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Insertional Peroneal Tendinopathy

Discussion in 'Biomechanics, Sports and Foot orthoses' started by RobinP, Jul 23, 2010.

  1. RobinP

    RobinP Well-Known Member


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    Dear All,

    Seeking the collective wisdom once again

    I've read through all the threads on here and Googled Peroneal tendinopathy and come up with little to describe a particular patient I have seen.

    PC

    Arch Pain - patient only able to localise it initially to the middle of the medial longitudinal arch (MLA) but at the end of the brief assessment was more specific about it's location at the base of 1st metatarsal and over the cunieforms on the plantar surface.

    Pain is only when walking

    RMH

    Orthotics as a child but no recollection of an explanation for their usage
    Taking NSAIDs for other condition which does not have any major effects on the pain she experiences

    SH

    Relatively active 21 year old. Pain is limiting her gym attendance
    Student Nurse so many hours on feet. Wears sensible lace up shoes which help a little.

    OE

    I only saw her as a freebie to see if there was anything I could do to help so I only spent a short time

    Largely normal foot anatomy

    Pes cavus with plantarflexed 1st ray and slight midfoot equinous(never sure how to quantify this)

    Sub talar joint (STJ) axes appear slightly medially rotated.

    Supination resistance is moderate - seems appropriate for body weight

    Non weight bearing reduced dorsflexion stiffness at 1st metatarso phalangeal joint(MPJ) - ie ROM is > 100 degrees

    Weight bearing greatly increased dorsiflexion stiffness at the 1st MPJ ie FHL present and quite stiff. No video footage taken to see if heel raise in late stance delayed and my Mark1 eyeball isn't good enough to pick it up without.

    Callosity under 1st MPJ but not significant

    Talo crural joint(TCJ) ROM is satisfactory but the midfoot equinous gives a nett 90 degree angle with knee extended

    Weight bearing RCSP is a little everted(approx 3 degrees)

    Double and single stance heel raise are satisfactory

    Walking - midstance calcaneal angle showed similar amount of deviation as RCSP but most notable element was marked forefoot abduction (compensation for midfoot equinous/greatly increasing medial rotation of STJ axis in stance phase?)

    Differential Diagnosis

    1. Assumed at first the pain was excessive tension on the plantar fascia(PF) secondary to increase pronation moments at the STJ and increase in PF tension from dorsflexion stiffness at the 1st MPJ. However, I put the PF under maximum tension by dorsiflexing 1st ray & forcefully pronating the foot then palapating all over the PF but there was no pain except in the areas described above.

    This is where I am stuck - I have no other differential diagnoses. The pain upon palpation is very much at the insertion of the peroneus longu(PL) tendon. There is mild palpable discomfort under the cuboid if I press hard but no pain more proximally in the other areas where the PL tends to become symptomatic.

    As I said, I have yet to find any information relating to insertional tendinopathy but I wondered if anyone had come across it before. I am just postulating but would it be possible to have insertional tendinopathy as a result of the PL pulling very hard to plantarflex the 1st ray against the pronated foot position. Bearing in mind that the plantarflexed 1st ray and midfoot equinous are being accommodated by pronation at the STJ, is it possible that the external dorsiflexion moment at the 1st ray is is great enough to cause insertional problems of the PL in order to overcome this.

    I wouldn't have said so as she is not a heavy girl or does not have grossly medially rotated STJ axes.

    TREATMENT

    At this stage, I haven't done anything as I didn't want to start charging even for temporary devices until I could give some type of diagnosis.


    I will be grateful to receive all help and ideas. Many thanks in advance

    Robin
     
  2. Admin2

    Admin2 Administrator Staff Member

  3. David Smith

    David Smith Well-Known Member

    Robin

    This is a reasonable conclusion but have you also considered the spring / plantar calcaneo-Navicular ligament (SL); this has slips into the Nav and 1st and 2nd cuneiform (http://en.wikipedia.org/wiki/File:Gray358.png) and may be strained if the 1st ray has excessive external dorsiflexion moments, although I would say it is more usual that the PF protects the SL from injury but in this case it may not be so.

    The upshot is tho that reducing external 1st ray d/flex moments will reduce stress in all the usual suspects anyway.

    Sound likely?

    Cheers Dave
     
  4. Phil Wells

    Phil Wells Active Member

    Robin

    Did you do any muscle power tests?
    Always worth looking out for imbalances between antagonistic muscle groups as this can create repeated trauma to tendons etc.

    My gut feeling is that there is some level of excessive (for the damaged structure) dorsiflexory force. If the pain is less with higher heeled shoes, then this would start to confirm it Or try loose heel raises as part of the diagnostic process.

    Phil
     
  5. RobinP

    RobinP Well-Known Member

    Hi David,

    I did once start reading a thread on the spring ligament but quickly realised that I needed better anatomical knowledge before reading into it further - it looks as though that time has come! Only thing is that I did palpate, quite forcibly, the inferior aspect of the navicular and there wasn't a whole load of pain which surprised me because it was early in the consultation and she had just pointed to the pain vaguely in that area.

    Phil

    Tested peroneal (group) and tib post which were normal. Didn't test tib ant. Didn't really do any other muscle tests which is a little remiss. What were you thinking specifically?

    I should have given her a heel raise, even if only to accommodate the midfoot equinous. Stupid not to really as you are right of course, it would be part of the diagnostic process.

    Thanks for the input guys

    Robin
     
  6. drsarbes

    drsarbes Well-Known Member

    Is there pain on NWB ROM of the 1st Met-cun?
    When during the gait cycle does your patient experience pain?
    Any history of trauma?
    Any symptoms in the other foot?
    Type of pain? Duration?
    X-ray? AP, Lat and Med/oblique projection will visualize this joint well.

    Not unusual for a plantar flexed first ray type foot to develop arthritic changes, soft tissue in the area may become symptomatic as well, of course.

    Steve
     
  7. RobinP

    RobinP Well-Known Member

    No - I thought there was but it was only where I was holding the foot to try and perform the movement
    Tried to get her to think about it, but she couldn't distinguish it. I asked her if she could feel it just before her heel lifted from the ground and she said possibly but I think she was telling me what I wanted to hear

    None
    None

    She described as a sharp pain but it doesn't stop her in her tracks - unable to reproduce the same pain

    Stance phase

    Unfortunately no access to these services


    Even in a 21 year old with no h/o trauma? I'll see if her GP can get her x rayed.

    Thanks

    Robin
     
  8. drsarbes

    drsarbes Well-Known Member

    Hi Robin:
    Yes, even in a 21 year old with no Hx of trauma.

    I think an xray will help quite a bit. One slight problem is having radiology read the xray and having non weight bearing standard views taken. They really don't visualize the med/med-plantar aspect of the 1st Met-cun well. That's why I suggested a med-lateral/oblique projection. Your standard lat-medial oblique will not be helpful. Also the non weightbearing lateral will not visualize the joint you're interested in as much as a weight bearing lateral would.

    Steve
     
  9. efuller

    efuller MVP

    A lot of conflicting data. No simple answer jumps out. I usually recheck all the observations to see if I missed something when this happens. Keep the observations that your are more sure of. For example, calluses don't lie.

    High loads sub 1st. Sometimes if you have a more extremely laterally deviated STJ axis, the peroneal muscles can be constantly contracting. This would give a higher than expected supination resistance. Recheck the STJ axis position.

    There are two kinds of pronators. Pronators, in this sense, are people who evert far enough to get high loads sub 1st met. There are muscular pronators (lat STJ axis ground causes supination moment that is overcome by pronation moment from muscles.) There are ground reaction force pronators. (Medial STJ axis creates high pronation moment in conjuction with enough eversion available to allow the foot to evert to put high force on the medial forefoot.



    Calcaneal angle? It sounds like you are describing late stance phase pronation. There is an intial contact phase pronation that stops at forefoot loading and then there is additional STJ and/or midtarsal joint pronation (talar adduction) around the time of heel lift. I usually attribute this to muscular pronation.

    Sutton's law. Go where the money (pain) is. Willie Sutton, a bank robber was asked why he robbed banks. He replied, "that's where the money is."

    So, anatomically, yes the peroneus longus insertiion is right there. A laterally positioned STJ axis that is causing a high use of the peroneus longus tendon would cause the pronation that you see and could be hurting from over use.

    Did you directly test peroneus longus strength? Are the peroneals tight in stance? You could try a valgus forefoot wedge and see if this feels better. (Increased pronation moment from the ground leads to decrease need for pronation moment from the tendon.)

    On the other hand high medial loads can cause stress on the first met cuneiform ligaments and that is also in this location.

    Another thing that happens in this location is a subluxing 2nd cuneiform. This hurts with range of motoin, especially plantar flexion of the 2nd metatarsal.

    I hope this helps.

    Eric
     
  10. RobinP

    RobinP Well-Known Member

    Thanks guys - I have a bit to go on now.

    ACTION

    Request GP x ray as suggested by Steve.
    See patient again and re - plot the STJ axis
    Test peroneal strength and look for peroneal (over)activity in stance (trial lateral forefoot wedge - valgus)
    Test for subluxing second cunieform
    Trial heel raise in shoes to see if decreasing the external dorsiflexion moment at the 1st MPJ reduces pain

    I'll keep you updated

    Many thanks for everyone's help

    Robin
     
  11. Mart

    Mart Well-Known Member

    Based on location and history I’d add to your list of possible suspects;

    mild lisfranc dysfunction ( Eric and Steve hinted at this).

    The synovial membrane between the first cuneiform and the first metatarsal forms a distinct sac. The synovial membrane between the second and third cuneiforms behind, and the second and third metatarsal bones in front, is part of the great tarsal synovial membrane.

    Pain generation from there is easily tested with dorsal intra-articular diagnostic injections. I agree with Steve about value of radiographic exam but have found this lacks sensitivity for early midfoot DJD and US much more sensitive because you can see synovitis and also appreciate small osteophytes by choosing imaging plane more selectively.

    Another issue to see on film might be an irritating os intermetatarseum

    os intermetatarsal.png

    Also to consider might be flexor digitorum longus tenosynovitis (any pain with resisted hallux plantarflexion?).


    God luck and please keep us posted on outcome.

    Cheers

    Martin

    The St. James Foot Clinic
    1749 Portage Ave.
    Winnipeg
    Manitoba
    R3J 0E6
    Phone [204] 837 FOOT (3668)
    Fax [204] 774 9918
    www.winnipegfootclinic.com
     
  12. Robin:

    Interesting case. Thanks for sharing this one with us.

    Peroneus longus insertional tendinitis is not common. In fact, I don't think I have seen peroneus longus insertional tendinitis once in 25 years of practice. This is probably because the peroneus longus tendon, which of all the extrinsic tendons of the foot makes the most directional changes on the way to it's insertion point on the foot [three in number...can you name them?] will much more likely be damaged at one of the points where the tendon makes a directional change. If you can name one of those three "pulleys" for the peroneus longus tendon, then you will also know where peroneus longus tendinopathy most commonly occurs...and it is not at the insertion point.

    Now, using the basic steps required for proper clinical application of tissue stress theory, we must first accurately identify which anatomical structure is injured before we can decide how best to treat it. The first question the clinician must ask when using tissue stress theory is: what structures are the most likely to be injured at the plantar-medial aspect of the first cuneiform and proximal first metatarsal? With the clinical information given, I would consider, in order of clinical likelihood, one of three discrete anatomic structures:

    1. Anterior tibial tendon: Inserts onto the plantar-medial aspect of the base of the first metatarsal and first cuneiform in 90% of specimens.

    2. Plantar first cuneiform-first metatarsal ligament: A broad, rectangular ligament arising from the plantar aspect of the first cuneiform and inserting onto the lateral half of the first metatarsal base.

    3. Medial head of flexor hallucis brevis: Originates from the metatarsal component of the posterior tibial tendon insertion and its muscle belly passes directly plantar to the first cuneiform-first metatarsal joint.

    (Sarrafian SK.: Anatomy of the Foot and Ankle, J.B. Lippincott Co., Philadelphia, 1983.)

    All of these discrete anatomical structures may become injured by overloading of the medial column with increased external subtalar joint (STJ) pronation moments. The anterior tibial muscle will often become overactive in the pronated foot due to the central nervous system (CNS) sensing that this muscle may help increase internal STJ supination moments or the tendon may be become over-strained by trying to reduce STJ pronation motion. The plantar first cuneiform-first metatarsal ligament will have increased tensile force placed on it by increased external first ray dorsiflexion moments due to overloading of the medial column with increased ground reaction force acting on the first metatarsal head. Finally, the medial head of the flexor hallucis brevis may become overactive in the pronated foot due to the CNS sensing that this muscle may help decrease the pronated position of the foot or it may become overstrained by trying to prevent STJ pronation/first ray dorsiflexion during weightbearing activities.

    Therefore, in order to treat this young lady the most effectively, again using tissue stress theory, we must design a mechanical treatment plan that will reduce the most likely abnormal tissue stresses that are causing her complaints. Here is what I would have done on the first visit:

    1. Apply a medial heel varus wedge and medial longitudinal arch pad to the shoe insole/sockliner with adhesive felt to increase external STJ supination moment and increase external medial forefoot plantarflexion moment.
    2. Apply a reverse Morton's extension to the shoe insole/sockliner to reduce the external first ray dorsiflexion moment.
    3. Add a 3 mm heel lift to the shoe insole/sockliner to reduce the passive Achilles tendon tensile force.

    If these modifications work, then a custom orthosis may be ordered with similar modifications.

    My clinical experience in using the tissue stress approach for 20+ years in similar cases has demonstrated that, if these wedges are applied correctly to the shoe insole, the patient has a 90% chance that she would notice a near immediate reduction in symptoms within the first few minutes of walking with the pads in place.

    Hope this helps. Please keep us all informed of her clinical progress.:drinks
     
  13. Mart

    Mart Well-Known Member

    That was a very nice analysis Kevin, worthy for inclusion into your Intracast series?

    cheers

    Martin

    The St. James Foot Clinic
    1749 Portage Ave.
    Winnipeg
    Manitoba
    R3J 0E6
    phone [204] 837 FOOT (3668
     
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