‘Traumatized’ by a ‘simple’ case of trauma

Hello guys! Halfway!

I am doing my musculo outpatients at the moment. Initially when I received this case of a patient with (R) bi-malleolar # and ORIF done (11 weeks post-op now, WB as tolerated), I really didn’t think it could be too complicated. He presented with two areas of pain, Pa – anterior ankle and Pb – posterior and inferior to medial malleolus which bothered him during standing (immediate Pa) and walking (Pa during stance, Pb during both stance and swing but more on stance). He also has constant ‘altered sensation’ over the lateral dorsum of foot and tightness around the ankle. Physical examination revealed the following asterisks – Obs: swelling anterior ankle, calf wasting, knee hypertension, anterior pelvic tilt, low abdominal tone. Gait: using w/f (which already ‘abnormalizes’ walking), decreased WB + tibial translation over foot. Functional tests in standing: heel raise – unable to perform on (R), repro Pa + Pb; stand on medial borders – decreased range on (R), nil pain; stand on lat borders, nil pain. ROM: decreased actively for df (Pa repro with OP) and ev (no Pb repro); OP of pf repro Pa; inv repro pulling at Pb. Resisted ms testing: weaker pf, FHL and FDL; tib post (L) = (R) and repro pulling at Pb. Palpation: TOP of both Pa (which seems to be in region of ATFL) and Pb. Glides: decreased talocrural AP and subtalar lat. Treatment so far has been AP glide on talocrural jt, education on ice + elevation, gave a tubigrip, active-assisted ankle ROM exercises and correction of the way she uses her w/f. Pa and Pb haven’t been getting better.

We hypothesized Pa could be ATFL sprain during the time he had the # (would have to check the ant drawer test) – supported by area of pain, TOP, pf OP repro pain; swelling present and confined at ant ankle would not do this ligament good and is a contributing factor to decreased df besides decreased AP glide. As he tries to put weight over the foot, there is restriction to forward translation of tibia; compression forces ant ankle repro Pa. Pb seems to be ‘muscular’ in nature (pointing to tib post) – area of pain, repro with AROM inv and resisted tib post, TOP and repro in gait. From footflat to mid stance, pronation of foot for shock absorption should occur with eversion at subtalar joint – he has decreased lat glide which I thought could limit this resulting in increased forces to the medial ankle. During this time, the tib post is also active to internally rotate tibia. These could explain Pb repro during stance. From mistance to toe-off, foot supinates which involves tib post (but with w/f, I think this part of the gait cycle is not relevant). In swing, foot returns to neutral so I believe a component of pronation occurs again which could explain Pb repro. Negating evidence is present most definitely, I was expecting Pb with ev but nil. It also occurred to me there could be tarsal tunnel syndrome (with the swelling, screws, her hx of arthritis and area of pain) but again, the negating evidence is lack of Pb with ev. Perhaps I need to do a more specific test on the post tibial nerve for this. I am still thinking of other possible causes of Pb...

Does anyone have any ideas on what else I need to assess / treat to come up with appropriate diagnoses and solve his problems? I would really really appreciate some help! Thank you!!!

Cheers Peiying ~