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Case Study

Discussion in 'Biomechanics, Sports and Foot orthoses' started by Podski, Jun 17, 2007.

  1. Podski

    Podski Member

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    Patient: 29 years old and was very active before accident.

    Hx: mountain biking accident 12/12 ago caused AJ and distal fibula #. Steel plate inserted into distal fibula. Pt contracted osteomyelitis shortly after Sx and remained in hospital for 5/12 on IV antibiotics. 3/12 on oral antibiotics. Patient began receiving physio joint manipulation therapy 4/12 ago.
    Currently Pt has nil DF at AJ and has regained approx. 10 degrees PF through joint mobilisation. Minimal abd. or add. present. In gait, he has minimal heel strike with majority of WB in forefoot and contralateral limb.

    QUESTION: Joint mobilisation from physio is excruciating for this Pt but has been the only thing providing him with greater ROM. Is there anything I can do to increase his AJ ROM with conservative therapy? orthotics? a night splint? What do the gurus think?

    Cheers, Podski1
  2. LuckyLisfranc

    LuckyLisfranc Well-Known Member

    There are a number of variables to consider, but one should remember firstly that the underlying ethos of physiotherapy is to "get joints moving", whilst podiatrists tend to "restrict joints moving".

    Firstly, there has been an ORIF - how well was this done? - and how much is this limiting ankle joint ROM. Secondly, there has been osteomyelitis, and is there was any hint of septic arthritis also that will not be helping the situation. Whenever there has been significant surgery and osteomyelitis the outcomes are generally poor.

    If this is purely posterior calf and ankle joint capsular tightness, then ROM should improve. However if this chap now has an osseous equinus - which sounds like the most likely scenario - nothing short of revision surgery will help ROM. A weight-bearing lateral, and a stress dorsiflexion lateral x-ray will help to assess this properly.

    Conservatively, is the situation is osseous, accomodate the equinus and try to allow him to cope with it, or discuss surgical options if this fails.

  3. efuller

    efuller MVP

    Those are some interesting abbreviations, I'm still trying to figure them out.

    Don't treat the goniometer measurements. The pain/complaints the patient is having can certainly be related to decreased ankle joint range of motion. Where is the pain? In what activities does it occur?

    The answer to your question lies in diagnosing the cause of the limited ankle joint plantar flexion.

    You can still bike with a fused ankle. What are the patient's expectations?


    Eric Fuller
  4. tarik amir

    tarik amir Active Member

    The mobilisation could be done under local anaesthesia. Depending where the pain is when mobilisation is performed.

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