Peter
Here's my thoughts after reading your posting...

Was any of the onset acute or insidious? My first impression is get him
off the tib post tendon asap.  Has he had any scans on the tendon itself
If there is a tear or avulsion at its insertion this would need rest
before any further treatment is considered. I would certainly lay off
the steroid injections and even the NSAIDS if they are helping him to
walk through the pain.  It's a tricky one as you want to break the
inflammatory cycle so I understand wanting to keep on with the NSAIDs
since they appear to help.

What about his back?  Has he had any problems in the lumbar region?  It
sounds like he may have multiple problems which is confusing the
diagnosis. You need to define the groin pain - is it neural or
physicial such as a bursitis?  Get him to bring his knee to his chest
when supine and see if that elicits pain - it could be the
communicating bursa from the hip capsule.  What's his hip ROM like?
and quality of motion too?  Any possibility of OA here?

Also you may wish to check his ability to control transverse plane
rotation at his trunk and hip level - get a physio to help you with
this one if you don't know how to check for rigidity across segments
and ability to dissociate rotation.  If he is unable to control
rotation here his weight will drive a transverse plane moment into the
foot when it is planted which could stress out the MTJ and cause strain
in Tib post.

If he has a trunk and hip problem then the foot may well be taking the
brunt of the problem.  A key one to check is the posterior belly of
glut medius - does he have problems separating his knees while keeping
his ankles together when lying on his side with his knees and hips
flexed to about 45 deg (crook line)?

Well I hope you see some improvement in him soon

Emma Cowley

On Wed, 12 Mar 2003 08:22:06 -0000 "peter.barrow1"
<[log in to unmask]> wrote:

> Dear All,
>
> I would be grateful for any constructive advices re:
>
> Male aged 45; 17 stone (238 lbs); pain 10 years; long history of hospital podiatric consultations, physio and orthopaedic treatment - all so far unsuccessful it seems. Recent X ray is NAD O/A, it seems. Pod t/t has ben orthoses without heel-raises; orthop t/t has included steroid inj Rx diclofenac has been best t/t to date, plus NSAID topicals. Left foot esp affected, but "right is catching up". Nature of pain is mainly on left side - left groin pain is described, left medial arch feels like it;s on fire; foot constantly swollen; describes left shin locks up if goes for a walk. "My toes go numb". Occupation: self-employed long-hours retail, often carrying heavy loads. Orthopod has said cannot help.
>
> On examination the region of left narvicular is v. tender; left medial longit arch is low and much lower than right; trigger points +++ in left tib post tendon and muscle; foot oedematous without other apparent cause than lack of ankle pumping. Ankle ROM is 110 (ie not even reaching 90 degrees). Helbing's sign v marked; left f/f supinatus v marked. Gait style is pronounced limp. Pain scores 8.5 bad day reported; 3.5 good day.
>
> Treatment since 3rd Feb 03 has been dye strapping, additiion of half inch to heels of shoes, UCBL flanged orthoses to decrease MTJ comp pronation with 5mm heel raises.
>
> Patient feels too pitched forward now, top-heavy and unstable (he likens it to putting big wheels on a 4x4 vehicle and that the type of rubber used by he shoe-repairer is not giving him the same grip as the sole) and that "the treatment is never going to work" The left arch is collapsing into the arch of the orthosis (left) and a Poron U pad has helped.
>
> Patient tells me he has built up gradually with heels/devices but it's still made no difference. Acupuncture to ah shi left tib post, gastrocs, ant compartment and ankle has made no diffeence.
>
> This guy is on the road to complete collapse of the left MTJ.
>
> Any suggestions (no in-shoe pressure equip available) appreciated.
>
> Peter Barrow
> BSc, MChS, LLB
> Clifton Road Poditry Practice
> 71-73 Clifton Road
> Rugby
> UK
>
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Emma Cowley
Lecturer/Researcher
Staffordshire University
School of Health
Inter-Professional Education
Blackheath Lane
Stafford
ST18 0AD
tel: 01785 353690/07941 056565

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