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Difficult case

Discussion in 'Biomechanics, Sports and Foot orthoses' started by kd1987, Jun 23, 2010.

  1. kd1987

    kd1987 Welcome New Poster

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    Hi all - First time poster

    I'm a new podiatrist and have recently come across a case that has me stumped.

    Patient Profile:
    male, late 20's, tall and slightly overwieght - put on 20kg in the last year, work and uni involves standing for periods of time, does not do much exercise, young family

    Foot profile: has a fairly flexible pes cavus foot type - one of the higher arches I have come across, wears shoes out quickly, has orthotics with the aim to help with shock absorption

    1) over the last few months has had a slight case of plantar fasciitis, which has resolved with appropriate exercises and orthotics.

    2) Secondly he has been experiencing an insidious dull aching pain at the base of the right 4th metatarsal - there has been no prior injury to this area, pain can be elicited by plantar palpation
    - This dull pain comes about after a period of standing and at times forces him to have to rest to relieve the pain.
    - Initial ultrasound imaging diagnosed a vascular effusion at the base of the 4th met which may be irritating the EDL tendon.
    - After the orthotics were administered and appropriate activity modifications/icing etc, the pain slightly improved but is still irritating
    - Through the GP he was booked to have the effusion fluid aspirated with an ultrasound guided injection, but this was abandoned during the procedure due to a lack of fluid and cortisone was injected instead
    - since the cortisone sx's have improved by 30-40% but still a concern and affecting his ability to stand during uni placements. A subsequent ultrasound came back negative
    - after the 2nd ultrasound results, I was thinking there could possibly be a stress reaction/fracture at the 4th base, but xrays came back negative (previous ct imagaing 3 weeks into the sx's were also negative).
    - I recommended to go non weight bearing (cam walker) for the next two weeks and to review


    So seeing recent ultrasounds and xrays have come back negative and the symptoms are still present, if anybody has an idea of a potential diagnosis and some experience in treatment that would be greatly appreciated.

    Thanks kd
  2. Hi KD :welcome: To Podiatry Arena.

    I would recommend you look at a plantar plate tear as your diagnosis and before you say whats that ? Read this thread from last week. Plantar plate tear threadThe 1st post I put up a paper which I think you might find very useful. We also discussed treatment for the condition.

    Goodluck and hope it helps
  3. kd1987

    kd1987 Welcome New Poster

    Hi Michael, thanks for your response and the welcome!

    I will definatley have a look through the link you provided,

    however I probably didnt explain it well enough in this case, the pain is actually a midfoot pain, in the area towards the base of the 4th met at the joint with the lat cunieform/cuboid.


  4. Hi again KD You did write base sorry my bad, reading what I want to read I think

    Kevin Kirby has written about Dorsal Midfoot Interosseous Compression Syndrome http://www.podiatry-arena.com/podiatry-forum/showthread.php?t=1980 Which when reading your detailed 1st post again, to read all of the words !! May fit the bill for your patient.

    The none trauma, increased weightbearing leading to increased sysmptoms which Kevin writes about, Hopes its more helpful than the last thread for this patient.
  5. CraigT

    CraigT Well-Known Member

    Can the patient localise the pain themself easily? ie: does the patient say that the pain is on the spot you palpate before you palpate, or the pain more vague over the dorsolateral midfoot?
    If it is a vague pain, then it could be peronel nerve tension. The tender point and imaging results may be incidental.
    Dave Smith gives an excellent description of the test technique here
    If the test is positive, then increase lateral support in the orthoses and prescribe neural stretching.
    Another possibility to consider would be cuboid syndrome. Similar modification to the orthoses.
    Last edited: Jun 23, 2010
  6. conp

    conp Active Member

    kd welcome,

    Just as a side issue......20Kg in a year is a hell of a lot of weight in 12 months. With weight gain I always ask whether they can account for this (lifestyle change etc). If not I would suggest they see their GP about this. Unexplained weight gain is not good!

    How does he go without orthoses? Any better or worse?

  7. kd1987

    kd1987 Welcome New Poster

    michael - thanks that was a really interesting read, does sound like something my pt could have

    craigT - the pt can definitley localise the area, but I will try those tests just to exclude anyway

    conP - the weight gain is definitley an issue I have brought up with the patient, by no means he his obese, but is overweight. He did state that he previously went on a diet/exercise and really slimmed down, however over the last year or so, has put it all (and some) back on. Therefore I would put his weight gain down to lifestyle factors.
    Due to his extra weight and his pes cavus foot type, obviously addressing shock absorbtion (via orthotics) is one of my goals. However since the othotics were issued, only the plantar fasciitis symptoms have improved in any significant manner. The midfoot pain has only improved since the cortisone (briefly during activity mod - taking time from work/uni, obviously cant keep taking time away from). Hopefully offloading with a walker for a couple of weeks will show some improvement,

    any other suggestions will be much apprecitated!
  8. drsha

    drsha Banned

    Random thoughts:

    I would consider adding heel height to his everydau shoes.

    Check for TIP.

    Consider vaulting the foot to relieve midfoot symptomatology.

    Motor Control and training of peroneus longus should also prove helpful.

    Consider altering his plant gait away from rearfoot contact.

    Dr Sha
  9. David Smith

    David Smith Well-Known Member


    Dull ache sounds like a fracture. Try Pressing on the end of the 4th MPJ i.e. compressing the met shaft longitudinally, see if it hurts. If it does this is a good test for a fracture. Is there pain if you press on dorsal foot 4th base? Some fractures only show with a bone scan. Ultimately however the Cam walker is probably a good solution whatever the cause.

    Does he have a sever ankle equinus? some people can not dorsiflex the foot to 90dgs with the tibia and so when standing there is high moments about the midfoot due to increased GRF at the forefoot. After Cam walker you might want to address this for ongoing prevention of recurrence.

    Cheers Dave

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