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Discussion in 'Introductions' started by littlechud, Nov 15, 2010.

  1. littlechud

    littlechud Welcome New Poster


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    chronic achilles tendonsynovitis Treatment Thoughts?

    47y.o. female presents with c/o continued pain in heel, achilles insertion and shooting pain in medial calcaneal area w/ FWB along w/ parasthesia of mid-sole to hallux/2nd toe. Pt is a nurse, mild obesity, non-smoker, previous thyroid ablation secondary to goiter/hyperthyroidism/Graves Ds., post-menopausal, with no cardiac, respiratory or underlying diabetes issues.

    Pt gives h/o of fall trauma nearly 5 yrs ago as a result of "twisting ankle in depression of floor". Pt reports initiallytaken to ECU, treated and dx with R ankle strain/sprain, B/L knee strain and B/L Shoulder strain, lacerations to wrist & knees. XR neg for fx of R ankle. Pt tx over course of year with therapy to knees/shoulders then progressed with arthroscopies of knees then shoulders. Following 2nd knee sx, discovered "lump" on posterior ankle superior to AT insertion. U/S revealed thickening of AT. MRI done, revealed healing 2cm partial thickness rupture of achilles. PT was initiated for strengthening and ROM improvement, nSAIDs, night splint and pt was fitted for custom orthodics B/L. After 1yr of tx, pt reported increased pain in posterior heel, posterior to calcaneal nodule as well as plantar fascia pain. Heel cups and pad lift added. Of note, pt is a nurse and reported footwear included rotation between Dansko and Nursemate clogs on a daily basis. Pt was advised to avoide clogs ad continued with closed athletic shoes or nursing shoes. After additional 6 months of therapy, pain continued to increase, pt was fitted w/ MB.

    After 3 years of conservative tx, pt presented to this practice w/ c/o increased pain and decreased function over time. Exam findings included palpable thickening of AT with pain induced w/ deep palpation, contracture of AT,clawing of digits and decreased ROM including limitation of flexion/extension. XR neg, MRI once again notes plantar fasciitis, thickening of Achlles at watershed area, tendinosis, calcaneal edema and tendinitis of peroneal tendon all worse from original MRI. In Nov '09, pt underwent R achilles debridement with 4c lengthening in Z-type fashion, plantar fasciotomy and exploration of peroneal tendon. Peroneal tendon free o tnosynovitis on clinical findings compared with MRI. Ganglion cyst excised from anterior lateral ankle.

    Pt progressed well with minimal complaints during initial post-operative stage. However, pt did c/o numbness and tingling to plantar hallux that was non resolving through recovery. As a result of non-resolving parasthesia complaints, pt referred to partner for evaluation. It was noted that a large nodular mas had formed at the instep plantar fasciotomy site. Pt then underwent widening of fasciotomy, excision of adhesions and decompression of right medial plantar nerve in March 2010 .

    Pt continued to c/o regression of ROM wth increased of AT contracture throughout summer. States has not been abe to return to any sports or work, but does tolerate swimming for exercise with some difficulty getting in and out of pool. Continues to c/o numbness, tingling and burning of plantar surface from fascia incision forward extending into plantar hallux and plantar surface of medial aspect of 2nd toe. Numbness migrates throughout 2nd toe with increased activity, FWB & edema. there is palpable thickening of AT noted along entire length of tendon, tightness is once again seen on flexion/extension, clawing of toes noted in 2nd & 3rd, plantar arch once again has notabl palpable nodule at fascitomy incision. MRI repeated and reveals increased signal at istep consistent with adhesion scarring, along with scarring and shortening of achilles worse in comparison to Sept 09 study.

    Physical therapy discontinued in late August as patient was deemed at maximal medical improvement at the time. Pain management with analgesia and anti-inflammatories continue. Pt uses aircast if extended periods of standing or walking required. Pt reports unable to tolerate MB to degree it iritates fascia nodule and illicts shocklike sensations to toes but reports frequently uses nightsplint. Pt reports increased difficulty with ambulation, uses cane cntinuously. Pt pronates foot to minimize shock sensations when ambulating. C/o acilles pain withextension of foot and worse with step off.

    Have discussed possibility of steroid injection with immobiliation vs surgical intervention to include debridement and widening of fasciotomy along with further debridement and introduction of graft to achilles. Pt is anxious to return to active lifestyle.

    Any thoughts or suggestions?
     
    Last edited: Nov 15, 2010
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