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Burning Sensation in area of Base of 1st met, medial cuneiform and navicular

Discussion in 'Biomechanics, Sports and Foot orthoses' started by JaY, Oct 11, 2012.

  1. JaY

    JaY Active Member

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    I have had 2 patients with the same complaint!

    Burning sensation in area of medial cuneiform/navicular/base first metatarsal area with severe point tenderness at these joint lines and on dorso-medial area cuneiform.

    Gradual medial arch collapse in these areas.

    Joint ranges of motion NAD; muscle tests NAD. Slight discomfort on active inversion of the foot.

    One patient had x-rays which showed no fractures, or joint fushions, but definite change in position of the medial arch bones... This patient was sent to the chiropractor who manipulated bones and gave ultrasound which helped. I have also recently dispensed a pair of simple insoles to see if this relieves some discomfort.

    Any ideas what I may be dealing with?

    Many thanks
  2. efuller

    efuller MVP

    Two possibilities that are markedly different.

    Subluxing cuneiform. I've had this on my intermediate cuneiform when I was doing the fellowship at CCPM. Jack Morris popped it back in for me. For a few years it kept slipping out and I taught my wife how to pop it back in.

    Subluxing 2nd cuneiform: Tender at second cuneifrom. As you follow the 2nd met shaft proximally you can feel more of a bump when you reach the 2nd cuneiform on the affected side compared to the unaffected side. Hurts with plantarflexion of the forefoot on the rearfoot. May happen with active inversion. The bed sheets can create the plantar flexion of the forefoot on the reafoot and the pain.

    Treatment: Before manipulation you should probably have an x-ray taken to make sure there isn't something else going on. I've seen one x-ray shot with the foot tilted so that the intermediate cuneiform obviously rose above its neighbors.
    The manipulation: wrap both of your hands around foot, thumbs on bottom near met heads. have a finger from both hands over the 2nd cuneiform. A quick thrust. A light person on a slippery table will move an inch or two. The thrust is sort of a dorsiflexory, at the ankle, while pulling the foot and body toward you. The thumbs push dorsally, as the fingers push plantarly. Most of the time, you will hear the click when you get it.

  3. One possible idea is anterior tibial insertional tendinitis....have seen it a few times recently in patients that seemed to be associated with them wearing the Skecher Shape-Up/MBT style shoes. Area of maximum tenderness is at the insertion of the anterior tibial tendon and is often associated with mild to moderate edema in this area.
  4. JaY

    JaY Active Member

    Thanks Kevin - how did you treat your patients who presented like this?

    Can you explain the beginning of the midfoot collapse as I have seen in both my patients? Should I perhaps investigate post tib dysfunction?
  5. If they are very symptomatic, then they go into a cam walker boot/brace along with twice daily icing therapy, Voltaren gel topical applications three to four times a day and I put a medial longitudinal arch pad inside the brace. If they are less symptomatic, generally the ice, Voltaren gel and a good foot orthosis with medial heel skive, well-formed medial arch in a supportive shoe or boot works quite well. A modified over-the-counter orthosis will also work well for this condition, depending on your and the patients preference.

    If the patient also has posterior tibial tendon dysfunction, then these treatments should work well for that diagnose also.

    How do you know that these patients have developed "midfoot collapse"? Did you see it occur, or are you relying on the patient's account of their foot shape? Patients are notoriously unreliable of knowing anything about their foot shape and foot biomechanics.

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