I recently had a 32 year old female arrive to my clinic under Direct Access (without a physician referral) with right foot pain.  The pain started about 3-4 weeks ago from insidious onset and seeking my assistance as the pain is not improving.  The location of the symptoms are circled below:

Right Foot Pain

Her main deficits are pain with weight-bearing, especially walking.  She has not been able to work-out (a recreational walker/runner but not avid) and difficulty negotiating the classroom as she is a school teacher.  She has tried wearing more tennis shoes (vs flip-flops) with some improvement but not enough where she thinks it will get better on her own.  She has not tried any exercises, self-modalities or self-medication from OTC drugs.  Medical history is unremarkable besides a 5th ray fracture 5 to 6 yrs ago treated conservatively through wearing a boot but no physical therapy.  She fully recovered.

Clinical findings are below:

1. Patient has an abnormal gait pattern with altered weight acceptance in stance phase on right side, especially mid to terminal stance.  She has most pain with toe-off and really avoids this resulting in early heel rise.  Symptoms come on immediately and not necessarily get any better as she walks more (she also claims to walk differently now to avoid the pain).

2. Patient has full, pain-free ROM of the ankle and foot.

3. Manual muscle testing unremarkable.

4. Reproduction of concordant symptoms with mild to moderate palpation at location circled in picture above.

What do you think is the diagnosis?  How would you go about treating this individual? 

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6 comments

  1. I’d say a Morton’s neuroma. I know they usually occur between the 2nd and 3rd digits but they can go anywhere. I’d start by making her a foam donut pad so I could unload the painful area. I’d then look up the chain to see why she is placing more weight on that side. Maybe a leg length issue? So many things to consider here. Maybe tib anterior is under active forcing early push off leading to increased pressure on the ball of the foot?

    Looking forward to part 2!

    1. Hey Jesse, thanks for the reply. You are right on…no tricks with this case! I definitely had your treatment of padding in mind but you will see what I did in next post. I believe it is coming out Wednesday.

  2. Sounds like a neuroma. Epidemiological studies would tend to suggest that the most common site for neuroma development is between the 3rd and 4th ray or 4th and 5th ray, likely irrotated by ligamentous compression on the neural structures during toe off. I would try to confirm with special test such as the metatarsal squeeze test. The diagnosis also makes sense due to the fact that she has a history of flip flop use, which are not the most supportive shoe. I would suggest tactics to reduce inflammation such as modalities, soft tissue, cryotherapy, in addition to oral anti-inflammatories. Topical anti-inflammatory was such as traumeel gel may help. If not, consultation with the medical team for possible corticosteroid injection woul be the next step for me. Good case!

    1. Hey Steve, thanks for your very detailed comment. I am definitely on board with you. I actually forgot to mention that the Morton’s test was positive! Thanks for bringing that back up to remind me.

      I had originally brought out a special test book by Cook to show my intern the data on the test (sensitivity, specificity, etc) and actually he has no studies! If you tweet, I’m getting ready to put a picture of the page in the book. Check it out @intouchpt

      1. Hey Harrison,

        The other test that came to mind to me that we learned in PT school was Gauthier’s test. It’s where you isolate a single interdigital nerve by compression and then shearing of the METs past one another for a period of 30 seconds to try and provoke symptoms. I will look up if I can find some sensitivity/specificity of the Morton’s test for you. I googled around a bit and came across a really good patient education site that actually explains things really well: http://foothealth.about.com/od/neuroma/a/MortonsNeuroma.htm.
        Do you know of any tape jobs with athletic tape like they describe in the treatment options section? I don’t, but I was thinking maybe an offloading technique with kinesiotape to help reduce stress during toe off phase along with a donut cutout to further offload?
        As for the case, I think you laid it out pretty well and you were probably already on a hunch that it was a neuroma before you even got to your special tests. That being said, probably a compilation of special tests to confirm it would be best for us to get to as PTs (to be in accordance with best practice) such as: pain with palpation over the affected inter-tarsal space, positive Morton’s test, positive Mulder’s click, positive Gauthier’s test, and pain with ambulation and/or single leg heel raise (because the dorsiflexion of the toes aggravates the inflammed nerve as you described with aggravating toe off phase in your case). Maybe a future CPR to be done.. Perhaps you should write up a case report on this, I think it would be good paper for JOSPT.
        By the way, I was looking up special tests and came across this paper on a interdigital nerve stretch test: http://www.sciencedirect.com/science/article/pii/S1268773106000385. Perhaps they’re onto something here – I can’t access the article from my current location but maybe you can.
        Lastly, going back to my question regarding if you knew anything about taping techniques, maybe check out this paper: Spina R, Cameron M, Alexander R. The effect of functional fascial taping on morton’s neuroma. Australas Chiropr Osteopathy. 2002 Jul;10(1):45-50.
        Hope this helps, again great case, think about typing it up 🙂

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