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Help with dorsal lateral foot pain

Discussion in 'Biomechanics, Sports and Foot orthoses' started by Phil Wells, Mar 18, 2008.

  1. Phil Wells

    Phil Wells Active Member

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    Dear all

    I would appreciate a bit of guidance with a patient.

    10 year old girl who is very physically active - good level cross country runner, horse riding

    The presenting complaint was dorsal lateral foot pain. bilateral of a duration 3-4 months.
    On palpation this was located over the dorsum of the intermediate/lateral cuneiform.
    There was also some heat in this area.

    The pain was elicited by dorsiflexion of the forefoot on the rearfoot but not on inversion or eversion.
    Bio asses showed no significant finding with reasonable ROM and QOM. Plantar Stjt and ankle axis 'normal', midtarsal joint goos quality ROM.

    Slight in toeing in gait.

    Any ideas?


  2. Ella Hurrell

    Ella Hurrell Active Member

    Do you have an x-ray?
  3. efuller

    efuller MVP

    Hi Phil,

    I'm usually not a big fan of subluxations and manipulations, but this something that sounds like what I had in my own foot that improved with manipulation.

    Dorsal subluxation of the 2nd cunieform: As you slide your fingers up the shaft of the 2nd metatarsal you can palpate a painful bump compared to the opposite side at the 2nd cunieform. It will hurt with dorsiflexion of the forefoot on the rearfoot as well as plantar flexion of the forefoot on the rearfoot. It hurts with bed covers plantarflexing forefoot. It will also hurt with dorsiflexion and plantar flexion of the 2nd metatarsal.

    Rule out fracture:

    Jack Morris at CCPM used to teach this manipulation. Patient seated, bottom of foot toward you. Wrap both hands around the foot with one finger specifically on the cuneiform. Thumbs on the plantar surface of the metatarsal heads. Give a firm yank with downward pressure directly on the cuneiform and slight upward pressure with the thumbs to prevent plantar flexion at the ankle. A 10 year old girl on a sliippery chair should slide toward you about 3 inches. The most common error is to apply pressure too slowly. When sussesful there is an audible pop/click. Warn patients that this may hurt for a second.

    I had one guy almost slap me after doing it and then say "Hey, that feels better." In my own foot it took several manipulations before it stopped going back out. One time I stepped down after the manipulation and I could feel it immediately starting to slip back out of place. When traveling, I showed my wife how to do the manipulation.

    If it doesn't hurt at the 2nd cunieform the manipulation does not good.

    Good luck with your patient,


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