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Diagnostic features 5th metatarsal stress # vs dorsal metatarsalcuboid ligament sprain

Discussion in 'Biomechanics, Sports and Foot orthoses' started by Mart, Mar 23, 2012.

  1. Mart

    Mart Well-Known Member


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    quick presentation:

    elite athlete male 42 yo reported being in good general health

    - competing Boston marathon next month seeking opinion re left foot dorso-lateral pain (DLFP)

    VAS (visual analogue pain scale range 0-10) VAS 5: moderate pain to severe pain which interferes with tasks and occasionally concentration.

    Occupation is sedentary, mostly non weight bearing at work

    Has trained past seven weeks + day on day off 1 hour 8.3 miles approx 1hr outdoors street. At this speed he reported heel/toe gait. No lower limb issues until four weeks ago.

    then noted mild dorsal 1st metatarsal pain - diagnosed by physiotherapist with EHL strain - laser/US/tens problem gradually resolved continues to run with slightly decreased frequency and intensity.

    2 weeks ago sudden onset DLFP day after playing ice- hockey - patient reported putting cushioning on top of foot because he thought this might reduce irritation to EHLt, noted some pain during game but intenser following day.

    Continued to run and pain worsened to to VAS 6: severe pain which interferes with concentration. No significant swelling or ecchymosis reported.

    Saw sports MD - radiographic exam showed no significant findings - ordered scintigraphy to ?? stress#, has to wait two weeks for this.

    Has stopped running, modification routine cardio-vascular exercise regimen stationary bike and water runs - has weight-bearing pain 0-5 according to weight-bearing duration walking.

    I observed: no signs of swelling, erythema, heat or skin lesions,

    tenderness to palpation at 5th metatarsal-cuneiform joint MCJ,

    discomfort with passive range of motion 5th MCJ,

    walks with limp, Provocative testing with double limb stance heel raise resulted in recreation of pain.

    B-mode high-resolution ultrasound examination; no evidence of reactive hyperaemia or edema at visible 5th metatarsal periosteum, no signal with power Doppler imaging at joint margins, equivocal for small dorsal MCJ defect,

    ultrasound guided diagnostic injection with lidocaine dorsal to MCJl almost eliminated ambulatory pain, further injection into joint pain gone - can run no pain.

    Anyone feel that this could be stress # given this evidence?

    Any suggestions other than dorsal MCJ ligament strain?

    How best to proceed? He desperately wants to complete ambition to run Boston and qualified with 1 second headroom (once in lifetime) so stakes for him huge.

    Plan tomorrow - do Fmat to look for excessive, possibly unilateral barefoot lateral midfoot peak pressures and force time integrals which imply inadequate stability.

    Also look for other clues to explain this other than inadequate plantar restraint of dorsiflexion moments.

    Design foot orthoses to provide ground reaction force adjacent to MCJ margins as much as tolerated to set up favorable plantar flexion moments prior to heel off.

    Consider any other evidence of causes for compensatory foot inversion such as 1st metatarso-phalangeal joint behavior (FuHL).

    Was thinking of adding sole stiffner to encourage stability during 3rd rocker phase.

    Wondering if peroneus longus activity may be factor by increasing dorsiflexion moments at MCJ but unable to see how to evaluate this other than looking at 1st metatarsal head ground reaction forces through stance.

    Any thoughts/recommendation appreciated - poor guy is pretty desperate to run.

    Thanks in anticipation.

    Martin

    Foot and Ankle Clinic
    1365 Grant Ave.
    Winnipeg Manitoba R3M 1Z8
    phone [204] 837 FOOT (3668)
    fax [204] 774 9918
    www.winnipegfootclinic.com
     
  2. RobinP

    RobinP Well-Known Member

    COnfused. Is the location of the pain at the 5th met/cuboid joint or on the 4th /lat cunieform joint?

    Is plantarflxing the forefoot on the rearfoot sore?
     
  3. Mart

    Mart Well-Known Member

    My impression was 5th metatarsal-cuneiform joint; could also be 4/5 inter-metatarsal joint lig but ultrasound guided diagnostic injection targeted 5th MCJ.

    Inference was root of pain being dorsal MCJ lig - could also be described by what Kevin Kirby refers to a "dorsal TMT joint impingement syndrome" of 5th metatarsal.

    passive plantarflexion of 5th TMT joint was slightly uncomfortable, more so with dorsiflexion . attempting stabilization of prox/distal 5th metatarsal plantar and applying dorsal mid bone plantar force seemed well tolerated.

    Cheers

    Martin

    Foot and Ankle Clinic
    1365 Grant Ave.
    Winnipeg Manitoba R3M 1Z8
    phone [204] 837 FOOT (3668)
    fax [204] 774 9918
    www.winnipegfootclinic.com
     
  4. dragon_v723

    dragon_v723 Active Member

    "dorsal TMT joint impingement syndrome"

    any link plz?
     
  5. Mart

    Mart Well-Known Member

    What I should have written was DMICS "dorsal midfoot Interosseus compression syndrome". I bet Kevin has posted this term somewhere on podarena; he sometimes does :). If you have not read his "trilogy" and need jargon free, clear and precise clinically relevent understanding of foot behaviour and how this relates to MSK problems go get them; great foundation and value!

    cheers Martin
     
  6. Martin:

    Sorry I didn't reply sooner..I've been busy on lecture-vacation.

    This sounds like lateral dorsal midfoot interosseous compression syndrome (DMICS) that is being caused by him "favoring the medial forefoot" from the initial injury on the medial forefoot. Lateral DMICS is also one of the most common sequllae from plantar fasciitis where the patient actively supinates the foot during stance phase to reduce the ground reaction force under the medial forefoot, but, in doing so, places greater stress on the lateral column.

    First of all, have him stop running unless he can run pain free. Second, put a 1/4" heel lift bilaterally into all his shoes to see if this eliminates or significantly reduces the pain. This heel lift should "open up" the dorsal lateral midfoot joints and may reduce symptoms. If this doesn't help, put him into a cam walker brace for a week or two to see if this calms down the pain enough to allow him to run the race. Third, have him ice the dorsal lateral midfoot 20 minutes twice a day to reduce inflammation and, if you can, inject about 0.5 cc of your favorite cortisone solution into the dorsal aspect of 5th metatarsal-cuboid joint and then have him not run for at least 3 days after the injection.

    Since there is just three weeks to the Boston Marathon, it will be tough to be able to allow him to run his best at this point. Just remind him of my favorite saying that I often say to my runner-patients in similar types of situations:

    "It is much better to be slightly out of shape before the race and uninjured so that you can enjoy and finish the race, rather than being in great shape, injured and frustrated that you couldn't enjoy and finish the race."
     
  7. Mart

    Mart Well-Known Member

    Thanks Kevin; words of wisdom as usual.

    Patient had already stopped running prior to seeing me and continues to do so.

    We had broached the idea of corticosteroid injection and may try that as last resort.

    I agree with your speculation about mechanism stemming from 1st ray pain and had same thoughts. To validate that a little I did an FMat test on Friday to look for walking barefoot elevated midfoot or metatarsal head peak pressures and force time integrals. I found them within normal limits and fairly symmetrical left to right. I felt that suggested low probability for some biomechanical predisposition.

    Empirically we then tried a foot orthoses with theoretical aim of allowing the TMT 5 joint a little more headroom during 2nd rocker by applying a small distally rising wedge under the cuboid. Same goal I think you had using a heel lift. Foot topography was digitised semi-weight bearing with talo-navicular joint congruent and plantar flexed first ray position and milled with EVA (Shore-C 80). After “tuning” stiffness there was some increased comfort walking, this seemed improved with addition of the wedge. Difficult to know if this was simply witchcraft at this stage but we were clear regarding limitations of this kind of process.

    If that is ineffective I will try your suggestion of the heel raise.

    One thing I was seeking opinion about was my assumption that, given the presentation, a stress fracture seems very unlikely. Scintigraphy will unlikely be timely enough locally via Medicare apropos the race and he is thinking of going to US and pay to do this. I told him that if he is going to spend money traveling to US he would better get MR than scintigraphy but that if I am correct in my evaluation this will likely simply rule out significant bone stress and not much else.

    Anyone think this would represent reasonable value to improve diagnostic specificity at this stage?

    Cheers

    Martin

    Foot and Ankle Clinic
    1365 Grant Ave.
    Winnipeg Manitoba R3M 1Z8
    Phone [204] 837 FOOT (3668)
    Fax [204] 774 9918
    www.winnipegfootclinic.com
     
  8. Martin:

    Metatarsal stress fractures nearly always cause dorsal edema of the forefoot. DMICS only occasionally (when more severe) causes dorsal forefoot edema.

    Metatarsal stress fractures rarely are tender at the joint space and are nearly always tender at a narrower section of the metatarsal (this is where the metatarsal bends the most during plantar loading of the forefoot). DMICS is always most tender at the dorsal joint space.

    Metatarsal stress fractures don't normally hurt with the forefoot plantarflexion test. DMICS nearly always hurts with the forefoot plantarflexion test.

    Hope this helps with your diagnosis.

    By the way, the MR scan would be more diagnostic but would be about twice as expensive as the technetium bone scan. Just tell him that if he can't run without significant pain for a mile, he shouldn't do the marathon and should save his money (from not doing an MR or bone scan) for next year's race since resting the foot for about two to three weeks will likely make it feel much better.
     
  9. CraigT

    CraigT Well-Known Member

    The use of Low dye tape I also find effective as a trial treatment for these types of cases... can also be used with the heel raise.
     
  10. Craig:

    Good point. However, I have found low dye taping is not as effective for lateral DMICS as it is for medial DMICS.
     
  11. I have found by reversing the tradition Low dye technique taught to me and then Modified over time works well with lateral DMICS.

    ie the 3 bands run 5th - heel - 1st

    and the cross bands medial to lateral

    As an aside the term low dye seems to mean different things to different people.
     
  12. Dananberg

    Dananberg Active Member

    Mart,

    Manipulate the cuboid. Dorso-lateral foot pain without the presence of edema or erythema are often the result of cuboid fixation and a restriction in dorsal ROM of the lateral column of the foot. Relief can be spontaneous....and you will have one very happy runner on your hands.

    Howard
     
  13. Mart

    Mart Well-Known Member

    Thanks Kevin . . . . . Mentor extraordinary !

    Cheers

    Martin

    Foot and Ankle Clinic
    1365 Grant Ave.
    Winnipeg Manitoba R3M 1Z8
    phone [204] 837 FOOT (3668)
    fax [204] 774 9918
    www.winnipegfootclinic.com
     
  14. Mart

    Mart Well-Known Member

    Thanks Mike and Craig.

    Is your idea to preferentially stiffen lateral column with strapping?

    I guess theoretically what we are trying to do with these patients is protectively limit the TMT dorsiflexion moments as much as possible to allow healing. I see a limitation with a foot orthoses design which is basically a total contact / talonavicular joint congruent topography, is its ability to achieve this effect after heel off, since once weight-bearing is transferred to metatarsal heads, the foot orthoses will lose application of useful protective ground reaction forces.

    One thing I have tried a couple of times with DMICS is using a prefab and cutting a window under 4 and 5 metatarsal heads- the idea then to reduce lateral column dorsiflexion moments after HO.

    I may try this approach if initial is inadequate.

    I will post an ongoing blog of progress of this case.

    Cheers

    Martin


    Foot and Ankle Clinic
    1365 Grant Ave.
    Winnipeg Manitoba R3M 1Z8
    phone [204] 837 FOOT (3668)
    fax [204] 774 9918
    www.winnipegfootclinic.com
     
  15. Mart

    Mart Well-Known Member

    Thanks Howard

    I guess I have never had any improvement from trying this and removed it from my tool box; perhaps my technique is poor or selecting wrong patients. I understand the principle of the technique.

    Do you tend to try this empirically for everyone with the presentation you mentioned and do you regard the instant effect a diagnostic feature?

    Cheers

    Martin

    Foot and Ankle Clinic
    1365 Grant Ave.
    Winnipeg Manitoba R3M 1Z8
    phone [204] 837 FOOT (3668)
    fax [204] 774 9918
    www.winnipegfootclinic.com
     
  16. efuller

    efuller MVP

    Mechanically, the latteral low dye strap would work if you "pre-stress" aka preload the lateral column in plantar flexion. So, for this case, the tape holds the lateral arch in plantar flexion, so when ground reaction force on the met heads, creates a dorsiflexion moment on the metatarsals. The tape will create a plantar flexion moment before the bones have reached their dorsiflexion end of range of motion. This is not really increasing stiffness, but it may, but more of a changing of the location of the load.

    I agree, most orthotics are designed to load the lateral forefoot more, especially when the problem is medial forefoot overload. This is an important concept in tissue stress approach. You have to realize that the "default" orthotic is usually designed to increase load on the lateral forefoot. When the problem is too much load on the lateral forefoot, then you have to change away from the "default" orthotic. Lowering load on the lateral metatarsal heads does make sense. Even shifting the lateral load more proximally will decrease the dorsiflexion moment on the lateral metatarsal heads. So, a traditional orthotic may be helpful, especially if there is a high lateral arch to shift the load proximally. before heel off in gait. (Tissue stress does take into account architecture.)

    Eric
     
  17. Mart

    Mart Well-Known Member

    Thanks Eric

    I guess what I meant was to preferentially "stiffen the lateral portion of the strapping" which of course then might increase extrinsic redistribution of stress.

    Pre-stressing the joint before applying tape is a good idea which I had not thought about; probably will need extra pair of hands.

    I was wondering about extending a loop from the strapping dorsal to proximal phalanx to attempt stabilizing the distal anchor at heel off, sort of augmenting the extensor hood. Great chance of creating skin irritation perhaps; anyone tried doing this?

    Cheers

    Martin
     
  18. efuller

    efuller MVP

    I've never tried this, but the theory is interesting. The line of pull of tape is critical for this to work. The line of action of the force/tape has to go from the distal aspect of the metatarsal and then extend proximally inferior to the joint. The further inferior to the joint, the greater leverage it will have to create plantar flexion moment of the joint.

    You can always test the effect after the tape is on by trying to dorsiflex the forefoot and see if the tape tightens.

    Eric
     
    Last edited: Mar 26, 2012
  19. Mart

    Mart Well-Known Member

    For those interested I saw this patient today for review;

    he had scintigraphy done - was normal

    foot orthoses helpful other than irritation from cuboid wedge, this was removed and inner longitudinal arch stiffness "tuned" to be slightly more compliant.

    Site seems more comfortable with foot orthoses than not.

    had intra 5th TMT corticosteroid injection done last week which quickly removed residual pain

    ran today for first time since injury for approximately 10 minutes - at TMT 5 VAS 2: mild pain which can be ignored

    Has tickets booked for Boston at weekend

    thanks to those who contributed to thread

    Cheers

    Martin

    Foot and Ankle Clinic
    1365 Grant Ave.
    Winnipeg Manitoba R3M 1Z8
    phone [204] 837 FOOT (3668)
    fax [204] 774 9918
    www.winnipegfootclinic.com
     
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