Dear Colleagues,

	I would appreciate any insight or recommendations into the following case.
She has been to several doctors over the last 11 months and no one has yet
to solve her problem.
	The patient is a 28 y/o female, 5'6", 200 lbs., and truck driver by trade.
She was in an auto accident 11 months ago and had her right foot/leg jammed
in the vehicle. There were no fractures appreciated at the time. She
initially said her anterior right shin had hurt, but there was no other pain
until two weeks later when she started having lower back pain, right hip
pain, and then the right foot started to hurt when she ambulated. She had
seen an orthopedic surgeon who wanted to do knee surgery because she was
complaining of some mild knee pain at the time, but she didn't get it done
because that wasn't what was causing her the 'real' pain. She started with
physical therapy and also goes to a chiropractor twice a week. The
chiropractor snaps her right hip back into place by pushing from posterior
to anterior and also re-aligns her back as well. Physical therapy works both
the upper and lower extremities including ROM exercises in both ankles.
	The patient first came to our office 5 weeks ago and a biomechanical exam
was done. Nothing stood out except that it was noted she could only evert at
the STJ 2-3 degrees on each side, the right side having a little less motion
than the left. On resting calcaneal stance, the right STJ inverts
approximately 10 degrees. On neutral calcaneal stance, the right STJ can be
put into a rectus position. When ambulating, there is slight inversion of
the right foot, but more notable is an in-toeing of the right side. The left
side is normal, but the right side is in-toeing a couple of degrees. No
in-toeing can be appreciated on a biomechanical exam, and there is normal
internal/external rotation of both hips. When laying supine in the
examination chair, there are no rotational abnormalities noted.
	I am wondering if the problem is more in the right hip since that is where
she is still experiencing pain and if it is possibly rotating at that level
thus causing the foot to in-toe. She has been in a CAM walker now for 3
weeks with only a mild relief of pain. The pain she mainly has now is on the
plantar portion of the lateral column of the right foot. This is where she
appears to bear the most weight.
	I am sorry for the lengthy e-mail, but any ideas or suggestions would be
most appreciated.

Sincerely,

Jim Licandro, DPM




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