation, so in her case it turned out to be a search for the cause of her peripheral neuropathy.

Martha’s painful, discolored toes felt only a bit cold, and the rest of her feet had normal temperature. Her calf blood pressures weren’t bad, but she had femoral bruits and a CT angiogram showed severe atherosclerosis of her aorta and iliac arteries; she was throwing emboli into her toes, causing the pain and the discoloration. The vascular surgeon explained to me on the phone “we call them trash toes”. The emboli aren’t pure blood clots, but more plaque fragments. So anticoagulation, he answered my question, doesn’t do much. What she needed was a new aorta. One vascular surgeon wanted to stent her, but she ended up with a second opinion from the one who told me about “trash toes”. He said she was too young to expect a stent would last her lifetime. He recommended a graft. She went for it and did well.

Mary had Raynaud’s disease, a manifestation of scleroderma. She eventually developed dry gangrene. This was early during the pandemic when specialty consultations were hard to come by. The rheumatologist I talked to approved of my nifedipine prescription, encouraged me to treat the pain and said, “don’t let the surgeons near her”. He ended up leaving the state and she eventually saw another rheumatologist and a vascular surgeon. The two of them decided together to amputate the affected toes.

Two men who presented with more than just cold feet are vivid memories from my career. They were screaming with pain from sudden onset of pain in only one foot. The first one happened to come in just after we purchased a Doppler at my downstate clinic. He lived very close to our clinic. His foot wasn’t all that cold, but he had no dorsal pedal pulse by Doppler due to major embolization. He did well with his surgery. The second one was up north, where I had asked for a Doppler shortly after I arrived. He had the same classic presentation. It helps to know that there is absolutely no pulse, because your fingers often can’t palpate a weak pulse accurately. In both of these cases the diagnosis was firm. We called the ambulance and the hospital was ready for action.

Today I saw a woman with foot pain, bluish toes and excellent blood pressure at her calves. She carries a diagnosis of rosacea, and when she removed her mask for me, her cheeks looked much worse than I remember them. “It’s this mask”, she said.

“Maybe, but I’d like to do a bunch of blood tests to see if you have an autoimmune disease”, I explained. Was this an innocent Raynaud’s phenomenon or Raynaud’s disease secondary to previously unrecognized lupus? We will soon know. I started her on nifedipine while we wait for the blood test results.

A common symptom we may not always pursue can be big trouble:

“Feet cold, huh, let me see…”