What hurts?
Some possible conditions • Foot Pain – Outside of Foot – Midfoot
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Midfoot Impingement Syndrome -
Cuboid Syndrome -
Sinus Tarsi Syndrome
Some possible conditions • Foot Pain – Outside of Foot – Midfoot
A somewhat common condition of the midfoot is called Midfoot Impingement Syndrome. This condition is defined by pain to the entire top of the foot, only the inner or medial side, or only the outer or lateral side. The impingement felt by patients is due to a pinching effect to the joints of the midfoot or arch. When this occurs inflammation builds within the joints and surrounding tissues. If inflammation and pinching progresses, the cartilage begins to thin and degenerative joint disease or arthritis presents. The end stage can be a bone on bone presentation due to the pinching of the joints. The midfoot is composed of multiple small joints that together appear as the height of the arch.
The most common presentation of midfoot impingement syndrome consists of pain and swelling to the top of the foot or medial foot. Other presenting symptoms may include pain with walking, running or long periods of standing. Pain is more often described as a dull ache, but can progress to a sharp stabbing sensation, which increases throughout the day. Bony ridging or spurring can be felt across the top of the midfoot. Depending on severity, pain with shoes that lace-up or have straps across the midfoot can become very problematic.
When the height of the arch begins to sag, flatten or collapse, the small joints of the midfoot impinge on each other causing increased pressure to the stabilizing ligaments and joint capsules. Factors that are most common to causing the midfoot collapse include obesity, tight calf muscles, overuse, increased age, and improper footwear or inadequate arch support. Shoes that are very flexible often do not have a stabilizing arch, and this leads to excessive motion in the midfoot joints.
There are a multitude of treatment options for this condition with many conservative options to exhaust before considering surgical intervention. The first treatment should include changes in shoe gear, including a good arch support and a stable, well-fitting instep. Avoidance of barefoot walking or walking in unsupportive sandals/slippers is an important factor. Maintaining a healthy weight will decrease the stress to the midfoot, as well as beginning a home stretching routine for tight calf muscles. Additional treatment options include both over-the-counter and prescription non-steroidal anti-inflammatory medications such as ibuprofen and naproxen, as well as icing, orthotics (custom made) and steroid injections. Seeking a professional consultation with a Chiropodist or Pedorthist will aid in reducing the impingement and treating your symptoms. Most patients improve with conservative therapy only; those that do not may require surgical intervention.
Cuboid syndrome is not common and is an often misdiagnosed foot injury. The cuboid is a pyramid-shaped bone on the outside of the foot and sits just in front of the heel bone. The peroneus longus muscle on the side of the leg, wraps around the cuboid bone, continuing to the bottom of the foot to insert onto the first metatarsal bone. This muscle’s job is the eversion of the foot, or when the bottom of the foot is rotated outwards. Cuboid syndrome occurs when the cuboid bone becomes partially dislocated or subluxed from the heel bone, causing pain on the outside, middle of the foot. The peroneus longus muscle exerts excessive force on the cuboid during movement, lifting it up and popping it out of position, causing subsequent pain.
Cuboid syndrome causes pain on the outside, middle of the foot. The pain can occur after an ankle sprain or suddenly on its own. There may be diffuse swelling, redness and/or bruising around the area of the cuboid. Pain is aggravated by weight-bearing and side-to-side movements. Cuboid syndrome pain often leads to a limp when walking. A dimple on the top of the foot coupled with a fullness or protrusion on the bottom of the foot indicate a partial dislocation of the cuboid bone.
Cuboid syndrome is poorly understood, but there are two proposed mechanisms of action (MOA) of this foot injury. It can occur at the same time or following an ankle sprain, when the ankle rolls over. When this happens, the peroneus longus muscle contracts as a reflex to counteract the force causing the ankle sprain. This reflex can result in subluxation of the cuboid bone. The other MOA is overuse and it is compounded by overpronation of the foot when walking. When the foot overpronates, the middle of the foot moves excessivel, causing the peroneus longus muscle to pull on the cuboid. This may result in cuboid syndrome.
The treatment goal for subluxation or partial dislocation of a joint is ensuring that the joint/bone goes back into its proper place. If cuboid syndrome has occurred, assessment and treatment from a lower limb clinician or primary care professional is important to avoid complications and long-term pain. A “cuboid whip” is a treatment technique known as manipulation and is carried out by “whipping” the cuboid back into place. If there is swelling, redness, bruising and pain, cold therapy will ease symptoms of cuboid syndrome. Custom foot orthotics will control overpronation of the foot and stabilize and reduce the overpull of muscles and strain on ligaments. Well-fitting and supportive footwear is key, as is safe stretching of the peroneus muscle to increase flexibility and suppleness and prevent overpulling on the cuboid.
Sinus tarsi syndrome is a rare injury to the subtalar joint, the joint just below the ankle joint. The sinus tarsi is a tunnel or opening between the talus and calcaneus, the two bones in the foot that make up the subtalar joint. Several ligaments, nerves and blood vessels pass through the sinus tarsi. When any of these structures becomes injured, sinus tarsi syndrome may result. If the normal position and function of the subtalar joint is disrupted, the sinus tarsi tunnel will be affected and can result in pain and discomfort. The subtalar joint and the sinus tarsi also play an important role in proprioception. Proprioception is the awareness of the body in space and goes hand-in-hand with balance and stability.
Pain on the outside of the foot that is difficult to pinpoint can be indicative of sinus tarsi syndrome. The area of pain is similar to that of an ankle sprain and often occurs in conjunction with a traumatic sprain of the ankle joint. The ankle and foot may feel stiff in the morning when first waking and improve as the day progresses. Pain associated with sinus tarsi syndrome typically develops over a period of time, not suddenly. In other words, if an ankle sprain does not seem to fully heal or continues to be problematic, it may be due to a resultant sinus tarsi syndrome caused by the initial ankle sprain itself.
Pain due to sinus tarsi syndrome can be caused by a traumatic injury or from overuse. An injury to the sinus tarsi following a traumatic ankle sprain can cause synovitis, which is an inflammation of the synovial lining of the joint. It can also cause permeation of fibrous scar tissue into the joint. If sinus tarsi syndrome is due to overuse caused by repetitive walking or standing, or overpronation of the foot, the subtalar joint will be abnormally positioned causing issues with balance and instability during gait. A pronated subtalar joint causes compression of the two bones of this joint, and if they make contact with one another, arthritis and pain will result.
Early treatment and intervention is crucial to prevent long term pain and discomfort. Rest and modification of the activities that aggravate the symptoms of sinus tarsi syndrome will help to relieve the pain and discomfort. To control instability, ankle braces and taping are effective in restricting the movement at the subtalar joint. Custom foot orthotics support and lift the arch of the foot, opening up the sinus tarsi to reduce compression. Footwear that is designed to control pronation and increase stability is an important component of treatment. Surgical treatment is a last resort for chronic pain from sinus tarsi syndrome. If this syndrome is a result of severe flat feet and range of motion at the subtalar joint is limited, surgery may be required to reconstruct the foot and arch and reduce the compression within the sinus tarsi.
