This topic contains 3 replies, has 3 voices, and was last updated by Christopher Stepien September 23, 2020 at 8:46 am.
September 8, 2020 at 11:38 am #9461
Adam Holen D.C.
I know I’m missing something, which is why I’m reaching out to you guys. When it comes to ankle/foot cases, what are the primary dx (most likely) aside from adhesion/strength?
Here’s why I’m asking: about 4-5x now I’ve had ankle/foot pain cases that have limited dorsiflexion in the ball park of 2.0-4.0″ of motion. The first 3-5 visits typically go smooth, breaking down adhesion in FHL, FDL, Tib Post (other structures if involved) and their ranges improve by 1-2″. Then all of a sudden, the next visit they’re regressing in terms of range of motion. They maintained it for several visits then it drops off and goes backwards. I’ve had this happen in both cases where patients are still improving, feel great, or their symptoms begin to backslide (mildly). Even with their tissues palpating clean (sustained progress).
So, the 2 main things that come to mind are possibly strength limitation (correct time to add heel raises?) or an underlying irreducible block. And the 2nd item is what I struggle with. Cartilage damage to the saddle joint (anterior pinching primary symptom), tibialis posterior tendinopathy (not sure how to dx without typical tendin-osis presentation), plantar fasciosis/severe adhesion in the bottom of the foot structures.
My questions are, in your experience, what are the most common ankle/foot diagnoses that you encounter? What can we confidently diagnose without or prior to imaging? What info do you look for/ask to establish these diagnoses?
Have you had any ankle cases that present and ultimately follow what I’ve described? Great initial progress then either solid plateau or regression in ROM? Can 2-3 graded adhesion in the foot (yet to be addressed) cause this backslide? Is strength a limiting factor? What am I missing?
These are the types of cases that keep me up at night, so any feedback is greatly appreciated. Thanks guysSeptember 16, 2020 at 8:18 am #9483
Brian Zelasko, DCParticipant
A few things come to mind here, all would need some further information to confirm, but I’ll just throw them out there.
I’ve had this discussion with Dr. Brady before, and the ankle joint is very similar to the hip joint in the sense that genetic malformation is common. Faulty joint shape, as you know, will get angry at times especially when motion is increased but there hasn’t been enough time to increase strength.
So you are right on with the strength exercises needing to be started if this is the case. I’ve seen some motion decreased due to protective tension in the posterior leg structures a few visits in, but it’s almost always because the patient increased their load too quickly and the strength is not there yet. The patient is feeling better, so they just do more without even realizing or they do more simply because we didn’t communicate load management well enough.
Your other thought of adhesion in the plantar aspect of the foot causing this regression. I would think yes. If the person is not comfortable loading the foot, compensation will come from the leg structures you have been treating and create again protective tension possibly limiting your DF test in an attempt to unload the plantar foot structures. In this case, just as you’re thinking, time to switch priorities of treatment to the plantar foot while still managing load.
As far as Posterior Tib tendinopathy, I would palpate the attachment on the navicular bone to see if it’s tender similar to Achilles and elbow extensor tendinopathies to aid in the suspicion of this diagnosis. But ultimately an MRI is needed to confirm I think, maybe someone else has more experience with this and can assist further.September 16, 2020 at 9:36 am #9484
Adam Holen D.C.
Thanks for the input Brian. I didn’t realize, or just forgot that the ankle joint can have highly variable joint shape impacting motion/load. I would imagine, like genetic disc durability or hip joint shape, that patients with joint shape malformations are (probably) more likely to be those who become symptomatic, obviously not 100% of the time tho.
In retrospect, I don’t think my communication is dialed in for load management discussion and establishing a healing environment. I’ll work on that to set the stage better.
Appreciate the feedback on the strength component and addressing foot structures. I was just unclear as to when we implement strength in these cases because even though their ROM is improving, it’s still not 5-6″ which would be when I’d traditionally begin strength.
Clarifying that this is still most likely a load/capacity issue keeps it clear. Communicate better, balance strength, keep treating what’s most relevant.September 23, 2020 at 8:46 am #9487
Beautiful dialogue Adam and Brian.
For the purpose of being comprehensive to the thread, you probably know this Adam – considering Bill’s statement – “For the love of God, get orthotics” to unload.
Ideally, “We don’t put a bad foot into a good orthotic”. But in stubborn cases or when we really need to deload, I’ve put people into orthotics sooner.
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