lateral pain syndromes of the foot and ankle - The Podiatry Institute

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$closure of deep fascia in ankle fracture surgery - The Podiatry Institute$

16 CHAPTER 3 IMPINGEMENT OF THE TALOFIBULAR JOINT Another source of lateral ankle pain may be an impingement between the fibula and talus in the lateral ankle gutter (Figure 5). In this syndrome, pain is usually well defined at the tip of the fibula. A lesion marker at the site of pain may help with radiographic interpretation. If the palpatory examination reveals pain not only on the tip of the malleolus, but also in the gutter and anterolateral ankle joint, then consider an MRI for assessment of an osteochondral lesion (Figure 6). A diagnostic injection of local anesthesia may aid in the diagnosis especially with ruling out other sources of pain. Treatment will usually require surgical intervention, which can be done arthroscopically or through an open approach. Conservative treatments will typically involve biomechanical control with orthotics. PERIOSITIS OF THE METATARSALS Pain in the dorsolateral foot overlying the bases of the fourth and fifth metatarsals is usually a stress syndrome (Figure 7). Patients will complain of a sharp stabbing pain or a dull ache upon activity. Aggravating symptoms include barefoot walking or wearing flimsy shoes. In my practice, I see more of this problem in the summer when people are wearing flip flops and and/or going barefoot around the Figure 5. Radiograph of an ankle illustrating an osseous impingement of the talofibular joint as well as a suspicious looking lateral shoulder of the talus. This patient had chronic lateral ankle pain that upon examination revealed pain in the anterolateral gutter of the ankle and on the inferior aspect of the fibula. house. Treatment involves anti-inflammatory medication, wearing supportive stiff soled shoes, and orthotics. Surgery is usually unnecessary as this problem generally gets better with nonoperative therapies. The notable exception would be the patient that presents with these symptoms and there is an underlying compound deformity of the foot, such as the equinovarus foot, contributing to excessive stress. COMMON DENOMINATOR IN LATERAL PAIN SYNDROMES When we carefully look at the common link with most of these lateral pain syndromes, the cavus foot and metatarsus adductus foot type are typically seen. The notable exception is sinus tarsi syndrome, which is seen more often in the pronated foot type. The high arched foot is vulnerable to lateral ankle injuries especially if there is a forefoot valgus. The metatarsus adductus foot type will be a lateral over loader in gait, which will contribute to periostitis of the metatarsals and peroneal tendon pathology. Lateral ankle bony impingement is most likely a due to repetitive strain and stresses on the lateral ankle joint and/or acute injuries resulting in avulsions that heal causing exostoses. When reviewing cases of Jones fractures and avulsion fractures of the fifth metatarsal, more often than not, these patients have a component of metatarsus adductus (Figures 8 and 9). Figure 6. MRI of the same patient in Figure 5. Note the talofibular impingement and osteochondral lesion of the lateral shoulder of the talus.
Figure 7. Radiographs of a patient who underwent cavus foot reconstructive surgery. Note that there is cortical hypertrophy of the fourth and fifth metatarsals. This is consistent with lateral overloading of the foot that can cause dorsolateral foot pain. Figure 9. Radiograph of a Jones fracture. Note the underlying metatarsus adductus. When a patient presents to the office with lateral ankle and/or hind foot complaints, diagnosis is more difficult than medial complaints due to the proximity of anatomic structures of joints, ligaments, and tendons. Careful interpretation of symptoms including pain and instability in conjunction with a thorough clinical examination is paramount. The examination should include careful palpatory and range of motion maneuvers, laxity testing of the ankle, manual muscle testing of the peroneals, CHAPTER 3 17 Figure 8. Radiograph of an avulsion fracture of the fifth metatarsal. Note the underlying metatarsus adductus. Figure 10. MRI illustrating a stress fracture of the cuboid. This is a less common source lateral foot pain. diagnostic anesthetic injections, radiographs and MRI if necessary. MRI is generally used as a confirmatory study as we typically know what is wrong and want to rule out other less common pathologies (Figure 10). For these clinically challenging cases, I find it particularly helpful to examine patients multiple times. Subsequent examinations on a patient with a complicated case make the clinical diagnosis clearer. I always reevaluate a patient after an MRI so that I can focus on MRI
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