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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