Originally Posted by One Foot In The Grave
Very fit female patient aged 52 presented yesterday with a 3 year history of pain in her right foot. Prior to the injury she was an avid runner - has not been able to since due to pain. She is unable to tolerate anti-inflammatories.
Pain commenced while OS, after non-direct trauma in which she fell forward, "bending" (her description) the mid-tarsal joint. Pain was immediate.
On her return home one week later she consulted her GP & a Podiatrist, had x-rays and a CT scan which showed no abnormalities. She has 'tolerated' the pain since.
She has since experienced an aching pain 24/7. She occasionally has very short pain-free periods (minutes) which end with a sharp return of the same aching.
Pain is generalised throughout the foot, but with palpation was more focused at the dorsal mid-tarsal area around the BOM 2,3 articulations.
Her foot joints are generally "tight" in response to years of guarding and pain.
I have not sighted the earlier x-rays (she's bringing them on Monday) however I suspect she has had a Lisfranc joint dislocation which spontaneously reduced with attempted ambulation prior to radiographic assessment.
All references to Lisfranc Joint Injuries refer to treatments only within the first week - month after injury.
Does anyone have any experience treating an injury which has gone undiagnosed for 3 years?
Any alternative Differential diagnoses?
Is surgical fixation still a possibility after so long?
Thank you for providing your name. Now I will give you a more complete description of how I would treat this patient.
First of all, you must suspect some sort of Lisfranc joint sprain due to 1) the mechanism of injury and 2) the location of the pain. Even an MRI would not likely show much abnormality at 3 years post injury however I would bet that a technetium bone scan would show increased activity at the midfoot.
There are two clinical tests that I have developed in order to determine the diagnosis of Lisfranc joint injury or Dorsal midfoot interosseous compression syndrome
(DMICS) and to clinically assess their healing. First of all is the Forefoot Plantarflexion Test
where I stabilize the rearfoot and ankle and then plantarflex the forefoot on the rearfoot. The patient will find this maneuver extremely painful on the affected foot. Secondly, is the Midfoot Compression Test
were one hand is used to squeeze the midfoot where laterally-directed manual pressure is applied to the first metatarsal-cuneiform joint along with medially-directed manual pressure that is applied to the base of the fifth metatarsal. Patients with Lisfranc's joint injuries and DMICS will also find this test very painful.
On the first visit the patient is placed in a cam-walker brace and told they will be wearing it daily, and to avoid any barefoot walking....just like they had a fractured foot . They will be told that they need to be casted for functional foot orthoses as soon as possible so that when they come out of the brace they can go directly into foot orthoses in running or walking style shoes. These shoes should have at least a 3/8" heel height differential, the higher the heel the better (up to 1" heel height differential). They are also instructed on icing 20 minutes twice daily to the midfoot.
The foot orthoses must be able to resist deformation from the foot and must be extremely well fitted to longitudinal arch of foot. In other words, use minimal arch fill, at least a 3/16" polypropylene device, with 3-4 mm heel contact thickness, balance it inverted 3-5 degrees with a 2-3 mm medial heel skive and standard rigid rearfoot post. Once the orthoses are received, the patient should avoid barefoot walking for at least 3 months.
She may bike ride and possibly do elliptical trainer once she is out of the brace but probably won't be running anytime soon. Mechanical goal of the treatment with the orthoses?: increase the forefoot plantarflexion moments so that the dorsal midfoot joints have less interosseous compression force and so that the plantar ligaments have less tensile force.
Hope this helps.
Kevin A. Kirby, DPM
Adjunct Associate Professor
Department of Applied Biomechanics
California School of Podiatric Medicine at Samuel Merritt College
107 Scripps Drive, Suite 200
Sacramento, CA 95825 USA
Voice: (916) 925-8111 Fax: (916) 925-8136