Doug and Aimee,
I'm curious to know what the rationale is for a CT and bone scan after 16
weeks of casting? Is it still possible for a fracture, if there was one,
to still be symptomatic and not healed after 4 months of immobilization?
Thanks in advance,
> From: Douglas M. White <[log in to unmask]>
> To: [log in to unmask]
> Subject: Re: Perplexing Case
> Date: Tuesday, October 06, 1998 8:41 AM
> While she doesn't show "overt signs of RSD" I would be concerned that she
> may be exhibiting early RSD. If not, she is certainly very susceptible to
> it. I agree with Aimee that you should look to occult injuries. More work
> is indicated. What radiographs were done? Consider bone scan and CT of
> etc. The stocking distribution of her sensation deficits is not readily
> explained by an occult injury or by peroneal neuropraxia. I don't think
> malingering is an issue at this point although she does need a lot a
> reassurance etc.
> Good Luck. Keep us posted.
> Douglas M. White, PT, OCS
> Milton, MA USA
> Klein, Aimee B. wrote:
> > Nick:
> > 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
> > a contusion could actually be a talar fracure. MRI would assist in the
> > diagnosis. The case presented was an ankle sprain, that did not
> > to the "conventional" PT intevention.
> > Article: PT Case Reports, September 98 1(5):242-249. (Lippincott is
> > publisher)
> > 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
> > the "WB" component.
> > Good Luck..
> > **************************************************
> > Aimee Klein, MS, PT, OCS
> > Graduate Programs in Physical Therapy
> > MGH Institute of Health Professions
> > 101 Merrimac Street, Suite 605
> > Boston, MA
> > (617) 724-4848
> > (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
> > 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
> > 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
> > 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
> > of
> > peroneal neuropraxia nor his treatment. Also, the patients deficits
> > 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