Patient #20: Dorsal Foot Pain in College Softball Pitcher
History and Chief Complaint
- College softball pitcher developed acute pain in the front of the ankle during a game
- She had had some symptoms in the weeks prior, but nothing severe
- The pain was so severe that she had to leave the game being carried off by her coaches
- She could not put any weight on the foot and was referred to our sports clinic by the ER.
Question #1: What are you thinking about a diagnosis with acute disabling pain like this?
Gait Evaluation
- None could be performed other than insuring that her crutches were the right height (eventually her dad mailed me a video of her pitching motion for sports specific gait)
- Patient did not want to put any weight on her foot
Question #2: For many sports specific injuries, gait evaluation has to be sports specific. How can videos sent by email be an important part of your practice?
Physical Examination
- Swollen ankle and dorsal foot without any ecchymosis or erythema (yet!)
- Palpable pain on the navicular bone both dorsal and medial as the #1 point of tenderness (some pain in the surrounding area where there was swelling)
- I did not have this patient point to the one most painful spot with one finger which can be used when a large area is sore. You tell them if they could only have one painful point removed today where would they point with one finger (the one finger test)
- The pain prohibited a good range of motion and muscle strength examination
Question #3: You see them within 2 hours of the onset with swelling already. Are you thinking of sprain or a broken bone?
Cursory Biomechanical Examination and Asymmetry Noted
- Pes Cavus foot type with high degree of forefoot everted position due to a plantar flexed first ray
- Achilles flexibility and standing measurements were not done due to pain and inability to stand
Question #4: We are dealing with a navicular injury. Why do you think a pes cavus foot type could be part of the cause of this injury?
Tentative Working Diagnosis
- Navicular fracture until proven otherwise
Question #5: What is the ideal image technique to decide on the extent of the navicular fracture?
Common Differential Diagnosis (2ndary Working Diagnosis)
- Midfoot Sprain or another type of fracture
Question #6: What would be the best imaging technique if a midfoot sprain was to be evaluated?
Occam’s Razor and Rule of 3
- Simplest Solution is fracture repair with ORIF
- Rule of 3 can be applied in pre- or post operative time period based on the decision to try to attempt to avoid surgery or perform surgery fixation
- 3 possible causes that we can treat are the high arches with lack of support to the navicular area (needs a good supportive orthotic device), bone health issues (the need here is to question diet, Vit D deficiency, and menstrual irregularities), and shoe gear that is too flexible in the arch (the shoe needs to bend forefoot area and not the midfoot easily)
Question #4: Why did Dr Saxena’s study find that the return to activity (RTA) was the same or actually slower in surgical fixation?
What Phase of Rehabilitation?
- Immobilization
Question #5: The Immobilization in this case will probably be surgical fixation followed by cast immobilization and non weight bearing. Discuss the mechanical changes needed from surgery to full recovery.
Should We Image?
- X Rays showed irregularity in the navicular
- CT Scan next day showed a through and through mid-navicular break in the sagittal plane with 2 mm displacement of fragments
Question #6: How many screws are commonly used to have good fixation?
First Decision: How to Reduce Pain 0-2
- Off Weight with crutches and soft compression cast
- Schedule ORIF
Question #7: It is so important to imagine all the needs going forward even in this pre-op stage. What would be the role of custom orthotic devices in this patient, and when would they be dispensed?
Second Decision: Inflammation Concerns
- Ice Packs
Question #8: Ice Packs for 5-10 minutes for this relatively superficial injury seems enough, but inflammation settles plantarly (so fairly deep). How long would you ice for this deep inflammation?
Third Decision: Any Nerve Component?
- None apparent
Question #9: Just wait, surgery is happening, and with surgery can come entrapped nerves, nerve hypersensitivity, and damaged nerves (hopefully not). What are 4 common nerve treatments to begin if the need arrives?
Fourth Decision: Initial Mechanical Changes
- Crutches
- Compression Casting
Question #10: What are Canadian crutches and when are they needed?
Here is a case where surgery is needed to be done first before any other treatment. Our foot surgeon both performed the surgery and then followed the patient during the standard almost 3 months progression from non-weight bearing to partial weight bearing to complete weight bearing. I re-took over the case to fit this high arched athlete with good supportive orthotic devices and she learned how to tape the area well. Besides the crutches in the early stages, the patient had a RollaBout to give her arms a rest when she went out to a mall, etc. The following link shows this well: https://youtu.be/iymbwW30zd8 I was slowly able to progress her through the stages of rehabilitation adding strengthening and gradually a return to activity.
Question #11: The Return to Activity Phase can be both nonspecific and specific for a certain sport. What are some of the beginning activities she was able to do sport specific for her softball?
Answers:
#1 Since the pain was so acute, and there was no fall that would produce a sprain, a fracture is the most likely candidate.
#2 In a busy practice, you will not have time usually to go to every patients practice or events. Having them send video clips of 1-2 minutes max of close-ups on how they ice skate, pitch, ski, racewalk, etc can tune you into their unique sports specific biomechanics.
#3 Broken bone especially since the mechanism of a sprain was not reported in historical review.
#4 Saxena's explanation was that the ones operated on were the most severe injuries increasing the time to rehab in the surgical patients.
#5 Since the navicular bone is crucial in arch support, post op full supportive custom made orthotic devices should be made with or without a navicular cut-out. Most clinicians begin some form of arch or midfoot taping as weight bearing begins and they are waiting for the inserts to be made. Transition from non weightbearing to full weight bearing is done is crutches, and removable boots. The athletic shoes they wean into should be very supportive like Brooks Beast or Ariel. Definitely need the orthos for the shoe stage. As soon as simple active range of motion exercises can be started, every surgeon has their own timing, they are started for the posterior tibial tendon. Out of the cast, strengthening is progressed to isometric and then progressive resistance.
#6 Typically one, but each surgeon has their own protocols
#7 Custom orthotic devices can be dispensed while the patient is still in a removable cast, but essential in the period when weaning from the boot to a shoe.
#8 15-20 minutes at a time
#9 Neural flossing, topical nerve lotions like Neuro-One or some Compounded concoction, Lidoderm patches, TENS units for home us.
#10 Canadian crutches attached loosely to the forearm and used when the patient has shoulder issues from a standard crutch. Much harder to be non weight bearing with Canadian crutches.
#11 Playing catch again without much foot motion, flungo bunting drills back to your partner, and shagging fly balls without running to name a few. The Return to Activity Phase is so emotional uplifting for athletes.
