Need thoughts on patient case

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Permalink Reply by Violette Aubry on April 15, 2008 at 12:13am

Hi clem,
Thanks to leave some homework for your fellow colleagues. I agree with you that there is some sort of vascular source to this pattern of bilateral P n N and it seems to affect the muscles that stiffens up as a result of hypoxia. The o/s was after wearing tight shoes which could tighten the fascias an lock up the IVM. Other idea, is she generally hypermobile? has she got dropped arch or lose ligaments at the ankles? Did she have any ankle sprains or pb in L/E? a reason that would explain why the muscles try to stabilise the ankle like ligts. If her ankles are hot, it also make me think of inflammatory joints diseases. Can still suggest a blood test if you have a doubt on it, but I would suggest to try your osteopathy first as I personally think that sometimes patients do come up with very weird and very individual pain patterns and do tend to get better if you focus on your osteopathic findings, even if there pain doesn't quite make sens any syndrome that you've learn so far. One other idea: is your patient mad with smelly feet and looking desperate that a devoted osteopath make her feel her ankle worthwhile?
Good luck and I would recommend the supreme IVM and fascial work to save the supreme artery with stillness. And also psoas, hamstring and intraosseus tibia-fibula, I advice you not to forget the little finger to remain properly holistic!
Take care.
Violette

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Permalink Reply by Ross on April 18, 2008 at 12:42am

you dont say where the ankles are hot but 1 minute morning stiffness is not really worrying. how often does she snowboard and is it a lot? if it is or has been she is most likely suffering from a common or garden irritation of the osteoligamentous plate of the foot, some sort of capsular irritation or ischaemic muscle change due to reduced joint mechanics as a result of having her feet packed in tight snowboarding boots. The exacerbation of pain during menses (& pain in general) supports a ligamentous cause (see Dr Sandler's research for more info). Tarsal tunnel syndrome with the same eitiology explains the pins and needles as does sub-clinical compartment syndrome (much more unlikely). It is most likely structural as she aint a candidate for pelvic venous congestion or a, v insuffiency, the latter 2 requiring more cardiac morbidity factors that you have told us about. Meaningful soft tissue with mobilisation (and avoidace of exacerbating activity for a short while) is probably going to get her sorted very quickly. seropos/neg inflammatory disorders probably aint there either in the absence of other symptoms. Good case though, I think Ronan/someone should set up a difficult case discussion group, get everyone's fingers typing!

P.S My collegue Mr Abulaban says hello!

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Permalink Reply by Clement Rhein on April 20, 2008 at 9:42pm

Violette, nice to see you here, finally!
And Ross, tell Abdul to get properly involved! :-)

She works here, in the French Alpes all year round, so i guess she does quick a bit of snowboarding. The sx started last summer tho.

Spoken to a physio colleague here and he told me that RA can get worse with periods. I'm thinking of RA-like because I have it, and all I get is a bit of red, hot and stiff MTPs on occasions.
Enventho its late onset, no family history - could be one of them weird ones.

I don't recal any biomechnical issues in the lower limbs, everything nice an perrty smooth.

Cheers guys, any more, don't hesitate.
Clem

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