A 62-year-old male presents with red, swollen, pruritic toes 2,3,4 on the left foot after hiking for an hour on snowy trails in 5-degree weather. He reports that his feet felt cold and numb after about thirty minutes of hiking in wool socks and non-insulated hiking boots that were a bit tight (due to thicker socks), but he continued the hike.  Upon returning home and removing the shoes, all digits were extremely cold when compared to other feet, red, purple, and white in appearance, and remained so for 1-2 hours. Treatment was a change of socks, loose-fitting shoes, and diclofenac 75mg p.o. BID.  Within an hour, there was significant pain, swelling of the toes, itching, and burning.  Gradual resolution of the discoloration was noted, but the pain and itching continued for 48 hours (and still does), as did some of the erythema to the digits.  No blistering or deep bruising was noted.

Pertinent medical history noted that he had neuroma excision 2^nd and 3^rd interspaces of the left (affected) foot many years before the incident.

Diagnosis: Pernio/chilblains due to prolonged cold exposure with Raynaud-like symptoms secondary to the disruption/removal of the plantar digital nerves post-neurectomy.

I am the patient in this case study. As I write this, my foot still hurts! 

I have treated many cold injuries over the past 30 years of practice, including my years treating patients in the cold weather in Pennsylvania and my time in which I was stationed abroad during my time in the U.S. Armed Forces.  I had seen frostbite in Alaska, trench foot in New Jersey, and pernio in Texas when the temperatures dropped, and the soldiers I cared for weren’t prepared for it.  I had a podiatrist who was stationed in Korea send me photos of a soldier's foot with red swollen toes, blotchy skin, and deep bruising on the distal aspects of several toes after being on guard duty in subzero temps.  It was not frostbite but pernio/chilblains; he had never seen this before and only vaguely remembered being taught about it in school. 

Every winter, icy ones like this year, many patients present with cold, discolored toes (and sometimes fingers) who have undiagnosed Raynauds Phenomenon. Less likely is Pernio/Chilblains and the aftereffects.  Recognition of these types of injuries/diseases is imperative, as is proper treatment and consultation with the appropriate medical specialty. Podiatrists must recognize these types of injuries and be prepared to treat them. DPMs may want to consider Googling this diagnosis and finding qualified content to familiarize themselves with symptoms, diagnosis, and effective treatments of conditions of the foot and ankle that mother nature has impacted during the cold winter months.  Investing a few minutes in enhancing your knowledge can only benefit you and your patients.

My feet are feeling better. I have decided to invest in more costly hiking boots that will be insulated, as well as better socks so that I can continue to enjoy being active in the outdoors during the cold winter months while reducing my risk of injection or injury.

Pete Smith, DPM, is a podiatrist practicing in Lancaster, Pennsylvania. Dr. Smith is a past president of the Pennsylvania Podiatric Medical Association and a board member of its educational component, The Goldfarb Foundation.