I had a 13 year old come in yesterday in a great deal of pain.
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She has no medical history/med's/allergies
She is a slight/average build and dances 2-3 times a week - jazz, tap and hip hop only.
I saw her in October last year:
- pain at the navicular and on active supination
- Slight pronation at the subtalar joint but not the amount that should have been giving that amount of discomfort
- Able to single leg heel raise but with pain
- No tightness or tonal issues at the G&S or hamstrings
- x-ray found probably the largest Os Navicularis I've ever seen
Tx:
- Advised that a surgical consult would be appropriate but in the public system it may take a while.
- Strength/stretch program
- Orthotics
- Rest for about 6-8 weeks from dance, iced regularly
Pain resolved within 8 weeks. I still re-iterated that she should get a surgical consult
Well, return it did! Mum rang last week and mentioned she had a mild lateral ankle sprain at dance the night before. She was able to hobble for a couple of steps but was fine after and still continued the dance class. The next morning she was in pain at the navic. Mum mentioned she was able to walk with mild pain. It progressed through the week (without mum ringing). She presented with:
- PT tendon prominent but still tracking around the med mal.
- Totally unable to dorsiflex or evert the foot without extreme pain.
- Inversion ROM normal and pain free
- PT full of trigger points and no massage or mobs were able to improve ROM
- Physio also had a little go but due to pain stopped.
Tx this time:
- Ref to GP for referral for surgical opinion. Due to finances, public is the only option.
- I ended up popping a BK soft-cast with the foot held slightly inverted and plantarflexed and getting her on crutches to buy time for me to think about what else to do.
- RV in 7/7 (due to Pod Conference) and cast removal and ultrasound to confirm post tib sheath integrity
Phone call confirmed non-wb cast has given a great deal of pain relief. My dilemma is, it's going to be over a month if not more to get her a surgical consult, what do I do in the meantime to assist with pain relief and keep her slightly mobile? Or am I totally on the wrong treatment path here?
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