Working Diagnosis:
Mueller Weiss Syndrome

Treatment:
Initially, he elected conservative management (CAM boot, weight-bearing as tolerated) and physical therapy. Due to persistent pain, approximately two months after being diagnosed with Mueller Weiss Syndrome, he decided to proceed with surgical intervention, which entailed a talonavicular cuneiform fusion with autograft and navicular fracture repair Case Photo #4 Case Photo #5 Case Photo #6 . After surgery, he was placed in a splint and was made non-weight bearing for six weeks.

Outcome:
He returned to practice seven months after surgery. Two weeks later, he sustained a stress fracture to his 4th metatarsal, which was treated conservatively. Three months later, he developed left mid-foot pain due to progression of Mueller Weiss Syndrome. He underwent left mid-foot fusion surgery and returned to practice six months later. Two weeks later, he developed right foot pain and was diagnosed stress fractures of his 3rd and 4th metatarsals. Since then, he has been weight-bearing as tolerated in a post-op shoe and has decided to medically retire from football.

Author's Comments:
Mueller Weiss Syndrome is a rare cause of mid-foot pain, characterized by adult-onset osteonecrosis of the navicular bone (1-7). It predominantly affects women, usually in the fourth to sixth decades of life (2, 5, 6). Mueller Weiss Syndrome typically presents with chronic, progressive mid-foot pain, which can be exacerbated by weight-bearing activity (1, 5, 6). As the navicular collapses, osteoarthritis often develops, and with further collapse, pes planovarus may develop (5-7). Characteristic imaging findings for Mueller Weiss Syndrome include dorsomedial dislocation of the navicular bone along with collapse of the lateral navicular bone, resulting in a "comma-shaped" configuration (2, 3, 5, 7). In this case, the deformity of the navicular bone was consistent with Mueller Weiss Syndrome. Bilateral findings also favored Mueller Weiss Syndrome over non-union from previous trauma (2, 5, 6).

Editor's Comments:
Mueller- Weiss Syndrome is a rare idiopathic degenerative condition involving osteonecrosis of the navicular bone and degenerative arthritis of surrounding joints. It is believed that the degenerative changes begin in childhood but symptoms typically present in adulthood. Keep in mind systemic diseases such as rheumatoid arthritis, lupus, renal failure and Pagets disease in the differential for patients with suspected MWD. It is typically treated conservatively initially with NSAIDs, limited weightbearing and physical therapy. Operative treatment should be considered after 6 months of failed conservative management. (6)

References:
1. Bartolotta RJ, McCullion JC, Belfi LM, Hentel KD. Mueller-Weiss syndrome: imaging and implications. Clinical Imaging. 2014
2. Janositz G, Sisak K, Toth K. Percutaneous decompression for the treatment of Mueller-Weiss syndrome. Knee Surgery, Sports Traumatology, Arthroscopy. 2011
3. Nguyen AS, Tagoylo GH, Mote GA. Diagnostic Imaging of the Mueller-Weiss Syndrome. Journal of the American Podiatric Medical Association. 2014
4. Reade B, Atlas G, Distazio J, Kruljac S. Mueller-weiss syndrome: An uncommon cause of midfoot pain. The Journal of Foot and Ankle Surgery. 1998
5. Samim M, Moukaddam HA, Smitaman E. Imaging of Mueller-Weiss Syndrome: A Review of Clinical Presentations and Imaging Spectrum. American Journal of Roentgenology. 2016
6. Volpe A, Monestier L, Malara T, Riva G, Barbera GL, Surace MF. Muller-Weiss disease: Four case reports. World Journal of Orthopedics. 2020
7. Wang X, Ma X, Zhang C, Huang J-Z, Jiang J-Y. Flatfoot in Muller-Weiss syndrome: a case series. Journal of Medical Case Reports. 2012

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