Global foot pain

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Dear all

I have an 11 year old neice (she is a keen trampolinist) who has presented with sudden onset idiopathic footpain. She woke up this morning with the foot pain and is unable to weight bear (no previous trauma recalled). Passive plantarflexion or dorsiflexion causes severe pain, direct palpation of the deep peroneal nerve causes dorsal medial - lateral pain. medial or lateral palpation of the calcaneous causes relative medial and lateral foot pain. Simultaneous Lateral compression of the calcaneous causes severe pain in the calc and foot borders. palpation of the post tib nerve below the medial malleolous causes medial foot pain. Longitudinal compression of the 3rd or 4th metatarsal causes pain at the met cuboid joint that radiates back along the metatarsal.
D/FLEX/ P/FLEX of the 3RD 4TH metatarsal causes midfoot pain. pressure on the digitorum brevis muscle causes pain at that site. Passive dorsiflexion of the foot causes midfoot pain, passive plantarflexion of the foot causes heel pain. The plantar foot is swollen and in particular plantar foot is swollen in the lateral arch under the cuboid. I had thought of Lisfranc dislocation which seemed the only logical explanation that would give such global foot pain.
X ray report says no fracture or abnormalities but I have not seen the films. X rays were evaluated at a minor injuries unit so the report is not entirely reliable.
There is no plantar ecchymosis. No paraesthesia or anaesthesia in the foot or tinels sign on percussion of nerve sites, superficial neuro checks are all good. Foot is too painful for any further assessment of RoMs or alignment. Achilles tendons bilateral are very tight and tender to palpate. Contralateral foot is asymptomatic,and normal alignment and RoMs except fot ankle equinus.

Any thoughts?

Thanks Danny Kaysmitt

 

In the abscence of clinical findings at this time, proceed to a bone scan.

LL

 

The plantar swelling indicates real trauma or some other inflammatory process of some sort. Put her non-weightbearing with crutches for two days with ice therapy (20 minutes 3-4 times a day), ace wrap and elevation. On the third day, have her start range of motions of ankle, STJ and digits up to 30 minutes a day, with icing continued as long as swelling persists. Weightbearing to tolerance in a cam walker style boot brace can be allowed on the third day.

Diagnostic studies should include MRI scan since there is likely some soft tissue pathology involved. The bone scan is likely to be too nonspecific to give you a good diagnosis at this time. However, you may also consider infection. Any warmth or erythema to the foot? Oral temperature, chills or fever? Blood tests may be considered if you do suspect infection??

 

Consider a tarsal coalition. A patient attended my clinic recently with a similiar presentation to what you have described. Sudden onset global foot pain following a relatively benign event of kicking a foot ball (albeit barefoot!) the day before. Standard Xrays did not reveal much and the pain was so severe (limping) but without heat, cardinal signs etc. I referred her onto orthopaedics and sure enough a MRI showed a talo-navicular coalition.

Hope this helps.

Louise

PS Patient walked with a supinated/inverted foot rather than presenting with a spastic flat foot!

 

Dear all

Thanks for replies, patient resolved to no pain after 10 days on crutches non w/b. I advised Icing but I think it was only used once. Didn't appear to be an infection.
Dx Sudden Onset Idiopathic Juvenile Arthralgia ;-) cool!