Entrapment syndrome possibly TTS advise please

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Hi Guys

Yesterday I saw a 13 year old girl with a painful medial foot and ankle, she mainly complained of pain in the medial arch and heel.

Clinical notes

No previous med hist reported.

Plantar medial arch pain right foot, started as cramps in bed and then woke up one morning 3 weeks ago and it was very painful to walk on. sometimes it seems to be swollen.

Pain on palpation of PF esp at origin, pain in sinus tarsi, pain on palpation of abductor Hallucis, pain in ach ten lower 1/4 some pain in PTib tendon trac. pain in medial heel which is described as sometimes like a needle going right into the foot or like a tooth ache. Positive Tinel's sign for medial calc nerve. She reports sometimes there is like a heart beat when the foot is swollen and she reports that the skin feels really hot. Reports Post static pain after 30 mins rest with foot up.

she reports a traumatic injury to the foot about 10 days before the present foot pain started but she cant remember how it was caused?? ("I have a bad memory I always have done")

Bmech assess

No notable variations, except that the right foot has slightly lateral stj axis. The right has light jacks and supination test and left is heavier in both. she has genu valgum about 6dgs. Tendency to lateral instability but reports no ankle sprains.

Today she is walking with a limp and cannot fully weight bear on the foot.
There is not any exceptional pronation or excursion from STN, which is slightly inverted and the tendency is toward supination in stance and gait. The only biomech dysfunction of note is mild ankle equinus and slightly low right hip.

This is a bit of a mysterious complaint with many possible diagnoses and painful pathologies. The most likely Dx is Tarsal Tunnel syndrome but her biomechanical function does not tend to predispose her to this condition - I will have to think about this and report on what the next step is -

NB there may be a space occupying lesion or a higher /more proximal level entrapment at the FHL muscle tendon junction perhaps or there may also be entrapment under the abd hallucis or both. Think about how a supinating foot would cause medial entrapment syndrome???

send letter for School to excuse her PE. Letter to GP for Diagnositic ultrasound scan or MRI.

Any thoughts on this one guys?

Regards Dave Smith

 

Any suggestion of inflammatory arthritis? Another thought, is there any leg length discrepancy? I know that if she has a slight one it is rare that symptoms such as this would emerge at such a tender age, but I once had a patient around this age who had such a condition and also put on weight suddenly so similar symptoms presented. Also what about diet?

 

Dave:

The first step are x-rays of the foot and ankle to rule out fracture or bone tumor. From what you present, I would put her in a cam walker brace boot for at least two weeks to see how she progresses and have her ice the areas of maximum tenderness 15-20 minutes once to twice per day.

I have never seen tarsal tunnel syndrome in someone this age but I would be suspicious of trauma and/or something more sinister such as tumor if no trauma can be remembered. MRI of the area would be best if nothing else can be found or she doesn't get better in the boot.

Hope this helps.