Though I will agree that this is not presenting as a
neuromuscular problem (neuroapraxia). What you and the MD should
consider is the extent of the "contusion". There is a very interesting
article in Physical Therapy Case Reports Re: Ankle Injuries - and that
a contusion could actually be a talar fracure. MRI would assist in the
diagnosis. The case presented was an ankle sprain, that did not respond
to the "conventional" PT intevention.
Article: PT Case Reports, September 98 1(5):242-249. (Lippincott is the
This could be what is occuring in your patient. Perhaps fx
(stress type) is limiting the patient's ability to WB and causing soft
tissue swelling, thus resulting in pain. Something to consider. Might
benefit from aquatic therapy which could assist in strengthening without
the "WB" component.
Aimee Klein, MS, PT, OCS
Graduate Programs in Physical Therapy
MGH Institute of Health Professions
101 Merrimac Street, Suite 605
(617) 724-4854 (fax)
email: [log in to unmask] edu
From: [log in to unmask]
To: [log in to unmask]
Subject: Perplexing Case
Date: Sunday, October 04, 1998 6:13PM
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.
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
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
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
with the ES off. She can tolerate 60 pounds of weightbearing on her
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