Sounds to me like she's suffering from 16 weeks of immobilization for a
bruise (ligament sprain at worst). Her talocrural and subtalar joints are
undoubtably hypomobile and are in need of mob's; as well as every joint in
her foot for that matter. What are the end feels like? Where is the site
of pain with TTWB? Is there pain with PROM? If so, where? I doubt she's
outright malingering as you have objective evidence of dysfunctions ie. str
and arom loss and inhibited functional gait. Whether or not she's
enhancing her pain experience is of no consequence as we cannot measure
such things nor prove a patient is in fact being overreactive; just focus
on the dysfunctions and correct them. Her apprehension should decrease
with improved use of the LLE, plus she's 35 and still resilient. Have you
thought of desensitizing Tx's? Is her skin sensitive to light brushing?
Stiff joints aren't painful in and of themselves, but they are prone to
symptoms with stresses to the capsule, and the adaptive shortening that no
doubt has occurred unnecessarily , this may be a contributing factor to her
discomfort, as well as possible gastroc pain while being put on stretch
with weight bearing. Does she know the difference between stretch
discomfort and pain due to soft tissue injury? Does she equate them? The
MD should've considered a NCV test in addition to an EMG, as EMG does not
test sensation. Also, peroneal nerve apraxia at the fibular head is common
with tight casting for long periods of time (and she sure had plenty of
time to produce this dysfunction!) How is her peroneal muscle group
Hope this helps and let us know how she turns out. Push her.
Jason Steffe MS, PT
> From: [log in to unmask]
> To: [log in to unmask]
> Subject: Perplexing Case
> Date: Sunday, October 04, 1998 6:13 PM
> Dear Colleagues,
> I have been treating a 35 yo female postal worker who was struck
> just above the left ankle with a heavy steel mail bin five months ago.
> suffered no boney injuries and was diagnosed with a contusion. She was
> by an orthopedist who placed her in a short leg cast for two months. The
> was removed and PT at another site was initiated. However, according to
> 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.
> patient was then placed back into a plaster cast for two more months.
> orthopedist office notes do not describe the rationale for doing so and
> not very helpful.
> She presented to me two weeks ago NWBing on the left for physical
> She had no c/o pain at rest. The *entire* left foot was insensate to the
> monofilament except the toes which were insensate only to 10g. She
> painful apprehension upon testing tarsal joint play. There was minimal
> 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
> slightly wiggle the toes ( and states a week ago she could not do this ).
> Calf atrophy seemed proportional to the amount of immobilization. No
> sign was elicited t/o the left foot and leg.
> I have since worked with her for two weeks. My treatment has included
> joint mobilizations (tolerated well), neuromuscular electrical
> the DF and PF groups set for reciprocal AAROM, calf stretching (manually
> the clinic and with towel at home), gait training for PWB heel-toe
> with B/L axillary crutches, and standing weight shifts onto the left
> ROM has improved to DF= 0 and PF= 35. She shows a small amount of active
> with the ES off. She can tolerate 60 pounds of weightbearing on her left
> 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
> peroneal neuropraxia nor his treatment. Also, the patients deficits do
> follow a peripheral nerve pattern. And lastly, the EMG is normal!
> My differential for this case is 1) residual effects of a compartment
> (a stretch I know, the EMG finding don't support this), 2) malingering,
> 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