Evidence in Motion, LLC

1. Evidence in Motion, LLC June 8, 2013 Kahn Nirschl, PT, DPT, OCS EIM OMPT Fellow in Training

2. Rationale for choice of this case • Interesting case involving regional interdependence. • Patient has a functional stature in relation to his foot pain that needed to be considered. • Good initial response but regression led to a surgical outcome. • Interested how others would have proceeded in the same situation.

3. Patient Information • 48y/o caucasian male; large endomomorph: 6’0” 270 pounds examined on 1/30/2013. • Referred to PT by PCP • PMH: • HTN, lumbar HNP 3/2012 (unknown level: patient couldn’t recall; no access to imaging) • Chief complaint: right 5th metatarsal pain burning in nature with sharp pain with weightbearing. • Removed orthotic 6 months ago which around time of onset of symptoms.

4. Body Chart • P1 described as a burning, sharp pain that is localized to base of posterior 5th MET. • Aggravating factors • Walking for up to 60 minutes with pain to 6/10 that eases to 1/10 following one hour sitting • Squatting for up to 5 minutes pain up to 5/10 eases to 1/10 following sitting x 15minutes • AM pain stiff with initial weightbearing; increased pain throughout day into PM. P1

5. Subjective • Patient reports insidious onset without a specific injury November 2012. In the past has had 1st digit pain with bunion. Saw an othopedist one year ago who wanted to release calf and address bunion; patient declined. • Red Flag: None. • Yellow Flag: recent history of LBP 8 months prior to this onset of lateral foot pain right • LEFS score: 47/80; Should have considered ODQ as well but was not taken at exam.

6. SINSS • Severity: Mild: still working and performing all ADLs; pain is present but is not interfering with his walking functionally or at work but is causing pain. • Irritability: Mild: symptom onset is not immediate and while it does take up to an hour to abate I do not feel that I will limit vigor of exam based on this • Nature: (highest to lowest probability): Potential Stress fracture 5th MET, avulsion injury of peronealtendinosis, L5-S1 somatic referral. • Stage: Chronic • Stability: Worsening course

7. Objective • NPRS pain average for week= 2/10 • Posture reveals ER in bilateral LE congenital that produces ER LE with gait right >left increasing stresses at right 5th MET. • Gait: limited toe off with hypomobility at 1st MTP; ER stance phase with limited ankle dorsiflexion. • TTP right base of 5th MET • No lateral shift noted. Cleared lumbar spine with OP with normalized ROM. Negative hip scour. Negative SLR/dural. • MMT: L1-S1 WNLs except ankle eversion secondary to pain to 4/5 MMT, as well as right glut medius weakness to 4/5 with some mild trendelenberg. • Sensation: intact to light touch • DTRs 2+ bilateral LE

8. Objective • AROM right ankle DF=0, PF=65, INV=20, EV=30; 1st MTP=25 degrees • PROM left ankle DF=2, PF=70, INV=40, EV=30 • AROM right hip IR=0 degrees comparable to left. • X-ray was negative for fracture; however, vibrational testing coupled with stethoscope revealed decreased bone conduction and pain reproduction at 5th MET when compared to uninvolved extremity • Moore, Bryan. The Use of a Tuning Fork and Stethoscope to Identify Fractures. Journal of Athletic Training. 2009. May-Jun; 44(3): 272-274 • Contacted PCP regarding this. PCP instructed to monitor his LE and advise against strenuous activity and to continue PT.

9. Assessment • Symptoms of P1 with history and testing are consistent with stress reaction of 5th MET, still potential for peronealtendinosis based on similar mechansim of injury thus treatment would be very similar to remove stresses from this 5th MET region by increasing dorsiflexion, 1st MTP extension and IR of right hip if possible. • Have ruled out lumbar or hip involvement to this point.

10. Treatment (visit 1) • Manual Therapy: • HVLA right 1st MTP, right talocrural joint, followed by mobilization of same structures; increased DF to 5 degrees, 1st MTP extension to 30 degrees • MFR right gastroc, soleus, posterior tibialis to decrease stresses at 5th MET • Therapeutic Exercise: • Right FHL stretch with strap, standing right gastroc/soleus stretch limiting any pain at 5th MET

11. Plan • If better: progress manual therapy package to include mobilizaton to HVLA at right hip to address IR loss that is present. • If same, re-assess asterisk signs and progress manual therapy package as appropriate including hip interventions additionally in a regional interdependence approach but possibly with increased dosing. • If worse, re-assess asterisk signs, and if same remain readjust intensity of exercise and manual therapy to reflect patient’s current status.

12. Treatment (visit 2) • After 1st session decrease in pain rating from 6/10 to 0-1/10. • Addition of IR mob prone at right hip. • Continuation of manual therapy similar to first visit. • Exercise remained the same but addition of seated BAPs board to address talocrural mobility that was not evident at exam based on talocruralhypomobility, as well as prone AROM IR with exercise and sidelying YTB clam exericse to address IR loss and glut medius weakness

13. Treatment (visit 3-8) • Same treatment program administered over course of next 2 visits maintaining overall decrease in pain to 1/10 from 6/10. However returning to 5th visit, without any significant change in activity, patient’s symptoms increased again to previous levels with a GROC of 1+. This was maintained for next 3 visits with temporary decreases in pain for a few hours then pain would return. Overall AROM of ankle DF=10 degrees with first MTP extension to 40 degrees which were marked improvements from IE. Due to this lack of progress, retested with vibrational testing and ultrasound directly on 5th MET which dramatically increased patient symptoms. Referred patient back to physician with original concerns. Patient was referred to orthopedist who repeated films and MRI and didn’t see a stress fracture. Patient was scheduled for surgery to debride near base on peroneal insertion near 5th MET base, as well as to address his bunion and to perform a gastroc release. Surgery put on hold with surgery. Surgery performed on 3/8/13, and patient returned to PT on 4/8/13 to progress weightbearingout of CAM, gait, ROM and overall strength. He was NWB initially following surgery, then 50% WB with crutches and CAM until PT began.

14. Post-operative PT • Post-operatively pain had decreased following surgery even with progressive increases in weight. • Patient had 13 post-operative visits. • Post-operative ROM had decreased as follows actively: DF=+20, PF=40, INV=15, EV=28. This was addressed successfully and at DC was DF=17, PF=65, INV=45, EV=35. 1st MTP ext=40. Gait had improved with decreased ER in stance phase and more heel toe transition. Strength increased to 4/5 MMT post-operatively in all planes. • DC at 5/22/13 with a GROC of +4, LEFS=65/80. • However, 3 visits post-operatively, patient had been working too much on LE and experienced an actual fracture of 5th MET. CAM walker and diminished weightbearingallowed this to heal and for a successful outcome to be achieved but it made me question whether that was the ultimate issue responsible for his symptoms with a stress reaction causing his initial pain and the rest post-operatively allowed it to heal until failure. Once healed, he had no additional return of pain. • Curious about everyone else’s thoughts on this and how they would proceed?