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Hello all,

I'm a student and assistant with a case here that has left this clinic but still has me flummoxed. It's been bothering me and I'm hoping that maybe some collective thought from the bright minds on here would help. This is far different than the normal patients that walk into our doors. Trying to give as much detail as I can from our notes/forms so please excuse the many words. Also, I've been told by friends I'm still bad at speaking like a medical doctor so I'm trying to use as much plain language here as possible.

Patient is 26 year old male. 6'3 210lbs. Active runner with no history of foot issues. Patient finished a marathon with no issues but did note un-even terrain, after a week of rest went out for a jog when on landing felt a surge of pain ("like a gunshot") into the lateral side of his right foot. Presented with a slight limp, had tried to rest/ice for a week before coming in with no results. Pain on palpation (7 out of possible 10) in base of 5th metatarsal. Xray was normal, no evidence of fracture. Right foot is flat, again no issues with it until now.

Resident prescribes Feldene (generic version) for inflammation of peroneal tendon, also a cast and walking boot for two weeks and further evaluation at next appt.

Patient came back with no improvement, was able to pinpoint pain even further on right foot. Took another X-ray to be sure of no fracture, with was again clean. Resident gave a steroid injection into the spot as the patient was insistent on running a race soon, though we advised NO activity without significant improvement. Also, fitted for lateral heel wedge orthotics, not custom. Again two weeks waiting time to next appointment.

Currently patient returned with further symptoms. Lateral pain in foot has not gone away and there is now bilateral popping/snapping in both feet lateral side near the heel, which I'm assuming is tendon subluxation although resident felt there should be pain with the popping for that diagnosis. This was demonstrated to us three times, if the patient gets up from rest and takes steps the popping is very audible. Patient also feels tightness in both feet on the lateral side along now with pain and tightness in the heel and up to the calfs, he gets bouts of pain even at rest and non-weight bearing. Patient has not run at all now for 4 weeks, takes warm baths for blood-flow and compression socks and elevation whenever at rest. Resident threw up hands, referred for MRI and to an Orthopedic Surgeon specializing in the foot/ankle. I doubt we will see him again.

This case has me flummoxed for a variety of reasons. It appears to be significant damage to the peroneal tendons but to present bilaterally and with no history of even a rolled ankle? Again, out of our hands now but just got the mind rolling, also feeling for the patient, seemed to be in far more pain than he was letting on. Resident is wonderful but elderly and I didn't agree with approach (especially injection) but I'm just the idiot student.

Anyway, I'm been revisiting over and over again, probably because it's one of the first cases we've seen in a while with no obvious answer. Any insights on this? If I can get the MRI results at a later date will forward.

Thanks in advance to all,
Rick

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Did you test the strength of the peroneus brevis muscle?
Swelling, bruising after injury?
Eric

We did test but they were quick. Strength and walking tests were unremarkable. No discernible swelling or bruising in area upon exam or on xray.

Did you issue Bilateral valgus wedges? if so did the bilat popping start then? Remember that Fib/Pero Long is a Supinator in CKC (By pulling 1st Ray down) Cuboid Pain can refer all around that area, could be lots of things. Personally I wouldnt Pronate an already flat foot by lateral wedges, using a cuboid bump to support the cuboid whilst varus wedgesto supinate the foot may have reduced inflamm of Fib long and Brev, Just a thought.

The action of Peroneus longus is variable at the STJ depending on STJ axis position. In a foot with a medially positioned STJ axis, the muscle will at the cuboid create a pronation moment. It will also increase pressure under the first met head. If the first met head is lateral to the axis, force here is still on the pronation side of the axis.

A good thing to do before adding valgus wedges is examine maximum eversion height and STJ axis position.

????


Eric

Sorry, should've went into more detail on the orthotics. Bilateral Powerstep 3/4 with a heel cradle. Size 14.

I take it you believe it might be Cuboid Syndrome?

Originaly pain was in that area, however the tendon popping was after issue of insoles ? I suggest you contact the Pt or Referred Othopaedic surgeon and get some feed back. It would be a great mystery to solve.......I know you probably dont have much time for extra curricular research, but it will rest you mind so you can concentrate on your exams etc......oh and partying !

Hi Rick.
There doesn't appear to be a history of actual damage, so perhaps it is a peroneal referral pain issue. The area affected and the peroneal "clicking" lend some support to this assumption. It may well require some kind of orthotic intervention, but it is worth trying some simple measures first to achieve pain relief. If pain relief is achieved, then the pt might be able to ease gently back into running.

Referral pains can be quite easy to reduce by muscle release techniques. If there are biomechanical issues which cause the problem to return, then orthoses may subsequently be needed.

There are many muscle release techniques, such as ischaemic pressure, positional release, acupuncture, massage, etc, usually followed up by stretching and exercise.

I often prefer to start with these quick and simple techniques (usually positional release or acupuncture), then try other therapies if required. This approach has greatly reduced my income from orthoses (sadly), but can give speedy relief to the appropriate patients.

Regards,
Ian.

Sorry to backtrack guys Eric asked about stength of peroneus brevis - is it really possible to assess power of peroneus brevis muscle? If so how would you isolate it? I only ask as I have tried many times to isolate different muscles (especially smaller muscles) in the foot and just don't seem to have any joy. I have spoken to many physios when I have a problem patient who I beleive has an injury or weakness to a specific muscle and I seem to always get a puzzled look from them when asking about isolation rehabilitation to a specific muscle? Peroneus tetius is another good example?

would appreciate any help or advice

Thanks

Barty

According to Daniels & Worthingham, to test peroneus brevis, the patient must have his foot plantaflexed and do an external rotation of the foot while you apply pressure on the lateral border. If there isn't enough strength, just palpate the tendon (near apophysis stiloides) while the patient tries to do the movement.
Peroneus longus would require applying the pressure under the 1st met head instead.
I'd post the pictures, but I'm afraid that might be seen as a copyright infraction.

One way to figure it out is to look at cadaver legs. Move the foot into various positions and look at how much the tendon moves. When you find the directions of greatest motion you find which directions you should test muscle strength. I've done this and the peroneal tendons barely move with ankle joint motion. They move the most with STJ motion. So, I disagree with the above advice about needing to plantar flex the ankle to test peroneus brevis. To test peroneus brevis move the foot into the maximum pronated position, ask the patient to use their leg muscles to hold it there and then apply a force that would supinate the STJ. (From lateral to medial along the shaft of the 5th metatarsal while using the other hand to stabilize the leg by pushing the leg in the opposite direction.)

Eric

Serafian notes that peroneus tertius is absent a signficant percentage of the time. Its action is very similar to peroneus brevis so you can essentially count them as the same muscle. The task you care about is creating eversion moment. The task is more important than the individual muscles.

Tertius may have more of an effect at the ankle joint than peroneus brevis. How much of an effect depends on the retinaculum that holds the tendons in place. The retinaculum changes the effective direction of pull of the tendon. The extensor retinaculum is arraigned in such a way that it allows the direction of pull of the anterior tibial tendon to have a much greater effect at the ankle joint than either the extensor digitorum longus or extensor hallucis longus.

I don't recall off of the top of my head the relationship between the retinaculum and peroneus tertius.

Eric

Barty:

The peroneus brevis muscle may be isolated and tested fairly easily once proper muscle testing technique is learned and practiced repeatedly on different sizes and ages of female and male subjects.

The ankle should first be plantarflexed to help eliminate the risk of the extensor digitorum longus and peroneus tertius (absent in 8.5% of feet) firing and causing a subtalar joint (STJ) pronation moment. With the patient seated on the exam table, and the examiner seated also, for the left lower extremity, the examiner should place their right hand lateral to their distal 5th metatarsal shaft with the patient's medial ankle pressed against the examiner's distal thigh. The patient is then instructed to to abduct their foot against the examiner's right hand while the patient's ankle is plantarflexed. With the examiner's left hand, the peroneus brevis tendon is palpated from its insertion on the styloid process of the 5th metatarsal to the lateral malleolus and then proximally along the tendon as it courses posterior to the lateral malleolus to inspect for tendon integrity, edema, tenderness and to rule-out nodules or defects within the tendon. In a normal strength adult, the individual should be able to easily resist the very firm right hand pressure of the examiner.


The peroneus longus muscle may also be isolated using basically the same procedure for the patient's left lower extremity but in this case the right hand of the examiner should be placed under the first metatarsal head, with the patient's foot plantarflexed and the patient asked to plantarflex and evert the foot into the examiner's hand while the medial ankle is stabilized by the examiner's distal thigh. The left hand is then used to palpate the peroneus longus tendon (it passes proximal and plantar to the peroneus brevis tendon) at the lateral-plantar aspect of the cuboid to the lateral malleous and then along its course posterior to the lateral malleolus.

Two important points:

1) There is no other muscle which can plantarflex the first metatarsal head other than the peroneus longus muscle so that when there is a peroneus longus rupture or true weakness, the patient will not be able to firmly plantarflex their first metatarsal head into the examiner's hand without the peroneus longus muscle.

2) When testing for gastrocnemius-soleus strength, the examiner's hand should be placed under only the 4th and 5th metatarsal heads, not under the medial metatarsal heads. This is because the Achilles tendon is only two joints away from the 4th and 5th metatarsal heads while the Achilles tendon is four joints away from the 1st-3rd metatarsal heads and therefore the lateral column is nearly always more stiff than the medial column. With a weak gastroc-soleus muscle the peroneus longus will still be able to fairly effectively plantarlex the first ray while the 4th the 5th rays will be quite easy to dorsiflex so that the examiner that tests for gastroc-soleus muscle strenth by placing their hand under the first metatarsal head is not testing for the gastroc-soleus but testing more for the peroneus longus muscle.

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 first to all who have replied with thoughts, it means alot.

Received faxed notes from the Orthopedist. MRI has been ordered for suspected peroneal subluxation in the right foot. Also, looking for bruising in the 5th Metatarsal and issues with any other ligament. There is also possible subluxation in the left foot though on physical exam there was not as much evidence (audible snapping, visible limited strength/mobility). The patient's insurance did not approve an MRI for the other foot though so we are limited to this foot. Results will be faxed to our office as well along with the orthopedist.

Some thoughts here, I've read some recent studies, one of which I've linked below, stating that sonography may be better to confirm, can anyone advise on which imaging techniques they prefer?

http://www.ajronline.org/content/183/4/985

Also, I remained intrigued by the earlier reply to keep an eye on the cuboid bone. Should be interesting.

Thanks again to all, will respond back with results of MRI.

I would guess that it is cuboid syndrome as well. You mentioned he has flat feet and ran on uneven terrain, both of which can theoretically sublux the cuboid (usually plantarmedially). You usually won't find anything on X-ray for that. If it was me, I'd ask the attending if he would let me perform a cuboid whip :P

You could also try cuboid mobilisation. Look at Video that is on www.footmobilisation.com.
If it(the mob) helps you should get positive feedback from the patient within a few days.

In my experience, things that improve with cuboid manipulation usually hurt with midtarsal joint motion during the exam. Also, they don't have point tenderness at the styloid (base of 5th met.) Of course peroneal subluxation shouldn't hurt at the base of the 5th met either. Interesting case with many conflicting findings. Welcome to the real world where not everyone has textbook symptoms.

Eric

Thanks for the advice guys isolation and muscle testing is an area in my practice that I want and need to improve on. Can anyone advise on any literature or books that would be good learning tools in this area??

thanks

Barty

If your own foot is lean enough to palpate the tendons you can practice activating individual muscles in your leg. Also, the Hicks' paper mentioned in the biomechanics and orthotic section of podiatry arena would be good to add to looking at your own foot.

Eric

Sorry Eric I am unable to find this paper I did a search and about 150 pages came up do you know what date it was posted? or would you happen to have a copy to hand???

thanks

Barty

In the biomechanics section there is a sticky that has a lot of classic papers. Kevin's post I believe it was around no 10 there are pdf's of three of Hicks' papers. After a quick look I didn't see the one I wanted you to read.

Hicks JH: The mechanics of the foot IV. The action of muscles on the foot in standing. Acta. Anatomica, 27:180-192,1956.

Unfortunately I do not have a pdf. The other 3 by hicks are still good. I'll see if I can dig it out.

Eric

Here is Hicks #4 (Hicks JH: The mechanics of the foot IV. The action of muscles on the foot in standing. Acta. Anatomica, 27:180-192,1956).

Merry Christmas!

Attached Files

HIcks. The Mechanics of the Foot IV.Action of Muscles on Foot in Standing.pdf (1.10 MB, 10 views)

__________________
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 guys

merry new year!!!!

Happy Holidays to everyone. Just thought I'd provide an update since so many have been so helpful. The MRI was done and we received the results.

Radiologist noted extensive tendonitis in the peroneal brevis tendon along with noting a large buildup of fluid and inflammation behind the pinky toe. We believe this fluid is what is giving him the most pain. Resident said he has never seen so much fluid buildup in that area behind the pinky toe but that based on this he would still recommend rest/warm baths and just wait and see if it went away. Based on these results the orthopedist doesn't want to do anything too drastic either. I've asked the patient to come back in two weeks and in the meantime he may see a chiropractor to get some stretching advice (just reporting what he told me).

Still not satisfied with this, tendonitis should resolve in two to four weeks, and we're now going on eight. I'm starting to suspect patient non-compliance on rest?

Thanks again to everyone and I hope everyone is having a good holiday. Cheers all.