Last week I was evaluating a 50 year old male status post peroneal tendon debridement and repair. The patient had spent 6 weeks in a cast and was seeing me 1-week after cast removal. The two pictures below show how the foot and ankle presented upon initial evaluation.
My initial differential diagnosis included: 1. normal foot, 2. infection, 3. CRPS.
Further inspection revealed signs of skin trophic changes, swelling, pain, hypersensitivity to light touch, nail bed changes, coolness of the lower limb and difficulty initiating movement. The patient denied constitutional signs and symptoms- fever, chills, headaches, night sweats. The incision appeared to be healing normally. He had limitations in ankle ROM and strength. Interestingly, the patient had a positive SLUMP test with intermediate dorsal cutaneous nerve bias (branch of the superficial peroneal).
The patient's symptoms had centrally sensitized! After being in a cast for 6 weeks with high levels of pain, the CNS forgot how to interpret normal sensation and movement of the foot. On the initial evaluation, I performed a thoracic manipulation to stimulate the autonomic nervous system as well as performed common peroneal nerve glides. Additionally I prescribed the ankle alphabet and towel scrunches bilaterally to facilitate bloodflow and movement as well as promoting small amounts of weight bearing. I chose to perform each exercise bilaterally so that the patient would receive neural overflow from the intact side. Additionally, I gave ample education to the patient regarding the nervous system and pain science.
Even in surgical cases, remember that the cause of dysfunction may be distant from the site of injury! More pictures and progress updates to come.
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