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Puzzling symptoms in a gardener

Discussion in 'Biomechanics, Sports and Foot orthoses' started by Ann PT, Aug 11, 2014.

  1. Ann PT

    Ann PT Active Member

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    Hi All,

    I evaluated a 180# female gardener yesterday who spends a lot of her day in a full squat, toed out, with heels on the ground weeding gardens. Her symptom is tingling in all her toes, esp. 2 and 3, and in the soft tissue between her met heads and bases of toes when in this full squat position. She is less symptomatic, however, if in Crocs than if in a supportive hiking shoe with a wide toe box. She also gets the symptom when driving and walking when foot wear does not make as much difference. Her presentation is as follows on the left symptomatic foot:

    RCS: vertical
    Arch ht: low
    STJN: 20 deg calcaneal varus
    Forefoot: neutral
    Joint mobility tests: restricted distraction at talocrural joint and restricted A/P glides at calcaneocuboid and talonavicular joints
    Muscle length: short gastroc/achilles in STJN
    Special Tests: positive anterior drawer and varus stress tests at the ankle
    Palpation: Pain in all intermetatarsal spaces bilaterally; second space did reproduce tingling in toes 2 and 3
    Gait: increased navicular drop R>L coming into midstance which surprised me because she seems to have more reasons for this gait pattern on the left than the right
    Other: Bilateral bunions with significant HAV

    She said she has a history of an ankle fracture (she thinks left) as a child and bilateral plantar fasciitis which always resolves with rest.

    She would like me to make orthotics to help her symptoms. She has already tried just a met pad on her regular inner soles with some relief but she isn't sure if the relief is due to the met pads or just altering her activities (less squatting and driving).

    Any thoughts on the symptoms with squatting and why she is less symptomatic in Crocs? I thought the increased pronation allowed in the Crocs would allow more shear between the metatarsals and therefore more symptoms but in fact she is less symptomatic. The toe box looks sufficiently wide in the hiking shoe that compression should not be a problem.

    Any thoughts?

    Thank you!

  2. davidh

    davidh Podiatry Arena Veteran

    It would be useful to know her age and general health.

    Off the top of my head I would say:
    Squatting for extended periods is causing pressure on a nerve somewhere in the hip/lower limb. Vague, I know, but without the patient in front of me its the best I can do.
    The Crocs are allowing some compensation to occur at the ankle, which is why they help.

    BTW, that plantar fasciitis is not resolved.
    If I read your post right she has plantar fasciitis which moves from asymptomatic to symptomatic periodically.
  3. Ann:

    My guess is that she has possibly a plantar plate tear/strain that is causing swelling at the MPJs which, in turn, causes neuritic symptoms.

    People with plantar plate tears/symptoms generally do better in soft-soled shoes such as Crocs. This lady needs to stop squatting and get a knee pad and garden on her knees for a while.

    Is she most tender at the base of the 2nd and 3rd digit proximal phalanges plantarly? Is she swollen on the plantar MPJs? Many patients with plantar plate tears/MPJ capsulitis complain of neuritic symptoms which dissappear once the plantar MPJ swelling is reduced (try plantar icing to bare forefoot 20 minutes two to three times a day).

    Hope this helps.:drinks
  4. Ann PT

    Ann PT Active Member

    Thank you gentlemen...

    She is 57 and in otherwise good health...

    The position for weeding is a bit challenging because if she's on her knees then she will flex her lumbar spine a lot. Although she does not have a back problem now, I would be concerned about the increased disc pressure in a flexed lumbar spine for so many hours of the day. The position I usually recommend for weeding is quadruped, however, she has carpal tunnel symptoms so having her wrist flexed makes part of her hand and fingers numb. Regarding the issues at the met heads such as possible plantar plate injury, I can recheck but I don't remember seeing or feeling any instability at that joint and she was definitely more tender to palpation in the intermetatarsal spaces than over the met heads. Thank you for your thoughts. I will look again with your thoughts in mind... Ann
  5. Kaleidoscope

    Kaleidoscope Active Member


    You say the tingling between 2 and 3 MTPjs is worse? Well I know it is NOT the common place to get it - but I certainly do - and its impingement at the nerve - hence why the met pads helped her a little - so Morton Neuroma perhaps?

    Also its exacerbated by over-use - squatting for such long periods of time! Mine always hurt during driving ! (It doesnt now as I dont wear the shoes that start it off (tapered) and crocs do wallow about rather a bit - which doesnt help her problem!

    Certainly doesnt sound like her Plantar Fasciitis is resolved though?

    Linda Russell
  6. W J Liggins

    W J Liggins Well-Known Member

    Agree with the diagnosis of potential neuroma. Not all that uncommon in the 2/3 met space, although much less frequently symptomatic. Quite honestly, whether it's a plantar plate tear, neuroma, or simply overuse syndrome, with her multiplicity of problems the best advice might be to change her occupation, perhaps working in a garden centre etc?

    Bill Liggins

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