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HELP!!! Multiple Intermetatarsal Bursiitis not responding to treatment.

Discussion in 'Biomechanics, Sports and Foot orthoses' started by AWFeet, Mar 7, 2018.

  1. AWFeet

    AWFeet Welcome New Poster

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    Hi All,

    I have a case I would love some advice about. Pt has been putting up with pain for over 7 years as multiple specialist attempted diagnosis but they basically did nothing for her. I started seeing her 6 months ago.
    Patient Information:
    Female - mid 30's
    Diabetes T1
    Works in retail standing long periods of time in R.M. Williams boots
    Patient Complaint: RIGHT FOOT
    Multiple Intermetatarsal Bursiitis
    Interstitial Bursiitis 5th
    Initial: 7-8 Years ago, patient felt a sting and then her foot swell up. No treatment provided and was off work for one year.
    Pain on WB and worsens the longer she is WB. At work is worst.
    Foot feels hot and burns.
    Valiex sign from forefoot to posterior knee
    Foot feels tight and restricted
    Foot Function:
    Mulders Click - Positive
    Retracted toes due to compensation pattern of patient to try and walk on the side of her foot to reduce pain
    EDL 3rd-5th Digits - little to no movement upon active attempt, can be passively moved (I do have a video demonstrating this)
    Rearfoot and Midfoot ROM normal
    Ankle Joint ROM: Reduced by not restricted. Muscular tightness.
    Gait Analysis: Difficult due to antalgic gait. Lesser toes do not WB/ load due to forefoot swelling.

    Metatarsal Dome and Metatarsal Pad trialled with and without orthotics. Both caused increase in pain despite multiple attempts at positioning.
    Footwear: Advised wider fitting shoe to reduce pressure. Any enclosed shoe causes pain. Thongs not so much, but still is uncomfortable.
    Calf muscle stretches prescribed
    Soft rubber ball massage to reduce soft tissue tightness
    None of this worked.

    Cortisone Injection into the two largest bursas with 1 week rest from work with the use of crutches was recommend. Crutches were unable to use due to shoulder injury. Complete rest - was not entirely compliant while off work.

    It has been 2 weeks since the injections and I have the feeling that her results have been minimal.

    I have suggested to the GP that surgical intervention may be required if pain does not subside. She saw a GP (not her regular GP) who advised her that he does not think surgery will go ahead and that all she needs to do is to improve her forefoot biomechanics by performing stretches to reduce retracted toes.

    What do you all think?

    Any helpful advice is very much appreciated! :)
  2. WillMo

    WillMo Member

    - I would try some intrinsic muscle exercises to aim to improve the dynamic stability of her foot (whether or not this is what actually happens is a debate within itself), and to improve the clawing of her toes: think piano toes and doming
    - Dry needling is another "arrow in your quiver"
    - It may be the case that she needs a soft material to stand on. So perhaps recovering her orthotics with something like poron might help relieve symptoms a bit?

  3. AWFeet

    AWFeet Welcome New Poster

    Hi WillMo,

    Thank you so much for your reply!

    So I would agree with with exercises usually however she cannot move her lesser toes as all. To passively extend the toes is very uncomfortable and then of course with the ppt metatarsal dome, she just does not tolerate it at all. In fact the pain worsens with the dome. Could this be due to the fact that there are multiple bursitis present as well as their large size? I tried placement into so many different positions which was unsuccessful, particularly at work. The problem is that any shoe which applies a slight amount of transverse pressure to the metatarsal heads (including cam walkers) just aggravate her foot.

    Dry needling may benefit, but after the cortisone injections, I can see that her pain is far worse off than before the injections. Her foot is also alot more swollen. I think it is past the ability to calm it all down. Is it common for the cortizone injection to worsen intermetatarsal bursitis? It is the first time I have not had a great result with conservative therapy and actually had to take the next step. From her reaction, I am not inclined to recommend it again!

    Soft material ie poron, another great suggestion! I should mention that she opted for prefabricated devices because she had already bought custom orthotics from a podiatrist previously which did not help her. Again a met dome was placed in many different positions with absolutely no luck. I am not sure if the problem was that fact that any transverse pressure applied just aggravated her foot and therefore made me think the dome is not working. If she could wear thongs to work, that would be the most comfortable option!

    Thanks again for your response! You have given me some food for thought.

  4. footplant

    footplant Active Member

    Hi Ash,

    Is the diagnosis definitely bursitis? It sounds like the patient has an 8 year history of unilateral swelling and burning pain, with hypersensitivity to shoes, following some sort of minor injury? I just thought that this sounds a bit like complex regional pain.


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