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FDL tendonitis advice

Discussion in 'Biomechanics, Sports and Foot orthoses' started by jack_loveday, Dec 12, 2011.

  1. jack_loveday

    jack_loveday Member

    Members do not see these Ads. Sign Up.
    I have a patient who I believe has flexor digitorum longus tendonitis.

    She is a 59 year old lady who had a severe ankle sprain at the end of August causing an evulsion fracture of the cubiod. She has since received rehab for this and has no pain in the ankle, however while recovering from this injury she found that she was walking on her toes to help the pain in her ankle (?)

    She now has pain in her FF which comes on in terminal stance, with the toes extended. Clinically symptoms are only elicited on dorsifelxion of the lesser toes 2,3,4. No pain on palpation of these MTPJs or on digital distraction.

    She has function al hallux limitus (Hubscher score -0) and ankle dorsifelxion was linited to 0deg, now up to about 5deg.

    She was keen not to have orthoses at the start of treatment, although is now more open to the idea. I have treated with dry needling LR3 and 2/3, 3/4 IM and US on the plantar FF. I have also used an SCF rocker bar across 2-5 MTPJs which has seemed to have some short term effect, but symptoms are still much the same as when I first saw her nearly 6 weeks ago.

    Any advice on treatment and/or orthotic prescription would be much appreciated! thank you!
  2. Griff

    Griff Moderator

    Avulsion fracture of the cuboid??
  3. jack_loveday

    jack_loveday Member

    Hi Ian,

    Yes, I'm afraid thats all the information that was given with the referral, I assumed it to mean a CCJ ligament avulsion under the circumstances. (Would this be right to assume??) It is no longer symptomatic and there is no notable laxity in the CCJ now, but it clearly played a big part in the onset of the current problem.

  4. Griff

    Griff Moderator

    I guess its not impossible, but following a severe inversion injury I'd say a styloid process avulsion fracture was more common/likely.

    Back to the symptoms at hand - have you tested your theory that this may be related to 1st MTPJ dysfunction by trialling any other forefoot modifications which may try to address this? I'd say that may be a good place to start. Also, any imaging performed at this stage?
  5. jack_loveday

    jack_loveday Member

    Thanks for the advice. Yes, I guess thats the only other option, what would make a styloid process avulsion more likely in an inversion injury out of interest?

    I have started testing that with a simple insole with a 2-5 met bar and 1st met cutout, will see how she gets on this week.

    No imaging since the initial injury back in August.
  6. First off, if I were testing the flexor digitorum longus, I would use a combination of active and resisted plantarflexion of the digits, not dorsiflexion. Is there a capsular or non-capsular pattern? If pain is elicited by passive dorsiflexion of the digits this suggest ligamentous /plantar capsular injury, not flexor digitorum longus injury.

    For anyone interested in history taking and diagnostic testing for musculo-skeletal podiatry, as a starting point I would recommend combining the work of Cyriax, Maitland and the Kendalls:

    Cyriax: http://www.amazon.co.uk/Cyriaxs-Illustrated-Manual-Orthopaedic-Medicine/dp/0750632747

    Maitland either: http://www.amazon.co.uk/Musculoskel...=sr_1_1?s=books&ie=UTF8&qid=1323798565&sr=1-1

    or: http://www.amazon.co.uk/Maitlands-P...=sr_1_8?s=books&ie=UTF8&qid=1323798658&sr=1-8

    And Kendall: http://www.amazon.co.uk/Muscle-Test...=sr_1_1?s=books&ie=UTF8&qid=1323798717&sr=1-1

    I'm trying to attach a couple of very old Powerpoints to the lectures I used to give on this to the undergraduates back in the day in .pdf format but I'm currently getting a database error.
  7. Got one to work. For some reason the others don't want to play. I actually typed this one in a horses stable in the middle of winter, it was freezing... but that's another story. It's all from Cyriax. On reflection now, it's interesting that while my colleagues were still more interested in teaching students to draw lines on the back of patients legs and to have them come up with diagnoses like "rearfoot varus", I was trying to get them to identify the tissue under stress and come up with a real diagnosis. It was around this time I first dispensed a rearfoot valgus wedge for medial knee pain..... Not for the first, or the last time, I received the cold shoulder in the staff room. I actually remember another lecturer "having words with me" about "intentionally pronating a foot".

    Attached Files:

  8. Because the styloid process sticks out laterally, with excessive inversion a fracture at the styloid process from ground reaction forces may occur and the tension from peroneus brevis at it's attachment here increases with increasing inversion, increasing the risk of avulsion of the fractured segment.
  9. jack_loveday

    jack_loveday Member

    Hi Simon, thanks for your input.

    Makes sense about the styloid process, now I've read that I've got no idea why that hadn't clicked in the first place!

    I didn't include the whole history taking process in the initial post but resisted and active flexion of the lesser digits also both very painful (difficult to pinpoint but seemed to be focussed just proximal to the MTPJs). No pain on firm palpation of the MTPJs or digital distraction which led me to think extra-capsular.
  10. efuller

    efuller MVP

    With inversion injuries, ground reaction force will adduct the forefoot on the rearfoot. One of the structures that limits adduction of the forefoot is the bifurcate ligament that attaches at the anterior process of the calcaneus proximally and the cuboid and navicular distally. An avulsion fracture can occur at the anterior process of the calcaneus. Although the styloid fracture is probably more common with an inversion injury.

    Walking on the ball of the foot would require co contraction of the PT and Peroneus brevis muscles. I would suspect that the styloid would hurt more to walk on the toes. However, the history is fuzzy.

  11. Strange that. Could have sworn you said:
    Note to all: we generally don't care that you don't know everything and that you may miss things in your clinical work up- none of us know everything and we all do miss things at times; but lets not let our ego's get in the way of learning by "pretending that we'd really already done that" when frankly our earlier posts tell everyone else that we hadn't.

    And people ask me why I don't respond to clinical case threads very often... There is a sticky somewhere on presenting clinical cases. I should have thought the important clinical findings should be the ones included in the post.

    Never mind, eat your own ego and you'll learn much more.
  12. jack_loveday

    jack_loveday Member

    Simon, I think that was unnecessarily confrontational. No ego here, just genuinely trying to do the best for my patient - I am happy to admit that I have lots to learn, don't we all. I certainly have not pretended that I have done anything that I have not to cover up cracks in my assessment, however my statement in the original post saying that dorsiflexion was the 'only' thing to elicit symptoms was wrong. I apologise, I have not seen or read a thread on presenting cases, I'm afraid I don't have the time or mentality to spend my days reading or writing thousands of forum posts but in this case thought it might be useful. Thank you for your previous posts which I'm sure myself and others will find useful.
  13. I think your original post was unnecessarily weak and lacking the pre-requisites of a case presentation, but each to their own. Indeed, since when was the confrontation you feel a bad thing? Too much namby pamby in the world. You clearly stated that
    which is not the same as: clinical symptoms were reproduced on active / resisted plantarflexion of the lesser digits... is it now? You do not need to spend your days reading nor writing thousands of posts (yet "scientia potentia est"). However, if you use the search functions here you'll find threads like this: http://www.podiatry-arena.com/podiatry-forum/showthread.php?t=22144

    Good luck with your future, Jack. Bet you learn more from this than anything else in your podiatric life this week. "Is this the right room for an argument?" Yes, except we call it "academic debate". You'll find lots of people who don't agree with you and are "confrontational" here.

    con·fron·ta·tion (knfrn-tshn)
    1. The act of confronting or the state of being confronted, especially a meeting face to face.
    a. A conflict involving armed forces: a nuclear confrontation.
    b. Discord or a clash of opinions and ideas: an age of ideological confrontation.
    3. A focused comparison: an essay that brought elements of biography, autobiography, and general European history into powerful, meaningful confrontation.
  14. jack_loveday

    jack_loveday Member

    Fair point, it was a poorly presented case.

    I had pointed out in a previous post that my use of 'only' was not accurate.

    I am not asking anyone to agree with me, that is why I was asking for advice. I can't see though how telling me to 'eat my own ego' has anything to do with academic debate or is in any way constructive. But this seems to be how you spend your time, so as you say - each to their own.

    I have now read the thread on presenting patients for clinical advice, thank you for pointing me in the right direction there. I will repost and any advice or pointers would be genuinely appreciated.
  15. jack_loveday

    jack_loveday Member

    CC - A 59 yr old female with an 8 week history of pain under the left forefoot. She is sedentary at work, but walks everywhere otherwise.

    HPI - Forefoot pain comes on when walking, no pain static wb, only when toes are extended in terminal stance. Some relief has been gained from wearing trainers at home, but this is not a possibility at work. Treatment for the past 6 weeks with US of the L plantar FF and dry needling of LR3, 2/3, 3/4 IM - some pain relief after each session but short lived. Despite discussion with the patient she was keen to avoid any orthotic therapy, so a SCF met bar 2-5 MTPJ was applied, again providing some level of relief until it squashed down.

    PMH - Inversion of the L ankle in late August causing an avulsion fracture of the cuboid. Rehab from physio and chiropractor - now no pain in this area. During rehab she found it more comfortable to walk on her forefoot (not sure why) but this has led to the current problem.

    Musculoskeletal - Symptoms are recreated on passive extension of the L 2nd, 3rd and 4th toes as well as active and resisted flexion of the same toes (resisted flexion being the most painful with the pain being fairly diffuse but focussed just proximal to the met heads - appologies for completely missing this out in original post). No pain on firm palpation of the MTPJs or digital distraction. Ankle dorsiflexion was originally limited to 0deg but is now up to 5deg. Hubscher Score - 0, non-wb hallux dorsiflexion is adequate. RCSP mildly everted. No LLI.

    Gait - difficult to examine due to symptoms. Moderate level of pronation at initial contact and into midstance but patient lifts foot early when going into terminal stance due to pain. Low gear apropulsive gait bilaterally. Currently strongly favouring right side.

    Neurological / Vascular / Dermatological - NAD

    Imaging - none undertaken since initial injury in August

    Diagnosis - FDL tendonitis (due to pattern of pain, caused by lengthening and loading of the FDL tendons while toe walking) - open to opinion here please!

    Treatment plan -
    Wear trainers as often as possible and when walking anywhere
    2x daily gastrocnemius stretching on an incline board
    Icing L FF 2x daily (has been managing once at best)
    Weekly US 3MHz 0.8w/cm 5mins + dry needling LR3 + 2/3, 3/4 IM
    SCF met bar
    More recently (not yet reviewed) - simple insole with 2-5 met bar and 1st met cutout with a view to prescribing a longer term orthotic solution (pt now more open to this due to duration)

    Thank you for your time and any advice on going forwards and what I've done so far would be much appreciated.
  16. efuller

    efuller MVP

    She was keen to avoid orthotics, but was ok with dry needling??? Why dry needlling if your diagnosis is FDL tendonitis. From the presentation I would agree that it is tendonitis.

    Not everyone uses the same abbreviations so spelling out is helpful. SCF = ?
    Another nomenclature thing is the hubscher score. I'm not aware of any published papers giving the score a number. You could say that in stance when observer attempts to dorsiflex the hallux there was....

    Since the pain seems to have been brought on by walking on balls of feet, I would attempt to reduce stress on the metatarsal heads. Rocker bottom shoes, a metatarsal bar attached to the bottom of the shoe, metatarsal cookie, orthosis!! etc.


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