Clinical experience 24th September 2019 – 2 Hours

Graduate therapist Mike Pyrnn Peroneal longus Subluxation

Overview of injury: twisted ankle bowling 1 week ago (inversion, abduction). AUDIO POPPING
A & E xray, no #, NWB, no driving
MOI was that of sprain but not classic presentation, no swelling, minimal bruising

Tests: AROM, PROM, RFOM, OTTAWA , all -ve but severe Px PROM inv. L ankle and RROM ever. L ankle.
Visual subluxing of peroneal longus tendon over lateral malleolus and associated Px.

Subjective: Peroneal longus subluxation, poss. Avulsion # although no pain at base of 5th so unlikely, tear of peroneal?
Tx: referral to GP to be referred for specialist Tx
EAB tape to attempt to hold peroneal tendon in place to stop it subluxing.

Immediately post injury, this patient attended the accident and emergency department for a suspected ankle fracture or sprain, where assessment took place and an x-ray was taken and a fracture was ruled out. The patient was then advised about ankle sprains, given walking aids and this concluded hospital treatment. The mechanism of injury (inversion of ankle joint) may have led the practitioners to their diagnosis, however the presentation of the injury is not that of a typical ankle sprain; the patient did not have typical associated swelling or bruising. The current available advice on the Ottawa rules for ruling out a fracture in lateral ankle injuries was discussed by Bachmann et al. (2003) and Vuurberg et al. (2018) stating a specificity of 25-46% but a sensitivity of 86-99% and as such demonstrating to be the most reliable. It is understandable for the misdiagnosis of ankle sprain due to the mechanical nature of the injury and therefore often mistaken for lateral ligament injuries (Heckman et al., 2009).

After an assessment in the clinic, a peroneal subluxation became apparent. This is when either or both of the peroneal tendons has become detached from the retromalleollar groove; this was evident in the patient due to the mechanism of injury (combined inversion and dorsiflexion), the visible and palpable movement of the peroneal tendon over the lateral malleolus and associated pain during eversion and dorsiflexion movements and the history of a pop sound when the initial injury occurred (Heckman et al., 2009).

For this patient, a referral letter was passed on to his GP in the hope of a more firm diagnosis and further treatment, which could be of a surgical nature. It was stated that non-surgical treatment had a 50% success rate and as such surgical intervention was recommended as the most effective treatment, most specifically when repair of retinaculum and groove deepening was performed (Saxena & Ewen, 2010).

From this patient, not only did I visually experience the assessment and diagnosis of an uncommon injury, but it was brought to my attention the importance of keeping an open mind when diagnosing injuries due to the similar presentation of symptoms and different outcomes of provocation tests. For example, the positive anterior drawer test with a sensitivity of 84% and a specificity of 96% (Vuurberg et al., 2018), to indicate lateral ankle ligament instability can show as positive in this instance and as such could result in a misdiagnosis or inability to understand the connected nature of these two injuries (Heckman et al., 2009).

Graduate therapist Alfie Jones Follow up for shoulder pain
Overview of patient: Previous A/C sprain after skiing fall 18months ago, 6/7 rockwood SCALE (8 fully detached, less is torn major ligaments). Suspected rotator cuff tear or impingement at present due to stabbing pain in shoulder, pins and needles and tingling down to upper arm. Had treatment 3 weeks ago but tests inconclusive and no diagnosis, but given exercises to improve general shoulder mobility and strength, in particular rotator cuff muscle group.

During the session, a Spurling’s provocation test was performed to determine whether the patient had any cervical radiculopathy as it was important to rule this out, especially as this patient was presenting with neurological symptoms such as pins and needles and tingling. I was unsure as to the nature of this test and the rationale behind it’s use, so in further research I was able increase my understanding of how it is used in clinical testing. The Spurling’s test is used to diagnose disc herniations at the cervical spine and according to Chhanalal Shah and Rajshekhar (2004), boasts a sensitivity score of 92%, specificity and positive predictive value of 95% and 96.4% respectively with a negative predictive value of 90.9%, warranting it’s use in a clinical setting.
In research by Anekstein et al. (2012), it was suggested that the Spurling’s test was able to determine the presence of nerve compression as opposed to other symptom mimicking pathologies such as brachial plexitis or shoulder impingement, which in this patient was likely due to a negative Spurling’s result.
This study also determined the best method, out of 6 proposed and currently used methods, of performing the Spurling’s test by way of effectiveness in relation to pain scales; extension and lateral bending of the cervical spine was found to best reproduce the symptoms (Anekstein et al., 2012).

A diagnosis remained unclear but clinical signs were suggestive of scalene tightness, tension in the upper back and shoulders and brachial plexitis

In an investigation into the treatment of rotator cuff tears by (Baumer et al., 2016), it was found that after an 8 week physical therapy exercise plan given to 25 participants with symptomatic rotator cuff pathology, ROM, all measured joint measurements apart from scapulothoracic tilt and pain scores increased. The types of exercises performed in this study included those to improve ROM and strength and were performed up to 3 times a week.

Soft tissue massage was also performed to relieve tension to the patient’s upper back and therefore help in allowing greater ROM of the shoulder and allow for more effective strengthening exercises thereafter.

Interestingly, a study on A/C injury (Pallis et al., 2012) found the prevalence of injury to be twice as common in men than woman.

References – 

Anekstein, Y., Blecher, R., Smorgick, Y., & Mirovsky, Y. (2012). What is the best way to apply the spurling test for cervical radiculopathy? spine. Clinical Orthopaedics and Related Research, 470(9), 2566–2572. https://doi.org/10.1007/s11999-012-2492-3

Bachmann, L. M., Kolb, E., Koller, M. T., Steurer, J., & Ter Riet, G. (2003). Accuracy of Ottawa ankle rules to exclude fractures of the ankle and mid-foot: Systematic review. British Medical Journal.

Baumer, T. G., Chan, D., Mende, V., Dischler, J., Zauel, R., van Holsbeeck, M., … Bey, M. J. (2016). Effects of Rotator Cuff Pathology and Physical Therapy on In Vivo Shoulder Motion and Clinical Outcomes in Patients With a Symptomatic Full-Thickness Rotator Cuff Tear. Orthopaedic Journal of Sports Medicine, 4(9), 1–10. https://doi.org/10.1177/2325967116666506

Heckman, D. S., Gluck, G. S., & Parekh, S. G. (2009). Tendon disorders of the foot and ankle, part 1: Peroneal tendon disorders. American Journal of Sports Medicine. https://doi.org/10.1177/0363546508331206

K Chhanalal Shah & V Rajshekhar (2004) Reliability of diagnosis of soft cervical disc prolapse using Spurling’s test, British Journal of Neurosurgery, 18 (5), 480-483

Pallis, M., Cameron, K. L., Svoboda, S. J., & Owens, B. D. (2012). Epidemiology of acromioclavicular joint injury in young athletes. American Journal of Sports Medicine, 40(9), 2072–2077. https://doi.org/10.1177/0363546512450162

Saxena, A., & Ewen, B. (2010). Peroneal Subluxation: Surgical Results in 31 Athletic Patients. Journal of Foot and Ankle Surgery, 49(3), 238–241. https://doi.org/10.1053/j.jfas.2010.02.007

Vuurberg, G., Hoorntje, A., Wink, L. M., Van Der Doelen, B. F. W., Van Den Bekerom, M. P., Dekker, R., … Kerkhoffs, G. M. M. J. (2018). Diagnosis, treatment and prevention of ankle sprains: Update of an evidence-based clinical guideline. British Journal of Sports Medicine, 52(15), 956. https://doi.org/10.1136/bjsports-2017-098106

 

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