A 54 year old male hill walker develops medial forefoot pain while walking downhill and decides to tighten the boot laces to give extra support to the foot. Afterwards, the pain persists and continues over the next 12 months resulting in gait disturbances and reduced walking distances.
Multiple examinations and investigations by orthopods ruled out the usual suspects such as stress fracture of the first or second metatarsal, plantar fasciitis, metatarsalgia, hallux valgus and neuropathies. He was told to go and stretch his calf muscles and all would be well.
Well, not quite...
He presented recently at our clinic at his wits end to see if something could be done using acupuncture - a technique we have become well known for including in our treatment process. I was hesitant to make any promises given the now chronic, yet undiagnosed nature of the problem. However while walking through my usual ankle/ foot assessment, which includes careful palpation of the intrinsic foot muscles, I was able to reproduce his pain by palpating the medial portion of flexor hallucis brevis just distal the bulk of the abductor pollicis. Taut bands and local twitches were also evident during manual examination. Perhaps there was an indication for needling here? I suspected another case of undiagnosed myofascial pain, albeit with more distal symptoms than the sort of myofascial pain which is usually misdiagnosed as plantar fasciitis.
After three sessions of local trigger point needling with plenty of local twitches (he’s a hardy chap and was fine with stronger treatment), local soft tissue release, stabilisation exercise and yes some calf stretching, the results have been very positive. His pain is now negligible as he is progressively increasing his walking distances with the use of a temporary insole.
So another reminder as to how it’s important to always consider the muscles as a source of pain, particularly when other diagnoses have been excluded.