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3rd & 4th met arthropathy in pt with fibro-cartilaginous calcaneonavicular coalition

Discussion in 'General Issues and Discussion Forum' started by Leah Claydon, Feb 25, 2013.

  1. Leah Claydon

    Leah Claydon Active Member

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    Dear Colleagues

    I am posting this case history with the consent of the patient. If you have any ideas as to where she may go from here, I would be very interested to hear from you.

    Patient: 54 female, thin 56Kg, BMI 21, prior to problem was keen runner & cyclist

    History: Pain on dorso-lateral aspect LF. Dorsal swelling over 3rd & 4th mets of
    6 year duration. Fanned toes 3rd/4th. Equisite pain plantar aspect of 4th/5th.

    Initial diagnosis (not mine) was Morton's neuroma. X-rays, U/S and MRIs undertaken - neuroma not specifically identified.

    Last Autumn local hospital administered IM space corticosteriod and issued a pneumatic Aircast boot with rocker. The boot reduced the swelling.

    Pt presented at our clinic in November. In spite of boot and injection therapy problem persists.

    RCSP: LF pronated, RF neutral.
    Supine: RF all foot and lower limb ROMs/alignments normal. LF STJ normal eversion, absent inversion - felt entirely blocked. Practice physio attempted to mobilise - would not budge. Attempted fibula manip, made no difference. Both of us thought it felf like an osseus block.
    Forefoot supinatus - 35 degrees

    Gait: RF exhibits normal flow. LF lands in pronation with audible 'plonk', marked abductory twist with heel adduction - pt appears to 'screw' 3rd,4th,5th mets into supporting surface, 3rd,4th,5th toes appear flacid.

    Action: letter to GP requesting access to radiological reports to check for tarsal coalition/accessory ossicles. Made temporary orthosis with 3 degree rearfoot varus post and cautious forefoot valgus post. Reluctant to interfere too much as pt was in midst of t/t from hospital.

    Pt came out of boot, symptoms quickly returned.
    New MRI in December showed "fibrous/cartilaginous calcaneonavicular coalition. No bony bar. Oedema within 3rd met head and proximal 3rd phalanx. No joint effusion but loss of joint space and cortical irregularity. Large 4th MTPJ effusion/synovitis, loss of cartilage and cortical regularity".

    My diagnosis prior to the finding of the calcaneonavicular coaltion was compensated forefoot varus with complications arising from STJ dysfunction. I had written in detail to the patient which she showed to the orthopaedics department. They were "dismissive" of my diagnosis and said "it was nothing to do with that".

    A recent letter from the orthopaedic surgeon to GP gives diagnosis of "arthropathy 3rd toe". Surgeon says "I am not sure of the cause, it's worth referring her to Rheumatology, I don't think there is a surgical cure".

    I genuinely believe the problem is mechanical in origin, based upon compensation for a non-supinating rearfoot.

    For now, I have advised her to try to wear rocker-type trainers to mimic the success of the Aircast boot. Her orthoses have not really helped but they are a very conservative prescription for fear of aggravating the lateral border of her foot with a large valgus wedge.

    I attach copies of screen shots of MRIs and X-rays plus Footscan.

    If anyone has any ideas, I'd be grateful. Do you think separation of the fibro-cartilaginous bar would be beneficial for example. This patient is truly fed up with the painful condition.

    Her appointment at the Rheumatology clinic is 6 March so some feedback will be gratefully appreciated. BTW: previous bloods did not reveal any underlying disease.

    Leah :empathy:

    Attached Files:

  2. efuller

    efuller MVP

    So, you have to explain how a STJ coalition is going to cause pain in lateral forefoot. It could just be an uncompensated varus. That might create the gait you describe as the STJ has no range of motion to bring the medial forefoot to the ground. If that is the case the temporary device with a forefoot valgus wedge should make the problem worse.

    The foot scan was interesting in how little weight bearing there was along the lateral forefoot of both feet. If it was a partially compensated varus you would see heel contact, lateral forefoot contact, and then a long delay before medial forefoot contact. You might even see the hallux contact before the first met as the patient tries to get medial loading by plantar flexing the toe.

    One thing to check. In static stance can you run your fingers under the medial or lateral forefoot. If there is very little pressure under the medial forefoot and the lateral forefoot crushes your finger, then a forefoot varus wedge should help decrease the load under the 4th and 5th met heads.

    Of course, it could just be some serious arthritis of the 4th met head as you have seen on the x-ray. (The uncompensated varus could cause that though)

    To people who don't know the foot very well all forefoot pain is a Morton's neuroma. Any classic neuroma findings?

  3. Admin2

    Admin2 Administrator Staff Member

  4. Leah Claydon

    Leah Claydon Active Member

    I attach a pdf file showing patient's stance. The medial border of the foot is in contact.

    To clarify: the left foot is pronated, right foot neutral. When in STJ neutral the forefoot is inverted on the rearfoot by 35 degrees. Compensation for this achieved with subtalar pronation. There is plenty of subtalar pronation available but zero supination from the neutral position.

    The foot lands in pronation and appears to remain pronated - the supination seen on the scan is achieved by lower limb abduction with heel adduction. On the scan dynamic scan it does not show overloading of the 3rd,4th or 5th mets but something interesting is occuring with the toes. On the right foot the toes load at midstance in the order of 4,3,2,1, but the left foot loads 1,2 at midstance and then 5,3 just prior to toe off - this probably is the heel adducting. The 4th toe is elevated and this is why it doesn't show. The fanning of 3rd/4th could be a sign of plantar plate rupture (?).

    Could this heel adduction be causing the irritation of the 3rd & 4th mets?

    In answer to Mr Fuller's question re Mortons Neuroma, this was investigated with U/S and not found.

    Attached Files:


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