This is my final case study submitted to the USOC medical director, Bill Moreau DC, for my diplomate exam. Scott A. Rubin, DC CCSP Rubin Health Center 1500 MLK North St. Petersburg, Fl 33704 A case study. 59 year old female, runner, with left lateral ankle pain. History: 59 year old female,recreational runner, overall health excellent, taking no meds, taking general supplements for joint health, glucosamine sulfate, EFAs, chondroitin, vit. d. She does have lifelong thoracic scoliosis with forward head posture. Has been a runner for the passed five years, about 50 miles per week, with no negative sequella. 4 months ago she develop lateral ankle (L) pain distal to the lateral malleolus. Pain and tenderness have been increasing, she has been to podiatrist who diagnosed peroneal tendinitis and recommended injections. Difficulties were noted in plantar flexion and eversion. She has been icing after running and taking Nsaids. No history of popping noise was heard. She has been using a brooks beast motion control shoe. Physical exam and tests: Pt is 56 tall and weighs 145 pounds. Blood pressure is 122/76. respiration is 10 breaths per minute, pulse is 58. General appearance is bright and communicative. Visual inspection of both ankles appear symmetrical, although distal to the left lateral malleolus, there is a little swelling, non colored. Standing and supine, rearfoot (calcaneous) appear inverted with a total supinated appearance with a forefoot valgus. A true cavus foot presentation. Screening for fracture was done with no positves on the 4 step torsion test, she did not meet Ottawa ankle rules requirements. Palpation was positive over the atfl ligament and pinpoint tenderness just below the lateral malleolus. Functional assessment revealed pain on the left lateral ankle on squat, heel and toe walk. One leg balance tests were poor with eyes open and worse with eyes closed. ROM for the ankle was normal except for dosiflexion which was diminished by 50%. Myotomes: Hip flexion (L1-L3, femoral nerve) EN Knee extension (L3-L4, femoral nerve) EN Knee flexion (L4-L2, sciatic nerve) EN ankle dorsiflexion (L4,L5 deep peroneal ) tib anterior 3/5 ankle eversion (L5,S1 superior peroneal) peroneous longus brevis and tertius, 3/5 with pain. ankle inversion. (L5,S1 superior peroneal) 3/5 Neurovascular: dorsal pedal pulse, EN popliteal pulse, EN femoral pulse, EN tibial pulse, EN Sensory: light touch, sharp/dull vibration, EN UMNL: Babinski EN DTRs: patella, hamstrings, and Achilles all EN Orthopedic tests: Heel walk, neg toe walk pos, eliciting pain lat ankle, but able to do. Ligament tests: Anterior drawer, plantar flexed EN Anterior drawer, neutral EN Inversion, talar tilt pos inversion, talar tilt with plantar flexion, post eversion,talar tilt, pos for pin point tenderness distal lat malleolus rotational stress neg mortons squeeze test, neg calcaneal squeeze test, neg Achilles tendinopathy/rupture, all neg Hoffas/Simmonds/ Thompsons test all neg nerve compression, Tinels test, Mortons squeeze, all neg Differential Diagnosis 1.peroneal tendinitis 2,Grade 1 ATFL Sprain 3. Severe ankle proprioception weakness bilateral. Care Plan. 1.Passive therapies include, Ultrasound for the tendinitis and Strain/Sprain injury, 2.ART, Active Release Technique, to increase functioning of the tibialis anterior, peroneals, posterior tibialis, extensor digitorum brevis, extensor retinaculum superior and inferior , and ATFL ligament. Other various stuctures were also treated with ART. 3. adjusting of the talus was done to improve dorsiflexion. 4. eccentric contraction calf exercises were given for lengthening posterior compartment of lower leg. (alfredsons protocol) 5. heel walks were given to strengthen anterior compartment 6. band exercises were given to strengthen inverters, everters, dorsiflexors, plantarflexors, and internal rotaters of the knee (popliteus, to help stabilize anterior translation of tibia over ankle rocker), 7. balance exercises were given in particular single leg with eyes open and eyes closed, use a balance pad to improve. 8. non tripod exercise, and bird dog were given for core and lumbopelvic stabilization. 9. bridge and hip hikes were given to activate glutes along with repatterning execises for right gate regulation. 10. rock tape was done to the tib anterior for added support of stabilizing improved dorsiflexion. 11. pt was seen 2 times a week for three weeks, then one time a week for 9 weeks. All exercises were to be done two times a day for 20 minutes minimum. 12. due to the cavus foot, a pair of neutral shoes was advised with no orthotic. 13 yoga was recommended for overall full body conditioning OutCome. After 12 weeks patient began running after learning dynamic stretches and doing jump rope and grass with no shoes to establish better proprioception, and continue to strengthen dorsiflexion. She was having no pain and dorsiflexion of ankle improved to 40 degrees at talocrural joint. Rock tape was no longer needed. One legged balance improved to double what she could do in the beginning. All muscle tests were 5/5. Recommendations are to continue with all protocols but with an ok to return to running . No more than 3 miles for 3 weeks, while continue with all exercises. Then increase running 1 mile per week until the desired 6 miles was attained. She is now running 6 miles without pain. Scott A Rubin DC CCSP Rubin Health Center 1500 MLK St North St Petersburg, Fl 33704 a
Posted on: Sun, 11 Jan 2015 19:51:24 +0000
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