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Hey guys,
Please see the following attachments and answer the questions at the end of the case. Also please see attached article to prepare for discussion next week.
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1. List your differential diagnosis after the subjective exam. Does this change after the
objective exam?After subjective: acute synovitis in anterior ankle / impingement, CAI, peroneal tendon tenosynovitis, peroneal tendon tear, OCD talar dome
After objective: CAI with anterior ankle synovitis and impingement
2. List any yellow or red flags you’d consider this case.
Red: peroneal tendon tear or frature
Yellow: avoidance of ADL’s3. Are there any components of subjective or objective exam you would have included
during the IE to help clarify your DD list?Subjective: imaging, detail regarding ankle sprain history (when was the first, what was the worst sprain, are they all in the same direction, any immobilization, how many times has she had rehab, weight bearing), walking up vs downhill, bruising, swelling, popping, give-way, bilateral?
Objective: double/single hop test, y-balance, single leg lateral and forward hop tests; edema in anterior ankle/sinus tarsi, tuning fork on lateral malleolus, distal tib/fib mobility, cuboid motion, foot joint/ROM assessment
4. What would be your manual, exercise, and educational interventions are for IE? Does her
past treatment influence interventions during day 1?education: Anti-inflammatories and ice for 1 week (2x/day), potentially ASO brace for 1 week to limit TC dorsiflexion with weight bearing and provide some stability laterally,
Manual: TC posterior mobz and distraction (grade II-III),
Exercise: Unloaded pain-free AROM (stationary bike, half foam roll) and potentially single leg balance on half foam with different directions based on irritability
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1. List your differential diagnosis after the subjective exam. Does this change after the objective exam?
– CAI
– anterolateral impingement
– peroneal tendon pain
– DJD of TCJ or distal tibfib
– isolated ATFL/CFL high grade sprain
– stress fx
– After the objective: I agree with your primary hypothesis. Would have ruled out stress fx, isolated high grade lig sprain, and peroneal tendon pain based on your findings.2. List any yellow or red flags you’d consider this case.
– yellow: history of sprains, fear avoidance with walking on uneven ground/recreational activities3. Are there any components of subjective or objective exam you would have included
during the IE to help clarify your DD list?
– description of antalgic gait
– SLS on stable and unstable surface
– description of the most recent sprain and comparison to hx of sprains
– what kind of MT did she get before? Was it appropriate?
– pop/bruising/swelling both from her perspective and yours
– CKC DF since this was the most limited ROM in OKC
– is she still doing any of her PT exercises from the other clinic?4. What would be your manual, exercise, and educational interventions are for IE? Does her past treatment influence interventions during day 1?
– Manually, I would try a TCJ posterior glide graded to tolerance – possibly MWM in CKC based on your findings there. If successful, you could show her how to perform at home with band at talus off step. Could also give strengthening exercises for her DF/Evertors, but she is likely already doing some of these if she was just in PT. You could ask what she is still doing any of those exercises and base your decisions off of this. Based on this you could fill the hole that might have been there (i.e. add proprioception drills if she was just doing isolation stuff). Depending on her irritability at your IE, you might have to tailor this accordingly since she just recently had an exacerbation in sx. Could educate her with some hurt vs harm talk, how to manage her current inc in sx (RICE/NSAIDS if appropriate), and your anticipated POC. -
1. List your differential diagnosis after the subjective exam. Does this change after the objective exam?
– CAI
– Ant ankle impingement
– Peroneal tendinopathy
– High ankle sprain2. List any yellow or red flags you’d consider this case.
– History of ankle sprains
– New injury occurred during PT
– Avoiding recreational activities3. Are there any components of subjective or objective exam you would have included
during the IE to help clarify your DD list?
– I’m generally wondering if her new injury feels familiar to her or if it feels different from past injuries
– Is she hypermobile in other joints/high Beighton scale indicating general instability?
– How far into med school is she, and is this impacting her schooling at all? (like walking around hospital)
– Does she want to return to dance? What are her goals?
– SLS
– If any symptoms with single leg squat, does this change with ankle positioning?4. What would be your manual, exercise, and educational interventions are for IE? Does her past treatment influence interventions during day 1?
– Manual: G-V TCJ manip if patient not fearful. If she was or you wanted to wait until further visits, I would do a posterior MWM into lunge if patient could tolerate, and then show her how to do this for HEP.
– Exercise: I would start fairly gentle with patient to improve her confidence with exercise again. Probably SLS and other balance exercise without any dynamic components. Also ankle eversion strengthening in non-painful AROM. -
1. List your differential diagnosis after the subjective exam. Does this change after the objective exam?
Subjective:
– ATFL/ CFL sprain or rupture
– CAI
– perennial synovitis
– impingementObjective:
– CAI with peronneal synovitis2. List any yellow or red flags you’d consider this case.
– Apparently switched via Direct Access to visit a different PT company after experiencing pain with a different PT
– Passive approach to easing factors
– She notes at best being in 4/10 pain (I.e, constant pain), but only reports having dull ache intermittently and occasional high grade sharp pain
– avoidance behaviors3. Are there any components of subjective or objective exam you would have included during the IE to help clarify your DD list?
– How deep were her squats? That requires DF, but these weren’t painful…
– Was SL squatting painful?
– Subj: Clarify what is her “at best 4/10” pain when she only intermittently has dull ache
– Subj: What type of dance history?
– What part of walking is painful?
– Why is driving painful, which requires primarily DF? Is this only on the table after she’s been flared?
– I’d wonder what her DF tracking looks like… If the TC jt is hypo mobile, does it track her into EVR?
– What depth palpation elicited her pain? Is the tenderness a recreation of her Ache or Sharp sx?
– Posture: She pronates… can she actively supinate?4. What would be your manual, exercise, and educational interventions are for IE? Does her past treatment influence interventions during day 1?
– She has extensive history with PT, but I’d want to check in on her understanding of the problem at hand. It doesn’t sound like she believes the prior PT knew what s/he was doing, so I’d want to get on the same page here.
– Use the Education piece to address her apparent fear of certain activities
– Manual: TC mobs to tolerance in either OKC or CKC with transition to HEP
– Ex: Open and closed chain weight bearing proprioceptive challenges that incorporate AROM to tolerance -
1. List your differential diagnosis after the subjective exam. Does this change after the objective exam?
– CAI- with active synovitis or hemarthrosis
– anterolateral impingement
– peroneal tendinopathy
– ATFL/CFL injury2. List any yellow or red flags you’d consider this case
I agree with Jeff- on the new onset occurring at PT and self-report of passive interventions as easing factors. I would dive deeper into this topic to gauge her beliefs on previous treatment.3. Are there any components of subjective or objective exam you would have included during the IE to help clarify your DD list?
–What part of walking, jogging, jumping are bothersome (PF or DF motions)
-CKC DF symptoms
-PF activities (swimming and driving, different location, or description of pain)
description of antalgic gait
– description of the most recent sprain and comparison to hx of sprains (agree with this one)
-Forefoot and rearfoot position (NWB and WB)
-kinematics of ankle and associated joints, midfoot,STJ with functional/WB movements and activites
-Palpation in sinus tarsi
– Looking into yellow flags; gauging patients beliefs of passive versus active
– DF limited on the uninvolved side, or excessive? -
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Great discussion last journal club – please keep it up for this one.
Think about ways to change the pathomechanics that persist the ankle effusion/synovitis, with resultant IMP at the sinus tarsi – think her foot type, what causes that IMP in the region, and how to control those pathomechanics.
Minimal intra articular differential with an apparent persistent synovitis – should make you think more intra versus extra articular pathology.
Manual Therapy to improve the pathomechanics that are causative for IMP, not just impairments found necessarily.
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