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Unusually persistent forefoot pain in elite footballer

Discussion in 'Biomechanics, Sports and Foot orthoses' started by toomoon, Jul 5, 2013.

  1. toomoon

    toomoon Well-Known Member

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    I would appreciate arenees thoughts on the following unusual case:
    24 elite Australian Rules footballer:
    Bilateral, poorly defined mid/forefoot pain, loosely located around the TMTJ's
    # year history. this athlete has benefited from the investigation and care of the medical staff (all very competent) at a professional team.
    Hx.. L Jones fracture.. ORIF.. 1 year later.. same foot Jones #.. bigger better ORIF.
    Facet joint issues now completely resolved.

    investigations.. CT and MRI show mild bony injury not characteristic with fracture. Some marrow oedema and signal change in area of pain, but indicative of bony overload more than anything.

    Biomechanics.. unremarkable. Mild genu valgum with efficient stride. Mid to forefoot strike pattern which would not be helping. Has full length laterally posted orthoses which have not helped.

    Has persistent long standing 1st MCPJ pain which makes me think about undisclosed ideopathic arthropathy.
    Plan.. specific taping to try to change FF loading and reduce pain to give a pointer to long term management. Bloods to rule out arthropathy.

    Any PEARLS Ladies and gentlemen?
  2. Craig Payne

    Craig Payne Moderator

  3. toomoon

    toomoon Well-Known Member

    unfortunately there is NO pain with plantaflexion (or for that matter dorsiflexion)of the forefoot on the rearfoot,,and indeed very little pain to palpation. The complication may be that this is a very tough young man indeed who is not given to great pain reactions, even though he undoubtedly feels it...
  4. LuckyLisfranc

    LuckyLisfranc Well-Known Member


    Request a SPECT and see if that defines the area of greatest metabolic/inflammatory activity within Lisfranc's joint further.

    2 x ORIFs in the same area = long term drama's IMHO.

    Tough one.

  5. Brian A. Rothbart

    Brian A. Rothbart Active Member

    Very similar to cases I saw when working with the Seattle Supersonics (as their team Podiatrist).

    Have you screened this athlete for either the PreClinical Clubfoot Deformity or the Primus Metatarsus Supinatus Foot Structure?

    I am not mentioning this in a condescending matter, but if you have a positive screening result, an effective theapy to eliminate his symptoms is available.

    Hope this helps.

    Professor Rothbart
  6. efuller

    efuller MVP

    What is the wear pattern on the sock liner?

    Another condition that can present similar to the above and DMICS is a subluxed cuneiform. I've had it in my own foot and had the late Jack Morris whip it back into place. Although it also tends to create the vague symptoms on examination with plantar flexion of the 2nd metatarsal. Motion of the second metatarsal will recreate the symptoms and it will be tender at the 2nd Met cunieform joint. As you palpate up the shaft of the 2nd metatarsal you will often find a bony lip where the 2nd cuneiform will feel dorsally displaced relative to the base of the 2nd metatarsal. The thing that made me think of it is the vague midfoot pain. It usually occurred at the push off phase in walking.

    If you want I'll describe the manipulation.

  7. toomoon

    toomoon Well-Known Member

    Thanks Eric, but I am confident this is not what we are dealing with.. the problem is bilateral, which is not impossible for a cuneiform subluxation.. but would be pretty unusual I guess.. and the confounding issue is that there is almost nothing on examination... although having said that, i have not examined him after a game, which is when the pain is worst.
    All the same.. please describe the manipulation technique to me just in case.. similar to cuboid but localised over the cuneiforms?
  8. efuller

    efuller MVP

    Patient in exam chair with feet pointed toward you. Place the pipj of your 3rd finger of one hand directly over the cuneiform. Wrap the other hand over the top of the first. Place your thumbs close to the patient's metatarsal heads. The manipulation is a dorsal push with the thumbs with a simultaneous plantar pull with the fingers trying to concentrate the force over the cuneiform. With a slight person and a slippery chair you may move the patient a couple of inches. The upward push at the metatarsal heads is needed because the downward push on the cuneiform will just plantar flex the ankle and you need the inertia of the body to resist your pull.

    When my cuneiform was out, there was a noticeable click when this was performed. One time, after the manipulation I stood up and I could feel it slipping back out. I eventually had to teach my wife how to do it. After a couple of months it finally stopped popping out.

    I agree this doesn't quite sound like it, because the weight of sheets plantar flexing the metatarsals would reproduce my symptoms. It was quite vague and quite irritating.

    Good luck with him.

  9. JasonR

    JasonR Member

    Hmmm- hard to apply tissue stress model when it is not precisely clear which tissue is under stress! (i.e generating pain). I am sure the rest of the team is comfortable with ruling out central factors, but canal structures inc slump testing with appropriate sensitisations should be double checked- how common is lower lumbar disc pathology in AFL players! Does it happen equally in both feet at the same time? Does he have am stiffness, or is it clearly load related?
    Are his gait observations made in his footy boots?
    It is a challenging case- cant see anything, cant clinically reproduce the pain- makes me think of central/ systemic (seronegatives, metabolic?)
  10. toomoon

    toomoon Well-Known Member

    yeah ii I thought the same jason.. ideopathic athropathy of some description.. had bloods over weekend so will have results tomorrow. He does have an Hx of severe facet joint injury, but it was a long time a go and completely resolved.. still...
  11. RobinP

    RobinP Well-Known Member

    Sounds fairly systemic although have you ruled out localised neural compression from laces "biting" on to peroneal nerves? Gap lacaing for one training session will probably rule it out?

    If their boots are as tight as their shorts, well, you never know!
  12. Brian A. Rothbart

    Brian A. Rothbart Active Member

    If everything else fails, check for the PreClinical Clubfoot Deformity or the Primus Metatarsus Supinatus foot structure.

    Professor Rothbart

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