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40yr women with lower leg swelling and pain

Discussion in 'Biomechanics, Sports and Foot orthoses' started by My steps are healthy, Dec 9, 2008.


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    patient came to me as she was concerned that her gait was causing the muscles in her lower leg to over work and enlarge. Specifically the postero-medial aspect of the lower 1/3, palpation of this area was quite painful. During gait this area bulged giving the impression of over pronation. She had been fitted with anti-pronatory footwear for the last 8 years or so. Assessment of her foot revealed hypermobility of the ankle and STJ, but rather high arched and restricted MTJ. All the usual suspects (sup resistance test, jacks test RCSP/NCSP) came out as normal to supinated foot position and on closer analysis of her gait, her foot does function relatively normally, so much so that no matter what I put in her shoe (if I was to do so) is not going to resolve the problem she came in with. Most of the lower limb mucsles are tender on palpation but specifically tib ant especially at its insertion. Here's a bit of an analogy; Its as if there is something that needs to be drained from the lower leg as it is strangeling the muscles and preventing them from functioning effectively. My instinct is telling me something else is going on but I'm needing a point in the right direction as to where to go to next. Your thoughts would be hugely appreciated. :confused:
     
  2. matt007

    matt007 Welcome New Poster

    Have you considered a compartment syndrome?
     
  3. Itchyfeet

    Itchyfeet Member

    Hi There

    Is there any oedema? Remedial Massage or Manual Lymphatic Drainage above the area could help reduce excess tissue fluid. But -

    I think this patient needs to be checked by Physiotherapist or Medic, could be a torn muscle, or muscle detaching from bone. Has she been doing anything out of the usual or too much of the same? Had a patient this week who badly tore one of her Quads trying to lift a heavy TV (they say television is no god for you).

    If this is compartment syndrome this needs dealing with ASAP.

    Merry Christmas (If that's not too controversial)

    :santa:
     
  4. drsarbes

    drsarbes Well-Known Member

    MY STEPS>>>>>

    I'm having difficulty getting a clinical picture.

    Are you saying that when you examine her gait she has a soft tissue, possibly muscle, that becomes prominent?
    And this is on the lower 1/3 post medial (area of the FDL muscle belly)?
    Her pain is at the dorso medial foot and not her leg? Any symptoms in the leg? Warmth? Overlying skin normal?
    Is this "enlargement" bilateral? Is it apparent when seated?
    Chronic or acute? She's 40, what brings her in now? Any lifestyle changes?
    Does it appear different than the usual enlarged calf from talipes equinus?
    General health status?
    Occupation?
    Activity level?

    Steve
     
  5. Are you saying that when you examine her gait she has a soft tissue, possibly muscle, that becomes prominent?Yes
    And this is on the lower 1/3 post medial (area of the FDL muscle belly)?yes
    Her pain is at the dorso medial foot and not her leg? She has general lower leg pain and cant specify a location although palpation on the navicular seemed to have the highest pain response. Any symptoms in the leg? Tib ant muscle belly, FDL tendon at musculotendonos junction level and PL muscle belly tender to palpateWarmth? NO Overlying skin normal? Yes
    Is this "enlargement" bilateral? Yes, however its more obvious on Right side. Is it apparent when seated? No not really although overall swelling masks it.
    Chronic or acute? Chronic She's 40, what brings her in now? Refered from sports shoe shop and issue progressively worsening, she has gained weight over the last 5 yrs from giving up smoking and is trying to exercise to loose the weight but finds it hard due to these symptoms Any lifestyle changes?
    Does it appear different than the usual enlarged calf from talipes equinus? Cant say I am aware of what this would look like, but it is definately separate from the calf.
    General health status? good
    Occupation? office manager
    Activity level? varied but tries to walk (40+mins) and does an aerobics video at home on occasion


    I hope this helps and thank you for responding and your assistance
     
  6. drsarbes

    drsarbes Well-Known Member

    Hi My Steps:

    As long as it's bilateral there is little chance of neoplasm. You can also R/O vascular etiology such as aneurysm or hemangiomatous lesion since it, again, is bilateral and also not warm.

    Itchyfeet's suggestion of a compartment syndrome may be accurate in accounting for her leg symptoms. The bulging may be caused by progressive bilateral fascia rupture or merely biomechanical overuse of the deep post crural muscles; PT, FDL, FHL with secondary hypertrophy. This is common in the gastroc-soleus.

    You can refer out for compartment pressure evaluation.

    Simple compression with an ace may giver her symptomatic relief while you establish a possible biomechanical etiology.

    I'm interested in what others might think of this.

    Hope that helps

    Steve
     
  7. pgcarter

    pgcarter Well-Known Member

    Pain at navicular and swelling along tendon track of post tib?.....sounds like a duck, looks like a duck?.....what about pain in post tib muscle belly?......long term post tib failure can be like this.....does a cam walker relieve symptoms?...I would second the suggestion of compression stockings to see if this helps, it's a fairly cheap diagnostic test.
    regards Phill
     
  8. Mark_M

    Mark_M Active Member

    I would want to rule out compartment syndrome. If you suspect it I would refer to a sports physician or notify their GP for approprite referral.

    Once a diagnosis is made then you will have your treatment plan
     
  9. Romeu Araujo

    Romeu Araujo Active Member

    Hi,

    Your description reminded me of Periostitis. See how tender is the tibia's surface when comparing to muscles/tendons.

    Regards,

    Romeu
     
  10. Adrian Misseri

    Adrian Misseri Active Member

    G'day My Steps Are Healthy,

    Sounds like compartment syndorme as everyone esle is saying, howevre a couple of ideas did come to mind. As Phil suggested, the posterior tibialis tendon/muslce seems like it could be the underlying factor, possibly a sports induced ischaemia? Or could it be compresing the saphenpous veing causing a compression similar to a superficial venous thrombosis? Possibly myocitis/fasciitis? Also bear in mind that just because the mechanics appear normal, the underlying forces on the tarsal tunnel may be anbormal (see all the arguments on kinetics vs. kinematics to see what I mean). Could it also be a tarsal tunnel pathology i.e. irritation of the tarsal tunnel leading to acute sinovitis?

    I'd be keen to whack a bit of padding in the shoe to offload some force from the tibilais posterior tendon and see how you go, whilst also getting a intracompartmental pressure test organised.

    Good Luck!!
     
  11. Peter

    Peter Well-Known Member

    I agree with PG Carter, most plausible lesion is Tib Post tendonosis. Get her to single leg toe- rise, and if OUCH! you have found it.

    I have also seen varicose veins in the tarsal tunnel region, and compression Rx identifies these easily.
     
  12. Cheers for all the advice and ideas. She is awaiting a intracompartmental pressure test. Not sure how I missed that one!!! I'll blame my baby brain!!
     
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