Dear Colleagues
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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?
Regards
Rory
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