Arch pain differential diagnosis (help)

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Hello all, would like your thoughts on the following patient

26 year old female flight attendant, in good health, weight 60kg

Presenting complaint: left arch pain, localised to the middle/centre of the medial longitudinal arch and to the medial aspect of this point.

History: twisted left knee at work 9 months ago, (having physio treatment under workers compensation) diagnosed with medial collateral ligament tear.

Arch pain present for 4 months, pain worse in the afternoon and better in the morning.
Pain exacerbated by aerobics and massaging with tennis ball.

Footwear. patient wears a high heel to work fitted with a slim fit orthoheel orthotic, on board changes to a flatter shoe. For exersise (gym, running) asics GT with sports orthoheel.

Examination: moderatley pronated bilaterally, mediaum arch height, minimal 1st MTP dorsiflexion resistance weight bearing.
single heel raise satisfactory
knee to wall satisfactory
palpation of the plantar fascia was tender at the centre of the band, (no tenderness was noted around the calcaneus).
tenderness was also noted in the belly of abductor hallucis.

Treatment: I applied a plantar fascia taping (low dye sports tape), patient reported felt initially uncomfortable, I advised patient the tape will stretch and feel more comfortable.
Referred the patient for an ultrasound.
Spoke to the patient a week later and she felt the taping exacerbated her symptoms. (i have applied many plantar fascia tapes all with very good success, so i found this strange)

Diagnostic tests: I have not viewed the ultrasound report, but spoke to her physio who informed me no swelling, inflammation or tear was picked up.

Diagnosis: Initially i was suspecting a muscle tear (possibly to flexor digitorum or hallucis brevis) or anterior tibialis tendinopathy at its insertion.

Not too sure what tests clinical or otherwise i shoud do next.
I have only seen this patient once and will be reviewing the ultrasound report this week.
Any help appreciated
Regards mark

 

Mark:

Unless you can more precisely pinpoint the exact anatomic structure which is tender and symptomatic in your patient, we will be just groping in the dark for an answer for you. If you are unsure of the anatomy of your patients foot, then take a photo of the patients foot with the area of maximum tenderness outlined and then we should be better able to help you. Knowledge of foot anatomy is critical in cases such as this.

In other words, there is quite a difference in anatomic location of the medial slip of the central component of the plantar aponeurosis and the anterior tibial tendon insertion. If you can't discern the difference between these two structures in your patient's foot, then send us a photo and we will do it for you.

 

thanks for replying Kevin.

I reviewed this patient again (still no ultrasound report) but was assured ultrasound found nothing.

In the 2 1/2 weeks since the initial consultation, the patient has been put on light duties and taking a course of anti-inflammatories (diclofenac) due to her knee pain. This has helped with her foot pain.

Knee pain is worse, medial and postereior with swelling present , patient is limping, and has the knee strapped. Patient is awaiting approval from workers compensation for MRI and referral to specialist.

As mentioned her foot pain is better. Light duties, wearing her asics with otc orthotics, with no stretching massaging or exersise.

On examination patient described pain at flexor hallucis brevis, although no pain on palpation. She also described pain as shooting up her medial ankle (this was not mentioned at her first consultation), palpation posterior to the medial malleolus was painful.
Muscle testing was uneventful. single heel raise again was no problem.

My opinion is her symptoms may be neurological, irritation to the posterior tibial nerve (from excessive pronation or referred from the tibial nerve posterior to her knee) radiating into the medial plantar nerve.

I have strapped her foot to offload the medial ankle.

 

Hi Mark,

This thread reminds me of your patient's presentation

http://www.podiatry-arena.com/podiatry-forum/showthread.php?t=57056

Sounds tarsal tunnel but check SLR and slump tests