Peroneal tendonitis is not a common problem that occurs on the lateral side of the ankle, usually starting with an ache above and/or below the lateral malleolus. It seems to occur in those with low supination resistance. This mean that the peroneal muscles are having to work much harder to resist that force that is easy to supinated. Combine that with some sports activity, then there is a high risk for peroneal tendonitis. This means that the treatment for peroneal tendonitis is to use some sort of lateral foot wedging to reduce the force that the peroneal muscle need to contract. There is a paranoia among some clinicians about the lateral wedging pronating the foot more and creating more problems, but those that use this do not see this problem. Peroneal tendon problems can be difficult to manage.
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Sinus tarsi syndrome can be a tricky problem. It usually presents with pain on the outside of the ankle joint. Sinus tarsi syndrome can be due to two quite distinct causes. It can follow a lateral ankle sprain in which the structures in the sinus tarsi are damaged as part of the ankle sprain. This usually presents as a chronic problem following the ankle sprain. The other cause of an sinus tarsi syndrome is a chronic pronated subtalar joint in which the joint functions at its end range of motion. If the forces driving the joint into its pronated position are great enough, sinus tarsi syndrome can result. Treatment of the post-ankle sprain sinus tarsi syndrome is best managed with physical therapy and mobilisation. The chronic sinus tarsi syndrome from a pronated foot is best managed with a foot orthotics. In either case, if they are resistant to treatment, they can be helped with a sinus tarsi injection.
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Chilblains are a common skin condition in the colder climates that occur on the toes. Chilblains, however, are NOT caused by the cold and they are NOT caused by poor circulation. The cause of a chilblain is a too rapid warming of the foot or toe after it has got cold and the circulation not responding quick enough to that warming. It is not the cold that is a probem in chilblains, it is the rewarming that the problem. It’s not the quantity of circulation that is the problem, it how the circulation responds. The best way to prevent chilblains is not get cold in the first place and if you do, make sure any warming of the foot happens very slowly.
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Severs disease is a relatively common problem in youngsters aged 10-15 years. The pain is felt at the back and sides of the heel. This is where there is a thin cartilage growth plate that allows the heel bone to grow. This growth plate merges with bone by age 15, so it’s no longer a problem after that. Severs Disease tends to be much more common in those who are more active, particularly on the harder sports fields. The Achilles tendon also attaches to the back of this growth area, so that increases the pull on it. It has been suggested that severs disease be thought of as a stress fracture and should be treated like a stress fracture (but there is no evidence if it is or not actually a stress fracture). The best initial treatment of severs disease is a reduction in sports activity to tolerable levels and the use of a cushioned heel raise. Sometime foot orthotics are used to correct foot alignment and calf muscle stretches are also considered important. Ice is often helpful when the severs disease is painful.
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- what are the best golf shoes for someone who has severs disease in the heel
Plantar fasciitis has got to be by far the most common musculoskeletal problems of the foot. It also gets commonly mislabelled as a heel spur which are not a problem. The problem is the plantar fascia inserting into the heel bone. The key symptom of plantar fasciitis is plantar heel pain after arising from rest, especially getting out of bed in the morning. This pain after rest for the first few steps is almost diagnostic of the problem. Plantar fasciitis is due to too much load in the long ligaments that supports the arch of the foot (the plantar fascia). This load can come from higher levels of activity, being overweight and having tight alf muscles. As this is a load issue, then the only proper way to manage plantar fasciitis over the long term is to reduce the load in the plantar fascia. This can only be done with low dye strapping and certain foot orthotic design parameters. All other treatment modalities (eg shockwave, ultrasound, accupuncture, etc) are really aimed at helping the tissue heal that are damaged as part of the plantar fasciitis. They are not going to be very helpful if the load going through the plantar fascia is not addressed.
Kohler’s disease is a problem of the tarsal navicular bone in young children. Something goes wrong with the blood supply to the bone and it becomes avascular and the bone does not develop properly. The child can usually have a limp and there is local tenderness over the bone. Depending on how severe it is, the best treatment will be a plaster cast or other splinting or some type of foot orthotic to support the foot.
Most of the time gout affects the first metatarsophalangeal joint (big toe) joint of the foot and the diagnosis is usually obvious. However, gout can affect any joint. As its not common in these other joints it may take some time to reach the diagnosis. Gout can also affect the heel, but affecting the subtalar joint and also the urate crystals can deposit around the plantar heel and mimic plantar fasciitis. Suspected gout in the heel can be treated initially with colchicine to help with the diagnosis.
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Masai Barefoot Technology or MBT shoes are shoes with a rocker bottom that is supposed to simulate the natural gait of walking barefoot. The company make some extraordinary claims for the efficacy of these shoes. There is some limited evidence to support the claims, but not enough to support the wide range of claims made. Do MBT shoes work? There is probably enough evidence and theory to suggest that they will probably be helpful in some sub-populations and not in others. What is lacking is some good research to guide the decision making.
Cracked heels are common in those who are overweight, have dry skin, have callused skin around the edge of the heels and wear open heel shoes. When we stand or walk, the fat pad under the heel expands outwards. If the skin around the edges of the heel are not supple, then the skin is likely to crack. Cracked heels are best prevented with applying emollients to the skin, wearing shoes or a heel cup to keep the fat pad under the heel from expanding. Any thick skin is best removed by a Podiatrist on a regular basis. Once a cracked heel does occur, it is best to see a podiatrist as they are hard to heel. They are hard to heel as continuing to walk on them opens the crack with each step. Heel fissures are best treated with removal of the hard skin and strapping to hold the edges together.
Cuboid syndrome is a common cause of pain on the lateral side of the foot. If you think about the anatomy, then no wonder it is common. The cuboid is a small bone with three joints – the calcaneocuboid joint; the joint between the fifth metatarsal and cuboid; and the joint between the lateral cuneiform and the cuboid. Now think about the role of the cuboid – its role is to act as the pulley for the tendon of peroneus longus. Imagine the kinds of forces that go through the cuboid when the peroneus longus muscle contracts. Imagine the strain on those three joints as this happens. No wonder if these joints are not stable, that cuboid syndrome can develop. Cuboid manipulation is often needed to help “put the subluxed cuboid” back.
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- pain the in the lateral cuneiform and cuboid
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Everyone probably has a leg length difference, but in most it is probably clinically not detectable and unimportant. A few people have a large difference in leg length, that causes compensation and clinical symptoms. It has been shown that leg length differences do affect quality of life. Where a lot of debate arises is what is a clinically significant difference and when should it be treated. Just because someone has symptoms and a leg length difference does not mean that the difference caused the symptoms. Some have tried to argue that a few millimeters is clinically significant; others argue that a lot more is needed before it should be treated. There is no evidence and each person will need to be treated on their merits.
Within podiatry it has been suggested that the longer leg will cause a foot to pronate, but this foot pronation for a leg length difference as been dismissed as a myth.
Medial Tibial Stress Syndrome (MTSS) is an overuse injury of the leg that is reasonably common. The pain is felt along the inside of the tibial or shin bone. The most common assumed causes are poor foot biomechanics and training errors (such as too much training too soon). The role of foot biomechanics and foot orthotics is somewhat controversial as the clinical experience with them is that they are effective, but the rationale to explain how they work is not clear. Recent suggestions on medial tibial stress syndrome is that it is due to increased bending moments in the tibia, which could go some way to explaining how foot orthotics may work in medial tibial stress syndrome.
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- medial tibial stress syndrome
Functional hallux limitus is defined as a limitation in the range of motion of the first metatarsophlangeal joint when functioning (ie walking). It is not present on a normal weightbearing examination, where there is a full range of motion at the joint. The controversy surrounding functional hallux limitus is, is it a primary or a secondary problem? Does the functional hallux limitus occur first and cause the midfoot to collapse or does the midfoot collapse and this causes the functional hallux limitus? Both theories are rational and depending on your world view (ie root theory vs sagittal plane theory) as to which one you believe in. Unfortunately, the research is not much help either in deciding the primary or secondary nature of functional hallux limitus.
On a different note there has been an attempt to reconceptualise functional hallux limitus as one end of a continuum and consider functional hallux limitus, structural hallux limitus, hallux rigidus, and the various windlass dysfunction all as a problem of the shape of the dorsiflexion stiffness curve of the first metatarsophalangeal joint.
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A Jones fracture is a fracture to the base of the fifth metatarsal bone at metaphyseal-diaphyseal junction. A Jones fracture is located within 1.5 cm distal to tuberosity of 5th metatarsal base and should not be confused with the more common avulsion fracture of the styloid process of the fifth metatarsal. It was first described in 1902 by Sir Robert Jones in a paper called “Fractures of the Base of the First Metatarsal Bone by Indirect Violence.” He had the fracture himself.
If the fracture is non-placed and is an initial acute presentation, cast immobilization for 6 weeks is the usual treatment. If it is displaced or is a chronic presentation surgical management is normally preferred.
Growing pains in children are common, and the term is often inappropriately used as diagnosis for any unexplained musculoskeletal leg pain in children. The true syndrome of growing pains that the diagnosis should be reserved for:
- it usually peaks around ages 4 to 5, but can occur up to age 12.
- it generally occurs just behind the knee at night and is usually relieved by rubbing.
- growing pains do not occur during the day.
- growing pains occur in the muscle and not the joints.
The cause of pain is not known or is poorly understood, but is unlikely to be solely related to ‘growth’. The differential diagnosis of growing pains is important as it can include bone tumours and problems of the hip that refer pain to the knee area. While these problems are not very common, they do need to be ruled out.
Many concerned parents have asked about growing pains in children at the Foot Health Forum and Podiatry Arena has several threads on growing pains in children.
