Hi Everyone,
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I'm looking for any ideas about a case.
PC
23 y/o male experiencing peroneal impingement in ankles, Lt>Rt
After 10 mins on elliptical trainer, has burning sensation at the distal end of the gastroc muscle belly, i.e. the proximal formation of the tendo achilles. Not problematic when running but is painful when playing football/soccer
RMH
Orthotic treatment for 2 years which has reduced the lateral impingement pain, but the burning is no better
SH
Formerly very sporty but now attends gym for fitness only
Sedate job
OE
Anatomically normal appearance feet
Talo crural joint ROM restricted - just reaches 90 degrees with knee extended. +ve Silverskiold test
Medially rotated STJ axis Lt>Rt
STJ and MTJs satisfactory
Weight bearing shows excess pronation.
Gross examination of gait (no motion analysis equipment in clinic) shows normal foot position at initial contact. Shock absorption is normal and at midstance, there is a slightly excessive degree of pronation. Terminal stance shows strong movement into supination in preparation for push off.
Palpation of the offending area illicits no symptoms, although I have been unable to assess this when the burning takes place
No altered sensation along the course of the sural nerve
Current orthotic Rx is 3/4 polyprop shell with medial heel skives bilaterally and posted to 2 deg inversion. This reduces the lateral impingement pain. However, has little effect on the burning at the proximal end of the TA
Does anyone know whether compression of the Sural nerve at this level is likely? I know it can be easily trapped further up the leg and be a cause of medial knee pain. However, I could not illicit the symptoms in clinic and the patient does not report any loss of sensation down the lateral aspect of the foot when the burning arises. Is it something else?
Many thanks
Robin
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Relationship Between Pathologies of the Peroneal, Achilles, and Posterior Tibial Tendons
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Robin,
A couple of Questions
Have you tried a heel lift ?
Does the patient have a FF Equinus ? -
You may want to try it with a pair of heel lifts.
-
There is no midfoot equinous present
He does regular stretching to give improved TCJ ROM
Regards,
Robin -
Hi Robin,
What are the lower limb pulses like? Doesnt sound particularly like his symptoms are vascular/ischaemic in nature from your description above, but a while back I missed a vascular condition in a road racing cyclist (altered haemodynamics at the time not being something I generally considered in young fit athletes). Vascular syndromes can and do mimic common neuromusculoskeletal presentations - and it only takes a minute to rule them out.
I agree with the above posts - start off with adding bilateral heel raises to his devices and see if this alters his pattern of pain. Was there any neural tension/sensitisation on testing (SLR/Slump)? What is gastroc/soleus power and control like? Basically - what makes you think symptoms are neural in origin?
Ian
EDIT: Sorry - cross posting - only just saw you had tried heel raises already -
Hi Again Robin,
Here what I would do with the info we have.
- Ref to good physio for a nerve assessment, that will possibly lead to nerve mobilisation stretching
- get the patient to wear heel lifts when exercising- change lace set up to stop heel slippage around 10 mm
- sports type massage for posterior leg every week for a month
-streching 3-4 times every day for hamstring, gastroc and soleus.
- talocural mobilisation treatments.
-support type socks when training.
It sounds more like a Triceps surea overuse problem which can be made worse thru reduce nerve mobility.
I get very similar symptoms and the above treatment program helps alot.
Hope that helps
Edit Ian was writing similar thought about nerve mobility as I was writing the same -
Thanks Ian
-
It was only one day when he mentioned his leg felt heavy as well when symptoms started, and then dropped in that sometimes when he got off the bike his foot felt cold and looked a bit pale that the penny dropped. (A learning experience for us in history taking one could argue). Popliteal and pedal pulses were checked and were fine. Then popped him on the bike until symptoms peaked - quick jump off and re-check and there was a marked reduction on symptomatic side.
Not suggesting this is the case in your chap of course - just thought it was worth a mention.
Keep us posted
Ian -
Thanks Ian. The main thing I am likely to struggle with is seeing him immediately having stopped exercising. Might have to bring him in as a private patient and put him on the cross trainer. Gives me the chance to do some 2D gait analysis at the same time.
I'll let you know -
Robin another idea, Slightly leftfield. There has been some debate about the effect of a low
b12 levels can have on exercise induced muscle pain. I tried to look some peer reveiwed stuff but found nothing. I have a couple of patient who have been tested and found to be low in
b12 and have had injections and amazing results. I can´t find any science to back up the claims there maybe, but something to consider if you still can´t get anywhere. It a simple blood test from a GP.
and if too leftfield heres leftfield to listen too http://www.youtube.com/watch?v=8D56eqR-qiM -
It is more at the musculotendinous junction and it is only occuring when on the elliptical trainer and playing football. However, I will bear it in mind and it has made me think of another patient for whom it may be a more appropriate explanation.
That kind of music is far to energetic for the likes of me! I exercise to Val Doonican!
Thanks Michael -
Hi Robin,
I include chronic exertional compartment syndrome in my DDx whenever I get an athlete in who presents with burning or cramping pain in a muscle of the foot or lower leg which is relieved by rest and displays no palpable tenderness on examination. Biomechanics often irrelevant. Definitive Dx made on intracompartmental pressure test on exercise.
Hope this helps,
Barry Hawes -
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From a purely anatomical standpoint, a sural nerve impingement doesn't seem the most obvious answer though I am aware of case reports of sural anomalies discovered in cadavers that could lead to sural impingements. An example: http://www.neuroanatomy.org/2007/041_042.pdf
I would agree with those above that a triceps surae overuse syndrome sounds more likely. -
sural anomalies discovered in cadavers that could lead to sural impingements. An example: http://www.neuroanatomy.org/2007/041_042.pdf
Good article but you are right, it is sounding more like sural nerve impingement is unlikely. I'll post when I do the test
Thanks
Robin -
Barry
Definitive Dx made on intracompartmental pressure test on exercise.
I'm not sure what that test involves. Could you describe or give me an idea of where I might find a description.
many thanks
Robin -
I would agree with Barry - biomechanics is often largely irrelevant. No amount of fiddling with pieces of plastic is likely to fix the condition and release the septae. It is a surgical case.
In saying that, I don't think this case sounds like compartment syndrome to me...
LL -
In saying that, I don't think this case sounds like compartment syndrome to me...
What do you think if not a compartmental syndrome?
Robin -
Robin:
This does not sound like chronic exertional compartment syndrome to me since the superficial-posterior compartment is the least likely compartment to have chronic exertional compartment syndrome (CECS). However, the consistancy of the timing of the onset of pain is a characteristic feature of CECS. Another likely diagnosis is continued scarring around a previous myotendinous junction tear of the gastrocnemius musle-Achilles tendon. This myo-tendinous junction is a natural weak spot within the gastrocnemius-Achilles tendon complex and is the source of many posterior leg injuries in running/jumping athletes.
Medial gastrocnemius myotendinous junction tears are so common that they have been given the name of tennis leg but more commonly these tears occur in older athletes. Another alternative to consider is plantaris tendon rupture that hasn't healed completely or has residual scar tissue left in the area. It would be helpful to ask the patient if the pain came on suddenly one day or gradually developed over time since tears are generally start with one or two steps fairly suddenly into a running or jumping activity. Also, to help diagnosie myontendinous tears, I will have the patient lay prone on the examining table, dorsiflex their ankle maximally and palpate deeply at the gastrocnemius myotendinous junction since often times the defect from the tear is readily palpable when the examiner's thumb is moved across the myotendinous junction, with the area of maximum tenderness being the site of the defect and site of the tear.
http://emedicine.medscape.com/article/91687-overview
Deep tissue massage along with heel lifts or switching to shoes with higher heel height differential should help this young athlete. Another thing that will help is to tell your patient to lean farther backwards during his elliptical trainer sessions since people who lean forwards habitually on elliptical trainers may develop posterior calf pain and/or temporary numbness/tingling of the forefoot. Standing up straighter, with more weight on their heels, generally resolves this problem.
Hope this helps. -
So I agree that with compartment syndrome controlling stj position is not so important but saying biomechanics is irrelevant I´m not sure I can agree with. Even treating and discussing the sitting position as Kevin suggested is in my world treating biomechancially, would you agree with that?
I will however agree that if the problem is so far along no amount of conservative treatment will have much success and a release must be considered.
So to summarize. Early to medium stage increase in compartment pressure I believe conservative/biomechical treatment to reduce the load on muscle can have great effect.
What do you think? -
So this real issue is the cause - which you have alluded to.
IMHO this cause is overuse in the presence of low incidence anatomical variation, which may be subtly influenced by massage, acunpuncture, heel lifts, orthoses and the like. However, I am yet to see anyone actually get any meaningful lasting improvement with and of these approaches. Hence my belief that this is eventually always a surgical condition - unless suitable activity modification occurs. I saw a lot of this when treating infantrymen - who have no choice but to either have surgery or quit the army.
Its a bit like treating bunion pain with a gel cushion. It doesn't address the cause - and I think this is where we diverge in opinion.
LL -
morning all
i'd never heard of Silverskiold test, so i googled it ( as you do) and got this article fro japma. dont know if its of any use to some of the more learned contributors but might help folk like me who hadnt heard of it.
cheers
JB
http://www.japmaonline.org/cgi/reprint/95/1/18 -
Here the full text version of what JB mentioned
Attached Files:
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I joined this forum because I get referrals for cases like this. When I first met the referring podiatrist and explained what I do he exclaimed "I need you, I am trained up to the knee but I know the problem is coming from higher up."
The differential between running and football and probably the elliptical is having the head down. The head down or forward places additional stress on the distal heads of the metatarsals. The support of the planter muscles has to be matched at the attachment of the soleus and the anatomy train continues up the gastrocs.
This young man is fortunate to have such an attentive doctor. I usually get the referral after there has been a sprain strain at T11/12 and the anatomy train which continues up the adductors to the psoas minor and through T11/12 to the lower trapizius to the upper trapizius and the skull. When that is broken at T11/12 the posture really gets ugly and correspondingly the feet.
Hans Albert Quistorff, LMP
Antalgic Posture Pain Specialist
http://hansmassage.blogspot.com/index.html -
I will always try the conservative pah to +ve outcome 1st and if not succes look to the more envasive treatment plans, but maybe that just meLast edited by a moderator: Jan 25, 2010 -
Hey nothing wrong with following conservative treatment through to its end conclusion. However, I don't think a bunion is an 'extreme' example to get this point across.
Many podiatrists will literally :deadhorse: with a symptomatic deformity such as a bunion or hammertoe - pads, splints, shoe modifications, insoles, orthoses, reiki, acunpuncture...you name it. And keep doing it for year after year. In my mind most of these interventions may provide some modest or temporary benefit, but ultimately the 'solution' is surgical. It always stuns me that many new patients who see me about a common complaint such as these have never been even offered a surgical option - that almost cry with relief that someone has finally offered an opportunity to 'fix' the problem.
Sure you can live with it, but in the same way you can live with exertional compartment syndrome by not exercising so much.
But maybe I just draw a line in the sand on conservative care a lot earlier than you? But probably not as early as Steve ;)
LL -
Like a professional dance instructor who had some sort of 1st MTP pain, Surg said A little op and the pain will disappear, Patient ended up with a fused 1st and was told by the "surgeon" to consider a new career when she complained. :butcher: -
Well folks,
Here is the update on this patient. I saw him privately(as a freebie) last weekend having resupplied him with some heel raises following the advice on this thread.
He still experiences the burning sensation after 10-15 mins but it is less severe and is more noticeable on the Lt than on the Rt.
As advised by Ian, I did a slump test as opposed to to just an SLR test and this showed some neural tension bilaterally but more noticeably on the Lt side.
Pulses were fine in this instance.
On Kevin's advice, deeply palpated the musculotendinous junction and found a defect on the Lt side so there does appear to have been some type of plantaris tendon problem although the patient can remember no particular injury.
Had the patient run until the burning began and then palpated the problematic area which was quite lateral and there was considerable discomfort. Unfortunately, where I live, there are no practitioners who can do compartment testing.
I have given the patient the advice of having a proper nerve test and deep tissue massage to the area along with a programme of stretching to be sorted by the physio.
I plan to review in 6/52 and will keep you updated on progress but I expect that we will see some positive results. Many thanks for all of your advvice. What a great resource this website is.
Regards,
Robin -
Robin:
Thank you very much for the update on your patient. Your thoughtful attention to reporting back to us on your patient's progress greatly enhances the clinical education environment of Podiatry Arena for podiatists around the world. -
Fascial entrapment of the sural nerve and its clinical relevance.
Paraskevas GK, Natsis K, Tzika M, Ioannidis O.
Anat Cell Biol. 2014 Jun;47(2):144-7.
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Relationship Between Pathologies of the Peroneal, Achilles, and Posterior Tibial Tendons
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Practising Medicine without a licence?
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