Input please - cause of foot pain?

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Hi All

I'd be very grateful for any help you could provide regarding a new patient I have.

She's a 19 year old student who lives on a farm. Suffered a dorsal impact to the right foot two years ago when a sheep trod on her foot. XR and MR at the time showed no fractures or anything remarkable... but she had to use crutches for 6/12 as she couldn't weight-bear.

She now walks with a limp and points to (and I can identify) Right 3rd and 4th mid-met tenderness.

She's had numerous pairs of orthoses from several pods over the past two years and nothing has improved her residual 3 and 4 met pain. She's had steroidal injection and assessment from 4 orthopaedic surgeons and feels nothing's helped there either. Each surgeon finds nothing remarkable with her XR or MR (including the most recent images taken 2/12 ago).

Physio's, Chiropractors and Osteopaths have also seen her over the period and ensured there is no issue in lower back or lower limbs.

Any ideas on where to go from here? In my initial assessment I haven't found anything remarkable in her physical or biomechanical presentation. Only thing to report is congenital adductovarus 5th ph.

I've attached two XR and MR if that helps

Many thanks in advance.

https://www.dropbox.com/s/migo1wk290ds2rq/injury xr 1.jpg?dl=0

https://www.dropbox.com/s/qk31akazukt720b/injury xr 2.jpg?dl=0

https://www.dropbox.com/s/cbur18nmnt931oa/MR injury 1.jpg?dl=0

 

The history made me think of a Lisfranc's injury. Looking at the AP there is some gapping between the first and 2nd cuneiform. Only problem with that is that is not matching up with where it hurts. Good luck to you and your patient.

Eric

 

Thanks very much Eric ... I noticed that and considered the same possibility too ... Would be interesting to see if any other members observe similar.

Thanks again for the quick reply.

 

Hi Kahuna.

There seems to be some general marrow oedema present within the 4th met. Stress reaction? Possibly undisplayed fracture which involved the adjacent TMTJ.

I'm guessing this is the MRI taken at the time of injury, If so I would repeat it and see if there are still signs of oedema within the met, or from your description, the joint. It may be that you are now dealing with early post traumatic degeneration of the 4th TMTJ.

Is the joint painful when stressed (piano key test)?

Naturally I would also ensure I've ruled out CRPS which I'm sure you have.

Kindest Regards,

George

 

Hi George

Thanks for your reply... it is a tricky one indeed... piano key test doesn't produce any midfoot pain, standing on tiptoe on the affected foot is also pain free too.

I was considering CRPS; thanks for adding it into your list!

Kind regards
K

 

Kahuna:

I see lots of crush injuries in my office since about 1/3rd of my practice involves treating work-related injuries. In injuries such as this, often times the x-rays are negative but the MRI is more likely to be positive. However, MRI scans are not useful for detecting traumatic neuropathies of the dorsal foot which often occur due to crush injuries or in detecting more subtle injuries of the structural components of the midfoot.

Are you sure the "tenderness" is not neural in origin? Is the any hypersensitivity or allodynia present in the area of "tenderness"? Is there a positive Tinel's sign over medial dorsal or intermediate dorsal cutaneous nerves? Traumatic neuropathies are very common in dorsal midfoot crush injuries.

Also check the dorsal tendons including the extensor digitorum longus to see if they are inflamed. Try plantarflexing the less digits and also try testing for active dorsiflexion resistance to the lesser digits to see if this elicits pain. Also try what I call the "Midfoot Compression Test" where you squeeze the foot from side to side at the level of the LisFranc's joint to see if this is painful. Normally this test is negative with no pain being elicited.

Lastly, make sure that her shoes do not place any dorsal compression force over the area of pain. Have you tried relacing her shoes? Is barefoot less painful than being in shoes? Are sandals less painful than shoes? Do shoes with higher heel height differential make a difference with pain? Are there any activities that exacerbate the pain?

These crush injuries may be difficult to treat but as long as you use a thorough history and physical examination and understand the mechanism of tissue damage and know your anatomy well, generally you can help these patients immensely.

Hope this helps.:drinks

 

Kevin,

Thanks so much for your most insightful suggestions.

Having reviewed the patient and carried out the checks you advised, I would now agree the symptoms are Neural in origin.

* there is notable hypersensitivity in the area of dorsal "tenderness"

* there is a positive Tinel's sign over both medial dorsal and intermediate dorsal cutaneous nerves

* the dorsal tendons appear inflamed.

* your "Midfoot Compression Test" at the level of the LisFranc's joint is negative with no pain being elicited.

* driving her car (pressing accelator) makes the dorsal pain worse

In short, you're a genius drinks!)

How would you proceed now? Neurophysiology / Nerve conduction tests?

I've immediately started her on re-laced shoes, and she's finding these an improvement (and she clearly reported that being barefoot is less painful than being in shoes

Also, when wearing shoes, the higher the heel, the less the dorsal pain...... So orthotics with heel lifts too..... Any other useful orthotic features for this type of midfoot dorsal presentation in your experience?

Many thanks again for your assistance,

:good:

 

Topical anesthetic patches work very well for post-traumatic neuropathic pain. The most common patches here in the USA are Lidoderm patches which can be cut to fit the are of pain and should be worn 12 hours on and 12 hours off. Generally this cuts the pain at least in half. There are a prescription item.

Nerve conduction tests will be useless since the nerves involved are too small to be accurately tested.

She may have a little bit of dorsal joint pain (Dorsal Midfoot Interosseous Compression Syndrome) and would benefit from increased heel height differential in shoes, a good-fitting orthosis and trying to avoid any dorsal shoe pressure on the midfoot.

Hope this helps.:drinks

 

That's brilliant; much appreciated Kevin

Thank-you

 

It's worth trying some massage work and gentle stretching around the sites of +ve tinels as well. Sometimes these post traumatic entrapments can be eased just by doing this in a targeted way.