Advice needed to treat complex patient.

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Hi all, this is the first time posting so sorry if its not well formated.

I have a question regarding a patient I saw earlier this week, he came to my clinic complaining of very severe right ankle pain.
Previous history was vague and revealed he had had surgery to his right knee, due to severe trauma. The surgeon requiring a tendon and ligament for the knee reconstruction removed the flexor hallucis tendon.
On examination it was apparent that the patient was unable to dorsiflex the AJ using TA muscle as it seems paralysed, his only means of dorsiflexion comes via the extensors and what seems to be a prominant perineous tertius (which is extreamly tight, and so holding the foot in a pronated position).
This is as you can imagine causing abduction of the foot.
On standing the STJ almost looked subluxed as both feet are excessively pronated. RCSP are both everted approx 11 degrees.
Pain is experienced in the region of the sinus tarsi especially on palpation, most likely due to the excesively pronated foot.
Pain is also experienced on any form of adduction of the foot or supination of the MTJ.
slight relief is provided on forced inversion of the calcaneous, although the fore foot stays abducted, andslight dorsiflexed
My question is this; should i refer this patient to a podiatric surgeon for a release of the extensor tendon, or due to this being the only means of dorsiflexion would this be pointless?
I've rescheduled this patient for a casting for custom orthoses but would like some advice on the kind of orthotic i should prescribe him. Is there something that can exert the kind of inversion on the calcaneous that gained relief while facillitaing the forefoot in its current state?
thank you for taking the time to read this long posting.
steve

 

Pretty good history Steve. The fact that your assessment was thorough enough to obtain aggravating and easing factors makes decision-making a touch easier.

(The active dorsi-flexion issue is a concern and its (neurological/musculo-tendinous etc) source may be investigated further. Signs of foot-drop in swing???? Ultra-sound investigation +/- MRI($$$) may give you some indication of the integrity of the TA tendon. The MRI, if sought, may also give you some idea regarding the possible impingement laterally.)

It sounds like this fellow could possibly be experiencing an impingement pathology in the lateral aspect of the ankle. As you have pointed out, inverting the calc opens this side up and reduces compression forces on the lateral side. Some would perhaps suggest a DC wedge or a blake inverted device; particularly for that side. You might even want to get things going now with a medial (inverting) rear-foot wedge. You might want to check ankle sprain history etc. before surging ahead with such devices.

You also mentioned that MTJ supination is provocative. An inverted rear-foot device will relatively pronate the forefoot. To go further though, a forefoot valgus post may insure that the MTJ is supported away from the provocation.




This is complex case. If there is some foot-drop...Tib Ant issue, maybe talk to a P&O regarding an AFO for at least the short-to-medium term.



BTW, how has the FlexorH tendon's removal impacted on "Jack's test"?




Ron

 

In regard to the Tibialis Anterior, it may just be inhibited and may respond to dry needling / spray and stretch to activate it. Then the long extensors / peroneus tertius won't have to work so hard. Also check that the anterior compartment aren't being overworked due to a tight gastroc / soleus.