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Hi all,

I'd be gratefull for any advice regarding this patient:

Male, aged 26, works as Phys Ed teacher, plays football and runs.
Was referred to me about 6 months ago from physio for lateral foot pain.
Has shocking feet; lots of rearfoot eversion, midfoot hympermobility, hallux limitus etc...

I made him a pair of inverted style orthoses which have been very succesful, except...

...the problem now is pain and tightness in the middle of his feet that occurs within 10 minutes of running and eases on rest. This has been occuring since he started running in the orthoses and a reduction in bulk under the MLA has made no difference.

Suspecting compartment syndrome I got him to go for a run and on return the middle of his feet was sore and slightly swollen (an area corresponding to the middle compartment). Pain was reproduced on repeated flexion of the lesser digits.

I assume that he has chronic compartment syndrome that has been caused/aggravated by the orthoses.

My questions...

Is there an alternate and/or more obvious diagnosis that I'm missing?

Should I refer for compartment pressure testing or diagnostic ultrasound? (To exclude other pathology before he has the pleasure of a jab in the plantar surface of the foot!)

What should I do with the orthoses?
Is it worth remaking them with an even lower arch before we proceed with further diagnostic testing?
Or are there any magic additions I can pop on to cure him? (clutching at straws here!)

Thanks for any input,
Josh

Your testing seems pretty good thus far.


Try to discover what else provokes the midfoot/forefoot pain.

(passive) Supination about the LAMTJ? (passive) Pronation?

Once you have discovered this test, this will guide possible optional additions to the device.

Josh

At the risk of being slated I'll try and answer your query.

Sounds to me as if this patient has saggital plane progression blockage and compensates by pronating and dorsiflexing thru the MTJ.
Is his hallux limitus functional, is his 1st ray and TC joint stiff to dorsiflexion moments, or are they compliant like the MTJ.
Perhaps he cannot progress over the stiff hallux and so breaks laterally and straining the lateral MTJ and perhaps subluxing the cuboid plantarly

Did you fit heel lifts to your orthoses. I would suggest a less controling EVA orthosis with lowered 1st ray and kinetic wedge c/o for the 1st MPJ, cuboid lift and Heel lifts. Plantar facia groove if its tight and get the ankle mobilised and perhaps try a rocker sole walking shoe.

Thanks Atlas and David for your replies,
I'll try to clarify a few things...

Atlas, nothing else provokes pain. Only running and repeated contraction of FHB. The site of pain is proximal to the MTP joints and distal to the midtarsal joint. Also, it doesn't seem, or 'feel' joint related, but more 'soft-tissue-ish'

David, his hallux limitus is structural, first ray stiffness seems fairly normal and lunge test is reduced. Your explanation makes sense, but he has no problems around the cuboid or MTJ; his pain is further distal and plantar and seems more of a soft tissue problem.

I didn't put heel lifts on, but can do so at his next visit.

plantar fascia may be a little tight but his symptoms are more lateral to the main part of the plantar fascia.

I really think it's compartment syndrome. I've had this myself (anterior tibial) and did a comprehensive lit review of it years ago as a student, and the nature of his symptoms fit (pain only at a certain intensity, onset after 5-10 minutes, relieved on rest, the feeling of tightness/swelling/cramping...). I've never actually encountered it in the foot though. The compartment pressure test involves a needle in the bottom of the foot and I was wondering if a diagnostic ultrasound might be a better bet initially, if only to rule out other soft-tissue problems.

I'm happy to make a few modifications so his devices, but my gut feeling is that the source of his problem is not purely mechanical (he can spend all day in his orthoses comfortably, it's only the intensity of running that causes pain).

Thanks again for your replies, I'll keep you posted as to his progress.

Hi Josh,

As a general rule I'd expect that if an intervention, i.e. orthoses, has settled the presenting symptoms and caused a new symptom ( this is my reading of your outline) then you have "overcorrected" or gone too far in your control with your prescribed devices and now you are trying to treat the problem that only occurs if the devices are worn.

My apologies if I have got htis wrong.

You could test this by adding a small lateral wedge to the rearfoot of the devices and see if the time for the onset of the symptoms changes. This will help if the inversion is too great. Another possibility is that the arch height is too high and you can see in stance and in gait if the foot is remaining supinated.

I'd also very thoroughly check that the devices are not too long at any point along the distal edge which would be interferring with MPJ flexion. This could also create the new symptoms.

It sounds to me as thogh the problem that has developed is in the deep plantar intrinsic musculature going into spasm for whatever reason. In this case trigger points may have developed in these muscles which would respond to dry needling.

I'd be very reluctant to consign this case to 'surgical release' before quite a few other avenues were pursued. I'd say worst case you'll need to replace orthoses (and hopefully, only modify them)

Cheers
Shane

Josh,

I have to agree with Dave, as he covered all the orthotic aspects very well. The only additional thing you would want to check is for a shortage of the leg. (The mechanism of this is if the opposite foot was compensating for a long leg, the orthotics would make the opposite leg longer, which would result in a shortage of the affected foot. The compensatory equinus would result in central pain in the arch)
On a manual therapy basis, I would look for a dropped cuneiform. Palpate the cuneiform area, and you will feel the lowered cuneiform, and the patient will tell you it is sensitive there.
For fun, you can do some muscle testing with the FHB. Press up on the cuneiform and immediately check the FHB strength. The think about muscle testing is to find the ability of the muscle to lock, not its absolute strength. If it locks, then this is the cause of the weak muscle. Also check the cuboid in the same manner. There many other things to check, (ie accupuncture meridian-this muscle is related to the circulation sex meridian) or if it works short term only, then let me know, and we can go from there.

Regards,

Stanley

Thanks Shane and Stanley,
I'll be seeing this guy soon and will let you know how he goes.