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Fifth metatarsal/styloid process pain

Discussion in 'Biomechanics, Sports and Foot orthoses' started by DaveJames, Jul 13, 2011.

  1. DaveJames

    DaveJames Active Member

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    Hi All,

    I just wanted to get some advice on a current patient who is increasing her walking distance/tolerance in order to complete a walking holiday. This holiday will have five consecutive days with distances ranging between approximately 8 miles and 16 miles.

    PC: right 5th styloid process pain

    HPC: Patient reports pain after walking for 8-10 miles. Pain subsides pretty quickly after finishing activity. She walks for recreation on weekends and has worn in/broken in walking boots which have not caused any problems prior to now.

    PMH: Nil of note. No fractures noted. She has had some inversion injuries to both feet before.

    NWB examination:
    Callus to 2nd MTPJ and 1st IPJ
    AJDF - some stiffness but able to get to approximately 5 degrees past 90 with leg extended
    Reducible met adductus (right worse than left)
    Laterally deviated STJ axis
    No obvious swelling to the area, no callus or blistering, no crepitus, patient reports aching on palpation and after activity

    WB examination:
    Supination resistance is moderate
    Hubschers - delayed with moderate force required
    Foot posture suggests a more pronated position in relaxed stance

    Nothing obvious of note

    Differential diagnoses:
    Simple rubbing of footwear on the foot
    Soft tissue overload from foot function/deviation of STJ axis
    Foot fracture

    Treatment plan:
    Relative rest
    Calf muscle stretches

    She's undertaking her walking holiday in the next 5 weeks, so she's being reviewed with a view to orthoses next week. I'm looking at a heel raise with possibly a lateral forefoot valgus wedge. The rationale being to reduce the 1st MTPJ dorsiflexion stiffness and also to provide an external pronation moment on the foot and reduce the tension in peroneus brevis and tertius.

    Any thoughts/comments would be most welcome.

    Many thanks in advance.

    Kind regards,

  2. Peroneal tendonitis.
  3. Hi Dave sounds good nice patient presentation - be little careful with abbreviations

    anti-inflammatory drugs
    Look at the walking boots/shoes for lateral wear
    Ankle brace or taping
    to further aid the pronation moment from the device maybe a lateral Skive.

    Also what you need to find out is why the muscle is strained ie supination moment from ground - GRF or muscle spasm may not change the orthotic prescription but may change the of physical treatment you use

    Hope that helps
  4. Griff

    Griff Moderator

    Nice info Dave.

    I'd probably trial a full length lateral wedge underneath the sock liner of her walking boot.

    Let us know what you go for and how she gets on.

  5. DaveJames

    DaveJames Active Member

    Short but sweet Dr Spooner! ;)

    I was thinking along those lines, but concerned it was too obvious!

    Mike, that's a great help, thank you. I'll keep an eye on the abbreviations; I'm not even sure I know what half of them mean!

    Hi Ian. It seems lateral wedging is the way to go. Why full length, as apposed to just forefoot wedging? I'll hazard a guess that full length will provide a greater (or perhaps prolonged would be a better term) external pronation moment than forefoot (or even rearfoot) alone.

    Cheers for your help guys!

  6. If it walks like a duck and quacks, it's usually a duck.

    Dave, common things are common and rare things are rare, it's still more likely to have a common thing with an unusual presentation than a rare thing presenting as itself. Doesn't mean it isn't a rare thing though.

    Personally, I'd tend to start with valgus wedging just at the forefoot- longer lever arm here, plus think about when the force from the peroneal's is required during contact phase. If that doesn't get the results, then I'll extend the wedging proximally.

    p.S. given the history of previous inversion injuries, I'd get her doing some proprioceptive rehab too, as 9 out of ten cats won't have had any. Wobble-board work etc. Might also be worth looking at superior and inferior tib-fib joints (posterior to anterior glides) and a bit of mobilisation work if necessary while you're there.
  7. Griff

    Griff Moderator

    If you want to reduce load on the peroneii, it's best to have forefoot wedging rather than rearfoot wedging (due to a longer lever arm at the forefoot as I know you already know). However my rationale for using full length wedging is that in my experience when throwing some EVA under someone's sockliner, most will find a full length wedge much more comfortable than a forefoot valgus wedge in isolation (they won't feel the raised edges).
  8. Use a grinder and bevel the edges ;) Seriously, I do hear you on that and it is a reasonable call, Ian.
  9. BTW, if you haven't already, a test of maximum eversion height might be helpful before you start trying to stick wedges of EVA under the forefoot.
  10. DaveJames

    DaveJames Active Member

    Simon, that's a good point!

    We've done some brief mobilisation work and adding proprioception exercises isn't an issue.

    Ian, that makes perfect sense.

    Cheers guys.

  11. DaveJames

    DaveJames Active Member

    I'm assuming fingers under the lateral border off the forefoot and lifting (similar to supination resistance, but other side of the foot); the more you can lift, the greater the wedging.

    If I'm wildly off the mark you'll need to elaborate for me!
  12. RobinP

    RobinP Well-Known Member

    Good advice that

    Just finished one where I had the (full length - for the same reason as Ian)lateral wedge cut and was sticking it on the sock liner when i decided that testing max eversion height might be an idea. Only able to get half the amount in that I had planned in the end.

    So definately always the thing not to forget.

    Good presentation Dave

    The Equalizer
  13. Dave, got this one off Eric Fuller a decade or so ago, maybe he'll chip in. Basically in relaxed standing have patient evert feet (I stick my fist between their knees to stop them cheating and gives me a feel of how much force they are using to try to add to the eversion from proximal to the foot), If they can only get their lateral forefoot off the floor by say 5mm, you don't want to be using a wedge greater than 5mm thickness at this point as you'll probably cause too much compression at their sinus tarsi/ run the risk of pronation moment related pathology.

    Hopefully Eric will elaborate, but thats a rough outline.
  14. Good theme tune- ya' man from The Police. Ewar Woowar- can't remember the joke, but that was the punchline.

    Oh, yeah: Why has Edward Woodward got 4 d's in his name?
    Because otherwise he'd be Ewar Woowar. Now, that's a joke.
  15. efuller

    efuller MVP

    Hi Dave,

    Any pain, and where, with resisted eversion (testing strength of peroneus brevis)? Stress the tissues in the location of the pain to get an idea of what's causing the pain. The answer will help choose from your differential.

    Some conflicting things: lat dev STJ axis and moderate supination resistance. No obvious gait changes.

    Look at the peroneals when you do the supination resistance test. Activation of the peroneals will often happen in a foot with a laterally positioned STJ axis when you attempt to supinate the STJ. The patient may not even realize that is what they are doing.

    In gait, with a laterally positioned STJ axis, there will often be late stance phase pronation. This will occur if there is range of motion availble at the joints that will allow eversion. If, in addition to the lateral axis there is a rearfoot varus, (the stj is maximally everted in stance), there will be no range of motion for further eversion, so you won't see late stance phase pronation.

    So, with that thought process, I would say that the most likely cause of the pain is a peroneus brevis insertional tendonits. However, if you did not get pain with resisted eversion, I would start looking for other diagnoses.

    If you have an STJ that is maximally pronated and has a laterally positioned STJ axis then you have to be careful about how much wedge you add. Simon's description of the maximum eversion height test was pretty good. The patient may also try and cheat by leaning back on their heels to get range of motion. I will tell them that if they are unable to lift their lateral forefoot off of the ground that is the information that I'm looking for.

    If you have a peroneal tendonitis with a very low eversion height, I would suggest a valgus heel wedge as a forefoot wedge could create some lateral forefoot overload. However, that's what you may need to do to prevent the insertional pain. You may have to educate the patient to go back and forth between no lateral forefoot wedge and putting the wedge in to find what works best for her trip.

  16. DaveJames

    DaveJames Active Member

    Hi Eric,

    That's not something I've tested with focus at this stage; I certainly will be doing it when I next see her.

    It seems key to know what the eversion height is for this patient, and is something I will test when I see her next. I'll attempt to keep you updated!

    Thanks guys for the great advice! :drinks

    Kind regards,

  17. mgates01

    mgates01 Active Member

    Hi all
    really good informative post.
    Maybe I'm going to ask a daft laddie question but part of Eric's post confused me, he said,
    "If, in addition to the lateral axis there is a rearfoot varus, (the stj is maximally everted in stance), there will be no range of motion for further eversion, so you won't see late stance phase pronation."
    I thought that rearfoot varus was inversion of the calcaneum, not eversion

    Do you mean a rearfoot varus that is fully compensated by maximally everting the foot on relaxed stance.
    Perhaps I'm just not understanding this correctly.
    Apologies if this is daft
  18. efuller

    efuller MVP

    You have to understand whether we are talking about position or motion or both. A heel can have an inverted heel bisection and be at the end of range of motion in the direction of eversion of the STJ.

    A rearfoot varus as classically described by Root Weed and Orien was when neutral position was inverted relative to the leg. The STJ pronates away from neutral position to get the forefoot flat on the floor (>95% of people) to the point where there is less range of motion for eversion in the resting position. Those authors also coined a term partially compensated rearfoot varus, where there is eversion away from neutral position, but not enough to get the heel bisection to vertical. In this case there, there is no further range of motion available in the direction of eversion at the STJ. This is what I was referring to in short hand above. A fully compensated varus would be one where neutral position is inverted, but there is enough range of motion to get the heel to vertical.

    I don't particularly like those definitions, but they are out there. They do describe an important concept related to the end of range of the Subtalar joint. Anatomically, when the lateral process of the talus hits the floor of the sinus tarsi of the calcaneus. There is no further range of motion, or it becomes quite stiff to further attempted motion. I think these anatomical structures are much more important than the heel bisection and that is one reason why I don't really like their definition of rearfoot varus.

  19. Not daft. Rearfoot varus is a static positional deformity defined using a Rootian protocol. Root suggested that this will compensate via pronation. So, we can have a situation during dynamic function in which the rearfoot is at its end of range pronation, i.e. it is maximally everted, yet the heel is still inverted, etc.
  20. Cross-posted with Eric, he and I are essentially saying the same thing. Better to think of this in terms of zones of optimal stress (ZOOS) . If the rearfoot is inverted (position) but functioning at it's end of range of eversion (motion) then something must be preventing it from everting (motion) further, thus the stress on the tissue(s) preventing further eversion will be elevated in this foot. Viz. you can have a "high arched" foot with pronation moment related symptoms because its at end of range pronation(motion) even though it is supinated (position). Hence, the "wet footprint test" is rubbish. Its all about ZOOS: Someone told me it's all happening at the ZOOS, I do believe it, I do believe its true-

    Someone told me
    It's all happening at the zoo.
    I do believe it,
    I do believe it's true.

    Mmmmm. Mmmmm. Whoooa. Mmmmm.

    It's a light and tumble journey
    From the East Side to the park;
    Just a fine and fancy ramble
    To the zoo.

    But you can take the crosstown bus
    If it's raining or it's cold,
    And the animals will love it
    If you do.
    If you do.

    Something tells me
    It's all happening at the zoo.
    I do believe it,
    I do believe it's true.

    Mmmmm. Mmmmm. Whoooa. Mmmmm.

    The monkeys stand for honesty,
    Giraffes are insincere,
    And the elephants are kindly but
    They're dumb.
    Orangutans are skeptical
    Of changes in their cages,
    And the zookeeper is very fond of rum.

    Zebras are reactionaries,
    Antelopes are missionaries,
    Pigeons plot in secrecy,
    And hamsters turn on frequently.
    What a gas! You gotta come and see
    At the zoo.
    At the zoo.
    At the zoo.
    At the zoo.
    At the zoo.
    At the zoo.
    At the zoo.
    At the zoo.

    Me, I'm a monkey (or the zoo-keeper), which are you?

    BTW, on a scale of 1-genius, Simon and Garfunkel... Genius +1

    Talking of genius: What do you want?

    Dedicated to anyone who saw ZOO TV and to anyone who didn't, this gives a feeling of what it was like imagine this on lots and lots of screens some big some huge: watch more TV
    "A friend is someone who lets you help"
  21. Dave:

    Even though there have been some excellent replies already on this topic, let me add my two cents.

    Any structural deformity of the foot which increases the external subtalar joint (STJ) supination moment caused by ground reaction force (GRF) acting on the plantar foot during weightbearing activities will "force" the central nervous system (CNS) to use one or both of its only significant STJ pronators, the peroneus longus and brevis, more forcefully and/or more frequently than normal to increase the internal STJ pronation moment and, therefore, prevent inversion ankle instability during gait. Of course, a laterally deviated STJ axis will cause this increase in external STJ supination moment. However, we could also describe a laterally deviated STJ axis by using the Root et al terminology. In other words, a laterally deviated STJ axis may be structurally caused by a high degree of metatarsus adductus deformity and/or a high degree of rearfoot varus deformity and/or a "rigid forefoot valgus deformity".

    In the case of styloid process of the 5th metatarsal pain, the most likely culprit is the insertion of the peroneus brevis tendon on the styloid process (i.e. peroneus brevis insertional tendinitis). One must be also aware that other differentials for styloid process pain include occult fracture of the styloid process, accessory bone inflammation (i.e. os vesalianum), and/or lateral plantar fasciitis (i.e. where the lateral component of the plantar aponeurosis inserts onto the plantar aspect of the styloid process).

    If a peroneus brevis insertional tendinitis is suspected, valgus rearfoot and forefoot wedging should be used on the shoe sockliner initially to shift the center of pressure laterally on the rearfoot, midfoot and forefoot which will, in turn, decrease the magnitude of external STJ supination moment from GRF. Icing therapy, 20 minutes 2 to 3 times a day also helps greatly, and, in the worst cases, 2-4 weeks in a cam-walker style brace may be required.

    This mechanical effect from the valgus forefoot and rearfoot wedging will cause the CNS to "sense" that it doesn't need to increase the magnitude and duration of efferent activity to the peroneus brevis and peroneus longus muscles as much during gait since the CNS will now no longer "sense" excessive STJ supination moments that could cause a catastrophic inversion ankle sprain or fall. In other words, the external STJ pronation moments that the valgus forefoot and rearfoot wedges are now providing for the foot and lower extremity to allow optimal and safe gait function are effectively replacing the internal STJ pronation moments that the CNS previously determined were necessary from contractile activity of the peroneal muscles to allow optimal and safe gait function.

    Hope this helps.:drinks
  22. DaveJames

    DaveJames Active Member

    Hi All,

    Many thanks for all your advice; really useful stuff, and certainly worth more than two cents! :drinks

    I'l keep you posted on what happens.

    Kind regards,

  23. musmed

    musmed Active Member

    Dear All

    All this knowledge is for treating a diagnosis.
    There has not been a diagnosis made.

    The patient has told you the problem is in the active stuff:muscle, tendon, musculottendinous junction and the Sharpies fibres.
    According to the late Dr. James Cyriax the problem is subacute. This is because the pain starts after exercise has begun and stops not long after stopping.

    A simple suggestion is to have an X-Ray and ultrasound when she has the pain. No other time.

    Possibilites it will find is a stress fracture (doubt it) insertional tendinitis, peropneal tendinitis.

    A simple test is the Craig Payne test. When they have their pain palpate the tendon at the fibular area. If tender, place a small lateral wedge under the lateral heel and retest. There should be no pain. This is a very simple method of treating this problem. It works a treat.

    If the tendon is not tender, the most likely diagnosis is insertional tendinitis.
    another cause can be a subluxed cuboid.

    Other muscles to look at that cause overloading to the peroneals are: short head biceps, popliteus, tibialis posterior and abductor hallucis inhibition. All easy to test.

    One thing we never mention regarding muscles is that they can act weakly or be inhibited. This will place a greater load on other muscles.

    Finally a simple rule. Never treat where it hurts, just treat dysfunction. You will get more results than you can ever imagine.

    Paul Conneely

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