Post tib/sinus tarsi probs, some advice please

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Hi all,

I was hoping for some advice on a interesting case

Male patient, 64 years old. Healthy, only taking Lipitor

PRESENTING COMPLAINT
Many months of on again off again pain in the left foot
1: Lateral aspect of Inf Extensor retinaculum. This is mild
2: When rearfoot is fixed and midfoot/forefoot everted. This is severe and at its worst when walking on uneven ground

BIO
Pes planus
STJ / MTJs restricted
Tib Post weak compared to right side, other muscles showed good strength
Equinus (gastro and soleal)
Supinatus
RSCP 10 deg NCSP 0 (right side is 8 and 0)
Medially deviated STJ
Very very high SRT
Functioning at the end ROM (minimal pronation possible when standing in RSCP)
Abducted gait

The severe pain the patient reported was concerning me so I asked him to get an MRI. The results indicated advanced tib post dysfunction with secondary sinus tarsi syndrome. It also mentioned that there was degeneration of the deltoid, spring and bifurcate ligaments.

I am interested to know if this man would benefit from an injection into the sinus tarsi, and if I should be seeking a surgical opinion. He has been wearing what looks like a pair of modroots since 2004 that are not giving him the control he needs so I was planning on an inverted device made from rigid polyprop, a medial skive of 8mm, high heel cup and a rearfoot post. Am I missing anything?

Thanks
Eliza

 

Eliza:

Here is a paper I wrote eleven years ago which should help. Good luck.

 

Kevin, thanks for the article very interesting

Eliza

My standard approach is similar to what Kevin describes, early immobilisation is essential to allow the posterior tibial tendon to settle. Don't be bewildered by the MRI - these cases typically show up like a Christmas tree on T2 films. Kevin's article summarises the pathological forces that occur to the supportive ligamentous structures very well.

The only other thing I routinely do is put the patient in an ASO brace (or similar) immediately, incorporating an inversion/supination bias when applying the brace. In the future depending on the patient I may consider immobilisation as Kevin has suggested depending on the severity of the case.

With regards to sinus tarsi injection, a small number of my patients have had this performed by local sports physicians who they have been concurrently seeing with good success, however I would be interested to hear others' experience with it.

Good luck.

 

Trezatment: Ritchie Brace, stretching , mobilisation, massage.

 

Thanks everyone.

Kevin, thanks for passing on your article, it neatly summarises everything I need to know.
One more question. The severe pain my patient experiences when the rearfoot is fixed and the midfoot and forefoot are everted, is that likely to be due to the closing off of the sinus tarsi and therefore compressing already damaged structures?

Enjoy this magnificant day Melbournians

Eliza

 

Honourable Dr Kirby, Love your work,
When is your new book being published?