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Hurdling injury results in loss of muscle power????

Discussion in 'Biomechanics, Sports and Foot orthoses' started by Rory McFadden, Jan 27, 2009.

  1. Rory McFadden

    Rory McFadden Active Member

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    Dear Colleagues

    I am looking for some help/guidance/enlightenment regarding a most interesting case.
    Young female, 22 years of age presents with history of weakness in her left ankle and an associated tendency to trip as she tires. She reports that at the age of 16 she competed as a hurdler. During a race her she felt something "go" in her lead foot as she crossed a hurdle. On impact with the ground she felt her left foot collapse , before she fell on the track.Due to adrenaline, she promptly jumped up and continued pursuing the other athletes.Needless to say she managed 4 to 5 paces before she keeled over in pain.
    Subsequent investigations of her foot included an MRI , US scan and an x-ray. The MRI results were inconclusive possibly due to oedema ( she reports her foot was "black"), the US diagnosed rupture of the plantar fascia and the x-ray a Lisfrancs injury.
    On examination, six years on, she exhibits minimal active ankle joint dorsiflexion or plantarflexion.She displays minimal power when asked to resist my attepts to dorsiflex/plantarflex her left foot at AJ. Passively I can move the AJ through an unrestricted ROM.However she has no reduction in tone nor any muscle wasting when compared with her other leg. Her sensation is intact , with normal readings recorded for monofilament and neurothesiometer tests.She is also very hypermobile.
    She has attended a number of Orthopaedic clinics, Physiotherapists and a Podiatrist .
    She was advised that what she felt "go" as she hurdled was her plantar fascia. I find it hard to comprehend that this would spontaneously rupture and it does not explain the loss of motor control.
    My initial thoughts are that what she felt "go" was related to neural tissue (given the stretch which may have been applied with text book hurdling technique), she then landed at speed on rather flaccid hypermobile foot thereby rupturing the fascia and incurring the Lisfrancs injury

    Regarding the loss of motor control,I have also questioned whether 6 years on, she may be suffering from a reflex sympathetic dystrophy.. However she has only pain when she is actively weightbearing and shows no signs of muscle atrophy.

    I intend to get a new MRI carried out and to refer her on to Neurologist re: nerve conduction tests.

    I am concerned that she has been passed from profession to profession for the past 6 years without ever getting a diagnosis. Whilst spending money on consultations

    I would appreciate your thoughts. Is there something i am missing?


  2. Rory:

    I find it hard to believe that a 22 year old that has a significant lack of power to dorsiflex and plantarflex the ankle during clinical examination does not have a signficant decrease in calf muscle girth on the affected side. Please measure her again with a tape measure, don't eyeball it, and give us your findings.

    A good functional test for calf muscle strength is the single leg toe raise. A patient balanced on one foot, and lightly holding onto a chair, table or wall, should be able to tiptoe stand repeatedly to a 45 degree angle, ten times in a row, if they have normal strength. Can she do this?

    If she has a significant loss of ankle dorsiflexion strength, then she should have a steppage gait pattern, or trip often on that foot during swing, especially after a long walk. Does she exhibit any of these findings?

    She could have a sciatic nerve injury (stretched sciatic nerve from the hurdling race) but this will nearly always cause calf atrophy on the affected side and the electromyogram/nerve conduction (EMG/NCS) study would be positive. Has she had a EMG/NCS?

    Unfortunately, if there is no calf atrophy, only shows "calf weakness" when performing clinical tests that require volitional muscle use and has a normal EMG/NCS, I think that she may need to see a psychologist, rather than a podiatrist, neurologist or orthopedic surgeon.
  3. Rory McFadden

    Rory McFadden Active Member

    Thanks for your advice regarding specific clinical tests. I will post my findings once i had reviewed this patient. As stated earlier my intention is to refer her to Neurologist but I have not ruled out the psychologist.

  4. Rory McFadden

    Rory McFadden Active Member


    Calf muscle girth measured: identical values
    Single leg raises: Unable to achieve more than 1cm raise on affected side.

    Patient has appointment to see Orthopaedic consultant next week. I have recommended EMG and NCS.

    Also discussed psychologist with patient. I am covering my options!


  5. Rory:

    How many times in a row can the patient raise to the 1 cm height? This is a good indication of muscle power under more repetitive loads.

    My next thought would be, as treating clinician, to determine what is causing the patient, that has perfectly symmetrical calf girth, to not have the ability to do a normal toe-raise exercise. Is it a actual lack of strength, is it because of pain during motion, is it due to some central nervous-peripheral nervous system dysfunction, or is it psychological? Does she report pain during the toe-raise maneuver? Does she notice increased fatigue of calf muscles or pain during bike riding (i.e. high reps, lower loads)? With theraband ankle plantarflexion exercises on both sides, does she fatigue earlier on affected side than on non-affected side?

    I always think of the psychological aspect of dysfunction in these types of patients, but consider it very low on the scale of possibilities, especially initially, since I want to give the patient the benefit of the doubt. However, there is nothing wrong with asking the patient how motivated she is to return to activity or whether she has a fear of the pain returning, since this can happen to many individuals, even the tough ones, with this type of injury.

    Keep us informed of the results. Very interesting case!
  6. Rory McFadden

    Rory McFadden Active Member

    Though obviously not a pyschologist myself, i have chatted a length to this young lady regarding the fact that she can no longer compete at the high she previously attained and how she feels about this. She has no aspirations to get back to athletics and is putting all her energies into her academic studies.She is very keen to get a diagnosis, almost more so that a cure. I have discussed the possible investigations and have also suggested the possiblity of pyschological issues. She has no reservations about exploring all options.My gut feeling is that there is a neurological basis to all of this. An Intriguing case!

    Kevin, I appreciate the further advice regarding clinical tests.



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