Help diagnosing a problem

[dankowen]

Hello all forum members.
I am a PT trying to diagnose myself with no success. This is the history of the problem: 4 weeks ago I kicked a solid wall with the plantar part of my forefoot. The foot made contact with the wall at approximately the TMT joint, plantar side, while the phalanges were extended(similar to a martial arts kick). Immediately I felt a sharp pain in the dorsal aspect of the TMT joint. Since then, whenever I extend the 1st phalanges of the foot I feel the same pain. The pain persists in passive extension also. During walking and running it is also there, weak at first and after 5 minutes it aggravates. I have underwent xray imaging to r/o fracture. I tried RICE, passive movement, mulligan treatment and also NSAIDs. Nothing seems to help :-( . The pain was MUCH worse the first few days after the trauma, I could barely bear weight, but since then I can walk with only slight pain. The problem is, it isn't going away, and it gets worse while running(which is a major sport I am occupied with). I am thinking there was some kind of compression damage to the joint capsule.
Anyone with any ideas of what the problem is, and how to hasten recovery?
P.S: pain with full flexion of the 1st phalanges too!


Thanks a lot!

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[mohit rastogi]

Hello I think it is a combined injury and you might not had given proper protection to it so it went chronic. Since u r in sports so my suggestion is to use taping techniques for stability to joint and soft tissue support during your daily activities along with that use Ultrasound and intrinsic muscle training.
Best of luck

[violablue]

When did you get the xray? Because often with feet fractures an xray won't pick up the fracture if done right after the injury. It tends to pick it up better as the bone starts to heal. Is it possible to get re-xrayed?

Barring actual fracture, I'd check out trigger points in your feet. Especially the interosseus muscles between the metatarsals. Feet can harbour some seriously painful trigger points that make walking or even putting a tight shoe on agony.

[MrPhysio+]

Hello dankowen,
As Violablue suggests a stress fracture will not show on X-Ray for three weeks and then only as bone calcification begins. If you are much improved and you had a stress fracture it would
be on the way to healing by now, negating the need for an x-ray. The type of injury causation described will very likely have caused bone bruising and possibly ligamentous disruption to the toe.
This will show up as pain, stiffness and aggravation upon movement. There may also have been tendon sheath involvement. Mohit is correct stating that you have sustained a 'combined' injury.
Two years ago I sustained a severe hyperextension injury to all fingers of my Left hand after falling about 1.5 metres with full body weight onto the extended hand. The pain was sufficient to cause
a mild shock reaction. It took 9 months of daily massage before my hand had no stiffness or pain.
I sugggest that you use a heparinoid based cream massaged into your toe initially, twice a day. Holding onto your toe with a traction force to the joint then mobilising antero-posteriorly with a glide
may also help.
Hopefully the above information will be of benefit. You may need to be patient if you have a bone bruise, 4 weeks is not enough, think more 3 to 4 months. Feet take longer than the upper limb to recover.
Cheers,
MrPhysio+

[dankowen]

First, thank you all for such helpful and important answers. I must say you all(and especially MrPhysio+) made me much more relaxed about the problem because I was fearing that the pain was persisting because I am still bearing weight daily on the foot. Your suggestions all sound very good and I will try them, and still remember that the rehab might take longer then expected
My biggest fear was, as I said, was the fact that this type of injury might require non-weight bearing for a certain amount of time or partial weight bearing. Do any of you think this might be the case? Also, what about returning to running? I can certainly bear the pain but do not want the healing process to slow down if I return too early....

Also- answer to violable:

When did you get the xray? Because often with feet fractures an xray won't pick up the fracture if done right after the injury. It tends to pick it up better as the bone starts to heal. Is it possible to get re-xrayed?

Thankyou for your answer, Violablue. The X-ray was done 10 days after the trauma occured. I can ask for another one but as MyPhysio+ said, I think it might not be needed at this time...

Thanks again everyone!

[violablue]

I'd say 4 weeks healing time no matter bone, tendon, ligament, may be too soon for the high impact of running. It's important to always let pain be your guide. It sounds like you are having pain with weight bearing and walking, so running will likely be pushing it at this point.

[MrPhysio+]

Hi Dankowen,
Your feedback is helpful. Judge the effect of running by how long you have pain for and whether or not you have swelling or redness around the joint. If you have pain for over two hours post running, you may need to reduce the intensity of the run. Sometimes correct taping of the area can spread the load over a wider area whilst supporting the injured region.
It may be that the joint requires more mobilisation and massage. As I have said, it can be a slow process. Non steroidal anti inflammmatory gel application may also be of benefit, as would pre and post run icing for pain and inflammation control. If your symptoms disappear within 30 minutes post run you should not be causing any significant problem. If you have aggravation from a run into the next day, back off the run intensity. A different type of running shoe can sometimes assist, but that can be an expensive experiment. If you are using a light weight running shoe you could try a cross training shoe with more support. I prefer minimalist barefoot running type shoes eg Nike FreeRun or Vibram 5, however barefoot running shoes tend to have runners spread the load more through the mid and forefoot which is usually a good thing, but not if you have a sore toe!
Contrast baths for swelling can reduce pain eg 20 seconds in ice slush then 20 seconds in warm water (not hot) repeated 5 times twice daily. If you have minimal swelling, do not bother with this technique.
Good luck.
MrPhysio+

[dankowen]

Hello again dear thread helpers,
thanks again for the replies. I am have gradually started to get back to running, I have been doing a small 10 minute run on the treadmill X2 /week, and today ran 10 minutes outside and another 10 on the treadmill. The pain is very tolerable during the run and disappears as soon as I stop running. There is very minimal redness in the area and for that inflammation I am using an NSAID cream. I will also ice the area after running.
Progression seems to be going well.
Thanks again!
Dan

[MrPhysio+]

Hello Dankowen,
I am glad that progress is being made. Continue the graduated return as outlined. Should problems occur, please let us know via the forum.
Cheers,
MrPhysio+