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Fibularis Brevis tendon sheath inflammation - Help with case please

Discussion in 'Biomechanics, Sports and Foot orthoses' started by sezza, May 8, 2012.

  1. sezza

    sezza Member

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    Hello everyone,

    I recently saw a new patient who I would appreciate any advice about. Apologies in advance for the lengthy post (I know it's going to be lengthy, as I have already typed it out once, and then lost it somehow!).

    24 year old female; works as a physiotherapist
    Recently increased length of running sessions from 1 hour to 1.5 hours, in preparation for a half marathon.
    Began to experience pain in R foot which continued to become much worse
    When I saw her, she had been resting from running for 7/52
    She describes it as 4/10 pain, even during walking
    Anti-inflams help for 4-6 hours; ice helps; both only provide short-term relief
    Changing direction or walking quickly aggravates the pain

    Had a diagnostic ultrasound which showed 'mild tendon sheath thickening of fibularis brevis' and no other pathology. X-ray showed no pathology.
    Had a cortisone injection which did not provide any relief.

    Wears Mary-Jane style shoes at work (comfortable); sneakers were not comfortable. Has custom orthoses in sneakers, and pre-fab devices in work shoes. Has new Brooks sneakers which have a fair amount of midfoot support.

    There was pain on deep palpation of the area inferior to the lateral malleolus only. No pain at insertion or higher along the tendon or muscle.
    There was pain with inversion; no muscle weakness was evident.
    Gait showed moderately excessive midfoot pronation

    I felt that her new Brooks sneakers + custom devices were likely causing an increased inversion force, and therefore excessive tensile stress on the fib brevis tendon, leading to the sheath inflammation.
    I advised her to wear the sneakers without the devices, or change to a more 'neutral' sneaker + the devices, in order to decrease this stress.
    I added valgus wedging to her shoe.

    Since then, I have only had email contact with her - being a physiotherapist, she is better informed regarding tendon injury and rehabilitation than I am, and as such, has not returned for an appointment.
    She has recently been to see an orthopaedic surgeon who ordered an MRI, which showed the same findings as the ultrasound.
    He advised that surgery is not an option for this injury, and rest is the order of the day.

    She has emailed me wondering where to go from here; and frankly, I don't know. Am I missing something here? I would expect that 'mild thickening' of the tendon sheath would be resolving by now with adequate rest and offloading, but she has had no change in her symptoms.

    She has scaled back all activity ie no housework, grocery shopping etc, and has even recently cut back her hours at work. It is now 6 weeks since I saw her; 13 weeks since she stopped running completely.

    She is asking my thoughts on an offloading boot as the next step.
    I just thought I would run it by my superior colleagues on this forum for any other ideas.

    Thank you in advance.
  2. Hi Sarah

    I can recall two patients over the past 18months with seemingly persistent Peroneal tendinopathy.

    Both presented with lateral foot pain, and the 1st case did present with palpable pain when the foot was held inverted and everted against resistance. But barely then. The pain to the tendon was enough to prevent walking running etc as you describe.

    The 1st case was resolved at 4-6 months of very little activity. The highly arched foot type required softer walking boots for day use and a heavily posted orthoses (valgus) with 1st ray cut out and advanced lateral post and lateral flare of the rear-foot post. It was a very 'beefy' device, but the patient was 6ft 2" and 16 stone.

    Now the second would not resolve with footwear/physio/orthotics but was treated successfully with steroid injection under ultrasound guidance.

    The rear-foot had a lateral deviation to the sub-talar joint. We were initially surprised by the lateral plantar foot presentation, but treated for an inversion based injury as above. A referral for diagnostic ultrasound confirmed the peroneal injury and at the same time allowed for visual guidance of steroid.

    The severe pain resolved within 3 days. The injury was actually near the tendon/muscle junction.......some way from the presenting pain.

    All other peroneal injuries that i have dealt with are associated with an acute or chronic inversion injury and seem to take frequently up to 4 months post treatment to completely resolve.

    My guess, and obviously it is is a guess! Would be offloading will work. Is the physio still treating patients whilst standing at work? as it may well have something to do with the persistent nature.

    You seem to be doing everything possible.....But i will keep an eye here in case of other pertinent treatment tips being shared :)
  3. drsarbes

    drsarbes Well-Known Member

    I would suggest she may have a linear tear if nothing is helping. These are frequently missed on MRI so if you do order one let the technician know that is what you are looking for and where along the tendon you think it is.

  4. sezza

    sezza Member

    Thanks for your replies, so far... keep them coming please!!

    A couple of questions:

    1. Regarding the MRI - I have not seen it (and cannot interpret them anyway) as this was organised through the Ortho surgeon - but if there was a 'missed' linear tear, would it be visible on the MRI & has just not been noticed during reporting, or would a new MRI need to be done, specifically looking for a linear tear?

    2. I have always wondered about using a 'valgus' device with all the lateral modifications etc for peroneal tendinopathy in someone who does not have a cavus foot type, and who has always worn a 'medially posted' device for excessive pronatory force problems. Can people please discuss thoughts, opinions, rationales here - as it seems like in treating one condition (ie peroneal tendinopathy), we would be exacerbating the previous problems caused by the excessive pronation, and vice versa.

    Thanks in advance,
  5. efuller

    efuller MVP

    Sarah, are you familiar with Kevin's paper on rotational equilibrium about the STJ axis. Reading that should help you a lot in understanding the valgus wedge for peroneal problems. The position of the projection of the STJ axis into the transverse plane can explain a lot about foot function and treatment.

    I see a fair number of people who have been given medial heel skive devices that should not have them because they have a laterally positioned STJ axis. The theory is this there are two kinds of "pronators". The first kind has a medially positioned STJ axis and ground reaction force will tend to cause a greater pronation moment in these feet than a foot with an average axis location. Their pronation is caused by a large moment from ground reaction force. The second kind of pronator is one that has a laterally positioned STJ axis. In these feet the ground will cause a much smaller pronation moment than a foot with an average location of its STJ axis. In extreme cases, the ground will tend to cause a supination moment. In these feet, there has to be constant activity of the peroneal muscles to prevent the foot from rolling into maximum supination of the STJ. I call these feet muscular pronators. Heel contact will appear normal at forefoot loading there may be some supination and then there is a lot of pronation around heel off and into propulsion. This constant activity is what is theorized to cause the peroneal tendonopathy.

    So, to "relax" the peroneal muscles you need to increase the pronation moment from the ground. This can be done with valgus wedges that will shift the center of pressure under the foot laterally. Also, these wedges can cause internal leg rotation, with pronation, and this will tend to shift the axis of the STJ more medial. Not all feet with a lateral position of the axis will have a lot of eversion range of motion. So, it is possible to put too big of a wedge under these feet. I do a test that I call maximum eversion height where I ask the patient to stand and evert maximally, without moving their knee in the frontal plane. Your wedge should be no higher than the amount that they can lift their lateral forefoot off of the ground. I've gone higher and most people will complain of too much force under the lateral forefoot.

    hope this helps

  6. Bev Ashdown

    Bev Ashdown Welcome New Poster

    Good Morning,
    With regard to your post, it does sound as if you have had a very logical approach and one that I would have taken myself. I wonder how long your patient has had the orthoses, was the thickening perhaps due to the pre-orthotic state of peroneal over-use? Perhaps the correction from the devices is too much too soon, if her peroneals had shortened....
    I now would be using low level laser therapy to try and resolve the conditon.
    The other thing to check, you have virtually touched on this, is the inflare of her running shoes and like you I would always go for a 'neutral shoe'.
    I hope this helps, do let me know and if not I will think again.

    Bev Ashdown Potters Bar

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