I have had quite a few patients in the last 2 months who i have been treating following lateral ankle sprains of varying severity.
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Three of them have been slightly unusual. 2 had moderate injuries treated conservatively, neither had fractures but both sustained significant ATFL tears (partial). During their rehab both developed dorsal pain at the base of their 4th metatarsal. Both patients had plantarflexion/inversion injuries as a mechanism. No prior injuries.
On exam both had significantly reduced stiffness in their 4th ray (i.e its ROM was at least twice that of the unaffected limb). Both have settled with rigid custom orthotics.
The third patient was different. She has a mechanically unstable ankle (ATFL insufficiency). She has declined surgery. First injury resulting in avulsion fracture was 5 years ago. Episodes of instability are weekly now despite decent physiotherapy input. No foot orthoses/orthotic intervention prior to seeing me this week. 2 years ago she developed a mortons neuroma in same side between 3/4 toes. This was dorsally excised. Neuroma recurred 14 months later and was again revised surgically with a plantar approach. She now has a 3rd recurrence! MRI confirms neuroma and no ligamentous abnormalities.
On exam she is excessively pronated throughout stance, significant functional hallux limitus confirmed via in shoe analysis. Ankle joint rom is good, 15 deg dorsiflexion fully extended. Ankle proprioception poor. STJ axis medially deviated, MTJ ROM's acceptable as are other ROM's. However the 4th ray is as stiff as wet lettuce! If any joint was ever "hypermobile" this one is. She is in temporary orthotics while her custom devices are being made.
Chris Nester's lecture at PFOLA in chicago got me thinking. In any patient experiencing a moderate/severe lateral ankle sprain, how commonly is the 4th ray loaded to a point where its proximal ligamentous structures are damaged?
Has this been investigated/documented? I have searched and cannot find any mention of 4th ray deficiency following lateral ankle spain!
Any comments welcome
Sincerley
Simon
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