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Advice required: Planter fascial or nerve damage?

Discussion in 'General Issues and Discussion Forum' started by Steve5572, Jun 10, 2009.

  1. Steve5572

    Steve5572 Active Member


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    Can anyone give mw some ideas on a difficult case I am dealing with at the moment? My initial impressions were that this was biomechanical issue, most probably planter fascial but im beginning to think that it could be some kind of nerve lesion or neuroma. Are there any tests I should be doing to look for nerve problems?
    Case details are below.

    HPI
    - Male, 35 years, 6 foot, solid build, steel cap boots
    - discomfort in Left big toe and 1st ray at night, tightness in arch during day for 6 years
    - discomfort will wake pt up in the morning, describes as ‘the feeling before a cramp’
    - bed sheets on toe are unbearable, pt. has to sleep with foot outside of bed.
    - NO heel pain upon rising/weightbearing

    RH
    - Pt had been a to a podiatrist 3 years prior
    - Prescribed a Mod Root device, 6mm poly prop, PF accom, and heel stabilizer, pt. wears orthotic daily
    - With no noticeable improvements in night pain
    - X ray and bone scan normal

    O/E
    - On palpation of foot there is some tenderness of L planter fascia
    - Pain can not be reproduced with metatarsal compression, MTJ DF, Inv/Ev
    - Foot posture appears with in normal range
    - Lunge test 10 cm on both legs
    - Sup resistance is high BF
    - Jacks/Windlass is high BF
    - Very little nav drift or drop, Pronation stopped by planter facial tension

    Gait
    - No obvious abnormalities
    - Mild abductory twist and early heel lift BF
    - No obvious asymetry

    Dx/Ddx
    - Planter fascial tightness or fasciites
    - Starting to think there is a problem with the medial planter nerve

    Tx
    - At the first consultation I added a 3mm poron arch cookie, large met dome, and 5 mm heel raise to his L orthotic
    - After 4 weeks the pt. noted an improv in ‘arch tightness’ during the day increased comfort from met dome but no change in night or morning pain
    - I further increased the arch cookie to 6mm and added a MTY pad
    - AT the 2nd review after another 4 weeks pt. had not noticed any change

    Your Thoughts?

    Steve
     
  2. Admin2

    Admin2 Administrator Staff Member

  3. Sounds like you should investigate nerve mobility.

    There is a range of tests which you or a Physio can do which will detect if there is a problem with nerve mobility.

    When you have positive sign of tightness you can target the required nerve/s.

    Slump stretching is the most common known of this stretching, where you "bounce " stretch the nerve to get greater mobility.

    The great thing with this is the tests will give you specific nerve to target with different stretching for each nerve section , but the stretching must be done correctly or you can get more problems.

    I find that its a great tool with unresponsive plantar fasiciitis type pain.

    Michael Weber
     
  4. Griff

    Griff Moderator

    Hi Steve,

    Have you performed any neural tests (Straight leg raise/Slump)? If you suspect neural tension/sensitisation then it might be an idea - if any of these are positive then bump them over to a Physio for neural glides etc.

    Anything of note/consideration more proximally?

    Ian
     
  5. LuckyLisfranc

    LuckyLisfranc Well-Known Member

    Steve

    Firstly - "plantar" not "planter". eg Plantar fasciitis, medial plantar nerve, plantar wart, et al.

    You describe the patients description of pain occuring principally in and around the great toe, with some secondary "tightness" in the medial arch. Where does the patient point to when you ask him where it hurts?

    From your description, I would be thinking of some simple issues around the 1st MTP joint, rather than less common options.

    Gout, osteoarthritis/OCD/sesamoid pathology, or Joplins neuroma seem more likely than issues more proximal. A mononeuropathy is possible (eg saphenous nerve compression).

    Don't get too hung up about all the biomechanics jingoism, and get back to the history and physical exam.

    LL
     
  6. Steve5572

    Steve5572 Active Member

    Thankyou all for your help. I have answered all questions asked so far below.

    Have you performed any neural tests (Straight leg raise/Slump)? If you suspect neural tension/sensitisation then it might be an idea - if any of these are positive then bump them over to a Physio for neural glides etc.

    Michael and Ian
    I have not done a classic slump test, what i have done is lay the pt supine, raise their leg (knee straight) dorsiflex the foot and hallux. The pt. noted tightness in the hamstring, however the pain was not recreated, the hamstring tightness was the same on both sides.
    I work with a physio, i will ask him to take a look at the next appt.

    Anything of note/consideration more proximally?

    nothing noted

    You describe the patients description of pain occuring principally in and around the great toe, with some secondary "tightness" in the medial arch. Where does the patient point to when you ask him where it hurts?

    LL
    The pt notes the feeling is non-specific, he can not locate the painfuill area exactly.
    I have palpated the hallux, 1st mjp and 1st ray, all joints feel relatively normal bilaterally. There is definetly no sign of gout, OA or RA, i'm not familiar with Joplin's neuroma ? Is that the same as Morton's neuroma?

    Steve
     
  7. David Smith

    David Smith Well-Known Member

    Steve

    Are you sure the two symptomologies are related? Maybe they are maybe they are not!

    Barring gout, when someone says they can't bear bed sheets resting on the toe at night, the first thing I look for is sub ungual heloma durum and this is nearly always the problem.

    Maybe they are related -- Perhaps the plantar pain is due to antalgic response i.e. curling the hallux toe in plantarflexion to protect from irritation from the bed sheets. This would keep the hallux abductor, flexor and plantar fascia short and so when weight bearing would increase tensile forces in those tissues. The continual over night contraction of the plantar muscles would likely lead to cramping.

    Regards Dave
     
  8. Nat Smith

    Nat Smith Active Member

    You mention that he wears steel caps? Elastic-sided pull-on or a lace-up? I work in a fairly industrial area and I find the biggest problem arises from elastic-sided steel capped boots for many presenting complaints. As Lisfranc suggests, go back to the basics before getting hung up on all the biomechanical possiblities. If he's in an elastic-sided pull-on boot, get him to switch to a lace-up for greater stability. I have found many symptoms resolved when patients make that simple switch. They are also easier for orthotics to fit in comfortably. Lace-ups provide a far greater fit. Elastic-sided boots stretch out too much and cause excessive movement and splaying of the FF causing many shearing stresses.
    Cheers,
    Nat Smith
     
  9. MikeM

    MikeM Member

    Have you thought about needling the Flexor hallucis longus and Abductor Hallucis? This is a classic referral pattern for these muscles if a person has an active trigger point in them.
     
  10. Steve5572

    Steve5572 Active Member

    Dave
    Im quite confident it is not a sub ungal HD, i inspect the nails as part of my assessment and did not see anything out of the ordinary.
    The pt has changed his sleeping position to prone, with foot hanging off the bed. If it was an antalgic response i thnk the change in sleeping pattern would have rectified the problem. As there is no pressure or tension on the hallux and planter fascia during sleeping at the moment. however the pt. is still woken up in the morning with the sensation so i am assuming there must be something else i'm missing.
     
  11. Brandon Maggen

    Brandon Maggen Active Member

    Hi Steve

    Sounds like you've comprehensively searched and excluded most possibilities so far. But I agree with LL when she mentions other differential diagnoses such as gout/ OA etc.
    You said x-rays and bone scan were normal so it does seem unlikely. However until you ascertain the exact cause of this pain, why not rule out Gout by asking pt to have a Uric acid blood test at the correct time. I recently attended a lecture from a Rheumatologist who has dispelled uric acid as diagnostic of gout for 2 main reasons, 1) the test is done during an acute episode so a false negative is obtained (I agree) and 2) the best way to diagnose gout after xrays fail to observe gouty arthritis is joint aspiration and crystal observation under microscope!
    Assuming gout is the cause, its associated soft tissue swelling could easily impact the surrounding nerve and tendon function.

    Good luck

    Brandon M
     
  12. Steve:

    Have you considered a Joplin's neuroma/neuritis (i.e. neuroma/neuritis of medial plantar proper nerve of hallux)?? These are not uncommon and may be uncomfortable at night. Consider shoe irritation or late midstance pronation or abducted gait pattern as a cause. The pathologic area of the nerve can be readily palpated just medial plantar to the medial sesamoid and/or medial plantar to the hallux IPJ, and the nerve can easily be palpated even in the normal foot. "Plucking" it with your finger will reproduce the symptoms (i.e. parasthesias in medial plantar hallux). If you have never attempted to palpate this nerve, try some skin lubricant (e.g. K-Y jelly) on the area before manual examination and the nerve will be readily palpable.

    Hope this helps.
     
    Last edited: Jun 12, 2009
  13. Steve5572

    Steve5572 Active Member

    Thanks Kevin

    A Joplin's neurom does seem to fit the symptoms best. When i have palpated the plantar fascia the distal 1/3 of the medial slip were tender, i could have been pressing on the medial planter nerve and interpreting the pain as a plantarfascial problem.
    I will try the test as described and let you know the results.

    Cheers

    Steve
     
  14. Admin2

    Admin2 Administrator Staff Member

    Related thread: Adverse neural tension
     
  15. Steve5572

    Steve5572 Active Member

    Thanks everyone for your help

    I tested the pt today for a Joplin'e neuroma. The pain was recreated by flicking the medial planter nerve along the medial border of the 1st MPJ.

    Can anyone reccommend any treatment options?

    The pt has loose fitting elastic sided boots, a mod root orthotc made from 5mm poly prop, 5 mm heel raise, 5 mm arch cookie and MTY pad plus met done. None of these seem top be releiving the pain thus far.

    Thoughts?

    Steve
     
  16. LuckyLisfranc

    LuckyLisfranc Well-Known Member

    Common problem with steel caps. Change the boot for a wider steel cap.

    Steroid/local anaesthetic injection. Surgical excision if not helped after a few months of conservative care.

    LL
     
  17. David Smith

    David Smith Well-Known Member

    All

    Just thought this attached might be handy.


    Cheers Dave
     

    Attached Files:

  18. Steve:

    I have never had to surgically resect a Joplin's neuroma to relieve the symptoms from a Joplin's neuroma. If you can get them out of any shoegear that has a "ridge" at the medial-plantar aspect of the 1st MPJ of the shoe (i.e. stick your hand inside the shoe and feel for any areas of potential irritation in the medial insole), and if you can prevent them from undergoing late midstance pronation, then the nerve should feel better over time.

    Try a 2-5 1/8" felt/korex forefoot extension on the orthosis (i.e. reverse Morton's extension) to give the patient increased lateral stability which should allow them to better resupinate during late midstance and propulsion. However, sometimes a forefoot extension under just the 4th and 5th metatarsal head works better. A little trial and error experimentation will be a good learning experience for you.

    The forefoot extension needs to be used on an orthosis that is controlling their early stance pronation well also. Like LL stated, cortisone injections around the nerve may also calm it down. I prefer to have them start icing the inflamed nerve 20 minutes twice daily at first since this generally works very well and prevents the need for a cortisone injection.
     
  19. drsarbes

    drsarbes Well-Known Member

    I have seen numerous Tarsal Tunnel Syndromes that cause symptoms in very localized ares, e.g., hallux, 5th digit, heel only, arch, etc...... A Tinnel's sign from percussion of the Tarsal Tunnel will often radiate only to the symptomatic area.

    To differentiate you can inject 1cc of decadron into the tarsal tunnel and 1. the symptoms may increase 2. the symptoms may decrease or be alleviated 3. nothing will happen.

    In my experience if either the localized symptoms are aggravated or alleviated a Dx of TT can be made.

    For instance: I have seen 2 patients over the years with considerable pain just in the 5th digit that were totally relieved with a tarsal tunnel release (after YEARS of treating the 5th digit!)

    It's easy enough to check for.

    Steve
     
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