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Hi guys any input on the following case would be of great help!

* A 22yr old female patient presents with unilateral midfoot pain duration of approx 3-4 weeks. Nil remarkable medical history, healthy weight, no competitive activity but walks regularly.

* There is no acute event recalled that caused the pain - it was a gradual onset and has steadily worsened over the past month. It is painful on weight bearing, but especially after a walk (struggled to weight bear on the foot) and then greatly improves when resting.

* The location of pain is vague -on palpation there is pain at the: the medial cunieform/navicular/bae of 1st mtpj area medially and plantarly and quite a focal area of pain. There is pain when standing on toes in the cunieform/navicular area (nil heel inversion). The N spot does not seem to reproduce pain.

- Abductor hallucis?
- Navicular stress fracture?
- Cunieform injury???

Any thoughts would be very helpful :)

 

You could also add in plantar ligament strain of any of the ligaments of the first ray. Welcome to real world clinical practice where there is no book to look in the back of for the correct answer.

Most/all of those diagnoses can be associated with high medial forefoot loads. Is there more callus under 1st met head and hallux? Is there impression in shoe under those locations? If there is high medial column load, you could just try to shift the load somewhere else and see if the pain goes away. If it does you can claim your diagnosis was correct even though you can never know for sure. (Well, an MRI might tell you, but trying to treat it first might be less expensive.) To reduce load on the medial forefoot you can increase supination moment from the ground e.g. varus heel wedge, medial heel skive orthosis, Or you can try and increase load on the lateral column, e.g. Lateral forefoot wedge.

Let me know if you want me to explain how each of those anatomical structures can be stressed by high medial forefoot load.

Regards,

Eric

 

New Grad:

Go back to your anatomy book and check out where the anterior tibial tendon inserts into the foot. Expert clinicians all have an excellent knowledge of foot and lower extremity anatomy.

 

Diagnostic ultrasound also helpful in evaluating stress/strain overload injuries by revealing hypoechoic tissue changes,joint effusions or change in fibrillar pattern, periosteal elevation/changes associated with stress fractures or tendon pathologies with both static and dynamic live imaging.