Help with an interesting case

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Post traumatic Flexor Hallucis Tendonitis?

I recently read this sad story and I would be most interested in peoples thoughts.

From a purely theoretical standpoint what do people think?

Regards
Robert

 

Re: Post traumatic Flexor Hallucis Tendonitis?

DDx:
1. CRPS/RSDS
2. Tarsal tunnel syndrome
3. Soft tissue findings on MRI

I would want to see a bone scan next, before moving forwards.

LL

 

Personally, call me simplistic if you like but I'm tempted to say that if the MRI shows

I'd be looking for some kind of tendonitis of the flexor hallucis tendon. A more interesting question for me is what treatments can be tried for it.

Steroid injections have been tried, although we don't know exactly where the steroids were injected.

Orthotics have been tried, although we don't know what the prescription was.

I'm wondering if strapping would be worth a try, if the steroids were deposited into the inflamed tendon area and what orthotic prescription would be good for reducing flexor hallucis demand. Anyone else got any ideas?

Regards
Robert

 

What that then?

Regards
Robert

 

Complex regional pain syndrome/reflex sympathetic dystrophy syndrome.

Robert, I personally think this trauma has produced something a hell of a lot more complex than anything any orthotic will address.

LL

 

Re: Post traumatic Flexor Hallucis Tendonitis?

"burning shooting pain in the inside arch of my foot, ankle, shooting through my big toe, also on the outer ankle, outer side of my foot through my pinky toe. "

With all that I'd like them to put a number (e.g. 7 out of 10) for each location and how often. I really hate it when patients say it hurts everywhere. At that point, it's tempting to ask if they have any disability forms for me to fill out. It always seems that they hand the forms to you after a long fruitless exam that doesn't make much sense. It's especially annoying when there are now two other patients waiting.

Although, the MRI findings can correlate with the majority of the history and physical findings. If there is both a peroneus longus and flexor hallucis longus (FHL) tendonitis then that covers anatomically all of the pains except for the pinky toe.

Hick's in his article that described the function of the muscles of the foot noted that the FHL muscle could create most of the same motions as peroneus longus. If someones peroneus longus hurt then they could develop overuse of FHL. The description of the initial injury hinted at peroneus longus tear in the arch. Of course this is all theoretical.

I wonder if this doctor injected the heel for pain in the arch? Nothing on the MRI? Was this guy thinking at all? Or was he thinking I get paid for making orthotics and giving injections?

It reminds me of Sutton's law. Willie Sutton the bank robber was asked why he robbed banks. "Because, that's where the money is." You should inject the steroid where the pain is if you want to reduce inflammation.

Dr. Thought: Oh darn, it didn't get better with time. Now what do I do? It might get better while waiting for the second MRI. Oops, I shouldn't have mentioned surgery before I knew what was going on.

Go in and look around and clean up sounds so cool. Id like to see a comparison between the results of someone going in and looking and cleaning up and post operative recovery and the same time resting as the post op recovery.

With those pain everywhere patients it's easy to give up. Some tests I'd like to see. Peroneus longus strength; pain with testing? FHL stength; pain with testing? Referred pain from the back?

Robert, when you asked about what people thought were you asking about what the doctors did or what the patients condition might be? There's not enough info to say what's going on with the patient.

Cheers,

Eric

 

Re: Post traumatic Flexor Hallucis Tendonitis?

Robert:

When this patient is examined by a competent clinician, and it is reported back to us, then maybe we will be able to offer some help.

 

Definitely need more information- probably can't give any accurate advice without seeing the foot itself in this case.

I agree that simple taping would be useful if only to see what stabilising the foot and, at the same time, allowing function would do. If there is a possibility of CRPS, then part of the treatment is getting them to use the foot... so getting her out of the boot should be good, and physio is appropriate.

Also- When someone says they have had orthoses, you still need to ascertain whether they are appropriate, have been worn in good shoes, had any positve or negative effects etc.- it is all feedback!

 

Yeah I know. I was just wondering the approach people would take. I LOVE Suttons law.

Cheers
Robert

 

I have seen this type of syndrome countless times. Following mild to severe ankle sprains, the normal translation of the fibula becomes restricted and creates an arthrogenic inhibition of the peroneals. 1st ray stabilization becomes impossible, with 1st MTP joint pain and dorsiflexion tendon substitution (anterior tibial and flexor hallucis longus) a predictable sequalea.

Treatment involves manipulation of the ankle as a starter. This can return the peroneals to a normal facilitated state, stabilizing the 1st ray and rapidly reducing pain. The appropriate orthotic should NOT have any amount of RF varus posting, as this will overload the already strained lateral side of the foot and the sore and inflammed peroneal tendons. 1st ray cutouts are a must to relieve dorsiflexion stress on the 1st metatarsal head. Positive outcomes changes can be rapid, but complete "cures" take time, usually about one month/year of duration of symptoms.

Howard

 

Hi Everyone

I have to agree with Howard on this one. Have and do treat a lot of patients with similar problems and do resolve with the fibula being the key starting point of manipulation. Also trying to identify any planar locking that you can rehabilitate and joint restrictions you are able to improve upon. The speed for the initial improvement can be remarkable with time helping the soft tissue injuries

Cheers Dave:drinks

 

Hi Robert

I never knew before but, daily I try actively, to apply my newly learned Suttons Law. Thanks Eric for letting me know there was a Mr Sutton - who I might add, could have won a Nobel for physics- for his simplicity!

Like the old addage, "When in doubt, think of gout", I'm always amazed at how we overcomplicate things.

That said, however, Howard has probably 'hit the nail on the head' - so to speak, with the Fibula as the starting point. Keep it simple and work backwards towards diagnosis.

Was it an inversion or eversion ankle sprain? What does the arch and other area's mentioned have to do with her mechanism of injury, relative to the type of sprain? And why 2 years later is pain still persisting? And dare I say progressing.

I can't help but wonder (taking into account her originally incorrectly treated ankle 'sprain') why she is still fully weight bearing? Without much support?

Try manipulating her proximal fibula head anteriorly, allowing for much better use of her ab and adductors during gait.

Also, strapping and active physio and of course regular and monitored follow ups would be key to keep you on the right track.

Good luck

Brandon

 

Hi Robert
I tend to find the the superior tib fib joint becomes stuck in posterior translation and the inferior tib fib joint is stuck in anterior translation. This subsequent effect of this is the foot favours a plantarflexion and inversion. Post tib becomes over active to try and stabilise and peroneals seem to suffer antagonistic strain.

If the range of movement is then helped and restored the function with dramatically improve and physical therapy to help the soft tisssue aliments.

Dave

 

Interesting thoughts, but I'd say start with her back.
"Back surgery 2 years ago?" What kind of back surgery? She needs to see a competent orthopedic surgeon who specializes in back surgery first, then look distally.
-John

 

you could just isolate the foot with local and if the pain persists then look into the back.
Dave