A quick case for you…with the accompanying train of thought

66-year-old competitive tennis player presents with plantar and dorsal surface foot pain during bouts of exercise. Approximately one year prior during a tennis match, she describes attempting to sprint to reach a ball, then planting her foot abruptly in front of her to stop her forward motion. At that moment she heard (and felt) an audible ‘crack’ coming from the medial plantar surface of the foot.

“Thought process…” DDx: An audible crack could indicate several things including: articular cavitation, fracture, dislocation/subluxation, soft tissue tear

Following her injury, she was taken to the hospital where x-rays were taken revealing no fracture and/or dislocation.

“Thought process…” – DDx: Remove fracture, dislocation. Regarding articular cavitation, although it may possibly explain the audible noise…unlikely the cause of the symptoms based on the severity.

As is often done in the emergency room/conveyor belt….the patient was given an immobilizing boot with crutches, and instructions to wear the boot, and refrain from weight bearing for 5 weeks.

“Thought process…” The emergency doctor has never looked into the effect of immobilization on soft tissue healing. Further, treatment with no diagnosis will often break the first rule of medicine…first do no harm.
Following the five weeks of immobilization, the patient attended 5 physiotherapy visits where she was given ankle range of motion exercises using Theraband, calf raises, and ultrasound treatment.

“Thought process…” This particular therapist seemed to have no real interest in this patient’s condition as is indicated by the ‘general nature’ of their treatment/rehab approach. Further, the literature surrounding the effectiveness of ultrasound has obviously eluded them. Further still…why do most rehab protocols ignore the fact that the actual foot itself contains musculature?

Examination: During observation I noted that there was a notable circlular keloid scar on the medial plantar surface of the foot. Upon questioning the patient revealed that 5 years ago, she underwent surgery in the area to remove a large cyst in the area. Upon examination of the scar with palpation I found it to be deep routed, non-mobile, and causing a large amount of aberrant tissue tension.

“Thought process…” – Most people underestimate the effect external scars on soft tissue mechanics and fail to deal with them (treat them) appropriately.

Palpation also produced an exact reproduction of location and symptoms when layering through the plantar fascia and bisecting the Abductor Hallucis and Flexor Digitorum Brevis, then bypassing by the tendon of Flexor Hallucis Longus between the Naviular and Calcaneous. Aberrant tissue tension was noted in this region, which was just proximal to the keloid scarring.

I also noted a lack of functional dorsiflexion in the first metatarsalphalangeal joint, as well as a significant lack of mobility of the ipsilateral mortise joint. Functional evaluation of intrinsic foot strength demonstrated a complete lack of control of the toes as well as the common signs of wasting (prominent extensor tendons/metatarsals, etc).

“Thought process…” – Based on the findings I believe that the original injury was most likely a rupture/tear of the deep tissues of the foot…likely involving the plantar calcaneonavicular ligament (also known as the spring ligament), which connects the calcaneus with the navicular bone. Likely, this tear was predisposed by the accumulation of fibrosis that followed the cyst removal thus drawing an abnormally large amount of pre-tension in the area. Following the injury, the 5 weeks of immobilization likely lead to the loss of mortise mobility, as well as further contributing to the intrinsic foot weakness (this was bilaterally present however > on the symptomatic side.

Treatment for this patient will focus on releasing aberrant tension from the foot using Functional Range Release. For this we will have to take care to specifically layer the tissues to the appropriate tissue depth in order to access the originally injured tissue. Treatment will also include inter-layer release of the prominent keloid scar in order to restore tissue mobility. In addition to this, an approach using the Functional Range Conditioning system will readily correct the lost ankle mobility, as well as the mobility of the first ray (which cannot be ignored due to the its importance in lower limb mechanics). An intrinsic foot-strengthening program will also be necessary…I can’t stress enough the importance of intrinsic foot strength assessment on any and all lower kinetic chain/pelvic assessment.

Of course treatment will not resolve the problem in a single visit as I cannot access the parallel dimension in which tissue responses are dramatically sped up in our favour 😦