Bit of advice please

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Can anyone please *give me some advice on a patient's condition which is somewhat foxing me. It may well *be just some sort of sprain but it isn't something that I've come across yet. The injury is one which has previously occurred (approximately two years ago) and, at the time, x ray revealed no particular noteworthy features. The patient is now experiencing exactly the same symptoms as last time which seem to have come on quite suddenly with no particular traumatic incident. However he does note that on the day that the pain began, he did have to carry a very heavy object up a hill and wonders if this has something to do with the onset of this particular bout of problems.*

From what I can tell, the location of the pain is originating within the mid tarsal area and it seems to be radiating to both plantar and dorsal aspects. It is particularly bothersome as weight shifts towards the forefoot as the mid foot locks and heel starts to lift during propulsion. The patient can happily bear weight on his calcaneus and also stand on tiptoes on this foot with no particular complaints , but as weight shifts forward during normal gait, he reports that the pain is considerable and his gait is clearly antalgic. He is an otherwise healthy gentleman of 41 years of age by *the way.

There are no visible external signs that anything is wrong i.e.no redness or swelling or heat difference in comparison to the other foot. Having palpated the patient's foot, it is quite hard to locate exactly where an injury might be. Range of motion seems to be quite normal generally, *but *inversion of the forefoot in particular elicited a great deal of pain. The plantarfascia is not particularly tender nor is the plantar aspect of the calc.The patient reports that the weight of the duvet on his foot at nighttime is pretty bothersome and the pain is unbearable first thing in the morning.*

I tried using an *infrared lamp directed at the area in addition to application of a topical anti inflammatory. In addition, the patient tried a compression bandage to try but this didn't even to help much and in factthe condition worsened over the course of the next 24 hrs . I have considered strapping the mid foot to try and provide some support but the patient isn't convinced that this will help much , although if there is no improvement in the next couple of days I imagine he will be more keen to give this a go.

Wow, I can't think of any other details, but I seem to have written a lot. Forgive me if a particular 'condition' is ridiculously obvious *to all of you, but please feel free to enlighten me if it something that I am completely missing!*

Many Thanks*

 

hi I recently twisted my foot when playing football and started getting lots of pain in the mid tarsal area especially when inverting my fore foot. My lecturer applied some figure of 8 strapping and iv been taking some ibuprofen for a few days. This seems to have helped although i do get some pain every now and then when inverting fore foot. not sure how relevant this is, but hope it is useful

ben

 

Hi,

From the description your patient has probably aggravated the old (initial) injury.
X-ray will only show if there is bony damage or obvious inflammation, and only usually, but not always.

You really need to diagnose the problem, so I suggest referring your patient for an ultrasound scan, or an MRI if that is available.

Whatever you do, if this is a recurrence of an old injury it is unlikely to clear up either spontaneously, or quickly, so worthwhile spending some time diagnosing before your treatment plan.

 

Hi Alice. A particularly vague presentation, however, it could be a number of things in this area. Cuboid Sydrome, Sinus Tarsi Syndrome or a sural nerve entrapment, the peroneals could also be implicated. Or maybe DMICS as described by Dr Kirby, that would not account for the plantar pain though. He could have a fibrous coalition at the midtarsal or CC joint. Who knows, a few more hands on examination techniques are needed I think. Or as David alludes to, he may need further imaging. Most of the above are hard to determine through imaging alone though. The bed sheet conversation often implicates a neurological aetiology or generalised hyperalgesia / allodynia, the superficial peroneal nerve may be entrapped ie anterior tarsal tunnel (trapped beneath inferior extensor retinaculum)

I'm making the assumption that you are a Podiatrist and know how to examine and differentiate between these conditions, if not (why are you treating a Podiatry patient - See Dr Arbes recent posts), I will happily go through them with you.

ps Blumley I presume you are a student from your post and glad your foot is feeling better. I would suggest that whilst taping may be a treatment modality it is still always nice to actually make a diagnosis and treat appropriately instead of taping and hoping for the best (which in your case worked)

Regards,

George

 

Alice:

You should read this thread: Dorsal Midfoot Interosseous Compression Syndrome

 

Hi
my thoughts are also , more investigations too, but also just something simple, have you checked the range of motion of the cuboid, compare to other foot. Often a stiffness here gives pain on heel lift. Some mobilisation helps if this is the finding, need to be sure no other pathology is present first , ie fracture.
Just a quick point , otherwise "ditto" on above.