Learning Objectives
- •
Learn the common causes of foot pain.
- •
Develop an understanding of the innervation of the groin and pelvis.
- •
Develop an understanding of the anatomy of the posterior tibial tendons.
- •
Develop an understanding of the causes of posterior tibial tendinitis.
- •
Learn the clinical presentation of posterior tibial tendinitis.
- •
Learn how to use physical examination to identify posterior tibial tendinitis.
- •
Develop an understanding of the treatment options for posterior tibial tendinitis.
- •
Learn the appropriate testing options to help diagnose posterior tibial tendinitis.
- •
Learn to identify red flags in patients who present with foot pain.
- •
Develop an understanding of the role in interventional pain management in the treatment of posterior tibial tendinitis.
Ada Hunt
Ada Hunt is a 31-year-old customer service representative with the chief complaint of, “I pulled something in my foot, so I can’t exercise.” She explained to me, “Doctor, I have to exercise if I’m ever going to lose this weight. And I was doing so well! I’ve already lost 40 pounds. I just have to exercise, or I am dead.” Ada went on to say that since the weather got cold, she had been running on a treadmill rather than outside. The pain came on gradually, but it is so bad that it now hurts to bear any weight on her left foot. “Doctor, I got a new pair of running shoes, but that didn’t help. What am I going to do? I’m really having a hard time getting better in spite of massage, acupuncture, aromatherapy, Motrin, and a lidocaine patch.” She said she took a few pain pills that she had left over from having her wisdom teeth pulled, but they seized up her bowels, so she quit taking them, too.
I asked Ada if she ever had anything like this before, and she shook her head no. She also denied any current urinary or gynecologic symptoms, hematuria, or fever or chills. She also denied a history of previous foot or ankle injuries. Her last menstrual period was about 10 days ago. Ada is using oral contraceptives. I asked what she was currently doing to manage the pain, and she said, “Nothing really works—the Motrin barely takes the edge off.” I asked her to rate her pain on a scale of 1 to 10, with 10 being the worst pain she ever had. She said the pain was a 7 or 8. “Doctor, I have to get back to normal. I have to exercise. The pain is interfering with just about everything. I can’t walk, I can’t run, I can’t do aerobics. I am having a hard time getting around. I just really need to get my life back.”
I asked Ada to point with one finger to show me where it hurt the most. She pointed to the medial longitudinal arch of her foot, and said, “Doc, the pain is right here, right under the bone. It’s really killing me.”
On physical examination, Ada was afebrile. Her respirations were 16. Her pulse was 72 and regular, and her blood pressure was normal at 118/68. Her weight was 276 pounds. Her head, eyes, ears, nose, throat (HEENT) exam was normal, as was her thyroid examination. Her cardiopulmonary examination was negative. Her abdominal examination revealed no abnormal mass or organomegaly, and no groin mass or hernia was identified. There was no costovertebral angle (CVA) tenderness. There was no peripheral edema. Her low back examination was unremarkable. Her lower extremity neurologic examination was completely normal, with no evidence of tarsal tunnel syndrome. There was point tenderness over the medial longitudinal arch on the left. Active resisted inversion of the ankle reproduced the pain, as did passively flexing the left foot. Visual inspection of the arch revealed no ecchymosis or fibromatosis, but swelling and erythema was noted ( Fig. 13.1 ). “Ada, how about walking down the hall for me?” She carefully sat up and slid off the exam table. As she took off down the hall, I immediately noticed that she had an antalgic gait and was avoiding weight bearing on the left foot.
Key Clinical Points—What’s Important and What’s Not
The History
- ■
History of recent onset of left foot pain following jogging on a treadmill
- ■
Difficulty in ambulating because of left foot pain
- ■
Difficulty in carrying out activities of daily living
- ■
Pain is localized to the medial longitudinal arch of the left foot
The Physical Examination
- ■
Patient is afebrile
- ■
Normal visual inspection of the arch of the left foot
- ■
Tenderness to palpation of the medial longitudinal arch of the left foot
- ■
Active resisted inversion of the left ankle elicits pain
- ■
Passive flexion of the left ankle elicits pain
- ■
Patient has cautious gait with guarding of the left foot with weight bearing
- ■
The lower extremity neurologic examination is within normal limits with no evidence of tarsal tunnel syndrome
Other Findings of Note
- ■
Normal blood pressure
- ■
Normal HEENT examination
- ■
Increased body mass index
- ■
Normal cardiopulmonary examination
- ■
Normal abdominal examination
- ■
No peripheral edema
- ■
No groin mass or inguinal hernia
- ■
No CVA tenderness
What Tests Would You Like to Order?
The following tests were ordered:
- ■
X-ray of the left foot
- ■
Ultrasound of the foot with special attention to the posterior tibial tendon
- ■
Magnetic resonance imaging (MRI) of the pelvis with special attention to the posterior tibial tendon
Test Results
Plain radiograph of the left foot revealed calcific tendinitis of the posterior tibial tendon with no evidence of fracture or other bony abnormality ( Fig. 13.2 ).
Related posts:
Shirley McCain: A 62-Year-Old Dance Instructor With Right Foot Pain
Ryan Rostov: A 52-Year-Old Male With Right Ankle Pain
DeShawn Freely: A 29-Year-Old Basketball Player With the Feeling He Had Been Shot in the Ankle
Anna Coyle: A 24-Year-Old Dental Hygienist With Severe Medial Ankle Pain
Paul Reckinger: A 32-Year-Old Real Estate Agent With Severe Right Ankle Pain With an Associated Catching Sensation
Sarah Davidow: A 64-Year-Old Homemaker With Foot Pain
Full access? Get Clinical Tree
