Styloid pain: NOT fracture

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First proper post, be gentle.

CC: A 38 y/o female with a 4week history of pain in her right dorsolateral foot around base of 5th met.

HPI: Pt is slightly overweight. Works full time but not on feet much. Pain is worse in evening when she is on her feet more around the house. Recently had been ramping up physical activity with boot camps and running up to 5km. Has had to stop due to this foot pain. No recolleciton of any trauma, symptoms came on slowly and are getting worse. L foot no pain. No difference in pain between different shoes or when in barefeet.

Hx of plantar fasciitis resolved by another pod with orthoitcs (did not bring in to consult so I have not seen them but I understand them to be 8deg mod root)

PE: No pain when palpating distal 5th met, med mal, peroneas brev/long.
Very painful to palpate styloid process and severe pain in joint space between styloid and cuboid. The peroneals are pain free even right at the insertion.

Musculoskeletal:

Gait examination: Moderate pronation through midstance however gait is affected by limping due to the pain.

Neurological: WNL
Dermatological:WNL
Vascular: WNL

Tests: X-ray attatched - no sign of any fractures.

Diagnosis:

To me the styloid process itself appears elongated compared to most other people and is wraps around the cuboid more than usual. The proximal edge of the joint space appears narrow and there is some slight cloudyness in the ocntrast (may not be clear in photos). I suspect the pain is due to the unusual shape of the styloid process combined with footwear and increase in activity causing a pinching at the proximal joint space of the cuboid.

Treatment Plan:
Pt only had worn flats today not conducive to padding. Bringing in shoes this evening to try and combine padding and strapping to relieve pain.
Tried cam walker but as suspected there was no effect on pain. My concern is that this may be a surgical case if my suspicions of the cause are correct.

I appeal to the collective knowledge of my much more experianced and informed peers. It may be that I am way off here and am just looking at the result of an inflamed bursitis.

 

The styloid does look a little different

before you send for a surg consult I would think about the mechanics 1st

P Brevis inserts on the the styloid as this muscle is generally lateral to the STJ axis it will be a pronatory muscle

I would suggest you reduce loads on the muscle but actively pronating the foot through padding or orthotics - rest, ice and NASIDS and then review after 3 or so weeks.

Hope that helps

 

A quick thought on the maximum eversion height test: if the forefoot range of motion is in any way related to the rearfoot position (I think Daryl Phillips identified this to be the case in his paper "quantitative analysis of the locking of the midtarsal jointhttp://www.ncbi.nlm.nih.gov/pubmed/6630848) then the maximum eversion height will vary as a function of rearfoot position during stance.

 

This was my initial thoughts with this sort of injury however extensive passive and active/resisted muscle testing elicited 0 pain. Also since my initial post the pt returned with her runners and eversion strapping and padding made no difference. The extra lateral bulk in the shoe made the pain worse. Even a somewhat elaborate construction of lateral force application that completely kept pressure off the specific painful area was not much use as the act of weight bearing is enough.

The pain is also significantly more acute on the dorsomedial side of the styloid process as opposed to the lateral point.

I may be just looking for what I think is there but from what I saw today I don't see lateral force for 3 weeks doing the trick for this pt.

I forgot to mention the pt has had oral anti inflams that reportedly had no effect. She has not been icing however which she has now been instructed to do.

 

If you think it is intra-articular pain between the 5th metatarsal and cuboid that is causing the problem then injecting 1 cc of local anesthetic into the joint should reduce the pain signficantly for diagnostic purposes.

Looking at those radiographs, which are pretty unusual, my guess is the 5th metatarsal-cuboid joint has become symptomatic and may require surgery, if immobilization hasn't helped her.

However, I would inject whatever is most symptomatic with cortisone to see how she responded before any surgery is planned. Are you sure it isn't an insertional tendinitis of the peroneus brevis??

 

I agree with the conservative stuff. However, there is an oval radiolucency in the spot where you are describing the pain. There may be some bone altering process inside the bone. It is probably not an aggressive tumor because the margins are very regular. At first I thought that it was an artifact, but it is clearly visible on two of the views. Are all of those views different magnification of the same picture or is one one of those an ap view and the other an oblique view? If it's an artifact then it won't be in the other views. Anyway, with the pain right where you see an abnormality and MRI would be a good idea.

Eric

 

What did the asymptomatic styloid look like in comparison?

I'm a simple guy and like to compare...if structure is similiar without sigificant difference then I look at the most likely...which is tendonitis. Which I love to treat with ICE.

An interarticular injection is a useful tool also and cheaper than a MRI.

 

Hi
Just a quick comment.
You state in the original post that there is pain only at the styloid but the insertion of the PB is nonpainful. Also that the "space" between the styloid and cuboid is painful.

These areas are quite close together and do not function independently. I'd be interested as to how you differentiate insertional PB pain from isolated styloid process pain. Also how you differentiate pain between the styloid and cuboid from the 5th Met-cuboid joint articulation?

I'd also be interested to know, if in fact there is no pain along the PB or PL (I assume on palpation) whether there is pain on resistance.

Steve

BTW: The small lytic area at the styloid is an anatomic radiographic artifact. The styloid merely thins out from dorsal to plantar
as compared to the base articulation. This represents less bone density and consequently a "lytic" area, much like that seen at the peroneal groove in the same radiograph.

 

I agree completely.

I grabbed the first 3 x-rays I could lay my hands on and none of them had a "lytic" appearence like the posted ones do. Also, the thinning from dorsal to plantar should make the bone have the same appearance all the way across the bone. The lytic area goes halfway across. It could still be an artifact, but not using he dorsal to plantar thinning logic.

Eric

 

Hi eric
I Know what you are saying Re: lytic area. I have seen these rather thinned out, enlarged processes before, surgically. They are thinner than the base and metaphyseal area. The decreased bone density corresponds to this thin area anatomically. I can visualize this looking lytic radiographically.
Ill see if I can dig up an old similar xray showing this.

Thanks
Steve