A Case Study
A 40-year-old woman café owner and manager attended clinic with a 20-week history of left dorsum mid foot pain. No injury was highlighted on questioning. Prior to her experience of constant foot pain, the lady (Ms. J) was both a walker and a cyclist, which she enjoyed as part of her attempt to reduce her high Body Mass Index. The lady works long hours at her café and is currently unable to exercise or perform certain aspects of her work due to pain. Ms J. thinks that she may have broken a bone in her foot.
History of complaint: (*key findings)
Ms J’s injury occurred in October 2018 following a busy 12-hour day on her shop floor. She reports no specific mechanism of injury*. She stated that on the evening of injury she could not put her foot to the floor and that it was ‘swollen quite a bit’. A moderate amount of localised dorsolateral swelling* and stiffness* was reported at the mid foot but no bruising* identified. Ms. J noted that she felt the power* and stability* in her left foot had been compromised post injury, and ‘the pain has been terrible especially at the end of the day’. Ms J continues to experience reduced weight bearing and pain on the application of pressure to the mid foot and is therefore unable to exercise and mobilise as usual (Table 1).
Table 1. Usual Weekly Training Diary
Activities Frequency Duration Walking 3 times per week hours
Cycling 4 times per week ½ hour
Behaviour of present complaint: A 7/10 VAS pain score was identified at the onset of the pain. Since the time of the injury, the combination of rest, ice, compressions and elevation helped to reduce the swelling and pain to a degree. Walking however continues to be painful, and the lady complains of a consistent VAS score of 5/10 both during the day on activity and at night when resting. The pain does not improve following the self-administration of prescribed amitriptyline and naproxen (Table 2).
Table 2. Aggravating and easing factors
Aggravating factors (VAS) Easing factors
Application of direct pressure to the midfoot either weightbearing or at rest (5/10).
The lady also states that standing for 8-12 hours daily
Takes amitriptyline 25mg and naproxen 250mgs daily, but nothing seems to ease the pain in a meaningful way for this lady.
Past medical History: The patient disclosed that her health is generally good, with no history of previous injury. The lady however suffers from hypothyroidism (Hashimotos disease), the GP reports that her bloods demonstrate vitamin D insufficiency* (37nmol/litre). The lady’s HbA1c was also noted to be marginally elevated at 48mmols, rendering her an undiagnosed borderline diabetic. No other information was provided to suggest this lady is suffering from an autoimmune disease. The lady also states that for the last year has been suffering with back pain. Social History The lady is single, she admits to working long hours at her new business and has stated that she has very little time for socialisation. She has expressed a sense of loss
for not being able to exercise as she did prior to injury. She also states that the only relevant family history that comes to mind is that her Mother has suffered from cancer. Ms J’s. current medications history has been outlined below in Table 3.
Table 3. Medication history Medication Indication and duration Pholcodine opioid cough suppressant -taking since 2018
Levothyroxine synthetic form of thyroxine – since diagnosis of hypothyroidism
Naproxen Non-steroidal anti-inflammatory medication- since July 2018
Amitriptyline Treatment for neuropathic pain from her back – since July 2018
Multivitamins On advice from her GP -taking since December 2018
Figure 1. Body Chart Table 4. Initial symptom chart
Symptom VAS Ω P1 Sharpe* pain at dorsum of the mid left foot, with medial aspect of midtarsal region tenderness. Localised oedema lateral aspect 5/10 -initial pain levels on injury constant pain 5/10 tenderness following injury
P 1 =
Pain free areas
The location of Ms J’s pain is very specific to the talonavicular joint and medial cuneiform area, over the left midfoot at the dorsomedial arch. The lady complains of localised subcutaneous oedema on the dorsolateral aspect of the foot. Pain with ankle instability* was reported, with no episodes of collapse or giving way. A VAS pain score of 5/10 at the time of injury was reported. (Table 4).
Figure 2. demonstrates the current pain distribution experienced by the lady over a 24-hour period, stating that it is ‘a constant pain that does not improve’. The lady walks in unsupportive (ballet pump style) shoes, which she states are the only shoes that fit her well. The pain is evident as the lady walks with an antalgic gait with signs of overcompensation on the right foot as also demonstrates upper body lateral sway.
Figure 2. Pattern of pain over a 24-hour period
1. Osteoarthritis of the mid foot- talonavicular and medial lisfranc joint. 2. Stress fracture of the navicular 3. Stress fracture of the medial cuneiform
0 1 2 3 4 5 6 VAS score out of 10
00:00-23:00 hours-Pain reported as constant at VAS 5
*Prior to physical evaluation a base line x-ray in A+E revealed no fracture but identified congenital metatarsus adductus.
Examination findings- observational:
no evidence of upper body malalignment;
Slightly adducted legs with medially rotated patella alignment off the sagittal plane;
left leg demonstrated a mild flexion at the knee as a possible compensation for weight on painful left foot.
Swelling but no ecchymosis located at the dorsolateral aspect of the foot.
Both feet abducted with pes planus foot type, low navicular height and congenital metatarsus adducutus.
An antalgic gait, with reduced dorsiflexion and stepping on the affected limb was evident, with overcompensation on the right leg.
The functional tests that would normally be expected to be performed by the patient are the lunge (dorsiflexion) and tip toe tests (plantarflexion) which maximally stress the structures of the ankle and mid foot, especially the talonavicular joint and the joints of the medial arch. These tests however were unable to be carried out due to the patient’s pain levels. Table 5 demonstrates the assessments that are ideally required in Ms J’s clinical examination.
Table 5: Recommended clinical assessments of the foot and ankle (on static palpation and passive loading of the ankle and midfoot)
Left Sagittal ROM: Ankle ROM
Frontal plane motion: Inversion /eversion
1st MTPJ ROM Dorsiflexion, plantarflexion and passive extension as a possible indicator of OA (1). Identification of any ankle limitation to the active plantarflexion and dorsiflexion (2). Anterior drawer test ADT (3): The lower leg is firmly held at the anterior aspect with the fore foot with the foot plantarflexed. The other hand cups the calcaneus and it is drawn anteriorly and vertically, at about a 60° angle from its starting position. Note level of pain or excessive excursion Talar tilt test TTT (3): The lower leg is held in one hand with the calcaneus cupped in the other, then pressure is applied to the lateral aspect of the talus. The talus and calcaneus are assessed in relation to the tibia and fibula for pain or excessive mobility. Both ADT and TTT check the integrity of the talofibular and the calcaneofibular ligaments but are considered subjective to each practitioner (4). Foot Posture Index- shows the patients foot posture, the navicular height and whether the foot is flexible or rigid. A clinical correlation between foot posture and navicular height has been associated with midfoot OA (5), while foot type and BMI of 28Kg/m² have been associated with risk of midfoot injury (6).
Table 4b: Actual clinical assessments of the foot and ankle. (on static palpation)
Special questions: Bruising: NAD Swelling: YES Ankle Instability: Mildly evident on gait Clicking/Crepitus: NAD
N-Spot test (red flag): Tenderness of the dorsal midfoot and site of bone stress (7; 8)- result, positive to test. Very painful at central posterior dorsum of navicular bone at the talonavicular joint line also.
Plantar foot tenderness Palpation of midportion plantar surface (9) result - NAD.
Pulses and sensation: All neurovascular examinations are required to be performed. outcome- NAD.
Deformity: Evidence of any exostosis on the dorsum of the foot has been shown to indicate osteoarthritic joint changes (5). Ms. J demonstrated a small amount of osteophytic lipping around the navicular cuneiform joints (NCJs)
Following clinical assessment:
On palpation of her midfoot, Ms J experienced exquisite pain at the specific site of the navicular ‘N spot’ (mid dorsum of the bone) when pressure was applied. Such a response is strongly suggestive of a navicular fracture, as found in 81% of patients with navicular stress fracture (8). It was also evident from the lady’s gait that she had difficulty with dorsiflexion and plantarflexion on weight bearing, hence loading through the midfoot was impeded. The nature of the insidious onset of pain and trauma raises suspicion of a possible degenerative condition such as osteoarthritis (OA). In addition, the lady carries many of the characteristic indicators (foot type, age, gender and medical history) associated with OA or fracture, or both.
Ms. J had a 20-week history of a left painful midfoot with no apparent injury. Since that time, the localised pain has remained constant, with reduced sagittal ROM at the ankle; inability to properly weight bear and resulting poor mobility. Both subjective and objective findings are consistent with osteoarthritis of the midfoot or navicular fracture, or possibly both. A strong suspicion of an insufficiency fracture may correlate with multiple factors such as: reduced vitamin D levels; the lady’s BMI; and long periods of standing and weight bearing on her lower limbs.
Hypothesis and prediction levels:
Osteoarthritis of the mid foot- talonavicular and medial lisfranc joint (60%)
Stress fracture of the navicular (40%)
Midfoot osteoarthritis (OA) is considered a subtype of foot OA, which can affect the talonavicular joint (TNJ), the naviculocuneiform joint (NCJ) and cuneiform-metatarsal
joints (CMJ). This form of OA is considered debilitating and is linked to foot pain, lower medial arch, obesity, diabetes, previous injury and pain in the larger weight bearing joints (10; 11). Individuals with a combination of medial and central midfoot OA have also been shown to be older, to be primarily female, or have physically demanding roles (5), which draw parallels with Ms J’s presentations.
An OA grading system based on radiographic results has been suggested by Menz et al. (12), holds a scoring for presentations such as osteophytes and narrowing of specific joint spaces (1st metatarsophalangeal joint, both 1st and 2nd tarsometatarsal joints, the 1st navicular cuneiform joint and the talonavicular joint). This system is thought to have poor sensitivity (31%), as it requires multiple radiographic views to see each of the articulations previously mentioned, in addition to the subjective element to identified variations (13).
OA of the midfoot cannot be discounted, as Ms J has localised pain, swelling and exostosis of the navicular cuneiform joint. The 2nd Cuneiform metatarsal joint (CMJ) in most instances is thought affected due to the mechanics of forced dorsiflexion and rotation of the 1st CMJ in relation to the more static 2nd CMJ (5). However, no differentiation of pain is noted at the 2nd Cuneiform metatarsal joint (CMJ) in Ms J’s case. OA cannot accurately be proven on clinical presentation alone, and therefore cannot be discounted as a hypothesis. The need for further imaging such as x-ray, Magnetic Resonance Imaging (MRI) and Computerised Tomography (CT) should also demonstrate the affected joints of the midfoot and provide a more definitive diagnosis.
Radiographic images (Images 1+2) were taken following consultation, but insufficient definition failed to clarify the diagnosis. Osteochondritis dissecans sees a progressive deterioration of the cartilage and ultimately leads to damage of the subchondral bone
(14). The proximal convex articular surfaces seen on x-ray appear to represent subchondral sclerosis (14). Vague evidence of talonavicular joint incongruity, focal lucency at the Talonavicular and Calcaneocuboid joints with joint narrowing at the tarsometatarsal joints, indicate the need for further investigations under Magnetic Resonance Imaging (MRI).
Image 1 X-ray weight bearing, anterior view
This xray demonstrates congenital metatarsus adductus and marginal wear and tear, specifically
posterior to the painful site (N Spot) at the talonavicular joint (red arrow) of the left foot. Narrowing
of the joints of the mid foot at the cuneiform metatarsal joints bilaterally is also noted.
Image 2. X-ray- Oblique view of the left foot
Red arrow point to the irregular joint line with focal lucency and subchondral sclerosis of the navicular.
Marley et al. (15) suggest that the incidence of osteoarthritis associated with navicular stress fractures is most likely underreported, this propounds the notion that both pathologies may coexist.
Stress fracture of the navicular
The alternative hypothesis of navicular stress fracture is a strong possibility, given the exquisite pain on the application of minimal pressure at the ‘N Spot’ (dorsomedial aspect of the navicular bone) on Ms J’s left foot. Most impingement force is thought focused at this area of the navicular bone which is anatomically a distinct point of reduced vascularity (16) and therefore vulnerable to sagittal fracture (3). As tibalis posterior tendon inserts onto the medial tuberosity of the navicular, this further elevate the level of stress on the navicular bone (17). Ms J has limited dorsiflexion at the ankle, the midfoot is therefore thought to compensate for this, and influence navicular impingement with abnormal midfoot sagittal excursion (18).
The lady’s elevated BMI and age, as well as her hypothyroidism and vitamin D insufficiency levels noted in her bloods, suggest that multiple factors may be at play here. Insufficiency fractures are a legitimate concern, a subtype of fracture where decreased mineralisation and bone elasticity, results in a weakening of the bone and its potential failure (19).
Ms J is taking minimal amounts of vitamin D supplements to support her insufficiency. Low levels of vitamin D prevents the intestine from absorbing calcium which results in the upregulation of parathormone (PTH). This leads the bones to release their stored calcium, hence resulting in fractures and poor bone healing in fracture (20). Studies have argued that by taking vitamin D of over 800IU and 2000mg of calcium for a period of 8 weeks, there is a 20% reduction in the incidence of stress fractures (21). It has been shown that premenopausal women with acute lower extremity stress fractures, treated with parathyroid hormone, demonstrated an elevated bone healing rate
(osteoblastic action) proven on MRI (22). Such evidence would suggest that Ms J would benefit from similar treatment to support her bone turnover and repair.
Risk factors thought associated with navicular stress fractures include metatarsus adductus; limited subtalar joint (inversion/eversion-frontal plane) and sagittal ankle motion; medial narrowing of the talonavicular joint (TNJ) and a cavoid foot type (23). Ms J displays some similarities with metatarsus adducutus, TNJ narrowing and limited ankle range of motion (on both inversion and eversion and in the sagittal plain) as demonstrated by her gait.
An MRI of the foot and ankle was thought needed to evidence any pathological processes at play. The MRI images (Images 3+4) showed the presence and size of subchondral cysts both in the navicular and possibly on the lateral head of the talus. Talonavicular osteochondral lesions (OCL) are lesions of the articular cartilage and of the underlying subchondral bone, are thought uncommon and difficult to treat (24), however OCLs may not be conclusive evidence of the pain source. MRI has limitations as it is unable to identify discontinuity of tribeculae, hence stress fractures can go unnoticed (25). The structural changes identified therefore do not definitively indicate causation of pain and instability of the ladys left foot, and hence require further clarification under CT imaging.
Computerised Telemetry (CT) has been shown more accurate at diagnosing stress fractures, with approximately 80% of cases identified (26). CT (Images 5-9) show subchondral lesions from which a continuous fracture line in mid dorsal navicular on the sagittal plane is observed.
Image 3. MRI T1 Image 4. MRI T2
MRI T1 (left) and T2 (right)– Axial images of the left foot, identifies bone marrow oedema with
subchondral cyst in the navicular bone (red arrow). Also suspicion of a subchondral cyst on the lateral
talar head as indicated by the arrow with blue edge. T1 shows low signal intensity on the talonavicular
joint and ragged joint cartilage and a homogenious high signal intense cystic lesion of the mid portion
of the navicular bone, consistent with early osteoarthritis of the talonavicular joint because of the
preserved joint space.
Findings and management:
Findings suggest a well corticated cyst located in the body of the navicular (and possibly talar head) with linear fracture. No evidence of osseus coalition of the mid foot, but possible degenerative OA changes to the joints of the medial midfoot at the TNJ, NCJ and CMJs. Specifically, Osteochondral dissecans must be considered in this case, due to the advanced level of subchondral navicular bone involvement and cartilage damage at the Talonavicualar joint (14).
For management of symptomatic midfoot OA, limited evidence is shown for foot orthoses (27), intraarticular corticosteroid and local anaesthetic injection therapy (28).
CT Images 5-9 show degenerate navicular bone cyst with sagittal fracture
Image 5. Image 6.
Sagittal view Axial view
Image 8. Image 9.
Axia view Transaxial view
Ozturk et al. (24) has however reported positive outcomes to conservative treatment of tarsal navicular osteochondral lesions. This primarily involved an adjustment to the individual’s weight bearing and activity levels.
Surgical interventions (14) such as anterograde or retrograde drilling of the navicular, with excision and curettage of the subchondral cyst +/- bone graft, have shown effective results in bone regeneration and healing of fractures. Ross et al. (29) have also demonstrated the benefits of talonavicular arthroscopy which limits soft tissue damage, permits structures of the talonavicular joint to be seen, and allows treatment of the OCLs. This procedure involves the debridement of synovial hyperplasia (fibroblast like synoviocytes), removal of loose bodies, reduction of problem cartilage, and inflicting microfractures to the subchondral bone to stimulate a reparative response. The first 2 weeks of recovery require non weight bearing active and passive movements; the 2nd to 4th weeks are spent in a controlled ankle movement (CAM) boot with a 10% increase loading of partial body weight. Weeks 4-6 are spent increasing weightbearing by 10% daily (29). Such measures are linked to reduced pain, sooner return to activity and reduced cost on health care.
Given that over 50% of Ms J’s navicular bone appears to be affected, structural failure of the bone could lead to debilitating outcomes, such as medial foot collapsed and tibialis posterior failure, thus severely impeding gait and her mobility. As Ms J’s condition is more advanced, she may benefit from a surgical arthroscopic approach as mentioned by Ross et al. (29) or Beil et al. (14).
In order to optimise conditions for recovery, Ms J would benefit from BMI reduction, appropriate offloading of her affected limb, and considering surgical intervention if conservative efforts fail. Balancing intrinsic factors such as appropriate levels of vitamin D and the treatment of her hypothyroidism, will stimulate bone remodelling, the essential biological components of osteochondral defect and fracture repair.
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A Case Study
Mr P. a 48-year-old cyclist with previous history of bilateral complete Achilles rupture
repair, presented in clinic with pain in the posterior compartment of his right leg. The
pain was specifically located in the midportion of the tendon, which has also been the
site of regular cramping on eccentric loading for the last 3 months. No audible or
observable change was noticed in the localised area. Following a break from cycling
for 4 weeks, a return to sport saw the pain return. Since this time, enforced rest for a
further 4 weeks with anti-inflammatory oral medication and off-loading of the leg in an
aircase boot has been recommended by his medic.
Past Medical History
The gentleman is fit and well with no relevant previous history to report.
No medications are currently prescribed for Mr. P, nor has he been prescribed
fluroquinolones in the past which might have contributed to his tendon dysfunction or
The feet appeared to be cavoid in posture, while the ankle range of motion was a little
limited on inversion and eversion, sagittal motion was remarkable being limited to
barely 90°, with no additional motion for plantarflexion or propulsion. Guarding was
noted on attempted plantarflexion and dorsiflexion of the right foot. Pain on
compression of the Achilles tendon at the midportion was also experienced, however
Thompson test was positive, so acute rupture could be excluded. Atrophy of muscle
bulk was evident bilaterally at the gastrocnemius of approximately 30-40%.
Midportion Achilles tendinopathy+/- tear or incomplete rupture.
It is argued that diagnosis of partial tears of the AT cannot be identified uniquely on
clinical examination but require imaging with high resolution ultrasound and colour
doppler (4). Chronic degeneration of the Achilles tendon may be demonstrated under
sonography as: swelling or nodules; loss of collagen structure and integrity of the
fibres; calcification, or the infiltration of fat and capillaries within the tendon structure
Image.1 Right Achilles tendon Sagittal view on ultrasound.
= outer boarders of the Achilles tendon
= hyperechoic areas (calcification/dense material)
= hypoechoic areas (increased ground substance)
The scar tissue from image 1 shows disorganisation of tendon from insertion fibres to
the area around the free tendon (green x).
Image 2. Right mid portion Achilles disorganised due to 2 previous ruptures in 2008
= hypoechoic areas (increased ground substance)
= hyperechoic areas (boney/dense structures)
= possible suture repair in the tendon
Image 2 shows Mr P’s Achilles tendon fibrils as discontinuous and no longer parallel
in direction (i.e. not sagittal). It is also possible that the sutures used to repair the
tendon have provided visual irregularities which may be denoted by the structure
underneath the red arrow.
Image 3. (p.4.) shows an area of approximately 1.5 cm space /tear within the tendon.
However, this does not appear to be a focal point of inflammation as on colour doppler
there was no evidence of blood flow within the tissues. An increased blood flow along
the tendon is considered to indicate pathological tendon or possible repair or
regeneration (3). This is an example which demonstrates that abnormalities on
imaging may not necessarily be directly the cause of pain.
Image 3. Sagittal view of hypoechoic area of 1.52 cm seen at the level of the right
Achilles tendon (midportion)
= intratendinouos tears signified by the red arrows
The left leg images were compared to those of the right leg, gross deformity of both
tendons was shown on ultrasound.
Image 4. Measurement of left Achilles’ free tendon (posterior side in
sagittal/longitudinal plane) with measurement at banding of .95cms
Image 6. Left axial/transverse view of midportion band / clip at anterior aspect of the
The anterior tendon is thought to be the area of less tensile stress and hence
suggestive that there may be a friction and overload related degenerative process
taking place (5).
Ultrasound as a tool to aid the management of injury
Ultrasound has generally been considered a suitable (inexpensive compared to MRI)
tool in the diagnosis of both acute and chronic Achilles tendon pathologies (6). This
type of imaging enables evaluation of the tendons, other localised soft tissue
structures, as well as superficial aspects of osseous structures to be viewed,
permitting comparison with other limb, and clarification of any deformity.
Patterns of injury, recovery and reinjury on return to sport are thought to contribute to
biochemical changes within the matrix and the collagen, resulting with degeneration
and biomechanical compromise (8). Ultrasound is also commonly used to identify any
dynamic anatomical defects within the Achilles tendon that are associated with
injuries, presented during examination (3).
Alfredson et al have developed an eccentric gastrocsoleus training programme to aid
painful mid-Achilles tendonopathy (7). This 12-week exercise protocol elicits pain on
tendon loading but has had success in approximately 90% of cases with mid portion
Achilles tendon pathology and pain. It is thought that this approach is most appropriate
for Mr. P as surgical intervention may not be the most desirable course of action given
the presence of scar tissue, changed collage structures and resulting physical
restriction. Other proven interventions to consider might include hyperosmolarity
dextrose injection therapy under ultrasound for those with chronic symptom (9).
The information presented by the ultrasound enables decision making strategies to be
considered and selected as appropriate at incremental stages through to the recovery
process. This clinic-based form of imaging enables rapid decision making, supported
by the evidence presented by the ultrasound as a dynamic tool.
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guided intratendinous injection of hyperosmolar dextrose to treat chronic
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