Fibularis Brevis tendon sheath inflammation - Help with case please
I recently saw a new patient who I would appreciate any advice about. Apologies in advance for the lengthy post (I know it's going to be lengthy, as I have already typed it out once, and then lost it somehow!).
24 year old female; works as a physiotherapist
Recently increased length of running sessions from 1 hour to 1.5 hours, in preparation for a half marathon.
Began to experience pain in R foot which continued to become much worse
When I saw her, she had been resting from running for 7/52
She describes it as 4/10 pain, even during walking
Anti-inflams help for 4-6 hours; ice helps; both only provide short-term relief
Changing direction or walking quickly aggravates the pain
Had a diagnostic ultrasound which showed 'mild tendon sheath thickening of fibularis brevis' and no other pathology. X-ray showed no pathology.
Had a cortisone injection which did not provide any relief.
Wears Mary-Jane style shoes at work (comfortable); sneakers were not comfortable. Has custom orthoses in sneakers, and pre-fab devices in work shoes. Has new Brooks sneakers which have a fair amount of midfoot support.
There was pain on deep palpation of the area inferior to the lateral malleolus only. No pain at insertion or higher along the tendon or muscle.
There was pain with inversion; no muscle weakness was evident.
Gait showed moderately excessive midfoot pronation
I felt that her new Brooks sneakers + custom devices were likely causing an increased inversion force, and therefore excessive tensile stress on the fib brevis tendon, leading to the sheath inflammation.
I advised her to wear the sneakers without the devices, or change to a more 'neutral' sneaker + the devices, in order to decrease this stress.
I added valgus wedging to her shoe.
Since then, I have only had email contact with her - being a physiotherapist, she is better informed regarding tendon injury and rehabilitation than I am, and as such, has not returned for an appointment.
She has recently been to see an orthopaedic surgeon who ordered an MRI, which showed the same findings as the ultrasound.
He advised that surgery is not an option for this injury, and rest is the order of the day.
She has emailed me wondering where to go from here; and frankly, I don't know. Am I missing something here? I would expect that 'mild thickening' of the tendon sheath would be resolving by now with adequate rest and offloading, but she has had no change in her symptoms.
She has scaled back all activity ie no housework, grocery shopping etc, and has even recently cut back her hours at work. It is now 6 weeks since I saw her; 13 weeks since she stopped running completely.
She is asking my thoughts on an offloading boot as the next step.
I just thought I would run it by my superior colleagues on this forum for any other ideas.
Thank you in advance.