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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?

Hi there,

Lisfranc joint injuries can be acute and chronic. Typically if they are missed and not treated in the first month or so, they will slowly go on to be a degenerative problem affecting the relevant TMT joints where the injury has occurred.

I would suggest looking at the Hardcastle Classification system for Lisfranc injury. Usually plain x-rays (WB) will show the nature of any subluxation, dislocation and DJD. Consider a PA (reverse AP) view to show these joints a little better.

Generally my approach is to treat a chonic injury like the one you have described is firstly with orthoses. Then as more obvious posttraumatic arthritis develops, or if orthoses are ineffective, look to fusion of the painful joints in question. This might be any combination of the 1st through to 5th TMT joints. Consult your local podiatric surgeon for advice on this.

Hope this helps

LL

One Foot in the Grave (your actual name will be required for a more detailed reply):

Cam walker brace x 4-6 weeks. Possible cortisone injections. Foot orthoses with good medial arch contour and slight heel lift added, supportive oxford shoes with modified lacing, ice twice daily and avoid barefoot or tight dorsal vamp of shoe should help. Surgery only as last resort. See these patients commonly.

__________________
Sincerely,

Kevin

**************************************************
Kevin A. Kirby, DPM
Adjunct Associate Professor
Department of Applied Biomechanics
California School of Podiatric Medicine at Samuel Merritt College

e-mail: kevinakirby@comcast.net

Private Practice:
107 Scripps Drive, Suite 200
Sacramento, CA 95825 USA
My location

Voice: (916) 925-8111 Fax: (916) 925-8136
**************************************************

It's Sarah.
:)


Thanks for the input.

Dear Sarah

Has the possibility of chronic regional pain syndrome (Reflex sympathetic dystrophy) been excluded?

Cheers

Nigel

I can't rule it out entirely yet. She doesn't have any sympathetic nerve reactions that couldn't also be attributed to the menopausal hot flushes she is experiencing atm.

She did experience an extreme reaction to the cool water whilst doing contrast baths last week. Her xrays show somewhat increased spacing in the Lisfranc joint.

I'm not sure how successful treatment will ever be for her as she is quite reluctant even to use a Cam-walker for 4 weeks...though her pain has decreased and focussed following some mobilisation of her foot joints and massage of foot & leg musculature.

Sarah:

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.

__________________
Sincerely,

Kevin

**************************************************
Kevin A. Kirby, DPM
Adjunct Associate Professor
Department of Applied Biomechanics
California School of Podiatric Medicine at Samuel Merritt College

e-mail: kevinakirby@comcast.net

Private Practice:
107 Scripps Drive, Suite 200
Sacramento, CA 95825 USA
My location

Voice: (916) 925-8111 Fax: (916) 925-8136
**************************************************

Just wanted to say thanks for the info on the diagnostic tests Kevin.
(I also hunted down your essays on the topic from 1997 to boost my knowledge.)

She was positive to both tests this afternoon, but is still refusing the cam walker and cortisone injections!

Can lead a horse to water.....

:)