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Help with diagnosis and management of localised dorsal midfoot pain.

Discussion in 'Biomechanics, Sports and Foot orthoses' started by Matt Kimball, Jun 9, 2009.

  1. Matt Kimball

    Matt Kimball Member


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    Hi everyone! This is my first thread so be gentle. I should also point out that this patient is my housemate, and I've been copping grief about being unable to diagnose or manage her sore foot. I also have a great support base of more experienced podiatrists here where I work, I'd just like to cast a wide net!

    Here we go, case presentation...

    21 year old female, moderate activity levels. Pain instigated from stopping suddenly and foot sliding forward playing netball around 2 weeks, same level of discomfort now.

    Chief Complaint (CC) - Pain localised to the dorsal aspect of the 1st metatarsocuneiform joint left foot. Radiates through the other metatarsocunieform joints. Worse with cold and prolonged activity, slightly relieved by heat and rest. Post-static dyskinesic pain also. Better in more supportive footwear, but only a little better. Best in high heeled shoes. Described as a deep ache. Nil associated redness, heat, swelling etc.

    History of Present Illness (HPI) - no current other medical problems. Slightly overweight.

    Past Medical History (PMH) - Has orthotics (blake, 6 degrees) for management of occasional plantar fasciitis, along the medial band, not the insertion point. Really only wears them playing netball, was wearing them when injured foot. No complaints with orthotics or plantar fascia at the moment. Orthotics have no effect (negative or positive) on the current complaint.

    Physical Exam (PE) - See above. Biomechanically, moderately pronated through the rearfoot, moderately pronated through midfoot both feet. If I had to put a figure on it I'd say 6 degrees everted rearfoot in resting calcaneal stance position, compared to rectus "neutral". Slight, occasional in-toeing at gait. Normal muscle strength, tone, slight bilateral muscular equinus. Sharp pain elicited with passive inversion.

    Diagnostic Tests - Haven't done any yet. The initial management of RICE doesn't seem to be helping much, probably doesn't help she detests sensible supportive footwear. Thinking x-ray to identify any stress fracture but should wait weeks for that right? Can't really afford to dish out for anything better than an ultrasound i.e. bone scan.

    Differential Diagnosis - Initially thought a tendon sprain as it's not exactly at the point of joint margin. Now thinking "bone jarring, bruising", synovitis, capsulitis and other vague ideas.

    Treatment Plan - sticking with RICE at the moment, heat instead of ice. Also thinking heel lifts, to take off some of the dorsal impingement that might be going on. I should also add that I've just read the other threads on dorsdal midfoot pain and will go home now and try out the different diagnostic tests - in particular the superficial peroneal nerve percussion for nerve entrapment and the plantarflexing forefoot to rearfoot. I'll also try those heel lifts and see if strapping helps, although hopefully the orthotics are already helping with some of that.

    Any other ideas, my fellow wise podiatrists? Would be greatly appreciated, thank you. I'll be back to let you know how it works! Would also like to know what length of time we'd expect for improvement to allow her back to her exercise activities?

    Matt.
     
    Last edited: Jun 9, 2009
  2. Craig Payne

    Craig Payne Moderator

    Articles:
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  3. Mark_M

    Mark_M Active Member

    Craig has given you the link to my first thought.

    But for diferential diagnosis it sounds a little like Lis Franc dislocation.
     
  4. Matt Kimball

    Matt Kimball Member

    Thanks Craig and Mark. I read through that, and other related links. The forefoot plantarflexion to rearfoot test made no difference. I did find however that I could replicate the pain with passive inversion and adduction, no problem with eversion.

    The heel lifts I fitted made no immediate difference. And given the pain on inversion I thought that low-dye strapping would be counter-intuitive. Nerve percussion was unsuccessful.

    She says it feels "full" and is worst when she first stands as the foot is slightly inverted. She's also getting just a general ache when sitting, which again steers me towards the fracture idea. :confused:

    Thanks for your help so far! :drinks
     
  5. Matt:

    Here is my first bit of friendly advice...it is not an ideal situation to try to treat someone that you live with....the problem will be that she probably won't do exactly what you tell her to do. She should be seeing someone else, not you, since she likely won't take you as seriously as she should for her own good. Familiarity breeds contempt.

    My guess for a diagnosis is dorsal midfoot interosseous compression syndrome, acute onset, due to dorsal joint jamming of first metatarsal-cuneiform joint. She should avoid any dorsal shoe pressure (relace shoes in running/walking shoes), should wear her orthoses as much as possible, should do no running or jumping exercises for 4 weeks, should be icing 20 minutes once to twice daily, and she shoud avoid walking barefoot or walking in low heeled shoes with no arch support (shoes with 3/8" - 1" heel height differential with no upper pressure on 1st MC joint and with orthoses inside them are perfect). If she does not improve any within 3-4 weeks, then she should be in a cam-walker style brace for 3-4 weeks.

    I tend to doubt it is a fracture from the information you provided. Hope this helps.
     
    Last edited: Jun 9, 2009
  6. Matt Kimball

    Matt Kimball Member

    Thanks Kevin. I am finding that she's a difficult patient in more ways than one! for that reason I'll handball her off to our senior podiatrist if symptoms persist. Your diagnosis and management suggestions (and everyone else's) make good sense to me - thanks again!
     
  7. CraigT

    CraigT Well-Known Member

    Agree with the dorsal compression pain provisional diagnosis.
    Definately try Low Dye taping. The pain in passive inversion is during your examination and is more likely related to the tissue which is damaged rather than the mechanism of injury.
    In addition the Low Dye does not put a significant inversion force through the midfoot, but rather decreases the eversion/ midfoot dorsiflexion force.
     
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