Case Study

My patient is a 34 y/o male who presented about 4 months post surgery. Patient states the problem began in 2005 when he was four wheeling and his right foot went through the floor boards as he was driving over a brush pile, causing his foot to be dragged. At that time he fractured his distal fibula. He states he wore a boot-type brace for three weeks before figuring out he could get his work boot on. Due to insurance issues causing him not to have medical coverage to pay for his treatment and not being able to take time off, her returned to work very prematurely.

A few years later he fell on some icy stairs and believes he fractured some bones in the arch of the same foot. He went to the urgent care clinic but did not receive X-rays and was told to just rest it and he would be fine. Patient states he continued his normal activities, learning to live with the pain.

In 2017 he was on a fishing trip in Canada. When the boat was docked and they were unloading it, he jumped, landing with the center of that same arch on a rock. He did not seek medical attention and just dealt with the pain.

Ever since his injury in 2017, he had been walking with an antalgic gait to avoid bearing weight on that foot. He also began to fall at times because the pain was so intense. When his wife found out he was falling she insisted he see a doctor.  He finally did so in October of 2017.

Pre-Surgery Images

Medical Diagnosis

The assessment described hindfoot valgus, loss of longitudinal arch height, tenderness over the sinus tarsi and limited subtalar joint motion, possible post-traumatic coalition. The X-rays revealed an unusual pattern of injury/sprain about the cuboid/lateral cuneiform articulation. There is bone marrow edema, contusion of the cuboid and lateral cuneiform, joint effusion and inter-tarsal ligament injury. At that time, he was diagnosed with sinus tarsi syndrome and referred for surgery.

On 12-18-2018, the surgeon performed a interval subtalar cannulated screw arthrodesis fusion with two screws. A small plate and screws were also used, traversing the medial aspect of the first cuneiform. These can be seen on the post surgery X-rays. It appears this was done to provide support to the arch, which was very flat. Patient also states the surgeon lengthened his calf muscle. The surgical history is described as:

1. Right subtalar joint fusion
2. Right Cotton osteotomy
3. Right CMC/CC coalition resection
4. Gastroc recession
5. Bone marrow aspirate retrieval, calcaneus

Following surgery the patient reports he had numbness on both sides of the foot, swelling and his foot tends to turn outward. He wore a splint for the first 15 days and then wore a boot up until 3 weeks before his PT eval on 4-9-2019. He was told at that time he could be weight bearing as tolerated so he stopped using his crutches. He is back to work and now just wears a regular work boot. He is allowed to walk one hour for every four hours of sitting.

12-27-2018

PT Diagnosis

The patient received a PT Evaluation on April 9th which indicated myofascial and joint restrictions, decreased functional strength and mobility.

The following impairments were listed:

• pain
• decreased weight bearing tolerance
  
• swelling
• decreased ROM
• decreased flexibility
• decreased strength and endurance
• impaired balance
• impaired gait
• numbness

The entire evaluation is included below.

Manual and theraband resistance for inversion, eversion, PF and DF, heel and toe raises, manual gastroc stretches, standing gastroc stretches, weight shifting, ant. tib stretches, joint mobs of all foot and ankle joints (especially talocrural), balance activities with inverted BOSU, BAPS board, standing on foam, tandem and SLS, STM and scar mobs both manually and instrument assisted MFR and TPR, compression/cryotherapy with game ready. Patient has noted a decrease in his pain level, a less antalgic gait and increased ROM are observed. Patient also reports he is tolerating weight-bearing for longer periods of time.

HEP: Tband Inv/Ever/DF/PF and standing gastroc stretch

We will continue with these interventions, progressing the difficulty of balance/neuro exercises and increasing resistance as tolerated by patient. When ready, patient will move into ballistic exercises.