Post Tib Spasm

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I had a 13 year old come in yesterday in a great deal of pain.

She has no medical history/med's/allergies
She is a slight/average build and dances 2-3 times a week - jazz, tap and hip hop only.

I saw her in October last year:
- pain at the navicular and on active supination
- Slight pronation at the subtalar joint but not the amount that should have been giving that amount of discomfort
- Able to single leg heel raise but with pain
- No tightness or tonal issues at the G&S or hamstrings
- x-ray found probably the largest Os Navicularis I've ever seen

Tx:
- Advised that a surgical consult would be appropriate but in the public system it may take a while.
- Strength/stretch program
- Orthotics
- Rest for about 6-8 weeks from dance, iced regularly

Pain resolved within 8 weeks. I still re-iterated that she should get a surgical consult

Well, return it did! Mum rang last week and mentioned she had a mild lateral ankle sprain at dance the night before. She was able to hobble for a couple of steps but was fine after and still continued the dance class. The next morning she was in pain at the navic. Mum mentioned she was able to walk with mild pain. It progressed through the week (without mum ringing). She presented with:
- PT tendon prominent but still tracking around the med mal.
- Totally unable to dorsiflex or evert the foot without extreme pain.
- Inversion ROM normal and pain free
- PT full of trigger points and no massage or mobs were able to improve ROM
- Physio also had a little go but due to pain stopped.

Tx this time:
- Ref to GP for referral for surgical opinion. Due to finances, public is the only option.
- I ended up popping a BK soft-cast with the foot held slightly inverted and plantarflexed and getting her on crutches to buy time for me to think about what else to do.
- RV in 7/7 (due to Pod Conference) and cast removal and ultrasound to confirm post tib sheath integrity

Phone call confirmed non-wb cast has given a great deal of pain relief. My dilemma is, it's going to be over a month if not more to get her a surgical consult, what do I do in the meantime to assist with pain relief and keep her slightly mobile? Or am I totally on the wrong treatment path here?

 

" - PT tendon prominent but still tracking around the med mal.
- Totally unable to dorsiflex or evert the foot without extreme pain. "

Where was the pain when you tried to evert. People will often spasm to protect something else. A lot of the pain that you get related to the PT could be symptoms related to a spasm that is secondary to the main problem. Coalition with fracture? Just a thougt.

If the patient was able to relax the PT enough to allow you to attempt to evert the foot then I would not blame the spasm on the PT but rather pain avoidance.

Regards,

Eric

 

Can I clarify, you initally said,

"pain at the navicular and on active supination"

Did you mean active pronation as you later said her inversion ROM was normal and pain free?


Seems to me like you're doing all the right things.

If it's not practical for her to keep the foot in a cast until her surgical consult then personally I would be considering a rigid orthosis with a 4mm / 6mm medial skive with a deep heel cup (say 18mm) and a high medial flange. I'd probably consider the need for a larger lateral lip to ensure she doesn't feel like she's sliding off the lateral edge of her device.
Depending on the prominence of the Os Navicularis I'd maybe want to create a groove in the device to accomodate this so as to prevent excessive pressure over this area.

I imagine you've already suggested that dancing is not advised at this stage!!

Don't know if any of this helps at all

Michael

 

That pain was from the navic and through the PT when trying to evert the foot and I wasn't able to get her to relax at all but she was so guarded. I will make sure I reassess that when seeing her next week to see if the pain has shifted after immobilization.

Sorry for the confusion, I meant when she was relaxed I could invert her foot through ROM testing just not evert it but if she had to invert the foot against resistance (my hand) it substantially increased the pain.

The Os navic is quite medial so she isn't wbing on it at all. I have her in almost that sort of device now without a medial flange but to be honest I didn't even look at it when I saw her. Was too busy trying to work out whether I needed to send her off to A&E or not.

Thanks so much for your time. Will put those things on the list when I see her next.

 

Just an update:

Spasm resolved with the cast but she is still requiring crutches most days for pain.

Ultrasound found that the Tib Post is actually connected to the os navicularis so there is a good reason for the abnormal tracking but the tendon sheath is intact.

Will wait and see what the surgeon thinks needs to be done.

 

Bug:
As you are aware, there are various types of Accessory Naviculars. It might be helpful if you could be more exact with what type she has.

In this age group, it's been my experience that once they have a separation of the ossicle surgical excision is indicated and very successful.

Steve

 

Sorry Steve, I had totally forgotten there was more than one. I will grab her x-rays next week and scan them in but I dare saw she has Type II or III. It very large and very prominent. It would almost be a similar size as the navic and very prominent.

 

Hi Bug

Trigger points in the Tib post are notoriously difficult to manage with deep tissue massage, due to the somewhat hidden/deep posterior position of tibialis posterior muscle. These points can be well treated with dry needling by someone who is experienced at locating and needling this particular muscle. In my experience, it is significantly less painful when compared to deep tissue massage, and is very effective at relieving muscle spasm and referred pain from this muscle. Hopefully the effect for this young girl would be temporary management of spasm and referred pain whilst waiting for surgical consult. By reducing muscle spasm, you should in theory decrease tensile load on the injured Navicular. The triggers will keep returning until the problem settles, however needling can be done quite regularly if necessary.

Obviously not the long term solution but hopefully it would help to reduce this childs pain while she waits for more permanent options

Kind Regards

 

Hi Pod29,

A little off the topic...

I have been using dry needling too with great success in many lower limb pathologies. My only concern with needling Tib post is acertaining where exactly the triggers in the muscle actually are? I usually use palpation to identify active triggers in any muscle, as you know doubt do to. As we all know tib post is very difficult to reach being so deep.

I have not obtained Travel and Simons so they may help to assist in approximate targets to needle that generally have trigger points but would love to be more accurate before I start needling this muscle.

Any advice here would be greatly appreciated.

Gareth

 

Hi Gareth

As you have noted, Tib Post is quite difficult to palpate. I would usually palpate with my index and middle fingers along the medial border of the middle third of the tibia. By using these two fingers you can hook them around the medial aspect to the posterior surface of the tibia. This will be a little uncomfortable fo the patient, but it will give you a good idea of the triggers. That is the easy part!!!

Tib Post is a difficult muscle to needle..... I will always try to guide the needle as close to the posterior aspect of the tibia as possible. Usually will actually hit the tibia then retract the needle a fraction to reguide. This may happen two or three times. I was taught that this is safe practice to steer clear of the tibial artery, which courses very closey to the belly of tib post. The patient will let you know when you have a trigger as they will feel the referral down the back of their leg and sometimes to the Navicular. I don't use a peppering technique for this muscle, simply find the spot and leave the needle in situ for a few minutes. I would typically repeat this for two or three triggers.

Care is required though!!!

Happy and safe needling:drinks