The majority of patient encounters to the podiatrist are secondary to pain in the foot and/or ankle. If we draw an imaginary line bisecting the lower leg and extending distally to the third toe, pain in the medial aspect of the foot and ankle is typically straightforward.
A predominance of medial heel pain is usually plantar fasciitis. When it comes to medial arch symptoms such as posterior tibial tendinitis, we frequently see these symptoms with the pes valgus foot type. Less frequently, one may see tarsal tunnel syndrome. First ray pain syndromes are typically associated with hallux valgus or hallux limitus. In regard to degenerative joint disease, we frequently see this in the medial column and the second tarsometatarsal joint. One can typically evaluate and diagnose these disorders without much ambiguity.
It has been my experience that pain in the lateral foot and ankle presents challenges in clinical diagnosis. If one draws a silver dollar-sized circle on the lateral ankle in the region of the lateral malleolus, one can appreciate the significant number of structures that can be pathologic and are in close proximity to one another. Moreover, one can appreciate that there is overlap in potentially pathologic structures when doing a palpatory exam. These structures include the fibula, lateral ankle gutter, lateral ankle ligaments, the sinus tarsi and the peroneal tendons. An area the size of your thumb can encompass many of these structures.
Distally in the foot, pain seems to affect the lateral two metatarsals and the region of the styloid process of the 5th metatarsal. When evaluating pain juxtaposed to the fifth metatarsal base, one is usually dealing with peroneal tendon pathology. If the pain is directly on the styloid process, this is usually what I term “an insertional peroneus brevis tendinitis.”
The other common area of pain will be in the cubital tunnel, which is where the peroneus longus tendon will traverse under the cuboid. Oftentimes, an X-ray will reveal an os peroneum. When there is pain with palpation between the cuboid and the fibula, one should be concerned about peroneal tendinosis, especially if there is any edema in the area. Podiatrists may note peroneal tendinitis in the retromalleolar region of the fibula. The syndrome of subluxing peroneal tendons may be in this area as well. The physician may see stenosing peroneal tendinitis inferior to the tip of the lateral malleolus. This is more common in the pes cavus foot type. Pain on the dorsolateral foot overlying the bases of the fourth and fifth metatarsals is a stress syndrome that I term periostitis of the metatarsals.
When a patient presents to the office with lateral ankle and/or hindfoot 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 exam is paramount.
The exam should include careful palpation and range of motion maneuvers, laxity testing of the ankle, manual muscle testing of the peroneals, diagnostic anesthetic injections, X-rays and MRI if necessary. Do not forget to watch your patient walk barefoot. When it comes to MRI, one would generally use this as a confirmatory study as we typically know what is wrong and want to rule out other less common pathologies.
For these clinically challenging cases, I find it particularly helpful to examine patients multiple times. Subsequent exams on a patient with a complicated case make the clinical diagnosis clearer. I always reevaluate a patient after a MRI is done so I can focus on MRI pathology and confirm clinical correlation. We need to remember though that we do not treat X-rays/MRIs. I have found that peroneal pathology such as split tears are very common in older patients but often do not clinically correlate with the patient’s symptoms. Once the physician has arrived at a firm clinical diagnosis, he or she can initiate treatment.
I typically consider surgery for lateral ankle instability with pain, symptomatic osteochondral lesions of the talus, impingement syndromes and tendinosis of the peroneal tendons. Conservative care is usually successful in the treatment of periostitis, stress fractures, acute tendinitis, sinus tarsi syndrome and acute ankle sprains. For orthotic management in the cavus foot type, I will typically try to address the forefoot valgus with a first ray cutout and a dancer’s pad. A valgus wedge on the orthotic device may also be of benefit to reduce lateral foot strain.
When we carefully look at the common links with most of these lateral pain syndromes, we are typically looking at the cavus foot and metatarsus adductus foot types. The notable exception is sinus tarsi syndrome, which is more common with 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 (stress) of the metatarsals and peroneal tendon pathology. Lateral ankle boney impingement is most likely due to repetitive strain and stresses on the lateral ankle joint, and/or acute injuries that result in avulsions, which 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.
I have some final thoughts on the subject of reconstructive surgery. When conservative care is not satisfactory for the patient, one needs to consider surgical intervention. It is important to determine the biomechanical reason for the underlying pathology.
For example, in the case of a rigid pes cavus deformity with the chief complaint/diagnosis of lateral ankle instability and peroneal tendinosis, the repair of the tendon and ligaments may not be prudent in the long run. This is one of those scenarios when a long discussion with your patient is necessary to explain why the problem started and why merely repairing the “defects” may not prevent recurrence.
It may seem aggressive or overkill to the patient to suggest a Dwyer calcaneal osteotomy, dorsiflexory wedge osteotomy (DFWO) of the first metatarsal along with lateral ankle ligament repair for a “weak ankle.” In a nutshell, this is what makes the podiatrist special. We are not only fixing a problem (i.e. torn tendon), but assessing the biomechanics of the lower extremity and incorporating that into the overall treatment plan.