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Complication post inversion sprain injury

Discussion in 'Biomechanics, Sports and Foot orthoses' started by trophikas, Jun 5, 2008.

  1. trophikas

    trophikas Active Member


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    Gday ALL

    29 Y/O Male pt presents 6 wks post L inversion sprain. Pt is an amatuer athlete who is extremely fit and has had a history of inversion sprains on L ankle.
    Pt has fairly neutral RSCP, Moderate To High Sup Resitance (suprisingly given his Hx of Inv Sprains I assumed it would be low), Average Tib Varum and a history of calf strains and Achilles tendonitis.
    Swelling around med/lat ankle has all but completely resolved and pt has been adhering to physio regime of ice, Gentle mobs/ proprioception exercises. Pt has been training (AFL) over last week and experiencing pain even with gentle jogging at the posterior aspect of his heel, deep to his achilles tendon (posterior aspect of Talo Craural Jnt).
    Pt experiences pain with both passive Plantar flexion AND Dorsi Flexion. Pain when mobilising Talo Craural Jnt when foot is maximally inverted. Weakness in peroneals was treated successfully using trigger point therapy and cuboid mobilisation.
    Pt feels like there is a block when he goes onto toes.

    My Differentials include
    Posterior Impingement/os trgnm Sx (unlikely due to pain on D/F, but included regardless)
    Talar dome lesion (seems more probable)
    Scar tissue/granulation secondary to trauama/repair in Post talo Fib Lig

    Would appreciate any advice in regards Tx and diagnosis.
    If Sx do not begin to ease over next 2 wks Im thinking of ordering an MRI to investigate injury to talar dome, but Im holding off due to prohibitive cost of scan.

    Look FORWARD TO HEARING YOUR THOUGHTS.

    MrT
     
  2. trophikas

    trophikas Active Member

    Anyone out there???? Any advice or have I just about got it wrapped up?

    MrT
     
  3. CraigT

    CraigT Well-Known Member

    All seems pretty reasonable to me...
    Does he already have a plain film xray? If not, that would be a faster and cheaper way of ruling out impingements, and may show a talar dome fracture if it is there.
    Have you got the physio's thoughts also?
     
  4. Atlas

    Atlas Well-Known Member

    I would imagine that kicking would be quite provocative.
     
  5. CraigT

    CraigT Well-Known Member

    I can confirm that every patient I have kicked became provoked.
     
  6. brevis

    brevis Active Member

    what have you tried doing?(strapping,bracing etc)....and how has he responded?
     
  7. MelbPod

    MelbPod Active Member

    Just a thought:

    possible injury of Tib-fib ligament??
     
  8. drsarbes

    drsarbes Well-Known Member

    Hi:
    Reading over your initial HPI, it would be reasonable to find symptoms on ROM after 6 weeks.
    Is he still improving?

    If not, and if he is limitied in his activity to the point of looking into this further, I have the following thoughts;

    • Repeated inversion sprains cause an increased likelihood of ATF lig damage.
    • Repeated injury with continued increased activity certainly would cause chronic synovits, in any form, from common reactive type to impingment syndromes or miniscus type lesions.
    • Osteochondral fracture or injury would need to be ruled out.
    • Certainly posterior pathology is possible; i.e., posterior process or posterior capsule injury.
    •Chondroma or even chondromatosis in the anterior recess.
    • Talar neck exostosis with secondary synovitis/extensor tendinitis.

    Here's a picture of an Osteochondral fracture with some synovitis I repaired via Ankle scope in case you haven't had a opportunity to see these first hand.

    If you'd like I could attach pictures showing the other pathologies I mentioned. Didn't want to get too carried away!

    Hope this helps
     

    Attached Files:

  9. Ella Hurrell

    Ella Hurrell Active Member

    Has the patient been limping heavily since the initial injury? I have found with lateral ankle sprains (my own partial AFTL tear :boohoo: included!!) that the more prolonged the protective limping, the more posterior calf pain was experienced on the affected side - just a thought
     
  10. trophikas

    trophikas Active Member

    Gday

    Thanks for response. The patient is currently 6 wks post inversion sparin and I guess the thing that was unusual to me was the location of the pain. It is quite painful to palpate Deep/proximal to achilles insertion and anterior so my thinking was it was unlikely to be a soft tissue injury (aside from post talo fib) that would mend up uneventfully. I have never seen a patient with pain in this area post inversion sprain in my admittedly limited practical experience so it raised a few alarm bells. With some gentle STJ and talo crural mobilisation/ peroneal trigger point via dry needling, pt reports a 20% reduction in Sx so far. So I will wait and see if there is further improvement over next 2 wks and if not will get cracking with xrays.

    I would love to see the other pics, and thanyou for these they are great. Cheers all for your assistance.
     
  11. Stanley

    Stanley Well-Known Member

    I like your differential. There are a few more that I would include. A fracture of Stiedas process. Dorsiflex the hallux, and see if the pain increases. This is similar to the Os trigonum, except that the accessory bone was not there in the first place.

    Another possibility is the patient could have a strain of the posterior talocalcaneal ligament. Obviously, an MRI is the best way to diagnose something when you are having difficulty figuring out the damaged structures.
    A simple test you could do is a simple muscle test. Check the strength of the peroneals, then rub the ligament downwards, recheck the strength of the peroneals, then rub upwards and recheck. Rub the ligament 10 times with moderate pressure in the direction that strengthens the peroneals.

    Regards,

    Stanley
     
  12. drsarbes

    drsarbes Well-Known Member

    The Os Trigonum and or post process is fairly easy to palpate and test. Stanley's hallux dosriflexion test is a good one.
    If you were to have the patient prone and, at the level of the posterior ankle/STJ push a needle straight in just at the lateral border of the tendo achilles (90 degree to it) you would usually hit the post process. If you place a finger (yours preferably) in this area (medial to the peroneals) you can palpate the process. By dorsiflexing and plantarflexing while palpating you can get a good idea if it is symptomatic or not.

    First, just take bilateral lateral x-rays and compare them. Even if your patient has os trigonums, if one is Fx or separated it will be relatively easy to Diagnose when compared to the normal one.

    Steve
     
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