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I recently saw a 16 year old boy who has been having random midfoot pain coupled with swelling which occurred for 3-4 days at a time and prevented him from being able to walk. He states this has happened 6-7 times in the last 3 years and was eased with massage, being kept warm and rest.
On examination it appears to be at the base of his 2nd and 3rd metarsals but has not occurred for 6 months. He has a slightly increased STJ and MTJ range of motion, but his RCSP is neutral and he has an effective windlass mechanism on weight bearing. Of note, he has extremely tight calf muscles for which I have given gastroc and soleus stretching. He has had recent growth spurts in the last 3 years and is quite big for his age now, even though he has lost weight in the last year. He also states he did used to wear narrow fitting shoes.
I felt that he did not require orthotics as his footwear was appropriate and supportive. My question is was his pain which appears to have settled, due to growth spurts, excess body weight, and tight calf muscles coupled with increased motion in the Midtarsal joint which likely caused pain at the met/cuneiform joint. I haven’t been able to find anything about this on the internet.
I would appreciate any opinions.

 

Hi Victor,
It may be helpful and allow you to have better responses if you are a little more specific about the site of pain. Also , this thread might give you a little better idea about what readers will be looking for in terms of information
http://www.podiatry-arena.com/podiatry-forum/showthread.php?p=201581

Regards
Robin

 

The patient may have synovitiis of the Cuniform-metatarsal joints caused by increased sagittal plane pressure from tight calf complex

 

This is along the lines of what I was thinking. Cant explain the randomness and infrequency though.

 

Thankyou Robin for your advice,
here is a more indepth view of my assesment, I would appreciate opinions on if I did the right thing with my discharge.

Chief Complaint:
16 year old boy with random midfoot pain and swelling lasting 3-4 days at a time.
History of presenting illness:
Pain location: Patient points to base of his 2nd and 3rd metatarsals
Occurred 6-7 times in last 3 years in either foot
Pain (8/10 VAS), duration 3-4 days eased with massage, being kept warm and rest.
Patient has had recent growth spurts in the last 3 years, including significant weight gain, weight & growth have now settled
Past medical history:
Unremarkable
Physical exam:
Footwear: supportive ankle boot trainers
Pain location: Patient points to base of his 2nd and 3rd metatarsals (no pain for 6 months)
Weightbearing:-
-Right foot abducted, left foot straight
-Supination resistance:medium
-Hubshers: 3/3 both feet
-Navicular drop:<20% both feet
-RCSP: neutral
-Single heel raise: Calcaneus inverts with good arch congruity
Supine:-
-STJ: 2:1 both feet
-MTJ: Both feet slightly increased (OMTJ) and (LMTJ) no pain through or at end range of motion
-1st MPJ: 90°
-Forefoot/rearfoot: Parrallel
-1st Ray position: neutral
-Ankle: Equinus+++
Gait analysis:
Slight postural sway from side to side in shoulders, slight abductory twist, mild pronation at midstance
Differential diagnosis:
Synovits/inflammation of cuneiform/metatarsal joint which appears to have settled, due to growth spurts, excess body weight, and tight calf muscles coupled with increased motion in the MTJ which likely caused pain at the met/cuneiform joint during
Treatment Plan
Footwear advice
Gastroc and soleus stretching twice daily
If it occurs again Patient to attend A&E for imaging of acute swelling to aid future diagnosis
Patient discharged

 

Victor:

You may want to consider dorsal midfoot interosseous compression syndrome (DMICS) as a diagnosis. DMICS is not so common in adolescents, but I have seen it, especially when patients have extremely limited ankle joint dorsiflexion.

http://www.podiatry-arena.com/podiatry-forum/showthread.php?t=1980

Treatment:

Icing dorsally 20 minutes 2 times a day
Relace all shoes to avoid dorsal shoe pressure on dorsal midfoot at base of metatarsals
Heel lifts, no barefoot, three times a day gastroc-soleus stretching
OTC or custom foot orthoses with good arch congruity

 

Thanks Kevin,
I have read your post on DMICS and I think that is a very likely diagnosis. I now have a name for it!

Thanks very much
Vic