Help with Diagnosis

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Can I have a bit of help with a diagnosis please.

8 year old boy presents with dorsal foot pain, referred by GP. Patient pointed to site of pain at 4th-5th met bases bilaterally. Pain reproduced on palpation of base of 4th met junction with cuboid bilaterally. Pain not too intense, patient thinks about 5-6 out of 10. No pain palpated or reported at any other site of the feet. The pain has been present for approximately 12 months and progressively getting worse with Mum reporting the child complaining of the pain more often now, nearly daily. Pain worse after activity and present on torsion of midfoot, ie. when FFT everted on rearfoot upon testing of midfoot ROMs. Slight right shoulder drop, however no LLD or scoliosis present.

The painfull site seems to relate to the anatomy within the Lisfranc complex, however the symptoms are bilateral and no trauma/injury pre onset.

The foot type is a 9/12 FPI bilaterally, met adductus bilaterally but more prominant on the left. MLA maintains some contour throughout gait and in stance, despite STJ pronation from heel strike through propulsion. Hip ROMs WNL. Gastroc/soleus moderately tight with only a minimal restriction of ankle joint dorsiflexion. Genicular position normal.

The patient has a history of upper back and neck pain over the past three years or so and has seen oeteopaths and Chiro's with no real results. He complains of back and neck pain after activity and when mum rubs his back he reports tenderness. The neck pain seems to be worse than the back pain. There was no pain present in the back or neck when in clinic.

I rarely send children for X-ray, however I have sent this boy for some film. My thinking was to rule out any osseous anomalies such as coallition.


Do you guys have any suggestions for me?

Trent

 

Hi

Was there any family Hx of this?

Progression of Coalition - possibly - but also have a look at Talipes Equinovalgus.

Passively move the foot into an everted and plantar flexed position. Is the pain still there?

Hope this has helped a little - or should i leave my head in the sand?

Kiwi AD:bash:

 

Thanks for the odds Moose, keen for a day at the races fella?

Kiwi, no family Hx of coalition, though I'll try the test you have prescribed when I see this patient next week, thanks. Oh, although I haven't seen it, I'm sure your head is best above the sand. ;-)

Regards and thanks to both of you
Trent

 

Hi Trent,

Have you considered Lateral Column Overuse Syndrome (LCOS). This can occur in metatarsus adductus foot types in addition to a laterally deviated STJ axis, however, in your pt it appears that he is pronating.

Regards,

Daniel

 

He is pronating heavily through the STJ, 9/12 Foot Posture Index. I'm keen to get the X-rays back, however if they are negative then I'll have to start considering soft tissue conditions. The bifurcate ligament seems to be one of the only structures specifically related to the 4th met/cuboid junction. Can anyone shed a bit more light on the localised anatomy?

 

calcaneocuboid coalition is not a common condition associated with met adductus. could it be a 1.cuboid subluxation, 2. peroneal tendonoses (as the STJ is pronating) 3. tarsometatarsal ligament (interoseus) tear (unlikely but can be considered. an ultrasound cud be usefu. 4. os peroneum 5. fracture of styloid (x-ray)

 

Still waiting on X-rays. If negative results then it might not be a bad idea to send off for an ultrasound. Thanks

 

Trent:

Just out of interest, what is the shape and contour of the longitudinal arches, do they appear convex? Im just tyring to throw some ideas out there....

 

Hi;
Neck and back pain since age 5; bilateral "tenderness" 4th met/cuboid.
Anything else?
--------------------

What's his general health like?
Medications?
Other joint pains?
Stiffness in AM?
Is he active? Sports? What do his shoes like like? Sitting habits? Sleeping position? Does he skate board? Video gamer?

EXAMINATION:
DTR OK?
Any dermatome symptoms.
Muscle strength normal?
Is he well developed for his age?
Gait normal?


Steve

 

His ILA has some contour, even though the STJ is pronated throughout gait his arch does maintain some contour throughout. All other areas that you have mentioned are also clear. he is otherwise a healthy boy who contributes intellectually and physically well for his age.

Something just doesn't feel right here, that's all. The X-rays came back clear so we are dealing with a soft tissue issue or a larger sytemic issue or both. The back and neck pain worries me.

 

Trent:

The most common cause of pain in this specific anatomical area of the foot in adults is lateral dorsal midfoot interosseous compression syndrome (also known as lateral column overload syndrome). However, I have never seen this syndrome in this age group. Increased dorsiflexion loads on the lateral column will increase the interosseous compression forces at the dorsal margins of the 4th met-cuboid joint and 5th met-cuboid joint. First try a pair of 6 mm adhesive felt heel lifts on top of the insoles of his shoes with the heel lift ending at the calcaneo-cuboid joint. This will reduce the lateral longitudinal arch flattening moment and most likely reduce his symptoms significantly.

Good luck and keep us informed of his progress.

 

Thanks Kevin. That makes alot of sense, I'll try the lift on him in the next few days.

 

Kevin:

Is it possible for dorsal midfoot interosseous compression (DMICS) to occur in the lateral column of a foot which has a medially deviated STJ axis? Trent’s pts FPI score was 9, which would indicate that the foot is excessively pronating. Trent hasn’t confirmed yet whether or not the pt has a medially deviated STJ axis, but I would suspect that the pt does. Therefore, I was under the impression that dorsal lateral column pain would be more associated with a foot that has a laterally deviated STJ axis. Can the same condition occur in a foot type that has a medially deviated STJ axis? As a result, in these foot types, I would have thought they would have been more susceptible to dorsal medial column pain. Is it possible for lateral column and medial column pain to appear in both foot types?

Regards,

Daniel

 

Daniel,

The patient does have a medially deviated STJ axis, he is pronating heavily through the STJ and compensating throught the MTJ. I'm keen to see Kevin's response to your question.

 

Hi Trent,

Yes, I'll be really interested too...

 

In general, dorsal midfoot interosseous compression syndrome (DMICS) tends to occur in the medial Lisfranc's joint in feet with medially deviated subtalar joint (STJ) axes and tends to occur in the lateral Lisfranc's joint in feet with laterally deviated STJ axes. However, just because the young lad has a medially deviated STJ axis does not mean he can not develop lateral DMICS.

We know the boy has a equinus deformity and also has a metatarsus adductus deformity. These two in combination by themselves can create increased lateral column overload. In the older Root type terminology, we might say that if he had a partially compensated rearfoot varus deformity either due to an increased tibial varum deformity, an increased rearfoot varus deformity or due a limitation of STJ eversion range of motion, then this will create an increased loading force on the lateral metatarsal rays and a decreased loading force on the medial metatarsal rays. In other words, even though his foot is maximally pronated at the STJ and the foot has a medially deviated STJ axis, if the STJ is at the end of its pronation range of motion with the lateral metatarsal rays being loaded more by ground reaction force (GRF) than the medial metatarsal rays, then there will be more tendency to develop lateral DMICS than medial DMICS.

This is exactly where the Foot Posture Index falls short. It combines the pronation and supination related postural changes of both the forefoot and rearfoot to one measure so that it gives you little good information on how to treat the patient or as to why the patient has developed the pathology.

Hope this helps explain the mechanical concepts sufficiently. By the way, excellent questions!!

 

Could I summarise this by saying that there is the type of loading problems seen in garden variety (I am sure someone will commment on this) pronated foot which are commonly more medial (plantar tension, dorsal compression etc.), but symptomatic through the lateral column due to the GRFs being greater in this area?
I have seen this many times (cuboid syndrome perhaps most commonly) and it is one foot type which is often poorly recognised by non podiatrists.
I find that Low dye tape with extra force through the cuboid is also very useful...

 

just out of curiosity, i recall from a post by Dr.Kirby that a felt pad under the MLA plantaflexes the forefoot. if this lad had a mid tarsal joint collapse then why not opt for a felt pad then a heel raise.

Regards

dave

 

Just because a foot has a medially deviated STJ axis, does not also mean that the GRF will also be greater medially than laterally on the forefoot. Think of a person with a high degree of tibial varum that is maximally pronated at the STJ. If the forefoot cannot evert significantly relative to the tibia, then there is a good chance that the lateral forefoot will have large loading forces on it relative to the medial forefoot, even if the STJ axis is medially deviated.

 

Daniel and Colleagues:

For those of you who may be confused by the idea that lateral dorsal midfoot interosseous compression syndrome may also occur in a foot with a medially deviated STJ axis, I am providing an illustration of the foot to better describe how mechanically this could occur. Remember, the relative loading forces from ground reaction force acting at each metatarsal head is not dependent solely on STJ axis spatial location, but is also dependent on many other factors, to name a few, forefoot to rearfoot relationship, dorsiflexion stiffness of each metatarsal ray, and tibial and rearfoot frontal plane position. Hope this illustration makes these facts more clear.

 

I wanted to report back to this thread on the progress of our young 8 year old lad with dorsal midfoot interosseous compression syndrome. I placed the patient on 6mm heel lifts 6 weeks ago, he reported today for review of his symptoms and he and his mum both report 100% resolution of pain bilaterally.

This was a great result for this young boy, as he had been suffering the symptoms for over 12 months. There has also been an interesting bonus outcome here, the upper back and neck pain has also settled down. I'm not sure how the two are related though, any ideas?

Thanks so much for your help though everyone, this has been a very positive outcome thanks to Pod Arena.

Regards
Trent

 

just want to say thanks to all involved in the above thread. not only have i learnt a great deal from all your contributions, but its encouraging to read a positive result from treatment from start to finish. congrats to you all and thanks

 

Trent:

Thanks for providing this followup for all of us. You have provided a valuable service to the worldwide podiatric community and their patients.

One must always remember that even the most perplexing clinical problems may require only simple solutions for their resolution, if the proper treatment method/theories are used. By using the concepts of the tissue stress model of mechanical therapy which involves specifically identifying the anatomical structure that is injured, determining the forces/moments that are the most likely causative agent of the injury and then providing a treatment plan that will best resolve those pathological forces/moments without causing other injury/pathology, the clinician will be able to provide the treatment for the patient that is not only relatively simple but effective.

Trent, this case report is an excellent example of how, by using these tissue stress concepts, you were able to heal your patient's pain, of 12 months duration, completely within 6 weeks with just the simple addition of heel lifts. Awesome job!

 

The "awesome job" was done by yourself Kevin and others that contributed to this thread. Thanks so much for your help. Taking away a child's pain is the best result for me, it's the ultimate reward. It's great to be a part of this community that openly shares it's knowledge and experience for the betterment of our profession and patient outcomes.

Regards
Trent

 

Yes more of this please ..............................

jude

 

Thanks so much for this thread and all your contributions!