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Extreme lateral midfoot pain ? advice needed please

Discussion in 'General Issues and Discussion Forum' started by AdamB, Feb 24, 2014.

  1. AdamB

    AdamB Active Member

    Members do not see these Ads. Sign Up.
    looking for a little advice on a 45 yr old male patient that presented today -

    CC - severe lateral right foot pain. Pain rated 10/10 (for a male) :D.

    HPI - approximately 4 weeks ago got out of bed with foot pain.
    No trauma or injury reported.
    Pain primarily around lateral midfoot, radiating distally down 4th and 5th metatarsals.
    Patient unable to put much weight through foot and pain causes significant difficulty in walking. Oral anti-inflammatory advised by the GP did not help.

    PMH - no significant past medical history, no significant medical conditions/illness.

    Exam - Severe pain on palpation of cuboid / lateral cuneiform, bases of 4th and 5th metatarsals and 5th met from underneath. Some diffuse swelling around lateral midfoot and patient reports the area to feel "warm". No redness or bruising was evident.

    Clinical tests - Plain films were ordered immediately, however no bony pathology was noted and no evidence of stress fractures. Radiologist has suggested CT as the next step if I suspect a tarsal fracture.

    DD - ?

    I am stuck. The nature and severity of his symptoms suggest something serious. Simple cuboid syndrome is not likely - unless it is significantly dislocated. I have strapped his foot and ankle to reduce joint motion and partially immobilise in the hope that it may help.

    Any suggestions where to from here?

    Thanks in advance.
  2. chellep

    chellep Member

    Maybe PB , PT or
    PL tear? Ultrasound investigation would clear any doubt and be much cheaper than a ct. Good luck!
  3. Would be worthwhile doing an MRI to rule out osteopenia or bone marrow oedema.
  4. footdoctor

    footdoctor Active Member

    Hi Adam.

    A Partially dislocated cuboid can be extremely painful.

    Is there restricted d/f p/f of the 5th ray?

    If no boney pathology exists I would attempt to mobilise the CC joint.

    Had a patient in last week who could barely weight-bear. lat border pain, pain on palpation plantar to cuboid, red hot and swollen. One mobilisation and on follow up, pain free.

    Pain on resisted eversion? could be peroneus brevis tendinopathy.

  5. AdamB

    AdamB Active Member

    Thanks for the replies guys.

    I kind of ruled out cuboid dislocation as there was no pain on palpation plantar to cuboid... but there was plenty when I palpated dorsally.

    Maybe it was dislocated dorsally? I will reconsider this.

  6. Adam:

    This sounds like lateral dorsal midfoot interosseous compression syndrome (lateral DMICS). Most of the patients with lateral DMICS have higher than normal arch height or metatarsus adductus deformity. They will be tender dorsally over the 4th and 5th metatarsal cuboid joints, may have some slight edema and will have intense pain with manual plantarflexion of the 4th and 5th metatarsals relative to the rearfoot (i.e. Forefoot Plantarflexion Test).

    Lateral DMICS is caused by excessive lateral column dorsiflexion moments which likely causes microfractures in the dorsal cortical margins of the 4th and 5th metatarsal-cuboid joints. A bone scan may show increased uptake in this area of the foot and an MRI is likely to show slight dorsal bone edema in this area of the foot. X-rays and CT scans for this injury are useless.

    Here is what you should do when presented with a patient with this syndrome.

    1. Place them into a cam walker boot brace which should greatly eliminate their pain with walking and have them wear it from 2-6 weeks depending on their level of symptoms and their clinical response to the brace.

    2. Have them ice the dorsal aspect of the lateral midfoot 20 minutes twice daily and have them take oral NSAIDs and or use topical NSAIDS 3-4 times a day.

    3. Once they are out of the brace and able to walk more normally, put them into a rearfoot and forefoot valgus wedged insole/orthosis to off load the lateral column during weightbearing activities.

    In June 2010 I wrote a newsletter about this specific injury which is now published in my fourth book where I describe the mechanism and treatment of this injury (Kirby KA: Foot and Lower Extremity Biomechanics IV: Precision Intricast Newsletters, 2009-2013. Precision Intricast, Inc., Payson, AZ, 2014, pp. 95-96).

    Hope this helps.:drinks
  7. AdamB

    AdamB Active Member

    Thank you Kevin! I did not consider this diagnosis because his pain levels were well beyond what I thought were typical for DMIC syndrome. However, your explanation of the pathophysiology could explain his symptoms. He also does have a mild cavus foot type as you suggested is common with DMICS.

    Thanks also for the suggested treatment regime.
  8. Adam:

    Send me your e-mail address privately and I'll send you that newsletter I mentioned on Lateral DMICS. kevinakirby@comcast.net
  9. David Smith

    David Smith Well-Known Member

    Nice one Mark
    Painful bone marrow edema syndrome of the foot and ankle.
    Orr JD1, Sabesan V, Major N, Nunley J.
    Author information
    Bone marrow edema syndrome (BMES) of the foot and ankle is an uncommon and often undiagnosed disorder that, to our knowledge, has not previously been reported in the orthopaedic literature. The current study reviews a consecutive series of patients who were seen with this musculoskeletal disorder in order to highlight the clinical presentation and diagnostic imaging characteristics specific to this disorder.
    A retrospective chart study was performed involving 601 patients who underwent magnetic resonance (MR) imaging of the foot and ankle at our institution from April 2005 to April 2006. We identified 14 patients whose MR imaging demonstrated findings consistent with BMES.
    All 14 patients demonstrated characteristic diffuse, irregularly increased signal intensity on T2-weighted MR imaging and variable areas of decreased signal intensity on T1-weighted MR images in an average of three bones within the foot and ankle. Average patient age was 16.4 (range, 10 to 27) years, and no patient reported a history of prior trauma. Eight patients received treatment for an incorrect initial diagnosis with two of those patients undergoing surgical procedures. Twelve patients were successfully treated with supportive nonoperative therapy for an average length of 19.4 months. Four patients had followup MR imaging demonstrating signal changes consistent with their clinical improvement/changes.
    BMES of the foot and ankle is a clinical disorder seen in younger patients with a clinical history of prolonged foot and ankle pain of unknown etiology and without prior trauma. MR findings from this series are consistent with previous descriptions in the radiology literature. Furthermore, MR imaging can be utilized to monitor the progression or resolution of this disorder. Proper diagnosis and treatment may prevent further unnecessary diagnostic testing or surgical procedures.
    PMID: 21189186 [PubMed - indexed for MEDLINE]

    Although having said that getting an MRI out of a GP is getting very difficult these days now that they hold and allocate funds. This has been the case for me at least in a number of referrals lately and the GP said, and I kid you not, you don't need an MRI the best therapy is just to walk on it till the pain goes!!!
  10. I think there is a typo in the above: a forefoot valgus post will increase the dorsiflexion moments acting on the lateral metatarsals and exacerbate the problem if it is a lateral DMICS. Better to offload the lateral forefoot with a varus forefoot post. I usually use a dual density forefoot extension too, with more compliant material under 4th and 5th met heads.
  11. Kevin

    What would be interesting is a study to determine the incidence of osteopenia with DMICS. I had assumed that compression would give rise to a symtomatic osteitis - but it may well be the precursor to BME. Are you aware of any studies where MRI have been routinely done in cases of DMICS?

  12. Actually, it was not a typo. I do use slight forefoot valgus wedges to help deviate the STJ medially in these patients. However, it is better to put most of the valgus correction into the rearfoot (i.e. lateral heel skive) and midfoot of the orthosis with a relatively small valgus forefoot extension under the metatarsal heads, in my experience.
  13. This is what I was looking up ;) I think it's a skinning cats situation.
  14. Mark:

    I would love to see a MRI study on DMICS since I would bet that bone edema would e present at the dorsal articular margins of the affected midfoot joints. However, since I don't routinely order MRI scans on these patients, it's hard to know.
  15. Just because a young patient has bone marrow edema in some of the bones of the foot, does not also mean that they have "bone marrow edema syndrome". Bone marrow edema can occur without trauma in athletically active individuals and the bone edema is not always symptomatic but likely does represent microfractures within the bone.

    Many collegiate and professional sports teams now use MRI to detect bone edema in the feet and lower extremities and assume that these are areas of increased bone stress. We don't call the bone marrow edema in these athletes "bone marrow edema syndrome" so be careful labeling athletically active individuals with the diagnosis of "bone marrow edema syndrome" since the areas of bone marrow edema may simply be areas of increased bone stress due to abnormal biomechanics and/or abnormal mechanical stresses on the affected bones.

    Role of MRI in Prevention of Metatarsal Stress Fractures in Collegiate Basketball Players

    Clinical Outcome of Edema-like Bone Marrow Abnormalities of the Foot

  16. AdamB

    AdamB Active Member


    Just a follow up on my original post.... I was ready to put my patient in a CAM walker for 2 - 4 weeks and also suggested an MRI (both costly here) when he called the clinic and told me that he was driving (injured foot on the accelerator) and he heard this loud "pop" and felt a massive release in his foot and it now feels much better!

    He is coming back in today, but I suspect that he may have had a dorsally subluxed cuboid that all of a sudden reduced itself back into place as he moved his foot in a certain way.

    I didn't consider the diagnosis of a subluxed cuboid at first due to the unique presentation and very high pain levels. However, it was in the back of my mind, and I'm glad we now have a diagnosis.

    Any thoughts on what the best management is from here? More strapping? Gentle Mob's?

    Thanks everyone for your input.
  17. Ian Linane

    Ian Linane Well-Known Member

    Hi Adam
    Should a similar situation present again there is a very simple, usually effective, mulligan MWM, done semi-weightbearing, for the cuboid. This is often one of my first treatment steps in dealing with pain in this area when I suspect cuboid involvement. It has saved me and my patient time in terms of recovery. The nice thing about it is that it is applied from a dorsal angle which allows you to be more precise, and targeted, in where you are applying a gentle force.
  18. Ian Linane

    Ian Linane Well-Known Member

    Whoops just seen your other questions:

    Never had the need to apply strapping with the cuboid but it could be my pt population (?).

    I would certainly look to mobilise the remaining tarsus bones but as foot mobs can be done so easily, gently and quickly you might as well gently mob the lot.
  19. AdamB

    AdamB Active Member

    Hi Ian, thanks for the reply.

    This Mulligan technique you describe sounds interesting - any links to how I might learn this one?

  20. Ian Linane

    Ian Linane Well-Known Member

    I'm not too sure but I guess someone will have done a youtube somewhere. The essence of MWM is to take one bone of the joint into an appropriate glide and sustain it while the pt then moves that limb themselves. The method of the MWM is one that can be applied to many joints within the foot.

    An underlying principle is that the mob should be pain free and the results long lasting (slight discomfort is acceptable e.g. in the case of the cuboid you may be applying pressure upon the EDB in some cases). If the joint is painful in the direction of glide then change the direction and see if there is pain there. If no pain in that direction then that is the direction you would glide bone and sustain the glide in whilst the pt moves the limb.

    Assuming a right foot

    1 Pt seated on a chair with both feet on the ground.

    2 You kneeling at the lateral side of the affected foot.

    3 Place one or more thumbs (not the apex) upon the cuboid and note the angle your thumb is at. Apply a firm but light downward pressure upon the cuboid so that it glides inferiorly. There will be varied amounts of the downward glide available depending whether you apply pressure on lateral medial proximal or distal aspect of the cuboid.

    4 Once the glide is achieved sustain it and ask the pt to slowly raise their heel of the floor.

    5 As they raise their heel off the floor so the plane in which your thumbs are resting will alter as the foot starts to invert. Let your thumbs follow this plane. Ask them to lift the heel about about 5 times.

    6 If the inhibition of the joint is present then often the heel raise is slight and increases as the inhibition releases. Have them walk around the room and feed back to you. Be willing to redo again in that session.

    7 One other thing to do if the cuboid is too tender, say against the base of mets 4 & 5 is to apply the pressure to the base of the mets just distal to the cuboid.

    It works well for me and you can direct quite where your applying the pressure, even move it around the cuboid in the same treatment session.

    Hope this helps.
  21. Ian Drakard

    Ian Drakard Active Member

    Hi Adam

    Sorry to come late to this. A lot of very good comments already and glad there has been progress in symptoms and diagnosis.

    In my experience, I see issues around the cuboid more commonly dorsally than plantar, both in terms of presenting symptoms as well as palpable differences.

    I will also often find the peroneals are all very tender and especially their insertions. Usually abductor hallucis is also very tender.

    I have wondered whether there is sometimes a cross over with DMICS. As Scott mentioned there is usually an increase in 5th ray stiffness. I'm presuming this would mean an increase in dorsal compression forces between the joints also- is this plausible?
  22. David Smith

    David Smith Well-Known Member

    Along the same lines, I have a female customer who 3 months ago severely inversion sprained her ankle off the edge of a step. After going thru GP and NHS, no Dx of fracture or dislocation from Xrays, and still being in pain for several weeks she came to my clinic. She had diffuse dorsal foot pain somewhere around the 4th 5th met - cuboid cuneiform area but radiating toward the toes. After weight bearing for a few hours (she runs a hardware shop) the foot becomes very painful and all over the dorsal lateral aspect and into the anterior and lateral ankle.

    I fitted an Airwalker boot which does significantly reduce painful symptoms but after 6 weeks using it the pain has not reduced when not wearing the boot. She returned to GP with my request for MRI but was turned dow and told just to walk on it till it was better.

    My view of the x rays seems to show a swelling and displacement of the third /fourth met cuneiform joint but the radiology report of the first x ray and this one attached taken later after 6weeks, does not agree with this. Perhaps you could give an opinion as to if you see anything oon the xray and any advice as to where to go with a treatment plan??



    Cheers Dave
  23. Ian Drakard

    Ian Drakard Active Member

    Hi Dave

    I'm no expert in reading radiographs so will pass on that one. I can sometimes feel differences pre and post mobilisation of cuneiforms and cuboid and often wonder how sensitive x -rays would be in picking this up. The differences on palpation are quite small so not sure you would see much.

    Have you tried any mobilisation techniques on her?

  24. David Smith

    David Smith Well-Known Member

    Ok so today she returned with much more well defined symptoms that fit well with Cuboid syndrome and DMCIS. This fits well with the supinated foot posture and valgus forefoot. She also has no STJ eversion past 0dgs (heel bisection parallel to tibia)
    So I mobilsed the ankle and foot joints, used felt cuboid pad and medial f/foot varus post with rearfoot valgus post (all SA 5mm felt) This immediately made walking more comfortable. Now going to bespoke Amfit EVA orthoses.

    Still like your opinions on the X rays tho and any other thoughts you have

    Regards Dave Smith

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