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Hi All. I am currently seeing a patient with an unusual foot pain. He is male, approx 40 years of age with multiple general health issues, see below.

His pain is in the general area of the distal 3 cm of the plantar fascia, but more acutely medial to this. The medial sesamoid is somewhat painful. He is highly reactive to palpation, even quite light touch and found ultrasound assessment nearly unbearable. The fascia appears normal on u/s and the only anomaly found is some fluid inside the FHL tendon with the tendon otherwise unremarkable. Doesn't light up with colour doppler. No calc spur, No fibroma in fascia, PF thickness 3.3 mm. No pathology of sesamoids or MPJ1 or 2 by u/s.

He did not respond to standard plantar fascia strapping. He cannot tolerate an arch pad. Can tolerate arch pad with cut out to area of pain - but it does not help. Some relief with medial figure 6 taping with the emphasis of the tape crossing the base of the 1st metatarsal. I have tried some neural prolotherapy to the point of pain and the afferent nerves without success on one occasion - he has a dislike of needles and so is reluctant to try again.

General medical: Heart attack, Heart valve repair, Diabetes, Stroke, Gout. He ambulates quite normally without physical impairment - except for a limp from the painful foot.

I am perplexed as to the nature of the injury - particularly the superficial hypersensativity. Does anyone have any thoughts of different avenues to try? Thanks in advance.

 

Plain XR's are ok? Neuropathic pain? (diabetes). Whats his ankle ROM like? Any equinus? He could be overloading the FF. Try calf stretching or a heel raise.
Cheers
Burke

 

Any pain on flexion and extension at the 1st MTPJ

 

Have you ruled out sesamoid pathology by x-ray, bone scan or MRI scan?

 

Not passively buy there is pain on dorsiflexion of the hallux / loading of the plantar structures while walking.

 

No. The medial sesamoid is a bit tender to push laterally against the crista. The real pain is in the 'soft bits' about 2 cm proximal to this, on and medial to the fascia. Unfortunately there are no Medicare rebates for the scan or MRI and they are prohibitively expensive for this patient who does not work.

 

Re neuropathic pain - I think there may be a neural element to his pain. I don't think it is diabetic though. It is very specific in location, reasonably proximal, doesn't involve the toes, has no dulling of sensation. To give you a sense of the nature of the pain, I expected to see something like a tear in the H.Abductor or similar. GP sent for u/s of the plantar fascia before I saw him which showed a minor thickening of the proximal structure. I sent for u/s of the specific area, no pathology identified including the sesamoid articulations, apart from the small amount of fluid in the tendon sheath of FHL. I have used my (admittedly fairly poor) point of care ultrasound unit and can't identify anything that looks suspicious.

 

Functional Hallux Limitus? Tight gastroc/soleus complex? Footwear/orthotic irritation? I feel there is a biomechanical cause. You may need to figure this one out using a process of elimination. Try calf stretching +/- heel raise, a reverse morton's extension (2-5 padding). If you had some result with the strapping then the extension could be incorporated into the shoe insole. I understand your frustration at not having a definitive diagnoses, however this sometimes happens. Just remember that common things happen commonly. Cheers Burke.