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I was hoping for some brain storming ideas. I saw a 30 year old gentleman who returded to running 8 miles per week on the road after a 6 month lay off following a laporectomy.

about 1 mile into his run he develops posterior medial lower leg pain.
The pain is located about 5cm above the medial malleolus but doesnt track down into the area. pain was elicited with dorsiflexion of the 1st mtpj and inversion of the foot. The pain doesnt get sufficient enough to stop him running, however he only does 4 miles, he feels if he went over this distance the pain would stop him.

I will save you the detailed biomech assess but this patient has a medially deviated STJ axis, he XS pronates at STJ along with forefoot abduction with walking bearfoot, when he begins to run he converts to a forefoot striker, he xs pronates in an attempt to get foot plantigrade but doesnt make heel contact before required to toe off again. I noted he runs with xs hip and knee flexion (although the physio who jointly assessed him found no restriction in adductors or abductors of hip as well as iliopsoas etc.

My initial thoughts with this patient is that he was suffering with FHL Tendonopathy / Tenosynovitis, if iam honest i havent come across this much. I have a differential of Post Compartment Syndrome but excluded Post Tib Tendon Pathology becuase the site of pain was not consistent with post tib tendon position and becuase this gentleman could perform multiple single heel raises pain free. i also ruled out MTSS or tibial stress injury as the pain was not anyway near the tibia and his symtpoms didnt match that of either.

any thoughts or advise on anything ive missed or should have done would be really appreciated. The only way to access imaging for this patient if needed is via his General Practitioner and then onto radiology with a total waiting time of 2-3 months.

Is there a standard treatment for FHL injuries and not just orthoses - I have taken casts anyhow for a 3/4 length polyprop device with 5 degree medial post and 3mm medial kirby skive?.

 

Matt:

Your patient probably has developed a small tear at the myotendinous junction of the flexor hallucis longus muscle which is not very common, but I have seen it a number of times in my runner patients. Have him get on the bicycle or elliptical trainer for two weeks, have him ice it 20 minutes twice a day during that time and make orthoses for him like you suggested, possibly with a little greater heel lift to get more pressure under the heel with his running style. Then start him back to gradual running after 2 weeks to see if he is doing better. In all likeliehood, he was significantly weakened when he returned to running after the lay-off from his surgery and should cross-train a little as he returns back to his normal activities.

Hope this helps.

 

Many thanks Kevin, it always nice to get someone else's perspective on things, and the treatment you suggested is something you cant read in books- i was thinking of ways to rehab this guy so i will definately try that routine.

 

Hi Matthew,

I have a patient demonstrating the same symptoms as yours although her seemed to have come about from a inversion injury which I wonder if anyone else have come across. Same area of pain. I also thought it was an injury of the FHL but I am not sure why or how it happened?

Pain can be replicated with resistance of plantar flexion of the big toe as well as with walking in unsupportive shoes ( she is a laywer and is unwilling to change her shoes) strapping greatly settled her issues so custom orthotics were fitted several weeks ago. I had a phone review with her last week she is still not wearing supportive shoes with her orthotics at work but wears the devices in joggers and has even gone for a run and done some sprints (even after I told her to aviod running and do something else i.e. swim or cycle) she reports that the problem is still there but not as severe and she is not suffering as much the next day following activity. I will review her next week and hope she has finally got some shoes for work and has eased up on the excessive WB activities.