This is an interesting case study that demonstrates the necessity of a thorough assessment. This is a current fitness client who I originally met at the clinic.
Patient is a female runner, who has been having chronic foot issues for the last couple of years. The pain initially started after returning to running following the birth of twins. After intermittent pain and treatment with NSAIDs, she saw an orthopedist who referred for PT at another clinic. She was treated with modalities and basic planar ankle exercises. When she also complained of lateral foot pain, she was urged to ice to control pain. DEXA scan revealed hot spots at fifth metatarsal head and cuboid. Treatment consisted of this for 3 months, with some improvement in symptoms. After a few months pain did not improve much so she saw another local doc who referred her to me.
ROM: limited DF active and passive
Joint Mobility: limited posterior glide of talus, limited tibial internal rotation
Palpation: very tender at medial calf/posterior tib
Dynamic Tests: Poor single limb stance on involved side, limited DF with overhead squat
Neurodynamics: No symptoms with SLR, but strong replication of lateral foot pain during SLR with ankle inversion (peroneal nerve bias). Check out Zac Cupples below, who is a guy I follow and is really sharp.
So she had no pain around the cuboid or fifth metatarsal, no pain during the dynamic tests, and no pain with ROM or strength testing. However, with a neurodynamic test in the appropriate end-range of motion we finally got a strong reproduction of symptoms. So what did I do (keeping in mind that this was an interesting case from two years ago, and I would naturally do many things different now).
Interventions: Talocrural distraction with thrust manipulation, Mulligan mobilization with movement in NWB and half-kneeling, tibial internal rotation with knee in flexion. Also instructed her on peroneal nerve glide in modified-Ober position in supine after doing a few rounds manually.
When she returned after the first visit she had at least a 50% decrease in pain, if not 75% since two days ago. Her dorsiflexion remained almost 15 degrees improved, and she has minimal symptom provocation in the same SLR position. It’s amazing what happens when you include a thorough assessment with manual therapy and neurodynamic treatment. And to think the previous advice was to do calf raises and ice for 3 months? I hope that isn’t too self-congratulatory, but we can so so much better for our patients!
As I stated before, this was two years ago, and now I would likely add some dry needling to the calf complex, dynamic tape the foot to decrease pain threat (or get a placebo from cool-looking tape?), and I would also refer her out to a women’s health PT given her lumbopelvic issues from popping out twins like a boss.
Thanks for the read and feedback is welcome.