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Hi there, I don’t know if anyone can help me with this case. Sorry, it is very wordy...
Male, age 37, overweight, military personnel
Sports: football, basketball, swimming, running and cycling.
Medical history: 2011 Right knee surgery; 2017 March R/F tarsal tunnel release and plantar fascia release; 2017 July L/F tarsal tunnel release; 2018 March Left ankle injury
Clinic features: B/F fully compenstated rearfoot varus; B/F ankle equinus; B/F tibial varum; B/F functional hallux limitus (L>R); apulpusive gait – early heel lift, medium colum collapsing, lesser toes gripping
This patient first came to see me in early March with R/F burning pain at medial tubercle of calcaneus and along the course of tibialis anterior & lateral border; L/F burning pain under medial arch and Achille’s tendon.
I gave him a pair of temporary insoles with semi-compressed felt (SCF) a 5mm functional hallux wedge, a 5mm SCF plantar metatarsal pad, a 19mm SCF whale, a 7mm SCF lateral stabiliser and a 7mm SCF heel raise to B/F
He came back after 2 weeks and reported that he had a left ankle injury when playing basketball and was using crutches and was on air boots when came to see me. He said that the temporary insoles were ok to ease the pain in the bottom of the foot but Achille’s tendon still hurting and pain on the lateral border hasn’t changed. He wasn’t sure whether or not the ankle injury prevented him to try the insoles properly. I thus suggest him to try the insoles after he stopped using crutches and air boots.
I advised him to do calf stretch exercises every day and asked him to try the insoles again after the ankle injury was recovered.
Due to insurance issues, he decided to go to a different clinic (where the American insurance company will pay) to mould his foot and had a pair of insoles (3/4 length polypropylene base, full length EVA sole, no heel lift, no functional hallux wedge) made by a company in America. He said the insoles made very little difference to his right foot and his left Achille’s still tight. I checked and the insoles have put his right foot back to neutral but the left still 2 degrees inverted. I then added a 2 degree medial wedge to his left heel and functional hallux wedges to B/F. The patient showed me how he did his calf stretch and it was not adequate so I showed him how to do it properly.
When I saw him again in June, he said some pain is better (pain under arch and Achille’s tendon have gone) but some new pain has appeared. Now, he has R/F pins and needles pain above and below medial malleolus, which comes out randomly during the day, i.e. sleep, activities, at rest; shooting pain at extensor digitorum brevis muscle which radiate to the 4th metatarsal; burning pain from medial base of 1st MTPJ radiating to the calf (on and off – particularly after long activities) L//F pins and needles pain above and below medial malleolus; hallux spasm and separated from the lesser toes.
I suppose that he has flexor Retinaculum strain and extensor digitorum brevis muscle strain now? I know he has functional hallux limitus but the pain shouldn't radiate back to calf, should it? He said that he didn’t really do much exercise now although he is very eager back to running and playing basketball but his foot pain prevents him from doing those activities.
I’m really stuck now. Could anyone help?

 

You can't treat it with insoles.

 

Hi, thanks...
Do you think my diagnosis is correct? If insoles can’t treat it, what else can the patient do? Just use hot/ cold therapy or ankle brace?

 

The best approach to all tendinopathys is reduce or modify the activity and then institute a loading program.

 

I am not sure you have a correct diagnosis yet. The paraesthesia smacks of a neural origin either local or referred and I note the history of tsral tunnel release. I suspect this chap has generally reduced motion as well as the known TA inflexibility and the prescription he has been provided will increase lateral load.

The lateral symptoms may not be muscle and more the articulations of the cuboid but would need more careful investigation. If this is the case, reducing the orthoses prescirpion / heel raises may help. For the neural symptoms, need to investigate further.

 

Thanks so much, Trevor.

Like you said, I'm not sure if I made a correct diagnosis. I did wonder if the paraesthesia is related to other nerve issues or some sort of complications due to his tarsal tunnel release. However, he said that the paraesthesia only came up since he wore the new insoles... Could the insoles trigger it because it affects muscle balance? Or, would a neural origin problem just come up unrelated to the insoles?

I'm sorry but I'm a bit ignorant regarding "TA inflexibility". Could you tell me more about it? Is it the same as TA overuse? He has a very tight calf so the ankle ROM isn't good. Otherwise, his rearfoot and forefoot ROM is normal.

Thanks for pointing out the cuboid issue. I completely forgot to check that! I suppose it was because he described the lateral column pain as burning, I was then too quick to assume it was a soft tissue issue. I will check it when he comes to see me this Friday.