The Dangers of Surf

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Hi All,

I have been contemplating putting this one up for assistance for awhile, after reading the latest Kirby brain teaser and reading the stuff in STS (sinu tarsi syndrome) I would be really interested to others thoughts on the following case.

7 months ago a patient walked in ?? actually she hobbled, she is a Uni student studying medicine. This is her story -

In 2002 while on student exchange in Japan she suffered a L inversion sprain which she admits she did not seek appropriate treatment for assuming it would get better on it's own. She had rolled ankles before playing Netball and dancing. Pain and issues remained for several months before she finally went to a physiotherapist for treatment by this time though the ankle pain was not so bad it was more a lateral leg complaint located within the peroneals of the L lower leg, at two distinct points; adjacent to the lateral malleolar and at a point 4cm superior to this. The pain when it strikes is aching and cramping in nature and can occur within 20 seconds of WB, yet this pain pattern does not occur 100% of the time. Discomfort could be replicated with direct palpation of the peroneals and with some active forefoot inversion. I could not detect a subluxation of the peroneals. In stance she does not have planus feet actually they are pancakus with rearfoot eversion and complete midfoot collapse, a mobile rear foot with some restriction in the forefoot. NWB demostrates a large forefoot varus in BF

Previous treatment has involved extensive physical therapy and 3/4 rigid othotics which when she stood on them appeared to place her in an improved position yet they were doing nothing to control her issues as she could walk just as far with the orthotics as she could without them before the symptoms occurred. Plain film investigations revealed NAD other than an bilateral os trigonum. General health was reported to be good and she had no other lower limb complaints other than lower back pain which she was seeing a chiropractor for (and had been for several years prior to the ankle injury)

I attempted to control her symptoms in the room with strapping and padding without success - controlling pronation, although I could ease her pain when it hit by getting her to stretch the peroneals which gave short term relief. Measuring the circumference of the area did not reveal any increase in size and there were no reports of numbness or drop foot type problems.

I was not sure what was going on so I referred her off to a sports physician quering nerve entrapment and fibriod scaring he ordered MRI's which demonstrated NAD within the peroneal tendons. He administered a corticosteriod injection to peroneal tendon area which provided relief for several weeks but then wore off with a follow up injection not as successful. During this time I prescribed a set of full length CAD CAM with forefoot varus wedging and a cubiod notch. These devices were more effective than the 3/4 rigids and she placed her painlevels at around 4-5/10 improvement. The sports physician sent her to an orthopaedic surgeon who felt the os trigonum could be causing some issues so it was removed 3 months ago post op all went well. 2 months after the surgery I reviewed her to find that her problems had resolved by 80% and seemed to be getting better.

Then "the Dangers of Surf" 1 month ago she was at the beach and was knocked over by a wave and she guess what ..............rolled the L ankle again and felt something go straight away. Her ankle issues are starting to return again in the L ankle but more within the sinus tarsi area she has already had a steriod injection which has not eased her pain and I have added a 6 degree rearfoot Valgus wedge to open out the sinus tarsi. It gets better she is also now starting to have issues with her R lateral ankle and sinus tarsi. I have spoken to the sports physician and the surgeon and they are a bit perplex as to what is going on as I am. I am planning to trial her in a 3/4 aircast walker on the L foot with the orthotic in the walker in an effort to stabilise the foot and stop as much movement as possible - no movement = no pain??

I welcome any thoughts, questions,

 

Oops I meant rearfoot varus wedge to open out the sinus tarsi

 

Mark

My differential diagnosis on this is;

* subtalar joint sprain/interosseous ligament instability
* ATF/CFL attenuation

I would look at doing a subtalar joint diagnostic block on this (maybe your colleague at Woolloongaba can help you with this if unsure ).

I have a sneaking suspicion this will go on to requiring a STJ fusion in the long term.


LL

 

thanks for your reading through my case and thanks for your thoughts LL

I hadn't even considered the STJ as the current area is the sinus tarsi. the block is another good idea and i think i will discuss this with mr short. in your opinion would the walker boot be still a good option to trial or a waste of the patient money as if it is the STJ would we also get a good response with the imobilistation. i suppose that if i say lets do another injection this patient might start feeling like a pin cushion.

 

Mark

The sinus tarsi IS the subtalar joint. The deeper part of the sinus tarsi (AKA Hoke's tonsil) is probably where the pain is coming form - this is the anterior fringe of the posterior facet.

If she were to get instant pain relief with a diagnostic block to the STJ (via introduction into the sinus tarsi), I would hang my hat on the STJ as the symptomatic region, and she will jump up and kiss you if it provides immediate relief.

My approach for these is;
1. DEEP heel bup UCBL orthotic - we are talking 40,50,60mm - whatever you can get into the shoe. This is to help immobilse the STJ, rather than alter its position. +/- CAM walker in the short term.
2. If still symptomatic in 3-6/12 -> subtalar fusion.

Cheers,

LL

 

oops not thinking before i write

why have the previous injections in the sinus tarsi failed? or is this because the injections were focus more into the sinus tarsi and not in to the STJ more?

 

I would suggest you have not blocked the entire STJ.

Take a 1.5 inch 25g needle and bury it down to the hub, via the sinus tarsi, and this will be enough length to reach into the STJ. Deposit at least 5ml of your choice of local anaesthesia, preferably long-acting.

A 1 inch in neelde won't be long enough in most instances.

LL

 

Mark,

Are the symptoms within the sinus tarsi now or in the lateral ankle? You aren't clear on this. I would agree that possibly she has suffered some form of lateral ankle ligament injury however you should try to be as specific anatomically as possible. Is there an anterior drawer or talar tilt sign? Does she feel better in the brace-boot? Where is the tenderness exactly?

If the patient is maximally pronated at the subtalar joint (STJ) and you think the symptoms are caused by excessive STJ pronation moments, then I would not use a UCBL orthosis, since these aren't necessary to control excessive rearfoot pronation moments and tend to make shoe-fit difficult. You will get better results with a medial heel skive, deep heel cup, inverted orthosis with a rearfoot post in a relatively rigid shell with a high top shoe/boot initially.

In addition, I would think that a subtalar fusion will not be a likelihood for this patient as long as the proper diagnosis and treatment is instituted and would only consider this if there was evidence of STJ osteoarthritis.

Also, please if you are going to use abbreviations (and you are not alone in this), then please spell them out for us. I have no idea what BF or NAD means. And pancakus??? How is this different from pes planus??

 

Kevin

Thanks for your Reply, to answer your questions -

Pain is now predominately within the sinus tarsi - deep pain and as I mentioned the R is now starting to give her troubles in the same area. She is getting the boot today so I will keep you informed of her progress with that .

Can you explain the anterior drawer and talar tilt sign (I think the anterior drawer is the test foot placed on flat surface knee flexed and stabilise the foot with one hand and push or glide talo crural anterior positeriorly?)

With regards to my abbreviations - BF = both feet and NAD = no abnormalities detected and pancakus = as flat as a ...... really just a planus foot type.

 

Mark:

The boot should help her. Continue her in it for 2-6 weeks until the symtpoms and tenderness improves. Type in "anterior drawer sign, ankle" and "talar tilt sign, ankle" into any search engine and you will be reading about these tests for hours.

Please keep us informed of her progress.

 

Thanks Kevin and LL for your input,

she recieived her boot yesterday which appeared to provide immediate improvement i will review her in 4 weeks or sooner if need be and will keep you informed of her progress. I will also have a look at at those signs

 

Kevin and LL

Just an update on the patient, she called to say that she is pain free with walking with the boot on (3 weeks after being fitted with it) good news!!!

She reports for the past 4 days that she is now having pain in the sinus tarsi area when resting bad news????? any ideas why??

 

Mark:

Thanks for the update. I just wish that all of the other podiatrists who asked for patient advice on this website were as courteous as you at keeping all of us informed of the progress that their patients are making as a result of the time that we have spent trying to answer their queries regarding their patients' diagnosis and treatment. [That is, by the way, a hint to all of you who are reading this posting and have not kept us informed of your patients' progress when we have spent considerable time out of our day to offer you and your patients expert medical advice, free of charge.]

At this stage, now that the inflammation is probably reduced within the sinus tarsi area, I would transition her into a foot orthosis with a hiking boot or high top shoe or into a soft ankle brace. This should be combined with cortisone injections into the sinus tarsi and range of motion and strengthening exercises of the invertors and evertors of the STJ. The idea is to allow gradual healing of the injury by preventing the patient's sinus tarsi from being overcompressed by the maximally pronated STJ position and by preventing further traumatic inversion injuries that may irritate the contents of the sinus tarsi again.

Make sure that, during gait, that late midstance pronation is minimized since it is this motion that seems to exacerbate the symptoms of sinus tarsi syndrome the most. One relatively easy and effective method to reduce the tendency of late midstance pronation and reduce the compression force within the sinus tarsi is to put the patient into a shoe with a relatively large heel height differential, such as a cowboy boot, and then gradually wean them into lower heel height shoes.

 

Thanks for the quick reply Kevin, I appreciate everyone who responds to my queries as with only 4 years of practice behind me there is so much I don't know.

Your suggestions make sense, although could you explain why she would be suffering the NWB (non weight bearing)pain she is having at the moment. As I would have thought that the boot would stabilise the area not allowing movement - no movement no pain. The boot also has a rocker bottom which I thought would reduce the midstance pronation issues, I also have her wearing her amfit full length orthotic in the boot. Would exercises be a gradual increase in intensity i.e. gravity resisted increasing to using eleastic resistance eg therabands?

She is seeing her surgeon next week (see my first posting) and I have kept him up to speed with everthing, I will again make contact with him ot get his feedback on your suggestions. And will keep you posted.

Regards

Mark

 

The brace-boot will hopefully immoblize the ankle joint-STJ complex enough to reduce the pain and inflammation to the area. I would bet that her rest pain is either caused by walking too much in the brace or her not wearing the brace while doing some activities.

Exercise protocol should be as you have outlined above...gradual to more resistance. However, it would be good to get a more firm diagnosis of where her pain is originating from. Possibly some diagnostic joint blocks with local anesthetic would give you a better of where the pain is originating from. Where is she most tender anatomically??? I suggest you spend 15 minutes examining her (with your anatomy book close by) and tell us exactly what structure is likely the most tender or most painful with range of motion/testing...this would help immensely in directing further treatment.

 

Hi Kevin and interested others

I saw the patient last week 6 weeks after recieving her cam- walker boot to find -

Symptoms have improved to around 70% prior to getting the boot. She has seen her surgeon who is unable to explain her symptoms and was going to discuss it with some collegues. I have been unable to speak with him after leaving several messages re your thoughts as well as LL.

Last visit I again went through the area to make sure there was nothing I missed to find - no pain with forced inversion, no pain with inversion and plantarflexion, no pain with AP and PA talo glides, no pain with squeeze test of the fibula and tibia syndesomis. There was discomfort central to the begining of the sinus tarsi with palpation there was also pain with palpation of the talar neck when the foot was inverted. No obvious signs of swelling in either area.

I have follwed your advise and done the following -

removed the boot, dispensed a support stabilising ankle brace advised her to wear stabile heeled shoes (which she was very excited about) and advised on a gradual exercise proagram for the problem ankle.

I will keep you informed as to how it goes.

Regards

Mark

 

Mark:

Sounds like she has something going around at the insertion of the anterior talo-fibular ligament (most like a partial tear). Your treatment sounds excellent. I wouldn't be surprised if she has a significant anterior drawer sign and may be experiencing some synovitis due to the "extra slop" in the ankle now. Continue the strengthening exercises and consider a few more cortisone injections at the areas of maximal tenderness.

 

Thanks Kevin,

The cortisone I am not allowed to inject which is why I want to talk to the surgeon. We will see how it all goes.

regards

Mark

 

Kevin and others

Another follow up on the patient who I saw last week as after hearing Craig Payne's presentation on orthotics I wondered if there was something more I could do for this patient. She did not end up having another cortisone shot as she felt it was getting beeter on it's own. To show how much better she is she infomred me that she is starting to do some tap dancing.

She has found as long as she wears her CAD CAM full length orthotics with FFVR control and her joggers she is able to do most things pain free overall she is now over 80% pain free. But she is 19 years old and a girl I want to see if I can at least give her some other form of support that can go in other types of shoes.

She has had 3/4 rigid devices previously prescribed that were inverted RF posted 4.5mm polyprop beasts that could only go in joggers which alinged her foot to her leg exactly when you placed the bisection lines on the leg. But she was never able to wear them "too hard and uncomfortable" even when she gradually wore them in.

After hearing Craig I have instigated the following orthotic -
Casts taken in the prone position with the foot slightly inverted and the 1st Ray plantar flexed casts poured 5 degrees inverted and no medial or lateral fill added to the casts. Material used is 3mm polyprop 3/4 device with 1st ray cut outs at the point that the fascia allows the big toe to dorsiflex. I have advised her to walk over a piece of wooden dowel in an effort to loosen up the intrinsic musculature of her feet daily as well as to make a conscious effort to walk heel to toe and gradually wear the devices in. Will it work ? only time will tell.

regards

 

Kevin - I have on two (?) occasions had the benefit of valuable input from PA. Sadly those patients did not return for follow up. However, contributions are ALWAYS gratefully received and now (hopefully) correctly acknowledged.

 

Mark:

Thanks for getting back to us on your patient. It looks like she won't need that subtalar joint arthrodesis after all.

However, she has had two ankle sprains in a fairly short period of time so it would be appropriate at this time to put her on an aggressive anlke strengthening program with Theraband or some other aid to try and prevent another ankle sprain.

As far as gait stability and prevention of future ankle sprains, generally using an orthosis with a well formed-stable arch, a varus rearfoot and valgus forefoot extension works well for many patients. However, shoes will greatly affect their gait stability and likelihood of inversion sprains also. In a young lady such as this, it may be difficult to convince her that shoe function is better for her than shoe style. I would still recommend that she wear shoes under 1" heel height with a broad heel to improve inversion/eversion stability. Better yet, have her stay in her joggers as much as possible.

Mark, you have done a wonderful job so far with this young lady considering she was nearly unable to walk when you first saw her and the other healthcare providers didn't know what to do with her. Much of how she responds and does in the future is now up to her.....her willingness to exercise....her willingness to wear stable shoes and orthoses....and her luck in not suffering another significant inversion sprain. Keep up the good work!

 

Thank you