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I have had several patients present with localized pain between the 4th and 5th metatarsal shafts- well proximal to a potential neuroma site. The only common finding is that in WBing the 5th met seems to protrude laterally throughout its entire length when compared to the hindfoot.

Any thoughts as to the source of pain / diagnosis?? Is this a separate unique entity other than lateral column overload ???

Thanks,

Nick

Nick:

These patients probably have some sort of injury to the 4th-5th metatarsal-cuboid ligaments and/or joint. I try to differentiate the source of the pain with some clinical tests which I have developed recently:

1. Forefoot plantarflexion test: While stabilizing the rearfoot, plantarflex the forefoot to detect inflammation in the dorsal 4th-5th metatarsal-cuboid joint ligaments and/or their insertion points on these bones.

2. Midfoot compression test: Grab the midfoot from medial to lateral and then squeeze them together with one hand so that the dorsal midfoot arch is made more convex to detect dorsal joint ligament inflammation and/or other intermetatarsal pathology.

I treat these patients by trying to unload the lateral column with shoe inserts, orthoses, and/or boot-brace walkers and/or decrease the local inflammation with cortisone injuections.

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

Here's a thread where I discuss this test and clinical entity some more........http://www.podiatry-arena.com/podiat...ead.php?t=1980

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

Also, lateral dorsal midfoot interosseous compression syndrome , or lateral column overload syndrome, may be caused as a gait compensation for plantar heel pain or plantar fasciitis. This is the topic I am writing on currently for my November 2007 Precision Intricast Newsletter.

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

Ok, Kevin. Now that you have diagnosed 1 and/or 2, what do you do specifically to expedite healing/recovery etc. Let's ignore injections for the moment, as this mechanical problem should have a mechanical solution.

Ron:

I will treat this condition generally using the following orthosis prescription:

1. Use 5 mm (3/16") polypropylene shell with flat rearfoot post.
2. Balance orthosis 2- 5 degrees everted to increase forefoot valgus correction.
3. Use 2-3 mm lateral heel skive to increase rearfoot eversion moment.
4. Use orthosis filler plantar to orthosis shell at lateral column to increase orthosis stiffness at lateral column.
5. May or may not use full length topcover with valgus forefoot extension.
6. Use 2-5 mm heel contact point thickness (also suggest using shoes with higher heel height differentials).
7. Use increased medial expansion plaster to prevent orthosis from supinating foot onto lateral metatarsals.

Hope this helps.

I love my flying pigs, Craig!!

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

Kevin I have a client who has this sydrome and also has cuoid marrow oedema and fractured trabecula evident on MRI which may habe been precipitated by jarring injury, but which is still quite sore despite orthotic therapy. Can you tell me anything that you know about this and whether immobilization through casting would present the best possible outcome.

If its of any use, aside from the mechanical intervention, I have found these mechanical (?) induced inflammations to respond well to simple deep tissue massage.

For example, in the case of Kevin's first test proving positive, it has been:

first session, massaging the interspace area when the joints are under least flexion(neutral?) This appears to reduce stiffness

Second and any subsequent sessions involve massage at Joint neutral and then take the joints into gradually increased flexion and applying the same massage technique.

First session often is quite relieving and a further two to three sessions has frequently proved to resolve the pain (unless there are other issue that do not respond to massage).

Of course orthotic options can be considered. In some cases the orthotic and massage are a combined treatment.

On just reading your question, my apologies, this is not address it. Still hope it benefits someone.

Ian

Jacky:

Even though I have never had an MRI scan performed on these patients with lateral dorsal midfoot interosseous compression syndrome (lateral DMICS), I would expect that some bone marrow edema in the dorsal margins of the lateral midfoot joints would be present in the more symptomatic individuals. Bone marrow edema is representative more of a "bone bruise" than a stress fracture, but, on a microscopic level, bone marrow edema likely represents microfractures of the trabeculae within the cancellous bone of the region. The pain that occurs with forefoot plantarflexion on the rearfoot (what I call the Forefoot Plantarflexion Test), is most likely due to the dorsal capsular ligaments pulling on the injured bone at the dorsal margins of the joint during the Forefoot Plantarflexion Test, rather than an injury to the ligaments themselves.

If the patient is very symptomatic, then I would put the patient into a cam-walker style brace for 3-6 weeks after I casted them for custom foot orthoses and was waiting for the orthoses to come back from the lab. Sometimes immobilization is required to allow enough healing of the bone edema/brusiing to allow the patient to walk comfortably in their foot orthoses.

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

In these cases, I find a suspension type cast fails to cast correct the lateral column and so I recommend prone fifth met pressure (thumb under fifth met head) casting.

I would prescribe a 1st ray cutout, a fifth ray cutout and a 5-7 mm 2-3-4 extrinsic bar posting for the forefoot.

Varus posting is a no no and so as close to 0 degrees as possible for a rearfoot posting. I would make all posting materials low durometer crepe so as to be shock absorbing and I would make sure that The Vault of The Foot was supported, foot type-specific.

I would then recommend a course of physical therapy stressing p.longus and FHL as well as core intrinsic training after Centrings are dispensed if symptoms are not completely resolved.

Dennis