Big Toe Pain When Stretching Leg and Foot

DISCLAIMER:
THE FOLLOWING IS OFFERED GRATIS AS GENERAL INFORMATION ONLY, AND, AS SUCH, MAY NOT BE APPLICABLE TO THE SPECIFIC QUESTIONER AND/OR HIS/HER PROBLEM. IT IS CLEARLY NOT BASED ON ACTUAL KNOWLEDGE AND/OR EXAMINATION OF THE QUESTIONER OR HIS/HER MEDICAL HISTORY, AND IT CAN NOT AND SHOULD NOT BE RELIED UPON AS DEFINITIVE MEDICAL OPINION OR ADVICE. ONLY THROUGH HANDS- ON PHYSICAL CONTACT WITH THE ACTUAL PATIENT CAN ACCURATE MEDICAL DIAGNOSIS BE ESTABLISHED AND SPECIFIC ADVICE BE GIVEN. NO DOCTOR/PATIENT RELATIONSHIP IS CREATED OR ESTABLISHED OR MAY BE INFERRED. THE QUESTIONER AND/OR READER IS INSTRUCTED TO CONSULT HIS OR HER OWN DOCTOR BEFORE PROCEEDING WITH ANY SUGGESTIONS CONTAINED HEREIN, AND TO ACT ONLY UPON HIS/HER OWN DOCTOR’S ORDERS AND RECOMMENDATIONS. BY THE READING OF MY POSTING WHICH FOLLOWS, THE READER STIPULATES AND CONFIRMS THAT HE/SHE FULLY UNDERSTANDS THIS DISCLAIMER AND HOLDS HARMLESS THIS WRITER. IF THIS IS NOT FULLY AGREEABLE TO YOU, THE READER, AND/OR YOU HAVE NOT ATTAINED THE AGE OF 18 YEARS, YOU HEREBY ARE ADMONISHED TO READ NO FURTHER.
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Especially as you should be privy to but have said nothing more about the nature of the injury which you supposed elicited the problem, that might be the starting point in understanding your situation. The next logical step would be an actual physical examination. Lacking that most important capability, there is little definitive and meaningful advice which can be offered upon which you might reasonably act.

Owing to your spelling of "colour" you may not be living in the U.S., and I do not know the general quality of podiatric care which can be expected in whatever location you might be. But, if I can offer an answer as if you were in the U.S., clearly most GP's would not have the slightest clue as to the nature and treatment of your problem, and in most, if not all States here, physical therapists treat under the direction of a doctor, but do not themselves make diagnoses. In the U.S. I would recommend either a podiatrist or an orthopedist.

My initial recommendation, though, is to cease the Jiu Jitsu and other physical activities which might aggravate your situation until at least a diagnosis is made and you have been professionally instructed as to what you may or may not do.

 

Hi FootDoc,

Yes I live in the United Kingdom (Scotland actually) - sorry maybe I should have mentioned this... I have been to physiotherapists before for wrist and neck injuries and they are certainly able to operate independently of doctors in both diagnosis and treatment although I am unsure if they have the power to issue prescription medications or not or to arrange surgery or the like.

As for the cause of the injury, I don't actually know. I cannot remember a particular event, only that I became aware over a period of a week or so that my toe was becoming painful under the extension conditions I mentioned earlier. It doesn't hurt at all most of the time it is just as if a ligament or tendon is tight, perhaps damaged and is letting me know about it. If I stretch it gently before doing sports it seems to be okay but I take your point that I might be doing more damage and should proceed in getting it looked at. I was hoping to talk to the physio who sometimes comes to our Jiu Jitsu club to ask if he thought he could offer treatment but he's not been at the club recently. I might drop him an email and see if he thinks he could help or if he can recommend a podiatrist nearby who may be able to. I agree that a GP would be unlikely to be able to help directly.

Thanks for your advice, it is much appreciated.
Craig.

 

Hi again,
I've arranged an appointment with a physiotherapist for Monday but in the meantime I have noticed something about my complaint which I think is important.

I believe I am actually suffering some form of nerve impingement since I can trigger the pain in my big toe by lightly tapping the dorsal medial cutaneous nerve around 105mm away from the tip of my big toe (my total foot length is 250mm toe to heel). I understand this is called Tinel's sign and when I tap the nerve I get distal radiation of the pain which I have read is often caused by compression or trauma to the nerve.

If I do have nerve impingement, is it easy to treat or is it likely to require surgery?

Many thanks,
Craig.

 

DISCLAIMER:
THE FOLLOWING IS OFFERED GRATIS AS GENERAL INFORMATION ONLY, AND, AS SUCH, MAY NOT BE APPLICABLE TO THE SPECIFIC QUESTIONER AND/OR HIS/HER PROBLEM. IT IS CLEARLY NOT BASED ON ACTUAL KNOWLEDGE AND/OR EXAMINATION OF THE QUESTIONER OR HIS/HER MEDICAL HISTORY, AND IT CAN NOT AND SHOULD NOT BE RELIED UPON AS DEFINITIVE MEDICAL OPINION OR ADVICE. ONLY THROUGH HANDS- ON PHYSICAL CONTACT WITH THE ACTUAL PATIENT CAN ACCURATE MEDICAL DIAGNOSIS BE ESTABLISHED AND SPECIFIC ADVICE BE GIVEN. NO DOCTOR/PATIENT RELATIONSHIP IS CREATED OR ESTABLISHED OR MAY BE INFERRED. THE QUESTIONER AND/OR READER IS INSTRUCTED TO CONSULT HIS OR HER OWN DOCTOR BEFORE PROCEEDING WITH ANY SUGGESTIONS CONTAINED HEREIN, AND TO ACT ONLY UPON HIS/HER OWN DOCTOR’S ORDERS AND RECOMMENDATIONS. BY THE READING OF MY POSTING WHICH FOLLOWS, THE READER STIPULATES AND CONFIRMS THAT HE/SHE FULLY UNDERSTANDS THIS DISCLAIMER AND HOLDS HARMLESS THIS WRITER. IF THIS IS NOT FULLY AGREEABLE TO YOU, THE READER, AND/OR YOU HAVE NOT ATTAINED THE AGE OF 18 YEARS, YOU HEREBY ARE ADMONISHED TO READ NO FURTHER.
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Yes, Tinel's sign is precisely what you have demonstrated. In the foot, it is more commonly associated as a finding in tarsal tunnel syndrome, but it can apply to any nerve entrapment disorder. So, it would seem that your toe pain may be due to nerve compression or inpingement or other nerve disorder proximal to the site of pain. The ease with which it might be corrected is totally dependent upon the nature of the exciting cause. There are some cases where eleviating possible fluid pressure about the area of the nerve, such as with local corticosteriod may relieve the problem unless and until the swelling recurs. If there is direct physical entrapment by . . say an overlying ligament (although the dorsal cutaneous nerves, which incidentally are poorly padded, are superficial to ligaments in the area) or by scar tissue, then it is more likely than not that some sort of invasive procedure will be necessary. But it is entirely premature to discuss specific methods of treatment and prognosis, both of which will first require a definitive diagnosis.

 

Thanks Foot Doc, your comments are appreciated as always. As I said, I have an appointment with a physio tomorrow so I'll see what he says. I don't know about other poster's on this forum but as a professional engineer I find it very interesting to learn the anatomy of the body. In many ways it is a shame that we only tend to show an interest when things go wrong. Perhaps anatomy should be taught throughout school as a mandatory subject and then maybe we wouldn't be so likely to damage our bodies or at the very least we would be able to provide better description of symptoms to our health professionals when we do injury ourselves.

Thanks again,
Craig.

 

I would doubt that a greater knowledge of anatomy would necessarily make anyone less likely to damage his/her body, but assuredly, it would assist him/her in being more specific in relating the location of symptoms to their doctors. Diagnosis is more than perhaps the most important aspect of effective medical care, and too many patients discount their participation in the process. That is graphically demonstrated here and on forums such as this, which rely totally on the words employed by the questioners, where the descriptions are often so vague and generalized so as to make a meaningful response all but impossible . . though none-the-less expected and even demanded. One of the topics of my postings here which, to my curiosity, seems to often provoke the ire of posters and other readers is my attempts to involve patients in their own care and assert that THEY bear a major responsibility in both presenting to their doctors their stories, which they surely know better than anyone else, and in demanding that the verbal feedback they get from their paid professionals be in language and terms which they can understand. Far too many patients assume and are willing to accept that their doctor is simply too busy to take the time to both serve them professionally and to listen attentively to their complaints and clearly discuss their treatment in layman terms, its purpose, reasoning and its goals. It is always troubling to me, but not totally unexpected, that many folks come to forums such as this for an explanation of what should have and what could far been more effectively explained by their own doctor. Beyond the proper selection of a good doctor, the key for patients expecting good doctoring is to come prepared with a cogent, chronological tale of their problem. It is not always a plus for them to have engaged in extensive research prior to seeing their doctor, as it potentially locks them into a need to direct their doctors toward their preformed conclusions, which may be both disconcerting to the doctor and subsequently non-productive. Patients should tell their stories replete with all of the nuances of their conditions which they surely have experienced, and let their doctors take in that information so as to be able to ask appropriately targeted questions and perform physical and machine tests as necessary. Being a good and effective patient is often just as important and, at its level, just as much of a skill as being a good provider of care.

 

Hi again, Just a quick update after my visit to my physio.

Slightly puzzling diagnosis - my physio thinks that I may have fractured my foot at some point although I am unaware of an event which supports this theory. He noted a thickening of the bone at the head of the 1st metatarsal when compared to the other foot. He used a sharp pointed instrument to jab my skin, I think along the course of my nerves, on both feet and asked me to compare the sensation on each. I found both feet felt the same. I think this ruled out nerve impingement in his mind. Would that sound correct?

He then palpated the spot where I had noticed distal pain shooting into my big toe - I nearly fell off the table at that point as it was very painful. He could also trigger the pain by plantar flexing both the foot and big toe. His conclusion was that I had injured the tendon (although I think he meant the ligament) which I had mistaken for a nerve. I think he must be talking about the 1st dorsal tarsometatarsal ligament as I can't see anything else in the anatomy charts which could be causing the pain. As I understand it, this is the ligament which connects the 1st cuneiform with the 1st MT. Does that make sense?

He frictioned the site of the pain which was not much fun and also treated it with ultrasound. He has given me some exercises to carry out including sitting down and pressing against a wall with my toes with heel touching the wall. Pushing back with my big toe against resistance and then plantar flexing the toe and foot. I have a appointment to see him again next week.

I would appreciate your thoughts on the above. This is my first session with this particular physio and although he is highly regarded I would like to know if you think he is on the right lines.

Thanks,
Craig.

 

It is difficult to impossible to meaningfully comment on an examination which I neither perform nor saw performed. But I am willing to comment in a general sense on what various findings in a theoretical examination might indicate.

1. Thickening of a metatarsal bone might be due to a remnant of the healing callus from a fracture or indication that proper reduction was never accomplished. But it also might simply indicated that that metatarsal had chronically borne more weight rather than being evidence of a healed fracture. Not having seen the x-rays, I certainly cannot tell which, if either, it might be.

2. Normal sensitivity of the skin would not necessarily preclude a nerve entrapment, especially if any adverse nerve effects occur only if and when the entrapped nerve is put on the stretch. Again, not having been there, I cannot offer any comment on the PT's conclusions which you have stated.

3. If direct palpation of the site of the pain elicits increased pain, then it is less likely that a remote proximal section of nerve is involved.

4. The fact that putting the ankle through ranges of motion elicits pain at the pain site could indicate tendonitis, or stretching of an entrapped nerve, but less likely, in my opinion, a ligament at the site of the toe pain.

Unless two problems co-exist, one cannot have it both ways in that both remote and direct palpation causes the same pain. By the treatment suggested, it would seem to me that he is considering that ligaments of the first metatarsal-great toe joint need stretching or that there might be some restriction from scar tissue. I am at a loss to connect those dots based on the information to which I am privy.

But this in no way to obtain treatment. I cannot and should not be expected to critique the examination and conclusions of the treating care-giver.

 

Hi FootDoc,

Please accept my apologies, it appears that I have placed you in an awkward position and that was certainly not my intention.

I will be seeing the PT at Jiu Jitsu training tonight so I will ask him to clarify his diagnosis. As you will appreciate, I simply want to be comfortable that I understand my diagnosis and treatment and as is probably often the case, it was only on my way home from treatment last night that questions started to arise in my mind.

Many thanks for your comments and once again my apologies for putting you on the spot.

Kind regards,
Craig.

 

No, no . . . not at all. You have apparently misinterpreted the intention of my closing comments. I am all too happy to attempt to discuss the salient features commonly seen in a diagnosis, how that diagnosis might be arrived at and what the treatment choices might be. But I do not feel appropriately qualified to judge examinations and the conclusions drawn by another care-giver when I was not privy to the actual examination nor had I made one of my own. Also, I considered how I might feel if a patient under my care repeatedly consulted another doctor about the minutia of my examination and the judgments drawn, when that other doctor never saw me. As I have often stated here, what I attempt to do is to discuss the generalities of a situation without the suggestion that it definitively pertains to any individual questioner. In no way do I feel put-upon or placed into an arkward position.

 

Hi,
No problem, I understand where you are coming from. I wasn't intending you to judge my PT's abilities, I just wanted to solidify my own understanding which I felt wasn't perhaps as good as it could have been. I think I was so sure that it was a nerve impingement that I didn't really take on board some of what he said at the time. One of the dangers of self-diagnosis I suppose...

Just for info, I spoke to my PT tonight and he clarified what he thinks is damaged. If I have understood correctly this time, he thinks I have injured the flexor brevis tendon and believes there is damage to the fascial sheath through which the tendon runs. He says this may be affecting some adjacent nerves. I must admit the anatomy charts I have seen don't show this tendon but I have no reason to doubt the diagnosis.

The thickening of the MT head is possibly not related to this specific injury but he thinks I just need to look after it and be alert for any changes.

Hopefully this explanation helps to join the dots as you put it.
No need to reply unless you want to, I just wanted to provide a (hopefully) better description of the PT's diagnosis as my last one had way too many assumptions and I think was misleading at best.

Thanks again for your help,
Craig.

 

Like the first entry, I'm having a pain/burning in my toes.

It started in my big toe, on top. My first thought was I pulled the ligament doing yoga.

Anyhow...Went to the doctor, he suspected the nerve. Gave me a shot of cortisone in the ankle and the top of the foot. Next appointment - 2 weeks. During that time the burning spread to the next 2 toes. It isn't constant - only when I stretch or cross my legs. The skin is numb unless I touch it, then it burns. Went back to the doctor today and he gave me another shot of cortisone between the third and fourth toes. Next appointment - 2 weeks.

Does this sound like the correct treatment?

I've done some research and my symptoms resemble those of "Turf Toe" except it effects the top of the foot instead of the bottom. The only time I've had pain in the bottom of the foot was today, after the injection.

Thoughts?

 

DISCLAIMER:
THE FOLLOWING IS OFFERED GRATIS AS GENERAL INFORMATION ONLY, AND, AS SUCH, MAY NOT BE APPLICABLE TO THE SPECIFIC QUESTIONER AND/OR HIS/HER PROBLEM. IT IS CLEARLY NOT BASED ON ACTUAL KNOWLEDGE AND/OR EXAMINATION OF THE QUESTIONER OR HIS/HER MEDICAL HISTORY, AND IT CAN NOT AND SHOULD NOT BE RELIED UPON AS DEFINITIVE MEDICAL OPINION OR ADVICE. ONLY THROUGH HANDS- ON PHYSICAL CONTACT WITH THE ACTUAL PATIENT CAN ACCURATE MEDICAL DIAGNOSIS BE ESTABLISHED AND SPECIFIC ADVICE BE GIVEN. NO DOCTOR/PATIENT RELATIONSHIP IS CREATED OR ESTABLISHED OR MAY BE INFERRED. THE QUESTIONER AND/OR READER IS INSTRUCTED TO CONSULT HIS OR HER OWN DOCTOR BEFORE PROCEEDING WITH ANY SUGGESTIONS CONTAINED HEREIN, AND TO ACT ONLY UPON HIS/HER OWN DOCTOR’S ORDERS AND RECOMMENDATIONS. BY THE READING OF MY POSTING WHICH FOLLOWS, THE READER STIPULATES AND CONFIRMS THAT HE/SHE FULLY UNDERSTANDS THIS DISCLAIMER AND HOLDS HARMLESS THIS WRITER. IF THIS IS NOT FULLY AGREEABLE TO YOU, THE READER, AND/OR YOU HAVE NOT ATTAINED THE AGE OF 18 YEARS, YOU HEREBY ARE ADMONISHED TO READ NO FURTHER.
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As you did not indicate any specific diagnosis which your doctor had made or suggested, I will have to make many assumptions which may or may not reflect the reality of your care. If your doctor had any real idea of what nerve might be involved, I would conclude that he/she would not have found it necessary to give a "cortisone" injection both in the ankle and on the top of the foot. But if I can conclude that whatever burning sensation you are experiencing is felt on the dorsum only of all involved toes (you don't specify which toes), as you stated that the burning began on the dorsum of your great toe, then I cannot see the thought behind given the injection in the ankle, as this would only affect the main nerve serving the plantar and not the dorsum. But then you state that your doctor gave you another "cortisone" injection between the 2nd and 3rd toes, but you don't say whether it was directed toward the area of the dorsal or the plantar nerves, so I can't really draw any conclusions there. If it was directed toward the plantar, my thought would be that he might suspect a neuroma. But that would not be consistent with your initial problem which you state was on the dorsum of the great toe. You don't state if any diagnostic measures or tests were performed, as should have been, prior to deciding on the injections, so clearly there is not enough detail in your post to draw any meaningful conclusions.

Turf toe is the result of a forceful hyper-extension of generally the great toe, typically during running and jumping sports where there is severe retrograde force, such as occurs to offensive lineman in football or where there is sudden acceleration requiring a great deal of push-off. You did not relate symptoms generally associated with that painful and disabling condition.

 

Sorry. Guess I wasn't very clear.

On the first visit the doctor suspected Tarsal Tunnel Syndrome.

He did xrays, being beat me with 3 different hammers, poked with 2 different types of pins, and topped it off with one "tuning fork".

This time, he did a lot of "pinching" specific areas of the toes and foot and said he suspected
a neuroma.

He also mentioned the possibility of a MRI, if this injection does not work, to check out the ligaments.

 

DISCLAIMER:
THE FOLLOWING IS OFFERED GRATIS AS GENERAL INFORMATION ONLY, AND, AS SUCH, MAY NOT BE APPLICABLE TO THE SPECIFIC QUESTIONER AND/OR HIS/HER PROBLEM. IT IS CLEARLY NOT BASED ON ACTUAL KNOWLEDGE AND/OR EXAMINATION OF THE QUESTIONER OR HIS/HER MEDICAL HISTORY, AND IT CAN NOT AND SHOULD NOT BE RELIED UPON AS DEFINITIVE MEDICAL OPINION OR ADVICE. ONLY THROUGH HANDS- ON PHYSICAL CONTACT WITH THE ACTUAL PATIENT CAN ACCURATE MEDICAL DIAGNOSIS BE ESTABLISHED AND SPECIFIC ADVICE BE GIVEN. NO DOCTOR/PATIENT RELATIONSHIP IS CREATED OR ESTABLISHED OR MAY BE INFERRED. THE QUESTIONER AND/OR READER IS INSTRUCTED TO CONSULT HIS OR HER OWN DOCTOR BEFORE PROCEEDING WITH ANY SUGGESTIONS CONTAINED HEREIN, AND TO ACT ONLY UPON HIS/HER OWN DOCTOR’S ORDERS AND RECOMMENDATIONS. BY THE READING OF MY POSTING WHICH FOLLOWS, THE READER STIPULATES AND CONFIRMS THAT HE/SHE FULLY UNDERSTANDS THIS DISCLAIMER AND HOLDS HARMLESS THIS WRITER. IF THIS IS NOT FULLY AGREEABLE TO YOU, THE READER, AND/OR YOU HAVE NOT ATTAINED THE AGE OF 18 YEARS, YOU HEREBY ARE ADMONISHED TO READ NO FURTHER.
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Based entirely on the perhaps incorrect assumption that this time your account is complete and accurate, it would be my impression that your doctor seems to be flailing about for a diagnosis. In my opinion, not only is it difficult to mix up tarsal tunnel syndrome, which generally gives rather diffuse and non-specific symptoms and an interdigital neuroma, which general gives rather clear, consistent and specific symptoms, but if he indeed thought at first that you had tarsal tunnel syndrome, why then the injection both in the ankle and on top of the foot, when tarsal tunnel syndrome is a condition only related to the entrapment of the main plantar nerve as it passes though the tarsal tunnel on the medial side of the ankle, and has nothing to do with doral nerves. I am also troubled by a doctor's intention at this stage to employ such as MRI's simply because he seems to be unable to come up with a real theory of the cause of a problem. I don't think that he has exhausted the traditional diagnosic process by physical examination if your account is complete, and I would think that if ANY tests were contemplated, nerve conduction testing would be more likely to be helpful, as you are complaining of sensory nerve problems. I don't really know what he means by "checking out the ligaments." But, once again, I must remind you that all of my impressions are based entirely on information gleaned through the words which you have supplied, and that may or may not represent all the thinking of your doctor.

 

Doctor and fellow big toe sufferers, I began having pains appx 2 months ago. I would describe everything exactly the same as our engineer in the UK. It has progressively gotten worse, with the shooting pain becoming more intense. At first the only time this would occur would be when I stretched my foot and pointed my toes out. Immediately a very sharp pain runs from just below the nail to the base of the big toe and continues until I stop stretching. This pain does not run down the center of my toe, but rather to the far right. It has gradually begun to be sensitive to the touch on top of the toe to the right, if touched just the right way. I can tap my desk with my foot and if it hits the middle of the toe to the outside, it almost takes my breath, the pain is so sharp. As with our other sufferer, the pain dissapates quickly once I straighten my foot out or cease the tapping on the desk. Another interesting point is that the very line to the outside right where the pain shoots out has gotten somewhat numb. I am scheduling an appt with my orthopedist over the next few days. After he discovered basal joint arthritis in both my hands - which deteriorated rapidly - he replaced both joints through the regular procedure using a tendom from each arm. This has been three years ago and both hands are doing very well. I trust this doctor explicitely and have had a great doctor/patient relationship for several years. I will definitely respond back to you after the appt. Also, I don't know if "my fellow UK sufferer" has noticed this, but for the last couple of weeks I notice that at night when I am turning over in the bed, if my toe rubs across the mattress at just the right spot as I turn over, the pain is again severe. Thanks to both of you, as soon as I got on the internet to see if I could find something on this today, the keywords I listed pulled up this page as the first site. I am stunned that everything you guys have discussed mirrors my symptoms and I feel much better after reading your comments. After a good self-kick to the ass, I realized I should have already gone to my doctor. I appreciate your candor, as well as your comments and will advise after I see him. Hopefully that will be some time this week. Thanks again for you r commissoration.

P.S. - I've had no injuries. I do not participate in any sports, nor do I go to the gym, I am 5ft 5in, weigh 125lb and try to eat right. Also, I am a buyer at a major shipyard in the U.S., so I'm not into a situation where I could injure myself. This just came out of nowhere. The only health problems recently was a 4 day stay in the hospital 7 weeks ago with pneumonia, where they also discovered my sodium as extremely low. However, after several drips they brought that back to the proper levels.

 

Hi, I have exact same problem in left big toe... Been like this for nearly a year (may be more). I dread putting on my boots or taking them off, as stretching foot to point sends very sharp pain. Also, moving around at rest in bad as described is also the same. Glad I found this page I hope some answers can be found as my problem does not seem to be going away. Incidentally though last week for an odd day I did not seem to have the usual pain, but a day or so later it was right back again as it mostly is.

 

Hi Guys,
Sorry to hear there are more sufferers out there but also glad to know I'm not the only one...

I have my second physiotherapy appointment in a couple of hours time and I'd say my condition has improved a bit since last week. Obviously it is dangerous to assume that my condition is the same as yours but I have found that flexing my foot (after warming up the joints) in just the right way seems to be helping.

What I do is sit on a chair and place the painful foot up on my opposite knee. I then point the toe and with one hand over my ankle and with my thumb cupping the heel I use the other hand with the palm directly over the big toe, and fingers across the other toes, to gently stretch the big toe and the forefoot towards me. This triggers the pain initially but with regular stretching it seems to have helped to loosen things up. I now find that I can move my foot farther without pain which I guess is a start.

If I learn anything new this evening from my physio I'll let you know.

Regards,
Craig.

 

Major kudos to you Craig. In the years during which I have been participating in Internet forums, I cannot recall a single other lay poster who acknowledged that when someone says that "I have the exact condition that you posted about," not only have they little or any basis for making that assertion, as there is rarely enough posted information to support such an un-categorical conclusion, but that conclusions and advice reflecting such a belief may actually be dangerous, as suggested actions which will inevitable subsequently flow might be taken as definitively appropriate for another. When I so state, as have you, it rarely goes over well. But I think it unlikely that you will get the guff that I often endure from those who often seemingly take perverse pleasure in disdaining authoritative professional opinion.