Chronic oedema and foot pain

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Thank you in advance to anyone willing / able to assist with the following patient complaint!
I'd particularly like to know what the surgeons have to say on the original management of the calcaneal injury.

Complaint:

A 45 year old otherwise healthy lady presented with significant dense, non pitting oedema from her right lateral malleolus to the dorsolateral R foot region (extending to the base of the toes), for approximately 2 months. Pain was precisely over the R CFL and vaguely in the dorsolateral forefoot region.

Histoy:

This lady fell off a 1.5m ledge onto her right foot 9 months ago which caused a comminuted fracture of her calcaneus, breaking into 5 fragments displaced in the body by approx 4mm.
The injury was not diagnosed correctly until a week of (painful) weight bearing.
The orthopaedic surgeon ordered her to be non weight bearing in a wheelchair for 3 months, then on crutches for another 3 months.
No other treatment or rehab was performed during this time.
She saw a physio 1 month ago who prescribed strengthening exercises for her foot which successfully increased strength, however, did not reduce her pain.

Medical Hx:

Nil significant history other than the calcaneal fracture 9 months ago
Nil past surgical history.
Medications:
Only panadol or neurofen for her foot pain which is ineffective.

Significant physical exam findings:

Differences in mm strength between feet / legs are negligible although visually R side has less muscle bulk.
STJ inversion / eversion and ankle plantar- / dorsiflexion within normal limits (WNL) R and L.
Slightly medially deviated STJ axis on the R
10g monofilament and vibration sensation intact BF
Dense, diffuse non pitting oedema in the painful region described (R foot), with small varicose veins infiltrating

WB:

FPI: R, 6 L, 4
Jack’s test is slightly restricted R>L in stance
Moderately hard supination resistance test R
Instance pain in dorsolateral R foot region upon rising onto toes.

Gait:

Slow and measured - places R (symptomatic) foot down carefully to avoid pain
Shooting pain in the CFL region if she tries to walk fast
Pain is felt during midstance as weight is transferred from the hindfoot through to the mid and forefoot (not on heel strike)
Slight genu valgum and tibial varum R>L
R >> L forefoot is abducted throughout gait
R calcaneus is slightly more everted than L throughout gait
Nil restrictions to sagittal plane motions at the ankle or 1st MPJ noted

Footwear:

Sneakers, thongs and barefoot.
Pain does not feel any better in sneakers and if anything, worse as the swelling increases!

Imaging:

X-Ray April 2013 (1 week post injury):

Showed undisplaced fractures of R calc
Fractures extended to STJ
Joint spaces WNL
Bohler’s angle 13 degrees

CT scan April 2013:

Comminuted # of calc body and post tuberosity and extending of sustentaculum talus and anterior process
5 large fragments
Displacement of the # fragments in the body by ~4mm
Bohler’s angle 13 degrees
STJ ant and post facets involved
STJ and sinus tarsi alignment anatomical

X-Ray May 2013:

Osteopaenia present
Slight incongruence of post STJ
Poor # detail

X-Ray July 2013:

Min incongruence across post STJ

X-Ray Dec 2013:

Bones osteoporotic in the ankle and mid tarsal region
Marked loss of bone density of: talus, calc, navicular and cuneiforms
Minor loss of density of forefoot bones

Ultrasound Dec 2013:

Small fluid deep to ATFL
Normal CFL
No tendon or lateral ligament abnormality identified

Assessment:

STJ synovitis and infiltration of fibrotic tissue from the fracture interrupting the STJ congruence. DDx: sinus tarsi syndrome, CFL impingement, complex regional pain symdrome
Compression of forefoot structures (?neuroma) from forefoot hypermobility and abduction, along with chronic oedema.

Plan:

Compression sock to help reduce oedema
Low dye strapping to help reduce forefoot abduction and trial functional support.

In all honesty, I’m not sure to what degree the original injury can be salvaged from here, but I would be very appreciative of any suggestions to help the cause!

Thank you in anticipation!

 

That jumps out at me as possibly underpinning the current problem.
Yes, use the strapping' also use a lot of physical therapy - manips and mobs.

 

Yes, and down the road the STJ will probably need to be fused.

Currently, it appears her main problem is CRPS and she needs to be referred to pain management for possible sympathetic blocks and medication.

Right now, I am inclined to think she has CRPS and the quicker it is diagnosed the better, so it can be aggressively treated.

Steven

 

Thank you for your advice and for replying so quickly Craig and Steven.

Are either of you aware of the potential role of bisphosphonates in CRPS where osteopaenia is present?

Thank you

 

I do not have experience in using bisphosphonates for CRPS. Why not refer her to a pain specialist that specializes in CRPS?

Steven

 

Thank you for your suggestion.

I have found such a doctor in SA and have referred her regarding pain management.

 

FPI: R, 6 L, 4
Jack’s test is slightly restricted R>L in stance
Moderately hard supination resistance test R
Instance pain in dorsolateral R foot region upon rising onto toes.


What is Jack's Test? (see above for context)... Not familiar with that one.

Also have you considered using a gauntlet style AFO?