Evaluation of Mid Foot Pain

Note that by definition, the midfoot is composed of three cuniform bones, the cuboid, the navicular, and the surrounding soft tissues.

Differential Diagnosis

Common

1. Navicular Stress Fracture

2. Midtarsal Joint sprain

3. Extensor Tendinopathy

4. Tibialis posterior tendinopathy

5. Plantar Fascii Strain

Less Common

1. Cuneiform stress fractures

2. Cuboid Stress fractures

3. Stress fracture at base of second metatarsal

4. Peroneal Tendinopathy

5. Abductor hallucis strain

6. Cuboid Syndrome

7. Tarsal Coaalition

8. Kohler's Disease (in young children)

Not to be Missed

1. Lisfranc's Injury (fracture or dislocation)

2. Osteoid Osteoma

3. Complex regional pain syndrome (after knee or ankle injury)

History

• Sudden versus gradual onset of pain

• Jumping from height

• Repeated heel strike

• Improvement or aggravation with exercise

• Night or Morning Pain

Physical Examination

Remember that a complete examination should include the joint above and below. Always examine the ankle

Inspection

1. Assess for swelling

2. View ankle from behind: loss of definition of acchilles tendon indicates significant swelling

3. Check condition of skin

Palpation

1. 'N-spot': the proximal dorsal surface of the navicular (tender in cases of stress fracture)

2. Extensor Tendon

3. Medial process of the calcaneal tubersosity

4. Palpate plantar fascia attachement

5. Heel fat pad

6. Achilles Tendon

7. Retrocalcaneal bursa

8. Posterior Talus

9. Calf Muscle

Motion

Muscular Strength

Muscular strength is graded on the MRC Scale

1. Plantarflexion; Gastrocnemius and Soleus,

2. Dorsiflexion; Tibialis anterior, extensor digitorum longus, extensor hallicis longus, peroneus tertius

3. Inversion; Tibialis anterior,

4. Eversion; peroneus longus, peroneus brevis

Neurovascular

1. Check the Heel Jerk Reflex (S1 S2) and grade

2. Check Distal Sensation

Investigations

1. Plain Films: To look for tarsal coalition, stress fractures, osteophytes, ossicals, or bony tumors. (note: stress fractures are not usually visible on Xray in the early stages)

2. Bone Scan: May reveal stress fractures

3. MRI: May reveal stress fractures.

Appendix

Muscular Movers of the Ankle

Index

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