dear matthew
i had a similar case pop into the office yesterday, this lady was very
overweight, medial arch pain with activity. her GP recommended soft arch
supports, stretches and runners which caused her more discomfort. patient
can only walk for for 200-400 metres before the onset of pain. palpation of
the abductor hallucis was tender and firm along it's entire course and
there was painful herniation at the proximal superior aspect of the origin
of this muscle. on clinical exam all pulses were present.i didn't have a
pressure cuff and elevated her leg just above heart level, about a 25
degree SLR. After 60 seconds of active dorsiflexion and plantarflexion pain
presented in the medial arch. (a quick and simple diagnostic test- though
not 100%) She also experienced some anterior ankle joint pain and
paraesthesia of the digits which she had not experienced before. Does your
lady have any of the other symtpoms. D/Dx- compartment syndrome, arterial
entrapment/aneurysm, popliteal artery entrapment syndrome, tarsal tunnel.
hope that this gave you some ideas. For simple test try the elevation of
the leg and see if she can exercise through the pain, i would like comments
from other out there if they have diagnosed alot of compartment syndrome
but from experience they have difficulty in continuing with exercise.
happy hunting
regards ben sibley
-----Original Message-----
From: Matthew Appleton [SMTP:[log in to unmask]]
Sent: Thursday, 28 October 1999 1:10
To: [log in to unmask]
Subject: Severe MLA Pain in a 15 year old
I would appreciate the thoughts of the mailbase on this very difficult
problem.
In summary, A 15 yo female pt presented today with a 2.5 year history of
severe bilater MLA pain which she localised over the plantar facia,
adbductor hallucis region with asscocited posteromedial ankle pain and
sinus
tarsi pain laterally. This problem has been diagnosed in tha past as
plantar
fasciitis for which she has seen 4 Pods, 4 orthopods, Rheaumatologists,
Chiros, Neurologist, Kinesiologist, Masseur Naturopath, Physio and
Anaethetists with past treatment including taping padding strapping lots of
orthoses, accupuncture manipulation and even a week in a Rehab Hospital.
She
is unable to walk two laps of an oval without deep aching pain and requires
Paracetamol if she wishes to walk beyond a abot 400m . No past intervention
has changed her pain. Investigations include Ultrasounds of the Plantar
Fascia and invertor tendons, Nerve conduction studies, Bone Scans and CT
Scans for Coalition, MRI and plain films all of which are unremarkable.
Clinically she was acutely tender over the proximal and midslip bands of
the
plantar facsia and over the abductor hallucis. biomechanically she had
slightly reduced STJ and MTJ ROM and end range STJ and MTJ hyperpronation
through the entire stance phase. She had mild tenderness over the Tib Post
tendon but a normal single toe raise. Neurological evaluation was NAD.
It would appear she has chronic debilitating plantar fasciitis and abductor
hallucis overload with other secondary symptoms ( Tib Post / Sinus tarsi)
which have not responded to any conservative measures.
I would be appreciative of the mailbases thoughts on surgical options given
her age and the prognosis of these options and indeed any other thoughts.
Regards
Matt
Matthew Appleton
Director of Podiatry
Sports Medicine Centres Of Victoria
316 Malvern Rd Prahran 3181
Melbourne Australia
Phone (61) 03 9529 8899 Fax (61) 03 9529 4248
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