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Hi guys,

I had a 60yo pt present this week with lateral foot pain. Details as follows:
- Pt has pain around the sinus tarsi area and extends under the plantar 5th met. Tender to palp only at the sinus tarsi; 5th met not tender to palp
- Pt is a mental health nurse and routinely works 12 hour shifts
- Pain is intermittent but tends to be related to load - ie it hurts most after a long time WBing. Nil pain @ rest
- He wears an ankle compression brace, which tends to help the pain slightly
- Nil pain on palpation of the fibula or peroneal tendons...
- No Hx of inversion sprain
- In gait, he has significant rearfoot eversion motion and midfoot drop
- This pt has orthotics from another pod from 4/12 ago. They improved the pain slightly, but it is still present. The orthotics have a high medial skive, I query whether they are over controlling him

In the apptmt, I moccasin taped this pt, advised him to get some footwear with a midsole and supportive upper, and intrinsic mm exercises, and I'd like to adjust his orthotics next time.

My provisional Dx would be a sinus tarsi syndrome.

As I think the orthotics are over-controlling, I'd like to add some forefoot wedging to the device to push him over and off his lateral foot and onto his 1st ray a bit more. My questions are:
- What is the best way of incorporating forefoot lateral wedging to a rigid polypropylene device? Should I add a 2-5 EVA valgus pad under the topcover, or is there something I can do to the underside of the orthotic?
- Is there anything I could be missing in my Dx

Any help greatly appreciated...

 

Sitting here in my armchair, it really sounds like sinus tarsi syndrome. Was there pain with peroneal muscle testing (peroneal tendonitis from over supination?) Different things can cause high loads on the fifth met/ lateral column. A partially compensated varus will have high loads laterally and low loads medially under the forefoot. For this you could consider a forefoot varus extension under the met heads.

Another thing that can cause high lateral loads is constant posterior tibial muscle activity. An unusually high medial arch of an orthosis can be very uncomfortable unless the patient constantly contracts their posterior tibial muscle. Look at the patient standing on their orthotic. Does it look like the meidal arch could be hurting (blisters callus) or can you see/palpate the posterior tibial tendon? If the arch of the orthosis is too high you can use a heat gun and lower it. If you did that you could leave the inverted heel cup alone.

Another thing to look at is the maximum eversion height test. Attempting this while standing will often hurt those with sinus tarsi syndrome. If there is no eversion range of motion available, you could look to see if there is an intrinsic forefoot valgus post in the orthotic that could be attempting to evert the STJ while the medial heel skive is attempting to invert it.

Just some thoughts.

 

Thanks for the reply eric. Will definitely try those things. There was no pain on resisted eversion of the STJ or palpation of the peroneal tendons, so I'm ruling out a peroneal tendonopathy for now...

Just in regards to you saying "For this you could consider a forefoot varus extension under the met heads." I'm just struggling to see where this will fit in. It will support under his medial foot more, but I just don't want to 'push' him over more laterally with a FF varus extension when he is already striking laterally. Any thoughts on this?

 

There is a difference between force and position. One way to think about this is that since there is lateral column overload, you need to increase load on the medial column. Putting a forefoot varus extension on the orthotic will not necessarily cause the STJ to supinate and shift load over to the lateral column. In a partially compensated varus foot, the lateral forefoot is loaded and there is not enough range of motion of the STJ to fully load the medial forefoot. In this case the forefoot varus wedge is increasing load on the first met head, but not necessarily changing the position of the rearfoot. Often the STJ axis runs medial to the first met head and this makes upward force on the first met head cause a pronation moment at the STJ.

Of course the forefoot varus wedge would probably be bad in a laterally deviated axis foot.

 

Goodaye Will, no contribution here, sorry; am interested in your use of 'mm' for muscle. I used to use it also but after doing so on P-A once I was queried on its meaning and then origin.
Would you know whence it came?, thanks mark

 

Just something I've picked up from physio nomenclature - not sure of the etymology sorry

 

I think I remember seeing it in an anatomy textbook when I was a student. Must be very old.