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Lateral midfoot pain in runner

Discussion in 'Biomechanics, Sports and Foot orthoses' started by spodd, May 13, 2013.

  1. spodd

    spodd Member

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    Needing some advice please.
    Have seen a 28 y.o patient who is running 30-50km a week with a view to run a marathon.
    He is 75kg and runs mainly on roads/paths
    Has a cavus foot, and wears a minimalist shoe and has had no previous foot pain. He came to me experiencing quite severe pain that began 8km into a 15km run in his lateral midfoot, it was nagging and he could feel it for the remainder of the run. The pain can be reproduced with palpation not directly over the base of the 5th met but slightly proximal and dorsal in the area of the tarso metatarsal ligament and plantar cuboid. Pain was felt with single leg raise. Stressing the 5th met caused no pain and no pain at base of 5th.

    My Dx- Gait analysis reveals a plantarflexed lateral column and very little pronation throughout. I think it may be a strain of the peroneus brevis but ? why no pain at the base of the 5th proper? I have advised him to ice and rest from activities and take some OTC ibuprofen and given him some lateral wedging to pronate his rearfoot and offload the peroneals. What are peoples thoughts ? and if I am on the right track, how can we prevent this from reoccurring??
    Much appreciated
  2. spodd

    spodd Member

    Any help?
  3. Craig Payne

    Craig Payne Moderator

    Cuboid syndrome?
  4. Ian Drakard

    Ian Drakard Active Member

    I'd want to rule out cuboid issues. The pain reduction should be nearly immediate so if it's still there after working on it then you know it's something else (like lateral column dmics?). Is there pain on palpation of the peroneals? When you say plantar cuboid can you be more specific on location- are you palpating any other structures in trying to locate the cuboid plantarly?

    If it is cuboid related then the lateral wedging may help by reducing the requirement on the peroneus longus but it may be helpful to have more of a lateral arch rather than just wedging
  5. BEN-HUR

    BEN-HUR Well-Known Member

    Provide a temporary elongated valgus wedge (i.e. via firm EVA or cork) with a cuboid pad (i.e. felt or softer EVA ,material) placed/stuck on top of the valgus wedge... & see what happens. Ask him also to self-massage the Peroneals. I'm sure you have assessed his running foot attire for any contributing factors to the symptoms.
  6. N.Knight

    N.Knight Active Member

    I would be careful using a cuboid pad, they are so uncomfortable, I would start with a full length lateral wedge and look at cubiod mobs to hep free up the lateral column.
  7. drdebrule

    drdebrule Active Member

    Seems like cuboid syndrome and time for the good ol' cuboid whip manipulation? Agree with N. Knight on cuboid pads.

    Also why not also a diagnosis of dorsal metatarsal- cuboid ligament sprain? I think that is possible too. Rest, ice, offload, maybe pool running?
  8. Spodd:

    This is likely to be lateral dorsal midfoot compression syndrome (i.e. lateral DMICS) otherwise known as lateral column overload syndrome.

    I talked about it in Podiatry Today Magazine five years ago:Pertinent Roundtable Insights on Indications for Orthotic Management.

    I described here on Podiatry Arena last year: Diagnostic features 5th metatarsal stress # vs dorsal metatarsalcuboid ligament sprain

    and I also described it here on Podiatry Arena over five years ago:Lateral column pain

    I also wrote about lateral DMICS in my November 2007 Precision Intricast Newsletter in my third book (Kirby KA: Foot and Lower Extremity Biomechanics III: Precision Intricast Newsletters, 2002-2008. Precision Intricast, Inc., Payson, AZ, 2009, pp. 117-118). Here is the illustration I drew and caption I wrote from that Precision Intricast Newsletter.

    You may want to read over my comments in these sources and see if it makes sense for your patient.

    Hope this helps.:drinks
  9. spodd

    spodd Member

    Thanks all for the advice so far. Further info- Peroneals were not painful to palpate. When palpating cuboid was quite isolated to plantar cuboid (pushing up into soft tissue structures). Fascinated by Mr Kirby's alternate view point and subtle difference between cuboid syndrome and lateral DMICS. I can certainly recognise the differences now.. it certainly seemed more isolated to the cuboid itself and potentially now I think of it the calcaneocuboid joint indicating some cuboid subluxation.
    Have never done a cuboid 'whip' technique however seem to remember it talked about from uni days. Is this truly an effective technique in repositioning a subluxed cuboid ? If it is then how can the injury respond well to rest and NSAIDS without repositioning? Reviewing the patient on friday, will update.
    Thanks so much to all who have responded. This is genuinely interesting to me and feel like I have learnt alot by your questions and links already
  10. BEN-HUR

    BEN-HUR Well-Known Member

    Naturally with all forms of treatment comes education/advice on what & why you have carried out a form of treatment... & the potential implications thereof... which includes the potential of the cuboid pad being "so uncomfortable"... same applies when the likes of a Metatarsal pad/dome is "uncomfortable" (i.e. adjust the pad or remove it from the lateral wedge).

    I had very similar symptoms to this case study about 4 years ago. For 3 days, every time I got to about the 1 - 2 km mark of my run (as opposed to the 8km mark in the above case) I got very similar symptoms. The 4th day I had an extended lateral wedge with a cuboid pad & all was fine... removed the device 3 days later & everything remained good. Coincidently, I had a patient visit me with the same symptoms to mine about a week after my episode... thus gave him the same treatment & all was fine with him also. Of cause not everyone will respond as in my two cases due to other variable factors (particularly on internet advice) but certainly worth offering my experience up for consideration in this case (despite the possibility of the cuboid pad becoming "so uncomfortable").
  11. Matthew:

    This is exactly the way I would treat a runner patient initially with lateral dorsal midfoot interosseous compression syndrome: rearfoot and forefoot valgus wedging (using 1/8" adhesive felt adhered onto the plantar aspect of the sockliner of their running shoe).
  12. No whiplash it is not something you do cause you kind of remember it from some place
  13. N.Knight

    N.Knight Active Member

    Matthew -

    I agree any addition can be painful, my fault I did not read the post correctly, just saw the Cuboid addition and didn't read the bit in brackets after ie using felt. My fault sorry, it come across rather harsh.

    I have seen a few come to me who have had HD EVA Cuboid addition on the dorsal aspect of the orthoses which aggravated things. I agree with Kevin always put my additions on the plantar aspect when I can.

  14. BEN-HUR

    BEN-HUR Well-Known Member

    You're such a wealth of information Dr Kirby... let alone resources ;). Thanks for collecting the info together for this region of symptoms.

    Glad to know my treatment plan regarding symptoms of this nature correlates with yours & may be valid in cases such as this.
  15. BEN-HUR

    BEN-HUR Well-Known Member

    That's fine Nick (no need to apologise - thanks all the same) - just thought I further explain my experience/rationale behind my views on this case (ironically, of which my post may have come across rather defensive - that's the ambiguity of this writing medium for you ;)).

    Yes, I agree about the potential irritation placing the likes of cuboid paddings on the dorsal surface - may come across as too aggressive with some patients (of which you could reduce thickness). I sometimes ponder on whether to go dorsal or plantar in cases such as this, as sometimes going plantar hasn't been that effective (particularly for a valgus wedge device i.e. thickness of lateral border). Be that as it may with some patients, it is probably a safer bet to advise the cuboid pad to be placed plantar (particularly if there is no accompanying lateral column correction/support to interfere)... & take it from there. Fortunately the little fellas (cuboid pads) can easily be modified/re-placed quickly to suit the patient/symptoms.

    Always good to get others opinions/experience on such matters (particularly when one works by themselves).
  16. Lorcan

    Lorcan Active Member

  17. As far as "subluxed cuboids" are concerned, do you realize there are no MRI or CT scan research evidence that the cuboid actually "subluxes"? Some clinicians seem to think that if pain involves the lateral midfoot, it is always a "subluxed cuboid". If someone could take an MRI scan or CT scan before and after a cuboid manipulation and show some actual changes in their alignment pre and post manipulation, then I would be more likely to be convinced that the "cuboid had subluxed". Until then, I will remain skeptical.
  18. Ian Drakard

    Ian Drakard Active Member

    This is something that I confess I struggled with for a while as there is very little perceptible change in palpation in terms of bony alignment pre and post mobilisation for most people, and I suspect there would be negligible change on imaging.

    However there is often a change in ray stiffness, joint pain and peroneal/ab hal muscles suggestive of a neuromuscular effect. Kevin- was it you who mentioned the joint labrum around the cuboid on another thread? The effect on joint packing around the cuboid and the richly innervated nature of the tissue was a more likely source to explain these effects imho

    I think the terminology is the issue in that subluxation is normally describes some alteration to joint (bony) position, which is not detectably the case here.
  19. Ian Drakard

    Ian Drakard Active Member

    Is there some pain coming from the soft tissue structures themselves? If there is this part of the problem or is it incidental? Even if it's incidental would some soft tissue work be helpful to reduce irritation from orthotic adaptions like cuboid pads?

    Mike made a good point re the 'whip'. It's not a technique I use but possibly not one to just have a play with! There are many several ways to approach a cuboid mobilisation and the link to Ted's demo from Lorcan is a good start.

    I also don't see that DMICS and cuboid syndrome would be mutually exclusive in some cases
  20. Ian Linane

    Ian Linane Well-Known Member

    "Have never done a cuboid 'whip' technique however seem to remember it talked about from uni days."

    Although I've learnt the cuboid whip approaches it is not something I personally advocate. In part because of the potential for the whip to involve tissues not directly involved in the "cuboid" situation, potentially traumatising them. There are more gentle and subtle ways of working the "cuboid".

    "Is this truly an effective technique in repositioning a subluxed cuboid ?"

    I think Kevin has a fair point on the lack of objective evidence to support the subluxed and repositioning theory. Clinically I have experienced cuboid issues and there has felt plantar prominences on palpation when the good foot and bad foot are compared. The bad foot has felt more stiff in gait in the cuboid area suggestive that something is "out" but I am not sure it can be argued as subluxed or exactly what it is.

    Certainly the lateral wedging is one way to address this, be it a temporary or permanent requirement. This would be in my arsenal of options but my first call would be a subtle manual therapy mobilising of the cuboid area and and soft tissue work. If this buys the result in the first session then great. If not then I would look to use mechanical intervention as well.

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