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PHYSIO  October 1998

PHYSIO October 1998

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Subject:

Re: Perplexing Case

From:

"Jason A. Steffe" <[log in to unmask]>

Reply-To:

<@[log in to unmask]>

Date:

Sun, 4 Oct 1998 21:11:29 -0400

Content-Type:

text/plain

Parts/Attachments:

Parts/Attachments

text/plain (110 lines)

Nick, 

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
strength?
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
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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