Javier
You wrote
<Anyway, I am a firm defender of manipulation techniques for improving a
large number
of conditions, but also I think that if there are well-trained professionals
(physical terapists) who do this work I can referred my patients to them
with total confidence.>
While I understand the reluctance to manipulate the foot as perhaps it is
outside the scope of podiatry, I feel the same way, you know what needs to
be done but lack the skill and technique to do it.
However I have yet to find a physio or osteopath, in my area, who have
sufficient understanding of foot mechanics to enable them to be confident in
the manipulation as required. Often they shy away from the referral.
Perhaps this is not typical?.
But Re the current discussion on HPC registration and worries about 'Dodgy'
qualifications. How far should Podiatrists go into the area of Physio
therapy without 'proper qualification'?
Cheers Dave Smith
----- Original Message -----
From: "Javier Ordoyo" <[log in to unmask]>
To: <[log in to unmask]>
Sent: Thursday, September 02, 2004 10:21 AM
Subject: Re: Peroneus Brevis tenosynovitis
Dear Paul,
Regarding your comments:
"As regards her pain. I would be only too keen to send her to a pain
management clinic for a diagnosis. Especially as Complex Regional Pain
Syndrome in the ankle is more common than one thinks"
In this case, the pain was not typical neurological ("burning sensation"),
it was anatomical located on the peroneus (particularly on the peroneus
brevis) and it was related to activity and locomotion. For these reasons,
the diagnosis was tendonitis instead of a neurological condition. Although,
as you have quoted the "Complex Regional Pain Syndrome" can be easily
misdiagnosed for other conditions.
"I note that you do not like to manipulate the foot and ankle. If you would
like to learn these techniques along with soft mobilisation techniques, I
will be back in the UK in January along with Shane Toohey to teach these
techniques. My website is www.musmed.com.au for all the details"
I appreciate your offer, but if I can hardly time to travel to Madrid I am
afraid that it would be much difficult to find time to fly to UK. Anyway, I
am a firm defender of manipulation techniques for improving a large number
of conditions, but also I think that if there are well-trained professionals
(physical terapists) who do this work I can referred my patients to them
with total confidence.
Regards,
Javier Ordoyo
Private Practice
Barcelona -Spain-
-----Mensaje original-----
De: A group for the academic discussion of current issues in podiatry
[mailto:[log in to unmask]] En nombre de Paul Conneely Enviado el:
domingo, 29 de agosto de 2004 9:49
Para: [log in to unmask]
Asunto: Re: Peroneus Brevis tenosynovitis
Dear Javier
I have followed this case with interest.
Several points I have noted that may be important.
The walk on the beach. Was it a long one and was the right foot the side
closest to the water?
The reason for this is the fact that long walks on the eversion side often
lead to peroneal problems with associated locking of the calcaneocuboid
joint. This in turn produces increased pronation and adduction of the
midfoot. This you have seen as a flattening of the medial foot during
walking especially after heel off.
As she is a ballet dancer, she will have a tendency to lock the lateral foot
(that is the cuboid and lateral cuneiform) so as to produce a very strong
foot for points/ballet.
The walk on the beach probably was the icing on the cake for an injury that
was probably there. As you said in your earlier notes she is semi
professional and thus like most of these individuals will train through
injury after injury.
As regards her pain. I would be only too keen to send her to a pain
management clinic for a diagnosis. Especially as Complex Regional Pain
Syndrome in the ankle is more common than one thinks.
I have a patient who slipped on 1 front door step last Christmas eve and she
now has it big time.
Two major things to look out for are:
1. Hyperalgesia. This is the state where a stimulus that is normally painful
is perceived as MORE painful (like turning up the volume on the
radio) than it should be under normal conditions.
2. ALLODYNIA. This means other force. This classic feature is when a
stimulus a light as stroking with a feather is perceived as painful.
The 64-dollar question is what causes the situation to get out of hand?
Nobody knows but two interesting things are aroused in these souls.
In the dorsal root ganglion there are neurones that only have branches to
the spinal cord especially in the lamina 1,3 and 7 of the spinal cord. These
ganglion sit there do nothing until they are stimulated after an injury.
This injury can be an almost nothing (Venipuncture) to major fractures etc.
after a motor vehicle accident.
Once they start nothing will stop them (in general).
This in turn leads to some of the cells in the lamina losing their receptor
sites (something turns on the DNA and the cell walls change forever). This
is similar to a house that has had all the windows and doors blocked up with
bricks thus no stimulus can come in, but there is nothing to stop it coming
out. These ganglia just yell at the thalamus and this is interpreted as
pain.
This is why medication in the majority of cases just does not work.
Some are lucky and respond to sympathetic blocks. Others have a life of
hell.
Another thing that occurs is a new process called "Centre surround
inhibition". This complex model explains how pain is felt more severely.
This model will hit the papers in the next few years. It can explain complex
pain problems. The model is very complex to say the least.
I note that you do not like to manipulate the foot and ankle. If you would
like to learn these techniques along with soft mobilisation techniques, I
will be back in the UK in January along with Shane Toohey to teach these
techniques. My website is www.musmed.com.au for all the details.
Regards,
Paul Conneely
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