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Biomechancial or surgery tx or both ? Patient discussion

Discussion in 'Biomechanics, Sports and Foot orthoses' started by mike weber, Apr 4, 2011.

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    Hi Folks had a bit on interesting one today, need a little guidance and maybe a good discussion patient.

    60 year old Female patient.

    Slightly overweight but in good General health.

    Presented with chronic Right ankle pain both medial and lateral, feels internal as well and swelling.

    Pain in the morning which gets worse on increased stress.

    Hx 9-10 months ago lateral sprain of the ankle went to Dr rest, NSAIDS you will be fine.

    1 month later still in pain but on holiday walking down some stairs missed a stair feel bodyweight on right foot pain in ankle, could not walk, very swollen. Fitted in a camwalker for trip home ??? ( I did ask how she walked in a cam walker if she could not walk - I won´t give you the answer)

    Came home went to Dr (GP)who told her it is a bad sprain and because of your age it takes time to heal. A few days later in to ER given some NSIADS and go home, patient went back a couple of times, sent to another hospital - X-rays finally taken Diagnosed with a fracture ( Patient can´t remember which bone) but was told bone in to many fragments so surg fixation not an option, continue with Rest, camwalker etc.

    Attached below are the latest X-rays I´m guessing Calc. fracture but there are bone fragments all over the shop.

    Subtalar joint ROM reduced but Talocural joint compensates as does change in gait so patient can walk short distances.

    Due to the talocural joint compensation pain in medial and lateral ligaments as well.

    I will be completing a more detailed assessment in a couple of weeks.

    In this patient I would try a total contact EVA device with Poron/PPT heel with a rocker shoe, but above patient is blind in one eye and has hearing issues and so has very, very bad balance and trying to walk in the camwalker she fell so Rocker soles are out. She also has other heal issues so crutches are a no go.

    She has been told Surg treatment is not an option due to the bone fragments and the orthopedic was pleased with how well in healed and she should `get on with life`. He did say amputation was an option ??

    There are many wholes in the patient history but sometimes the answer to the questions I asked had more info about the weather that day than anything else if you understand what I´m saying.

    Any ideas ?

    Attached Files:

  2. drsarbes

    drsarbes Well-Known Member

    Hi Mike:

    As far as surgical approach;

    First I would assess where her pain is; STJ or Ankle; or both.

    You can perform an ankle scope for debridement if she only has ankle pain. I realize the STJ looks bad, but I have seen this before where the STJ has pretty much self-fused and the ankle is where the pain is, for obvious reasons.

    If her STJ is painful, I would also assess whether it is from pain on motion (intra-articular) or pain associated with the secondary osteophytes/bone fragments.

    At times it is possible for a STJ to look this bad but the patient has localized pain resulting from the bone fragment or spurs which can be resected.

    If she has STJ pain I see not reason why a triple could not be done.

    Good luck.

  3. efuller

    efuller MVP

    Along with Steve's good suggestions:

    The pain may be from allignment issues with the fused STJ. Where's the impression in the shoe? If fused in varus a varus wedge to support could help. You could try gauntlet to limit motion to see if that helped. If the pain is in the joint and alignment is ok you are heading toward joint fusions.

  4. Thanks Gents.

    See how we get on in the full assessment in a couple of weeks.
  5. Berms

    Berms Active Member

    Hi Mike,

    thanks for posting your interesting case. I can't add anything of value to what has already been suggested, but just out of curiosity, you said you are going to be conducting a more "detailed assessment" in a couple of weeks..... exactly what details will you be looking at?

    Thanks, Berms.
  6. No Not yet - Next Monday will post up some results after that.

    I will be looking at mostly where rearfoot motion is coming from - Subtalar or Ankle or as in a more normal person both and how much. Also trying to determine where the pain is coming from - or as I suspect how many places.

    Also look at what motion increase and decrease the pain....

    Think thats it.
  7. Said patient has come back. If anyone interested

    Quality of ROM and Range of motion of the Subtalar joint very poor, when assessing the STJ ROM patient was quite uncomfortable - new shoes and icing have helped a lot and pain and swelling have improved.

    Cast patient with a full contact device high heel cup in mind. I noted the pressure wear in her old shoes (eric suggestion) and will fit a varus Edges from PPT/Poron into the heel in increase cushioning and surface area which comes in contact with the plantar surface of the foot.

    See how we go from here.
  8. For anyone who was interested,

    patient came in for a review 85% reduction in pain and swelling, walking levels increased.

    Very happy patient.

    Nice when you get the unusual ones and treatment works.

    Made my week.
  9. RobinP

    RobinP Well-Known Member

    Good follow up Mike. Good lesson iin doing something that is counter intuitive - giving a varus wedge to a varus ankle . Pts need some convincing some times

    Thanks for that


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