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Falling caused by instability?

Discussion in 'General Issues and Discussion Forum' started by JCRTilley, Oct 23, 2013.

  1. JCRTilley

    JCRTilley Member


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    I have a patient (male,35yrs) who has had numerous lateral ankle sprains over his lifetime with no treatment at all but bad enough to stop him playing rugby.
    No other relevant history. Current symptoms include pinpoint pain on palpation bilaterally at navicular/Tib Post (Neutral foot type w/b & in gait & normal weight) but reason for appointment was - intermittent falling (once a month) as MEDIAL ankle (right or left) 'gives way' causing him to 'hit the deck'; minor swelling thereafter but can walk normally once again within 10 mins. Normal ranges of motion. Good footwear. Quite unstable on a balance board - Does anyone think porprioception ex's & orthotics will help? Obviously worried about the falls. Have i missed something??
    Any suggestions appreciated......
     
  2. Craig Payne

    Craig Payne Moderator

    Articles:
    6
  3. JCRTilley

    JCRTilley Member

    Thanks Craig, May the rehab begin....
     
  4. efuller

    efuller MVP

    Muscle strength? Neuro exam? Why does he have trouble with balance board?
     
  5. MissB

    MissB Active Member

    I would request an ultrasound scan to assess the deltoid ligament, spring ligament and tib post. What was the anterior draw test result? This will be positive if the medial ankle is unstable. I agree that you need to look at muscle strength (use Oxford scale), the invertors will most likely be weak. You will need to establish if this is due to the post tib being weak due being 'over stretched'or the result of a neuro problem. His proprioception is going to be pretty rubbish if he has had a number of sprains because his nerve sensors will have been damaged - therefore his foot will find it difficult to establish where it is in space.
     
  6. JCRTILLEY:

    Here is the thread that I would first read and try to do if you actually want someone to have the background information to be able to help you and your patient here on Podiatry Arena:

    Presenting Patients for Clinical Advice
     
  7. Ian Linane

    Ian Linane Well-Known Member

    Hi

    Although your patient presents with a concern over his falls and apparent weakness of the medial ankle structures with attending pain I would want to stand back a little and not be so overly focused on the falling issue or simply the medial structures.

    Given the history of lateral ankle injuries that, apparently, have never been rehabilitated but of sufficient severity to stop him playing rugby, I would approach this as a whole Ankle Joint Complex (AJC) concern. I would also advise the patient accordingly.

    To address the medial structures alone may bring some initial or immediate benefit however if the lateral ankle structures are not assessed thoroughly (and treated if need be) the functional complex may be prone to failing again.

    I'm also concerned that if you do not assess the whole AJC but resolve the medial structure issues only (and the patient later re-injures and makes a complaint) given your knowledge of his injury history, it could be argued assessment and treatment was incomplete.

    If you have the training to do the assessment / rehabilitation then great. If not refer on to someone who does.

    Two further points.

    1. You mention pinpoint tenderness on the Navicular. Is he in pain walking and is the pain in that area? Is the fall preceded by a sense of pain in the navicular area? If so, and again given the patient history I would be tempted to refer for x-ray to rule out any possible fracture (past or present) to the navicular.

    2. You mention range of movement to be normal. Which range of movement? The functional ankle joint complex involves a lot of gliding and rotating motion. If one of the structures (osseous) of the AJC is inhibited in its function it might impact upon functional congruency of the joint which is not always apparent when testing non-weightbearing dorsiflexion ranges of motion.

    Add to this the above mention comments by others.

    Hope this helps the thinking process. Of course, it's just my take on it.
     
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