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Hi All,

Just wondering for some treatment advice for a patient i saw late last week. The pt is a 58yr old lady who presented to me with right heel pain. The pt has had this pain since march when she spent a whole day gardening and has concurrent left hip and knee conditions.

Pt described pain as sometimes sharp and it radiates into the forefoot, but normally its a dull pain

My examination revealed:

- Pain on palpation on the medial calcaneal border directly under the medial malleolus. (pt described as sharp pain on a focal point but dull pain in tissue surrounding)
- Also painful just posterior to the medial malleolus and an inch or 2 up the tibia
- Large discrepancy in temperature R heel inflammed
- VAPS 4/10 normally & 8/10 at most painful
- Moderately overpronated foot type (drop > drift)
- Pain in posterior calc, deep to the achilles
- Moderately active lifestyle caring for people with I.D's (takes them shopping, day trips etc.)

I was perplexed by some of her answers during the consult, but i was thinking tarsal tunnel syndrome, but wasn't confident as i couldn't replicate tinels. I thought about fatty tissue irriation but after 3 months i thought it may have resolved by then & it doesn't explain the radiating pain in the foot and leg. Thought about muscle/tendon issues but couldn't replicate pain when muscle testing.

Treatment:
- Prescription for X-ray (pt worried about a fracture so and X-ray was ordered)
- Rest
- Icing & anti-inflamms
- Review 1 week when x-rays undertaken

What i am specifically after is a diagnoses i may have missed as i'm assuming the x-ray will come back negative for a fracture

Thanks
Dean

 

have you excluded PTTD?

LL

 

No, i haven't excluded it yet, but couldn't detect any abnormality in the muscle testing or a weaknesses in the PTT. But thinking more about it, i may just re-run the testing again and try and get some more specific answers from the pt next time.

Thanks for the input, muchly appreciated :D

 

What sort of activity was she doing when gardening? Was she walking around or sitting and weeding? There would be a big difference in activity levels.
Was she in enclosed shoes? March in melbourne is warm and if she was not, could she have been bitten by something?
How did the pain come on? When is it better and worse? Is the pronation assymmetrical?
Is all the pain you palpate actually where she feels her symptoms?

 

Have you looked at neural tension - slump and SLR testing. May present similar to tarsal tunnel syndrome but Tinels' would be negative.

Regards,

Robin

 

Walking around when gardening, basically generally tidying up the house in her words. Pruning, weeding, raking etc.

The insect bite is an interesting idea in which i will explore further in the next consult. Should've thought of that :bang:

O/Pronation is not asymmetrical to any noticeable degree.

Palpated site is where she feels the bulk of her pain, but it does occasionally get sore along the course of the structures within the tarsal tunnel.

Feels best in the mornings after sleeping, then it gets worse as the day progresses, and the pt doesn't/hasn't try/tried much to help relieve the pain so very vague responses from her when questionned. Maybe i should ask the same questions again and re-word them to elicit a better response.

AM hoping we get a reduction in pain from regular icing this week and see how we go

Thanks for your help

Dean

 

No i haven't, what specifically would i be looking for? Problems relating from her lower back/hips due to compensating for the left sided issues?

 

I think Robin is think more of referred pain

Slump test = patient sitting upright with legs extended and the slumps forward as if trying to touch toes. (some say put hands behind back while doing this test {the patient that is, not the clinician ;)} but take care that the slump is controlled)

SLR (Single leg raise) = Patient lying supine on couch, rasie one leg with knee extended and flexing the hip, Hold the other knee flat and extended on the couch to stop trick movements of the pelvis. Take leg slowly and carefully to maximum hip flexion or 70dgs, which ever comes first. Stop if there is pain.

Both these techniques test for neural tension to see if the sciatic nerve is sliding out of the spinal neural foramen. Doing similar to SLR but with flexed knee gives a differential between sciatic and femoral nerve. D/Flexing the ankle simultaneously as doing SLR indicates if neural tension in tibial nerve and inverting the STJ indicates peroneal nerve tension if positive. Neural tension by Piriformis impingement can be differentiated by internal rotation and adduction of the hip and flexed knee but don't confusethis response with Greater Trochanter bursitis and ITB pain.

Cheers Dave

 

:good:

What he said, only in a not quite so succinct or knowledgeable fashion.

Robin

PS David, never realised about inverting ankle to check for peroneal nerve tension. Thanks

 

:good:

I really agree, thanks for a very insightful posting. I did as said and all tests were negative for neural impingement which was frustrating, but the patient did report that she had seen significant improvement with regular icing & some rest (who would've thought!)

I did find though that she had limited ROM at the ankle joint and advised regular stretching along with continuing conservative treatment.

Thanks heaps for your help everyone!

Dean