47 Year Old Female - Shart Shooting Pain medial ankle, navicular area, upon initial stance.

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Hi Everyone,

This is the first time posting to Pod Arena, however, this case is slightly puzzling and inconsistent in many aspects. I would just love some fresh eyes on it.

47 year old female presented to our podiatry clinic a few months ago with a log history of pain in her left medial ankle/ posterior tibial tendon region/ navicular region. It is a sharp shooting pain that presents on initial stance, 8/10 on the pain scale (she indicates) but goes away fairly quickly - ie. 100m of walking (equivalent of four aisles of the supermarket, she says).

She has a history of plantar fascitis which was resolved with a corticosterioid injection and conservative orthotic therapy, she is posted at about 3 degress inverted. Her feet are pronated, but not excessively flat. There is no injury in the history that has lead to the onset, pt says it just happened one day.

She has had X-rays and MRI on the regions, which have lead to a surgical referral for an arthroscope of the left navicular, so some level of arthritis was/is present. This arthroscope has not improved the symptoms. MRI results showed degenerative changes centred on the articulation between the navicular and medial cuneiform characterised by subchondral cysts, some areas of articular cartilage loss and marrow oedema.There was also some bony remodelling along the medial aspects of the metatarsal head with several subcortical cysts noted and a trace of marrow oedema. Mild overlying soft tissue thickening including thickening of the joint capsule. No tendionopathy is noted and apart from a slight beginning of bunion formation, nothing else was worth noting on the MRI report.

Notes from the surgeon indicated that improvement was 70%, however, upon consultation with us, she has indicated that it hasn't significantly improved the symtom for which she hoped the surgery would correct.

Recent visits, we have been exploring continued orthotic use, possible inverting devices further and increasing the support through the arch to reduce the movement throughout the affected joints; massage to try and loosen the area up (which the patient say helps in the short term, she may go a day that she doesn't get the symptom). We have been thinking about possible differentials including tarsal tunnel impingements, however, symptoms are not wholly consistent. I have also pondered the idea that a nerve is being 'flicked' or stimulated by some sort of structure in the area that flicks out of place when standing and gradually works into the correct position??

Basically, it just in't making sense completely and more input would be great!

Cheers

Pod J & Pod P

 

Any trauma prior to onset?
What happens when you test the posterior tibial strength? Increased symptoms?
Ant Tibial strength?
Pain with first ray range of motion?
Can the pain be reproduced with various foot positions while weight bearing? Does it feel better in one position as opposed to another when standing?

You've got degenerative changes on MRI that is really close to where it hurts in the navicular first cuneiform joint. The more load there is on the medial column, the more compression there will be of this joint. What happens when you put a reverse Morton's extension (3mm EVA/cork under mets 2-5) under the sock liner?


Eric

 

Optimus Josie:

The MRI findings of bone edema, subchondral cysts and articular cartilage loss at the naviculo-medial cuneiform joint (NMCJ), along with the clinical findings of tenderness at this joint is the first step in using Tissue Stress Theory to identify how to next proceed. Basically, this patient has a arthritic NMCJ and your goal now should be to reduce the pathological forces at that joint so that the inflammation and pain may be resolved. Patients like this are common in my practice since I get lots of referrals such as this patients of yours with the hopes that I can help them with foot orthoses and other conservative forms of treatment.

Here is how I would proceed:

First, I would make sure that the foot orthosis being used has good conformity to the medial longitudinal arch (MLA), has at least a 3-4 mm medial heel skive, has a stiff rearfoot post and make certain that the medial arch of the orthosis is not so flexible that when the patient stands upon it that it flattens excessively (i.e. Standing Barefoot Orthosis Test). As Eric suggested, a slight valgus forefoot extension added to the orthosis may also help. These orthosis modifications are critical to orthosis treatment success and are all designed with the mechanical goal of reducing the interosseous compression force at the NMCJ which is the likely cause of the majority of her symptoms.

Second, I would make sure that the patient understands that any barefoot walking or walking in low heeled shoes/sandals/flip flops without orthoses is hurting her feet and she should not do this...ever....even at home. Gravity still works in the home as it does outside the home....a fact of physics that seems to be lost on many of my own patients.

Third, I would put the patient into a motion-control athletic/walking shoe or, better yet, a hiking boot. Add the orthosis to the shoe or boot for at least a month to see how this helps. If the hiking boot/orthosis combination doesn't help, then the patient should be put into a boot-brace walker or weightbearing below knee cast for 4-8 weeks to allow the bone edema in the NMCJ area to decrease. This may be necessary just to allow the orthoses to work effectively for the patient.

Fourth, as Eric suggested, doing a thorough muscle testing of all the muscles of the foot and leg is helpful to make sure there is no muscle weaknesses that may need to be addressed. I am very suspicious of a Stage 1 posterior tibial tendon dysfunction from your description. In addition, you should determine the location of the subtalar joint (STJ) axis to see exactly how medially deviated her STJ axis is. In addition, use the supination resistance test to get an idea of how hard the orthosis will need to push up in the MLA of the foot to get the foot to supinate.

Finally, you may consider a diagnostic injection of local anesthetic into the NMCJ to see how much pain this injection actually resolves for the patient. I also would consider an intra-articular injection of corticosteroid solution into the joint if the patient's pain is truly isolated to just one joint (which would be a very likely scenario if the patient got 100% pain relief from the local anesthetic diagnostic injection into the NMCJ).

If you can post up the MRIs here on Podiatry Arena it would quite helpful for those following along since, in cases such as this that I have seen over the years, the MRI scans are much more impressive than the plain film radiographs.

Good luck to you and your patient. You have given a very thorough clinical presentation here. This is a great case and I hope my suggestions help.

And by the way, welcome to Podiatry Arena.:welcome:

 

DMICS

 

So true.

As Kevin says - in cases where there is bone marrow oedema, it is pretty critical that the pathological stresses are removed at any weight bearing point.
If that means wearing custom orthotic sandals into the shower, then so be it.

Not that I think that this is a case of DMICS but I frequently advise patients with DMICS to purchase a pair of Fit Flops to wear into the shower because the heel sole differential is enough to prevent getting the dorsal compression that leads to the subchondral changes

As for management, you have the best advice from two of the best in the business above. I wish you every success

 

Agree with Kevin And Eric.

Just to help with your clinical thought processes in managing the cause of the tissue stress...

Revisit the orthotic design features you have previously employed and match them to the anatomical / mechanical presentation of the patient.

Consider clinical testing such as Supination resistance and Windlass function.
- are your selected design features incorporated into the orthotic device able to reduce medial column compression in this case?

Is Sagittal function being assisted whilst increasing stiffness (relative bracing) of the symptomatic area.

Are there any specific design features you may trial to assist with reducing the physical strain during heel off / propulsion?

You may find it easier to (as Craig P would say), "better conceptualizes the foot orthotic prescribing process following the clinical test -> prescription variable -> design feature protocol".

Good luck with the outcome.

p.s. dont forget the environmental factors which may be continuing to contribute to the tissue stress.

 

Interesting and challenging case and as usual, excellent feedback given.

"47 year old female presented to our podiatry clinic a few months ago with a log history of pain in her left medial ankle/ posterior tibial tendon region/ navicular region. It is a sharp shooting pain that presents on initial stance, 8/10 on the pain scale (she indicates) but goes away fairly quickly..."

Unlike the other posters, I am very suspicious of tarsal tunnel syndrome, with compression of her medial plantar nerve due to the nature of the complaint. I would think that the left foot would be more pronated than the left even with stage 1 PT dysfunction since its been going on a few months.

I have seen many patients with a symptomatic os tibiale externum from the Posterior tibial tendon pulling on it but they did not have sharp shooting pain nor at the level of 8/10. I have also seen my share of patients with PT dysfunction and their pain was usually aching and throbbing and the pain would get worse the more they were on their feet. They can have sharp shooting pain but it usually does not happen for months and usually at time of injury. From her symptoms, I am inclined to put tarsal tunnel syndrome high on my differential diagnosis list.

For diagnostic testing, I dislike NCV and EMG tests as they are often negative until the later stages. You can try to see if you can reproduce the pain NWB and percuss and palpate the area. You can also have the patient stand with their feet in their normal angle of base of gait while having them turn only their upper body clockwise (right) so their left foot is pronating and putting more pressure in the tarsal tunnel area. Then see if you elicit a Tinel's sign and also press deep within the lacinate ligament and porta pedis to reproduce the pain.

If your able to reproduce the pain, do the same test on the right foot so the patient can feel the difference between the two and have confidence in your diagnosis.

You can also try a diagnostic injection or two into the tarsal tunnel area. I like to use a cocktail of 2cc .5% Marcaine with epi, 1cc dexamethasone, 1cc of vitamin B12. If she has any swelling/edema, I will also wrap her ankle with an unna boot and coban as well as apply a felt pad under the medial longitudinal arch to decrease pronation. With the diagnostic injection I am ascertaining how many days of relief the patient gets. The foot will be numb for 12 to 24 hours due to the Marcaine with epi. Rarely are the injections therapeutic.

After 24 hours I want to see when her pain starts up again. If the pain starts soon after the injection wears off, I am inclined to think I am dealing with something else within the differential diagnosis. If she feels good for a week, this gives me more confidence that there is a nerve entrapment. I may try a series of three injections spaced apart to see if it can be treated conservatively (If I am lucky) along with appropriate shoes and orthotics. If there is swelling in the ankles, I will rx compression stockings to further reduce the pressure.

If the injections do not give her long term relief, I will do a tarsal tunnel release. I have had cases like this, and I was making an educated clinical diagnosis. Often I would not even bother with the NCV/EMG as if they came back within normal limits, I would still do the surgery. In my experience, tarsal tunnel surgery was very successful and intra-op I would see the extent of compression in the area of the porta pedis, lacinate ligament or both. I would completely transect the laciniate ligament and open up the area within the porta pedis to ensure there was no compression along the nerve route.

Thats my two cents, best of luck and keep us posted.

Steven

 

Thank you everyone for your very insightful and thorough responses and guidance! It is very much appreciated.

After considering everyones input, we now have many avenues of clinical reasoning to apply to our course of action, regarding management of our patient!

She hasn;t returned for her follow up appointment yet, but as time progresses and tests each intervention, I will endevour to keep you all posted as to the outcome for this particular patient, and I will definitely not be shy in asking any further questions.

Thank you all

Pod J & Pod P