Dear Colleagues,

I have been treating a 35 yo female postal worker who was struck laterally
just above the left ankle with a heavy steel mail bin five months ago.  She
suffered no boney injuries and was diagnosed with a contusion.  She was seen
by an orthopedist who placed her in a short leg cast for two months.  The cast
was removed and PT at another site was initiated.  However, according to the
patient, the ankle and foot became very painful and she returned to the
orthopedist 1 week following the cast removal.  He diagnosed peroneal
neuropraxia despite that an EMG taken at that time was completely normal.  The
patient was then placed back into a plaster cast for two more months.  The
orthopedist office notes do not describe the rationale for doing so and are
not very helpful.

She presented to me two weeks ago NWBing on the left for physical therapy.
She had no c/o pain at rest.  The *entire* left foot was insensate to the 75g
monofilament except the toes which were insensate only to 10g.  She displayed
painful apprehension upon testing tarsal joint play.  There was minimal edema
and no overt signs of RSD.  Reflexes were normal. Sagittal ROM was DF:
negative 15 , PF: 30.  She was unable to move her foot upon request but could
slightly wiggle the toes ( and states a week ago she could not do this ).
Calf atrophy seemed proportional to the amount of immobilization.  No Tinel
sign was elicited t/o the left foot and leg.

I have since worked with her for two weeks.  My treatment has included tarsal
joint mobilizations (tolerated well), neuromuscular electrical stimulation to
the DF and PF groups set for reciprocal AAROM, calf stretching (manually in
the clinic and with towel at home), gait training for PWB heel-toe pattern
with B/L axillary crutches, and standing weight shifts onto the left lower
extremity.

ROM has improved to DF= 0 and PF= 35.  She shows a small amount of active DF
with the ES off.  She can tolerate 60 pounds of weightbearing on her left for
no more than ten seconds (limited by pain).  

Although she is making some improvement, I find the case unsettling for
several reasons.  First, I do not agree with the orthopedist's diagnosis of
peroneal neuropraxia nor his treatment.   Also, the patients deficits do not
follow a peripheral nerve pattern. And lastly, the EMG is normal!

My differential for this case is 1) residual effects of a compartment syndrome
(a stretch I know, the EMG finding don't support this), 2) malingering, 3)
hysteria.  Is there anything I'm missing here??  Are there additional
treatments that may benefit this patient?

I would appreciate any help.

Nick Taweel, DPM, PT, CPed


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