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Hi All,

Long time lurker, first time poster: I practice in Melbourne (Australia of course!) and am looking for some help regarding a young client with left foot pain, primarily medial and arch related.

Female patient is 17, normal height, higher part of normal weight range for height (not measured, just guessing). 2 years ago presented to me wearing wedge shaped (rear foot controlling), no-heel- counter-orthoses, half length in runners and runner type school shoes.

Symptoms were several years of medial arch pain, left foot worse than right. Orthoses have been helpful, but never completely removed pain. At the time of initial presentation the pain had worsened and was no present also in heels and foot. Exercise and sport difficult to do without pain, and working At McDonalds for 2 short shifts brought about increased pain.

NWB: pes planus both feet, left foot worse than right. ROM AJ barely 10 deg DF. STJ and MTJ restricted in left foot more than right, and 1st ray approximately neutral. MPJ ROM 55 deg left, 50 on right.

WB: Left foot pes planus very significant with talo navicular collapse (though not quite in contact with ground), everted calc position. Right foot also flattens signicantly however supination resistance is "medium" while on the left "very heavy." Significant internally rotated genicular position. Gait abducted.

Initial adjustments I made were inverting orthotic at rearfoot with metdome which improved pain for a few months. New shoes for work did not help a great deal, and approximately 10 months ago cast a new pair of orthoses for inversion only this time with a heel cup. Pain did not improve with these, and within the last few months an orthopaedic surgeon was consulted. MRI showed no issues intact, however there was a left talus stress reaction, which he believed the orthoses were causing / contributing to. After a CAM walker for the last 6 weeks, he suggested they visit an orthotist for some interim orthoses until surgery at a yet to be announced date.

Last week, the client returned: Rom measurements remain unchanged. Lunge test measured this time, and AJ DF is ok. The patient has stopped working all together because the pain is too great. Cast orthoses are worn only in school shoes, old orthoses are more comfortable in runners.

My suggestion was to attempt a soft rearfoot orthotic to minimise talus pressure(??) and if no assistance make my own accomodative orthoses in light of the fact that attempts at functionals have been unsuccessful? Is surgery really the best option?

I hope you guys on this fantastic forum can help provide me with some other options/ advice.

Sorry about the ramble, but I think I have covered the background sufficiently. Feel free to ask any questions if you want any more info.

Regards,

Bjorn

Bjorn:

In order to help you and your patient, first of all I need to know which exact anatomic structure is having the most symptoms. Saying a patient has "medial arch pain" could mean about 20 different structures so please provide us with exactly where it hurts or is tender.

Secondly, where exactly on the talus is the "stress reaction". Since the talus articulates with four different bones, it would be helpful to know exactly where on the talus the stress reaction is. Also, stress reactions don't normally occur on the talus since these microscopic fractures of bone are generally caused more in bones that are under significant bending moments, with the talus being subjected much more to compression stresses that would cause the MRI to show subcortical bone edema or bone marrow edema. Maybe your radiologist and orthopedic surgeons are using different terminology than what is typically used here in the States when reading MRI scans?

Third, I don't know what you could do surgically to heal a "stress reaction", which is basically a "pre-stress fracture", if that is actually what is happening in the talus. What surgery was the orthopedic surgeon planning on doing? Is there something else this patient has that you haven't told us about such as is there any history of ankle sprains or ankle trauma recently or before the pain began? Is there any way you could send us copies of the MRI images so that we can see this "talus stress reaction" for ourselves??

Here's a nice link on Imaging of Talar Fractures.

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
**************************************************

Thanks for your reply Kevin. Sorry I wasn't more specific to begin with

Pain is quite non-specific. Palpation is able to reproduce symptoms along the path of FHL plantarly up until approximately the navicular. There is also slightly more medial foot pain along the path of tib post as well as antero-medial ankle pain (medial talar head: grasping position with which I normally try to find sub-talar joint netural). Pain is worsened with activity and increased periods of weightbearing.


I am unsure as to the exact location, as the client did not bring the MRI report, nor the films (I did not request the MRI). But from what I understand the "stress reaction" was medial. As for the terminology, I don't know that either, but the client should be bringing the MRI in tomorrow I will try to take a picture of the scan's and post them up here.

Not sure of the details of this either. However I believe the surgery revolves more around correcting the pes planus in an attempt to minimse the stress, but most importantly the pain.

I will hopefully have more details for you tomorrow. Thanks again,

and i thought I was the only Björn on this forum! some Swedish blood in you?

cheers

Björn Englund

Any pain with muscle testing? FHL or posterior tibial?

Regards,
Eric

No swedish blood, but parents from Northern Germany. DOn't think its a common name up there, but not unheard of either.


Ok, some more information:

MRI report states the following:

" Tibial plafond and talar dome are intact. There is no ankle joint effusion. There is a moderate grade stress response within the talar side of sinus tarsi seen towards the posterior facet of the subtalar joint anteriorly. There is some scarring of the ligaments within the sinus tarsi. Also a low grade stress response in the dorsal aspect of the articular surface of the talus at the margin of the talo-naviicular joint. There is no advanced subtalar joint arthrosis. Anteromedial facet of the subtalar joint is well maintained. A small talo navicular jiont effusion effusion has been shown. The calcaneocuboid joint is well maintained. The navicular cuneiform and other joints of the midfoot are preserved. In particular the first tmt joint is intact. There is moderate scarring and hypertrophy of the dorsal talo navicular ligament. The medial collateral ligament is intact. Tibilais posterior is also intact. The other flexor tendons are normal. The anterior talo fibular ligament is intact. there is some scarring of the calcaneo fibular ligament and posterior talo fibular ligament. The peroneal tendons are intact. The aterior tendons have a normal appearance. The achilles tendon and plantar fascia are normal. Intrinsic muscles of the foot are well maintained.

COMMENT:
1. a stress response is present within the talus around the margins of the sinus tarsi and anterior aspect of the poasterior facet of the subtalar joint. Ther is also a stress response in the articular surface of the talus near the talo navicular joint.
2. Intact Tib post tendon
3. Normal appearing first TMT joint
4. normal subtalar joint.

Eric:
Tib post has always been weak ( I didn't in initial assessment note how many single leg raises were possible). This time however: Single leg raises on right leg - 10 before couldn't complete anymore. Left (symptomatic leg) could only do 2 without bending the knee. Knee bending was attempted on nearly each one!

I am trialling a rearfoot controlling premade "prothotic" which is a soft version of a rearfoot wedge shaped insole. Hopefully this weill provide enough control whilst providing softness. I was always waiting for the patient to get comfortable with some sort of orthotic before starting some Tib post strengthening, but maybe this could be useful now?

Regards,

Bjorn

Hi Bjorn:

Interesting MRI report. Apparently some "regional" terminology relative to findings.
I'm not exactly sure what your radiologist is referring to when he notes "scarring" - I am assuming he means fibrosis with or without joint effusion (stress response??!!!!)

All of this may represent a Sinus Tarsi Syndrome, but this does not correlate with your patients symptoms which are medial and medioplantar.

I think we need more info.

Steve

__________________
DrSArbes
Fellow American College of Foot & Ankle Surgeons
Board Certified Foot & Ankle Surgery, ABPS
Green Bay, Wisconsin, USA

Bjorn:

The two locations of "stress response" correspond to the locations where the greatest magnitudes of intereossous contact pressures will be within a maximally pronated foot with a medially deviated subtalar joint axis: 1) at the leading edge of the lateral process of the talus where it abuts against the floor of the sinus tarsi of the calcaneus (Kirby KA: Rotational equilibrium across the subtalar joint axis. JAPMA, 79: 1-14, 1989) and 2) at the dorsal articular margin of the talo-navicular joint. The diagnosis from the MRI and clinical presentation would be 1) sinus tarsi syndrome/sinus tarsitis due to excessive STJ pronation moments and 2) talo-navicular joint dorsal bone contusion due to excessive medial longitudinal arch flattening moments.

I would not use a "soft orthosis" in this patient. I would use a custom casted, 4-5 mm polyproplyene orthosis with a 3-4 mm medial heel skive, 18 mm heel cup, minimal arch fill, rearfoot post and possibly balanced slightly inverted to reduce both the sinus tarsi and dorsal talo-navicular contact pressures. Forget about over-the-counter orthoses in this patient, she needs true prescription foot orthoses. I am not certain of your orthosis terminology, but if you aren't able to reduce the STJ pronation moments and medial forefoot dorsiflexion moments with the foot orthoses, then you have little hope of this young lady improving.

Also, I don't know why a foot surgery is being planned for this patient unless a good pair of foot orthoses in sturdy shoes have been tried and/or cam-walker bracing have been tried and have failed. I am unclear as to how long she has been wearing custom foot orthoses. I certainly think that a trial of bracing or immobilization casting of the left leg/foot is warranted before foot surgery is planned. By the way, what is the height and weight of patient.....being over-weight, or as we say here in PC- California being "under-tall" could be playing a significant role in this young lady's symptoms.

__________________
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
**************************************************

Thank you very much for your input Kevin.

The patient has been wearing the customised orthoses for about the last 10 months - Never in complete comfort. They were 4.5mm polypropylene, with an inverted rearfoot (and what I would call skived). The heel cup was probably 8-12mm - so not as high as you suggest. Rearfoot extrinisic post was originally slightly inverted, however some grinding of the medial aspect of this proved more comfortable.

The orthoses worn with a similar degree of comfort previously for more than 2-3 years were shaped very similar to this as shown in the picture

http://www.podiatry-arena.com/images/Picture1.jpg.
However imagine that shape, with 4mm polypropylene and a heel post.

I respect and understand what you say about a harder orthoses: It was along my lines of thinking. However, still no improvement. The "soft" orthoses I have given the patient this time are almost the same as in the picture above, only of softer material. So control is still in the correct place, however I am trying to have the patient find them more comfortable.

The CAM walker was for the stress reaction,however the patient's pain persists after a 4 week period of wearing it. I agree surgery is drastic and am hopeful that a solution is not too far away.

I don't know the patients weight exactly but would guess approx 173cm (5"8) and 160-170 pounds (75-80 kg's) The problem here is a vicious circle - exercise causes pain, but exercise is necessary to lose weight.

Bjorn:

She doesn't sound as overweight as I thought. The orthosis you have sent has an extremely low heel cup so it looks like more of a varus wedge, rather than a custom foot orthosis that I am more familiar with and am basing my clinical judgement on. I don't know that I can help you anymore unless you can send some photos or videos of her feet.

__________________
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
**************************************************