Using a device  we built, the mean force to supinate the rearfoot is around 150-160 newtons. In those with peroneal tendonitis, its only arond 80 Newtons --> peroneals have to work harder --> lateral wedge to treat.
 
CP

________________________________

From: A group for the academic discussion of current issues in podiatry on behalf of Javier Ordoyo
Sent: Wed 25/08/2004 4:58 AM
To: [log in to unmask]
Subject: Peroneus Brevis tenosynovitis



 

Dear all,

 

I would like to share a clinical case that keep me puzzled. The patient is a 15 year old female semi professional ballet dancer, she used to train 3-4 hours a day, 8 months ago (after going to walk to the beach) she felt a terrible pain at the base from the fifth metatarsal at right foot. During the next days, the pain increased affecting the lateral aspect from the leg.

 

She went to an orthopaedic consultant who asked for radiology (negative results) and magnetic resonance (minor edema at STJ). He sent her for rehab and referred her to a podiatrist for evaluating orthotic treatment. The podiatrist considered that there was no reason for orthotic treatment because the foot was "normal" and no biomechanic condition was observed. Thus, she expent three weeks of rehab with a skilled PT who also was a dancer. No improvement was achieved, then the orthopaedic consultant referred her to an orthopaedic surgeon specialized on foot surgery, in case surgery would need it.

 

She went to the orthopaedic surgeon, who asked for new magnetic resonance (minor edema at STJ again and a little accessory bone at calcaneo-cuboid joint is described). He decided to perform a MIS surgery for relieve compression at the STJ joint. After the surgery, the patient felt a weeks of painless, but after one month the pain returned again but far worse that before the surgery.

 

She went again for rehab, and the PT referred her to a new podiatrist for orthotic treatment. This podiatrist decided to prescribe foot orthoses for pes valgus and leg external rotation. Again, she felt painless during three weeks wearing the orthoses but after this period the pain returned again as worse as before.

 

Well, and after 8 months she has come to my office. She is wearing now an ankle brace, she has left ballet; but she can not walk, run or doing any weight-bearing activity without pain. She refers some relieve when she is wearing the ankle brace but nothing more.

 

At palpation, she refers a terrible pain at base from the fifth metatarsal and at the distal segment from the lateral leg (origin and insertion from peroneus brevis), also and accessory bone is visible at calcaneo-cuboid joint). During walking, the medial arch from the right foot collapse at loading response phase and ankle instability is easily observed. Also, the right leg is at external rotation at contact heel phase.

 

My first diagnosis has been peroneus brevis tenosynovitis due to STJ pronation disequilibrium. At the last magnetic resonance (3 weeks ago), a signal in the fibres from peroneus brevis compatible with partial longitudinal break was observed.

 

But, my questions are:

 

1.      Does anyone have other ideas? 
2.      How can you manage this patient when almost all treatments have been done without much success? 

 

Regards,

 

Javier Ordoyo

Private Practice

Barcelona -Spain- 

 

 

   

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