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Iatrogenic problem

Discussion in 'General Issues and Discussion Forum' started by Mark Egan, Dec 18, 2006.

  1. Mark Egan

    Mark Egan Active Member


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    Hi All,

    A patient arrived last Friday for some advice re. lateral ankle pain in the L foot localised within the lateral gutter of the ankle and described as a sharp pain only with weight bearing, although after a full day on his feet there is usually some pain in the area. There is palpable pain but no pain with resistance testing. He is unable to do a single leg heel raise on the L foot. H e also commented that the pain was more noticable at heel raise in the gait.

    His history is interesting surgery wise - 2 years ago he fell from a retaining wall and fractured the shafts of the 2nd to the 5th shafts of the L foot the Rx was fixation of the bones and extensive physio eventually everything was fine. Then a year after that he noticed increasing discomfort in the L ankle went to a surgeon who told him his STJ was ruined due to the valgus positioning of the met shafts following his first surgery. Had a talo-calc fusion and went off for another year no issues all good until the last several months which is now the problem described above.

    Clinically he is pronated more in the L with no ROM in the STJ the R although pronated appears to be fine at this stage. Gait is a limping one and very late and prolonged supination of the L foot. He has no symptoms elsewhere in the body (isn't the body an amazing device?)

    Assessment in prone and placing the foot in a STJN position shows an everted rearfoot and forefoot. What I fear is happening is that the fibula is now jamming on the calcaneus.

    He admits to not wearing shoes out of work time even though his work boots are the most comfortable shoes he wears (lace up safety boots).

    My initial Rx involved -
    1. to wear supportive shoes over the weekend.
    2. to use ice therapy as much as possible.
    3. application of a rearfoot varus wedge EVA approx 6 degrees extending to be in line with the styliod process - to attempt to open the joint line up or at least reduce the discomfort at the lateral gutter and application of semi-compressed felt valgus forefoot wedge to accomodate the fixed deformity. He didn't like it but promised to perserve with it. In retrospect I should have also taped him.

    I am pretty confident that it has probably not worked - but should I perserve with it? I am also planning to address the lack of stength with heel raises

    Are there any other suggestions ?

    thanks
     
  2. davidh

    davidh Podiatry Arena Veteran

    Mark,

    If you can reproduce pain to pressure the chances are there are adhesions present from the last op.

    My advice is to go with your original idea of balancing the foot, but perhaps not as aggressively as you suggest. But I would also look at deep transverse frictions to the painful area. If there are adhesions present your pt feedback will be positive after the 2nd t/t or so.

    Regards,
    david
     
  3. LuckyLisfranc

    LuckyLisfranc Well-Known Member

    Mark

    Have you arranged any post op xrays?

    IF he has had an STJ fusion, then this is ideally fixated in a slight valgus position with the hindfoot appearing in slight valgus relative to the leg.

    Issues that arise from this:

    * any joint fusion will eventually affect joints proximal or distal to the fusion site - this could be occuring mechanically in the ankle
    * the position of the screw head through the neck of the talus may be irritating the anterior (usually medial - but depends on technique) ankle joint
    * there could have been a concurrent talar dome injury at the time of the initial injury which was thought to be causing STJ pain...?
    * I would expect the lateral incision over the STJ to be well away from the akle, and should not be causing post-incisional scarring/adhesions/nerve entrapment at the level of the ankle joint.

    I'm having a little trouble getting my head around the fact that # MT bases 2-5 would cause the STJ to require a fusion though... :confused:

    If you could post some xrays it would be interesting to look at.

    LL
     
  4. Mark Egan

    Mark Egan Active Member

    thanks David and LL for your thoughts -

    Adhesions issues - would this possible 1 year after the surgery? as he has been fine since the surgery.

    I will try and post some xrays for others to see.

    The incision is lateral and well below the area of irritation.

    Could the fusion be forcing the ankle joint to find some other form of movement for gait ie the lateral malleolar fibula which in turn over the past year has been gradually irritating the area around the retrotrochlear eminence? Which could explain why his pain is more of an issue at heel raise. If so could another form of treatment involve fibula mobilisations?

    cheers
     
  5. Mark:

    How do you place a subtalar joint in neutral position in a foot that has had the STJ fused?? :D

    The best thing at this point is to put the patient into bilateral 6 mm heel lifts, which will likely decrease his pain by 50-75%.

    Have you possibly considered peroneal tendinopathy or is the pain more in the sinus tarsi? An incomplete fusion of the STJ will often present as sinus tarsi pain and "pinching" at heel lift also. You may consider an MRI scan but the hardware, if it is still present, would likely cause significant artifact.
     
  6. Mark Egan

    Mark Egan Active Member

    Hi Kevin,

    Good point what I meant was placing it as close as I could.

    The pain does not appear to be at the sinus tarsi and resistance tests of the peroneals did not appear to increase his discomfort so I am fairly confident that there is no peroneal tendinopathy.

    I was considering HR also. I am hoping to get his films post surgery films on the site for others to view.

    cheers
     
  7. What is the exact anatomical location of the most tenderness? Does inversion of ankle/STJ cause pain laterally? Are the peroneal tendons tender to palpation (mild peroneal tendinopathy will not necessariy cause pain to active eversion against resistance). Get out the anatomy book, and give us your best shot at what structure(s) are involved. We will all learn in the process.
     
  8. Mark Egan

    Mark Egan Active Member

    hope these images get through
     

    Attached Files:

  9. Mark Egan

    Mark Egan Active Member

    Kevin - best description is the retrotrochlear eminance and distal aprox 10mm and proximal 10mm from this point no issues with inversion or eversion of the STJ but as you have mentioned the ROM is almost absent. I will compress the fibula to see if this replicates any issues.

    thanks for your thoughts
     
  10. davidh

    davidh Podiatry Arena Veteran

    Mark,
    You asked:
    "Adhesions issues - would this possible 1 year after the surgery? as he has been fine since the surgery"

    Think about this. His activity level after surgery will have been absolutely minimal, but hopefully increasing month on month. There comes a point when, if adhesions are present they will start to kick in as the pt reaches a level of activity where the adhesions are the weak-link in the physiological chain.
    Anecdotally :eek: , I've treated and improved ankle dysfunction up to ten years after the original traumatic incident, simply by stretching and frictioning areas where I supposed there may be adhesions (so have many others, I'm sure).

    Cheers,
    david
     
  11. Mark:

    I am trying to understand your description. I have never heard of the "retrotrochlear eminance". Do you have the name of an anatomy textbook that describes this part of the foot/ankle? Maybe try describing this area of the foot/ankle using other terminology? Even better, please describe precisely which anatomical structures are present in the area of the patient's symptoms.
     
    Last edited: Dec 20, 2006
  12. Mark Egan

    Mark Egan Active Member

    Kevin,

    The term comes from the text book "Anatomy of the lower Extremity" by Debra J Draves ISBN 0-683-02651-8, p116. I was under the impression this was a standard text book.

    I saw the patient yesterday to find that the rearfoot varus wedge aggravated his medial STJ joint line and the forefoot valgus padding did not assist in his presenting complaints. Although he had spent the weekend barefooted which he indicates does make his ankle sore. I have attached a photo of the area of his cheif complaint - (please ignore the pen this is not an attempt to place this companies name and logo in your subconscious it was just the pen that this man's wife grabbed from my desk so I could take the shot). I have also added a NWB view to hopefully demonstrate the alingment of the FF.

    Kevin a more thorough assessment of the area makes me now feel that the area of issues it is more likely the apex of the lateral malleolar and possibly involves the talar calcaneal joint line. There was generalised discomfort with inversion and eversion of the ankle, but not in the area of chief complaint, but there was pain within the CC with compression of the lateral malleolar and direct palpation at the site marked with the pen.

    I am now begining to think there might be some instability with the fusion as well as adhesions. I have sent him off for weight bearing views of the ankle - AP and lateral views requested.

    You will be happy to know that I added some 6mm heel raises in his new neutral joggers which he commented didn't feel that good (without telling him what I had done). After 3 walk throughs he turned to me and said they now feel really good.

    I have asked him to remain shod as much as possible with the heel raises and apply ice therapy 2-3 times a day to the area. I will review him in the new year and will keep everyone interested posted.
     

    Attached Files:

  13. Mark:

    Excellent!! My Gray's anatomy (huge version) and Grant's anatomy did not have the "retrotrochlear eminence", but in researching it in my copy of Sarrafian, I found it as the "eminentia retrotrochlearis". You are right, the retrotrochlear eminence" is a standard anatomical feature found in 98% of calcanei and absent only in 2% and appears to offer an insertion point for the inferior peroneal retinaculum. Mark, thanks for making me learn something new!!

    Your marker shows that you may be pointing directy to the peroneal tendons, or possibly to the insertion point of the calcaneal-fibular ligament. Since the talus is now relatively more inferiorly located due to the removal of the joint cartilage from the subtalar arthrodesis, the fibula will also be more inferior than normal relative to the calcaneus. There is a possibility that the peroneal tendons are being "pinched" at heel off, when they are under the greatest tension, in the area between the inferior tip of the fibular malleolus and the peroneal tubercle. You did not provide us with an AP or Mortice view of the ankle which would be more likely to demonstrate this are of the lateral ankle more nicely.

    The heel lift should help with peroneal pain. You may also try a valgus heel wedge and forefoot wedge under the 2nd - 5th metatarsal heads to decrease the demand on the peroneal tendons during late midstance and early propulsion. The everted forefoot deformity likely increases the STJ supination moment during late midstance and propulsion causing a reflex increase in peroneal activation. The valgus rearfoot and forefoot wedging should "shut down" the peroneals and possibly relieve some of his pain.

    Another possibility is that the calcaneal-fibular ligament is being irritated somehow. If during exam, you invert the calcaneus relative to the leg, this ligament should become prominent and palpable, so you can assess whether it is involved or not, via palpation.

    Still another possibility is that the peroneus quartus muscle insertion point is irritated. The peroneus quartus muscle inserts onto the retrotrochlear eminence of the calcaneus and is present in 12-22% of the population. Possibly this muscle insertion point is inflamed or scarred from the surgery?

    Cortisone injections into the area may be quite helpful. I would try at least one to see if there is any change in symptoms, then do a series of three, spaced 4 weeks apart, if initially helpful. If the symptoms persist, an MRI of the peroneal tendons may show a split in either the peroneus brevis or peroneus longus tendons. The MRI artifact from the screw would probably not hinder this area of the MRI. Here is a nice little article on the MRI anatomy of that area of the foot and the associated pathology. http://radiographics.rsnajnls.org/cgi/reprint/25/3/587

    Good luck.
     
  14. Mark Egan

    Mark Egan Active Member

    Hi All who have followed and especially those who have contributed to this case, my last treatment had involved HR as suggested by Kevin, the improvment was immediate. I have spoke today to the patients wife who has let me know that "he is feeling the best he has in years - walking without pain". I have suggested that he could come in and let me trial some valgus wedging to increase the comfort levels in the peroneals, but if what she is saying is the case then I am not expecting him to come in. I suppose if it was me I probably would not come back in either. Who would have thought a simple heel raise would be so effective !!!!

    Again thank you for the suggestions, I really appreciate the help.

    Regards
    Mark
     
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