Foot Pain & Posterior Tibial Tendon Rupture

Never ignore foot pain. A recent case of tibialis posterior tendon rupture is a case in point.

A 76 year old lady was brought to me by her daughter because she could barely walk and was in constant pain. She had been prescribed anti-inflammatories and sleeping tablets for ‘the arthritis.’

At her only previous visit to me in 2003, I had diagnosd the potential for flat foot related problems and made orthotics. The lady never kept any follow up appointments.

This time, the lady described her symptoms as “the left foot is giving me hell. Over the past year, it’s been getting gradually worse and now I can’t wear my shoes.”

When I asked about the previous treatment, she informed me that she gave up with orthotics because they didn’t fit easily into her shoes.

When I examined the foot, it was completely flat and rolled over and the arch was non-existent. The lady was unable to stand for more than a few seconds and she couldn’t manage more than two steps across the room. In addition she was unable to raise up onto tiptoe.

As I traced a path along the inside of the foot up behind her ankle to the lower part of her calf she experienced significant pain. This is the path of the Posterior Tibial Tendon, the main tendon to help form and hold the arch of the foot.

Posterior Tibial Tendon

I immediately sent the lady for X-rays and an Ultrasound scan.  The scan revealed a rupture of the Posterior Tibial Tendon.

Referral for surgery has been completed and now we wait for the outcome, except that she has developed a problem with her eyes that needs treating before any surgery can take place.

The moral of this story? Follow up is vital from both sides of the medical equation. Ignoring foot pain can have serious consequences, so managing it is a team effort.

READ THE FULL CASE HISTORY IN [Case Histories->]

A Sports Injury or Child Abuse?

How much sport is enough for a child? When does too much sport become abuse? Is an over-use injury at a young age, in the pursuit of excellence worth the possible long-term consequences? Consider this:

Last week, an 8 year old boy, barely able to walk, was brought to see me by his mother. He had a severe limp, walking with his foot out and his ankle stiff, to reduce the pain. Three days previously he had spent nearly 5 hours doing athletics at school. His mother told me that the initial pain began more than 6 months ago, after he had played a lot of rugby.

The school under 8 team had been very successful, winning their area age group, so had a long season. Then he moved up an age group to under 9 which extended the season further. Nevertheless he continued with all sports, despite the pain and the fact that he was not running as fast as before. A compounding factor is that athletics and rugby are both done barefoot.

The timetable of sports reads like that of a professional adult, with daily practice depending on the sport and season, with inevitable overlap; plus the fact that the school plays some sports out of season as well.

• Athletics: 1 hour a day, x 5 days, plus meetings
• Cricket: 1 & half hours a day x 5 days, plus club games on Saturdays for a university club junior side
• Rugby: 1 hour a day x 5 days, plus matches

The boy is obviously very good at his sports and according to his mother is always active at home whilst playing. However, this timetable with an injury would cripple most adults.

So what’s the point? How far must we/should we push or allow our children in pursuit of sporting excellence? We try to teach balance in most aspects of life, sleep, study, money etc., but when it comes to sport we seem to make up the rules as we go along.

After requesting X-rays of both feet and discussing them and my diagnosis with two different medical colleagues, it was agreed that the cause of the pain is damage to the growing part of the back of the heel bone, where the Achilles tendon inserts. Clinically called a Traction Apophysitis.

The initial treatment is rest and avoiding any vigorous activity that causes the Achilles tendon to pull on the heel bone. Raising the heel or possibly orthotics may help.

So ask yourself the question – is this youngster suffering an over-use injury or child abuse or both?

A full Case History will be posted during this week.

Sesamoid Fracture – A Holiday Injury

Best wishes for 2009. The first holiday injury came this week. Another sesamoid fracture . A  38 year old male patient returned to the practice for follow up to a visit in December, due to have impressions made for new orthotics.

He told me that on Christmas Eve he had slipped and fallen into a swimming pool with his  leg fully extended – ‘straight out in front and under me’. The leg had hit the bottom of the pool with the ball of his foot, jarring it severely.

Over the next few days he experienced varying degrees of severe pain, best relieved with wearing thicker soled shoes. However, with the weight off the foot there was a constant throbbing.

Remembering the young lady I wrote about about towards the end of last year, I sent for X-rays. Result a fracture shows clearly in one of the sesamoids.

Treatment? Take it easy. No excessive activity – but cycling in the gym is OK. Thick and soft soled shoes – probably sneakers. Be patient!

Sesamoid fractures should always be suspected with a history of sudden stamping under the foot. They usually heal well, but may take time.

Sesamoid Fracture – an interesting case – treatment

The case of the sesamoid fracture that I referred to the other day, has had an interesting development. You will have read that we ended up using an Aircast below knee walker. Unfortunately this was only successful for about one day. By the end of the day the pain was increasing.

I advised my patient to get advice from an orthopaedic surgeon who I know. The advice was really simple! Wear thick-soled soft trainers and take pain-killers until it is better. (Obviously only take the pain-killers as often as really necessary). This will allow normal movement – remember this condition is not treated by immobilisation in a cast – but not over use.

So what’s the lesson here? Simple treatments are often the most effective. Never ignore foot pain in the ball of your foot. Have it accurately diagnosed – it might be a sesamoid fracture.

An interesting case: Sesamoid Fracture

I diagnosed a sesamoid fracture in a young woman this week. The presenting complaint, on Wednesday, was of “pain in the ball of the foot under the big toe joint for nearly 9 months, but 3 days ago (Sunday), whilst doing a long day shift the pain got really bad and only stops when I take weight off the foot.”

The ball of the foot was noticeably swollen, but not inflamed. However, when I applied light finger pressure to the area the pain increased and was particularly bad at one spot. The lady has a high-arched foot (pes cavus), but it is flexible not rigid. She is not overweight, but is very active everyday of the week -including some weekends – working long hours. She told me that she usually wears a low heeled shoe or sandal, but it had become impossible to wear slip-ons or ‘push-ins’ because of the pain. The only relief was to wear trainers with a thick sole. When the weight was removed by sitting or resting in bed there was no pain.

By applying a protective pad to the sole and the arch, with a cut-out around the painful area, painfree walking was possible. An X-ray was requested; both feet for reasons that I’ll explain shortly and a follow-up appointment was arranged for Thursday morning.

We met on Thursday and the X-ray showed a clear break in the lateral sesamoid. The pain was also worse because the padding had slipped backwards and out of position. By repositioning the pad, the pain was relieved again. I instructed her to use trainers as often as possible and suggested that she do the replacement padding herself. In addition I arranged for her to be fitted with an Aircast below knee walker, which she could borrow from the practice on Friday after work.

The treatment for this condition is mainly patience and removal of pressure. Which is why I decided on the Aircast. When we fitted the Aircast walking was immediately painfree. Now we both have to wait for the bone to fuse as one or even two bones.

There are two sesamoids under the ball of each foot. They allow a particular muscle to pull the foot down during standing and walking; they also survive a lifetime of bending at the ball (the first metatarso-phalangeal joint). In some people, one of the sesamoids is naturally bifurcate and can look as if it is fractured – called a normal variant -that is why I asked for both feet to be X-rayed. This fracture may heal in two parts also, which won’t be a problem.

Pain in this part of the foot is quite common. It is caused by excessive amount of shearing, compression or tensile stress over the joint. It can be associated with sports like golf and tennis. Starting running or training and doing too much or running in old trainers. Wearing old worn shoes, where the inner sole gets a deep imprint. It can be associated with rheumatoid athritis, or even standing on a ladder for long periods, when you aren’t used to doing that! Nearly always it affects people with a high arched foot who have over-used their feet.

Initially the bone and the joint under them become inflamed and that is called sesamoiditis. Ignore this and a sesamoid fracture may result.