Thinking on your feet. You have less than 20 minutes with this gentleman, as he has to leave to catch a plane. See how you did.
Lateral foot pain and cowboy boots?
A 55 YO male patient presents with pain in his left foot area of the cuboid and tail of the fifth metatarsal. He was told that he had a “locked cuboid” on this side by his chiropractor, who provided some treatment and temporary relief. There has been no history of trauma and Most recently, he has been wearing cowboy boots and doing “a lot of walking” particularly when he was over in Europe and feels this was a precipitating factor.
Watching him walk in his cowboy boots, the rear foot and heel plate of the cowboy boot is worn into varus. Gait evaluation reveals his left foot to remain in supination (and thus in varus) throughout the entire gait cycle.
Examination of the foot revealed loss of long axis extension at the metatarsophalangeal and interphalangeal articulations. The cuboid appeared to be moving appropriately. (to see why cuboid function is integral, see this post here. ) There was weakness in the peroneus brevis and peroneus longus musculature with reactive trigger points in the belly of each. There is tenderness over the tail of the fifth metatarsal and the groove where the peroneal muscle travels through as well as in the peroneal tendon as it travels through here.
So, what’s up?
This patient has peroneal tendonitis at the point around the foot as it goes around the tail of the fifth metatarsal. Discomfort is dull and achy in this area. The cowboy boot is putting his foot in some degree of supination (plantar flexion, inversion adduction); this combined with the rear foot varus (from wear on the heel) is creating excessive load on the peroneus longus, which is trying to descend the 1st ray and create a stable medial tripod. Look at the pictures above and check out this post here.
What did we do?
Temporarily, we created a valgus post on an insole for him. This will push him onto his 1st metatarsal as he goes through midstance into termiinal stance. He was asked to discontinue using the boot until we could get the heel resoled with a very slight valgus cant. We also treated with neuromuscular acupuncture over the peroneal group (GB 34, GB 35, GB 36 and a few Ashi points between GB34 and 35) circle the Dragon about the tail of fifth metatarsal, GB41 as well as the insertion of peroneus onto the base of the first metatarsal (approximately SP4). We K-taped the peroneus longus to facilitate function of peroneus longus. He was given peroneus longus (plantarflexion and eversion) and peroneus brevis (dorsiflexion and eversion) theraband exercises.
How did you do? Easy peasy, right? If they were all only this straight forward….
The Gait Guys. teaching you to think on your feet and increasing your gait literacy with each and every post.