Hi All,
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I’m currently seeing a 10y/o Indian boy with 6 month history of pain in both ankles. Right much greater than left especially after playing sports (he currently plays football and tennis 3-4x p/w) which he described as an aching.
The patient indicates the pain is on the anterior aspect of the right ankle and the posterior medial aspect of the same ankle just behind the medial malleolus.
On examination he has a very restricted right ankle range of motion and appears to have spasm in the tibialis anterior, long extensors and peroneus tertius. With some myofascial release work the right ankle ROM improves but on plantar flexion he displays a bony end feel at approximately 45 Degrees.
On palpation he is very sore on the posterior medial ankle joint line and the anterior ankle appears slightly oedematous and painful on the long extensor tendons in the region of the retinaculi. The anterior muscle group in this right leg is in spasm and is painful along the course of the muscles. The peroneals are fine.. no peroneal spasm or pain on palpation of the brevis and longus muscles.
X-rays (attached below) show a reasonable size Os Trigonum on the right ankle and do not indicate tarsal coalition (which they probably wouldn’t as the coalition shouldn’t have ossified at this stage).
He has quite a flat footed gait however the right foot doesn’t appear to move as freely as the right. Shortish stride length.
My thoughts for the pain is that the Os Trigonum is causing a posterior ankle impingement which is causing the pain and as such I have prescribed (a week ago) OTC orthotics to try to reduce the arch drop thus reducing pronation and so how much the calcaneum dorsiflexes during pronation. The insoles have helped reduce the pain by about 50% (still not wearing them for football). Today I increased the control in the insoles a little and if this illicits further improvement I will probably look to move to casted insoles with a fairly high arch profile.
For further treatment I have asked his Mum to help with some massage on the right anterior leg and Ice the right anterior ankle to help reduce the swelling and pain associated with the long extensor tenosynovitis.
My questions are:
- why does he have spasm in the tib ant and long extensors? Is it the body trying to dorsiflex the foot to reduce the compressive forces of the posterior impingement?
- Should I be suspicious of a Tarsal Coalition (which by the way, as a Pt pointed out to me a while back is a great name for a Rock band)? And if so should I send for CT? The reason I am unsure is because of the unusual (?) location of the spasm.
- Has anyone seen spasm in this muscle group and not the peroneals in such a case?
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What point do we go from Orthotics to Orthopaedic Boots?
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Help with diagnosis Osgood-schlatter differential diagnosis
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What point do we go from Orthotics to Orthopaedic Boots?
|
Help with diagnosis Osgood-schlatter differential diagnosis
>
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