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Hi All

I have a Female patient 53 years old active tennis player that over the last 9 months has developed and indentation of around 20mm across and 15mm deep with a position slightly superior /posterior to the medial malleolus. She is c/o general non discript foot pain and a tightness in the met heads and toes. There are no signs of inflammation or pigmentation but The FDL TA and PT are all tender on palpation. She has now started to develop an "indentation" on the other ankle and is getting similar symptoms in that foot causing her now to be unable to do any exercise.
I have been through the obvious shoes /boots etc looking for a causative factor but I cannot believe that anyone wound tolerate anything that can cause this type of tissue damage and be unaware of it.

Has anyone got any idea's as to what could be causing this ??
Cheers
Derek

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Any additional info that might be helpful?
General medical conditions, previous treatments (e.g., cortisone injections). Medications. Duration of symptoms. Job description.
I assume you're describing the tarsal tunnel area or slightly proximal to it, correct?

DrSArbes

Hi

No predisposing medical conditions. She had some FFO 's fitted some time ago from another Pod( I have not seen them as they were ineffective and she no longer wears them) The indentation started to appear around 9 months ago and has got progressively bigger since.Occupation Housewife but runs a tennis club and plays competitive tennis herself.


The indentation is so big it covers that area the centre being right over FDL.

There is also and oblique bulge underneath the indentation which is firm to palpate
Cheers
Derek

Indentations can mean a loss of something in the area. A bulge means something extra is in the area. I would think that a partial tear of the FDL and or other tendons should be considered.
In any case, I would get an MRI and find out what is really going on.

Regards,

Stanley

Hi DTT,

I agree with Stanley - have an MRI done to see what the problem is.

Regards,
David

__________________
Old guys rule!

Hi Both

Thank you for your replies.
Yes I agree an MRI is called for but unfortunately the NHS waiting list for these is quite long( as you will know David), and I am trying to find a way of giving this lady some relief in the meantime.

I agree totally with you Stanley There would appear to be something Missing but ?????

The best way I can liken this indentation is to imagine an odaematous leg,push your thumb into it hard an that is a likeness of this indentation.
It does not alter shape or depth weight bearing or non weight bearing.
Cheers
Derek

Hard to say. I have seen localized scleroderma or Morphea cause more of an atrophy than lichenification. A rupture of the FDL should be relatively easy to Dx. Without seeing it, I'm more inclined to think dermatological rather than orthopedic. Perhaps a simple skin biopsy would answer a few questions.
DrSArbes

Hi Drsarbes et al

I would have thought with any dermatological explanation there would be visible signs of eruption /inflammation/irritation etc but there is nothing.

I have been contacted by the patient again today who is unable to get an appointment with her GP for over a week. She goes to Canada on holiday for 3 weeks from Monday next so I am beaten whichever way for the moment. I am seeing her in surgery on Saturday and will discuss a way forward which I think will have to involve her GP or a private consultation with a consultant.
Thanks all for your help.
Cheers
Derek

It could be a very active and contracting trigger point/s in FDL TP...
Try Active stretching and massaging along the posterio-medial tibial border and see if that improves. If it aggravates, while reproducing, the pain-massage longer and harder! If you know how to dry needle I would recommend that also.
Have you tried any tough love taping? Fully inverting the s/t jt etc?
Any way that's my 2c worth.
Hope it is of some help.

__________________
Cheers

Mahtay

"Time Wounds all Heels."

Hi Mahtay

Thanks for that, but I think I am going to wait until I get an MRI scan done before I disturb anything in a major way.

I still have this nagging question in my head of "Why has this indent appeared and what was there before in the tissues that is not now"???

She is bringing in the FFO's she got from another pod and I will see if I can modify them to give her relief for her holiday ,write to the GP and see where we go on her return.

Thanks for your advice it is much appreciated
Cheers
Derek