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Difficult midfoot case

Discussion in 'Biomechanics, Sports and Foot orthoses' started by Christian McErvale, Jun 4, 2015.

  1. Christian McErvale

    Christian McErvale Welcome New Poster

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    Hey guys,

    I have a very stubborn midfoot case that I would love to have an experienced podiatrist comment on (of course only if time permits)

    Pt background
    50 years

    Pr Co: Lt midfoot pain following fall on catamaran in 2012. Exact mechanism of injury unknown (suspected inversion ankle sprain).
    "Achiing" pain experienced during plantar flexion of foot whilst driving. Pain also present at night following prolonged periods of ambulation and is known to be "irritated" by bed sheets pushing the forefoot into plantar flexion.
    Patient does not tolerate any footwear with a heel beyond 10-12mm but also can not tolerate a flat heel/barefoot

    moderate OA at the 1st MTP joint and mild OA 3rd TMT joint. There was no active synovitis at the time of the study. There was no MTJ joint synovitis. The plantar nerves have a normal appearance. There is no evidence of Lisfrancs injury.

    Patient has come to me following exhausting care from a range of allied health professionals and sports medicine physicians


    Pt initially responded favourably to low dye taping, post compartment myofascial release, ankle mobilisation and proximal strength exercises.
    Following initial Tx the patient reported "the last 10 days has been the first time since the accident that I have been pain free"

    The Rx of custom foot orthotics (3 degree 2.5mm direct milled poly device, minimal arch expansion, 1st met cut away) has since provoked symptoms to a point at which we are back to square one. I removed the orthotics from the Tx plan and repeated the initial Tx approach only to again provoke symptoms (i.e. low dye taping this time around was intolerable).

    I have basically refrained from doing anything and have had the patient rest for the past 2 weeks, which has allowed the foot to settle but I am unsure as to what my next move should be.

    I suspect the TMT OA identified on MRI is more significant than first reported and likely implicated??? There appears no evidence e of synovitis nor nerve damage (atleast on MRI) to justify referral for injection therapy.

    If anyone has some insight/has managed a similar case, any input would be greatly appreciated.
    I am currently not charging the patient purely to ensure I don't lose her as I really want to get her back on her feet..

    I have attached some photos that demarcate the regions the patient feels the pain whilst driving below.

    Kindest regards,

    Christian McErvale
  2. Christian McErvale

    Christian McErvale Welcome New Poster

    I am struggling with the attachment of photos. I'm hoping they are attached this tim around

    Attached Files:

  3. Rich

    Rich Member

    has the cuboid got sufficient glide d-p and is pero longus got resisted strength? Can they single leg heel raise. Has a cuboid syndrome been considered
  4. Ok so from the Photos

    2 Points of Pain ?

    Dorsal lateral column Distal and slightly medialto the Styloid process of the 5th - Have you looked at the peroneus Tertius muscle and if that has been affected in the Injury

    As Rich mentions above the second point of pain the insertion of the Peroneus Longus

    Christian it is always hard Via the interwebz to give advice, but I would suggest you get her back in and look at the health and strength of those 2 muscles

    The injury on the boat thing is going to be a huge issue in trying to discover what the initial injury was, but you need to diagnosis what is hurting 1st ( yes easier said than done sometimes )

    But have a look at those 2 muscles , I do not thing Cuboid syndrome is the cause of the pain from the description For What it is worth

    Also you need to charge her for your time Business 101 , maybe you can make a plan with her re payments with a cap or something.

    Hope this helps get back to us with some more info
  5. efuller

    efuller MVP

    Up to this point it sounds exactly like a 2nd cuneiform subluxation. However, the locations of pain in the picture are not consistent with that. A 2nd cuneiform subluxation will have increased pain with plantarflexion of the 2nd ray. You can run your fingers along the 2nd metatarsal shaft and at the base of the metatarsal there will be a "bump" where the cuneiform sits more dorsal than the base of the metatarsal. It will be painful to palpation at the location of the bump. I've had the 2nd cuneiform subluxation and I've had it feel better after manipulation. (Thank you Jack Morris) The subluxation does cause some vague midfoot pain. It may not be what your patient has.

    Good Luck
  6. Christian McErvale

    Christian McErvale Welcome New Poster

    Thanks guys for your input. It is much appreciated. Joint manipulation is not my strong point so it might be worth referring to a practitioner experienced in this area.

    Again many thanks for taking the time to reply,

  7. Ian Drakard

    Ian Drakard Active Member

    Sorry to come in late but like Rich I would want to rule out cuboid involvement. There is some overlap between the areas marked in the pictures and where I would often expect pain with cuboid issues. It would also fit with the initial mechanism of injury.
  8. Hi

    Try the following:

    Check this isnt referred pain from the lumbar / sacral spine following her fall on the boat.
    Check alignment of midfoot on standing X rays.
    Consider referral for CT of the affected area.

    Hope this helps

    John Bickerstaffe
  9. drhunt1

    drhunt1 Well-Known Member

    More info would be helpful. Where is the pain, again? Where, specifically, is the patient symptomatic with direct palpation? ROM measurements might be very valuable in designing a treatment strategy. Sometimes we can be dissuaded into treating MRI's and not patients, but the MR findings of 1st MPJ DJD, along with the pics show an elongated 1st met with a hallux limitus condition, (note the dorsal, dorso-medial bunion). Note also that the great toe "looks like a thumb", indicating the same.

    Gait analysis when the patient's condition calms down, might further elucidate underlying condition, especially at the propulsive phase of gait. If I had to guess, (which I am anyway), patient doesn't quite use hallux as main propulsive digit, rolls outward at propulsion, abducts foot outward during swing phase of gait and/or walks with an abducted gait in order to compensate for hallux limitus condition.

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