Monday, April 20, 2015
Foot Pain
Please see the image below of patient with primary complaint of medial foot pain. Patient was training for marathon and when jumping off of a curb to pavement felt a "pop" while training. they have had foot pain ever since. Each student should add something to the thread. It does not need to be a positive finding that you add it could be something describing a normal finding.
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There seems to be an alignment issue with the first metatarsal. It seems as though it is migrating medially. The first intermetatarsal angle is an important anatomic feature formed by the intersection of the lines bisecting the 1st and 2nd MT shafts. This angle normally ranges form 5 to 15 degrees. In this image this angle appears to be more than 15 degrees.
ReplyDeleteThis woman presents with two sesamoid bones around the 1st metatarsal head, the medial and lateral sesamoid bones. This is very common. Sesamoiditis is a possibility if you look at the medial sesamoid bone which does not appear whole. While normally sesamoiditis presents with an insidious onset relating to constant friction against the flexor hallucis brevis tendon, it can also be caused by a sudden dorsiflexion motion of the big toe, such as when jumping off of a curb.
ReplyDeleteThere looks as if there might be some mal-alignment of the 1st tarsometatarsal joint. The patient may have possibly dislocate or subluxed the joint and it did not go back into the correct position. This can cause problems with vascular or nerve supply if not corrected.
ReplyDeleteRegarding the "B" of the ABCs, it appears that the density of bone in this radiograph appears normal. There is sufficient contrast between bone tissue and soft tissue to indicate relatively healthy bone density.
ReplyDeleteThe joint spacing of the Calcaneonavicular joint is appropriate without any signs of arthritis or degeneration. Additional views would be helpful in order to rule out a superiorly or inferiorly displaced navicular that may lead to the patient's complaints of medial foot pain.
ReplyDeleteBased on this finding and I would suspect that this is a result of not only of the impact of the injury, but also due to an underlying muscular imbalance of the muscles in the foot. I suspect she may be an over-pronator and have weakness indicating such. There also doesn't appear to be a fracture present based off of this particular radiograph.
ReplyDeleteI agree with Katie, that the 1st MT is more medial than typical. Her big toe seems to be in normal alignment right now, but she may be predisposed to developing hallux valgus deformity if the hallux begins to migrate towards the lateral toes. Rotation of the hallux can also occur so that the toe nail faces more medial. Another name for this is a bunion.
ReplyDeleteIn addition to other comments, another malalignment I observed is at the 3 metatarsal and the 3rd cuneiform. This could be secondary to the malalignment caused from the injury at the 1st tarsometatarsal joint causing a "shift" at the other tarsometatarsal joints. This lateral dislocation can also be classified as a "Lisfranc fracture".
ReplyDeleteFrom this radiograph it does not appear that there is a fracture at the base of the 5th metatarsal. This is a common site of fracture especially after a trauma. Another view may be helpful to confirm this reading.
ReplyDeleteAlthough I don't see one, there could be a possibility of a stress fracture. These are very common in runners, especially marathoners! You can avoid a stress fracture by gradually building up your training, using proper foot wear, and avoiding sudden changes to harder surfaces, like concrete. The patient may have sustained a minor stress fracture if they landed too hard onto concrete from the jump off the curb.
ReplyDeleteContinuing on the path Matt began with potential pronation of the foot and muscular imbalances: a pronated foot can cause uneven pull of the peroneal muscles leaving the cuboid bone outwardly/ superiorly rotated. This abnormality can not be well viewed on this image and the cuboid appears normal. The cuboid could be better seen on an oblique view. Palpation and mobilization of the cuboid would further help with a diagnosis.
ReplyDeleteIn this anteroposterior projection, we are able to identify her phalanges, metatarsals, cuneiforms, cuboid, and navicular bones; however, in this dorsoplanar view, the talus, calcaneus, and distal tibia are superimposed over each other, making viewing these structures difficult. A lateral projection of the ankle, where the central ray is directed vertically through the medial malleolus, demonstrates the anterior and posterior aspects of the distal tibia, the lateral relationship of the tibiotalar and subtalar articulation, the talus, and the calcaneus, all of which cannot be clearly seen in this anteroposterior view. Additionally, a lateral projection of the foot, where the central ray is directed vertically through the base of the third metatarsal, demonstrates the calcaneus, talus, subtalar joint, and the talonavicular and calcaneocuboid articulations, which are also difficult to discern on the image below. Should her ‘popping’ sensation have come from this area of her foot, we would need a better view to further rule-out common pathologies which occur in these areas of the ankle and foot.
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ReplyDeleteBased on this particular view it appears that the patient has equal joint space between the metatarsals and the proximal phalanges of 2-5. This suggests little to no anticipation of osteoarthritis or degeneration of the joints.
ReplyDeleteWhat immediately catches my attention is the fact that there seems to be a fracture of the medial sesamoid bone. Expanding upon what Nick was discussing earlier, sesamoid bone fractures can be either acute or chronic. Turf toe is also a possibility and this is an injury of the soft tissue surrounding the big toe joint. In this patient’s case, I feel that her “pop” could have been due to a rupture of her sesamoid tendon that is attached to the medial sesamoid bone.
ReplyDeleteSo I am going to go out on a limb here and say that it could possibly be a LisFranc Injury. Placing the foot in a plantar flex position (which most individuals do when coming off a curb) and putting weight through that plantar flexed foot can cause the injury. If the imaging is a non-weight bearing anterioposterior view than a mild Lisfranc injury is sometimes difficult to diagnosis. A weight bearing and a lateral view would help in the assessment of the injury with an increase spacing between the first and second metatarsals on the weight bearing AP and possible a dorsal dislocation of the second metatarsal on the lateral view.
ReplyDeleteThis image displays the head, neck, and shaft of the metatarsals clearly but the bases are blurred, consistent with a good AP radiograph of the foot. I would be interested in knowing when this image was taken compared to when they stepped off that curb. Based on this image, it doesn't demonstrate any increased substance around the metatarsals indicating a stress fracture, but many of the initial images can appear normal.
ReplyDeleteA possible cause of the medial ankle pain could be due to an avulsion fracture caused by the posterior tibialis muscle. As we know, this muscle inserts onto the navicular, plantar surfaces of the cuboid and cuneiforms as well as the base of the 2nd-4th metatarsals. When the patient jumped off the curb, they most likely landed in plantar flexion. Going from plantar flexion to dorsiflexion causes an eccentric load on the posterior tibialis muscle which could cause an avulsion. I would want further views taken to properly assess the medial and plantar surfaces correctly.
ReplyDeleteRegarding the S: Soft tissues - There does not seem to be any severe swelling or edema in the foot, or other foreign bodies present in the soft tissue. This may be more evident however in a different view.
ReplyDeleteI will have to disagree with Megan about swelling. In comparison to other x-rays, there appears to be some moderate edema medially. This could be due to an eversion sprain landing after jumping off the curb. Which would also fit in line with her medial foot pain.
ReplyDeleteIn regards to the "C" of our ABCs, the patient's subchondral bone appears smooth at all joint spaces readily observed, indicating an absence of degenerative joint disease. Her medial foot pain is most likely not a chronic or degenerative issue, and is more appropriately attributed to her recent mechanism of injury.
ReplyDeleteThis is definitely an image that needs another view. There are several areas that I would like another view of including many of the areas that my colleagues have already pointed out such as the first metatarsal alignment. While this is more than likely not the injury that occurred due to the subjective history, an area that can be examined clearly with this view is that of the MTP/IP joint spaces. There could be signs of degenerative changes in the future due to the repetitive nature of running. In this particular image I do not see anything that would indicate any degenerative changes, and the MTP/IP joint spaces appear normal on all toes.
ReplyDeleteUsing this anteroposterior image of the foot you can visualize the transverse tarsal joint, or Chopart’s joint. This joint consists of both the talonavicular and calcaneocuboid joints. It separates the hindfoot (talus and calcaneus) from the midfoot (navicular, cuboid, and three cuneiforms). Based on other google images in this view it appears that the transverse tarsal joint is more pronounced in this image. This could be normal for this patient though. This image could be compared with the same radiographic view of the patient’s other foot to determine the patient’s “normal”.
ReplyDeleteThe only thing I can see that could be wrong in this image is some possible malalignment at the 1st met, as well as a possible fracture of the medial sesamoid bone (there seems to be a line running through it). Other than that, I don't see any change in contrast at any of the joints to indicate degeneration. In this case, a comparative radiograph of the other foot could help determine whether this "malalignment" is in fact a true malalignment, or if that is just the patient's foot.
ReplyDeleteI agree with my colleagues regarding additional views. I would even be interested in an MRI to check the integrity of the deltoid ligament. After jumping off the curb, if this patient endured an eversion ankle sprain, his deltoid ligament could be compromised, which could be contributing to his medial foot pain. I’d also be interested in the integrity of the medial, dorsal cuneonavicular ligament, connecting the first cuneiform and navicular, and the dorsal tarsometatarsal ligament, connecting the first cuneiform to the first metatarsal. Possible disruption of these ligaments could contribute to the runner’s medial foot pain.
ReplyDeleteI would like to see a medial to lateral view to evaluate the arch of the foot better but with your scenario of the patient complaining of a pop when jumping off a curb and has been continuously training for a marathon I am gonna go out on a limb and say the pop is soft tissue and would be easier to evaluate on another type of radiology. Now in the clinic I would assume further imaging would not be needed secondary to the presentation of the injury. I am going to say it is a partial rupture to the plantar fascia with the pop. My reasoning is since we are looking at a view from the plantar surface, it looks like increased bone formation is taking place around the heel spur, which indicates increased stress to the plantar fascia. Further indicating overuse, leading to its rupture.
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ReplyDeleteThe MOI sounds like a lisfranc injury. If you look at the bony alignment you can see the metatarsals are generally going into slight lateral displacement in relation to the midfoot, it’s probably worse in WB. For example: 1st and 2nd intermetatarsal space should line up with the intertarsal space of the medial and middle cuneiforms.
I agree with others that additional radiographs would be useful to determine the medial and lateral arches. Considering this patient was training for a marathon the subluxation/dislocation of the first metatarsal could be due to an over use injury from having previous flat feet or not wearing proper shoes and the body decided to have its moment of weakness. The alignment and spacing of the rest of the metatarsals 2-5 appear to be normal with normal bone density.
ReplyDeleteAppears that medial sesamoid bone has been fractured in half (which lies within FHB) tendon, hence the reported "pop", and is plausible considering the repetitive microtrauma often associated with marathon training.
ReplyDeleteA: the first metatarsal head appears to be sitting at greater than a 15 deg angle. In order to rule-in or rule-out a lis frank injury a weight bearing radiograph is needed. I definitely agree that there is a fracture of the medial sesamoid bone.
ReplyDeleteI agree with Brandon that I'd like to see a lateral view to better evaluate the arch of the foot, but I can also do that in the clinic. If the patient has pes cavus, the pop could have been a partial rupture of the fascia as the foot went from plantarflexion to foot flat as he/she stepped off the curb. Continuing to run/walk creates additional microtears and continues the pain.
ReplyDeleteAlong with additional views or other diagnostic measures (MRI) that my classmates have already discussed that I would also like to look at, I would also like to do a gait analysis on this patient. As Matt and Nathan discussed, I would also like to look at her static and dynamic alignment to check for any dysfunction. Beside the malalignment of the first metatarsal I believe that this patient has good alignment of the other metatarsals and also by the bone density shown in this radiography, she has strong bones as many runners do.
ReplyDeleteI am interested to know if this is a weight bearing radiograph or not. If it is not, I would be curious so see what the weight bearing radiograph would show? Maybe a possible rupture of the ligaments of the mid-foot and more space between the 1st and 2nd metatarsals, as seen in Lisfranc injuries? Either way I feel as though additional imaging is needed.
ReplyDeleteLike most of my classmates ahead of me, I agree that the first intermetatarsal angle is greater than it should be. Anything above 9 degrees should be noted. Also addressing alignment, the lateral sesamoid bone seems to be more visible than in normal AP views. I thought maybe it was an oblique view but the tib/fib is vertical. I would expect to see some more superimposition from the first metatarsal over the lateral sesamoid in this view. Lastly, on occasion the medial sesamoid can actually be a bifurcated sesamoid bone meaning that this "fracture line" could in fact be normal. Tenderness to palpation may clue you in on if the pop was a fracture or soft tissue injury.
ReplyDelete-Cody Glick
I would point out the overall lack of joint space/inability to clearly define the 2nd and 3rd cuneiforms. Based on other similar radiographs, I would expect more definite joint lines in this area. While the malalignments above may be a cause of this, I believe its also important to determine if there is bony pathology at this area as well.
ReplyDeleteThe first thing I noticed (A) was the lack of ability to distinguish the all the tarsal bones. The navicular is quite clear but the 1st, 2nd, and 3rd, cuniforms (particularly the 2nd and 3rd) seem to have very little definition and poor joint spacing. The cuboid looks normal as far as alignment with the 4th and 5th metatarsals, but it almost seems as though there could be a possible fracture, dislocation or AVN of the cuneiforms.
ReplyDeleteWhen pointing out areas to rule in/out differential diagnoses, I noticed the joint surfaces - especially of the metatarsophalangeal joints - are well formed. (I originally thought this radiograph depicted a Lis Franc fracture - from a fall off a horse with the foot left in the stirrup.) However, the rounded joint surfaces tell me that there is no joint degeneration from Rheumatoid Arthritis. If I had seen degeneration/erosion of joint surfaces and/or subluxation-specifically at the first metatarsalphalangeal joint with visible hallux valgus-and the patient did have known RA, I would really restrict WB at that joint and look into a metatarsal bar orthotic.
DeleteIn addition to my previous comments, another differential diagnoses to rule in/out pathology that has not been discussed is nerve impingement! In this patient's case, the medial plantar nerve (which comes from the tibial nerve) - serves the great toe muscles. It could have been impinged with a jump off a curb. Gait training, as Whitney said, would also help the therapist key into the specific location of the pain. If it was nerve entrapment, manual therapy (i.e. joint distraction or STM) could be applied and then gait analysis re-performed to see if the nerve had been released.
DeleteOnce again you guys hit on a bunch of great points. I realize it is not really fair only giving you a small detail of history and only one view! However you came up with some really great points. A lot of you pointed out things that were obviously normal.
ReplyDeleteSome of you noticed a few things additionally that I did but even a few I did not. for example the metatarsal angle, questionable bone spurs, soft tissues, etc..
the actual pathology from this radiograph is the medial sesamoid fracture. Cody was correct in his post that this could be an actual congenital bifurcated sesamoid bone. The pain was very localized to the sesamoids but also into the medial portion of the plantar fascia. Weight bearing and any training and AROM and PROM were painful.
Great work on closely reviewing these images the last several weeks.