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I have a challenging paediatric case. 12 year old girl who presented with
right rearfoot and medial midfoot pain. No history of traumatic event. Pain
noticed about 5 weeks ago a few hours after playing basketball. Was quite
acute on inital presentation 4 weeks ago. O/E pain on inversion/eversion of
STJ and MTJs. No erythema, oedema or bruising. Some pain on max
plantarflexion and had pain on active resisted plantarflexion of FHL. GP did
x-ray reported as normal but actaully had os trigonum. Initially I thought
it was just a tendinopathy and maybe posterior impingement. Advised rest
from sporting activity for 2 weeks. On review no better infact pain was
worse in medial foot and very guarded on any inversion/eversion. Sent for
MRI ?os trigonum and also wanted to rule out tarsal coalition. Any no tarsal
coalition but os trigonum syndrome with fluid around FHL sheath. This
explained some symptoms but not all. Given degree of pain decided on CAM
walker and short course of NSAIDS. Little relief after 2 weeks of walker.
The degree of stated pain and the area of pain is out of proportion to the
os trigonum syndrome as most of the pain is actually over the distal tendons
of post tib and tib ant and passive eversion of the STJ and MTJ is very
guarded. In fact when the foot is just passively resting on the bed it is in
a position of inversion and plantarflexion. I think she is splinting the
foot in anticipation of pain and causing the muscles to spasm as she has the
pain both weight bearing and non weight bearing. By the way the MRI showed
no other changes in surrounding structures both soft tissue and bone. I
think she may have set up a difficult cycle of pain and muscle spasm. I am
going to try gentle heat using therapeutic ultrasound followed by gentle
mobilisation. I have also added a felt arch filler to try and offload the
invertors. X suggested a week of actaul casting using scothcast
semi-rigid soft cast but I don't know whether this will help as I really
want to start mobolising the foot to stop the spasm not immobilise it
further. The only that it may do is actually totolly offload the muscles a
let the foot relax. What do you think???. I have also advised the mother to
apply a heat pack for 15 mins then do very gentle mobilisation. I have
considered things like complex regional pain syndrome but she doesn't really
have any true signs ie no generalised hyperaesthesia, no increased warth or
coldness and no swelling. Do you have any other suggestions??????. I will
keep up with the CAM walker for another 2 weeks to treat the one known
problem of os trigonum syndrome but am a bit lost and frustrated with the
additional in an area seemingly not associated with the os trigonum.
Trigger point(s) and/or muscle inhibition may be worth a look at, but I would have thought that they would not produce the level of pain that the patient is experiencing.
thanks for posting my query. Just thought I'd give you an update on things.
On next review did a very thorough assessment of all trigger points that may
refer pain to the said area and found one in peroneus longus and one in tib
ant that both referred pain to the ant lateral ankle. Treated with 5 mins of
3 MHz continuous ultrasound at 1.2w/cm2 at the same time applying a mild
stretch to the muscles, followed by 1.5 mins of ischeamic compression and
finishing with a stripping massage technique along the muscles. The pain is
beginning to slowly reduce and the range of motion has increased all be it
only mildly. I am going to continue with this regime in addition to the
parents continuing gentle passive range of motion and hopefully continue to
see improvements. I plan to keep her in the CAM walker for another 2 weeks
to allow complete healing of the os trigonum but after that will commence
aggressive active range of motion exercises as pain levels dictate. Thanks
for you interest
I wondered if she sprained the ankle, as I just got a new patient with intense constant pain from such. I'm no expert here, but if her laces were loose the sprain could be inside loose shoes? the inversion also agittated the invertors, hence medial symptoms.
Mark here, coming from left field, does Juvenile R.A. present with intense pain like this? Or would it have been picked up on MRI? Just a thought.
Mark
Here is an interesting article to ponder regarding supination spasm of the foot. I would check again for tarsal coalition...did the MRI cover the whole rearfoot and midfoot?? http://www.jbjs.org.uk/cgi/reprint/47-B/3/533.pdf
I currently have a adult patient with a supination spasm of the posterior tibial muscle that seems to be related to something happening in the posterior subtalar joint. This is the first I have seen in 21 years of practice. Local infiltrations of local anesthetic into the posterior subtalar joint reduces pain and spasm but have not yet seen anything on a few x-rays. Casting improves pain and spasm, but does not resolve it. Awaiting an MRI. Sounds like a similar history. Try sequential diagnostic local anesthetic injections into the joint spaces of the rearfoot. I'll bet it reduces the spasm.
These are rare birds when you try to do a literature search for supination spasms.
__________________
Sincerely,
Kevin
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Kevin A. Kirby, DPM
Adjunct Associate Professor
Department of Applied Biomechanics
California School of Podiatric Medicine at Samuel Merritt College
Challenging pediatric case
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