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foot pain - July 9, 2000 3:45:00 PM
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Betty Smoot
Posts: 49
Joined: March 1, 2000
From: Sonoma CA
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I'm hoping for some guidance & suggestions with a patient I find challenging. Any ideas out there? This is long, hope it's not too...
HISTORY: JM is a 55 yo male, teacher and videographer, who sustained an injury to his right foot on August 21, 1999. He stepped on a rock (at his instep/arch) while wearing soft soled "water" shoes. He had local pain for 2 weeks, saw his MD who x-rayed (negative) and gave him NSAIDS, without benefit. Due to some out of the area family issues (Mom sick) he wasn't able to go back to the doc til November '99, with persistent foot pain, at which time he saw the FNP. She prescribed magnetic insoles that didn't help. He returned them after 2 days and was started on a new NSAID. 2 days later he recieved an injection into the painful area. This gave him some relief, but activity over the following weekend flared his sx. He saw an orthopod in mid November: x-rays again negative. A bone scan done in December showed evidence consistent with an occult fracture in the midfoot. He was placed in a proprietary boot for immobilization. An xray in January was thought to show a healing stress fx of the base of metatarsals 2 or 3. He did well with the boot, was a bit better, but pain and swelling persisted, with pain in the top of the foot now. Xrays in March showed a fuzzy irregularity in the mid metatarsals including all of the shafts. The radiologist & orthopod discussed the possiblity of early Pagets but the hx wasn't typical. They favored RSD, although felt it unusual to see so much reaction on the bone scan. MRI of the foot done in March showed abnormal marrow signal in the navicular and tarsus and 3-5 metatarsals, felt to be compatible with RSD.
Based on the imaging studies, the subjective report of hypersensitivy (pain) to touch, as in drying his feet with a towel, and the persistent/variable/changing pain presentation, he was diagnosed with Complex Regional Pain Syndrome.
Okay...
Treatment since the boot, and til P.T., consisted of Vioxx 25 mg daily (which he still uses), and Vicodin (which he uses only occasionally)
Past hx is significant for polio at age 8 affecting his left lower extremity: he's had his left ankle fused and had heel cord lengthened. He has a small leg length inequality & uses a lift in his left shoe.
He's working currently, uses 1 or 2 crutches with gait.
P.T. Eval: 5-31-00
SUBJECTIVE: The pain has changed since the initial injury, starting at the arch, moving up toward the top of the whole foot with pain and burning, pain then around the ankle anteriorly then posteriorly, now settling more at the anterior ankle. He had a period in which the foot was very sensitive to touch. He now c/o pain in the anterior ankle and less posteriorly, with gait & bearing weight. He has resting ache at end of day, but primary sx are sharp pain with gait during midstance and push off. He occasionally has pain with heel strike as well.
There's no numbness or tingling, and no other leg or back pain.
OBJECTIVE:
Posture: back, hips, knees WNL. In standing his right heel is everted slightly with a mild loss of the medial longitudinal arch.
Lumbar spine ROM is full and painless. Hip and knee ROM are full and painless. SLR and PKB show good mobility and negative tension signs.
Right LE sensation, reflexes WNL
Right ankle strength to MMT are WNL except inversion 4+ with pain at the anterior ankle.
ROM of the right ankle:
DF 5 degrees active, 10 degrees passive
PF WNL
Eversion 10 degrees
Inversion WNL
overpressure at all end ranges okay
Pulses: I couldn't detect dorsal pedal pulse on the right, did on the left. Right foot is warmer at the ankle & proximal foot, cool at toes.
Palpation/Observation: Swelling present at antero-lateral ankle and posteriorly adjacent to Achilles tendon bilaterally. He's tender along the anterior ankle especially palpating the talus in PF, posterior to the medial malleolus, and along the longitudinal arch. Metatarsal mobility WNL, tarsal mobility okay except pain at anterior ankle with anterior glide of calcaneus in position of mild PF, mild decrease in talar glide with dorsifexion.
Overall, he's improving gradually with therapy. 14 treatments so far have included: phonophoreses with fluocinonide or iontophoresis with dexamethasome over the antero-lateral ankle tender area, mobilization to restrictions, ice, and education. He's doing weight bearing activities and walking in his pool, and ROM exercises. Currently I'm working on the theory that the anterior capsule or perhaps the neural elements that cross the anterior capsule are at fault here.
His findings continue to be somewhat variable & this bugs me. His tenderness is consistent at the anterior ankle, but variable in other regions. Pain with ROM is variable too, as is stress to the ankle joint & subtalar joint. He doesn't have the hypersensitivity any more and sensation is normal. The orthopod tried another local injection to the antero-lateral hot spot, but this flared his sx.
What do you think of the dx (CRPS/RSD)?
What about the possibility of an anterior tarsal tunnel syndrome?
Any other thoughts on dx or treatment?
Thanks for looking this over. Any ideas would be appreciated.
Betty
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Re: foot pain - July 13, 2000 5:09:00 PM
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Betty Smoot
Posts: 49
Joined: March 1, 2000
From: Sonoma CA
Status: offline
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SJ,
Thanks for the reply, I appreciate the help.
This guy, thankfully, is doing a bit better (~25%).
Complex Regional Pain Syndrome is the new name for RSD, under the classification system by the International Association for the Study of Pain.
His orthopedist, who diagnosed the RSD/CRPS, wants to try the least aggressive stuff first (PT & meds). I'll talk to him about other meds & blocks...he's a pretty open fellow so if the patient doesn't get 'nuf better in a reasonable time we'll move on!
Thanks again!
And, re: your back pain patient with the shift...I think your caution with him was warranted. Sometimes the signs and sx just don't jibe and stuff doesn't feel right. We need to err on the side of caution in those situations and follow it through til we're satisfied that somebody's paying attention.
I hope he does well.
Thanks again.
B
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Re: foot pain - July 26, 2000 12:22:00 PM
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DamonPT
Posts: 1
Joined: July 10, 2000
From: Brattleboro, VT, USA
Status: offline
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Something I would consider is the accessory motion that has been referred to as the "talar swing". I find that many ankle patients have a minor anterior subluxation of the talus when the ankle is "sprained". This results in a very firm to hard endfeel when you try to DF the ankle. This subsequent limitation can result in the rest of the foot being under greater strain. Obviously this is very unlikely to be the source of the MRI/radiological changes but it may have been a part of the early dysfunction that has let up to your client's present condition. If the talus feels restriced it can be reduced by a traction/posterior glide manipulation (like a "J" motion) but I would stress EXTREME caution with this technique given the RSD diagnosis as this could flare it up significantly. If nothing else this may help with your next ankle patient. Good luck!
[This message has been edited by DamonPT (edited July 26, 2000).]
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Re: foot pain - July 26, 2000 5:42:00 PM
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Betty Smoot
Posts: 49
Joined: March 1, 2000
From: Sonoma CA
Status: offline
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Damon and SJ,
Thanks for the input.
He's doing better, with reduction in pain and swelling and improved gait with less assist device (cane now versus crutches).
It's slow but steady progress with caution not to exceed his tolerance.
Damon, good call. He did have limited talar glide with DF, and we're working on it...both with mobs in NWB doing DF with talar distraction & glide as you describe, and doing a knee to the wall exercise to promote increased DF in weight bearing. He tends to overdo with this and has a bit more pain now in the posterior tibial tendon region, but hopefully this'll settle with attention and support (in more ways than one!).
Thanks again very much.
Betty.
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